1
|
Sharafi A, Ghaderi A, Shahbazi P, Ghaseminejad‐Raeini A, Ramezani A, Soleimani M, Talebiyan P, Shafiei SH. Illicit drug abuse and complexity of tibial shaft fracture based on AO/OTA classification: Is there any connection? J Exp Orthop 2024; 11:e12003. [PMID: 38455452 PMCID: PMC10903434 DOI: 10.1002/jeo2.12003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 12/25/2023] [Indexed: 03/09/2024] Open
Abstract
Purpose Illicit drug abuse is a global epidemic afflicting millions worldwide. Several studies have investigated the contribution of this dependence as a risk factor for fracture, but its impacts on fracture severity have been rarely studied. The present study primarily aims to determine the relationship between illicit drug abuse and the severity of tibial shaft fractures. Methods This retrospective study consecutively included patients aged ≥18 years with tibial shaft fracture who attended Sina Tertiary Hospital, Tehran, Iran, between 2016 and 2021. The fracture patterns were assessed according to the Arbeitsgemeinschaft für Osteosynthesefragen Foundation/Orthopaedic Trauma Association classification. Participants were divided into three individual specialists into groups: simple (A), wedge (B) and multifragmentary (C) fractures. The association of illicit drug abuse and other recorded variables, including age, sex, body mass index (BMI), comorbidities, physical activity, smoking habits and mechanism of injury, was also examined and assessed in multivariate logistic regression. Results Of 219 patients, 26 were drug abusers, and 193 had no history of use. A total of 20 out of 26 drug abusers experienced a complex fracture, yielding a rate of 76.9%, while this rate for nonusers was 50.3% (97 out of 193), indicating a statistically significant difference between the two subgroups (p = 0.011). The smoking history also influenced the fracture pattern (p = 0.027) based on univariate analysis; however, using adjusted multivariate analysis yielded only illicit drug abuse (odds ratio = 3.495; confidence interval = 1.144-10.680) as a risk factor for more complex fractures. Conclusion The evidence from this study suggests that complexity and fracture patterns can depend on illicit drug abuse history. Level of Evidence Level III.
Collapse
Affiliation(s)
- Amirmohammad Sharafi
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University HospitalTehran University of Medical SciencesTehranIran
| | - Ali Ghaderi
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University HospitalTehran University of Medical SciencesTehranIran
| | - Parmida Shahbazi
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University HospitalTehran University of Medical SciencesTehranIran
| | - Amirhossein Ghaseminejad‐Raeini
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University HospitalTehran University of Medical SciencesTehranIran
| | - Akam Ramezani
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University HospitalTehran University of Medical SciencesTehranIran
| | - Mohammad Soleimani
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University HospitalTehran University of Medical SciencesTehranIran
| | - Parham Talebiyan
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University HospitalTehran University of Medical SciencesTehranIran
| | - Seyyed Hossein Shafiei
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University HospitalTehran University of Medical SciencesTehranIran
| |
Collapse
|
2
|
Azimi Manavi B, Stuart AL, Pasco JA, Hodge JM, Weerasinghe DK, Samarasinghe RM, Williams LJ. Antipsychotic medication use and fracture: a case-control study. Sci Rep 2023; 13:13709. [PMID: 37608079 PMCID: PMC10444797 DOI: 10.1038/s41598-023-40762-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 08/16/2023] [Indexed: 08/24/2023] Open
Abstract
It has been reported that antipsychotic use is associated with lower bone mineral density and bone quality. We aimed to determine whether antipsychotic use is associated with fracture risk in a population-based sample of adults living in the Barwon Statistical Division, south-eastern Australia. In this case-control study, 1458 participants (51.8% women) with radiologically confirmed fracture between June 1st 2012 and May 31st 2013 (cases) were compared with 1795 participants (46.5% women) without fracture (controls) for the same time period. Medication use, medical history and lifestyle factors were documented by self-report. Multivariable binary logistic regression was used to explore associations between antipsychotic use and fracture following adjustment for possible confounders. In women, antipsychotic use was identified for 20 of 755 (2.6%) cases and 10 of 834 (1.2%) controls (p = 0.034) and in men, antipsychotic use was identified for 13 of 703 (1.8%) cases and 5 of 961 (0.5%) controls (p = 0.010). Following adjustments, antipsychotic use was associated with a 3.0-fold increased risk of fracture in men and a 2.3-fold increased risk of fracture in women. Patterns persisted after exclusion of participants with non-fragility fractures and self-reported schizophrenia. While future research exploring underlying mechanisms is needed, regular monitoring of bone health in antipsychotic users is suggested.
Collapse
Affiliation(s)
- Behnaz Azimi Manavi
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, 3220, Australia.
| | - Amanda L Stuart
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, 3220, Australia
| | - Julie A Pasco
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, 3220, Australia
- Barwon Health, Geelong, 3220, Australia
- Department of Medicine-Western Health, The University of Melbourne, St Albans, 3021, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, 3004, Australia
| | - Jason M Hodge
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, 3220, Australia
- Barwon Health, Geelong, 3220, Australia
| | - D Kavindi Weerasinghe
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, 3220, Australia
| | - Rasika M Samarasinghe
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, 3220, Australia
| | - Lana J Williams
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, 3220, Australia
- Barwon Health, Geelong, 3220, Australia
| |
Collapse
|
3
|
Gallagher E, Mehmood M, Lavan A, Kenny RA, Briggs R. Psychotropic medication use and future unexplained and injurious falls and fracture amongst community-dwelling older people: data from TILDA. Eur Geriatr Med 2023:10.1007/s41999-023-00786-x. [PMID: 37157012 DOI: 10.1007/s41999-023-00786-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/13/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Psychotropic medications (antidepressants, anticholinergics, benzodiazepines, 'Z'-drugs and antipsychotics) are frequently identified as Falls Risk Increasing Drugs. The aim of this study is to clarify the association of psychotropic medication use with future falls/fracture amongst community-dwelling older people. METHODS Participants ≥ 65 years from TILDA were included and followed from Waves 1 to 5 (8-year follow-up). Incidence of falls (total falls/unexplained/injurious) and fracture was by self-report; unexplained falls were falls not caused by a slip/trip, with no apparent cause. Poisson regression models reporting incidence rate ratios (IRR) assessed the association between medications and future falls/fracture, adjusted for relevant covariates. RESULTS Of 2809 participants (mean age 73 years), 15% were taking ≥ 1 psychotropic medication. During follow-up, over half of participants fell, with 1/3 reporting injurious falls, over 1/5 reporting unexplained falls and almost 1/5 reporting fracture. Psychotropic medications were independently associated with falls [IRR 1.15 (95% CI 1.00-1.31)] and unexplained falls [IRR 1.46 (95% CI 1.20-1.78)]. Taking ≥ 2 psychotropic medications was further associated with future fracture (IRR 1.47 (95% CI 1.06-2.05)]. Antidepressants were independently associated with falls [IRR 1.20 (1.00-1.42)] and unexplained falls [IRR 2.12 (95% CI 1.69-2.65)]. Anticholinergics were associated with unexplained falls [IRR 1.53 (95% CI 1.14-2.05)]. 'Z'-drug and benzodiazepine use were not associated with falls or fractures. CONCLUSION Psychotropic medications, particularly antidepressants and anticholinergic medications, are independently associated with falls and fractures. Regular review of ongoing need for these medications should therefore be central to the comprehensive geriatric assessment.
Collapse
Affiliation(s)
- Eleanor Gallagher
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Mustafa Mehmood
- Department of Emergency Medicine, St James's Hospital, Dublin, Ireland
| | - Amanda Lavan
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
- Discipline of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Rose Anne Kenny
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
- Discipline of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Robert Briggs
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland.
- Discipline of Medical Gerontology, Trinity College Dublin, Dublin, Ireland.
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland.
| |
Collapse
|
4
|
Li GHY, Cheung CL, Tan KCB, Kung AWC, Kwok TCY, Lau WCY, Wong JSH, Hsu WW, Fang C, Wong ICK. Development and validation of sex-specific hip fracture prediction models using electronic health records: a retrospective, population-based cohort study. EClinicalMedicine 2023; 58:101876. [PMID: 36896245 PMCID: PMC9989633 DOI: 10.1016/j.eclinm.2023.101876] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Hip fracture is associated with immobility, morbidity, mortality, and high medical cost. Due to limited availability of dual-energy X-ray absorptiometry (DXA), hip fracture prediction models without using bone mineral density (BMD) data are essential. We aimed to develop and validate 10-year sex-specific hip fracture prediction models using electronic health records (EHR) without BMD. METHODS In this retrospective, population-based cohort study, anonymized medical records were retrieved from the Clinical Data Analysis and Reporting System for public healthcare service users in Hong Kong aged ≥60 years as of 31 December 2005. A total of 161,051 individuals (91,926 female; 69,125 male) with complete follow-up from 1 January 2006 till the study end date on 31 December 2015 were included in the derivation cohort. The sex-stratified derivation cohort was randomly divided into 80% training and 20% internal testing datasets. An independent validation cohort comprised 3046 community-dwelling participants aged ≥60 years as of 31 December 2005 from the Hong Kong Osteoporosis Study, a prospective cohort which recruited participants between 1995 and 2010. With 395 potential predictors (age, diagnosis, and drug prescription records from EHR), 10-year sex-specific hip fracture prediction models were developed using stepwise selection by logistic regression (LR) and four machine learning (ML) algorithms (gradient boosting machine, random forest, eXtreme gradient boosting, and single-layer neural networks) in the training cohort. Model performance was evaluated in both internal and independent validation cohorts. FINDINGS In female, the LR model had the highest AUC (0.815; 95% Confidence Interval [CI]: 0.805-0.825) and adequate calibration in internal validation. Reclassification metrics showed the LR model had better discrimination and classification performance than the ML algorithms. Similar performance was attained by the LR model in independent validation, with high AUC (0.841; 95% CI: 0.807-0.87) comparable to other ML algorithms. In internal validation for male, LR model had high AUC (0.818; 95% CI: 0.801-0.834) and it outperformed all ML models as indicated by reclassification metrics, with adequate calibration. In independent validation, the LR model had high AUC (0.898; 95% CI: 0.857-0.939) comparable to ML algorithms. Reclassification metrics demonstrated that LR model had the best discrimination performance. INTERPRETATION Even without using BMD data, the 10-year hip fracture prediction models developed by conventional LR had better discrimination performance than the models developed by ML algorithms. Upon further validation in independent cohorts, the LR models could be integrated into the routine clinical workflow, aiding the identification of people at high risk for DXA scan. FUNDING Health and Medical Research Fund, Health Bureau, Hong Kong SAR Government (reference: 17181381).
Collapse
Affiliation(s)
- Gloria Hoi-Yee Li
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
- Corresponding author. Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong.
| | - Kathryn Choon-Beng Tan
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Annie Wai-Chee Kung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Timothy Chi-Yui Kwok
- Department of Medicine & Therapeutics and School of Public Health, The Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Janus Siu-Him Wong
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Warrington W.Q. Hsu
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Christian Fang
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ian Chi-Kei Wong
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
- School of Pharmacy, University College London, London, UK
- Musketeers Foundation Institute of Data Science, The University of Hong, Hong Kong SAR, China
- Aston School of Pharmacy, Aston University, Birmingham B4 7ET, UK
| |
Collapse
|
5
|
Bloomer A, Wally M, Bailey G, Roomian T, Karunakar M, Hsu JR, Seymour R, Beuhler M, Bosse M, Gibbs M, Griggs C, Jarrett S, Leas D, Odum S, Runyon M, Saha A, Yu Z, Watling B, Wyatt S. Balancing Safety, Comfort, and Fall Risk: An Intervention to Limit Opioid and Benzodiazepine Prescriptions for Geriatric Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221125616. [PMID: 36250188 PMCID: PMC9561667 DOI: 10.1177/21514593221125616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/19/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction This study reports on the impact of a clinical decision support tool embedded
in the electronic medical record and characterizes the demographics,
prescribing patterns, and risk factors associated with opioid and
benzodiazepine misuse in the older adult population. Significance This study reports on prescribing patterns for patients ≥65 years-old who
presented to Emergency Departments (ED) or Urgent Care (UC) facilities
across a large healthcare system following a fall (n = 34,334 encounters; n
= 25,469 patients). This system implemented a clinical decision support
intervention which provides an alert when the patient has an evidence-based
risk factor for prescription drug misuse; prescribers can continue, amend or
cancel the prescription. Results Of older adults presenting with a fall, 31.4% (N = 7986) received an opioid
or benzodiazepine prescription. Women and younger patients (65-74) had a
higher likelihood of receiving a prescription (P <
.0001). 11% had ≥1 risk factor. Women were more likely to receive an early
refill (P = .0002) and younger (65-74) men were more likely
to have a past positive toxicology (P < .0001). A
prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an
alert. In 58 cases, the alert resulted in a prescription modification, and
in 80 the prescription was canceled. Conclusions Documented risk for opioid misuse in the elderly was 10% among patients
presenting to the ED/UC after a fall. The dangers associated with
opioid/benzodiazepine use increase with age as does fall risk. Awareness of
risk factors is an important first step; more work is needed to address
potentially hazardous prescriptions in this population.
Collapse
Affiliation(s)
- Ainsley Bloomer
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Meghan Wally
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Gisele Bailey
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Tamar Roomian
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Madhav Karunakar
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Rachel Seymour
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA,Rachel B Seymour, Department of Orthopaedic
Surgery, Atrium Health, 1320 Scott Ave, Charlotte, NC 28204, USA.
| | | | - Michael Bosse
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Michael Gibbs
- Department of Emergency Medicine,
Atrium
Health, Charlotte, NC, USA
| | | | | | - Daniel Leas
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Susan Odum
- OrthoCarolina Research
Institute, Charlotte, NC, USA
| | - Michael Runyon
- Department of Emergency Medicine,
Atrium
Health, Charlotte, NC, USA
| | - Animita Saha
- Department of Internal Medicine,
Atrium
Health, Charlotte, NC, USA
| | - Ziquing Yu
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | | | | |
Collapse
|
6
|
Houle J, Schweitzer L, Greenway KT. Complex Interaction of Lithium With Kidney and Bone Health. JAMA Psychiatry 2022; 79:936. [PMID: 35830180 DOI: 10.1001/jamapsychiatry.2022.1749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jonathan Houle
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Lorne Schweitzer
- Department of Medicine, McGill University, Montreal, Quebec, Canada.,University of Montreal, Montreal, Quebec, Canada.,Maisonneuve-Rosemont Hospital Research Center, Montreal, Quebec, Canada
| | - Kyle T Greenway
- Geri-Party Research Group, Lady Davis Research Institute/Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
7
|
Swiggett SJ, Ciminero ML, Weisberg MD, Vakharia RM, Sadeghpour R, Choueka J. Implant-related complications in patients with opioid use disorder undergoing primary shoulder arthroplasties: a matched-controlled analysis. Shoulder Elbow 2022; 14:395-401. [PMID: 35846397 PMCID: PMC9284306 DOI: 10.1177/1758573221994790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/26/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study was to investigate whether patients undergoing primary shoulder arthroplasty with opioid use disorder have higher rates of (1) implant-related complications; (2) in-hospital lengths of stay; (3) readmission rates; and (4) costs of care. METHODS Opioid use disorder patients undergoing primary shoulder arthroplasty were queried and matched in a 1:5 ratio to controls by age, sex, and medical comorbidities within the Medicare database. The query yielded 25,489 patients with (n = 4253) and without (n = 21,236) opioid use disorder. Primary outcomes analyzed included: 2-year implant related complications, in-hospital lengths of stay, 90-day readmission rates, and 90-day costs of care. A p value less than 0.01 was considered statistically significant. RESULTS Opioid use disorder patients had significantly longer in-hospital lengths of stay (3 days vs. 2 days; p < 0.0001) compared to matched controls. Opioid use disorder patients were also found to have higher incidence and odds (OR) of readmission rates (12.84 vs. 7.45%; OR: 1.16, p < 0.0001) and implant-related complications (20.03 vs. 7.95%; OR: 1.82, p < 0.0001). Study group patients also incurred significantly higher 90-day costs of care ($16,918.85 vs. $15,195.37, p < 0.0001). DISCUSSION This study can be used to help further augment efforts to reduce opioid prescriptions from healthcare providers in shoulder arthroplasty settings.
Collapse
Affiliation(s)
| | | | | | - Rushabh M Vakharia
- Rushabh M Vakharia, Maimonides Medical Center, 4802
10th Avenue, Brooklyn, NY 11219, USA.
| | | | | |
Collapse
|
8
|
Denfeld QE, Turrise S, MacLaughlin EJ, Chang PS, Clair WK, Lewis EF, Forman DE, Goodlin SJ. Preventing and Managing Falls in Adults With Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2022; 15:e000108. [PMID: 35587567 DOI: 10.1161/hcq.0000000000000108] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.
Collapse
|
9
|
de Filippis R, Mercurio M, Spina G, De Fazio P, Segura-Garcia C, Familiari F, Gasparini G, Galasso O. Antidepressants and Vertebral and Hip Risk Fracture: An Updated Systematic Review and Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10050803. [PMID: 35627940 PMCID: PMC9140335 DOI: 10.3390/healthcare10050803] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/14/2022] [Accepted: 04/23/2022] [Indexed: 12/10/2022] Open
Abstract
Although antidepressant drugs appear to play an active role in increasing fracture risk, their weight is still unclear. We conducted a PRISMA compliant systematic review and meta-analysis through PubMed/Scopus/Cochrane libraries and registered with PROSPERO (registration number CRD42021254006) to investigate the relationship between antidepressant drugs categories, including SSRIs, SNRIs, and TCAs, and the risk of hip and vertebral fractures. After screening 3122 items, we finally found 26 papers for qualitative analysis and 11 for quantitative synthesis. A total of 15,209,542 adult and elderly patients were identified, with a mean follow-up of 51 months and a major prevalence of women. We identified results largely for SSRIs, with only a small amount of data for SNRIs, TCAs, and NaSSA. No data were found among the most recent categories of antidepressants, such as vortioxetine and esketamine. All included studies reported hip fractures, while three of them also included vertebral fractures. Overall, we observed a significant effect of SSRIs on fracture risk with a mean effect of 0.98 (95% CI = 0.75–1.20). This meta-analysis reveals that the use of SSRIs increases the risk of fractures. Clinicians’ awareness in antidepressant prescription should optimize their potential while reducing this risk.
Collapse
Affiliation(s)
- Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy; (R.d.F.); (P.D.F.)
| | - Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, “Mater Domini” University Hospital, V.le Europa (loc. Germaneto), “Magna Græcia” University, 88100 Catanzaro, Italy; (G.S.); (F.F.); (G.G.); (O.G.)
- Correspondence: ; Tel.: +39-0961-3647122
| | - Giovanna Spina
- Department of Orthopaedic and Trauma Surgery, “Mater Domini” University Hospital, V.le Europa (loc. Germaneto), “Magna Græcia” University, 88100 Catanzaro, Italy; (G.S.); (F.F.); (G.G.); (O.G.)
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy; (R.d.F.); (P.D.F.)
| | - Cristina Segura-Garcia
- Psychiatry Unit, Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy;
| | - Filippo Familiari
- Department of Orthopaedic and Trauma Surgery, “Mater Domini” University Hospital, V.le Europa (loc. Germaneto), “Magna Græcia” University, 88100 Catanzaro, Italy; (G.S.); (F.F.); (G.G.); (O.G.)
| | - Giorgio Gasparini
- Department of Orthopaedic and Trauma Surgery, “Mater Domini” University Hospital, V.le Europa (loc. Germaneto), “Magna Græcia” University, 88100 Catanzaro, Italy; (G.S.); (F.F.); (G.G.); (O.G.)
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, “Mater Domini” University Hospital, V.le Europa (loc. Germaneto), “Magna Græcia” University, 88100 Catanzaro, Italy; (G.S.); (F.F.); (G.G.); (O.G.)
| |
Collapse
|
10
|
Part I: Interactive case: Rational deprescribing of benzodiazepine receptor agonists for insomnia. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
11
|
Xiang K, Liu Y, Sun L. Motoric Cognitive Risk Syndrome: Symptoms, Pathology, Diagnosis, and Recovery. Front Aging Neurosci 2022; 13:728799. [PMID: 35185512 PMCID: PMC8847709 DOI: 10.3389/fnagi.2021.728799] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/14/2021] [Indexed: 12/20/2022] Open
Abstract
The motoric cognitive risk (MCR) syndrome is a pre-dementia condition, marked by the enhanced risk for Alzheimer's disease (AD) and vascular dementia, together with falls, disability, and abnormal movements. The research studies revealed the distinct neurological and non-neurological clinical gait irregularities during dementia and accelerated functional decline, such as postural and balance impairments, memory loss, cognitive failure, and metabolic dysfunctions. The disabling characteristics of MCR comprise altered afferent sensory and efferent motor responses, together with disrupted visual, vestibular, and proprioceptive components. The pathological basis of MCR relates with the frontal lacunar infarcts, white matter hyperintensity (WMH), gray matter atrophy in the pre-motor and pre-frontal cortex, abnormal cholinergic functioning, inflammatory responses, and genetic factors. Further, cerebrovascular lesions and cardiovascular disorders exacerbate the disease pathology. The diagnosis of MCR is carried out through neuropsychological tests, biomarker assays, imaging studies, questionnaire-based evaluation, and motor function tests, including walking speed, dual-task gait tests, and ambulation ability. Recovery from MCR may include cognitive, physical, and social activities, exercise, diet, nutritional supplements, symptomatic drug treatment, and lifestyle habits that restrict the disease progression. Psychotherapeutic counseling, anti-depressants, and vitamins may support motor and cognitive improvement, primarily through the restorative pathways. However, an in-depth understanding of the association of immobility, dementia, and cognitive stress with MCR requires additional clinical and pre-clinical studies. They may have a significant contribution in reducing MCR syndrome and the risk for dementia. Overall, the current review informs the vital connection between gait performance and cognition in MCR and highlights the usefulness of future research in the discernment and treatment of dementiating illness.
Collapse
|
12
|
Shah R, Raji MA, Westra J, Kuo YF. Association of co-prescribing of opioid and benzodiazepine substitutes with incident falls and fractures among older adults: a cohort study. BMJ Open 2021; 11:e052057. [PMID: 35476819 PMCID: PMC8719209 DOI: 10.1136/bmjopen-2021-052057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 12/13/2021] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Examine the association between the co-prescribing of opioids, benzodiazepines, gabapentinoids (pregabalin and gabapentin) and selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors (SSRI/SNRIs) in different combinations and the risk of falls and fractures. DESIGN Retrospective cohort study from 2015 to 2018. SETTING Medicare enrolment and claims data. PARTICIPANTS Medicare beneficiaries with both chronic pain and anxiety disorders in 2016 with continuous enrolments in Parts A and B from 2015 to 2016 who were prescribed any combination of opioid, benzodiazepine, gabapentinoid and SSRI/SNRI in 2017 for ≥7 days, as documented in their Medicare Part D coverage. INTERVENTIONS Any combination of use of seven drug regimens (benzodiazepine +opioid; benzodiazepine +gabapentinoid; benzodiazepine +SSRI/SNRI; opioid +gabapentinoid; opioid +SSRI/SNRI; gabapentinoid +SSRI/SNRI; ≥3 drug classes). MAIN OUTCOMES First event of fall and the first event of fracture after the index date, which was the first day of combination drug use that lasted ≥7 days in 2017. RESULTS A total of 47 964 patients (mean [SD] age, 75.9 [7.1]; 78.0% woman) with diagnoses of both chronic pain and anxiety were studied. The median (Q1-Q3) duration of drug combination use was 26 (14-30) days. After adjusting for demographic characteristics, chronic conditions and history of hospitalisation and fall or fracture, the co-prescribing of ≥3 drugs (adjusted HR [aHR], 1.38; 95% CI 1.14 to 1.67) and opioid plus gabapentinoid (aHR, 1.18; 95% CI 1.02 to 1.37) were associated with a high fall risk, compared with benzodiazepineplus opioid co-prescribing, findings consistent with the secondary analysis using inverse probability of treatment weighting with propensity scores. The co-prescribing of benzodiazepine plus gabapentinoid (aHR, 0.76; 95% CI 0.59 to 0.98) was associated with lower fracture risk compared with the co-prescribing of benzodiazepine plus opioid, though this finding was not robust. CONCLUSIONS Our findings add to comparative toxicity research on different combinations of gabapentinoids and serotonergic agents commonly prescribed with or as substitutes for opioids and benzodiazepines in patients with co-occurring chronic pain and anxiety.
Collapse
Affiliation(s)
- Rahul Shah
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mukaila A Raji
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Sealy Center on Aging, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Jordan Westra
- Office of Biostatistics, Department of Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Yong-Fang Kuo
- Sealy Center on Aging, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| |
Collapse
|
13
|
Winkler SL, Urbisci AE, Best TM. Sustained acoustic medicine for the treatment of musculoskeletal injuries: a systematic review and meta-analysis. BMC Sports Sci Med Rehabil 2021; 13:159. [PMID: 34922606 PMCID: PMC8684070 DOI: 10.1186/s13102-021-00383-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/18/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Musculoskeletal injuries account for 10 million work-limited days per year and often lead to both acute and/or chronic pain, and increased chances of re-injury or permanent disability. Conservative treatment options include various modalities, nonsteroidal anti-inflammatory drugs, and physical rehabilitation programs. Sustained Acoustic Medicine is an emerging prescription home-use mechanotransductive device to stimulate cellular proliferation, increase microstreaming and cavitation in situ, and to increase tissue profusion and permeability. This research aims to summarize the clinical evidence on Sustained Acoustic Medicine and measurable outcomes in the literature. METHODS A systematic literature review was conducted using PubMed, EBSCOhost, Academic Search Complete, Google Scholar and ClinicalTrials.gov to identify studies evaluating the effects of Sustained Acoustic Medicine on the musculoskeletal system of humans. Articles identified were selected based on inclusion criteria and scored on the Downs and Black checklist. Study design, clinical outcomes and primary findings were extracted from included studies for synthesis and meta-analysis statistics. RESULTS A total of three hundred and seventy-two participants (372) were included in the thirteen clinical research studies reviewed including five (5) level I, four (4) level II and four (4) level IV studies. Sixty-seven (67) participants with neck and back myofascial pain and injury, one hundred and fifty-six (156) participants with moderate to severe knee pain and radiographically confirmed knee osteoarthritis (Kellgren-Lawrence grade II/III), and one hundred forty-nine (149) participants with generalized soft-tissue injury of the elbow, shoulder, back and ankle with limited function. Primary outcomes included daily change in pain intensity, change in Western Ontario McMaster Osteoarthritis Questionnaire, change in Global Rate of Change, and functional outcome measures including dynamometry, grip strength, range-of-motion, and diathermic heating (temperature measurement). CONCLUSION Sustained Acoustic Medicine treatment provides tissue heating and tissue recovery, improved patient function and reduction of pain. When patients failed to respond to physical therapy, Sustained Acoustic Medicine proved to be a useful adjunct to facilitate healing and return to work. As a non-invasive and non-narcotic treatment option with an excellent safety profile, Sustained Acoustic Medicine may be considered a good therapeutic option for practitioners.
Collapse
Affiliation(s)
| | | | - Thomas M Best
- UHealth Sports Medicine Institute, University of Miami, Coral Gables, FL, USA.
| |
Collapse
|
14
|
Yang BR, Lee E, Hwang BS, Lee SH, Kang YJ, Jung SY. Risk of fracture in antidepressant users with concurrent use of benzodiazepines: A self-controlled case-series analysis. Bone 2021; 153:116109. [PMID: 34252602 DOI: 10.1016/j.bone.2021.116109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Despite the fracture risk associated with both antidepressant (AD) medication and benzodiazepines (BDZs), they are commonly prescribed simultaneously. However, studies elucidating the effects of concurrent use of BDZs and ADs on the risk fracture are scant. The objective of this study was to evaluate the risk of fracture associated with concurrent use of BDZs in AD users, using a self-controlled case-series analysis. METHODS A self-controlled case-series analysis, in which the participants act as their own control, was conducted using the Korean National Health Insurance Service-National Sample Cohort database (2002-2015). We studied AD users who were prescribed BDZs and diagnosed with a fracture. The risk periods were subdivided into consecutive periods (1-30, 31-60, and > 60 days) after receiving a BDZ. A 2-week pre-exposure period and a 2-week post-exposure period were also included. The incidence rate ratio (IRR) was estimated after adjusting for age and use of co-medications. RESULTS A total of 3020 patients were identified during the study period. There was an increased fracture risk in the first 30 days following BDZ use (IRR: 1.88, 95% confidence interval [CI] 1.66-2.12), in the 31-60-day period (1.73, 95% CI 1.48-2.02), and beyond the 60-day period (IRR: 1.68, 95% CI 1.47-1.91). The risks of fracture were greater in men and older patients. CONCLUSION The concomitant use of BDZs and ADs was related to a significant increase in fracture risk. AD users should be aware of the fracture risk with concomitant BDZ use, especially for first-time BDZ users and for elderly patients.
Collapse
Affiliation(s)
- Bo Ram Yang
- College of Pharmacy, Chungnam National University, Daejeon, Republic of Korea
| | - Eunchae Lee
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Beom Seuk Hwang
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Sung Hoon Lee
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Ye-Jin Kang
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea; Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea.
| |
Collapse
|
15
|
Batteux B, Bennis Y, Bodeau S, Masmoudi K, Hurtel-Lemaire AS, Kamel S, Gras-Champel V, Liabeuf S. Associations between osteoporosis and drug exposure: A post-marketing study of the World Health Organization pharmacovigilance database (VigiBase®). Bone 2021; 153:116137. [PMID: 34343739 DOI: 10.1016/j.bone.2021.116137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/13/2021] [Accepted: 07/28/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Bone remodeling is a complex process, and many conditions (including drug exposure) lead to osteoporosis. Here, we sought to detect new disproportionality signals for drugs associated with osteoporosis. METHODS We performed a disproportionality analysis of the World Health Organization's VigiBase® pharmacovigilance database through April 12, 2020. The frequency of reports on osteoporosis for all identified drug classes was compared with that for all other drugs and quoted as the reporting odds ratio (ROR) [95% confidence interval (CI)]. RESULTS Of the 7,594,968 cases spontaneously recorded to VigiBase®, 4758 concerned osteoporosis. New disproportionality signals with a pharmacologically plausible mechanism were found for drugs used in neurology (levodopa (ROR [95%CI]: 10.18 [4.33-25.10]), selective serotonin agonists (4.22 [2.34-7.00]) and memantine (4.10 [1.56-8.93])), hematology (romiplostim (4.93 [1.15-21.10])), pulmonology (macitentan (3.02 [1.84-4.90])), ophthalmology (ranibizumab (3.31 [1.00-10.51])) and rheumatology (tofacitinib (3.65 [3.00-4.40])). The robustness of these new results is supported by the significant RORs for the vast majority of drugs already known to induce osteoporosis and/or increase the fracture risk, namely glucocorticoids, gonadotropin-releasing hormone analogs, anti-aromatases, androgen receptor blockers, thyroid hormones, proton pump inhibitors, thiazolidinediones, vitamin K antagonists, loop diuretics, protease inhibitors, nucleoside and nucleotide reverse transcriptase inhibitors, and enzyme-inducing antiepileptics including barbiturates and derivatives, hydantoin derivatives, carboxamide derivatives and fatty acid derivatives. CONCLUSION We established up a comprehensive list of drugs potentially associated with osteoporosis and highlighted those with pharmacologically plausible mechanisms leading to bone fragility. Our results might pave the way for additional exploration of these mechanisms.
Collapse
Affiliation(s)
- Benjamin Batteux
- Department of Pharmacology, Amiens University Medical Center, F-80054 Amiens, France; Department of Rheumatology, Saint-Quentin Medical Center, F-02321 Saint-Quentin, France; MP3CV Laboratory, EA7517, Jules Verne University of Picardie, F-80054 Amiens, France; RECIF, Amiens-Picardie University Medical Center, F-80054 Amiens, France.
| | - Youssef Bennis
- Department of Pharmacology, Amiens University Medical Center, F-80054 Amiens, France; MP3CV Laboratory, EA7517, Jules Verne University of Picardie, F-80054 Amiens, France
| | - Sandra Bodeau
- Department of Pharmacology, Amiens University Medical Center, F-80054 Amiens, France; MP3CV Laboratory, EA7517, Jules Verne University of Picardie, F-80054 Amiens, France
| | - Kamel Masmoudi
- Department of Pharmacology, Amiens University Medical Center, F-80054 Amiens, France
| | | | - Said Kamel
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, F-80054 Amiens, France; Biochemistry Laboratory, Amiens University Medical Center, F-80000 Amiens, France
| | - Valérie Gras-Champel
- Department of Pharmacology, Amiens University Medical Center, F-80054 Amiens, France; MP3CV Laboratory, EA7517, Jules Verne University of Picardie, F-80054 Amiens, France
| | - Sophie Liabeuf
- Department of Pharmacology, Amiens University Medical Center, F-80054 Amiens, France; MP3CV Laboratory, EA7517, Jules Verne University of Picardie, F-80054 Amiens, France
| |
Collapse
|
16
|
The Effects of Osteoporotic and Non-osteoporotic Medications on Fracture Risk and Bone Mineral Density. Drugs 2021; 81:1831-1858. [PMID: 34724173 PMCID: PMC8578161 DOI: 10.1007/s40265-021-01625-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 12/26/2022]
Abstract
Osteoporosis is a highly prevalent bone disease affecting more than 37.5 million individuals in the European Union (EU) and the United States of America (USA). It is characterized by low bone mineral density (BMD), impaired bone quality, and loss of structural and biomechanical properties, resulting in reduced bone strength. An increase in morbidity and mortality is seen in patients with osteoporosis, caused by the approximately 3.5 million new osteoporotic fractures occurring every year in the EU. Currently, different medications are available for the treatment of osteoporosis, including anti-resorptive and osteoanabolic medications. Bisphosphonates, which belong to the anti-resorptive medications, are the standard treatment for osteoporosis based on their positive effects on bone, long-term experience, and low costs. However, not only medications used for the treatment of osteoporosis can affect bone: several other medications are suggested to have an effect on bone as well, especially on fracture risk and BMD. Knowledge about the positive and negative effects of different medications on both fracture risk and BMD is important, as it can contribute to an improvement in osteoporosis prevention and treatment in general, and, even more importantly, to the individual's health. In this review, we therefore discuss the effects of both osteoporotic and non-osteoporotic medications on fracture risk and BMD. In addition, we discuss the underlying mechanisms of action.
Collapse
|
17
|
Herrera AV, Wastila L, Brown JP, Chen H, Gambert SR, Albrecht JS. Effects of Prescription Opioid Use on Traumatic Brain Injury Risk in Older Adults. J Head Trauma Rehabil 2021; 36:388-395. [PMID: 34489389 PMCID: PMC8428555 DOI: 10.1097/htr.0000000000000716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to estimate the risk of traumatic brain injury (TBI) associated with opioid use among older adult Medicare beneficiaries. SETTING Five percent sample of Medicare administrative claims obtained for years 2011-2015. PARTICIPANTS A total of 50 873 community-dwelling beneficiaries 65 years and older who sustained TBI. DESIGN Case-crossover study comparing opioid use in the 7 days prior to TBI with the control periods of 3, 6, and 9 months prior to TBI. MAIN MEASURES TBI cases were identified using ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Classification of Diseases, Tenth Revision) codes. Prescription opioid exposure and concomitant nonopioid fall risk-increasing drug (FRID) use were determined by examining the prescription drug event file. RESULTS The 8257 opioid users (16.2%) were significantly younger (mean age 79.0 vs 80.8 years, P < .001). Relative to nonusers, opioid users were more likely to be women (77.0% vs 70.0%, P < .001) with a Charlson Comorbidity Index of 2 or more (43.7% vs 30.9%, P < .001) and higher concomitant FRID use (94.0% vs 82.7%, P < .001). Prescription opioid use independently increased the risk of TBI compared with nonusers (OR = 1.34; 95% CI, 1.28-1.40). In direct comparisons, we did not observe evidence of a significant difference in adjusted TBI risk between high- (≥90 morphine milligram equivalents) and standard-dose opioid prescriptions (OR = 1.01; 95% CI, 0.90-1.14) or between acute and chronic (≥90 days) opioid prescriptions (OR = 0.93; 95% CI, 0.84-1.02). CONCLUSIONS Among older adult Medicare beneficiaries, prescription opioid use independently increased risk for TBI compared with nonusers after adjusting for concomitant FRID use. We found no significant difference in adjusted TBI risk between high-dose and standard-dose opioid use, nor did we find a significant difference in adjusted TBI risk between acute and chronic opioid use. This analysis can inform prescribing of opioids to community-dwelling older adults for pain management.
Collapse
Affiliation(s)
- Anthony V Herrera
- Departments of Epidemiology and Public Health (Mr Herrera and Drs Brown, Chen, and Albrecht) and Medicine (Dr Gambert), School of Medicine, and Department of Pharmaceutical Health Services Research, School of Pharmacy (Dr Wastila), University of Maryland, Baltimore
| | | | | | | | | | | |
Collapse
|
18
|
Moran KM, Calip GS, Lee TA, Koronkowski MJ, Lau DT, Schumock GT. Risk of fall-related injury and all-cause hospitalization of select concomitant central nervous system medication prescribing in older adult persistent opioid users: A case-time-control analysis. Pharmacotherapy 2021; 41:733-742. [PMID: 34328644 DOI: 10.1002/phar.2612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Concomitant use of central nervous system (CNS) medications frequently occurs in older adults with persistent opioid use. The risks of adverse outcomes associated with combinations of opioids, sedative hypnotics, or skeletal muscle relaxants have not been sufficiently described in this population. OBJECTIVE To compare the overall and incremental risk of (1) fall-related injury and (2) all-cause hospitalization associated with sedative hypnotics and skeletal muscle relaxants among older persistent opioid users. METHODS A case-time-control study was conducted using administrative claims of adults ages ≥66 years with a history of persistent (≥90 days) opioid use. Cases included those with first (1) emergency department, hospital, or outpatient visit for a fall-related injury, or (2) all-cause hospitalization. Exposure to CNS medications prior to the case event versus earlier periods, and the risk associated with CNS drug class combinations and sequence of use, was estimated using conditional logistic regression, adjusted for time trends and time-varying covariates. RESULTS Among 140,101 older persistent opioid users, 20,723 experienced fall-related injury and 39,444 were hospitalized during follow-up. Skeletal muscle relaxant use was associated with an increased risk of fall-related injury (Odds ratio [OR] 1.28) and all-cause hospitalization (OR 1.11). Statistically significant associations were observed for the joint effects of interactions involving skeletal muscle relaxants on fall-related injury (with opioid: OR 1.25; with sedative hypnotic: OR 1.24), and interactions involving opioids on all-cause hospitalization (with sedative hypnotic: OR 1.10; with skeletal muscle relaxant: OR 1.17). The addition of a skeletal muscle relaxant to an opioid regimen was associated with a 25% increased risk of fall-related injury. Additions of other CNS medications did not have apparent incremental effects on the risk of all-cause hospitalization. CONCLUSION The excess risks of fall-related injury and hospitalization associated with various combinations of CNS medications among older persistent opioid users should be considered in therapeutic decision making. Further research is needed to confirm these findings.
Collapse
Affiliation(s)
- Kellyn M Moran
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
- Takeda Pharmaceutical Company Limited, Lexington, Massachusetts, USA
| | - Gregory S Calip
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
- Flatiron Health, New York, New York, USA
| | - Todd A Lee
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Michael J Koronkowski
- College of Pharmacy, Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Denys T Lau
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
- National Committee for Quality Assurance, Washington, District of Columbia, USA
| | - Glen T Schumock
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
| |
Collapse
|
19
|
Kang YJ, Lee MT, Kim MS, You SH, Lee JE, Eom JH, Jung SY. Risk of Fractures in Older Adults with Chronic Non-cancer Pain Receiving Concurrent Benzodiazepines and Opioids: A Nested Case-Control Study. Drugs Aging 2021; 38:687-695. [PMID: 34159565 DOI: 10.1007/s40266-021-00872-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between the concurrent use of benzodiazepines and opioids and the risk of fractures in older patients with chronic non-cancer pain. METHODS Patients with osteoarthritis or low back pain (≥ 65 years of age) included in the Korean National Health Insurance Service-National Sample Cohort database of Korea and with an incident diagnosis of hip, humeral, or forearm fracture between 2011 and 2015 were identified as cases. For each case, four controls were matched for age (within 5 years), sex, and year of cohort entry. We estimated the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for fractures associated with concurrent use of benzodiazepines and opioids using a conditional logistic regression analysis, adjusting for comorbidities and comedications. RESULTS The aOR (95% CI) for the concurrent use of benzodiazepines and opioids was 1.45 (1.22-1.71), compared with those of non-use within 30 days before the index date. The aOR was 1.65 (1.22-2.23) in patients who were continuously receiving benzodiazepines and were newly initiated with concurrent opioids. The aORs for concurrent use were 1.95 (1.39-2.74) and 1.27 (1.03-1.56) in the case of hip fracture and forearm fracture, respectively. CONCLUSION The concurrent use of benzodiazepines and opioids was associated with an increased risk of fractures in older patients with chronic non-cancer pain. Therefore, patients continuously receiving benzodiazepines in whom opioids are newly initiated need careful monitoring, and such combined therapy should be limited to the shortest duration possible.
Collapse
Affiliation(s)
- Ye-Jin Kang
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Min-Taek Lee
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Myo-Song Kim
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Seung-Hun You
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Jae-Eun Lee
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Joo-Hyeon Eom
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Sun-Young Jung
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Seoul, Republic of Korea.
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea.
| |
Collapse
|
20
|
Houghton R, van den Bergh J, Law K, Liu Y, de Vries F. Risperidone versus aripiprazole fracture risk in children and adolescents with autism spectrum disorders. Autism Res 2021; 14:1800-1814. [PMID: 34080319 DOI: 10.1002/aur.2541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 04/26/2021] [Accepted: 05/03/2021] [Indexed: 12/19/2022]
Abstract
Risperidone and aripiprazole, commonly used antipsychotics in children with autism spectrum disorder (ASD), have previously been associated with elevated fracture risk in other populations. The aim of this study was to evaluate and compare the risk of fracture among children with ASD using risperidone or aripiprazole. This was a retrospective, propensity-score matched cohort study, set between January 2013 and December 2018. We used the MarketScan Medicaid insurance data, which covers multiple states of the United States. We included ASD children aged 2-18 years, who were new users of aripiprazole or risperidone and with no prior history of antipsychotic use or fractures. The main exposure was the continued use of aripiprazole or risperidone. The incidence rates of any fracture during follow-up were evaluated, and the risk between aripiprazole and risperidone was compared via Cox-proportional hazard models. Results were stratified by age, sex, duration of exposure and fracture site. In total, 3312 patients (78% male; mean [SD] age 11.0 [3.7] years) were identified for each cohort. Over the full duration of follow-up, fracture incidence rates per 1000 patient-years were 23.2 for risperidone and 38.4 for aripiprazole (hazard ratio and 95% confidence interval: 0.60 [0.44-0.83]). Risks were similar between cohorts throughout the first 180 days on treatment, but significantly higher in the aripiprazole group thereafter. Extremity fractures drove most of the increased risk, with the biggest differences in lower leg and ankle fractures. Differences widened for children aged 10 years or younger (HR [95% CI]: 0.47 [0.30-0.74]). In conclusion, compared to aripiprazole, risperidone was associated with 40% lower risk of fracture. Further analysis on the mechanism and long-term bone health of antipsychotic-treated children with ASD is warranted. LAY SUMMARY: We compared the risk of bone fractures among 6624 children with autism spectrum disorder (ASD), half of whom used risperidone and half of whom used aripiprazole. Taking other factors into account, risks were similar between the two groups throughout the first 180 days on treatment, but significantly higher in the aripiprazole group thereafter. The biggest differences were in lower leg and ankle fractures. Overall, compared with aripiprazole, risperidone was associated with 40% lower risk of fracture.
Collapse
Affiliation(s)
- Richard Houghton
- Personalized Health Care Data Science, F. Hoffmann-La Roche Ltd, Basel, Switzerland.,Department of Clinical Pharmacy and Toxicology, Maastricht UMC+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Joop van den Bergh
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht UMC+, Maastricht, the Netherlands.,Department of Internal Medicine, VieCuri Medical Center, Venlo, the Netherlands.,Faculty of medicine, Hasselt University, Hasselt, Belgium
| | - Kiely Law
- Kennedy Krieger Institute, Interactive Autism Network, Baltimore, Maryland, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yutong Liu
- Genesis Research, Real World Evidence Solutions, Hoboken, New Jersey, USA
| | - Frank de Vries
- Department of Clinical Pharmacy and Toxicology, Maastricht UMC+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
21
|
Yoshikawa A, Ramirez G, Smith ML, Foster M, Nabil AK, Jani SN, Ory MG. Opioid Use and the Risk of Falls, Fall Injuries and Fractures among Older Adults: A Systematic Review and Meta-Analysis. J Gerontol A Biol Sci Med Sci 2021; 75:1989-1995. [PMID: 32016284 DOI: 10.1093/gerona/glaa038] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is increasing concern about opioid use as a pain treatment option among older adults. Existing literature implies an association between opioid use and fracture, increasing the risk of death and disabilities; yet, this relationship with other fall-related outcomes has not been fully explored. We performed a meta-analysis to evaluate the associations between opioid use and adverse health outcomes of falls, fall injuries, and fractures among older adults. METHODS A systematic literature search was conducted using nine databases: Medline, Embase, CINAHL, PsycInfo, Global Health, Northern Light Sciences Conference Abstracts, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We log-transformed effect sizes (relative risk [RR], odds ratio [OR], and hazard ratio [HR]) to compute pooled risk estimates comparable across the studies. The random-effects model was applied to calculate the pooled risk estimates due to heterogeneity. Meta-regressions explored differences in risk estimates by analysis method, study design, setting, and study quality. RESULTS Thirty studies, providing 34 relevant effect sizes, met the inclusion criteria for this meta-analysis. Overall, opioid use was significantly associated with falls, fall injuries, and fractures, with effect sizes ranging from 0.15 to 0.71. In meta-regressions, no selected factors explained heterogeneity. CONCLUSION While heterogeneity is present, results suggest an increased risk of falls, fall injuries, and fractures among older adults who used opioids. Findings highlight the need for opioid education and nonopioid-related pain management interventions among older adults to decrease fall-related risk.
Collapse
Affiliation(s)
- Aya Yoshikawa
- Center for Population Health and Aging, Texas A&M University, College Station
| | - Gilbert Ramirez
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station
| | - Matthew Lee Smith
- Center for Population Health and Aging, Texas A&M University, College Station.,Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station.,Department of Health Promotion and Behavior, College of Public Health, The University of Georgia, Athens
| | - Margaret Foster
- Medical Sciences Library, Texas A&M University, College Station
| | - Anas K Nabil
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station
| | - Sagar N Jani
- Center for Population Health and Aging, Texas A&M University, College Station.,Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station
| | - Marcia G Ory
- Center for Population Health and Aging, Texas A&M University, College Station.,Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station
| |
Collapse
|
22
|
El-Tallawy SN, Nalamasu R, Salem GI, LeQuang JAK, Pergolizzi JV, Christo PJ. Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain. Pain Ther 2021; 10:181-209. [PMID: 33575952 PMCID: PMC8119532 DOI: 10.1007/s40122-021-00235-2] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/09/2021] [Indexed: 12/28/2022] Open
Abstract
Musculoskeletal pain is a challenging condition for both patients and physicians. Many adults have experienced one or more episodes of musculoskeletal pain at some time of their lives, regardless of age, gender, or economic status. It affects approximately 47% of the general population. Of those, about 39–45% have long-lasting problems that require medical consultation. Inadequately managed musculoskeletal pain can adversely affect quality of life and impose significant socioeconomic problems. This manuscript presents a comprehensive review of the management of chronic musculoskeletal pain. It briefly explores the background, classifications, patient assessments, and different tools for management according to the recently available evidence. Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of musculoskeletal pain. Both pharmacological, non-pharmacological, as well as interventional pain therapy are important to enhance patient’s recovery, well-being, and improve quality of life. Accordingly, recent guidelines recommend the implementation of preventative strategies and physical tools first to minimize the use of medications. In patients who have had an inadequate response to pharmacotherapy, the proper use of interventional pain therapy and the other alternative techniques are vital for safe and effective management of chronic pain patients.
Collapse
Affiliation(s)
- Salah N El-Tallawy
- Anesthesia and Pain Management Department, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia. .,Faculty of Medicine, Minia University and NCI, Cairo University, Cairo, Egypt.
| | - Rohit Nalamasu
- Department of Physical Medicine and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
| | - Gehan I Salem
- Rheumatology, Rehabilitation and Physical Medicine Department, Assiut University Hospital, Assiut, Egypt.,Rehabilitation Medicine Department, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | | | | | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
23
|
Ohara E, Bando Y, Yoshida T, Ohara M, Kirino Y, Iihara N. Fracture risk increased by concurrent use of central nervous system agents in older people: Nationwide case-crossover study. Res Social Adm Pharm 2020; 17:1181-1197. [PMID: 32980237 DOI: 10.1016/j.sapharm.2020.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Multiple medication use among older patients is reported to increase fracture risk. But this association is unclear in different subgroups and has not been confirmed by a case-crossover study, which can eliminate measurable and unmeasurable time-invariant confounders. OBJECTIVE To estimate the fragility fracture risk associated with concurrent use of multiple central nervous system (CNS) agents in older patients using a case-crossover design. METHODS This study targeted almost all patients aged ≥65 years in Japan who incurred fragility fractures from May 2013 to September 2014, based on the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB Japan). Conditional logistic regression analysis estimated the risk of fragility fracture associated with the daily number of CNS agents, including subgroup analyses stratified by sex, age, and fracture location. RESULTS For 446,101 patients, the adjusted odds ratios (ORs) of fragility fracture increased almost linearly with number of CNS agents; 0, 0-1, 1-2, 2-3, 3-4, 4-5, and >5: OR reference, 1.21 (95% confidence interval, 1.18-1.23), 1.40 (1.35-1.46), 1.58 (1.49-1.67), 1.89 (1.74-2.05), 1.80 (1.60-2.03), and 1.90 (1.61-2.23; trend p < 0.001), respectively. A similar trend was observed for several subgroups, especially in males and those aged ≥85 years, showing marked linearity. CONCLUSIONS The increased risk of fragility fracture associated with the use of multiple CNS agents was robust in older people in Japan.
Collapse
Affiliation(s)
- Eri Ohara
- Kagawa School of Pharmaceutical Sciences, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
| | - Yoshinori Bando
- Faculty of Health and Welfare, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
| | - Tomoji Yoshida
- Faculty of Health and Welfare, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
| | - Masaki Ohara
- Ayagawa National Health Insurance Sue Hospital, 1720-1 Ayagawa-cho, Ayauta-gun, Kagawa, 761-2103, Japan.
| | - Yutaka Kirino
- Kagawa School of Pharmaceutical Sciences, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
| | - Naomi Iihara
- Kagawa School of Pharmaceutical Sciences, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
| |
Collapse
|
24
|
Bushnell GA, Gerhard T, Crystal S, Olfson M. Benzodiazepine Treatment and Fracture Risk in Young Persons With Anxiety Disorders. Pediatrics 2020; 146:peds.2019-3478. [PMID: 32499386 PMCID: PMC7329250 DOI: 10.1542/peds.2019-3478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Benzodiazepines are commonly prescribed to treat anxiety disorders and have been associated with falls and fractures in older adults. It is unknown whether benzodiazepines increase fracture risk in youth. We examined whether youth with anxiety disorders initiating benzodiazepine treatment have an increased risk of fractures compared with youth initiating selective serotonin reuptake inhibitors (SSRIs). METHODS We used claims from commercially insured children (6-17 years) and young adults (18-24) with a recent anxiety disorder diagnosis, initiating benzodiazepines or SSRIs (2008-2016). Youth were followed until fracture, treatment discontinuation or switching, disenrollment, 3 months, or December 31, 2016. The primary end point was diagnostic codes for upper and lower limb fractures. Incident fracture rates, incident rate ratios (IRRs), and incident rate differences (IRDs) were estimated with propensity score inverse probability of treatment weighting. RESULTS The cohort included 120 715 children and 179 768 young adults. In children, crude fracture rates during treatment were 33.1 per 1000 person-years (PYs) for benzodiazepine initiators and 25.1 per 1000 PYs for SSRI initiators. Adjusted IRR and IRD were 1.53 (95% confidence interval [CI]: 0.94-2.50) and 13.4 per 1000 PYs. Risk was heightened in children initiating long-acting benzodiazepines versus SSRIs (adjusted IRR = 2.30 [95% CI: 1.08-4.91]). Fracture rates were lower in young adults, with minimal differences between treatments (adjusted IRR = 0.85 [95% CI: 0.57-1.27]; adjusted IRD = -1.3 per 1000 PYs). CONCLUSIONS An increased rate of fractures in children, but not young adults, with anxiety disorders initiating benzodiazepine treatment compared to SSRI treatment suggests a need for increased caution in the weeks after benzodiazepine initiation in children.
Collapse
Affiliation(s)
| | - Tobias Gerhard
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey,Center for Pharmacoepidemiology and Treatment Science, Rutgers, The State University of New Jersey, New Brunswick, New Jersey,Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey
| | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health and,Department of Psychiatry, Columbia University Irving Medical Center, Columbia University, New York, New York; and
| |
Collapse
|
25
|
Jhamb M, Tucker L, Liebschutz J. When ESKD complicates the management of pain. Semin Dial 2020; 33:286-296. [PMID: 32367543 DOI: 10.1111/sdi.12881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/08/2020] [Indexed: 12/12/2022]
Abstract
Pain is one of the most common symptoms reported by patients with end-stage kidney disease (ESKD) and negatively impacts their health-related quality of life (HRQOL), dialysis adherence, healthcare utilization, and mortality. There are a number of patient-related and health system-related barriers that make it very challenging to treat pain in these patients. Moreover, the limited availability of efficacious and safe nonopiate analgesic options has led to over-use of opioids in this population. We propose a framework for pain assessment and tailored treatment using nonpharmacological and pharmacological approaches to optimize pain management and opioid use. Additionally, we recommend system-level changes to improve care coordination and pain management in ESKD patients.
Collapse
Affiliation(s)
- Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Laura Tucker
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jane Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
26
|
Tamblyn R, Bates DW, Buckeridge DL, Dixon WG, Girard N, Haas JS, Habib B, Iqbal U, Li J, Sheppard T. Multinational Investigation of Fracture Risk with Antidepressant Use by Class, Drug, and Indication. J Am Geriatr Soc 2020; 68:1494-1503. [PMID: 32181493 PMCID: PMC7383967 DOI: 10.1111/jgs.16404] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Antidepressants increase the risk of falls and fracture in older adults. However, risk estimates vary considerably even in comparable populations, limiting the usefulness of current evidence for clinical decision making. Our aim was to apply a common protocol to cohorts of older antidepressant users in multiple jurisdictions to estimate fracture risk associated with different antidepressant classes, drugs, doses, and potential treatment indications. DESIGN Retrospective (2009–2014) cohort study. SETTING Five jurisdictions in the United States, Canada, United Kingdom, and Taiwan. PARTICIPANTS Older antidepressant users—subjects were followed from first antidepressant prescription or dispensation to first fracture or until the end of follow‐up. MEASUREMENTS The risk of fractures with antidepressants was estimated by multivariable Cox proportional hazards models using time‐varying measures of antidepressant dose and use vs nonuse, adjusting for patient characteristics. RESULTS Between 42.9% and 55.6% of study cohorts were 75 years and older, and 29.3% to 45.4% were men. Selective serotonin reuptake inhibitors (SSRIs) (48.4%‐60.0%) were the predominant class used in North America compared with tricyclic antidepressants (TCAs) in the United Kingdom and Taiwan (49.6%‐53.6%). Fracture rates varied from 37.67 to 107.18 per 1,000. The SSRIs citalopram (hazard ratio [HR] = 1.23; 95% confidence interval [CI] = 1.11‐1.36 to HR = 1.43; 95% CI = 1.11‐1.84) and sertraline (HR = 1.36; 95% CI = 1.10‐1.68), the SNRI duloxetine (HR = 1.41; 95% CI = 1.06‐1.88), TCAs doxepin (HR = 1.36; 95% CI = 1.00‐1.86) and imipramine (HR = 1.16; 95% CI = 1.05‐1.28), and atypicals (HR = 1.34; 95% CI = 1.14‐1.58) increased fracture risk in some but not all jurisdictions. In the United States and the United Kingdom, fracture risk with all classes was higher when prescribed for depression than chronic pain, a trend that is likely explained by drug choice. CONCLUSION The fracture risk for patients may be reduced by selecting paroxetine, an SSRI with lower risk than citalopram, the SNRI venlafaxine over duloxetine, and the TCA amitriptyline over imipramine or doxepin. There is uncertainty about the risk associated with the atypical antidepressants. J Am Geriatr Soc 68:1494‐1503, 2020.
Collapse
Affiliation(s)
- Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada.,Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | | | - David L Buckeridge
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | - William G Dixon
- Centre for Epidemiology versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Nadyne Girard
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | | | - Bettina Habib
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | - Usman Iqbal
- International Center for Health Information Technology (ICHIT), Taipei Medical University, Taipei, Taiwan.,Master's Program in Global Health and Development, PhD Program in Global Health and Health Security, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Jack Li
- International Center for Health Information Technology (ICHIT), Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Biomedical Informatics, College of Medicine Science and Technology, Taipei Medical University, Taipei, Taiwan.,Department of Dermatology, Taipei Wanfang Hospital, Taipei, Taiwan
| | - Therese Sheppard
- Centre for Epidemiology versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| |
Collapse
|
27
|
Fountas A, Van Uum S, Karavitaki N. Opioid-induced endocrinopathies. Lancet Diabetes Endocrinol 2020; 8:68-80. [PMID: 31624023 DOI: 10.1016/s2213-8587(19)30254-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/15/2019] [Accepted: 06/16/2019] [Indexed: 12/12/2022]
Abstract
The use of opioids is becoming a global epidemic, leading to a rise in the occurrence and recognition of the effects of opioid drugs on the endocrine system. Nonetheless, opioid-induced endocrinopathies still remain underdiagnosed, mainly because of symptom under-reporting by patients and poor clinician awareness. Hypogonadism is the most well recognised consequence of opioid use, but the inhibitory effects of opioid drugs on the hypothalamo-pituitary-adrenal axis and their negative effects on bone health also require attention. Hyperprolactinaemia might be detected in opioid users, but clinically relevant thyroid dysfunction has not been identified. The effects of opioids on other hormones have not been clearly defined. Assessment of gonadal and adrenal function (particularly if high index of clinical suspicion of hypogonadism or hypoadrenalism) and evaluation of bone health are advised in people that use opiods. Discontinuation or reduction of opioid dose and appropriate hormone replacement are the management approaches that should be considered for hypogonadism and hypoadrenalism. Further research is needed to facilitate the development of evidence-based guidelines on the diagnosis and optimal management of opioid-induced endocrinopathies.
Collapse
Affiliation(s)
- Athanasios Fountas
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stan Van Uum
- Department of Medicine, Schulich School of Medicine, Western University, London, OT, Canada
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| |
Collapse
|
28
|
Beneficial effects of anti-RANKL antibody in depression-like phenotype, inflammatory bone markers, and bone mineral density in male susceptible mice after chronic social defeat stress. Behav Brain Res 2019; 379:112397. [PMID: 31790783 DOI: 10.1016/j.bbr.2019.112397] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/19/2022]
Abstract
Multiple lines of evidence suggest a link between depression and osteoporosis in elderly people. Receptor activator of nuclear factor-κB ligand (RANKL) plays a role in the pathology of osteoporosis, and anti-RANKL antibody has been used in the treatment of osteoporosis. In this study, we investigated whether anti-mouse RANKL antibody could attenuate depression-like phenotypes, inflammatory bone markers and bone mineral density (BMD) in male susceptible mice after chronic social defeat stress (CSDS). We measured plasma levels of inflammatory bone markers, including osteoprotegerin (OPG), RANKL, and osteopontin. A single intravenous injection of anti-RANKL (2 mg/kg) elicited rapid antidepressant effects in CSDS susceptible mice. Furthermore, anti-RANKL significantly improved the increased plasma levels of RANKL and decreased OPG/RANKL ratio in CSDS susceptible mice. Moreover, anti-RANKL significantly attenuated the decreased BMD in CSDS susceptible mice. Interestingly, there is a positive correlation between anhedonia-like behavior and OPG/RANKL ratio in mice. These findings demonstrate that anti-RANKL may have beneficial effects in depression-like phenotype and abnormalities in bone functions of CSDS susceptible mice. It is, therefore, likely that anti-human RANKL antibody (i.e., Denosumab) would be a potential therapeutic drug for depression and osteoporosis.
Collapse
|
29
|
Emeny RT, Chang CH, Skinner J, O’Malley AJ, Smith J, Chakraborti G, Rosen CJ, Morden NE. Association of Receiving Multiple, Concurrent Fracture-Associated Drugs With Hip Fracture Risk. JAMA Netw Open 2019; 2:e1915348. [PMID: 31722031 PMCID: PMC6902800 DOI: 10.1001/jamanetworkopen.2019.15348] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
IMPORTANCE Many prescription drugs increase fracture risk, which raises concern for patients receiving 2 or more such drugs concurrently. Logic suggests that risk will increase with each additional drug, but the risk of taking multiple fracture-associated drugs (FADs) is unknown. OBJECTIVE To estimate hip fracture risk associated with concurrent exposure to multiple FADs. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a 20% random sample of Medicare fee-for-service administrative data for age-eligible Medicare beneficiaries from 2004 to 2014. Sex-stratified Cox regression models estimated hip fracture risk associated with current receipt of 1, 2, or 3 or more of 21 FADs and, separately, risk associated with each FAD and 2-way FAD combination vs no FADs. Models included sociodemographic characteristics, comorbidities, and use of non-FAD medications. Analyses began in November 2018 and were completed April 2019. EXPOSURE Receipt of prescription FADs. MAIN OUTCOMES AND MEASURES Hip fracture hospitalization. RESULTS A total of 11.3 million person-years were observed, reflecting 2 646 255 individuals (mean [SD] age, 77.2 [7.3] years, 1 615 613 [61.1%] women, 2 136 585 [80.7%] white, and 219 579 [8.3%] black). Overall, 2 827 284 person-years (25.1%) involved receipt of 1 FAD; 1 322 296 (11.7%), 2 FADs; and 954 506 (8.5%), 3 or more FADs. In fully adjusted, sex-stratified models, an increase in hip fracture risk among women was associated with the receipt of 1, 2, or 3 or more FADs (1 FAD: hazard ratio [HR], 2.04; 95% CI, 1.99-2.11; P < .001; 2 FADs: HR, 2.86; 95% CI, 2.77-2.95; P < .001; ≥3 FADs: HR, 4.50; 95% CI, 4.36-4.65; P < .001). Relative risks for men were slightly higher (1 FAD: HR, 2.23; 95% CI, 2.11-2.36; P < .001; 2 FADs: HR, 3.40; 95% CI, 3.20-3.61; P < .001; ≥3 FADs: HR, 5.18; 95% CI, 4.87-5.52; P < .001). Among women, 2 individual FADs were associated with HRs greater than 3.00; 80 pairs of FADs exceeded this threshold. Common, risky pairs among women included sedative hypnotics plus opioids (HR, 4.90; 95% CI, 3.98-6.02; P < .001), serotonin reuptake inhibitors plus benzodiazepines (HR, 4.50; 95% CI, 3.76-5.38; P < .001), and proton pump inhibitors plus opioids (HR, 4.00; 95% CI, 3.56-4.49; P < .001). Receipt of 1, 2, or 3 or more non-FADs was associated with a small, significant reduction in fracture risk compared with receipt of no non-FADs among women (1 non-FAD: HR, 0.93; 95% CI, 0.90-0.96; P < .001; 2 non-FADs: HR, 0.84; 95% CI, 0.81-0.87; P < .001; ≥3 non-FADs: HR, 0.74; 95% CI, 0.72-0.77; P < .001). CONCLUSIONS AND RELEVANCE Among older adults, FADs are commonly used and commonly combined. In this cohort study, the addition of a second and third FAD was associated with a steep increase in fracture risk. Many risky pairs of FADs included potentially avoidable drugs (eg, sedatives and opioids). If confirmed, these findings suggest that fracture risk could be reduced through tighter adherence to long-established prescribing guidelines and recommendations.
Collapse
Affiliation(s)
- Rebecca T. Emeny
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Chiang-Hua Chang
- Division of Geriatric and Palliative Medicine, Internal Medicine, Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Jeremy Smith
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Gouri Chakraborti
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Clifford J. Rosen
- Center for Clinical and Translational Research, Maine Medical Center Research Institute, Scarborough
| | - Nancy E. Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- now with Microsoft Artificial Intelligence and Research, Healthcare NeXT, Redmond, Washington
| |
Collapse
|
30
|
Trends in opioid use before critical illness among elderly patients in Ontario. J Crit Care 2019; 55:128-133. [PMID: 31715530 DOI: 10.1016/j.jcrc.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 10/11/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess temporal trends in pre-existing opioid exposure prior to hospitalization among elderly intensive care unit (ICU) patients and its association with adverse outcomes. MATERIALS AND METHODS We performed a population-based retrospective cohort study using health administrative data from the province of Ontario, Canada. We included all older adult (> 65 years) admissions to an ICU between April 2002 and March 2015. The exposure was opioid use before admission categorized as chronic use, intermittent use, and non-use. RESULTS The cohort included 711,312 elderly patient admissions to an ICU. Of these, 6.8% (n = 48,363) were chronic opioid users, 28.1% (n = 200,149) intermittent users, and 65.0% (n = 462,800) non-users. Compared with non-users, chronic opioid users and intermittent users had higher in-hospital mortality (adjusted odds ratio: 1.12, 95% CI, 1.09-1.15, p < 0.0001 for chronic users; adjusted odds ratio: 1.09, 95% CI, 1.07-1.11, p < 0.0001 for intermittent users), and a lower subdistribution hazard of time to hospital discharge, translating to a longer hospital length of stay (adjusted hazard ratio: 0.87, 95% CI, 0.85-0.88, p < 0.0001 for chronic users; adjusted hazard ratio: 0.93, 95% CI, 0.92-0.94, p < 0.0001 for intermittent users). CONCLUSIONS Among elderly ICU patients, opioid exposure prior to admission is prevalent and use is associated with higher in-hospital mortality.
Collapse
|
31
|
Westaway K, Blacker N, Shute R, Allin R, Elgebaly Z, Frank O, Pratt N, Roughead E. Combination psychotropic medicine use in older adults and risk of hip fracture. Aust Prescr 2019; 42:93-96. [PMID: 31363307 PMCID: PMC6594851 DOI: 10.18773/austprescr.2019.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Older people might be embarrassed to talk about falling as they worry this may be judged as a loss of their ability to live independently. Ask older patients, at least yearly, if they ever feel unsteady on their feet or if they have fallen Consider whether medicines may be contributing to feelings of unsteadiness or falling. Drugs such as benzodiazepines and selective serotonin reuptake inhibitors, particularly if taken together, are associated with a risk of falling and hip fracture Review the patient’s treatment regimen to see if there are drugs that are no longer required. Psychotropic drugs should usually be tapered gradually so that adverse effects can be minimised Involve a range of health professionals to identify and manage the risk of falls. Help patients stay physically active, independent and socially connected
Collapse
Affiliation(s)
- Kerrie Westaway
- Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) program, Adelaide.,Veterans' MATES Clinical Reference Group, Adelaide.,Drug and Therapeutics Information Service (DATIS), SA Health, Adelaide.,NPS MedicineWise, Sydney.,Oakden Medical Centre, Adelaide.,Discipline of General Practice, University of Adelaide.,Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| | - Natalie Blacker
- Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) program, Adelaide.,Veterans' MATES Clinical Reference Group, Adelaide.,Drug and Therapeutics Information Service (DATIS), SA Health, Adelaide.,NPS MedicineWise, Sydney.,Oakden Medical Centre, Adelaide.,Discipline of General Practice, University of Adelaide.,Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| | - Russell Shute
- Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) program, Adelaide.,Veterans' MATES Clinical Reference Group, Adelaide.,Drug and Therapeutics Information Service (DATIS), SA Health, Adelaide.,NPS MedicineWise, Sydney.,Oakden Medical Centre, Adelaide.,Discipline of General Practice, University of Adelaide.,Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| | - Rosemary Allin
- Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) program, Adelaide.,Veterans' MATES Clinical Reference Group, Adelaide.,Drug and Therapeutics Information Service (DATIS), SA Health, Adelaide.,NPS MedicineWise, Sydney.,Oakden Medical Centre, Adelaide.,Discipline of General Practice, University of Adelaide.,Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| | - Zain Elgebaly
- Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) program, Adelaide.,Veterans' MATES Clinical Reference Group, Adelaide.,Drug and Therapeutics Information Service (DATIS), SA Health, Adelaide.,NPS MedicineWise, Sydney.,Oakden Medical Centre, Adelaide.,Discipline of General Practice, University of Adelaide.,Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| | - Oliver Frank
- Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) program, Adelaide.,Veterans' MATES Clinical Reference Group, Adelaide.,Drug and Therapeutics Information Service (DATIS), SA Health, Adelaide.,NPS MedicineWise, Sydney.,Oakden Medical Centre, Adelaide.,Discipline of General Practice, University of Adelaide.,Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| | - Nicole Pratt
- Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) program, Adelaide.,Veterans' MATES Clinical Reference Group, Adelaide.,Drug and Therapeutics Information Service (DATIS), SA Health, Adelaide.,NPS MedicineWise, Sydney.,Oakden Medical Centre, Adelaide.,Discipline of General Practice, University of Adelaide.,Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| | - Elizabeth Roughead
- Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) program, Adelaide.,Veterans' MATES Clinical Reference Group, Adelaide.,Drug and Therapeutics Information Service (DATIS), SA Health, Adelaide.,NPS MedicineWise, Sydney.,Oakden Medical Centre, Adelaide.,Discipline of General Practice, University of Adelaide.,Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| |
Collapse
|
32
|
Sharma A, Shi Q, Hoover DR, Tien PC, Plankey MW, Cohen MH, Golub ET, Gustafson D, Yin MT. Frailty predicts fractures among women with and at-risk for HIV. AIDS 2019; 33:455-463. [PMID: 30702514 PMCID: PMC6361531 DOI: 10.1097/qad.0000000000002082] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine associations between frailty and fracture in women with and without HIV infection. DESIGN Prospective longitudinal cohort study evaluating associations between baseline frailty status and frailty components, with first and second incident fractures. METHODS We evaluated associations of frailty with fracture among 1332 women with HIV and 532 uninfected women without HIV. Frailty was defined as at least three of five Fried Frailty Index components: slow gait, reduced grip strength, exhaustion, unintentional weight loss, and low physical activity. Cox proportional hazards models determined predictors of time to first and second fracture; similar models evaluated Fried Frailty Index components. RESULTS Women with HIV were older (median 42 vs. 39 years, P < 0.0001) and more often frail (14 vs. 8%, P = 0.04) than women without HIV; median follow-up was 10.6 years. Frailty was independently associated with time to first fracture in women with and without HIV combined [adjusted hazard ratio (aHR) 1.71, 95% confidence interval (CI): 1.30-2.26; P = 0.0001], and among women with HIV only (aHR 1.91, 95% CI: 1.41-2.58; P < 0.0001), as well as with time from first to second fracture among women with HIV (aHR 1.86, 95% CI: 1.15-3.01; P = 0.01). CONCLUSION In this cohort of middle-aged racial and ethnic minority women with or at-risk for HIV, frailty was a strong and independent predictor of fracture risk. As women with HIV continue to age, early frailty screening may be a useful clinical tool to help identify those at greatest risk of fracture.
Collapse
Affiliation(s)
- Anjali Sharma
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Qiuhu Shi
- Department of Epidemiology and Community Health, New York Medical College, Valhalla, NY
| | - Donald R. Hoover
- Department of Statistics and Biostatistics, Rutgers University, Piscataway, NJ
| | - Phyllis C. Tien
- Division of Infectious Diseases, University of California at San Francisco and San Francisco Veterans Affairs Medical Center, CA
| | - Michael W. Plankey
- Department of Medicine, Georgetown University School of Medicine, Washington DC
| | - Mardge H. Cohen
- Departments of Medicine, Stroger (formerly Cook County) Hospital and Rush University
| | - Elizabeth T. Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Deborah Gustafson
- Department of Neurology, State University of New York Downstate Medical Center, Brooklyn, NY
| | - Michael T. Yin
- Division of Infectious Diseases, Columbia University Medical Center, NY, NY
| |
Collapse
|
33
|
Wang YC, Lin HT, Lu ML, Huang MC, Chen CH, Wu TH, Wang S, Mao WC, Kuo PH, Chen HC. The Association Between the Sedative Loads and Clinical Severity Indicators in the First-Onset Major Depressive Disorder. Front Psychiatry 2019; 10:129. [PMID: 30936841 PMCID: PMC6431631 DOI: 10.3389/fpsyt.2019.00129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/22/2019] [Indexed: 12/15/2022] Open
Abstract
Background: High sedative use in a major depressive episode may imply specific clinical features. This study aims to examine the correlation between sedative use and clinical severity indicators in the initial treatment phase of first-onset major depressive disorder. Methods: A study cohort in the first episode of major depressive disorder was used to conduct pharmacological dissection. All participants had at least a 2-year follow-up period with a complete treatment record. The defined daily dose of antidepressants and augmentation agents were calculated as the antidepressant load and augmentation load, respectively. Sedative use, which was calculated as the equivalent dosage of lorazepam, were defined as the sedative load. These psychotropic loads were measured monthly and the averaged psychotropic loads for each day were obtained. Results: A total of 106 individuals (75.5% female) were included. The mean duration of disease course in participants was 5.5 ± 3.5 years. In the multiple regression analysis, after controlling for other classes of psychotropics and comorbid anxiety disorders, the sedative load independently correlated with higher number of antidepressants used, higher number of antidepressant used with an adequate dose and duration, more psychiatric emergency and outpatient visits within 2 years of disease onset. Conclusion: High loading of sedatives correlated with several indicators of clinical severity in major depressive disorder. The sedative load may be used as a specifier to identify subgroups in patients with major depressive disorder.
Collapse
Affiliation(s)
- Yen-Chin Wang
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Hai-Ti Lin
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Mong-Liang Lu
- Department of Psychiatry, Wan-Fang Hospital & School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ming-Chyi Huang
- Department of Psychiatry, Taipei City Hospital, Songde Branch, Taipei, Taiwan
| | - Chun-Hsin Chen
- Department of Psychiatry, Wan-Fang Hospital & School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tzu-Hua Wu
- Department of Clinical Pharmacy, School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Sabrina Wang
- School of Medicine, Institute of Anatomy and Cell Biology, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Chung Mao
- Department of Psychiatry, Cheng-Hsin General Hospital & School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Po-Hsiu Kuo
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsi-Chung Chen
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Center of Sleep Disorders, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
34
|
Munson JC, Bynum JPW, Bell JE, McDonough C, Wang Q, Tosteson T, Tosteson ANA. Impact of prescription drugs on second fragility fractures among US Medicare patients. Osteoporos Int 2018; 29:2771-2779. [PMID: 30232537 PMCID: PMC6277051 DOI: 10.1007/s00198-018-4697-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 09/03/2018] [Indexed: 12/21/2022]
Abstract
UNLABELLED Drugs that increase the risk of fracture are commonly prescribed to survivors of a fragility fracture. This study shows that starting new high-risk medications after fracture increases the risk of a second, potentially preventable fracture. For most drug classes, however, it is safe to continue medications taken before the fracture. INTRODUCTION Most patients who survive a fragility fracture are subsequently exposed to prescription drugs that have been linked to increased fracture risk. This study was designed to quantify the extent to which current prescribing practices result in potentially preventable second fractures. METHODS We analyzed a cohort of 138,526 Medicare beneficiaries who returned to the community after a fragility fracture. Post-fracture drug use was defined using retail pharmacy fills. The risk of second fracture associated with individual drug classes was analyzed using Cox proportional hazard models. Data were further analyzed to determine whether there is a difference in risk between continuing previous therapy and initiating new therapy after fracture. RESULTS Many drug classes previously identified as increasing fracture risk were not associated with increased fracture risk in this cohort. Discontinuing therapy at the time of fracture was only beneficial for patients taking selective serotonin reuptake inhibitors; however, initiating therapy in previous non-users increased second fracture risk for five classes of drugs (selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotics, proton pump inhibitors, and non-benzodiazepine hypnotics). CONCLUSION Discontinuing high-risk drugs after fracture was not generally protective against subsequent fractures. Preventing the addition of new medications may result in greater improvements in post-fracture care.
Collapse
Affiliation(s)
- J C Munson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
- Department of Medicine, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Suite 5C, Lebanon, NH, 03756, USA.
| | - J P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - J-E Bell
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - C McDonough
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Q Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - T Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| |
Collapse
|
35
|
Aljawadi MH, Khoja AT, Alhammad AM, AlOtaibi AD, Al-Shammari SA, Khoja TA. The prevalence of benzodiazepines utilization and its association with falls among Saudi older adults; results from the Saudi national survey for elderly Health (SNSEH). Saudi Pharm J 2018; 26:1112-1119. [PMID: 30532631 PMCID: PMC6260491 DOI: 10.1016/j.jsps.2018.05.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023] Open
Abstract
PURPOSE First, to determine benzodiazepines prevalence (BDZs) among Saudi older adults (SOA); Second, to quantify the association between BDZs use and falls among SOA. Third, to determine falls effect on all-cause mortality among SOA. METHODS This is a cross-sectional study that used the Saudi National Survey for Elderly Health; a nationally-representative, population-based survey. Participants were asked about BDZs use and falls history during the 12 months prior to the interview. Demographics, medications, comorbidities and housing conditions were used as covariates. Multiple imputation was used to impute missing data. Modified poisson multivariable regression was used to study the association between BDZs and falls. Cox- proportional hazard regression was used to determine falls effect on mortality over nine years period. RESULTS Among 2946 SOA, BDZs prevalence was 4%. Around 13% reported falls. In the multivariable regression, relative risk (RR) of falls was 2 comparing BDZs users to non-users (95CI%: 1.02-3.99). Antidepressants (RR = 1.72; 95%CI: 1.10-2.74), laxatives (RR = 1.38; 95%CI: 1.11-1.7), low body mass index (RR = 1.94; 95%CI: 1.33-2.84), mild cognitive impairment (RR = 1.56; 95%CI: 1.21-2.03), high door steps (RR = 1.54; 95%CI: 1.23-1.93) and insufficient illumination (RR = 1.38; 95%CI: 1.11-1.71) increased falls risk. Lastly, the hazard ratio of falls on death was 1.48 (95%CI: 1.17, 1.89) over nine years. CONCLUSION Despite the recommendation against BDZs use among older adults, still there were subjects who were prescribed these drugs. falls are common among SOA. Preventive strategies such medication therapy management, nutrition improvement, elderly-friendly housing structures can reduce the prevalence of falls and consequent increase in mortality among SOA.
Collapse
Affiliation(s)
- Mohammad H. Aljawadi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah T. Khoja
- Public Health and Family Medicine Departments, College of Medicine, Al-Imam Muhammad ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Abdullah M. Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Azzam D. AlOtaibi
- Department of Medicine, College of Medicine, Al-Imam Muhammad ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Sulaiman A. Al-Shammari
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Tawfik A. Khoja
- Executive Board, Health Ministers’ Council for the Cooperation Council States, Saudi Arabia
| |
Collapse
|
36
|
Khanassov V, Hu J, Reeves D, van Marwijk H. Selective serotonin reuptake inhibitor and selective serotonin and norepinephrine reuptake inhibitor use and risk of fractures in adults: A systematic review and meta-analysis. Int J Geriatr Psychiatry 2018; 33:1688-1708. [PMID: 30247774 DOI: 10.1002/gps.4974] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 08/06/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the association between selective serotonin reuptake inhibitor (SSRI) and selective serotonin and norepinephrine reuptake inhibitor (SNRI) use and risk of fractures in older adults. METHODS We systematically identified and analyzed observational studies comparing SSRI/SNRI use for depression with non-SSRI/SNRI use with a primary outcome of risk of fractures in older adults. We searched for studies in MEDLINE, PsycINFO, Embase, DARE (Database of Abstracts or Reviews of Effects), the Cochrane Library, and Web of Science clinical trial research registers from 2011 for SSRIs and 1990 for SNRIs to November 29, 2016. RESULTS Thirty-three studies met our inclusion criteria; 23 studies were included in meta-analysis: 9 case-control studies and 14 cohort studies. A 1.67-fold increase in the risk of fracture for SSRI users compared with nonusers was observed (relative risk 1.67, 95% CI 1.56-1.79, P = .000). The risk of fracture increases with their long-term use: within 1 year, the risk is 2.9% or 1 additional fracture in every 85 users; within 5 years, the risk is 13.4% or 1 additional fracture in every 19 users. In meta-regression, we found that the increase in risk did not differ across age groups (odds ratio = 1.006; P = .173). A limited number of studies on SNRI use and the risk of fractures prevented us from conducting a meta-analysis. CONCLUSIONS Our systematic review showed an association between risk of fracture and the use of SSRIs, especially with increasing use. Age does not increase this risk. No such conclusions can be drawn about the effect of SNRIs on the risk of fracture because of a lack of studies.
Collapse
Affiliation(s)
| | - Jingyi Hu
- University of Manchester, Manchester, UK
| | | | | |
Collapse
|
37
|
van de Ven LI, Klop C, Overbeek JA, de Vries F, Burden AM, Janssen PK. Association between use of antidepressants or benzodiazepines and the risk of subsequent fracture among those aged 65+ in the Netherlands. Osteoporos Int 2018; 29:2477-2485. [PMID: 30112636 PMCID: PMC6208956 DOI: 10.1007/s00198-018-4632-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 07/03/2018] [Indexed: 11/29/2022]
Abstract
UNLABELLED This is the first study to examine the association between antidepressant and benzodiazepine use following a MOF and risk of subsequent fracture in those 65+. Using national data, drug use following MOF showed that the 1-year fully adjusted risk of subsequent MOF in those on antidepressants was more than doubled. INTRODUCTION We evaluated the association between the use of antidepressants or benzodiazepines and the risk of a subsequent major osteoporotic fracture. METHODS A cohort study was performed using the Dutch PHARMO Database Network. Between 2002 and 2011, a total of 4854 patients sustained a first major osteoporotic fracture after the age of 65 years, of which 1766 sustained a hip fracture. Incidence rates and adjusted hazard ratios were calculated using Cox proportional hazards models. RESULTS Within 1 year following a major osteoporotic fracture, 15% (95% CI 13.7-15.7) and 31% (95% CI 30.1-32.8) of patients were dispensed an antidepressant or benzodiazepine, respectively. Current use of antidepressants in the first year following a major osteoporotic fracture was associated with subsequent fracture (adjusted HR 2.17 (95% CI 1.37-3.43)). Recent and past use of antidepressants were also associated with an increased risk of subsequent fracture. When the complete follow-up period was included, only the current use of antidepressants was associated with subsequent fracture following a major osteoporotic fracture (adjusted HR 1.48; 95% CI 1.06-2.06). Current benzodiazepine use was not associated with an increased risk of fracture within 1 year following a major osteoporotic fracture (adjusted HR 1.18; 95% CI 0.76-1.81) or during the complete follow-up period (adjusted HR 1.18; 95% CI 0.90-1.55). CONCLUSION This study provides evidence that antidepressants should be used with caution following a major osteoporotic fracture. It provides needed insights that can be used to inform clinicians when assessing subsequent fracture risk in patients.
Collapse
Affiliation(s)
- L I van de Ven
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - C Klop
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - J A Overbeek
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | - F de Vries
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
| | - A M Burden
- Department of Chemistry and Applied Biosciences, Institute of Pharmaceutical Sciences, ETH Zürich, Zürich, Switzerland
| | - P K Janssen
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Departments of Hospital Pharmacy and Intensive Care, VieCuri Medical Center, Venlo, The Netherlands
| |
Collapse
|
38
|
Mokhar A, Topp J, Härter M, Schulz H, Kuhn S, Verthein U, Dirmaier J. Patient-centered care interventions to reduce the inappropriate prescription and use of benzodiazepines and z-drugs: a systematic review. PeerJ 2018; 6:e5535. [PMID: 30345166 PMCID: PMC6190800 DOI: 10.7717/peerj.5535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/08/2018] [Indexed: 12/30/2022] Open
Abstract
Background Benzodiazepines (BZDs) and z-drugs are effective drugs, but they are prescribed excessively worldwide. International guidelines recommend a maximum treatment duration of 4 weeks. Although these drugs are effective in the short-term, long-term BZD therapy is associated with considerable adverse effects, the development of tolerance and, finally, addiction. However, there are different interventions in terms of patient-centered care that aim to reduce the use of BZDs and z-drugs as well as assist health care professionals (HCPs) in preventing the inappropriate prescription of BZDs. Aim The aim of this systematic review was to identify interventions that promote patient-centered treatments for inappropriate BZD and z-drug use and to analyze their effectiveness in reducing the inappropriate use of these drugs. Methods To identify relevant studies, the PubMed, EMBASE, PsycINFO, Psyndex, and Cochrane Library databases were searched. Studies with controlled designs focusing on adult patients were included. Trials with chronically or mentally ill patients were excluded if long-term BZD and z-drug use was indicated. Study extraction was performed based on the Cochrane Form for study extraction. To assess the quality of the studies, we used a tool based on the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials. Results We identified 7,068 studies and selected 20 for systematic review. Nine interventions focused on patients, nine on HCPs, and two on both patients and HCPs. Intervention types ranged from simple to multifaceted. Patient-centered interventions that provided patient information effectively increased the appropriate use of BZDs. The educational approaches for HCPs that aimed to achieve appropriate prescription reported inconsistent results. The methods that combined informing patients and HCPs led to a significant reduction in BZD use. Conclusions This is the first review of studies focused on patient-centered approaches to reducing the inappropriate prescription and use of BZDs and z-drugs. The patient-centered dimension of patient information was responsible for a decrease in BZD and z-drug consumption. Further, in some studies, the patient-centered dimensions responsible for reducing the prescription and use of BZDs and z-drugs were the clinician’s essential characteristics and clinician-patient communication.
Collapse
Affiliation(s)
- Aliaksandra Mokhar
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Janine Topp
- Department of Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Schulz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Silke Kuhn
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Verthein
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Dirmaier
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
39
|
Kalisch Ellett LM, Lim R, Pratt NL, Kerr M, Ramsay EN, LeBlanc TV, Barratt JD, Roughead EE. Reducing hypnotic use in insomnia management among Australian veterans: results from repeated national interventions. BMC Health Serv Res 2018; 18:626. [PMID: 30092801 PMCID: PMC6085677 DOI: 10.1186/s12913-018-3443-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 08/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Australian Government Department of Veterans' Affairs (DVA) Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) programme conducted two intervention (March 2009, follow-up intervention June 2012) both of which aimed to reduce hypnotic use among Australian veterans. We evaluated the effectiveness of the interventions, and estimated the associated health consequences. METHODS Both interventions targeted veterans who had been dispensed hypnotics prior to the intervention. Patient-specific prescriber feedback containing patient details and the volume of hypnotics dispensed, along with tailored educational information, was mailed to general practitioners. Veterans, pharmacists and directors of care in residential aged care facilities were mailed tailored educational information. Interrupted time-series and segmented regression modelling were used to determine the effect of the two interventions on the rate of hypnotics dispensing. The cumulative patient-months of hypnotic treatment avoided as a result of the interventions was calculated. We estimated improvements in health consequences of as a result of hypnotic treatment avoided based on the results of cohort studies in the same population identifying the association between hypnotic and sedative use on the outcomes of falls, and confusion. RESULTS After the first Veterans' MATES intervention in March 2009, hypnotic use declined by 0.2% each month, when compared to the baseline level (p = 0.006). The intervention effect was attenuated after one year, and use of hypnotics was found to increase by 0.2% per month after March 2010. Following the second intervention in June 2012, there was a further significant decline in use of 0.18% each month over the 12 months of follow up (p = 0.049). The cumulative effect of both interventions resulted in 20,850 fewer patient-months of treatment with hypnotics. This cumulative reduction in hypnotic use was estimated to lead to a minimum of 1 fewer hospital admissions for acute confusion and 7 fewer hospital admissions due to falls. CONCLUSIONS The Veterans' MATES insomnia interventions which involved multiple stakeholders were effective in reducing hypnotic use among older Australians. Repetition of key messages led to sustained practice change.
Collapse
Affiliation(s)
- Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Renly Lim
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Nicole L. Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Mhairi Kerr
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Emmae N. Ramsay
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Tammy V. LeBlanc
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - John D. Barratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| |
Collapse
|
40
|
Pruskowski J, Wright R, Sprissler N, Bhatnagar M. Safety Considerations When Using Opioids for Older Adults #357. J Palliat Med 2018; 21:1187-1188. [DOI: 10.1089/jpm.2018.0266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
41
|
Association between the use of benzodiazepines and opioids with the risk of falls and hip fractures in older adults. Int Psychogeriatr 2018; 30:941-946. [PMID: 29223172 DOI: 10.1017/s1041610217002745] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED ABSTRACTBackground:To determine the association between the use of opioids and benzodiazepines and the risk of falls with hip fracture in populations older than 65 years in Colombia. METHODS A case-control study with patients older than 65 years with diagnosis of hip fracture. Two controls were obtained per case. The drugs dispensed in the previous 30 days were identified. Sociodemographic, diagnostic, pharmacological (opioids and benzodiazepines), and polypharmacy variables were analyzed. A logistic regression model was used to analyze the risk of fall with hip fracture while using these drugs. RESULTS We included 287 patients with hip fractures and 574 controls. There was a female predominance (72.1%) and a mean age of 82.4 ± 8.0 years. Of the patients, 12.7% had been prescribed with opioids and 4.2% with benzodiazepines in the previous month. The adjusted multivariate analysis found that using opioids (OR:4.49; 95%CI:2.72-7.42) and benzodiazepines (OR:3.73; 95%CI:1.60-8.70) in the month prior to the event was significantly associated with a greater probability of suffering a fall with hip fracture. CONCLUSIONS People who are taking opioids and benzodiazepines have increased risk for hip fracture in Colombia. Strategies to educate physicians regarding the pharmacology of older adults should be strengthened.
Collapse
|
42
|
Papola D, Ostuzzi G, Thabane L, Guyatt G, Barbui C. Antipsychotic drug exposure and risk of fracture: a systematic review and meta-analysis of observational studies. Int Clin Psychopharmacol 2018; 33:181-196. [PMID: 29688914 DOI: 10.1097/yic.0000000000000221] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
To investigate the extent to which exposure to first-generation and second-generation antipsychotics (APs) is associated with an increased risk of fractures, with a particular focus on hip fractures, and to ascertain the risk associated with exposure to individual drugs. We included observational studies that reported data on fractures in individuals exposed to APs compared with unexposed individuals or individuals with previous exposure. We extracted information on study design, source of data, population characteristics, outcomes of interest, matching and confounding factors, and used a modified version of the Newcastle-Ottawa Scale to judge study risk of bias. We pooled adjusted estimates of relative effects to generate pooled odds ratios (ORs) and their 95% confidence interval (CI) using a random-effects model. We rated the quality of evidence using the GRADE approach. Of 36 observational studies, 29 proved to have a low risk of bias and seven were found to have a high risk of bias. The risk of hip fracture (OR: 1.57, 95% CI: 1.42-1.74, low quality of evidence) and of any fracture (OR: 1.17, 95% CI: 1.04-1.31, very low quality of evidence) increased with exposure to APs, with similar increases in risk in the first generation and second generation. The risk was similar among different diagnostic categories. The few studies that provided data were insufficient to allow inferences on individual drugs. AP exposure in unselected populations was associated with a 57% increase in the risk of hip fractures and a 17% increase in the risk of any fractures. Between-study heterogeneity limits the confidence in this estimate.
Collapse
Affiliation(s)
- Davide Papola
- Department of Neuroscience, Biomedicine and Movement Science, WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Giovanni Ostuzzi
- Department of Neuroscience, Biomedicine and Movement Science, WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Corrado Barbui
- Department of Neuroscience, Biomedicine and Movement Science, WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy
| |
Collapse
|
43
|
Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research. Drugs R D 2018; 17:493-507. [PMID: 28865038 PMCID: PMC5694420 DOI: 10.1007/s40268-017-0207-7] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Various adverse events resulting from, or associated with, benzodiazepine and/or Z-drug use have been extensively reported on and discussed in great detail within the biomedical literature. It is widely accepted that motor vehicle accidents and falls leading to fractures in older adults are major adverse events that have been shown to occur more frequently in users of sedative-hypnotic medication, especially of the benzodiazepine and related Z-drug variety. However, the last few years have seen increasing reports in the literature raising the issue of benzodiazepine and Z-drug exposure in the development of other serious medical issues including dementia, infections, respiratory disease exacerbation, pancreatitis, and cancer. This article provides an overview and interpretation on the current state of evidence regarding each of these associations and proposes what gaps in the evidence for drug-exposure–harm associations need to be addressed in the future for the purpose of evaluating causality of harm as it relates to these drugs.
Collapse
|
44
|
Aparasu RR, Rege S. FRAX tool underestimates the risk of osteoporotic fractures in mental disorders. EVIDENCE-BASED MENTAL HEALTH 2018; 21:80. [PMID: 29463572 PMCID: PMC10270459 DOI: 10.1136/eb-2017-102815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/21/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Sanika Rege
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| |
Collapse
|
45
|
Nishtala PS, Chyou TY, Held F, Le Couteur DG, Gnjidic D. Association rules method and big data: Evaluating frequent medication combinations associated with fractures in older adults. Pharmacoepidemiol Drug Saf 2018; 27:1123-1130. [DOI: 10.1002/pds.4432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 11/08/2022]
Affiliation(s)
| | - Te-yuan Chyou
- School of Pharmacy; University of Otago; Dunedin Otago New Zealand
| | - Fabian Held
- Charles Perkins Centre; University of Sydney; Sydney NSW Australia
| | - David G. Le Couteur
- Centre for Education and Research on Ageing, Ageing and Alzheimers Institute, Concord Hospital; The University of Sydney; Sydney NSW Australia
- Faculty of Pharmacy; The University of Sydney; Sydney NSW Australia
| | - Danijela Gnjidic
- Charles Perkins Centre; University of Sydney; Sydney NSW Australia
- Faculty of Pharmacy; The University of Sydney; Sydney NSW Australia
| |
Collapse
|
46
|
Application and Interpretation of Functional Outcome Measures for Testing Individuals With Cognitive Impairment. TOPICS IN GERIATRIC REHABILITATION 2018. [DOI: 10.1097/tgr.0000000000000171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
47
|
Macri JC, Iaboni A, Kirkham JG, Maxwell C, Gill SS, Vasudev A, Whitehead M, Seitz DP. Association between Antidepressants and Fall-Related Injuries among Long-Term Care Residents. Am J Geriatr Psychiatry 2017; 25:1326-1336. [PMID: 28943234 DOI: 10.1016/j.jagp.2017.08.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/11/2017] [Accepted: 08/24/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Antidepressants are associated with an increased risk of falls although little is known of the comparative risks of different types of antidepressants or individuals who are at greatest risk for falls. We examined the association between new use of antidepressants and fall-related injuries among older adults in long-term care (LTC). DESIGN, SETTING, PARTICIPANTS This was a matched, retrospective cohort study involving LTC residents in Ontario, Canada, from 2008 to 2014. New users of antidepressants were matched to non-users of antidepressants. MEASUREMENTS The primary outcome was any fall resulting in an emergency department (ED) visit or hospitalization within 90 days after exposure. Secondary outcomes included hip fractures, wrist fractures, and falls reported in LTC. Multivariate logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval associated with antidepressants and outcomes. RESULTS New users of any antidepressant had an increased risk of ED visits or hospitalization for falls within 90 days when compared with individuals not receiving antidepressants (5.2% versus 2.8%; adjusted OR: 1.9, 95% CI: 1.7-2.2). Antidepressants were also associated with an increased risk of all secondary outcomes. The increased risk of fall-related injuries was evident among selective-serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, trazodone, and across multiple patient subgroups. CONCLUSIONS New use of antidepressants is associated with significantly increased risk of falls and fall-related injuries among LTC residents across different patient subgroups and antidepressant classes. The potential risk of fall-related outcomes should be carefully considered when initiating antidepressants among older adults in LTC.
Collapse
Affiliation(s)
- Jennifer C Macri
- Department of Psychiatry, Queen's University, Providence Care-Mental Health Services, Kingston, Canada; Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada; Department of Public Health, Queen's University, Kingston, Canada
| | - Andrea Iaboni
- Department of Psychiatry, University of Toronto, Toronto Rehabilitation Institute, Toronto, Canada
| | - Julia G Kirkham
- Department of Psychiatry, Queen's University, Providence Care-Mental Health Services, Kingston, Canada
| | - Colleen Maxwell
- Schools of Pharmacy and Public Health and Health Systems, University of Waterloo, Waterloo, Canada
| | - Sudeep S Gill
- Department of Medicine, Queen's University, Kingston, Canada
| | - Akshya Vasudev
- Department of Psychiatry, Western University, London, Canada
| | - Marlo Whitehead
- Institute for Clinical Evaluative Sciences, Queen's University, London, Canada
| | - Dallas P Seitz
- Department of Psychiatry, Queen's University, Providence Care-Mental Health Services, Kingston, Canada; Institute for Clinical Evaluative Sciences, Queen's University, London, Canada.
| |
Collapse
|
48
|
Hargrove JL, Golightly YM, Pate V, Casteel CH, Loehr LR, Marshall SW, Stürmer T. Initiation of antihypertensive monotherapy and incident fractures among Medicare beneficiaries. Inj Epidemiol 2017; 4:27. [PMID: 29043521 PMCID: PMC5645300 DOI: 10.1186/s40621-017-0125-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/04/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Research suggests antihypertensive medications are associated with fractures in older adults, however results are inconsistent and few have examined how the association varies over time. We sought to examine the association between antihypertensive class and incident non-vertebral fractures among older adults initiating monotherapy according to time since initiation. METHODS We used a new-user cohort design to identify Medicare beneficiaries (≥ 65 years of age) initiating antihypertensive monotherapy during 2008-2011 using a 20% random sample of Fee-For-Service Medicare beneficiaries enrolled in parts A (inpatient services), B (outpatient services), and D (prescription medication) coverage. Starting the day after the initial antihypertensive prescription, we followed beneficiaries for incident non-vertebral fractures. We used multinomial logistic regression models to estimate propensity scores for initiating each antihypertensive drug class. Using these propensity scores, we weighted beneficiaries to achieve the same baseline covariate distribution as beneficiaries initiating with angiotensin-converting enzyme inhibitors. Lastly, we used weighted Cox proportional hazard models to estimate hazard ratios (HRs) of having an incident fractures according to antihypertensive class and time since initiation. RESULTS During 2008-2011, 122,629 Medicare beneficiaries initiated antihypertensive monotherapy (mean age 75, 61% women, 86% White). Fracture rates varied according to days since initiation and antihypertensive class. Beneficiaries initiating with thiazides had the highest fracture rate in the first 14 days following initiation (438 per 10,000 person-years, 95% confidence interval (CI): 294-628; HR: 1.40, 0.78-2.52). However, beneficiaries initiating with calcium channel blockers had the highest fracture rate during the 15-365 days after initiation (435 per 10,000 person-years, 95% CI: 404-468; HR: 1.11, 1.00-1.24). Beneficiaries initiating with angiotensin-receptor blockers had the lowest fracture rates during the initial 14 days (333 per 10,000 person-years, 190-546, HR: 0.92, 0.49-1.75) and during 15-365 days after initiation (321 per 10,000 person-years, 287-358, HR: 0.96, 0.84-1.09). CONCLUSION The association between antihypertensives and fractures varied according to class and time since initiation. Results suggest that when deciding upon antihypertensive therapy, clinicians may want to consider possible fracture risks when choosing between antihypertensive drug classes.
Collapse
Affiliation(s)
- Jennifer L Hargrove
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Yvonne M Golightly
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Virginia Pate
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carri H Casteel
- College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Laura R Loehr
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephen W Marshall
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Til Stürmer
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
49
|
Leach MJ, Pratt NL, Roughead EE. The Risk of Hip Fracture Due to Mirtazapine Exposure When Switching Antidepressants or Using Other Antidepressants as Add-On Therapy. Drugs Real World Outcomes 2017; 4:247-255. [PMID: 28940138 PMCID: PMC5684049 DOI: 10.1007/s40801-017-0120-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Antidepressants are associated with adverse effects such as sedation and hypotension, which can result in falls and fractures. Few studies have assessed the risk of hip fracture due to mirtazapine, and no known studies have assessed whether the risk of hip fracture is higher in patients taking other antidepressant medicines in combination with mirtazapine. Objectives This study aimed to examine the risk of hip fracture in older people due to mirtazapine use as well as switching between or concurrently using mirtazapine and other antidepressants. Method A matched case–control study was conducted. Cases were people aged over 65 years who were eligible for Australian Government Department of Veterans’ Affairs (DVA) benefits and who sustained a hip fracture between 2009 and 2012. Each case was matched with up to four randomly selected controls of the same gender and age (± 2 years). Multivariable conditional logistic regression was used to estimate associations between antidepressant use and hip fracture. In order to assess whether combined antidepressant effects differed from the sum of individual effects, the relative excess risk due to interaction (RERI) was calculated. Results The study population comprised 8828 cases and 35,310 controls. The median age of these participants was 88 years and 63% were women. The risk of hip fracture was increased for mirtazapine (continuous use: odds ratio [OR] 1.27, 95% confidence interval [CI] 1.12–1.44). The combinations associated with increased odds of hip fracture were addition of selective serotonin reuptake inhibitors (SSRIs) to mirtazapine (OR 11, 95% CI 2.2–51; RERI 7.7, 95% CI −9.0 to 24), addition of tricyclic antidepressants (TCAs) to mirtazapine (OR 14, 95% CI 1.4–132; RERI 12, 95% CI −19 to 43) and continuous use of both SSRIs and mirtazapine (OR 2.4, 95% CI 1.4–4.2; RERI 0.4, 95% CI −0.9 to 1.7). RERIs indicated that the effect of each antidepressant pair equalled the sum of the effects of individual antidepressant use. There was no evidence of dispensing of lower strength mirtazapine upon introducing TCAs and SSRIs. Conclusions Our results show elevated risk of hip fracture following use of mirtazapine alone and in combination with other antidepressants. The overlapping use of antidepressants may reflect the treatment of comorbidities (e.g. anxiety), switching from mirtazapine to other antidepressants, or add-on therapy. Our results highlight the risks of employing add-on therapy or switching antidepressants in older people, providing further evidence to support cautious cross-tapering where switching between antidepressants is required. Electronic supplementary material The online version of this article (doi:10.1007/s40801-017-0120-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Michael J Leach
- Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia. .,Loddon Mallee Integrated Cancer Service (LMICS), Bendigo Health Care Group, 100 Barnard Street, Bendigo, VIC, 3550, Australia. .,School of Rural Health, Monash University, 26 Mercy Street, Bendigo, VIC, 3550, Australia.
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| |
Collapse
|
50
|
Souza BGSE, Carvalho LGVAD, Oliveira LFMMD, Ferreira AG, Amaral RDCSD, Oliveira VMD. Primary and secondary osteoporotic fractures prophylaxis: evaluation of a prospective cohort. Rev Bras Ortop 2017; 52:538-543. [PMID: 29062817 PMCID: PMC5643888 DOI: 10.1016/j.rboe.2016.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 09/01/2016] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To measure the prevalence of primary drug prevention of fractures due to osteoporosis in patients admitted to a tertiary teaching hospital, in a medium-sized city, admitted with osteoporotic fractures. Moreover, to identify the incidence of prescribing secondary prophylaxis after the first fracture event. At the same time, the prevalence of risk factors for such fractures as described in the literature was measured. METHODS This longitudinal prospective study was based on a cohort of patients admitted in a tertiary teaching hospital from October 2015 to January 2016. Patients with low energy or fragility fractures were included in the study regardless of gender or race, over the age of 50 years. All patients who did not have these characteristics were excluded. The follow-up lasted four months. Serial questionnaires were applied at admission and in the follow-up consultations at four to eight weeks and at 16 weeks. RESULTS Only one patient reported receiving treatment with specific drugs for the disease before hospital admission, resulting in a prevalence of primary chemoprophylaxis of only 2.27%. No patient was prescribed medication for the treatment of osteoporosis after the fracture. The prevalence of risk factors was similar to those found in the literature review. CONCLUSION In the present study, the frequency of primary and secondary osteoporosis chemoprophylaxis in patients who were admitted with fragility fractures was low, as well as the early indication of drug treatment after the first fracture. The prevalence of fragility fracture risk factors is similar to those reported in the literature.
Collapse
Affiliation(s)
- Bruno Gonçalves Schröder e Souza
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (Suprema), Juiz de Fora, MG, Brazil
- Hospital e Maternidade Terezinha de Jesus, Serviço de Ortopedia e Traumatologia , Juiz de Fora, MG, Brazil
| | | | | | - Anmy Gil Ferreira
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (Suprema), Juiz de Fora, MG, Brazil
| | | | - Valdeci Manoel de Oliveira
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (Suprema), Juiz de Fora, MG, Brazil
- Hospital e Maternidade Terezinha de Jesus, Serviço de Ortopedia e Traumatologia , Juiz de Fora, MG, Brazil
| |
Collapse
|