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McCormick N, Lin K, Yokose C, Lu N, Zhang Y, Choi HK. Unclosing Premature Mortality Gap Among Patients With Gout in the US General Population, Independent of Serum Urate and Atherosclerotic Cardiovascular Risk Factors. Arthritis Care Res (Hoboken) 2024; 76:691-702. [PMID: 38191784 PMCID: PMC11039387 DOI: 10.1002/acr.25292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/27/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
OBJECTIVE Gout flares are followed by transient major cardiovascular (CV) risk, implicating the role of inflammation; the aim of this study was to determine whether premature mortality rates in patients with gout and CV risk are independent of serum urate (SU) and atherosclerotic CV disease (ASCVD) risk factors. METHODS Using serial US nationwide prospective cohorts, we evaluated the independent association of prevalent gout with all-cause and CV mortality, adjusting for SU, ASCVD risk factors, comorbidities, medications, and kidney function and compared mortality rates between the early (1988-1994 baseline) and late cohorts (2007-2016 baseline). We replicated late cohort findings among patients with gout in a nationwide UK cohort (2006-2010 baseline). RESULTS Adjusted hazard ratios (HRs) for mortality rates in patients with prevalent gout were similar in early and late US cohorts (1.20 [1.03-1.40] and 1.19 [1.04-1.37], respectively); HRs with further adjustment for SU were 1.19 (1.02-1.38) and 1.19 (1.03-1.37), respectively. Adjusted HR among patients with gout from the UK late cohort was 1.61 (1.47-1.75); these associations were larger among women (P = 0.04) and prominent among Black individuals. Adjusted HR for CV mortality rates in the late US cohort was 1.39 (1.09-1.78); those for circulatory, CV, and coronary heart disease deaths among UK patients with incident gout were 1.48 (1.24-1.76), 1.49 (1.20-1.85), and 1.59 (1.26-1.99), respectively. CONCLUSIONS Patients with gout experience a persistent mortality gap in all-cause and CV deaths, even adjusting for SU and ASCVD risk factors, supporting a role for gout-specific pathways (eg, flare inflammation). These findings suggest gaps in current care, particularly in women and possibly among Black patients.
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Affiliation(s)
- Natalie McCormick
- Rheumatology & Allergy Clinical Epidemiology Research Center, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston MA USA
- The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston MA
- Department of Medicine, Harvard Medical School, Boston MA USA
- Arthritis Research Canada, Vancouver BC Canada
| | - Kehuan Lin
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston MA USA
| | - Chio Yokose
- Rheumatology & Allergy Clinical Epidemiology Research Center, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston MA USA
- The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston MA
- Department of Medicine, Harvard Medical School, Boston MA USA
| | - Na Lu
- Arthritis Research Canada, Vancouver BC Canada
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston MA USA
| | - Yuqing Zhang
- Rheumatology & Allergy Clinical Epidemiology Research Center, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston MA USA
- The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston MA
- Department of Medicine, Harvard Medical School, Boston MA USA
| | - Hyon K. Choi
- Rheumatology & Allergy Clinical Epidemiology Research Center, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston MA USA
- The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston MA
- Department of Medicine, Harvard Medical School, Boston MA USA
- Arthritis Research Canada, Vancouver BC Canada
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2
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Yokose C, McCormick N, Abhishek A, Dalbeth N, Pascart T, Lioté F, Gaffo A, FitzGerald J, Terkeltaub R, Sise ME, Januzzi JL, Wexler DJ, Choi HK. The clinical benefits of sodium-glucose cotransporter type 2 inhibitors in people with gout. Nat Rev Rheumatol 2024; 20:216-231. [PMID: 38472344 DOI: 10.1038/s41584-024-01092-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/14/2024]
Abstract
Gout is the most common form of inflammatory arthritis worldwide and is characterized by painful recurrent flares of inflammatory arthritis that are associated with a transiently increased risk of adverse cardiovascular events. Furthermore, gout is associated with multiple cardiometabolic-renal comorbidities such as type 2 diabetes, chronic kidney disease and cardiovascular disease. These comorbidities, potentially combined with gout flare-related inflammation, contribute to persistent premature mortality in gout, independently of serum urate concentrations and traditional cardiovascular risk factors. Although better implementation of standard gout care could improve gout outcomes, deliberate efforts to address the cardiovascular risk in patients with gout are likely to be required to reduce mortality. Sodium-glucose cotransporter type 2 (SGLT2) inhibitors are approved for multiple indications owing to their ability to lower the risk of all-cause and cardiovascular death, hospitalizations for heart failure and chronic kidney disease progression, making them an attractive treatment option for gout. These medications have also been shown to lower serum urate concentrations, the causal culprit in gout risk, and are associated with a reduced risk of incident and recurrent gout, potentially owing to their purported anti-inflammatory effects. Thus, SGLT2 inhibition could simultaneously address both the symptoms of gout and its comorbidities.
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Affiliation(s)
- Chio Yokose
- Rheumatology & Allergy Clinical Epidemiology Research Center (RACER), Mongan Institute, Massachusetts General Hospital, Boston, MA, USA.
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Natalie McCormick
- Rheumatology & Allergy Clinical Epidemiology Research Center (RACER), Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | | | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Tristan Pascart
- Department of Rheumatology, Lille Catholic University, Saint-Philibert Hospital, Lille, France
| | - Frédéric Lioté
- Université Paris Cité, Inserm UMR 1132 Bioscar, centre Viggo Petersen, Hôpital Lariboisière, Paris, France
- Rheumatology Department, Saint-Joseph Paris Hospital, Paris, France
| | - Angelo Gaffo
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham VA Medical Center, Birmingham, AL, USA
| | - John FitzGerald
- Department of Medicine/Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Veterans Health Affairs, Greater Los Angeles, Los Angeles, CA, USA
| | - Robert Terkeltaub
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Meghan E Sise
- Harvard Medical School, Boston, MA, USA
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - James L Januzzi
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Deborah J Wexler
- Harvard Medical School, Boston, MA, USA
- MGH Diabetes Center, Massachusetts General Hospital, Boston, MA, USA
| | - Hyon K Choi
- Rheumatology & Allergy Clinical Epidemiology Research Center (RACER), Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Arthritis Research Canada, Vancouver, British Columbia, Canada
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Kiadaliri A, Dell'Isola A, Englund M. Inflammatory rheumatic diseases and the risk of drug use disorders: a register-based cohort study in Sweden. Clin Rheumatol 2024; 43:81-85. [PMID: 37639149 PMCID: PMC10774176 DOI: 10.1007/s10067-023-06755-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: 05/29/2023] [Revised: 07/25/2023] [Accepted: 08/23/2023] [Indexed: 08/29/2023]
Abstract
To investigate the association between chronic inflammatory rheumatic diseases (CIRD) and drug use disorder (DUD). Individuals aged ≥ 30 years in 2009 that met the following conditions were included: residing in the Skåne region, Sweden, with at least one healthcare contact in person and no history of DUD (ICD-10 codes F11-F16, F18-F19) during 1998-2009 (N = 649,891). CIRD was defined as the presence of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), or systemic lupus erythematosus. Treating CIRD as a time-varying exposure, we followed people from January 1, 2010 until a diagnosis of DUD, death, relocation outside the region, or December 31, 2019, whichever occurred first. We used flexible parametric survival models adjusted for attained age, sociodemographic characteristics, and coexisting conditions for data analysis. There were 64 (95% CI 62-66) and 104 (88-123) incident DUD per 100,000 person-years among those without and with CIRD, respectively. CIRD was associated with an increased risk of DUD in age-adjusted analysis (hazard ratio [HR] 1.77, 95% CI 1.49-2.09). Almost identical HR (1.71, 95% CI 1.45-2.03) was estimated after adjustment for sociodemographic characteristics, and it slightly attenuated when coexisting conditions were additionally accounted for (1.47, 95% CI 1.24-1.74). Fully adjusted HRs were 1.49 (1.21-1.85) for RA, 2.00 (1.38-2.90) for AS, and 1.58 (1.16-2.16) for PsA. More stringent definitions of CIRD didn't alter our findings. CIRD was associated with an increased risk of DUD independent of sociodemographic factors and coexisting conditions. Key Points • A register-based cohort study including 649,891 individuals aged≥30 residing in the Skåne region, Sweden, was conducted. • Chronic inflammatory rheumatic diseases were associated with higher risks of drug use disorder independent of sociodemographic factors and coexisting conditions.
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Affiliation(s)
- Ali Kiadaliri
- Clinical Epidemiology Unit, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden.
- Clinical Epidemiology Unit, Skåne University Hospital, Remissgatan 4, SE-221 85, Lund, Sweden.
| | - Andrea Dell'Isola
- Clinical Epidemiology Unit, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Martin Englund
- Clinical Epidemiology Unit, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
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Horton DB, Yang Y, Neikirk A, Huang C, Crystal S, Davidow A, Haynes K, Gerhard T, Rose CD, Strom BL, Parlett L. Impact of the COVID-19 Pandemic on the Management of Juvenile Idiopathic Arthritis: Analysis of United States Commercial Insurance Data. J Clin Rheumatol 2023; 29:388-395. [PMID: 37798830 PMCID: PMC10843854 DOI: 10.1097/rhu.0000000000002035] [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] [Indexed: 10/07/2023]
Abstract
BACKGROUND/OBJECTIVE Given limited information on health care and treatment utilization for juvenile idiopathic arthritis (JIA) during the pandemic, we studied JIA-related health care and treatment utilization in a commercially insured retrospective US cohort. METHODS We studied rates of outpatient visits, new disease-modifying antirheumatic drug (DMARD) initiations, intra-articular glucocorticoid injections (iaGC), dispensed oral glucocorticoids and opioids, DMARD adherence, and DMARD discontinuation by quarter in March 2018-February 2021 (Q1 started in March). Incident rate ratios (IRR, pandemic vs prepandemic) with 95% confidence intervals (CIs) were estimated using multivariable Poisson or Quasi-Poisson models stratified by diagnosis recency (incident JIA, <12 months ago; prevalent JIA, ≥12 months ago). RESULTS Among 1294 children diagnosed with JIA, total and in-person outpatient visits for JIA declined during the pandemic (IRR, 0.88-0.90), most markedly in Q1 2020. Telemedicine visits, while higher during the pandemic, declined from 21% (Q1) to 13% (Q4) in 2020 to 2021. During the pandemic, children with prevalent JIA, but not incident JIA, had lower usage of iaGC (IRR, 0.60; 95% CI, 0.34-1.07), oral glucocorticoids (IRR, 0.47; 95% CI, 0.33-0.67), and opioids (IRR, 0.44; 95% CI, 0.26-0.75). Adherence to and discontinuation of DMARDs was similar before and during the pandemic. CONCLUSIONS In the first year of the pandemic, visits for JIA dropped by 10% to 12% in commercially insured children in the United States, declines partly mitigated by use of telemedicine. Pandemic-related declines in intra-articular glucocorticoids, oral glucocorticoids, and opioids were observed for children with prevalent, but not incident, JIA. These changes may have important implications for disease control and quality of life.
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Affiliation(s)
- Daniel B. Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | | | | | - Cecilia Huang
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
| | - Stephen Crystal
- Rutgers Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Rutgers School of Social Work, New Brunswick, NJ, USA
| | - Amy Davidow
- New York University School of Global Public Health, New York, NY, USA
| | - Kevin Haynes
- Janssen Research & Development, Titusville, NJ, USA
| | - Tobias Gerhard
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, New Brunswick, NJ, USA
| | | | - Brian L. Strom
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Rutgers Biomedical and Health Sciences, Newark, NJ, USA
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Hall OT, Teater J, Entrup P, Deaner M, Bryan C, Harte SE, Kaplan CM, Phan KL, Clauw DJ. Fibromyalgia predicts increased odds of pain-related addiction exacerbation among individuals with pain and opioid use disorder. Pain 2023; 164:1801-1809. [PMID: 36921216 PMCID: PMC10348630 DOI: 10.1097/j.pain.0000000000002878] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 03/16/2023]
Abstract
ABSTRACT Fibromyalgia and opioid use disorder (OUD) are highly impactful chronic illnesses with substantially overlapping psychosocial, biological, and clinical features. Little previous research has examined interactions between fibromyalgia and OUD. Limiting such research has been the previous requirement of a clinical examination to diagnose fibromyalgia. The 2011 American College of Rheumatology Fibromyalgia Survey (ACR-FMS) is a validated self-report instrument with high sensitivity and specificity for fibromyalgia intended to enable fibromyalgia research in settings where a clinical examination is impractical. The present observational study uses the ACR-FMS to determine whether fibromyalgia affects odds of acknowledging pain-related OUD exacerbations among a sample of participants with pain and OUD. Participants with pain and OUD (n = 125) were recruited from an academic substance use treatment facility. The ACR-FMS, along with an original scale measuring pain-related OUD exacerbation-the Pain-related OUD Exacerbation Scale-was administered through an electronic survey. The factor structure, internal consistency, and construct validity of Pain-related OUD Exacerbation Scale were tested. In addition, descriptive analyses, multiple hierarchical linear regression, ordinal logistic regression, and multinomial logistic regression analyses were performed. Although all participants had pain, those with fibromyalgia demonstrated significantly greater odds of acknowledging pain-related OUD exacerbations. Pain-related OUD Exacerbation Scale was found to have a single-factor solution, strong internal consistency, and construct validity. This study provides first evidence of fibromyalgia as a risk factor for pain-related exacerbation of OUD and introduces a new scale with promising psychometric properties to measure pain-related OUD exacerbation.
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Affiliation(s)
- Orman Trent Hall
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Julie Teater
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Parker Entrup
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Megan Deaner
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Craig Bryan
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Steven E. Harte
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Chelsea M. Kaplan
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Kihn Luan Phan
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel J. Clauw
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
- Departments of Anesthesiology, Internal Medicine (Rheumatology) and Psychiatry, University of Michigan, Ann Arbor, MI, United States
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McCormick N, Yokose C, Wei J, Lu N, Wexler DJ, Aviña-Zubieta JA, De Vera MA, Zhang Y, Choi HK. Comparative Effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors for Recurrent Gout Flares and Gout-Primary Emergency Department Visits and Hospitalizations : A General Population Cohort Study. Ann Intern Med 2023; 176:1067-1080. [PMID: 37487215 DOI: 10.7326/m23-0724] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2is) decrease serum urate levels, but whether this translates into prevention of recurrent flares among patients with gout and gout-primary emergency department (ED) visits or hospitalizations is unknown. OBJECTIVE To compare gout flares and cardiovascular events among patients with gout initiating SGLT2is versus dipeptidyl peptidase 4 inhibitors (DPP-4is), another second-line glucose-lowering agent not associated with serum urate levels or cardiovascular risk. DESIGN Propensity score-matched, new-user cohort study. SETTING General population database from 1 January 2014 to 30 June 2022. PARTICIPANTS Patients with gout and type 2 diabetes. MEASUREMENTS The primary outcome was recurrent gout flare counts ascertained by ED, hospitalization, outpatient, and medication dispensing records. Secondary outcomes included myocardial infarction and stroke; genital infection (positive control) and osteoarthritis encounter (negative control) were also assessed. Poisson and Cox proportional hazards regressions were used with 1:1 propensity score matching (primary analysis) and overlap weighting (sensitivity analysis). RESULTS After propensity score matching, the flare rate was lower among SGLT2i initiators than DPP-4i initiators (52.4 and 79.7 events per 1000 person-years, respectively), with a rate ratio (RR) of 0.66 (95% CI, 0.57 to 0.75) and a rate difference (RD) of -27.4 (CI, -36.0 to -18.7) per 1000 person-years. The corresponding RR and RD for gout-primary ED visits and hospitalizations were 0.52 (CI, 0.32 to 0.84) and -3.4 (CI, -5.8 to -0.9) per 1000 person-years, respectively. The corresponding hazard ratio (HR) and RD for myocardial infarction were 0.69 (CI, 0.54 to 0.88) and -7.6 (CI, -12.4 to -2.8) per 1000 person-years; the HR for stroke was 0.81 (CI, 0.62 to 1.05). Those who initiated SGLT2is showed higher risk for genital infection (HR, 2.15 [CI, 1.39 to 3.30]) and no altered risk for osteoarthritis encounter (HR, 1.07 [CI, 0.95 to 1.20]). Results were similar when propensity score overlap weighting was applied. LIMITATION Participants had concurrent type 2 diabetes. CONCLUSION Among patients with gout, SGLT2is may reduce recurrent flares and gout-primary ED visits and hospitalizations and may provide cardiovascular benefits. PRIMARY FUNDING SOURCE National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Natalie McCormick
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts; The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; and Arthritis Research Canada, Vancouver, British Columbia, Canada (N.M., H.K.C.)
| | - Chio Yokose
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital; The Mongan Institute, Department of Medicine, Massachusetts General Hospital; and Department of Medicine, Harvard Medical School, Boston, Massachusetts (C.Y., Y.Z.)
| | - Jie Wei
- Health Management Center, Department of Orthopaedics, National Clinical Research Center of Geriatric Disorders, and Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education, Xiangya Hospital, and Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China (J.W.)
| | - Na Lu
- Arthritis Research Canada, Vancouver, British Columbia, Canada (N.L.)
| | - Deborah J Wexler
- Department of Medicine, Harvard Medical School, and Diabetes Center, Massachusetts General Hospital, Boston, Massachusetts (D.J.W.)
| | - J Antonio Aviña-Zubieta
- Arthritis Research Canada, and Division of Rheumatology, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada (J.A.A.)
| | - Mary A De Vera
- Arthritis Research Canada, and Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada (M.A.D.V.)
| | - Yuqing Zhang
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital; The Mongan Institute, Department of Medicine, Massachusetts General Hospital; and Department of Medicine, Harvard Medical School, Boston, Massachusetts (C.Y., Y.Z.)
| | - Hyon K Choi
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts; The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; and Arthritis Research Canada, Vancouver, British Columbia, Canada (N.M., H.K.C.)
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7
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Treister-Goltzman Y, Peleg R, Sagy I, Menashe I. Medication use and factors associated with opiate use among patients with diagnosed fibromyalgia from two ethnic sectors in southern Israel. J Pharm Policy Pract 2023; 16:78. [PMID: 37365657 DOI: 10.1186/s40545-023-00586-5] [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: 04/03/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Our aims were to compare fibromyalgia (FM) rate, drug treatment and factors associated with the use of opiates in two ethnic sectors. METHODS A retrospective cross-sectional study in southern district of Israel was performed on diagnosed FM patients in 2019-2020 [7686 members (1.50%)]. Descriptive analyses were conducted and multivariable models for the use of opiates were developed. RESULTS There were significant differences between the two ethnic groups in FM prevalence at 1.63% and 0.91% in the Jewish and Arab groups, respectively. Only 32% of the patients used recommended medications and about 44% purchased opiates. Age, BMI, psychiatric co-morbidity, and treatment with a recommended drug were similarly associated with an increased risk for opiate use in both ethnic groups. However, male gender was associated with × 2 times reduced risk to use opiates only among the Bedouins (aOR = 0.552, 95%CI = 0.333-0.911). In addition, while in both of ethnic groups the existence of another localized pain syndrome was associated with an increased risk for opiates use, this risk was 4 times higher in the Bedouin group (aOR = 8.500, 95%CI = 2.023-59.293 and aOR = 2.079, 95%CI = 1.556-2.814). CONCLUSIONS The study showed underdiagnosis of FM in the minority Arab ethnicity. Female Arab FM patients in low or high, compared to middle socio-economic status, were a risk group for excess opiate use. Increased use of opiates and very low rate of purchase of recommended drugs point to a lack of effectiveness of these drugs. Future research should assess whether the treatment of treatable factors can reduce the dangerous use of opiates.
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Affiliation(s)
- Yulia Treister-Goltzman
- Department of Family Medicine and Siaal Research Center for Family Practice and Primary Care, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel.
- Clalit Health Services, Southern District, Israel.
| | - Roni Peleg
- Department of Family Medicine and Siaal Research Center for Family Practice and Primary Care, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel
- Clalit Health Services, Southern District, Israel
| | - Iftach Sagy
- Rheumatology Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Idan Menashe
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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8
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Schnitzer TJ, Robinson RL, Viktrup L, Cappelleri JC, Bushmakin AG, Tive L, Berry M, Walker C, Jackson J. Opioid Prescribing for Osteoarthritis: Cross-Sectional Survey among Primary Care Physicians, Rheumatologists, and Orthopaedic Surgeons. J Clin Med 2023; 12:jcm12020589. [PMID: 36675516 PMCID: PMC9864807 DOI: 10.3390/jcm12020589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 01/13/2023] Open
Abstract
Opioids are often prescribed for osteoarthritis (OA) pain, despite recommendations to limit use due to minimal benefits and associated harms. This study aimed to assess physicians' practice patterns and perceptions regarding opioids by specialty one year following the Centers for Disease Control and Prevention (CDC) published guidance on opioid prescribing. The 139/153 (90.8%) physicians who reported prescribing opioids in the previous year reported decreased prescribing for mild OA (51.3%, 26.5% and 33.3% of primary care physicians, rheumatologists, and orthopaedic surgeons, respectively), moderate OA (50.0%, 47.1% and 48.1%) and severe OA (43.6%, 41.2% and 44.4%). Prescribing changes were attributed to the CDC guidelines for 58.9% of primary care physicians, 59.1% of rheumatologists, and 73.3% of orthopaedic surgeons. Strong opioids were mostly reserved as third-line treatment. Although treatment effectiveness post-CDC guidelines was not assessed, perceptions of efficacy and quality of life with opioids significantly differed across specialties, whereas perceptions of safety, convenience/acceptability and costs did not. Physicians generally agreed on the barriers to opioid prescribing, with fear of addiction and drug abuse being the most important. Across specialties, physicians reported decreased opioid prescribing for OA, irrespective of OA severity, and in most cases attributed changes in prescribing to the CDC guideline.
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Affiliation(s)
- Thomas J. Schnitzer
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Rebecca L. Robinson
- Value, Evidence and Outcomes, Eli Lilly and Company, Indianapolis, IN 46285, USA
- Correspondence: ; Tel.: +1-317-224-5833
| | - Lars Viktrup
- Neuroscience, Eli Lilly and Company, Indianapolis, IN 46285, USA
| | - Joseph C. Cappelleri
- Statistical Research and Data Science Center, Pfizer Inc., New York, NY 10017, USA
| | - Andrew G. Bushmakin
- Statistical Research and Data Science Center, Pfizer Inc., New York, NY 10017, USA
| | - Leslie Tive
- Internal Medicine, Global Medical Affairs, Pfizer Inc., New York, NY 10017, USA
| | - Mia Berry
- Real World Research, Adelphi Real World, Bollington SK10 5JB, UK
| | - Chloe Walker
- Real World Research, Adelphi Real World, Bollington SK10 5JB, UK
| | - James Jackson
- Real World Research, Adelphi Real World, Bollington SK10 5JB, UK
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9
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Affiliation(s)
- Ted R Mikuls
- From the Department of Internal Medicine, Division of Rheumatology, University of Nebraska Medical Center, and the VA Nebraska-Western Iowa Health Care System - both in Omaha
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10
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Mhanna M, Jabri A, Omar YA, Al-Abdouh A, Beran A, Ramahi A, Alrifai N, Almahameed S, Altorok N, Hodgson-Zingman D. The Burden of Cardiac Arrhythmias in Gout: A National Representative Database study. Curr Probl Cardiol 2022; 48:101437. [DOI: 10.1016/j.cpcardiol.2022.101437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 09/27/2022] [Indexed: 11/17/2022]
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11
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Magel J, Kietrys D, Kruger ES, Fritz JM, Gordon AJ. Physical therapists should play a greater role in managing patients with opioid use and opioid misuse. Subst Abus 2021; 42:255-260. [PMID: 34524070 DOI: 10.1080/08897077.2021.1971818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The U.S. opioid crisis necessitates that health care providers of all types work collaboratively to manage patients taking prescription opioid medications and manage those who may be misusing prescription opioids. Musculoskeletal conditions are the most common diagnoses associated with an opioid prescription. Physical therapists commonly manage patients with musculoskeletal conditions and chronic pain. Some patients who attend physical therapy for pain management take prescription opioid medications for pain and some of these patients may be misusing prescription opioids. Physical therapists who manage patients with musculoskeletal conditions are well-positioned to help address the opioid crisis. Historically, physical therapists have not been adequately engaged in efforts to manage persons with co-occurring musculoskeletal pain and opioid misuse or OUD. The American Physical Therapy Association (APTA) has emphasized physical therapy over the use of prescription opioids for the management of painful conditions. The APTA, however, does not highlight the important role that physical therapists could play in monitoring opioid use among patients receiving treatment for pain, nor the role that physical therapists should play in screening for opioid misuse. Such screening could facilitate referral of patients suspected misuse to an appropriate provider for formal assessment and treatment. This commentary presents simulated musculoskeletal patient presentations depicting 2 common opioid use states; chronic opioid use and opioid misuse. The cases highlight and interactions that physical therapists could have with these patients and actions that the physical therapist could take when working inter-disciplinarily. Recommendations are provided that aim to increase physical therapists' knowledge and skills related to managing patients taking prescription opioid medications for pain.
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Affiliation(s)
- John Magel
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - David Kietrys
- Department of Rehabilitation and Movement Sciences, Rutgers School of Health Professions, Newark, NJ, USA
| | - Eric S Kruger
- School of Medicine, Department of Orthopaedics and Rehabiliation, Division of Physical Therapy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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12
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Brunetti L, Vekaria J, Lipsky PE, Schlesinger N. Treatment of Acute Gout Flares in the Emergency Department: Prescribing Patterns and Revisit Rates. Ann Pharmacother 2021; 56:422-429. [PMID: 34282640 DOI: 10.1177/10600280211032295] [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] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The incidence and health care costs of gout flares have increased in the United States. The increased costs may be a result of a lack of adherence to treatment guidelines and medication knowledge. Identifying causes for this trend is vital to mitigate inappropriate resource use. OBJECTIVES The aim was to identify pharmacotherapy use related to gout treatment before, during hospital visit or stay, and on discharge in patients presenting to the emergency department (ED) with gout flares. Secondary end points included opioid use, revisit rates, and associated risk factors. METHODS We performed a retrospective cohort study at a community teaching hospital ED. All consecutive patients visiting the ED from January 2016 to July 2019 with a primary diagnosis of gout flare were included. Data were extracted from the electronic medical records. RESULTS The analysis included 214 patients. Anti-inflammatory medication was not prescribed in 33.6% during the hospital visit and 29.6% of patients on discharge. History of opioid use (odds ratio [OR] = 3.3; 95% CI = 1.3-8.6; P = 0.014) and gastroesophageal reflux disease (OR = 3.5; 95% CI = 1.09-10.9; P = 0.035) were associated with opioid prescription on discharge. ED revisits within 90 days for any gout-related or non-gout-related cause were recorded in 16.8% of patients. CONCLUSION AND RELEVANCE Roughly 30% of patients did not receive an anti-inflammatory on discharge, and opioids were frequently overused in gout management in the ED. There is an opportunity for further education of health care providers regarding gout treatment.
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Affiliation(s)
| | | | - Peter E Lipsky
- RILITE Research Institute and AMPEL BioSolutions, Charlottesville, VA, USA
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13
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Kumar M, Manley N, Mikuls TR. Gout Flare Burden, Diagnosis, and Management: Navigating Care in Older Patients with Comorbidity. Drugs Aging 2021; 38:545-557. [PMID: 34105100 DOI: 10.1007/s40266-021-00866-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 10/21/2022]
Abstract
Gout is the most common form of inflammatory arthritis, and its incidence is highest in middle-aged and older patients. Adding to the diagnostic complexity, up to 50% of patients aged > 65 years present atypically, with subacute oligo- or polyarticular flares. Comorbidity and polypharmacy, common in older populations, affect real-world treatment decisions in gout management, and no specific guidelines are available to address these issues in these at-risk groups. Despite the growing public health burden posed by gout, suboptimal management has led to increased morbidity and substantial healthcare utilization and cost burden, as reflected by an increased incidence of emergency department visits and hospitalizations in recent years. Colchicine, nonsteroidal anti-inflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) should be considered as first-line agents for gout flare management. Urate-lowering therapy, with the goal of lowering and maintaining serum urate concentrations at < 6 mg/dL (< 360 μmol/L), is recommended to achieve optimal outcomes, including regression of tophi, reduction (or elimination) of flares, and reductions in total urate burden. In this review, we summarize the current burden posed by gout and discuss best practices in its diagnosis and management, focusing on best practices in the context of gout flare in older patients with comorbid conditions.
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Affiliation(s)
- Mukund Kumar
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Medical Center, Omaha, NE, 68198-6270, USA.,Medicine and Research, VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Natalie Manley
- Division of Geriatrics, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ted R Mikuls
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Medical Center, Omaha, NE, 68198-6270, USA. .,Medicine and Research, VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA.
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14
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Keller MS, Truong L, Mays AM, Needleman J, Heilemann MSV, Nuckols TK. How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study. BMC FAMILY PRACTICE 2021; 22:41. [PMID: 33610181 PMCID: PMC7896404 DOI: 10.1186/s12875-021-01386-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/08/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Given the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care. METHODS We identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2-4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication. RESULTS In our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1-4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1-3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5-9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0-3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: - 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08-0.23%), 0.44% (95%CI: 0.30-0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03-0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13-0.26%). CONCLUSIONS Patients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.
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Affiliation(s)
- Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA.
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| | - Lyna Truong
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Allison M Mays
- Division of Geriatrics, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | | | - Teryl K Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA
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Lacasse A, Pagé MG, Dassieu L, Sourial N, Janelle-Montcalm A, Dorais M, Nguena Nguefack HL, Godbout-Parent M, Hudspith M, Moor G, Sutton K, Thompson JM, Choinière M. Impact of the COVID-19 pandemic on the pharmacological, physical, and psychological treatments of pain: findings from the Chronic Pain & COVID-19 Pan-Canadian Study. Pain Rep 2021; 6:e891. [PMID: 33598594 PMCID: PMC7880148 DOI: 10.1097/pr9.0000000000000891] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Multimodal treatment is recognized as the optimal paradigm for the management of chronic pain (CP). Careful balance between pharmacological and physical/psychological approaches is thus desirable but can be easily disrupted. OBJECTIVES This study aimed at exploring the impact of the COVID-19 pandemic on pharmacological and physical/psychological treatments of CP. METHODS A Pan-Canadian cross-sectional web-based study was conducted between April 16th and May 31st 2020 among adults living with CP when the country was in the ascending slope of the first COVID-19 pandemic wave. RESULTS A total of 2864 participants shared their treatment experience (mean age: 49.7 years and women: 83.5%). Among medication users (n = 2533), 38.3% reported changes in their pharmacological pain treatment. The main reasons were as follows: (1) changes in pain symptoms, (2) lack of access to prescribers/cancellation of medical appointments, and (3) increased medication intake in compensation for stopping physical/psychological treatments because of the pandemic. Among participants who used physical/psychological pain management approaches before the pandemic (n = 2467), 68.3% had to modify their treatments or self-management strategies. Common reasons were lack of access to clinics/exercise facilities and the need to compensate for having to stop another type of physical/psychological treatment because of the pandemic-related public health safety measures. CONCLUSIONS Our study underlines the negative impact of the COVID-19 pandemic on access to pain relief, which is considered a fundamental human right. Results will help to justify resource allocation and inform the development of interventions to be better prepared for waves to come and future health crises.
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Affiliation(s)
- Anaïs Lacasse
- Département des Sciences de la Santé, Université du Québec en Abitibi-Témiscamingue (UQAT), Rouyn-Noranda, QC, Canada
| | - M. Gabrielle Pagé
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
- Département d'anesthésiologie et de médecine de la douleur, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
| | - Lise Dassieu
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Nadia Sourial
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
| | - Audrée Janelle-Montcalm
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l'Île-Perrot, QC, Canada
| | - Hermine Lore Nguena Nguefack
- Département des Sciences de la Santé, Université du Québec en Abitibi-Témiscamingue (UQAT), Rouyn-Noranda, QC, Canada
| | - Marimée Godbout-Parent
- Département des Sciences de la Santé, Université du Québec en Abitibi-Témiscamingue (UQAT), Rouyn-Noranda, QC, Canada
| | | | | | | | - James M. Thompson
- Department of Public Health Sciences, Queens University, Kingston, ON, Canada
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Manon Choinière
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
- Département d'anesthésiologie et de médecine de la douleur, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
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