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Thomas CD, Franchi F, Rossi JS, Keeley EC, Anderson RD, Beitelshees AL, Duarte JD, Ortega-Paz L, Gong Y, Kerensky RA, Kulick N, McDonough CW, Nguyen AB, Wang Y, Winget M, Yang WE, Johnson JA, Winterstein AG, Stouffer GA, Angiolillo DJ, Lee CR, Cavallari LH. Effectiveness of Clopidogrel vs Alternative P2Y 12 Inhibitors Based on the ABCD-GENE Score. J Am Coll Cardiol 2024; 83:1370-1381. [PMID: 38599713 DOI: 10.1016/j.jacc.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND An ABCD-GENE (age, body mass index, chronic kidney disease, diabetes, and CYP2C19 genetic variants) score ≥10 predicts reduced clopidogrel effectiveness, but its association with response to alternative therapy remains unclear. OBJECTIVES The aim of this study was to evaluate the association between ABCD-GENE score and the effectiveness of clopidogrel vs alternative P2Y12 inhibitor (prasugrel or ticagrelor) therapy after percutaneous coronary intervention (PCI). METHODS A total of 4,335 patients who underwent PCI, CYP2C19 genotyping, and P2Y12 inhibitor treatment were included. The primary outcome was major atherothrombotic events (MAE) within 1 year after PCI. Cox regression was performed to assess event risk in clopidogrel-treated (reference) vs alternatively treated patients, with stabilized inverse probability weights derived from exposure propensity scores after stratifying by ABCD-GENE score and further by CYP2C19 loss-of-function (LOF) genotype. RESULTS Among patients with scores <10 (n = 3,200), MAE was not different with alternative therapy vs clopidogrel (weighted HR: 0.89; 95% CI: 0.65-1.22; P = 0.475). The risk for MAE also did not significantly differ by treatment among patients with scores ≥10 (n = 1,135; weighted HR: 0.75; 95% CI: 0.51-1.11; P = 0.155). Among CYP2C19 LOF allele carriers, MAE risk appeared lower with alternative therapy in both the group with scores <10 (weighted HR: 0.50; 95% CI: 0.25-1.01; P = 0.052) and the group with scores ≥10 (weighted HR: 0.48; 95% CI: 0.29-0.80; P = 0.004), while there was no difference in the group with scores <10 and no LOF alleles (weighted HR: 1.03; 95% CI: 0.70-1.51; P = 0.885). CONCLUSIONS These data support the use of alternative therapy over clopidogrel in CYP2C19 LOF allele carriers after PCI, regardless of ABCD-GENE score, while clopidogrel is as effective as alternative therapy in non-LOF patients with scores <10.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Joseph S Rossi
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ellen C Keeley
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - R David Anderson
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Amber L Beitelshees
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Luis Ortega-Paz
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Richard A Kerensky
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Natasha Kulick
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Anh B Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yehua Wang
- Department of Pharmaceutical Outcomes and Policy and Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Marshall Winget
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - William E Yang
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA; Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy and Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Craig R Lee
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.
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Muñoz MA, Dal Pan GJ, Wei YJJ, Xiao H, Delcher C, Giffin A, Sadiq N, Winterstein AG. Sociodemographic Characteristics of Adverse Event Reporting in the USA: An Ecologic Study. Drug Saf 2024; 47:377-387. [PMID: 38353883 PMCID: PMC10955028 DOI: 10.1007/s40264-024-01397-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 03/21/2024]
Abstract
INTRODUCTION The Food and Drug Administration Adverse Event Reporting System (FAERS) is a vital source of new drug safety information, but whether adverse event (AE) information collected from these systems adequately captures experiences of the overall United States (US) population is unknown. OBJECTIVE To examine determinants of consumer AE reporting in the USA. METHODS Five-year AE reporting rate per 100,000 residents per US county were calculated, mapped, and quartiled for AE reports received directly from consumers between 2011 and 2015. Associations between county-level sociodemographic factors obtained from County Health Rankings and AE reporting rates were evaluated using negative binomial regression. RESULTS Reporting rates were variable across US counties with > 17.6 reports versus ≤ 5.5 reports/100,000 residents in the highest and lowest reporting quartile, respectively. Controlling for drug utilization, counties with higher reporting rates had higher proportions of individuals age ≥ 65 years (e.g., 2.4% reporting increase per 1% increase in individuals age > 65, incidence rate ratio (IRR): 1.024, 95% confidence interval (CI): 1.017-1.030), higher proportions of females (IRR: 1.027, 95% CI 1.012-1.043), uninsured (IRR: 1.009, 95% CI 1.005-1.013), higher median log household incomes (IRR: 1.897, 95% CI 1.644-2.189) and more mental health providers per 100,000 residents (IRR: 1.003, 95% CI 1.001-1.004). Lower reporting was observed in counties with higher proportions of individuals age ≤ 18 years (IRR: 0.966, 95% CI 0.959-0.974), American Indian or Alaska Native individuals (IRR: 0.991, 95% CI 0.986-0.996), individuals not proficient in English (IRR: 0.978, 95% CI 0.965-0.991), and individuals residing in rural areas within a county (IRR: 0.998, 95% CI 0.997-0.998). CONCLUSIONS Observed variations in consumer AE reporting may be related to sociodemographic factors and healthcare access. Because these factors may also correspond to AE susceptibility, voluntary AE reporting systems may be suboptimal for capturing emerging drug safety concerns among more vulnerable populations.
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Affiliation(s)
- Monica A Muñoz
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
| | - Gerald J Dal Pan
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Yu-Jung Jenny Wei
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
- Division of Outcomes and Translational Sciences, College of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - Hong Xiao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Chris Delcher
- Department of Pharmacy Practice and Science, College of Pharmacy, Institute for Pharmaceutical Outcomes and Policy, University of Kentucky, Lexington, KY, USA
| | - Andrew Giffin
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Nabila Sadiq
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
- Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
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Osborne V, Goodin A, Brown J, Winterstein AG, Bate A, Cohet C, Pont L, Moeny D, Klungel O, Pinheiro S, Seeger J, Chan KA, Edlavitch S, Tilson H, Layton D. Updated core competencies in pharmacoepidemiology to inform contemporary curricula and training for academia, government, and industry. Pharmacoepidemiol Drug Saf 2024; 33:e5789. [PMID: 38629216 DOI: 10.1002/pds.5789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/07/2024] [Accepted: 03/22/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE The first paper to specify the core content of pharmacoepidemiology as a profession was published by an ISPE (International Society for Pharmacoepidemiology) workgroup in 2012 (Jones JK et al. PDS 2012; 21[7]:677-689). Due to the broader and evolving scope of pharmacoepidemiology, ISPE considers it important to proactively identify, update and expand the list of core competencies to inform curricula of education programs; thus, better positioning pharmacoepidemiologists across academic, government (including regulatory), and industry positions. The aim of this project was to update the list of core competencies in pharmacoepidemiology. METHODS To ensure applicability of findings to multiple areas, a working group was established consisting of ISPE members with positions in academia, industry, government, and other settings. All competencies outlined by Jones et al. were extracted from the initial manuscript and presented to the working group for review. Expert-based judgments were collated and used to identify consensus. It was noted that some competencies could contribute to multiple groups and could be directly or indirectly related to a group. RESULTS Five core domains were proposed: (1) Epidemiology, (2) Clinical Pharmacology, (3) Regulatory Science, (4) Statistics and data science, and (5) Communication and other professional skills. In total, 55 individual competencies were proposed, of which 25 were new competencies. No competencies from the original work were dropped but aggregation or amendments were made where considered necessary. CONCLUSIONS While many core competencies in pharmacoepidemiology have remained the same over the past 10 years, there have also been several updates to reflect new and emerging concepts in the field.
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Affiliation(s)
| | | | | | | | | | | | - Lisa Pont
- University of Technology Sydney, Sydney, Australia
| | - David Moeny
- Food & Drug Administration, Silver Spring, USA
| | | | | | | | | | | | - Hugh Tilson
- University of North Carolina, Chapel Hill, USA
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Jeon N, Albogami Y, Jung SY, Bussing R, Winterstein AG. Comparing pregnancy and pregnancy outcome rates between adolescents with and without pre-existing mental disorders. PLoS One 2024; 19:e0296425. [PMID: 38483946 PMCID: PMC10939254 DOI: 10.1371/journal.pone.0296425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 12/13/2023] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND There are limited population-based data on the role of mental disorders in adolescent pregnancy, despite the presence of mental disorders that may affect adolescents' desires and decisions to become pregnant. OBJECTIVE This study aimed to examine the relationship between specific types of mental disorders and pregnancy rates and outcome types among adolescents aged 13-19 years, using single-year age groups. METHODS We conducted a retrospective cohort study using data from the Merative™ MarketScan Research Databases. The study population consisted of females aged 13-19 years with continuous insurance enrollment for three consecutive calendar years between 2005 and 2015. Pregnancy incidence rates were calculated both overall and within the different categories of mental disorders. The presence of mental disorders, identified through diagnosis codes, was classified into 15 categories. Pregnancy and pregnancy outcome types were determined using diagnosis and procedure codes indicating the pregnancy status or outcome. To address potential over- or underestimations of mental disorder-specific pregnancy rates resulting from variations in age distribution across different mental disorder types, we applied age standardization using 2010 U.S. Census data. Finally, multivariable logistic regression models were used to examine the relationships between 15 specific types of mental disorders and pregnancy incidence rates, stratified by age. RESULTS The age-standardized pregnancy rate among adolescents diagnosed with at least one mental disorder was 15.4 per 1,000 person-years, compared to 8.5 per 1,000 person-years among adolescents without a mental disorder diagnosis. Compared to pregnant adolescents without a mental disorder diagnosis, those with a mental disorder diagnosis had a slightly but significantly higher abortion rate (26.7% vs 23.8%, P-value < 0.001). Multivariable logistic regression models showed that substance use-related disorders had the highest odds ratios (ORs) for pregnancy incidence, ranging from 2.4 [95% confidence interval (CI): 2.1-2.7] to 4.5 [95% CI:2.1-9.5] across different age groups. Overall, bipolar disorders (OR range: 1.6 [95% CI:1.4-1.9]- 1.8 [95% CI: 1.7-2.0]), depressive disorders (OR range: 1.4 [95% CI: 1.3-1.5]- 2.7 [95% CI: 2.3-3.1]), alcohol-related disorders (OR range: 1.2 [95% CI: 1.1-1.4]- 14.5 [95% CI: 1.2-178.6]), and attention-deficit/conduct/disruptive behavior disorders (OR range: 1.1 [95% CI: 1.0-1.1]- 1.8 [95% CI: 1.1-3.0]) were also significantly associated with adolescent pregnancy, compared to adolescents without diagnosed mental disorders of the same age. CONCLUSION This study emphasizes the elevated rates of pregnancy and pregnancy ending in abortion among adolescents diagnosed with mental disorders, and identifies the particular mental disorders associated with higher pregnancy rates.
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Affiliation(s)
- Nakyung Jeon
- Pusan National University College of Pharmacy, Busan, Republic of Korea
- Research Institute for Drug Development, Pusan National University, Busan, Republic of Korea
| | - Yasser Albogami
- Department of Clinical Pharmacy, College of Pharmacy, King Saudi University, Riyadh, Saudi Arabia
| | - Sun-Young Jung
- College of Pharmacy and Department of Global Innovative Drugs, Chung-Ang University, Seoul, Republic of Korea
| | - Regina Bussing
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, United States of America
| | - Almut G. Winterstein
- Department of Pharamceutical Outcomes and Policy, Department of Epidemiology, and Center for drug Evaluation and Safety, University of Florida, Gainesville, FL, United States of America
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Wei YJJ, Winterstein AG, Schmidt S, Fillingim RB, Schmidt S, Daniels MJ, DeKosky ST. Short- and long-term safety of discontinuing chronic opioid therapy among older adults with Alzheimer's disease and related dementia. Age Ageing 2024; 53:afae047. [PMID: 38497237 PMCID: PMC10945292 DOI: 10.1093/ageing/afae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Limited evidence exists on the short- and long-term safety of discontinuing versus continuing chronic opioid therapy (COT) among patients with Alzheimer's disease and related dementias (ADRD). METHODS This cohort study was conducted among 162,677 older residents with ADRD and receipt of COT using a 100% Medicare nursing home sample. Discontinuation of COT was defined as no opioid refills for ≥90 days. Primary outcomes were rates of pain-related hospitalisation, pain-related emergency department visit, injury, opioid use disorder (OUD) and opioid overdose (OD) measured by diagnosis codes at quarterly intervals during 1- and 2-year follow-ups. Poisson regression models were fit using generalised estimating equations with inverse probability of treatment weights to model quarterly outcome rates between residents who discontinued versus continued COT. RESULTS The study sample consisted of 218,040 resident episodes with COT; of these episodes, 180,916 residents (83%) continued COT, whereas 37,124 residents (17%) subsequently discontinued COT. Discontinuing (vs. continuing) COT was associated with higher rates of all outcomes in the first quarter, but these associations attenuated over time. The adjusted rates of injury, OUD and OD were 0, 69 and 60% lower at the 1-year follow-up and 11, 81 and 79% lower at the 2-year follow-up, respectively, for residents who discontinued versus continued COT, with no difference in the adjusted rates of pain-related hospitalisations or emergency department visits. CONCLUSIONS The rates of adverse outcomes were higher in the first quarter but lower or non-differential at 1-year and 2-year follow-ups between COT discontinuers versus continuers among older residents with ADRD.
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Affiliation(s)
- Yu-Jung Jenny Wei
- Division of Outcomes and Translational Sciences, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL 32610, USA
- Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, FL 32610, USA
| | - Siegfried Schmidt
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Roger B Fillingim
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA
| | - Stephan Schmidt
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Michael J Daniels
- Department of Statistics, College of Liberal Arts and Sciences, University of Florida, Gainesville FL, 32610, USA
| | - Steven T DeKosky
- Department of Neurology, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
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Thai TN, Winterstein AG. Core concepts in pharmacoepidemiology: Measurement of medication exposure in routinely collected healthcare data for causal inference studies in pharmacoepidemiology. Pharmacoepidemiol Drug Saf 2024; 33:e5683. [PMID: 37752827 DOI: 10.1002/pds.5683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Observational designs can complement evidence from randomized controlled trials not only in situations when randomization is not feasible, but also by evaluating drug effects in real-world, considering a broader spectrum of users and clinical scenarios. However, use of such real-world scenarios captured in routinely collected clinical or administrative data also comes with specific challenges. Unlike in trials, medication use is not protocol based. Instead, exposure is determined by a multitude of factors involving patients, providers, healthcare access, and other policies. Accurate measurement of medication exposure relies on a similar broad set of factors which, if not understood and appropriately addressed, can lead to exposure misclassification and bias. AIM To describe core considerations for measurement of medication exposure in routinely collected healthcare data. METHODS We describe the strengths and weaknesses of the two main types of routinely collected healthcare data (electronic health records and administrative claims) used in pharmacoepidemiologic research. We introduce key elements in those data sources and issues in the curation process that should be considered when developing exposure definitions. We present challenges in exposure measurement such as the appropriate determination of exposure time windows or the delineation of concomitant medication use versus switching of therapy, and related implications for bias. RESULTS We note that true exposure patterns are typically unknown when using routinely collected healthcare data and that an in-depth understanding of healthcare delivery, patient and provider decision-making, data documentation and governance, as well as pharmacology are needed to ensure unbiased approaches to measuring exposure. CONCLUSIONS Various assumptions are made with the goal that the chosen exposure definition can approximate true exposure. However, the possibility of exposure misclassification remains, and sensitivity analyses that can test the impact of such assumptions on the robustness of estimated medication effects are necessary to support causal inferences.
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Affiliation(s)
- Thuy N Thai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Medication Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
- Faculty of Pharmacy, HUTECH University, Ho Chi Minh City, Vietnam
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Medication Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
- Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
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Winterstein AG, Wang Y, Smolinski NE, Thai TN, Ewig C, Rasmussen SA. Prenatal Care Initiation and Exposure to Teratogenic Medications. JAMA Netw Open 2024; 7:e2354298. [PMID: 38300617 PMCID: PMC10835507 DOI: 10.1001/jamanetworkopen.2023.54298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/11/2023] [Indexed: 02/02/2024] Open
Abstract
Importance With new legal abortion restrictions, timing of prenatal care initiation is critical to allow for discussion of reproductive options among pregnancies exposed to teratogenic medications. Objective To investigate the prevalence of prenatal exposure to teratogenic medications and prenatal care initiation across gestational weeks. Design, Setting, and Participants This descriptive, population-based cross-sectional study used health encounter data from a national sample of individuals with employer-sponsored health insurance. A validated algorithm identified pregnancies among persons identifying as female that ended with a live or nonlive outcome between January 2017 and December 2019. Data were analyzed from December 2022 to December 2023. Exposures Prenatal exposure to any of 137 teratogenic medications, measured via pharmacy and medical claims. Measurement of prenatal care initiation was adapted from the Children's Health Care Quality Measures. Main Outcomes and Measures Prevalence of prenatal exposure to teratogens and prenatal care initiation by gestational week. Timing of prenatal teratogenic exposure was compared with timing of prenatal care initiation and legal abortion cutoffs. Results Among 639 994 pregnancies, 472 472 (73.8%; 95% CI, 73.7%-73.9%) had a live delivery (mean [SD] age, 30.9 [5.4] years) and 167 522 (26.2%; 95% CI, 26.1%-26.3%) had a nonlive outcome (mean [SD] age, 31.6 [6.4] years). Of pregnancies with live deliveries, 5.8% (95% CI, 5.7%-5.8%) were exposed to teratogenic medications compared with 3.1% (95% CI, 3.0%-3.2%) with nonlive outcomes. Median time to prenatal care was 56 days (IQR, 44-70 days). By 6 weeks' gestation, 8186 pregnancies had been exposed to teratogenic medications (25.2% [95% CI, 24.7%-25.7%] of pregnancies exposed at any time during gestation; 1.3% [95% CI, 1.3%-1.3%] of all pregnancies); in 6877 (84.0%; 95% CI, 83.2%-84.8%), prenatal care was initiated after 6 weeks or not at all. By 15 weeks, teratogenic exposures had occurred for 48.9% (95% CI, 48.4%-49.5%) of all teratogen-exposed pregnancies (2.5% [2.4-2.5] of all pregnancies); prenatal care initiation occurred after 15 weeks for 1810 (16.8%; 95% CI, 16.1%-17.5%) with live deliveries and 2975 (58.3%; 95% CI, 56.9%-59.6%) with nonlive outcomes. Teratogenic medications most used within the first 15 gestational weeks among live deliveries included antiinfectives (eg, fluconazole), anticonvulsants (eg, valproate), antihypertensives (eg, lisinopril), and immunomodulators (eg, mycophenolate). For nonlive deliveries, most antihypertensives were replaced by vitamin A derivatives. Conclusions and Relevance In this cross-sectional study, most exposures to teratogenic medications occurred in early pregnancy and before prenatal care initiation, precluding prenatal risk-benefit assessments. Prenatal care commonly occurred after strict legal abortion cutoffs, prohibiting consideration of pregnancy termination if concerns about teratogenic effects arose.
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Affiliation(s)
- Almut G. Winterstein
- Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
- Epidemiology, University of Florida, Gainesville
| | - Yanning Wang
- Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
- Health Outcomes & Biomedical Informatics, University of Florida, Gainesville
| | - Nicole E. Smolinski
- Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Thuy N. Thai
- Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
- Faculty of Pharmacy, HUTECH University, Ho Chi Minh City, Vietnam
| | - Celeste Ewig
- Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
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Smith KM, Keshwani S, Walsh MG, Winterstein AG, Gurka MJ, Libby A, Hogan WR, Pepine CJ, Cooper-DeHoff RM, Smith SM. Initial Antihypertensive Prescribing in Relation to Blood Pressure Among Florida Medicaid and Medicare Recipients in the OneFlorida+ Research Consortium. Hypertension 2024; 81:e7-e9. [PMID: 38232142 DOI: 10.1161/hypertensionaha.123.21901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
- Kayla M Smith
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy (K.M.S., S.K., M.G.W., A.G.W., S.M.S.), University of Florida, Gainesville, FL
| | - Shailina Keshwani
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy (K.M.S., S.K., M.G.W., A.G.W., S.M.S.), University of Florida, Gainesville, FL
| | - Marta G Walsh
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy (K.M.S., S.K., M.G.W., A.G.W., S.M.S.), University of Florida, Gainesville, FL
- Now with Mayo Clinic, Rochester, MN (M.G.W.)
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy (K.M.S., S.K., M.G.W., A.G.W., S.M.S.), University of Florida, Gainesville, FL
| | - Matthew J Gurka
- Department of Pediatrics, College of Medicine (M.J.G.), University of Florida, Gainesville, FL
| | - Anne Libby
- Department of Emergency Medicine, School of Medicine, University of Colorado Denver, Denver, CO (A.L.)
| | - William R Hogan
- Department of Health Outcomes and Biomedical Informatics, College of Medicine (W.R.H.), University of Florida, Gainesville, FL
- Now with Data Science Institute, Medical College of Wisconsin, Milwaukee, WI (W.R.H.)
| | - Carl J Pepine
- Divisio of Cardiovascular Medicine, Department of Medicine, College of Medicine (C.J.P., R.M.C.-D., S.M.S.), University of Florida, Gainesville, FL
| | - Rhonda M Cooper-DeHoff
- Divisio of Cardiovascular Medicine, Department of Medicine, College of Medicine (C.J.P., R.M.C.-D., S.M.S.), University of Florida, Gainesville, FL
- Department of Pharmacotherapy and Translational Research, College of Pharmacy (R.M.C.-D.), University of Florida, Gainesville, FL
| | - Steven M Smith
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy (K.M.S., S.K., M.G.W., A.G.W., S.M.S.), University of Florida, Gainesville, FL
- Divisio of Cardiovascular Medicine, Department of Medicine, College of Medicine (C.J.P., R.M.C.-D., S.M.S.), University of Florida, Gainesville, FL
- Center for Integrative Cardiovascular and Metabolic Disease (S.M.S), University of Florida, Gainesville, FL
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Ndai AM, Morris EJ, Winterstein AG, Vouri SM. Evaluating Provider and Pharmacy Discordance in Potential Calcium Channel Blocker-Loop Diuretic Prescribing Cascade. Drugs Aging 2024; 41:177-186. [PMID: 38252391 DOI: 10.1007/s40266-023-01091-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Prescribing cascades occur when a drug-induced adverse event is treated with a new medication. Identifying clinical scenarios in which prescribing cascades are more likely to occur may help determine ways to prevent prescribing cascades. OBJECTIVE To understand the extent to which discordant providers and discordant pharmacies contribute to the dihydropyridine calcium channel blocker (DH CCB)-loop diuretic prescribing cascade. STUDY POPULATION AND DESIGN A retrospective cohort study using Medicare Fee-For-Service data (2011-2018) of adults aged ≥ 66 years. EXPOSURES Patients who initiated DH CCB with subsequent initiation of loop diuretic (DH CCB-loop diuretic dyad) within 90 days or patients who initiated angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) with subsequent initiation of a loop diuretic (ACEI/ARB-loop diuretic dyad; control). MAIN OUTCOMES The primary outcomes were provider and pharmacy discordance for prescribing cascades and control drug pairs. Baseline clinical and socio-demographic characteristics were balanced using inverse probability of treatment weighting with propensity scores. RESULTS Overall, we identified 1987 DH CCB-loop diuretic dyads and 3148 ACEI/ARB-loop diuretic dyads. Discordant providers occurred in 64% of DH CCB-loop diuretic dyads and 55% of ACEI/ARB-loop diuretic dyads, while discordant pharmacies occurred in 19% of DH CCB-loop diuretic dyads and 16% of ACEI/ARB-loop diuretic dyads. After adjustment, the risk of having discordant providers was 20% {Relative Risk (RR) 1.20 [95% confidence interval (CI), 1.14-1.26]} higher in the DH CCB-loop diuretic dyad compared with the ACEI/ARB-loop diuretic dyad. Moreover, pharmacy discordance was 17% (RR 1.17 [95% CI 1.02-1.33]) higher. CONCLUSION Our findings suggest that discordant providers and discordant pharmacies were more commonly involved in the potential prescribing cascade when compared with a similar control dyad of medications. Opportunities for enhanced care coordination and medication reconciliation should be explored to prevent unnecessary polypharmacy.
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Affiliation(s)
- Asinamai M Ndai
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
| | - Earl J Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA.
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.
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Wang Y, Jiao T, Muschett MR, Brown JD, Guo SJ, Kulshreshtha A, Zhang Y, Winterstein AG, Shao H. Associations Between Postdischarge Care and Cognitive Impairment-Related Hospital Readmissions for Ketoacidosis and Severe Hypoglycemia in Adults With Diabetes. Diabetes Care 2024; 47:225-232. [PMID: 38048487 DOI: 10.2337/dca23-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/01/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE Patients with severe hypoglycemia (SH) or diabetic ketoacidosis (DKA) experience high hospital readmission after being discharged. Cognitive impairment (CI) may further increase the risk, especially in those experiencing an interruption of medical care after discharge. This study examined the effect modification role of postdischarge care (PDC) on CI-associated readmission risk among U.S. adults with diabetes initially admitted for DKA or SH. RESEARCH DESIGN AND METHODS We used the Nationwide Readmissions Database (NRD) (2016-2018) to identify individuals hospitalized with a diagnosis of DKA or SH. Multivariate Cox regression was used to compare the all-cause readmission risk at 30 days between those with and without CI identified during the initial hospitalization. We assessed the CI-associated readmission risk in the patients with and without PDC, an effect modifier with the CI status. RESULTS We identified 23,775 SH patients (53.3% women, mean age 65.9 ± 15.3 years) and 140,490 DKA patients (45.8% women, mean age 40.3 ± 15.4 years), and 2,675 (11.2%) and 1,261 (0.9%), respectively, had a CI diagnosis during their index hospitalization. For SH and DKA patients discharged without PDC, CI was associated with a higher readmission risk of 23% (adjusted hazard ratio [aHR] 1.23, 95% confidence interval 1.08-1.40) and 35% (aHR 1.35, 95% confidence interval 1.08-1.70), respectively. However, when patients were discharged with PDC, we found PDC was an effect modifier to mitigate CI-associated readmission risk for both SH and DKA patients (P < 0.05 for all). CONCLUSIONS Our results suggest that PDC can potentially mitigate the excessive readmission risk associated with CI, emphasizing the importance of postdischarge continuity of care for medically complex patients with comorbid diabetes and CI.
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Affiliation(s)
- Yehua Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Tianze Jiao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Matthew R Muschett
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Serena Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Ambar Kulshreshtha
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA
| | - Yongkang Zhang
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Hui Shao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA
- Hubert Department of Global Health, Rollin School of Public Health, Emory University, Atlanta, GA
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Wei YJ, Winterstein AG, Schmidt S, Fillingim RB, Daniels MJ, Solberg L, DeKosky ST. Pain intensity, physical function, and depressive symptoms associated with discontinuing long-term opioid therapy in older adults with Alzheimer's disease and related dementias. Alzheimers Dement 2024; 20:1026-1037. [PMID: 37855270 PMCID: PMC10916940 DOI: 10.1002/alz.13489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/31/2023] [Accepted: 09/02/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Limited evidence exists on the associations of discontinuing versus continuing long-term opioid therapy (LTOT) with pain intensity, physical function, and depression among patients with Alzheimer's disease and related dementias (ADRD). METHODS A cohort study among 138,059 older residents with mild-to-moderate ADRD and receipt of LTOT was conducted using a 100% Medicare nursing home sample. Discontinuation of LTOT was defined as no opioid refills for ≥ 60 days. Outcomes were worsening pain, physical function, and depression from baseline to quarterly assessments during 1- and 2-year follow-ups. RESULTS The adjusted odds of worsening pain and depressive symptoms were 29% and 5% lower at the 1-year follow-up and 35% and 9% lower at the 2-year follow-up for residents who discontinued versus continued LTOT, with no difference in physical function. DISCUSSION Discontinuing LTOT was associated with lower short- and long-term worsening pain and depressive symptoms than continuing LTOT among older residents with ADRD. HIGHLIGHTS Discontinuing long-term opioid therapy (LTOT) was associated with lower short- and long-term worsening pain. Discontinuing LTOT was related to lower short- and long-term worsening depression. Discontinuing LTOT was not associated with short- and long-term physical function.
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Affiliation(s)
- Yu‐Jung Jenny Wei
- Division of Outcomes and Translational SciencesCollege of PharmacyThe Ohio State UniversityColumbusOhioUSA
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFloridaUSA
- Department of EpidemiologyColleges of Medicine and Public Health & Health ProfessionsUniversity of FloridaGainesvilleFloridaUSA
| | - Siegfried Schmidt
- Department of Community Health and Family MedicineCollege of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Roger B. Fillingim
- Pain Research and Intervention Center of ExcellenceUniversity of FloridaGainesvilleFloridaUSA
| | - Michael J. Daniels
- Department of StatisticsCollege of Liberal Arts and SciencesUniversity of FloridaGainesvilleFloridaUSA
| | - Laurence Solberg
- North Florida/South Georgia Veterans Health SystemMalcom Randall Department of Veterans Affairs Medical CenterGeriatrics Research, Education, Clinical Center (GRECC)GainesvilleFloridaUSA
| | - Steven T. DeKosky
- Department of NeurologyMcKnight Brain InstituteUniversity of FloridaGainesvilleFloridaUSA
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Wang Y, Smolinski NE, Thai TN, Sarayani A, Ewig C, Rasmussen SA, Winterstein AG. Common teratogenic medication exposures-a population-based study of pregnancies in the United States. Am J Obstet Gynecol MFM 2024; 6:101245. [PMID: 38061552 DOI: 10.1016/j.ajogmf.2023.101245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Risk mitigation for most teratogenic medications relies on risk communication via drug label, and prenatal exposures remain common. Information on the types of and risk factors for prenatal exposures to medications with teratogenic risk can guide strategies to reduce exposure. OBJECTIVE This study aimed to identify medications with known or potential teratogenic risk commonly used during pregnancy among privately insured persons. STUDY DESIGN We used the Merative™ MarketScan® Commercial Database to identify pregnancies with live or nonlive (ectopic pregnancies, spontaneous and elective abortions, stillbirths) outcomes among persons aged 12 to 55 years from 2011 to 2018. Start/end dates of medication exposure and pregnancy outcomes were identified via an adapted algorithm based on validation studies. We required continuous health plan enrollment from 90 days before conception until 30 days after the pregnancy end date. Medications with known or potential teratogenic risk were selected from TERIS (Teratogen Information System) and drug monographs based on the level of risk and quality of evidence (138 with known and 60 with potential risk). We defined prenatal exposure on the basis of ≥1 outpatient pharmacy claim or medical encounter for medication administration during target pregnancy periods considering medication risk profiles (eg, risk only in the first trimester or at a certain dose threshold). Sex hormones and hormone analogs, and abortion and postpartum/abortion hemorrhage treatments were not considered as teratogenic medications because of challenges in separating pregnancy-related indications, nor were opioids (because of complex risk-benefit considerations) or antiobesity medications if their only teratogenic mechanism was weight loss. RESULTS Among all pregnancies, the 10 medications with known teratogenic risk and the highest prenatal exposures were sulfamethoxazole/trimethoprim (1988 per 100,000 pregnancy-years), high-dose fluconazole (1248), topiramate (351), lisinopril (144), warfarin (57), losartan (56), carbamazepine (50), valproate (49), vedolizumab (28 since 2015), and valsartan (25). Prevalence of exposure to sulfamethoxazole/trimethoprim decreased from 2346 to 1453 per 100,000 pregnancy-years from 2011 to 2018, but prevalence of exposure to vedolizumab increased 6-fold since its approval in 2015. Prenatal exposures in the first trimester were higher among nonlive pregnancies than among live-birth pregnancies, with the largest difference observed for warfarin (nonlive 370 vs live birth 78), followed by valproate (258 vs 86) and topiramate (1728 vs 674). Prenatal exposures to medications with potential teratogenic risk were most prevalent for low-dose fluconazole (6495), metoprolol (1325), and atenolol (448). The largest first-trimester exposure differences between nonlive and live-birth pregnancies were observed for lithium (242 vs 89), gabapentin (1639 vs 653), and duloxetine (1914 vs 860). Steady increases in hydralazine and gabapentin exposures were observed during the study years, whereas atenolol exposure decreased (561 to 280). CONCLUSION Several medications with teratogenic risk for which there are potentially safer alternatives continue to be used during pregnancy. The fluctuating rates of prenatal exposure observed for select teratogenic medications suggest that regular reevaluation of risk mitigation strategies is needed. Future research focusing on understanding the clinical context of medication use is necessary to develop effective strategies for reducing exposures to medications with teratogenic risk during pregnancy.
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Affiliation(s)
- Yanning Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein); Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL (Ms Wang)
| | - Nicole E Smolinski
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein)
| | - Thuy Nhu Thai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein); Faculty of Pharmacy, Ho Chi Minh City University of Technology, Ho Chi Minh City, Vietnam (Dr Thai)
| | - Amir Sarayani
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein)
| | - Celeste Ewig
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein)
| | - Sonja A Rasmussen
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Rasmussen)
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein); Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL (Dr Winterstein); Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL (Dr Winterstein).
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13
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Winterstein AG, Rasmussen SA. Trade-offs in safety study design decisions on teratogenic gadolinium effects. Am J Obstet Gynecol 2023; 229:699-700. [PMID: 37544348 DOI: 10.1016/j.ajog.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Dr., HPNP Building, Gainesville, FL 32610; Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL.
| | - Sonja A Rasmussen
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Winterstein AG, Ehrenstein V, Brown JS, Stürmer T, Smith MY. A Road Map for Peer Review of Real-World Evidence Studies on Safety and Effectiveness of Treatments. Diabetes Care 2023; 46:1448-1454. [PMID: 37471605 PMCID: PMC10369122 DOI: 10.2337/dc22-2037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 05/05/2023] [Indexed: 07/22/2023]
Abstract
The growing acceptance of real-world evidence (RWE) in clinical and regulatory decision-making, coupled with increasing availability of health care data and advances in automated analytic approaches, has contributed to a marked expansion of RWE studies of diabetes and other diseases. However, a recent spate of high-profile retractions highlights the need for improvements in the conduct of RWE research as well as in the associated peer review and editorial processes. We review best pharmacoepidemiologic practices and common pitfalls regarding design, measurement, analysis, data validity, appropriateness, and generalizability of RWE studies. To enhance RWE study assessments, we propose that journal editors require 1) study authors to complete RECORD-PE, a reporting guideline for pharmacoepidemiological studies on routinely collected data, 2) availability of predetermined study protocols and analysis plans, 3) inclusion of pharmacoepidemiologists on the peer review team, and 4) provision of detail on data provenance, characterization, and custodianship to facilitate assessment of the data source. We recognize that none of these steps guarantees a high-quality research study. Collectively, however, they permit an informed assessment of whether the study was adequately designed and conducted and whether the data source used was fit for purpose.
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Affiliation(s)
- Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, Department of Epidemiology, and Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL
- International Network for Epidemiology in Policy, American College of Epidemiology, Washington Avenue Extension, Albany, NY
- International Society for Pharmacoepidemiology, Bethesda, MD
| | - Vera Ehrenstein
- International Network for Epidemiology in Policy, American College of Epidemiology, Washington Avenue Extension, Albany, NY
- International Society for Pharmacoepidemiology, Bethesda, MD
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Jeffrey S. Brown
- International Network for Epidemiology in Policy, American College of Epidemiology, Washington Avenue Extension, Albany, NY
- International Society for Pharmacoepidemiology, Bethesda, MD
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Cambridge, MA
- TriNetX, LLC, Cambridge, MA
| | - Til Stürmer
- International Network for Epidemiology in Policy, American College of Epidemiology, Washington Avenue Extension, Albany, NY
- International Society for Pharmacoepidemiology, Bethesda, MD
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Meredith Y. Smith
- International Network for Epidemiology in Policy, American College of Epidemiology, Washington Avenue Extension, Albany, NY
- International Society for Pharmacoepidemiology, Bethesda, MD
- Evidera, Inc., PPD, Boston, MA
- School of Pharmacy, University of Southern California, Los Angeles, CA
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Jugl S, Winterstein AG. Ectopic Pregnancy Risk and Levonorgestrel-Releasing Intrauterine Systems. JAMA 2023; 330:378. [PMID: 37490092 DOI: 10.1001/jama.2023.8888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Affiliation(s)
- Sebastian Jugl
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville
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Sajdeya R, Mardini MT, Tighe PJ, Ison RL, Bai C, Jugl S, Hanzhi G, Zandbiglari K, Adiba FI, Winterstein AG, Pearson TA, Cook RL, Rouhizadeh M. Developing and validating a natural language processing algorithm to extract preoperative cannabis use status documentation from unstructured narrative clinical notes. J Am Med Inform Assoc 2023; 30:1418-1428. [PMID: 37178155 PMCID: PMC10354766 DOI: 10.1093/jamia/ocad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/12/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVE This study aimed to develop a natural language processing algorithm (NLP) using machine learning (ML) techniques to identify and classify documentation of preoperative cannabis use status. MATERIALS AND METHODS We developed and applied a keyword search strategy to identify documentation of preoperative cannabis use status in clinical documentation within 60 days of surgery. We manually reviewed matching notes to classify each documentation into 8 different categories based on context, time, and certainty of cannabis use documentation. We applied 2 conventional ML and 3 deep learning models against manual annotation. We externally validated our model using the MIMIC-III dataset. RESULTS The tested classifiers achieved classification results close to human performance with up to 93% and 94% precision and 95% recall of preoperative cannabis use status documentation. External validation showed consistent results with up to 94% precision and recall. DISCUSSION Our NLP model successfully replicated human annotation of preoperative cannabis use documentation, providing a baseline framework for identifying and classifying documentation of cannabis use. We add to NLP methods applied in healthcare for clinical concept extraction and classification, mainly concerning social determinants of health and substance use. Our systematically developed lexicon provides a comprehensive knowledge-based resource covering a wide range of cannabis-related concepts for future NLP applications. CONCLUSION We demonstrated that documentation of preoperative cannabis use status could be accurately identified using an NLP algorithm. This approach can be employed to identify comparison groups based on cannabis exposure for growing research efforts aiming to guide cannabis-related clinical practices and policies.
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Affiliation(s)
- Ruba Sajdeya
- Department of Epidemiology, College of Public Health & Health Professions & College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Mamoun T Mardini
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Patrick J Tighe
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Ronald L Ison
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Chen Bai
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Sebastian Jugl
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Gao Hanzhi
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Kimia Zandbiglari
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Farzana I Adiba
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Thomas A Pearson
- Department of Epidemiology, College of Public Health & Health Professions & College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Robert L Cook
- Department of Epidemiology, College of Public Health & Health Professions & College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Masoud Rouhizadeh
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
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Sarayani A, Brown JD, Hampp C, Donahoo WT, Winterstein AG. Adaptability of High Dimensional Propensity Score Procedure in the Transition from ICD-9 to ICD-10 in the US Healthcare System. Clin Epidemiol 2023; 15:645-660. [PMID: 37274833 PMCID: PMC10237200 DOI: 10.2147/clep.s405165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/20/2023] [Indexed: 06/07/2023] Open
Abstract
Background High-Dimensional Propensity Score procedure (HDPS) is a data-driven approach to assist control for confounding in pharmacoepidemiologic research. The transition to the International Classification of Disease (ICD-9/10) in the US health system may pose uncertainty in applying the HDPS procedure. Methods We assembled a base cohort of patients in MarketScan® Commercial Claims Database who had newly initiated celecoxib or traditional NSAIDs to compare gastrointestinal bleeding risk. We then created bootstrapped hypothetical cohorts from the base cohort with predefined patient selection patterns from the ICD eras. Three strategies for HDPS deployment were tested: 1) split the cohort by ICD era, deploy HDPS twice, and pool the relative risks (pooled RR), 2) consider codes from each ICD era as a separate data dimension and deploy HDPS in the entire cohort (data dimensions) and 3) map ICD codes from both eras to Clinical Classifications Software (CCS) concepts before deploying HDPS in the entire cohort (CCS mapping). We calculated percent bias and root-mean-squared error to compare the strategies. Results A similar bias reduction was observed in cohorts where patient selection pattern from each ICD era was comparable between the exposure groups. In the presence of considerable disparity in patient selection, we observed a bimodal distribution of propensity scores in the data dimensions strategy, indicating instrument-like covariates. Moreover, the CCS mapping strategy resulted in at least 30% less bias than pooled RR and data dimensions strategies (RMSE: 0.14, 0.19, 0.21, respectively) in this scenario. Conclusion Mapping ICD codes to a stable terminology like CCS serves as a helpful strategy to reduce residual bias when deploying HDPS in pharmacoepidemiologic studies spanning both ICD eras.
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Affiliation(s)
- Amir Sarayani
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Safety and Evaluation, University of Florida, Gainesville, FL, USA
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Safety and Evaluation, University of Florida, Gainesville, FL, USA
| | - Christian Hampp
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Regeneron Pharmaceuticals Inc., Tarrytown, NY, USA
| | - William T Donahoo
- Division of Endocrinology, Diabetes, & Metabolism, College of Medicine, University of Florida, Gainesville, FL, USA
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Safety and Evaluation, University of Florida, Gainesville, FL, USA
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Nduaguba SO, Smolinski NE, Thai TN, Bird ST, Rasmussen SA, Winterstein AG. Validation of an ICD-9-Based Algorithm to Identify Stillbirth Episodes from Medicaid Claims Data. Drug Saf 2023; 46:457-465. [PMID: 37043168 DOI: 10.1007/s40264-023-01287-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION In administrative data, accurate timing of exposure relative to gestation is critical for determining the effect of potential teratogen exposure on pregnancy outcomes. OBJECTIVE To develop an algorithm for identifying stillbirth episodes in the ICD-9-CM era using national Medicaid claims data (1999-2014). METHODS Unique stillbirth episodes were identified from clusters of medical claims using a hierarchy that identified the encounter with the highest potential of including the actual stillbirth delivery and that delineated subsequent pregnancy episodes. Each episode was validated using clinical detail on retrieved medical records as the gold standard. RESULTS Among 220 retrieved records, 197 were usable for validation of 1417 stillbirth episodes identified by the algorithm. The positive predictive value (PPV) was 64.0% (57.3-70.7%) overall, 80.4% (73.8-87.1%) for inpatient episodes, 28.2% (14.1-42.3%) for outpatient-only episodes, and 20.0% (2.5-37.5%) for outpatient episodes with overlapping hospitalizations. The absolute difference between the dates of the algorithm-specified stillbirth delivery and the medical record-based event was 4.2 ± 24.3 days overall, 1.7 ± 7.7 days for inpatient episodes, 14.3 ± 51.4 days for outpatient-only episodes, and 1.0 ± 2.0 days for outpatient episodes that overlapped with a hospitalization. Excluding all outpatient episodes, as well as pregnancies involving multiple births, the PPV increased to 82.7% (76.8-89.8%). CONCLUSIONS Our algorithm to identify stillbirths from administrative claims data had a moderately high PPV. Positive predictive value was substantially increased by restricting the setting to inpatient episodes and using only input diagnostic codes for singleton stillbirths.
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Affiliation(s)
- Sabina O Nduaguba
- Department of Pharmaceutical Systems and Policy, College of Pharmacy, West Virginia University, Morgantown, WV, USA
- West Virginia University Cancer Institute, Morgantown, WV, USA
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, PO Box 100496, Gainesville, FL, 32611, USA
| | - Nicole E Smolinski
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, PO Box 100496, Gainesville, FL, 32611, USA
| | - Thuy N Thai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, PO Box 100496, Gainesville, FL, 32611, USA
- Faculty of Pharmacy, Ho Chi Minh City University of Technology (HUTECH), Ho Chi Minh City, Vietnam
| | - Steven T Bird
- Division of Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Sonja A Rasmussen
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
- Department of Epidemiology, College of Public Health and Health Professionals and College of Medicine, University of Florida, Gainesville, FL, USA
- Department of Pediatrics and Obstetrics and Gynecology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, PO Box 100496, Gainesville, FL, 32611, USA.
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA.
- Department of Epidemiology, College of Public Health and Health Professionals and College of Medicine, University of Florida, Gainesville, FL, USA.
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Wang Y, Cavallari LH, Brown JD, Thomas CD, Winterstein AG. Assessing the Clinical Treatment Dynamics of Antiplatelet Therapy Following Acute Coronary Syndrome and Percutaneous Coronary Intervention in the US. JAMA Netw Open 2023; 6:e238585. [PMID: 37067798 PMCID: PMC10111179 DOI: 10.1001/jamanetworkopen.2023.8585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Importance A platelet ADP P2Y12 receptor (P2Y12) inhibitor plus aspirin is standard therapy for patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Compared with clopidogrel, prasugrel and ticagrelor are associated with superior antiatherothrombotic effects but increased bleeding risk; with recent guideline updates, it is important to describe current treatment patterns and the role of bleeding risk in treatment choice. Objective To describe secular trends and determinants of initial P2Y12 inhibitor choice and switching, including deescalation (switch from prasugrel or ticagrelor to clopidogrel). Design, Setting, and Participants This retrospective cohort study used MarketScan Commercial Claims Data from 2010 to 2019 for patients aged 18 years or older who underwent PCI for ACS, had no P2Y12 inhibitor use in the past year, and filled a P2Y12 inhibitor prescription within 30 days after PCI hospitalization discharge. Data were analyzed from February to May 2022. Exposures Clopidogrel, prasugrel, and ticagrelor, with determinants including bleeding risk measured using Academic Research Consortium for High Bleeding Risk criteria, sociodemographic characteristics, P2Y12 inhibitor copays, and bleeding events during follow-up. Main Outcomes and Measures The prevalence of each P2Y12 inhibitor among patients who initiated the drugs and the prevalence of switching within 12 months after PCI were evaluated. The association between baseline bleeding risk and bleeding manifestations during follow-up and initial treatment and deescalation were calculated using multivariable logistic and Cox proportional hazards regression models. Results Between 2010 and 2019, 62 423 patients were identified who initiated P2Y12 inhibitors (females, 22.4%; males, 77.6%; mean [SD] age, 54.32 [7.13] years). The prevalence of clopidogrel as initial therapy decreased from 77.5% in 2010 to 29.6% in 2019, while initial use of prasugrel or ticagrelor increased from 22.5% to 60.4%. Within 1 year after PCI, 11.0% of patients switched therapy, mostly for deescalation. Deescalation prevalence increased from 1.8% in 2010 to 12.6% in 2018. Between 2016 and 2018, 8588 of 22 886 (37.5%) patients had major baseline bleeding risk, which decreased the selection of prasugrel or ticagrelor as initial therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.84). Among 11 285 patients who initiated prasugrel or ticagrelor, major bleeding risk at baseline (adjusted hazard ratio, 1.11; 95% CI, 1.00-1.23) and the occurrence of bleeding during follow-up (adjusted hazard ratio, 4.42; 95% CI, 3.62-5.93) were associated with deescalation. Conclusions and Relevance A strong shift in preference for prasugrel and ticagrelor as initial therapy following PCI for ACS was observed. Deescalation increased over the study period. Major bleeding risk at baseline was moderately associated with initial treatment choice but had a limited association with deescalation. The increasing use of more potent P2Y12 inhibitors emphasizes opportunities to enhance preemptive patient-centered treatment strategies to maintain optimal antiplatelet activity while reducing bleeding risk during the subacute period following PCI for ACS.
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Affiliation(s)
- Yehua Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
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Sarayani A, Donahoo WT, Hampp C, Brown JD, Winterstein AG. Assessment of the Risk Evaluation and Mitigation Strategy (REMS) for Phentermine-Topiramate to Prevent Exposure During Pregnancy. Ann Intern Med 2023; 176:443-454. [PMID: 36940443 DOI: 10.7326/m22-1743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
BACKGROUND The U.S. Food and Drug Administration approved phentermine-topiramate for obesity in 2012 and required a Risk Evaluation and Mitigation Strategy (REMS) to prevent prenatal exposure. No such requirement was introduced for topiramate. OBJECTIVE To evaluate the rate of prenatal exposure, contraceptive use, and pregnancy testing among patients with phentermine-topiramate compared with topiramate or other antiobesity medications (AOMs). DESIGN Retrospective cohort study. SETTING Nationwide health insurance claims database. PARTICIPANTS Females aged 12 to 55 years with no infertility diagnosis or sterilization procedure. Patients with other indications for topiramate were excluded to identify a cohort that was likely treated for obesity. MEASUREMENTS Patients initiated use of phentermine-topiramate, topiramate, or an AOM (liraglutide, lorcaserin, or bupropion-naltrexone). Pregnancy at treatment initiation, conception during treatment, contraceptive use, and pregnancy testing outcomes were ascertained. Measurable confounders were adjusted for, and extensive sensitivity analyses were done. RESULTS A total of 156 280 treatment episodes were observed. Adjusted prevalence of pregnancy at treatment initiation was 0.9 versus 1.6 per 1000 episodes (prevalence ratio, 0.54 [95% CI, 0.31 to 0.95]) for phentermine-topiramate versus topiramate. The incidence rate of conception during treatment was 9.1 versus 15.0 per 1000 person-years (rate ratio, 0.61 [CI, 0.40 to 0.91]) for phentermine-topiramate versus topiramate. Both outcomes were similarly lower for phentermine-topiramate compared with AOM. Prenatal exposure was marginally lower in topiramate users compared with AOM users. Approximately 20% of patients in all cohorts had at least 50% of treatment days covered by contraceptives. Few patients had pregnancy tests before treatment (≤5%), but this was more common among phentermine-topiramate users. LIMITATIONS Outcome misclassification; unmeasured confounding due to lack of prescriber data to account for possible clustering and spillover effects. CONCLUSION Prenatal exposure seemed to be significantly lower among phentermine-topiramate users under the REMS. Pregnancy testing and contraceptive use appeared to be inadequate for all groups, which deserves attention to prevent the remaining potential exposures. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Amir Sarayani
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, and Center for Drug Safety and Evaluation, University of Florida, Gainesville, Florida (A.S., J.D.B., A.G.W.)
| | - William Troy Donahoo
- Division of Endocrinology, Diabetes & Metabolism and Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida (W.T.D.)
| | - Christian Hampp
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, and Regeneron Pharmaceuticals, Inc., Tarrytown, New York (C.H.)
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, and Center for Drug Safety and Evaluation, University of Florida, Gainesville, Florida (A.S., J.D.B., A.G.W.)
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, and Center for Drug Safety and Evaluation, University of Florida, Gainesville, Florida (A.S., J.D.B., A.G.W.)
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Smith KM, Winterstein AG, Gurka MJ, Walsh M, Keshwani S, Libby A, Hogan W, Pepine CJ, Cooper-Dehoff RM, Smith SM. Abstract P394: Initial Antihypertensive Prescribing in Relation to Blood Pressure Among Medicaid and Medicare Recipients. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Introduction:
Early treatment for hypertension (HTN) portends better outcomes. However, few real-world studies have assessed initial antiHTN regimens and how they differ by baseline blood pressure (BP). We sought to compare initial treatment patterns, stratified by BP, between Medicaid and Medicare recipients.
Methods:
We performed a cross-sectional study of adults with newly-treated HTN in the One Florida+ Consortium(2012-2020) who had linked claims-EHR data from the treatment initiation visit. Eligible patients were Floridians with Medicaid or Medicare aged ≥18 years, with diagnosed HTN, who filled ≥1 first-line antiHTN class with no evidence of anti HTN fills during the year prior (in which continuous insurance enrollment was required). Baseline BP was categorized per current HTN guidelines, and logistic regression was used to estimate age-adjusted odds of combination vs. monotherapy, per 10 mmHg increase in systolic BP (SBP) or diastolic BP (DBP).
Results:
We included 2,902 patients (47% Medicaid, 53% Medicare); mean age was 44 (Medicaid) and 67 yrs(Medicare); 60% (64% and 56%, respectively) were women and 42% (57% and 29%, respectively) were Black. Initial antiHTN classes were similar comparing cohorts: ACEI, ARB and thiazide initiation varied little by BP category, in contrast to CCBs and β-blockers (Figure, panels A-B). In age-adjusted analyses, use of initial combination therapy was 40% more likely (OR, 1.40; 95% CI, 1.11, 1.76) among Medicare recipients and inversely related to BP category (panels C-D) among Medicare patients, in which each 10mmHg greater SBP (OR, 0.93; 95% CI, 0.88, 0.97) and DBP (OR 0.82; 95% CI, 0.75, 0.90) had lower odds of combination therapy. Among Medicaid recipients, only SBP associated with combination therapy (OR1.11; 95% CI, 1.03, 1.20).
Conclusions:
We observed similar initial class patterns among Medicaid & Medicare recipients across baseline BP, but differential use of combination therapy was less likely at higher baseline BP in Medicare recipients, which contrasts current guidance.
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Affiliation(s)
- Kayla M Smith
- Dept of Pharmaceutical Outcomes and Policy, College of Pharmacy, Univ of Florida, Gainesville, FL
| | - Almut G Winterstein
- Dept of Pharmaceutical Outcomes and Policy, College of Pharmacy, Univ of Florida, Gainesville, FL
| | - Matthew J Gurka
- Dept of Pediatrics, College of Medicine, Univ of Florida, Gainesville, FL
| | - Marta Walsh
- Dept of Pharmaceutical Outcomes and Policy, College of Pharmacy, Univ of Florida, Gainesville, FL
| | - Shailina Keshwani
- Dept of Pharmaceutical Outcomes and Policy, College of Pharmacy, Univ of Florida, Gainesville, FL
| | - Anne Libby
- Dept of Emergency Medicine, Sch of Medicine, Univ of Colorado Denver, Aurora, CO
| | - William Hogan
- Dept of Health Outcomes and Biomedical Informatics, College of Medicine, Univ of Florida, Gainesville, FL
| | - Carl J Pepine
- Div of Cardiovascular Medicine, Dept of Medicine, College of Medicine, Univ of Florida, Gainesville, FL
| | - Rhonda M Cooper-Dehoff
- Dept of Pharmacotherapy and Translational Rsch, College of Pharmacy, Univ of Florida, Gainesville, FL
| | - Steven M Smith
- Dept of Pharmaceutical Outcomes and Policy, College of Pharmacy, Univ of Florida, Gainesville, FL
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Thai TN, Rasmussen SA, Smolinski NE, Nduaguba S, Zhu Y, Bateman BT, Huybrechts KF, Hernandez-Diaz S, Winterstein AG. IMPACT OF CONTINUOUS MATERNAL ENROLLMENT ON STILLBIRTH GESTATIONAL AGE DISTRIBUTIONS AND MATERNAL CHARACTERISTICS AMONG MEDICAID ENROLLEES. Am J Epidemiol 2023; 192:497-502. [PMID: 36482740 DOI: 10.1093/aje/kwac206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 11/10/2022] [Indexed: 12/13/2022] Open
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23
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Albogami Y, Zhu Y, Wang X, Winterstein AG. Concordance of neonatal critical condition data between secondary databases: Florida and Texas birth certificate Linkage with medicaid analytic extract. BMC Med Res Methodol 2023; 23:47. [PMID: 36803103 PMCID: PMC9940322 DOI: 10.1186/s12874-023-01860-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 02/03/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Limited information is available about neonates' critical conditions data quality. The study aim was to measure the agreement regarding presence of neonatal critical conditions between Medicaid Analytic eXtract claims data and Birth Certificate (BC) records. METHODS Claims data files of neonates born between 1999-2010 and their mothers were linked to birth certificates in the states of Texas and Florida. In claims data, neonatal critical conditions were identified using medical encounter claims records within the first 30 days postpartum, while in birth certificates, the conditions were identified based on predetermined variables. We calculated the prevalence of cases within each data source that were identified by its comparator, in addition to calculating overall agreement and kappa statistics. RESULTS The sample included 558,224 and 981,120 neonates in Florida and Texas, respectively. Kappa values show poor agreement (< 20%) for all critical conditions except neonatal intensive care unit (NICU) admission, which showed moderate (> 50%) and substantial (> 60%) agreement in Florida and Texas, respectively. claims data resulted in higher prevalences and capture of a larger proportion of cases than the BC, except for assisted ventilation. CONCLUSIONS Claims data and BC showed low agreement on neonatal critical conditions except for NICU admission. Each data source identified cases most of which the comparator failed to capture, with higher prevalences estimated within claims data except for assisted ventilation.
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Affiliation(s)
- Yasser Albogami
- grid.15276.370000 0004 1936 8091Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida USA ,grid.56302.320000 0004 1773 5396Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Yanmin Zhu
- grid.15276.370000 0004 1936 8091Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida USA
| | - Xi Wang
- grid.15276.370000 0004 1936 8091Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA. .,Center for Drug Evaluation and Safety, University of Florida College of Pharmacy, Gainesville, Florida, USA.
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Nduaguba SO, Tran PT, Choi Y, Winterstein AG. Respiratory syncytial virus reinfections among infants and young children in the United States, 2011-2019. PLoS One 2023; 18:e0281555. [PMID: 36795639 PMCID: PMC9934310 DOI: 10.1371/journal.pone.0281555] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 01/26/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Although respiratory syncytial virus (RSV) immunoprophylaxis is recommended for high-risk infants, the American Academy of Pediatrics (AAP) recommends against immunoprophylaxis in the same season following a breakthrough hospitalization due to limited risk for a second hospitalization. Evidence in support of this recommendation is limited. We estimated population-based re-infection rates from 2011-2019 in children <5 years since RSV risk remains relatively high in this age group. MATERIALS AND METHODS Using claims data from private insurance enrollees, we established cohorts of children <5 years who were followed to ascertain annual (July 1-June 30) and seasonal (November 1- February 28/29) RSV recurrence estimates. Unique RSV episodes included inpatient encounters with RSV diagnosis ≥30 days apart, and outpatient encounters ≥30 days apart from each other as well as from inpatient encounters. The risk of annual and seasonal re-infection was calculated as the proportion of children with a subsequent RSV episode in the same RSV year/season. RESULTS Over the 8 assessed seasons/years (N = 6,705,979) and across all age groups annual inpatient and outpatient infection rates were 0.14% and 1.29%, respectively. Among children with a first infection, annual inpatient and outpatient re-infection rates were 0.25% (95% confidence interval (CI) = 0.22-0.28) and 3.44% (95% CI = 3.33-3.56), respectively. Both infection and re-infection rates declined with age. CONCLUSION While medically-attended re-infections contributed numerically only a fraction of the total RSV infections, re-infections among those with previous infection in the same season were of similar magnitude as the general infection risk, suggesting that a previous infection may not attenuate the risk for a re-infection.
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Affiliation(s)
- Sabina O. Nduaguba
- Department of Pharmaceutical Systems and Policy, College of Pharmacy, West Virginia University, Morgantown, WV, United States of America
- West Virginia University Cancer Institute, Morgantown, WV, United States of America
| | - Phuong T. Tran
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, United States of America
- Faculty of Pharmacy, HUTECH University, Ho Chi Minh City, Vietnam
| | - Yoonyoung Choi
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, United States of America
- Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States of America
- * E-mail:
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Tran PT, Antonelli PJ, Winterstein AG. Quinolone Ear Drops and Achilles Tendon Rupture. Clin Infect Dis 2023; 76:e1360-e1368. [PMID: 36065683 DOI: 10.1093/cid/ciac709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/15/2022] [Accepted: 08/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delayed eardrum healing has been observed in the ear opposite to the ear treated with otic quinolones (OQ) in rats. Case reports describe tendinopathies after OQ treatment, suggesting adverse systemic effects. METHODS We studied patients aged 19 to 64 years with diagnosis of otitis externa or media in private insurance between 2005 and 2015. We compared OQ treatment against otic neomycin, oral amoxicillin, or azithromycin. Outcomes included Achilles tendon rupture (ATR), Achilles tendinitis (AT), and all-type tendon rupture (ATTR). We applied an active comparator, new-user design with 1-year look-back and ceased follow-up at initiation of systemic steroids or oral quinolones, external injury, hospitalization, and after 35 days. We used trimmed stabilized inverse probability of treatment weights to balance comparison groups in a survival framework. Negative outcomes (clavicle fractures or sports injuries) were examined to rule out differences from varied physical activity (unmeasured confounding). RESULTS We examined 1 501 009 treated otitis episodes. Hazard ratios (HR) for OQ exposure associated with ATR were 4.49 (95% confidence interval [CI], 1.83-11.02), AT 1.04 (95% CI, 0.73-1.50), and ATTR 1.71 (95% CI, 1.21-2.41). Weighted risk differences (RD) per 100 000 episodes for OQ exposure were ATR 7.80 (95% CI, 0.72-14.89), AT 1.01 (95% CI, -12.80 to 14.81), and ATTR 18.57 (95% CI, 3.60-33.53). Corresponding HRs for clavicle fractures and sports injuries were HR,1.71 (95% CI, 0.55-5.27) and HR,1.45 (95% CI, 0.64-3.30), suggesting limited residual confounding. CONCLUSIONS OQ exposure may lead to systemic consequences. Clinicians should consider this potential risk and counsel patients accordingly. Risk factors and mechanisms for this rare, adverse effect deserve further evaluation. Mechanistic and other clinical studies are warranted to corroborate this finding.
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Affiliation(s)
- Phuong T Tran
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Faculty of Pharmacy, HUTECH University, Ho Chi Minh City, Vietnam
| | - Patrick J Antonelli
- College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA.,Department of Otolaryngology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA.,Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
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Goodin AJ, Tran PT, McKee S, Sajdeya R, Jyot J, Cook RL, Wang Y, Winterstein AG. Proceedings of the 2023 Cannabis Clinical Outcomes Research Conference. Med Cannabis Cannabinoids 2023; 6:97-101. [PMID: 37900895 PMCID: PMC10601943 DOI: 10.1159/000533943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 10/31/2023] Open
Abstract
The Consortium for Medical Marijuana Clinical Outcomes Research, a multi-university collaboration established by the state of Florida in the USA, hosted its third annual Cannabis Clinical Outcomes Research Conference (CCORC) in May 2023. CCORC was held as a hybrid conference, with a scientific program consisting of in-person sessions, with some sessions livestreamed to virtual attendees. CCORC facilitated and promoted up-to-date research on the clinical effects of medical cannabis, fostering collaboration and active involvement among scientists, policymakers, industry professionals, clinicians, and other stakeholders. Three themes emerged from conference sessions and speaker presentations: (1) disentangling conflicting evidence for the effects of medical cannabis on public health, (2) seeking solutions to address barriers faced when conducting clinical cannabis research - especially with medical cannabis use in special populations such as those who are pregnant, and (3) unpacking the data behind cannabis use and mental health outcomes. The fourth annual CCORC is planned for the summer of 2024 in Florida, USA.
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Affiliation(s)
- Amie J. Goodin
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
- Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, FL, USA
| | - Phuong T. Tran
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
| | - Sam McKee
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
- Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, FL, USA
| | - Ruba Sajdeya
- Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, FL, USA
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
| | - Jeevan Jyot
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
- Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, FL, USA
| | - Robert L. Cook
- Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, FL, USA
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Yan Wang
- Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, FL, USA
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
| | - Almut G. Winterstein
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
- Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, FL, USA
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Sajdeya R, Fechtel HJ, Spandau G, Goodin AJ, Brown JD, Jugl S, Smolinski NE, Winterstein AG, Cook RL, Wang Y. Protocol of a Combined Cohort and Cross-Sectional Study of Persons Receiving Medical Cannabis in Florida, USA: The Medical Marijuana and Me (M 3) Study. Med Cannabis Cannabinoids 2023; 6:46-57. [PMID: 37261066 PMCID: PMC10228286 DOI: 10.1159/000530052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 03/01/2023] [Indexed: 06/02/2023] Open
Abstract
Significant knowledge gaps regarding the effectiveness and safety of medical cannabis (MC) create clinical challenges for MC physicians, making treatment recommendations and patients choosing treatment among the growing number of options offered in dispensaries. Additionally, data describing the characteristics of people who use MC and the products and doses they receive are lacking. The Medical Marijuana and Me (M3) Study was designed to collect patient-centered data from MC users. We aim to describe preferred MC use patterns that patients report as "most effective" for specific health conditions and symptoms, identify user characteristics associated with such use patterns, characterize adverse effects, including cannabis use disorder, identify products and patient characteristics associated with adverse effects, describe concurrent prescription medication use, and identify concomitant medication use with potential drug-MC interaction risk. Among MC initiators, we also aim to quantify MC use persistence and identify reasons for discontinuation, assess MC utilization pattern trajectories over time, describe outcome trajectories of primary reasons for MC use and determine factors associated with different trajectories, track changes in concomitant substance and medication use after MC initiation, and identify factors associated with such changes. M3 is a combined study comprised of: (1) a prospective cohort of MC initiators completing surveys at enrollment, 3 months, and 9 months after MC initiation and (2) a cross-sectional study of current MC users. A multidisciplinary committee including researchers, physicians, pharmacists, patients, and dispensary personnel designed and planned study protocols, established study measures, and created survey questionnaires. M3 will recruit 1,000-1,200 participants aged ≥18 years, with ∼50% new and ∼50% current MC patients from MC clinics across Florida, USA. Study enrollment started in May 2022 and will continue until the target number of patients is achieved. Survey domains include sociodemographic characteristics, physical and mental health, cannabis use history, reasons for MC use and discontinuation, MC products and use patterns, concurrent use of prescription medications and other substances, and side effects. Data collected in the M3 Study will be available for interested researchers affiliated with the Consortium for Medical Marijuana Clinical Outcomes Research. The M3 Study and Databank will be the largest cohort of current and new MC users in Florida, USA, which will provide data to support MC-related health research necessary to inform policy and clinical practice and ultimately improve patient outcomes.
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Affiliation(s)
- Ruba Sajdeya
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
| | - Hannah J. Fechtel
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
| | - Gabriel Spandau
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
- Department of Agricultural Education and Communication, College of Agricultural and Life Sciences, University of Florida, Gainesville, Florida, USA
| | - Amie J. Goodin
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Joshua D. Brown
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Sebastian Jugl
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Nicole E. Smolinski
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Almut G. Winterstein
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Robert L. Cook
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
| | - Yan Wang
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
- Consortium for Medical Marijuana Clinical Outcomes Research, Gainesville, Florida, USA
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Smith SM, Winterstein AG, Gurka MJ, Walsh MG, Keshwani S, Libby AM, Hogan WR, Pepine CJ, Cooper‐DeHoff RM. Initial Antihypertensive Regimens in Newly Treated Patients: Real World Evidence From the OneFlorida+ Clinical Research Network. J Am Heart Assoc 2022; 12:e026652. [PMID: 36565195 PMCID: PMC9973585 DOI: 10.1161/jaha.122.026652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Knowledge of real-world antihypertensive use is limited to prevalent hypertension, limiting our understanding of how treatment evolves and its contribution to persistently poor blood pressure control. We sought to characterize antihypertensive initiation among new users. Methods and Results Using Medicaid and Medicare data from the OneFlorida+ Clinical Research Consortium, we identified new users of ≥1 first-line antihypertensives (angiotensin-converting enzyme inhibitor, calcium channel blocker, angiotensin receptor blocker, thiazide diuretic, or β-blocker) between 2013 and 2021 among adults with diagnosed hypertension, and no antihypertensive fill during the prior 12 months. We evaluated initial antihypertensive regimens by class and drug overall and across study years and examined variation in antihypertensive initiation across demographics (sex, race, and ethnicity) and comorbidity (chronic kidney disease, diabetes, and atherosclerotic cardiovascular disease). We identified 143 054 patients initiating 188 995 antihypertensives (75% monotherapy; 25% combination therapy), with mean age 59 years and 57% of whom were women. The most commonly initiated antihypertensive class overall was angiotensin-converting enzyme inhibitors (39%) followed by β-blockers (31%), calcium channel blockers (24%), thiazides (19%), and angiotensin receptor blockers (11%). With the exception of β-blockers, a single drug accounted for ≥75% of use of each class. β-blocker use decreased (35%-26%), and calcium channel blocker use increased (24%-28%) over the study period, while initiation of most other classes remained relatively stable. We also observed significant differences in antihypertensive selection across demographic and comorbidity strata. Conclusions These findings indicate that substantial variation exists in initial antihypertensive prescribing, and there remain significant gaps between current guideline recommendations and real-world implementation in early hypertension care.
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Affiliation(s)
- Steven M. Smith
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL,Division of Cardiovascular Medicine, Department of Medicine, College of MedicineUniversity of FloridaGainesvilleFL,Center for Integrative Cardiovascular and Metabolic DiseaseUniversity of FloridaGainesvilleFL
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Matthew J. Gurka
- Department of Health Outcomes and Biomedical Informatics, College of MedicineUniversity of FloridaGainesvilleFL
| | - Marta G. Walsh
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Shailina Keshwani
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Anne M. Libby
- Department of Emergency Medicine, School of MedicineUniversity of Colorado DenverAuroraCO
| | - William R. Hogan
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Carl J. Pepine
- Division of Cardiovascular Medicine, Department of Medicine, College of MedicineUniversity of FloridaGainesvilleFL
| | - Rhonda M. Cooper‐DeHoff
- Division of Cardiovascular Medicine, Department of Medicine, College of MedicineUniversity of FloridaGainesvilleFL,Center for Integrative Cardiovascular and Metabolic DiseaseUniversity of FloridaGainesvilleFL,Department of Pharmacotherapy and Translational Research, College of PharmacyUniversity of FloridaGainesvilleFL
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Wang X, Zimmermann EM, Goodin AJ, Brown J, Winterstein AG. Risk of preterm delivery and small for gestational age among women with inflammatory bowel disease using tumor necrosis factor alpha inhibitors during pregnancy. Am J Obstet Gynecol 2022; 228:474-476. [PMID: 36565900 DOI: 10.1016/j.ajog.2022.12.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Xi Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Ellen M Zimmermann
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Gastroenterology, University of Florida, Gainesville, FL
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL; Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL
| | - Joshua Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL; Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL; Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL; Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, FL.
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Sarayani A, Hampp C, Brown JD, Donahoo WT, Winterstein AG. Topiramate Utilization After Phentermine/Topiramate Approval for Obesity Management: Risk Minimization in the Era of Drug Repurposing. Drug Saf 2022; 45:1517-1527. [DOI: 10.1007/s40264-022-01244-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/27/2022]
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Chen C, Tighe PJ, Lo-Ciganic WH, Winterstein AG, Wei YJ. Perioperative Use of Gabapentinoids and Risk for Postoperative Long-Term Opioid Use in Older Adults Undergoing Total Knee or Hip Arthroplasty. J Arthroplasty 2022; 37:2149-2157.e3. [PMID: 35577053 PMCID: PMC9588599 DOI: 10.1016/j.arth.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Gabapentinoids are recommended by guidelines as a component of multimodal analgesia to manage postoperative pain and reduce opioid use. It remains unknown whether perioperative use of gabapentinoids is associated with a reduced or increased risk of postoperative long-term opioid use (LTOU) after total knee or hip arthroplasty (TKA/THA). METHODS Using Medicare claims data from 2011 to 2018, we identified fee-for-service beneficiaries aged ≥ 65 years who were hospitalized for a primary TKA/THA and had no LTOU before the surgery. Perioperative use of gabapentinoids was measured from 7 days preadmission through 7 days postdischarge. Patients were required to receive opioids during the perioperative period and were followed from day 7 postdischarge for 180 days to assess postoperative LTOU (ie, ≥90 consecutive days). A modified Poisson regression was used to estimate the relative risk (RR) of postoperative LTOU in patients with versus without perioperative use of gabapentinoids, adjusting for confounders through propensity score weighting. RESULTS Of 52,788 eligible Medicare older beneficiaries (mean standard deviation [SD] age 72.7 [5.3]; 62.5% females; 89.7% White), 3,967 (7.5%) received gabapentinoids during the perioperative period. Postoperative LTOU was 3.8% in patients with and 4.0% in those without perioperative gabapentinoids. After adjusting for confounders, the risk of postoperative LTOU was similar comparing patients with versus without perioperative gabapentinoids (RR = 1.07; 95% confidence interval [CI] = 0.91-1.26, P = .408). Sensitivity and bias analyses yielded consistent results. CONCLUSION Among older Medicare beneficiaries undergoing a primary TKA/THA, perioperative use of gabapentinoids was not associated with a reduced or increased risk for postoperative LTOU.
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Affiliation(s)
- Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida
| | - Patrick J Tighe
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida; Department of Epidemiology, University of Florida Colleges of Medicine and Public Health and Health Professions, Gainesville, Florida
| | - Yu-Jung Wei
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida
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Smolinski NE, Sajdeya R, Cook R, Wang Y, Winterstein AG, Goodin A. Proceedings of the 2022 Cannabis Clinical Outcomes Research Conference. Med Cannabis Cannabinoids 2022; 5:138-141. [DOI: 10.1159/000527080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/30/2022] [Indexed: 11/19/2022] Open
Abstract
The Consortium for Medical Marijuana Clinical Outcomes Research, a multi-university collaboration established by the state of Florida in the USA, hosted its second annual Cannabis Clinical Outcomes Research Conference (CCORC) in May 2022. CCORC was held as a hybrid conference, with a scientific program consisting of in-person and virtual sessions. CCORC fostered and disseminated current research on clinical outcomes of medical marijuana while stimulating collaboration and engagement between the scientific community, policymakers, industry representatives, clinicians, and other interested stakeholders. Three themes emerged from conference sessions and speakers: (1) disentangling research findings comparing use and outcomes of medical and nonmedical cannabis, (2) addressing barriers and promoting facilitators for clinical cannabis research, and (3) resolving uncertainties around cannabis dosing. The third annual CCORC is planned for the summer of 2023 in Florida, USA.
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Winterstein AG, Thai TN, Nduaguba S, Smolinski NE, Wang X, Sahin L, Krefting I, Gelperin K, Bird ST, Rasmussen SA. Risk of fetal or neonatal death or neonatal intensive care unit admission associated with gadolinium magnetic resonance imaging exposure during pregnancy. Am J Obstet Gynecol 2022; 228:465.e1-465.e11. [PMID: 36241080 DOI: 10.1016/j.ajog.2022.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Concerns have been raised about prenatal exposure to magnetic resonance imaging with gadolinium-based contrast agents because of nonclinical findings of gadolinium retention in fetal tissue and 1 population-based study reporting an association with adverse pregnancy outcomes. OBJECTIVE This study aimed to evaluate the association between prenatal magnetic resonance imaging exposure with and without gadolinium-based contrast agents and fetal and neonatal death and neonatal intensive care unit admission. STUDY DESIGN We constructed a retrospective cohort of >11 million Medicaid-covered pregnancies between 1999 and 2014 to evaluate the association between prenatal magnetic resonance imaging exposure with and without gadolinium-based contrast agents and fetal and neonatal death (primary endpoint) and neonatal intensive care unit admissions (secondary endpoint). Medicaid claims data were linked to medical records, Florida birth and fetal death records, and the National Death Index to validate the outcomes and gestational age estimates. Pregnancies with multiples, concurrent cancer, teratogenic drug exposure, magnetic resonance imaging focused on fetal or pelvic evaluation, undetermined gadolinium-based contrast agent use, or those preceded by or contemporaneous with congenital anomaly diagnoses were excluded. We adjusted for potential confounders with standardized mortality ratio weighting using propensity scores. RESULTS Among 5991 qualifying pregnancies, we found 11 fetal or neonatal deaths in the gadolinium-based contrast agent magnetic resonance imaging group (1.4%) and 73 in the non-gadolinium-based contrast agent magnetic resonance imaging group (1.4%) with an adjusted relative risk of 0.73 (95% confidence interval, 0.34-1.55); the neonatal intensive care unit admission adjusted relative risk was 1.03 (0.76-1.39). Sensitivity analyses investigating the timing of magnetic resonance imaging or repeat magnetic resonance imaging exposure during pregnancy and simulating the impact of exposure misclassification corroborated these results. CONCLUSION This study addressed the safety concerns related to prenatal exposure to gadolinium-based contrast agents used in magnetic resonance imaging and the risk thereof on fetal and neonatal death or the need for neonatal intensive care unit admission. Although the results on fatal or severe acute effects are reassuring, the impact on subacute outcomes was not evaluated.
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Affiliation(s)
- Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL; Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL.
| | - Thuy N Thai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL; Faculty of Pharmacy, Ho Chi Minh City University of Technology (HUTECH), Ho Chi Minh City, Vietnam
| | - Sabina Nduaguba
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL
| | - Nicole E Smolinski
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL
| | - Xi Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Leyla Sahin
- Division of Pediatrics and Maternal Health, Office of New Drugs, Center for Drug Evaluation and Research (CDER), Food and Drug Administration (FDA), Silver Spring, MD
| | - Ira Krefting
- Division of Imaging and Radiation Medicine, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD
| | - Kate Gelperin
- Division of Epidemiology, Office of Surveillance and Epidemiology, CDER, FDA, Silver Spring, MD
| | - Steven T Bird
- Division of Epidemiology, Office of Surveillance and Epidemiology, CDER, FDA, Silver Spring, MD
| | - Sonja A Rasmussen
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL; Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL; Departments of Pediatrics, College of Medicine, University of Florida, Gainesville, FL; Obstetrics and Gynecology, College of Medicine, University of Florida, Gainesville, FL
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Wei YJJ, Chen C, Cheng TYD, Schmidt SO, Fillingim RB, Winterstein AG. Association of injury after prescription opioid initiation with risk for opioid-related adverse events among older Medicare beneficiaries in the United States: A nested case-control study. PLoS Med 2022; 19:e1004101. [PMID: 36136971 PMCID: PMC9498946 DOI: 10.1371/journal.pmed.1004101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Injury, prevalent and potentially associated with prescription opioid use among older adults, has been implicated as a warning sign of serious opioid-related adverse events (ORAEs) including opioid misuse, dependence, and poisoning, but this association has not been empirically tested. The study aims to examine the association between incident injury after prescription opioid initiation and subsequent risk of ORAEs and to assess whether the association differs by recency of injury among older patients. METHODS AND FINDINGS This nested case-control study was conducted within a cohort of 126,752 individuals aged 65 years or older selected from a 5% sample of Medicare beneficiaries in the United States between 2011 and 2018. Cohort participants were newly prescribed opioid users with chronic noncancer pain who had no injury or ORAEs in the year before opioid initiation, had 30 days or more of observation, and had at least 1 additional opioid prescription dispensed during follow-up. We identified ORAE cases as patients who had an inpatient or outpatient encounter with diagnosis codes for opioid misuse, dependence, or poisoning. During a mean follow-up of 1.8 years, we identified 2,734 patients who were newly diagnosed with ORAEs and 10,936 controls matched on the year of cohort entry date and a disease risk score (DRS), a summary score derived from the probability of an ORAE outcome based on covariates measured prior to cohort entry and in the absence of injury. Multivariate conditional logistic regression was used to estimate ORAE risk associated with any and recency of injury, defined based on the primary diagnosis code of inpatient and outpatient encounters. Among the cases and controls, 68.0% (n = 1,859 for cases and n = 7,436 for controls) were women and the mean (SD) age was 74.5 (6.9) years. Overall, 54.0% (n = 1,475) of cases and 46.0% (n = 1,259) of controls experienced incident injury after opioid initiation. Patients with (versus without) injury after opioid therapy had higher risk of ORAEs after adjustment for time-varying confounders, including diagnosis of tobacco or alcohol use disorder, drug use disorder, chronic pain diagnosis, mental health disorder, pain-related comorbidities, frailty index, emergency department visit, skilled nursing facility stay, anticonvulsant use, and patterns of prescription opioid use (adjusted odds ratio [aOR] = 1.4; 95% confidence interval (CI) 1.2 to 1.5; P < 0.001). Increased risk of ORAEs was associated with current (≤30 days) injury (aOR = 2.8; 95% CI 2.3 to 3.4; P < 0.001), whereas risk of ORAEs was not significantly associated with recent (31 to 90 days; aOR = 0.93; 95% CI 0.73 to 1.17; P = 0.48), past (91 to 180 days; aOR = 1.08; 95% CI 0.88 to 1.33; P = 0.51), and remote (181 to 365 days; aOR = 0.88; 95% CI 0.73 to 1.1; P = 0.18) injury preceding the incident diagnosis of ORAE or matched date. Patients with injury and prescription opioid use versus those with neither in the month before the ORAE or matched date were at greater risk of ORAEs (aOR = 5.0; 95% CI 4.1 to 6.1; P < 0.001). Major limitations are that the study findings can only be generalized to older Medicare fee-for-service beneficiaries and that unknown or unmeasured confounders have the potential to bias the observed association toward or away from the null. CONCLUSIONS In this study, we observed that incident diagnosis of injury following opioid initiation was associated with subsequent increased risk of ORAEs, and the risk was only significant among patients with injury in the month before the index date. Regular monitoring for injury may help identify older opioid users at high risk for ORAEs.
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Affiliation(s)
- Yu-Jung Jenny Wei
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- Division of Outcomes and Translational Sciences, College of Pharmacy, The Ohio State University, Columbus, Ohio, United States of America
- * E-mail:
| | - Cheng Chen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Ting-Yuan David Cheng
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, United States of America
| | - Siegfried O. Schmidt
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Roger B. Fillingim
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida, United States of America
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida, United States of America
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Tran PT, Nduaguba SO, Diaby V, Choi Y, Winterstein AG. RSV testing practice and positivity by patient demographics in the United States: integrated analyses of MarketScan and NREVSS databases. BMC Infect Dis 2022; 22:681. [PMID: 35941563 PMCID: PMC9360654 DOI: 10.1186/s12879-022-07659-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/25/2022] [Indexed: 11/12/2022] Open
Abstract
Background RSV-incidence estimates obtained from routinely-collected healthcare data (e.g., MarketScan) are commonly adjusted for under-reporting using test positivity reported in national Surveillance Systems (NREVSS). However, NREVSS lacks detail on patient-level characteristics and the validity of applying a single positivity estimate across diverse patient groups is uncertain. We aimed to describe testing practices and test positivity across subgroups of private health insurance enrollees in the US and illustrate the possible magnitude of misclassification when using NREVSS to correct for RSV under ascertainment. Methods Using billing records, we determined distributions of RSV-test claims and test positivity among a national sample of private insurance enrollees. Tests were considered positive if they coincided with an RSV-diagnosis. We illustrated the influence of positivity variation across sub-populations when accounting for untested acute respiratory infections. Results Most tests were for children (age 0–4: 65.8%) and outpatient encounters (78.3%). Test positivity varied across age (0–4: 19.8%, 5–17: 1.8%, adults: 0.7%), regions (7.6–16.1%), settings (inpatient 4.7%, outpatient 14.2%), and test indication (5.0–35.9%). When compared to age, setting or indication-specific positivity, bias due to using NREVSS positivity to correct for untested ARIs ranged from − 76% to 3556%. Conclusions RSV-test positivity depends on the characteristics of patients for whom those tests were ordered. NREVSS-based correction for RSV-under-ascertainment underestimates the true incidence among children and overestimate rates among adults. Demographic-specific detail on testing practice and positivity can improve the accuracy of RSV-incidence estimates. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07659-x.
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Affiliation(s)
- Phuong T Tran
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, PO Box 100496, Gainesville, FL, 32611-0496, USA.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.,Faculty of Pharmacy, HUTECH University, Ho Chi Minh City, Vietnam
| | - Sabina O Nduaguba
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, PO Box 100496, Gainesville, FL, 32611-0496, USA.,Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia, Morgantown, WV, USA.,West Virginia University Cancer Institute, Morgantown, WV, USA
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, PO Box 100496, Gainesville, FL, 32611-0496, USA.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.,Global Value and Real-World Evidence, Otsuka America Pharmaceutical, Inc., Princeton, NJ, USA
| | - Yoonyoung Choi
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, PO Box 100496, Gainesville, FL, 32611-0496, USA. .,Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA. .,Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA.
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Thomas CD, Franchi F, Keeley EC, Rossi JS, Winget M, David Anderson R, Dempsey AL, Gong Y, Gower MN, Kerensky RA, Kulick N, Malave JG, McDonough CW, Mulrenin IR, Starostik P, Beitelshees AL, Johnson JA, Stouffer GA, Winterstein AG, Angiolillo DJ, Lee CR, Cavallari LH. Impact of the ABCD-GENE Score on Clopidogrel Clinical Effectiveness after PCI: A Multi-Site, Real-World Investigation. Clin Pharmacol Ther 2022; 112:146-155. [PMID: 35429163 PMCID: PMC9233085 DOI: 10.1002/cpt.2612] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/07/2022] [Indexed: 12/13/2022]
Abstract
The Age, Body mass index, Chronic kidney disease, Diabetes mellitus, and CYP2C19 GENEtic variants (ABCD-GENE) score was developed to identify patients at risk for diminished antiplatelet effects with clopidogrel after percutaneous coronary intervention (PCI). The objective of this study was to validate the ability of the ABCD-GENE score to predict the risk for atherothrombotic events in a diverse, real-world population of clopidogrel-treated patients who underwent PCI and received clinical CYP2C19 genotyping to guide antiplatelet therapy. A total of 2,341 adult patients who underwent PCI, were genotyped for CYP2C19, and received treatment with clopidogrel across four institutions were included (mean age 64 ± 12 years, 35% women, and 20% Black). The primary outcome was major atherothrombotic events, defined as the composite of all-cause death, myocardial infarction, ischemic stroke, stent thrombosis, or revascularization for unstable angina within 12 months following PCI. Major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, myocardial infarction, ischemic stroke, or stent thrombosis, was assessed as the secondary outcome. Outcomes were compared between patients with an ABCD-GENE score ≥ 10 vs. < 10. The risk of major atherothrombotic events was higher in patients with an ABCD-GENE score ≥ 10 (n = 505) vs. < 10 (n = 1,836; 24.6 vs. 14.7 events per 100 patient-years, adjusted hazard ratio (HR) 1.66, 95% confidence interval (CI), 1.23-2.25, P < 0.001). The risk for MACE was also higher among patients with a score ≥ 10 vs. < 10 (16.7 vs. 10.1 events per 100 patient-years, adjusted HR 1.59, 95% CI 1.11-2.30, P = 0.013). Our diverse, real-world data demonstrate diminished clopidogrel effectiveness in post-PCI patients with an ABCD-GENE score ≥ 10.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Ellen C Keeley
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Joseph S Rossi
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Marshall Winget
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - R David Anderson
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Alyssa L Dempsey
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Megan N Gower
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Richard A Kerensky
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Natasha Kulick
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jean G Malave
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Ian R Mulrenin
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Amber L Beitelshees
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Craig R Lee
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Abstract
BACKGROUND AND OBJECTIVES Updated guidelines continue to support watchful waiting as an option for uncomplicated acute otitis media (AOM) and provide explicit diagnostic criteria. To determine treatment prevalence and associated determinants of watchful waiting for AOM in commercially insured pediatric patients. METHODS This was a retrospective cohort study using IBM Marketscan Commercial Claims Databases (2005 to 2019) of patients 1 to 12 years old with AOM, without otitis-related complications within 6 months prior, with no tympanostomy tubes, and no other infections around index diagnosis of AOM. We examined monthly antibiotic treatment prevalence (defined as pharmacy dispensing within 3 days of AOM diagnosis) and used multivariable logistic regression models to examine determinants of watchful waiting. RESULTS Among 2 176 617 AOM episodes, 77.8% were treated within 3 days. Whereas some clinical characteristics were moderate determinants for watchful waiting, clinician antibiotic prescribing volume and specialty were strong determinants. Low-volume antibiotic prescribers (≥80% of AOM episodes managed with watchful waiting) had 11.61 (95% confidence interval 10.66-12.64) higher odds of using watchful waiting for the index AOM episode than high-volume antibiotic prescribers (≥80% treated). Otolaryngologists were more likely to adopt watchful waiting (odds ratio 5.45, 95% CI 5.21-5.70) than pediatricians, whereas other specialties deferred more commonly to antibiotics. CONCLUSIONS Adoption of watchful waiting for management of uncomplicated, nonrecurrent AOM was limited and stagnant across the study period and driven by clinician rather than patient factors. Future work should assess motivators for prescribing and evaluate patient outcomes among clinicians who generally prefer versus reject watchful waiting approaches to guide clinical decision-making.
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Affiliation(s)
- Nicole E Smolinski
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy.,Center for Drug Evaluation and Safety (CoDES)
| | - Patrick J Antonelli
- Center for Drug Evaluation and Safety (CoDES).,Department of Otolaryngology, College of Medicine
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy.,Center for Drug Evaluation and Safety (CoDES).,Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida
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Vouri SM, Morris EJ, Jiang X, Hofer AK, Schmidt S, Pepine C, Winterstein AG, Smith SM. Evaluation of a Beta-Blocker-Edema-Loop Diuretic Prescribing Cascade: A Prescription Sequence Symmetry Analysis. Am J Hypertens 2022; 35:601-609. [PMID: 35106529 DOI: 10.1093/ajh/hpac013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/12/2021] [Accepted: 01/29/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Drug-related adverse events associated with antihypertensive therapy may result in subsequent prescribing of other potentially harmful medications, known as prescribing cascades. The aim of this study was to assess the magnitude and characteristics of a beta-blocker-edema-loop diuretic prescribing cascade. METHODS A prescription sequence symmetry analysis was used to assess loop diuretic initiation before and after initiation of beta-blockers among patients 20 years or older without heart failure, atrial fibrillation, other arrythmias, or use of calcium channel blocker within a U.S. private insurance claims database (2005-2018). The temporality of loop diuretic initiation relative to a beta-blocker or negative control (renin-angiotensin system blocker) initiation was tabulated. Secular trend-adjusted sequence ratios (aSRs) with 95% confidence intervals (CIs) compared the initiation of loop diuretic 90 days before and after initiation of beta-blockers. RESULTS Among 988,675 beta-blocker initiators, 9,489 patients initiated a new loop diuretic prescription 90 days after and 5,245 patients before beta-blocker initiation, resulting in an aSR of 1.78 (95% CI, 1.72-1.84). An estimated 1.72 beta-blocker initiators per 100 patient-years experienced the prescribing cascade in the first 90 days. The aSR was disproportionately higher among older adults (aSR 1.97), men (aSR 2.25), and patients who initiated metoprolol tartrate (aSR 2.48), labetalol (aSR 2.18), or metoprolol succinate (aSR 2.11). Negative control results (aSR 1.09, 95% CI, 1.05-1.13) generally corroborated our findings, but suggested modest within-person time-varying confounding. CONCLUSIONS We observed excess use of loop diuretics following beta-blocker initiation that was only partially explained by secular trends or hypertension progression.
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Affiliation(s)
- Scott Martin Vouri
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Earl J Morris
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Xinyi Jiang
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Ann-Kathrin Hofer
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Stephan Schmidt
- Department of Pharmaceutics, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacometrics and Systems Pharmacology, University of Florida, Lake Nona, Florida, USA
| | - Carl Pepine
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA.,Department of Epidemiology, University of Florida College of Medicine, Gainesville, Florida, USA.,University of Florida College of Public Health and Health Professions, Gainesville, Florida, USA
| | - Steven M Smith
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA.,Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
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Cicali B, Da Silva L, Sarayani A, Lingineni K, Pressly M, Kim S, Wendl T, Hoechel J, Vozmediano V, Winterstein AG, Brown JD, Schmidt S, Cristofoletti R. Development of a Translational Exposure-Bracketing Approach to Streamline the Development of Hormonal Contraceptive Drug Products. Clin Pharmacol Ther 2022; 112:909-916. [PMID: 35723889 DOI: 10.1002/cpt.2690] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/05/2022] [Indexed: 11/06/2022]
Abstract
Worldwide, 922 million women of reproductive age (or their partners) use some sort of contraception to prevent pregnancy. Oral combined hormonal contraceptives (CHC) typically utilize a combination of a progestin and an estrogen. CHC are potentially at risk to metabolic drug-drug interaction (DDI) via CYP3A4, the main enzyme involved in the oxidative metabolism of ethinyl estradiol (EE) and most progestins, e.g. levonorgestrel (LNG) and drospirenone (DRSP). Recently, the FDA issued a guidance addressing metabolic DDIs in the realm of CHC, establishing an overall class-based recommendation with respect to avoidance of CYP3A4 induction interactions. Given that different progestins have varying magnitudes of fraction metabolized by CYP3A4 (fmCYP3A4 ), it would be of clinical benefit to determine if all progestins are at the same risk to CYP3A4-mediated metabolic DDI. LNG and DRSP are commonly used progestins that are at the margins of the rifampicin induction effect observed in vivo since they have the relatively lowest and highest fmCYP3A4 among commonly used CHC formulations containing norgestimate, desogestrel, norgestrel, and norethindrone. Therefore, we applied a multi-pronged strategy, i.e. (1) development of the PBPK models, (2) comparison of the effect of CYP3A inducers and inhibitors on DRSP vs. LNG, and (3) providing the clinical-practice context based on real world data, to explore the difference in DDI risk for oral CHCs.
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Affiliation(s)
- Brian Cicali
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Lais Da Silva
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Amir Sarayani
- Center for Drug Evaluation & Safety, Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, FL, USA
| | - Karthik Lingineni
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Michelle Pressly
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Soyoung Kim
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | | | | | - Valvanera Vozmediano
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Almut G Winterstein
- Center for Drug Evaluation & Safety, Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, FL, USA
| | - Joshua D Brown
- Center for Drug Evaluation & Safety, Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, FL, USA
| | - Stephan Schmidt
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Rodrigo Cristofoletti
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
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Huo T, Li Q, Cardel MI, Bussing R, Winterstein AG, Lemas DJ, Xu H, Woodard J, Mistry K, Scholle S, Muller KE, Shenkman EA. Enhancing Quality Measurement With Clinical Information: A Use Case of Body Mass Index Change Among Children Taking Second Generation Antipsychotics. Acad Pediatr 2022; 22:S140-S149. [PMID: 35339240 PMCID: PMC9092621 DOI: 10.1016/j.acap.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/02/2021] [Accepted: 11/21/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE We sought to examine the extent to which body mass index (BMI) was available in electronic health records for Florida Medicaid recipients aged 5 to 18 years taking Second-Generation Antipsychotics (SGAP). We also sought to illustrate how clinical data can be used to identify children most at-risk for SGAP-induced weight gain, which cannot be done using process-focused measures. METHODS Electronic health record (EHR) data and Medicaid claims were linked from 2013 to 2019. We quantified sociodemographic differences between children with and without pre- and post-BMI values. We developed a linear regression model of post-BMI to examine pre-post changes in BMI among 4 groups: 1) BH/SGAP+ children had behavioral health conditions and were taking SGAP; 2) BH/SGAP- children had behavioral health conditions without taking SGAP; 3) children with asthma; and 4) healthy children. RESULTS Of 363,360 EHR-Medicaid linked children, 18,726 were BH/SGAP+. Roughly 4% of linked children and 8% of BH/SGAP+ children had both pre and post values of BMI required to assess quality of SGAP monitoring. The percentage varied with gender and race-ethnicity. The R2 for the regression model with all predictors was 0.865. Pre-post change in BMI differed significantly (P < .0001) among the groups, with more BMI gain among those taking SGAP, particularly those with higher baseline BMI. CONCLUSION Meeting the 2030 Centers for Medicare and Medicaid Services goal of digital monitoring of quality of care will require continuing expansion of clinical encounter data capture to provide the data needed for digital quality monitoring. Using linked EHR and claims data allows identifying children at higher risk for SGAP-induced weight gain.
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Affiliation(s)
- Tianyao Huo
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida (T Huo, Q Li, MI Cardel, DJ Lemas, H Xu, J Woodard, KE Muller, and EA Shenkman), Gainesville, Fla.
| | - Qian Li
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida (T Huo, Q Li, MI Cardel, DJ Lemas, H Xu, J Woodard, KE Muller, and EA Shenkman), Gainesville, Fla
| | - Michelle I Cardel
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida (T Huo, Q Li, MI Cardel, DJ Lemas, H Xu, J Woodard, KE Muller, and EA Shenkman), Gainesville, Fla; WW International, Inc (MI Cardel), New York, NY
| | - Regina Bussing
- Department of Psychiatry, College of Medicine, University of Florida (R Bussing), Gainesville, Fla
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida (AG Winterstein), Gainesville, Fla
| | - Dominick J Lemas
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida (T Huo, Q Li, MI Cardel, DJ Lemas, H Xu, J Woodard, KE Muller, and EA Shenkman), Gainesville, Fla
| | - Hongzhi Xu
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida (T Huo, Q Li, MI Cardel, DJ Lemas, H Xu, J Woodard, KE Muller, and EA Shenkman), Gainesville, Fla
| | - Jennifer Woodard
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida (T Huo, Q Li, MI Cardel, DJ Lemas, H Xu, J Woodard, KE Muller, and EA Shenkman), Gainesville, Fla
| | - Kamila Mistry
- Agency for Healthcare Research and Quality (K Mistry), Rockville, Md
| | - Sarah Scholle
- National Committee for Quality Assurance (S Scholle), Washington, DC
| | - Keith E Muller
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida (T Huo, Q Li, MI Cardel, DJ Lemas, H Xu, J Woodard, KE Muller, and EA Shenkman), Gainesville, Fla
| | - Elizabeth A Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida (T Huo, Q Li, MI Cardel, DJ Lemas, H Xu, J Woodard, KE Muller, and EA Shenkman), Gainesville, Fla
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Chen C, Lo-Ciganic WH, Winterstein AG, Tighe P, Wei YJJ. Concurrent Use of Prescription Opioids and Gabapentinoids in Older Adults. Am J Prev Med 2022; 62:519-528. [PMID: 34802816 PMCID: PMC9426287 DOI: 10.1016/j.amepre.2021.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Concurrent use of prescription opioids with gabapentinoids may pose risks of serious drug interactions. Yet, little is known about the trends in and patient characteristics associated with concurrent opioid-gabapentinoid use among older Medicare opioid users with chronic noncancer pain. METHODS A cross-sectional study was conducted among Medicare older beneficiaries (aged ≥65 years) with chronic noncancer pain who filled ≥1 opioid prescription within 3 months after a randomly selected chronic noncancer pain diagnosis (index date) in a calendar year between 2011 and 2018. Patient characteristics were measured in the 6-month baseline before the index date, and concurrent opioid-gabapentinoid use for ≥1 day was measured in the 3-month follow-up after the index date. Multivariable modified Poisson regression hwas used to assess the trends and characteristics of concurrent opioid-gabapentinoid use. Analyses were conducted from January to June 2021. RESULTS Among 464,721 eligible older beneficiaries with chronic noncancer pain and prescription opioids, the prevalence of concurrent opioid-gabapentinoid use increased from 17.0% in 2011 to 23.5% in 2018 (adjusted prevalence ratio=1.48, 95% CI=1.45, 1.53). Concurrent users versus opioid-only users tended to be non-Black, low-income subsidy recipients, and Southern residents. The clinical factors associated with concurrent opioid-gabapentinoid use included having a diagnosis of neuropathic pain, polypharmacy, and risk factors for opioid-related adverse events. CONCLUSIONS Concurrent opioid-gabapentinoid use among older Medicare beneficiaries with chronic noncancer pain and prescription opioids has increased significantly between 2011 and 2018. Future studies are warranted to investigate the impact of concurrent use on outcomes in older patients. Interventions that reduce inappropriate concurrent use may target older patients with identified characteristics.
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Affiliation(s)
- Cheng Chen
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida; Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida
| | - Patrick Tighe
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida
| | - Yu-Jung J Wei
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida.
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Tang H, Kimmel SE, Smith SM, Cusi K, Shi W, Gurka M, Winterstein AG, Guo J. Comparable Cardiorenal Benefits of SGLT2 Inhibitors and GLP-1RAs in Asian and White Populations: An Updated Meta-analysis of Results From Randomized Outcome Trials. Diabetes Care 2022; 45:1007-1012. [PMID: 35349656 DOI: 10.2337/dc21-1722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/05/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Whether the cardiorenal benefits of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1RAs) are comparable between White and Asian populations remains unclear. PURPOSE To compare the cardiorenal benefits of SGLT2 inhibitors and GLP-1RAs between White and Asian populations and to compare the cardiorenal benefits between the two agents in Asian patients. DATA SOURCES Electronic databases were searched up to 28 March 2021. STUDY SELECTION We included the cardiovascular (CV) and renal outcome trials of SGLT2 inhibitors and GLP-1RAs where investigators reported major adverse CV events (MACE), CV death/hospitalization for heart failure (HHF), or composite renal outcomes with stratification by race. DATA EXTRACTION We extracted the hazard ratio of each outcome stratified by race (Asian vs. White populations). DATA SYNTHESIS In 10 SGLT2 inhibitor trials, there was no significant difference between Asian and White populations for MACE (P = 0.55), CV death/HHF (P = 0.87), or composite renal outcomes (P = 0.97). In seven GLP-1RA trials, we observed a similar MACE benefit between Asian and White populations (P = 0.10). In our networkmeta-analysis we found a comparable benefit for MACE between SGLT2 inhibitors and GLP-1RAs in Asian patients. LIMITATIONS The data were from stratified analyses. CONCLUSIONS There appear to be comparable cardiorenal benefits of SGLT2 inhibitors and GLP-1RAs between Asian and White participants enrolled in CV and renal outcome trials; the two therapies seem to have similar CV benefits for Asian participants.
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Affiliation(s)
- Huilin Tang
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL
| | - Stephen E Kimmel
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL
| | - Steven M Smith
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes, and Metabolism, University of Florida, Gainesville, FL
| | - Weilong Shi
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Matthew Gurka
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL
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Goodin AJ, Wilson DL, Cook RL, Wang Y, Brown J, Winterstein AG. Proceedings of the 2021 Cannabis Clinical Outcomes Research Conference. Med Cannabis Cannabinoids 2022; 4:143-146. [PMID: 35224433 DOI: 10.1159/000519037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 11/19/2022] Open
Abstract
The Cannabis Clinical Outcomes Research Conference (CCORC) 2021 was held virtually on April 8 and 9, 2021. The conference was hosted by the Consortium for Medical Marijuana Clinical Outcomes Research, a research organization instituted by the state legislature of Florida in the United States. The inaugural annual CCORC 2021 was organized as a scientific meeting to foster and disseminate research on medical marijuana (MM) clinical outcomes, while promoting engagement among MM researchers, patients, clinicians, policymakers, and industry partners. Key conference themes included: (a) the disconnect between policy, practice, and evidence and steps towards reconciliation, (b) approaches to overcome common barriers to MM research, and (c) the use of focused translational approaches utilizing both mechanistic and clinical research methodology to tackle the complexities of MM outcomes. CCORC 2022 is planned for spring 2022 in Orlando, Florida, United States.
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Affiliation(s)
- Amie J Goodin
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA.,Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, Florida, USA
| | - Debbie L Wilson
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
| | - Robert L Cook
- Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, Florida, USA.,Department of Epidemiology, University of Florida, Gainesville, Florida, USA.,Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Yan Wang
- Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, Florida, USA.,Department of Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Joshua Brown
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA.,Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA.,Consortium for Medical Marijuana Clinical Outcomes Research, University of Florida, Gainesville, Florida, USA.,Department of Epidemiology, University of Florida, Gainesville, Florida, USA
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Wei YJJ, Chen C, Lewis MO, Schmidt SO, Winterstein AG. Trajectories of prescription opioid dose and risk of opioid-related adverse events among older Medicare beneficiaries in the United States: A nested case-control study. PLoS Med 2022; 19:e1003947. [PMID: 35290389 PMCID: PMC8923459 DOI: 10.1371/journal.pmed.1003947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/14/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the rising number of older adults with medical encounters for opioid misuse, dependence, and poisoning, little is known about patterns of prescription opioid dose and their association with risk for opioid-related adverse events (ORAEs) in older patients. The study aims to compare trajectories of prescribed opioid doses in 6 months preceding an incident ORAE for cases and a matched control group of older patients with chronic noncancer pain (CNCP). METHODS AND FINDINGS We conducted a nested case-control study within a cohort of older (≥65 years) patients diagnosed with CNCP who were new users of prescription opioids, assembled using a 5% national random sample of Medicare beneficiaries from 2011 to 2018. From the cohort with a mean follow-up of 2.3 years, we identified 3,103 incident ORAE cases with ≥1 opioid prescription in 6 months preceding the event, and 3,103 controls matched on sex, age, and time since opioid initiation. Key exposure was trajectories of prescribed opioid morphine milligram equivalent (MME) daily dosage over 6 months before the incident ORAE or matched controls. Among the cases and controls, 2,192 (70.6%) were women, and the mean (SD) age was 77.1 (7.1) years. Four prescribed opioid trajectories before the incident ORAE diagnosis or matched date emerged: gradual dose discontinuation (from ≤3 to 0 daily MME, 1,456 [23.5%]), gradual dose increase (from 0 to >3 daily MME, 1,878 [30.3%]), consistent low dose (between 3 and 5 daily MME, 1,510 [24.3%]), and consistent moderate dose (>20 daily MME, 1,362 [22.0%]). Few older patients (<5%) were prescribed a mean daily dose of ≥90 daily MME during 6 months before diagnosis or matched date. Patients with gradual dose discontinuation versus those with a consistent low dose, moderate dose, and increase dose were more likely to be younger (65 to 74 years), Midwest US residents, and receiving no low-income subsidy. Compared to patients with gradual dose discontinuation, those with gradual dose increase (adjusted odds ratio [aOR] = 3.4; 95% confidence interval (CI) 2.8 to 4.0; P < 0.001), consistent low dose (aOR = 3.8; 95% CI 3.2 to 4.6; P < 0.001), and consistent moderate dose (aOR = 8.5; 95% CI 6.8 to 10.7; P < 0.001) had a higher risk of ORAE, after adjustment for covariates. Our main findings remained robust in the sensitivity analysis using a cohort study with inverse probability of treatment weighting analyses. Major limitations include the limited generalizability of the study findings and lack of information on illicit opioid use, which prevents understanding the clinical dose threshold level that increases the risk of ORAE in older adults. CONCLUSIONS In this sample of older patients who are Medicare beneficiaries, 4 prescription opioid dose trajectories were identified, with most prescribed doses below 90 daily MME within 6 months before ORAE or matched date. An increased risk for ORAE was observed among older patients with a gradual increase in dose or among those with a consistent low-to-moderate dose of prescribed opioids when compared to patients with opioid dose discontinuation. Whether older patients are susceptible to low opioid doses warrants further investigations.
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Affiliation(s)
- Yu-Jung Jenny Wei
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
| | - Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
| | - Motomori O. Lewis
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
| | - Siegfried O. Schmidt
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- Department of Epidemiology, University of Florida Colleges of Medicine and Public Health and Health Professions, Gainesville, Florida, United States of America
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Chen C, Winterstein AG, Lo-Ciganic WH, Tighe PJ, Wei YJJ. Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older US Medicare beneficiaries with chronic noncancer pain: A population-based cohort study. PLoS Med 2022; 19:e1003921. [PMID: 35231025 PMCID: PMC8887769 DOI: 10.1371/journal.pmed.1003921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 01/19/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Gabapentinoids are increasingly prescribed to manage chronic noncancer pain (CNCP) in older adults. When used concurrently with opioids, gabapentinoids may potentiate central nervous system (CNS) depression and increase the risks for fall. We aimed to investigate whether concurrent use of gabapentinoids with opioids compared with use of opioids alone is associated with an increased risk of fall-related injury among older adults with CNCP. METHODS AND FINDINGS We conducted a population-based cohort study using a 5% national sample of Medicare beneficiaries in the United States between 2011 and 2018. Study sample consisted of fee-for-service (FFS) beneficiaries aged ≥65 years with CNCP diagnosis who initiated opioids. We identified concurrent users with gabapentinoids and opioids days' supply overlapping for ≥1 day and designated first day of concurrency as the index date. We created 2 cohorts based on whether concurrent users initiated gabapentinoids on the day of opioid initiation (Cohort 1) or after opioid initiation (Cohort 2). Each concurrent user was matched to up to 4 opioid-only users on opioid initiation date and index date using risk set sampling. We followed patients from index date to first fall-related injury event ascertained using a validated claims-based algorithm, treatment discontinuation or switching, death, Medicare disenrollment, hospitalization or nursing home admission, or end of study, whichever occurred first. In each cohort, we used propensity score (PS) weighted Cox models to estimate the adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) of fall-related injury, adjusting for year of the index date, sociodemographics, types of chronic pain, comorbidities, frailty, polypharmacy, healthcare utilization, use of nonopioid medications, and opioid use on and before the index date. We identified 6,733 concurrent users and 27,092 matched opioid-only users in Cohort 1 and 5,709 concurrent users and 22,388 matched opioid-only users in Cohort 2. The incidence rate of fall-related injury was 24.5 per 100 person-years during follow-up (median, 9 days; interquartile range [IQR], 5 to 18 days) in Cohort 1 and was 18.0 per 100 person-years during follow-up (median, 9 days; IQR, 4 to 22 days) in Cohort 2. Concurrent users had similar risk of fall-related injury as opioid-only users in Cohort 1(aHR = 0.97, 95% CI 0.71 to 1.34, p = 0.874), but had higher risk for fall-related injury than opioid-only users in Cohort 2 (aHR = 1.69, 95% CI 1.17 to 2.44, p = 0.005). Limitations of this study included confounding due to unmeasured factors, unavailable information on gabapentinoids' indication, potential misclassification, and limited generalizability beyond older adults insured by Medicare FFS program. CONCLUSIONS In this sample of older Medicare beneficiaries with CNCP, initiating gabapentinoids and opioids simultaneously compared with initiating opioids only was not significantly associated with risk for fall-related injury. However, addition of gabapentinoids to an existing opioid regimen was associated with increased risks for fall. Mechanisms for the observed excess risk, whether pharmacological or because of channeling of combination therapy to high-risk patients, require further investigation. Clinicians should consider the risk-benefit of combination therapy when prescribing gabapentinoids concurrently with opioids.
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Affiliation(s)
- Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- Department of Epidemiology, University of Florida Colleges of Medicine and Public Health & Health Professions, Florida, United States of America
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
| | - Patrick J. Tighe
- Department of Anesthesiology, University of Florida College of Medicine, Florida, United States of America
| | - Yu-Jung Jenny Wei
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
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Beitelshees AL, Thomas CD, Empey PE, Stouffer GA, Angiolillo DJ, Franchi F, Tuteja S, Limdi NA, Lee JC, Duarte JD, Kreutz RP, Skaar TC, Coons JC, Giri J, McDonough CW, Rowland R, Stevenson JM, Thai T, Vesely MR, Wellen JT, Johnson JA, Winterstein AG, Cavallari LH, Lee CR. CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention in Diverse Clinical Settings. J Am Heart Assoc 2022; 11:e024159. [PMID: 35156424 PMCID: PMC9245803 DOI: 10.1161/jaha.121.024159] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Studies have demonstrated increased risk of major atherothrombotic events in CYP2C19 loss-of-function (LOF) variant carriers versus non-carriers treated with clopidogrel after percutaneous coronary intervention (PCI). We sought to evaluate real-world outcomes with the clinical implementation of CYP2C19-guided antiplatelet therapy after PCI. Methods and Results Data from 9 medical centers where genotyping was performed in the setting of PCI were included. Alternative therapy with prasugrel or ticagrelor was recommended for patients with a CYP2C19 LOF variant. The primary outcome was the composite of major atherothrombotic events (all-cause death, myocardial infarction, ischemic stroke, stent thrombosis, or hospitalization for unstable angina) within 12 months following PCI. Moderate or severe/life-threatening bleeding within 12 months was a secondary outcome. Among 3342 patients, 1032 (31%) were LOF carriers, of whom 571/1032 (55%) were treated with alternative therapy. In LOF carriers, the rate of major atherothrombotic events was lower in patients treated with alternative therapy versus clopidogrel (adjusted HR, 0.56; 95% CI 0.39-0.82). In those without a LOF allele, no difference was observed (adjusted HR, 1.07; 95% CI 0.71-1.60). There was no difference in bleeding with alternative therapy versus clopidogrel in either LOF carriers or those without a LOF allele. Conclusions Real-world data demonstrate lower atherothrombotic risk in CYP2C19 LOF carriers treated with alternative therapy versus clopidogrel and similar risk in those without a LOF allele treated with clopidogrel or alternative therapy. These data suggest that PCI patients treated with clopidogrel should undergo genotyping so that CYP2C19 LOF carriers can be identified and treated with alternative therapy.
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Affiliation(s)
- Amber L. Beitelshees
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Philip E. Empey
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart InstituteUniversity of North Carolina, Chapel HillNC
| | | | - Francesco Franchi
- University of Florida College of Medicine‐JacksonvilleJacksonvilleFL
| | - Sony Tuteja
- University of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Nita A. Limdi
- Department of NeurologyProgram for Translational Pharmacogenomics and Hugh Kaul Personalized Medicine InstituteSchool of MedicineUniversity of Alabama at BirminghamAL
| | - James C. Lee
- Department of Pharmacy PracticeUniversity of Illinois at ChicagoIL
| | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | | | | | - James C. Coons
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA
| | - Jay Giri
- Cardiovascular Medicine DivisionUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Rachel Rowland
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - James M. Stevenson
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA,Division of Clinical PharmacologyJohns Hopkins University School of MedicineBaltimoreMD
| | - Thuy Thai
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFL
| | - Mark R. Vesely
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Jacob T. Wellen
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFL
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Craig R. Lee
- Division of Cardiology and McAllister Heart InstituteUniversity of North Carolina, Chapel HillNC,Division of Pharmacotherapy and Experimental TherapeuticsUNC Eshelman School of PharmacyUniversity of North Carolina at Chapel HillNC
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Wei YJJ, Chen C, Winterstein AG. Discontinuation of Long-Term Opioid Therapy in Patients With Versus Without Dementia. Am J Prev Med 2022; 62:270-274. [PMID: 34702606 PMCID: PMC8748292 DOI: 10.1016/j.amepre.2021.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/01/2021] [Accepted: 07/28/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Discontinuation of long-term opioid therapy has increased in recent years, but whether this trend extends to patients with Alzheimer disease and related dementia remains unclear. METHODS Medicare data from 2011 to 2018 were analyzed to compare the trends in the use and discontinuation of long-term opioid therapy between patients with and without Alzheimer disease and related dementia who had chronic noncancer pain. Outcome measures were annual proportions of (1) patients who received long-term opioid therapy and (2) long-term opioid therapy users who subsequently discontinued opioids for ≥30, 60, or 90 days during 12-month follow-up. All analyses were performed in 2021. RESULTS The use of long-term opioid therapy decreased from 2011 to 2017 in both patients with and without Alzheimer disease and related dementia. In long-term opioid therapy users, discontinuation of opioids for ≥30, 60, and 90 days increased by 8% (95% CI=1.04, 1.12, p<0.001), 13% (95% CI=1.06, 1.20, p<0.001), and 18% (95% CI=1.10, 1.28, p<0.001), respectively, between 2011 and 2017 among patients with Alzheimer disease and related dementia, whereas the proportion was largely declining or unchanged among patients without the condition. Differences in long-term opioid therapy discontinuation by Alzheimer disease status widened over time (p<0.01 for interaction). CONCLUSIONS Discontinuation of long-term opioid therapy was consistently higher in patients with than in patients without Alzheimer disease and related dementia, with the gap between the 2 groups widening over time. The reasons for these differences and the risk-benefit of increased long-term opioid therapy discontinuation among patients with Alzheimer disease and related dementia warrant further investigation.
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Affiliation(s)
- Yu-Jung J Wei
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida.
| | - Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida; Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida
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Sarayani A, Albogami Y, Thai TN, Smolinski NE, Patel P, Wang Y, Nduaguba S, Rasmussen SA, Winterstein AG. Prenatal exposure to teratogenic medications in the era of Risk Evaluation and Mitigation Strategies. Am J Obstet Gynecol 2022; 227:263.e1-263.e38. [PMID: 35032444 DOI: 10.1016/j.ajog.2022.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Prevention of prenatal exposures to teratogenic drugs is a significant clinical and public health concern. With the enactment of the US Food and Drug Administration Amendments Act in 2007, the US Food and Drug Administration has begun to require manufacturers to implement Risk Evaluation and Mitigation Strategies to prevent prenatal exposures. Among 12 risk evaluation and mitigation strategy drugs, several had predecessor risk mitigation plans (eg, isotretinoin) and some were newly required (eg, mycophenolate). Only a small proportion of teratogenic drugs are currently subject to Risk Evaluation and Mitigation Strategies, and the extent of prenatal exposure to the universe of teratogenic drugs compared with drugs subject to Risk Evaluation and Mitigation Strategies is unknown. Moreover, the effectiveness of such advanced risk mitigation programs in preventing prenatal exposure is not clear. OBJECTIVE This study aimed to characterize the epidemiology of prenatal exposures to definite and potential teratogens during the risk evaluation and mitigation strategy era. STUDY DESIGN We constructed a time-series of pregnancies identified from a national private insurance claims database (IBM MarketScan) to estimate prenatal exposures to teratogenic drugs (2006-2017). Pregnancy outcomes, gestational age, and the onset of pregnancy were determined with previously validated algorithms. The Teratology Information Service and Clinical Pharmacology databases were used to identify drugs with definite (n=141) or potential (n=65) teratogenic effects, and drugs with debatable risks such as benzodiazepines, statins, tetracyclines, sex hormones, infertility treatments, and gonadotropin-releasing hormone analogs were excluded. We defined prenatal exposure as ≥1 prescription fill or medical encounter involving administration of drugs with a definite teratogenic risk (including 12 for which there is a "current or discontinued" risk evaluation and mitigation strategy) or a potential teratogenic risk. We evaluated secular trends and modeled the effects of age, preconception exposure, and state healthcare quality rankings on prenatal exposure, adjusting for demographic factors and clinical conditions. RESULTS The cohort included 3,445,612 pregnancies (2,532,444 live deliveries). Prenatal exposures to definite teratogens decreased slightly during the study years from 1.86 to 1.24 per 100 pregnancies between 2006 and 2017, whereas exposure increased for potential teratogens from 3.40% to 5.33%. Prenatal exposure prevalences were higher during the first trimester and for pregnancies that ended in nonlive outcomes. Drugs subject to Risk Evaluation and Mitigation Strategies had low background utilization and contributed to a small proportion of prenatal exposures (15.1 per 100,000 pregnancies). We also observed fewer prenatal exposures to risk evaluation and mitigation strategy drugs among women of childbearing age who used these treatments (0.14% vs 0.36% for any definite teratogen). Age extremes and low state-level healthcare quality rankings were independent predictors of prenatal exposure. CONCLUSION Fetuses in more than 1 in 16 pregnancies continued to be exposed to teratogenic drugs during the past decade. Drugs with Risk Evaluation and Mitigation Strategies imposed a small burden of prenatal exposure because of the low background utilization rates and lower pregnancy prevalence among women of childbearing age who used these drugs. Although the declining exposure rates to teratogenic drugs with definite risk are encouraging, the rising prenatal exposure to drugs with potential risk calls for more assessments. Future research is needed to elucidate the health outcomes of fetuses exposed to potential risk drugs, understand the effectiveness of risk evaluation and mitigation strategy programs, and prioritize teratogenic drugs for advanced risk mitigation.
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Vouri SM, Morris EJ, Usmani SA, Reise R, Jiang X, Pepine CJ, Manini TM, Malone DC, Winterstein AG. Evaluation of the key prescription sequence symmetry analysis assumption using the calcium channel blocker: Loop diuretic prescribing cascade. Pharmacoepidemiol Drug Saf 2022; 31:72-81. [PMID: 34553438 PMCID: PMC8688319 DOI: 10.1002/pds.5362] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To evaluate the prescription sequence symmetry analysis assumption regarding balance between marker drug (i.e., medication used to treat a drug-induced adverse event) initiation rates before and after initiation of an index drug (i.e., medication that is potentially associated with the drug-induced adverse event) in the absence of prescribing cascades, we used a well-described example of loop diuretic initiation to treat dihydropyridine calcium channel blockers (DH CCB)-induced edema. STUDY DESIGN AND SETTING The University of Florida Health Integrated Data Repository from June 2011 and July 2018 was used to assess temporal prescribing of DH CCB and loop diuretics within the prescription sequence symmetry analysis framework. Validation of the prescribing cascade was performed via clinical expert chart review. RESULTS Among patients without heart failure who were initiated on DH CCB, 26 and 64 loop diuretics initiators started within 360 days before versus after DH CCB initiation, respectively, resulting in an adjusted sequence ratio (aSR) of 2.27 (95% CI, 1.44-3.58). Overall, 35 (54.7%) patients were determined to have a prescribing cascade. Removing patients who experienced a prescribing cascade resulted in an aSR of 1.05, 95% CI 0.62-1.78). CONCLUSION Loop diuretic initiation rates before and after DH CCB initiation for reasons other a prescribing cascade were similar, thus confirming the prescription sequence symmetry analysis assumption.
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Affiliation(s)
- Scott M. Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL,Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL,University of Florida Health Physicians, Gainesville, FL,Department of Aging and Geriatric Research, University of Florida College of Medicine, Gainesville, FL
| | - Earl J. Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL
| | - Silken A. Usmani
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL,University of Florida Health Physicians, Gainesville, FL
| | - Rachel Reise
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL,University of Florida Health Physicians, Gainesville, FL
| | - Xinyi Jiang
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL
| | - Carl J. Pepine
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Todd M. Manini
- Department of Aging and Geriatric Research, University of Florida College of Medicine, Gainesville, FL
| | - Daniel C. Malone
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL,Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL,Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL
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50
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Choi Y, Meissner HC, Hampp C, Park H, Winterstein AG. Utilization of chronic lung disease treatment before the respiratory syncytial virus season as palivizumab prophylaxis qualifier in the American Academy of Pediatrics Guidelines. Eur J Pediatr 2022; 181:841-845. [PMID: 34365543 PMCID: PMC8349231 DOI: 10.1007/s00431-021-04233-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/31/2021] [Accepted: 08/02/2021] [Indexed: 11/23/2022]
Abstract
Guidelines from the American Academy of Pediatrics recommend palivizumab immunoprophylaxis for children with CLD in their second year of life if they continue to need treatment within 6 months before the RSV season. The utilization patterns of treatment (chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) are not well understood. We examined variations in CLD treatment for ten consecutive 20-day segments preceding RSV season onset. Among infants and children with CLD (n = 19,026), 35.2% received one or more medical treatments for CLD any time within 200 days before entering the second RSV season: 8.6%, 3.2%, and 29.7% received supplemental oxygen, diuretics, and corticosteroids, respectively. Utilization decreased as infants' age increased with corticosteroids surpassing oxygen and diuretics. To avoid the capture of intermittent use of corticosteroids for acute infections, we found requiring a minimum of 45 days cumulative exposure was reasonable to determine chronic use. What is Known: • Guidelines from the American Academy of Pediatrics recommend palivizumab immunoprophylaxis for children with CLD in their second year of life if they continue to need treatment within 6 months before the RSV season. • The utilization patterns of treatment (chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) are not well understood. A definition of chronic corticosteroid therapy in this setting is not available. What is New: • Among infants and children with CLD of prematurity, 35.2% received one or more medical treatments for CLD any time within 200 days before entering the second RSV season: 8.6%, 3.2%, and 29.7% received oxygen, diuretics, and corticosteroids, respectively. Utilization decreased as infants' age increased with corticosteroids surpassing oxygen and diuretics. • A minimum of 45 days cumulative corticosteroid use within the past 90 days would accurately capture chronic use to fulfill criteria for immunoprophylaxis while limiting the inclusion of intermittent use of corticosteroids for acute infections.
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Affiliation(s)
- Yoonyoung Choi
- grid.15276.370000 0004 1936 8091Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32611 USA
| | - H. Cody Meissner
- grid.415195.d0000 0004 0387 3237Tufts Children’s Hospital, Tufts Medical Center, Boston, USA ,grid.67033.310000 0000 8934 4045Tufts University School of Medicine, Boston, USA
| | - Christian Hampp
- grid.483500.a0000 0001 2154 2448Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, USA
| | - Haesuk Park
- grid.15276.370000 0004 1936 8091Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32611 USA ,grid.15276.370000 0004 1936 8091Center for Drug Evaluation and Safety (CoDES), University of Florida, 1225 Center Drive, Gainesville, FL 32611 USA
| | - Almut G. Winterstein
- grid.15276.370000 0004 1936 8091Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32611 USA ,grid.15276.370000 0004 1936 8091Center for Drug Evaluation and Safety (CoDES), University of Florida, 1225 Center Drive, Gainesville, FL 32611 USA ,grid.15276.370000 0004 1936 8091Department of Epidemiology, College of Public Health and Health Professionals and College of Medicine, University of Florida, 1225 Center Drive, Gainesville, FL 32611 USA
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