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Princk C, Kollhorst B, Haug U. Use of leflunomide among girls and women of childbearing age and occurrence of leflunomide-exposed pregnancies in Germany. Reprod Toxicol 2024; 125:108573. [PMID: 38460863 DOI: 10.1016/j.reprotox.2024.108573] [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: 02/09/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/11/2024]
Abstract
Leflunomide is contraindicated during pregnancy and treatment cessation is recommended two years before pregnancy. We aimed to describe leflunomide use in women of childbearing age in Germany, the occurrence of pregnancies in women using leflunomide and malformations among children possibly exposed in utero. Using the GePaRD database (claims data, ∼20% of the German population), we determined annual age-standardized prevalences of leflunomide use between 2004 and 2019 among females aged 13-49 years. Further, we estimated the number of exposed pregnancies by assessing whether the exposure window assigned to the last dispensation before pregnancy (days covered by the dispensation plus two years) overlapped the onset of pregnancy or whether there was a dispensation in the first eight weeks of pregnancy. For exposed live births, a mother-baby linkage was performed and the presence of congenital malformation was assessed. The age-standardized prevalence of leflunomide use ranged between 0.34 and 0.46 per 1000 females during the study period. About one third of the users were ≤40 years. We identified 205 leflunomide-exposed pregnancies ending during the study period. 71% of these pregnancies ended in a live birth (26% preterm) and 10% in an induced abortion. In 86% of the live births (n=125) the mother-baby linkage was successful. Among these 125 children, 13 children (10%) had congenital malformations. In conclusion, we observed a considerable number of pregnancies in women using leflunomide in the two years before or during early pregnancy. This highlights the importance of monitoring the implementation of existing risk minimization measures for leflunomide in Germany.
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Affiliation(s)
- Christina Princk
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, Bremen 28359, Germany
| | - Bianca Kollhorst
- Department for Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, Bremen 28359, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, Bremen 28359, Germany; Faculty of Human and Health Sciences, University of Bremen, Grazer Straße 2, Bremen 28359, Germany.
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Reinold J, Kollhorst B, Wentzell N, Platzbecker K, Haug U. Use of isotretinoin among girls and women of childbearing age and occurrence of isotretinoin-exposed pregnancies in Germany: A population-based study. PLoS Med 2024; 21:e1004339. [PMID: 38271295 PMCID: PMC10810459 DOI: 10.1371/journal.pmed.1004339] [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: 09/30/2022] [Accepted: 12/21/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Exposure to isotretinoin during pregnancy must be avoided due to its teratogenicity, but real-world data on its use are scarce. We aimed to describe (i) isotretinoin use in women of childbearing age in Germany; (ii) the occurrence of isotretinoin-exposed pregnancies; and (iii) malformations among children exposed in utero. METHODS AND FINDINGS Using observational data from the German Pharmacoepidemiological Research Database (GePaRD, claims data from approximately 20% of the German population), we conducted annual cross-sectional analyses to determine age-standardized prevalence of isotretinoin use between 2004 and 2019 among girls and women aged 13 to 49 years. In cohort analyses, we estimated the number of exposed pregnancies by assessing whether there was prescription supply overlapping the beginning of pregnancy (estimated supply was varied in sensitivity analyses) or a dispensation within the first 8 weeks of pregnancy. Data of live-born children classified as exposed in a critical period according to these criteria were reviewed to assess the presence of congenital malformations. The age-standardized prevalence of isotretinoin use per 1,000 girls and women increased from 1.20 (95% confidence interval [CI]: 1.16, 1.24) in 2004 to 1.96 (95% CI: 1.92, 2.01) in 2019. In the base case analysis, we identified 178 pregnancies exposed to isotretinoin, with the number per year doubling during the study period, and at least 45% of exposed pregnancies ended in an induced abortion. In sensitivity analyses, the number of exposed pregnancies ranged between 172 and 375. Among live-born children, 6 had major congenital malformations. The main limitation of this study was the lack of information on the prescribed dose, i.e., the supply had to be estimated based on the dispensed amount of isotretinoin. CONCLUSIONS Isotretinoin use among girls and women of childbearing age increased in Germany between 2004 and 2019, and there was a considerable number of pregnancies likely exposed to isotretinoin in a critical period. This highlights the importance of monitoring compliance with the existing risk minimization measures for isotretinoin in Germany.
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Affiliation(s)
- Jonas Reinold
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Nadine Wentzell
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Katharina Platzbecker
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
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Reinold J, Kollhorst B, Temme HL, Wentzell N, Haug U. Use of Acitretin Among Girls and Women of Childbearing Age and Occurrence of Acitretin-Exposed Pregnancies in Germany. Clin Drug Investig 2023; 43:865-872. [PMID: 37906397 PMCID: PMC10632260 DOI: 10.1007/s40261-023-01314-2] [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: 10/02/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND AND OBJECTIVE Acitretin has long-lasting teratogenic properties. Therefore, pregnancies must be avoided during and within 3 years after acitretin treatment. We aimed to describe (i) acitretin use in women of childbearing age in Germany, (ii) the occurrence of acitretin-exposed pregnancies, and (iii) malformations among children exposed in utero. METHODS Using 2004-2019 data from the German Pharmacoepidemiological Research Database (GePaRD-claims data from ~ 20% of the German population), we determined annual age-standardized prevalence of acitretin use among girls and women aged 13-49 years. In longitudinal analyses, we estimated the number of exposed pregnancies by assessing whether the exposure window assigned to the last dispensation before pregnancy (days covered by dispensation plus 3 years) overlapped the onset of pregnancy or whether there was a dispensation in the first eight weeks of pregnancy. Data of live-born children with in utero exposure to acitretin were reviewed to assess the presence of congenital malformations. RESULTS The age-standardized prevalence of acitretin use per 1000 girls and women was 0.04 in 2019. We identified 35 acitretin-exposed pregnancies; 94.3% of these pregnancies were classified as exposed because they occurred within 3 years after stopping acitretin treatment. Among 18 live-born children linked to their mother, four children (22.2%) had congenital malformations (three children with a major malformation). CONCLUSIONS We observed 35 acitretin-exposed pregnancies mainly because treatment ended too late before pregnancy. Approximately one in five children born from these pregnancies had malformations, highlighting the importance of drawing more attention to the long-lasting teratogenicity of this drug.
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Affiliation(s)
- Jonas Reinold
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany.
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Hellen L Temme
- Health Communication, Department of Implementation Research, Bernhard Nocht Institute for Tropical Medicine-BNITM, Bernhard-Nocht-Straße 74, 20359, Hamburg, Germany
- Institute for Planetary Health Behaviour, University of Erfurt-IPB, Nordhäuser Straße 63, 99089, Erfurt, Germany
| | - Nadine Wentzell
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Grazer Straße 2, 28359, Bremen, Germany
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Amann U, Nadine Wentzell, Kollhorst B, Haug U. Prescribing of endothelin receptor antagonists and riociguat in women of childbearing age in a large German claims database study. Reprod Toxicol 2023; 119:108415. [PMID: 37245698 DOI: 10.1016/j.reprotox.2023.108415] [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: 01/24/2023] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 05/30/2023]
Abstract
Use of endothelin receptor antagonists (ERAs) and riociguat, approved for treatment of pulmonary hypertension (PH), is contraindicated during pregnancy due to reported teratogenicity in animals. We aimed to investigate prescribing of these drugs in girls/women of childbearing age and to explore - as a secondary aim - the occurrence of pregnancies exposed to these drugs. Using the German Pharmacoepidemiological Research Database (GePaRD, claims data from 20% of the German population) we conducted cross-sectional analyses to determine prescribing prevalence of ERAs and riociguat between 2004 and 2019 and to characterize users and prescribing patterns. In a cohort analysis, we assessed the occurrence of pregnancies exposed to these drugs in the critical time window. Overall, we identified 407 women with ≥ 1 dispensation of bosentan between 2004 and 2019; the respective number was 73 for ambrisentan, 182 for macitentan, 31 for sitaxentan, and 63 for riociguat. In nearly all years, more than 50% of the girls/women were ≤ 40 years. Age-standardized prevalence was highest for bosentan (0.04/1000) in 2012 and 2013, followed by macitentan (0.03/1000) in 2018 and 2019. We observed 10 exposed pregnancies: 5 to bosentan, 3 to ambrisentan, and 2 to macitentan. The increased prevalence of macitentan and riociguat from 2014 onwards might reflect changes in PH treatment. Even though PH is a rare disease and pregnancy should be avoided in women with PH, particularly if they use ERAs, we identified pregnancies exposed to ERAs. Multi-database studies will be needed to assess the risk of these drugs on the unborn child.
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Affiliation(s)
- Ute Amann
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Nadine Wentzell
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Achterstraße 30, 28359 Bremen, Germany; Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany.
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Voss A, Kollhorst B, Platzbecker K, Amann U, Haug U. Risk Profiles of New Users of Oral Anticoagulants Between 2011 and 2019 in Germany. Clin Epidemiol 2023; 15:827-837. [PMID: 37483262 PMCID: PMC10362862 DOI: 10.2147/clep.s405585] [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: 02/14/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose Over the last decade, the use of direct oral anticoagulants (DOACs) has strongly increased. We aimed to describe and compare risk profiles including potential changes over time among persons with non-valvular atrial fibrillation initiating treatment with different DOACs or phenprocoumon (vitamin K antagonist) between 2011 and 2019 in Germany. Patients and Methods Using the German Pharmacoepidemiological Research Database (GePaRD; claims data of ~20% of the German population), we identified persons with a first dispensing of phenprocoumon or a DOAC and a diagnosis of non-valvular atrial fibrillation between August 2011 and December 2019. We described the morbidity of included patients prior to treatment initiation, stratified by year of treatment initiation. Results Overall, we included 448,028 new users (phenprocoumon: N = 118,117, rivaroxaban: N = 130,997, apixaban: N = 130,300, edoxaban: N = 38,128, dabigatran: N = 30,486). Comparing new DOAC users in 2019, the proportion with prior ischemic stroke was highest for dabigatran (17%) and lowest for rivaroxaban (8%). The proportion with prior major bleeding was also highest for dabigatran (25%) and lowest for edoxaban (20%). New users of apixaban were oldest and, eg, showed the highest prevalence of congestive heart failure. Changes over time were most pronounced for phenprocoumon. For example, among persons initiating phenprocoumon in 2012 vs 2019, the proportion with prior major bleeding increased from 18% to 35%; the proportion with renal disease increased from 20% to 36% and the proportion with liver disease from 18% to 24%. Conclusion This study demonstrated differences in risk profiles between new users of different oral anticoagulants and substantial changes over time among new phenprocoumon users. These differences have to be considered in head-to-head comparisons of these drugs based on observational data, especially regarding potential unmeasured confounding.
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Affiliation(s)
- Annemarie Voss
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Katharina Platzbecker
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Ute Amann
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
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Haug U, Kollhorst B, Schink T, Thöne K, Dathe K, Schaefer C, Onken M. Investigating drug safety in pregnancy based on the German Pharmacoepidemiological Research Database (GePaRD): A proof-of-concept analysis on the association between valproate and spina bifida. Pharmacoepidemiol Drug Saf 2023; 32:148-157. [PMID: 36401747 DOI: 10.1002/pds.5573] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/29/2022] [Accepted: 10/28/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Large health-care databases are increasingly used for research on drug utilization and safety in pregnancy. For the German Pharmacoepidemiological Research Database (GePaRD), covering ~20% of the German population, algorithms have been developed to identify pregnancies, to estimate their date of onset and to link mothers to their babies. Using this methodology, we aimed to conduct a proof-of-concept analysis on the known association between valproate (VPA) exposure in early pregnancy and spina bifida in the exposed child. METHODS We identified all pregnancies in GePaRD between 2006 and 2016 in women aged 12 to 50 years. To each VPA dispensation of these women, an exposure period was assigned, based on the dispensation date and the number of defined daily doses in the dispensed package. A pregnancy was classified as exposed to VPA in the critical time window if this exposure period overlapped with the first 55 days of pregnancy. Risk ratios were calculated for spina bifida in live births and induced abortions comparing VPA-exposed ones to all pregnancies. RESULTS Overall, we identified 1 271 384 pregnancies fulfilling the inclusion criteria. Of these, 668 pregnancies (0.053%) were classified as exposed to VPA in the critical time window regarding spina bifida. An induced abortion accompanied by a diagnosis of spina bifida was observed in one of the VPA-exposed pregnancies (0.15%) and in 154 of all pregnancies (0.012%), yielding a risk ratio of 12.4 (95% confidence interval [CI]: 1.7-88.2). Out of 775 875 pregnancies ending in a live birth, 366 (0.047%) were classified as VPA exposed. A diagnosis of spina bifida was coded in 3 of 366 VPA-exposed live births (0.82%) and in 260 of all live births (0.03%), yielding a relative risk of 24.5 (95% CI: 7.9-76.0). CONCLUSIONS Our proof-of-concept analysis based on GePaRD showed a strong association between intrauterine exposure to VPA and occurrence of spina bifida. The results are plausible and consistent with the literature, supporting the suitability of GePaRD and the developed algorithms to conduct studies on drug safety in pregnancy.
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Affiliation(s)
- Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany.,Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Tania Schink
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | | | - Katarina Dathe
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - Christof Schaefer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - Marlies Onken
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
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Kollhorst B, Reinders T, Grill S, Eberle A, Intemann T, Kieschke J, Meyer M, Nennecke A, Rathmann W, Pigeot I. Record linkage of claims and cancer registries data-Evaluation of a deterministic linkage approach based on indirect personal identifiers. Pharmacoepidemiol Drug Saf 2022; 31:1287-1293. [PMID: 36129372 DOI: 10.1002/pds.5545] [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: 12/15/2021] [Revised: 07/20/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE In Germany, record linkage of claims and cancer registry data is cost- and time-consuming, since up until recently no unique personal identifier was available in both data sources. The aim of this study was to evaluate the feasibility and performance of a deterministic linkage procedure based on indirect personal identifiers included in the data sources. METHODS We identified users of glucose-lowering drugs with residence in four federal states in Northern and Southern Germany (Bavaria, Bremen, Hamburg, Lower Saxony) in the German Pharmacoepidemiological Research Database (GePaRD) and assessed colorectal and thyroid cancer cases. Cancer registries of the federal states selected all colorectal and thyroid cancer cases between 2004 and 2015. A deterministic linkage approach was performed based on indirect personal identifiers such as year of birth, sex, area of residence, type of cancer and an absolute difference between the dates of cancer diagnosis in both data sources of at most 90 days. Results were compared to a probabilistic linkage using "direct" personal identifiers (gold standard). RESULTS The deterministic linkage procedure yielded a sensitivity of 71.8% for colorectal cancer and 66.6% for thyroid cancer. For thyroid cancer, the sensitivity improved when using only inpatient diagnosis to define cancer in GePaRD (71.4%). Specificity was always above 99%. Using the probabilistic linkage to define cancer cases, the risk for colorectal cancer was estimated 10 percentage points lower than when using the deterministic approach. CONCLUSIONS Sensitivity of the deterministic linkage approach appears to be too low to be considered as reasonable alternative to the probabilistic linkage procedure.
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Affiliation(s)
- Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz-Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Tammo Reinders
- Department of Biometry and Data Management, Leibniz-Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Susann Grill
- Department of Biometry and Data Management, Leibniz-Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Andrea Eberle
- Cancer Registry of Bremen, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Timm Intemann
- Department of Biometry and Data Management, Leibniz-Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | | | - Martin Meyer
- Bavarian State Office for Food Safety and Health, Nürnberg, Germany
| | | | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | - Iris Pigeot
- Department of Biometry and Data Management, Leibniz-Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.,Faculty of Mathematics and Computer Science, University of Bremen, Bremen, Germany
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Braitmaier M, Kollhorst B, Heinig M, Langner I, Czwikla J, Heinze F, Buschmann L, Minnerup H, García-Albéniz X, Hense HW, Karch A, Zeeb H, Haug U, Didelez V. Effectiveness of Mammography Screening on Breast Cancer Mortality – A Study Protocol for Emulation of Target Trials Using German Health Claims Data. Clin Epidemiol 2022; 14:1293-1303. [PMID: 36353307 PMCID: PMC9639456 DOI: 10.2147/clep.s376107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background The efficacy of mammography screening in reducing breast cancer mortality has been demonstrated in randomized trials. However, treatment options - and hence prognosis – for advanced tumor stages as well as mammography techniques have considerably improved since completion of these trials. Consequently, the effectiveness of mammography screening under current conditions is unclear and controversial. The German mammography screening program (MSP), an organized population-based screening program, was gradually introduced between 2005 and 2008 and achieved nation-wide coverage in 2009. Objective We describe in detail a study protocol for investigating the effectiveness of the German MSP in reducing breast cancer mortality in women aged 50 to 69 years based on health claims data. Specifically, the proposed study aims at estimating per-protocol effects of several screening strategies on cumulative breast cancer mortality. The first analysis will be conducted once 10-year follow-up data are available. Methods and Analysis We will use claims data from five statutory health insurance providers in Germany, covering approximately 37.6 million individuals. To estimate the effectiveness of the MSP, hypothetical target trials will be emulated across time, an approach that has been demonstrated to minimize design-related biases. Specifically, the primary contrast will be in terms of the cumulative breast cancer mortality comparing the screening strategies of “never screen” versus “regular screening as intended by the MSP”. Ethics and Dissemination In Germany, the utilization of data from health insurances for scientific research is regulated by the Code of Social Law. All involved health insurance providers as well as the responsible authorities approved the use of the health claims data for this study. The Ethics Committee of the University of Bremen determined that studies based on claims data are exempt from institutional review. The findings of the proposed study will be published in peer-reviewed journals.
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Affiliation(s)
- Malte Braitmaier
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Miriam Heinig
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Ingo Langner
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Jonas Czwikla
- SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Bremen, Germany
| | - Franziska Heinze
- SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Bremen, Germany
| | - Laura Buschmann
- Institute for Epidemiology and Social Medicine, Faculty of Medicine, Westfälische Wilhelms University of Münster, Münster, Germany
| | - Heike Minnerup
- Institute for Epidemiology and Social Medicine, Faculty of Medicine, Westfälische Wilhelms University of Münster, Münster, Germany
| | - Xabiér García-Albéniz
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- RTI Health Solutions, Barcelona, Spain
| | - Hans-Werner Hense
- Institute for Epidemiology and Social Medicine, Faculty of Medicine, Westfälische Wilhelms University of Münster, Münster, Germany
| | - André Karch
- Institute for Epidemiology and Social Medicine, Faculty of Medicine, Westfälische Wilhelms University of Münster, Münster, Germany
| | - Hajo Zeeb
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Vanessa Didelez
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- Faculty of Mathematics and Computer Science, University of Bremen, Bremen, Germany
- Correspondence: Vanessa Didelez, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Department of Biometry and Data Management, Achterstraße 30, Bremen, 28359, Germany, Tel +49-421-56939, Fax +49-421-56941, Email
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Platzbecker K, Wentzell N, Kollhorst B, Haug U. Fingolimod, teriflunomide and cladribine for the treatment of multiple sclerosis in women of childbearing age: description of drug utilization and exposed pregnancies in Germany. Mult Scler Relat Disord 2022; 67:104184. [PMID: 36174258 DOI: 10.1016/j.msard.2022.104184] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/30/2022] [Accepted: 09/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Authorizations of fingolimod, teriflunomide and cladribine were accompanied by risk minimization measures concerning their teratogenic potential. Real-world data on their use are scarce. We aimed to assess trends in the use of fingolimod, teriflunomide and cladribine among women of childbearing age, estimate the number of pregnancies occurring under treatment and explore the occurrence of malformations in newborns exposed during early pregnancy in Germany. METHODS Using the German Pharmacoepidemiological Research Database (GePaRD, claims data from ∼20% of the German population), we determined annual age-standardized prevalences of fingolimod, teriflunomide and cladribine use from their authorization until 2019 among women aged 13-49 years (cross-sectional analyses). In longitudinal analyses, we estimated the number of exposed pregnancies by assessing whether there was an overlap between the exposure windows assigned to dispensations and the onset of pregnancy or a dispensation in the first eight weeks of pregnancy. For live births, a mother-baby linkage was performed. All available data of children with in-utero exposure and malformation codes in the first year of life were reviewed to verify the occurrence of congenital malformations. RESULTS For fingolimod, the age-standardized prevalence of use per 1,000 females increased from 0.14 in 2011 to 0.46 in 2019; for teriflunomide, from 0.06 in 2013 to 0.28 in 2019; for cladribine, from 0.01 in 2017 to 0.07 in 2019. The proportion of users aged ≤40 years was 60% for fingolimod, 45% for teriflunomide and 65% for cladribine. We identified 136 pregnancies exposed to fingolimod, 50 to teriflunomide and one to cladribine. For fingolimod and teriflunomide, respectively, 72% and 62% of exposed pregnancies ended in a live birth. Mother-newborn linkage was successful in 64 (fingolimod) and 20 (teriflunomide) live-born children. Among these, there were six with relevant malformations (mainly heart defects) for fingolimod and two for teriflunomide. CONCLUSION Use of fingolimod, teriflunomide and cladribine among women of childbearing age has substantially increased in Germany. A high proportion of users was in age groups in which pregnancies typically occur. Despite risk minimization measures, early pregnancy exposure to these drugs was observed.
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Affiliation(s)
- Katharina Platzbecker
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany.
| | - Nadine Wentzell
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany; Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
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10
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Bongaerts B, Kollhorst B, Kuss O, Pigeot I, Rathmann W. Dispensation Patterns of Glucose-Lowering Drugs in Newly Diagnosed Type 2 Diabetes: Routine Data Analysis of Insurance Claims in Germany. Exp Clin Endocrinol Diabetes 2021; 130:587-595. [PMID: 34942670 DOI: 10.1055/a-1702-5151] [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: 10/19/2022]
Abstract
AIMS To describe dispensation patterns of glucose-lowering drugs in newly diagnosed type 2 diabetes in Germany. MATERIALS AND METHODS Based on claims data from four statutory health insurances (German Pharmacoepidemiological Research Database,>25 million insurants), all individuals with newly diagnosed type 2 diabetes were identified. Eligible patients had a first diagnosis for type 2 diabetes between January 2012 and December 2016. We analyzed the dispensation patterns of first-line glucose-lowering therapies initiated in the year after diabetes diagnosis and patterns of second-line therapies dispensed one year after first-line treatment. RESULTS A total of 356,647 individuals with newly diagnosed type 2 diabetes were included (average age [SD]: 63.5 [13.4] years; 49.3% males). Of the 31.6% of individuals who were pharmacologically treated in the year after diagnosis, metformin monotherapy was most frequently dispensed (73.1%), followed by dual therapy of metformin and dipeptidyl peptidase-4 inhibitors (DPP-4is) (6.4%), and monotherapy with DPP-4is (2.9%). From 2012 through 2016, sulfonylurea dispensations were reduced by more than 50%. Dispensations for combination therapies with DPP-4is increased up to 10.6%. Glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors contributed to 2% of all treatments. After a median of 5 months, 20.0% of individuals on pharmacological therapy initiated second-line glucose-lowering treatment. CONCLUSIONS Data from German statutory health insurances (2012 to 2016) showed that most individuals with newly diagnosed type 2 diabetes were dispensed metformin monotherapy in line with diabetes care guidelines. A substantial decrease in the use of sulfonylureas was observed after the introduction of DPP-4i and GLP-1 receptor agonists.
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Affiliation(s)
- Brenda Bongaerts
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, München-Neuherberg, Germany
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Oliver Kuss
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, München-Neuherberg, Germany
| | - Iris Pigeot
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany.,University of Bremen, Faculty of Mathematics and Computer Science, Bremen, Germany
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, München-Neuherberg, Germany
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11
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Börnhorst C, Reinders T, Rathmann W, Bongaerts B, Haug U, Didelez V, Kollhorst B. Avoiding Time-Related Biases: A Feasibility Study on Antidiabetic Drugs and Pancreatic Cancer Applying the Parametric g-Formula to a Large German Healthcare Database. Clin Epidemiol 2021; 13:1027-1038. [PMID: 34737647 PMCID: PMC8560066 DOI: 10.2147/clep.s328342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/07/2021] [Accepted: 10/12/2021] [Indexed: 12/21/2022] Open
Abstract
Purpose Investigating intended or unintended effects of sustained drug use is of high clinical relevance but remains methodologically challenging. This feasibility study aims to evaluate the usefulness of the parametric g-formula within a target trial for application to an extensive healthcare database in order to address various sources of time-related biases and time-dependent confounding. Patients and Methods Based on the German Pharmacoepidemiological Research Database (GePaRD), we estimated the pancreatic cancer incidence comparing two hypothetical treatment strategies for type 2 diabetes mellitus (T2DM), i.e., (A) sustained metformin monotherapy vs (B) combination therapy with DPP-4 inhibitors after one year metformin monotherapy. We included 77,330 persons with T2DM who started metformin therapy at baseline between 2005 and 2011. Key aspects for avoiding time-related biases and time-dependent confounding were the emulation of a target trial over a 7-year follow-up period and application of the parametric g-formula. Results Over the 7-year follow-up period, 652 out of the 77,330 study subjects had a diagnosis of pancreatic cancer. Assuming no unobserved confounding, we found evidence that the metformin/DPP-4i combination therapy increased the risk of pancreatic cancer compared to a sustained metformin monotherapy (risk ratio: 1.47; 95% bootstrap CI: 1.07–1.94). The risk ratio decreased in sensitivity analyses addressing protopathic bias. Conclusion While protopathic bias could not fully be ruled out, and computational challenges necessitated compromises in the analysis, the g-formula and target trial emulation proved useful: Self-inflicted biases were avoided, observed time-varying confounding was adjusted for, and the estimated risks have a clear causal interpretation.
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Affiliation(s)
- Claudia Börnhorst
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Department of Biometry and Data Management, Bremen, Germany
| | - Tammo Reinders
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Department of Biometry and Data Management, Bremen, Germany
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | - Brenda Bongaerts
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | - Ulrike Haug
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Department of Biometry and Data Management, Bremen, Germany
| | - Vanessa Didelez
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Department of Biometry and Data Management, Bremen, Germany
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Department of Biometry and Data Management, Bremen, Germany
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12
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Pigeot I, Kollhorst B, Didelez V. [Secondary Data for Pharmacoepidemiological Research - Making the Best of It!]. Gesundheitswesen 2021; 83:S69-S76. [PMID: 34695869 DOI: 10.1055/a-1633-3827] [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] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Studies using secondary data such as health care claims data are often faced with methodological challenges due to the time-dependence of key quantities or unmeasured confounding. In the present paper, we discuss approaches to avoid or suitably address various sources of potential bias. In particular, we illustrate the target trial principle, marginal structural models, and instrumental variables with examples from the "GePaRD" database. Finally, we discuss the strengths and limitations of record linkage which can sometimes be used to supply missing information.
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Affiliation(s)
- Iris Pigeot
- Leibniz-Institut für Präventionsforschung und Epidemiologie - BIPS, Abteilung Biometrie und EDV, Bremen, Deutschland.,Fachbereich Mathematik und Informatik, Universität Bremen, Bremen, Deutschland
| | - Bianca Kollhorst
- Leibniz-Institut für Präventionsforschung und Epidemiologie - BIPS, Abteilung Biometrie und EDV, Bremen, Deutschland
| | - Vanessa Didelez
- Leibniz-Institut für Präventionsforschung und Epidemiologie - BIPS, Abteilung Biometrie und EDV, Bremen, Deutschland.,Fachbereich Mathematik und Informatik, Universität Bremen, Bremen, Deutschland
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13
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Fortuny J, von Gersdorff G, Lassalle R, Linder M, Overbeek J, Reinold J, Toft G, Timmer A, Dress J, Blin P, Droz-Perroteau C, Ehrenstein V, Franzoni C, Herings R, Kollhorst B, Moore N, Odsbu I, Perez-Gutthann S, Schink T, Rascher K, Rasouliyan L, Rothman KJ, Saigi-Morgui N, Schaller M, Smits E, Forstner M, Bénichou J, Bircher AJ, Garbe E, Rampton DS, Gutierrez L. Use of intravenous iron and risk of anaphylaxis: A multinational observational post-authorisation safety study in Europe. Pharmacoepidemiol Drug Saf 2021; 30:1447-1457. [PMID: 34181291 PMCID: PMC8457074 DOI: 10.1002/pds.5319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 04/20/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE This post-authorisation safety study estimated the risk of anaphylaxis in patients receiving intravenous (IV) iron in Europe, with interest in iron dextran and iron non-dextrans. Studies conducted in the United States have reported risk of anaphylaxis to IV iron ranging from 2.0 to 6.8 per 10 000 first treatments. METHODS Cohort study of IV iron new users, captured mostly through pharmacy ambulatory dispensing, from populations covered by health and administrative data sources in five European countries from 1999 to 2017. Anaphylaxis events were identified through an algorithm that used parenteral penicillin as a positive control. RESULTS A total of 304 210 patients with a first IV iron treatment (6367 iron dextran), among whom 13-16 anaphylaxis cases were identified and reported as a range to comply with data protection regulations. The pooled unadjusted incidence proportion (IP) ranged from 0.4 (95% confidence interval [CI], 0.2-0.9) to 0.5 (95% CI, 0.3-1.0) per 10 000 first treatments. No events were identified at first dextran treatments. There were 231 294 first penicillin treatments with 30 potential cases of anaphylaxis (IP = 1.2; 95% CI, 0.8-1.7 per 10 000 treatments). CONCLUSION We found an IP of anaphylaxis from 0.4 to 0.5 per 10 000 first IV iron treatments. The study captured only a fraction of IV iron treatments administered in hospitals, where most first treatments are likely to happen. Due to this limitation, the study could not exclude a differential risk of anaphylaxis between iron dextran and iron non-dextrans. The IP of anaphylaxis in users of penicillin was consistent with incidences reported in the literature.
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Affiliation(s)
- Joan Fortuny
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Barcelona, Spain
| | - Gero von Gersdorff
- Department of Internal Medicine-QiN-group, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Régis Lassalle
- Bordeaux PharmacoEpi, INSERM CIC1401, University of Bordeaux, Bordeaux, France
| | - Marie Linder
- Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Jetty Overbeek
- Department Research, PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | - Jonas Reinold
- Clinical Epidemiology Group, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Gunnar Toft
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Antje Timmer
- Epidemiology and Biometry Group, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Jochen Dress
- Research Data Center (DaTraV), Federal Institute for Drugs and Medical Devices-BfArM, Bonn, Germany
| | - Patrick Blin
- Bordeaux PharmacoEpi, INSERM CIC1401, University of Bordeaux, Bordeaux, France
| | | | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Carla Franzoni
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Barcelona, Spain
| | - Ron Herings
- Department Research, PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands.,Amsterdam UMC, Vrije Universiteit Amsterdam, Epidemiology and Biostatistics, Amsterdam, The Netherlands
| | - Bianca Kollhorst
- Clinical Epidemiology Group, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Nicholas Moore
- Bordeaux PharmacoEpi, INSERM CIC1401, University of Bordeaux, Bordeaux, France
| | - Ingvild Odsbu
- Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
| | | | - Tania Schink
- Clinical Epidemiology Group, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Katherine Rascher
- Department of Internal Medicine-QiN-group, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Lawrence Rasouliyan
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Barcelona, Spain
| | - Kenneth J Rothman
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Waltham, Massachusetts, USA
| | - Nuria Saigi-Morgui
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Barcelona, Spain
| | - Mathias Schaller
- Department of Internal Medicine-QiN-group, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Elisabeth Smits
- Department Research, PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | | | | | - Jacques Bénichou
- Department of Biostatistics, Rouen University Hospital and Inserm U 1018, University of Rouen, Rouen, France
| | - Andreas J Bircher
- Allergy Unit, Dermatology Clinic University Hospital Basel, Basel, Switzerland.,Faculty of Biomedicine, Università della Svizzera italiana, Lugano, Switzerland
| | - Edeltraut Garbe
- Clinical Epidemiology Group, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - David S Rampton
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Lia Gutierrez
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, Barcelona, Spain
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14
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Komen JJ, Pottegård A, Mantel-Teeuwisse AK, Forslund T, Hjemdahl P, Wettermark B, Hellfritzsch M, Hallas J, Olesen M, Bennie M, Mueller T, Voss A, Schink T, Haug U, Kollhorst B, Karlstad Ø, Kjerpeseth LJ, Klungel OH. Persistence and adherence to non-vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation across five Western European countries. Europace 2021; 23:1722-1730. [PMID: 34096584 PMCID: PMC8576279 DOI: 10.1093/europace/euab091] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 01/22/2021] [Accepted: 03/23/2021] [Indexed: 12/17/2022] Open
Abstract
AIMS To assess persistence and adherence to non-vitamin K antagonist oral anticoagulant (NOAC) treatment in patients with atrial fibrillation (AF) in five Western European healthcare settings. METHODS AND RESULTS We conducted a multi-country observational cohort study, including 559 445 AF patients initiating NOAC therapy from Stockholm (Sweden), Denmark, Scotland, Norway, and Germany between 2011 and 2018. Patients were followed from their first prescription until they switched to a vitamin K antagonist, emigrated, died, or the end of follow-up. We measured persistence and adherence over time and defined adequate adherence as medication possession rate ≥90% among persistent patients only. RESULTS Overall, persistence declined to 82% after 1 year and to 63% after 5 years. When including restarters of NOAC treatment, 85% of the patients were treated with NOACs after 5 years. The proportion of patients with adequate adherence remained above 80% throughout follow-up. Persistence and adherence were similar between countries and was higher in patients starting treatment in later years. Both first year persistence and adherence were lower with dabigatran (persistence: 77%, adherence: 65%) compared with apixaban (86% and 75%) and rivaroxaban (83% and 75%) and were statistically lower after adjusting for patient characteristics. Adherence and persistence with dabigatran remained lower throughout follow-up. CONCLUSION Persistence and adherence were high among NOAC users in five Western European healthcare settings and increased in later years. Dabigatran use was associated with slightly lower persistence and adherence compared with apixaban and rivaroxaban.
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Affiliation(s)
- Joris J Komen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Healthcare Development, Stockholm Region, Public Healthcare Services Committee, Stockholm, Sweden
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Tomas Forslund
- Department of Healthcare Development, Stockholm Region, Public Healthcare Services Committee, Stockholm, Sweden.,Department of Medicine Solna, Clinical Epidemiology/Clinical Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology/Clinical Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Björn Wettermark
- Department of Pharmacy, Pharmacoepidemiology & Social Pharmacy, Uppsala University, Uppsala, Sweden
| | - Maja Hellfritzsch
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Olesen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Marion Bennie
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Public Health and Intelligence Strategic Business Unit, NHS National Services Scotland, Glasgow, UK
| | - Tanja Mueller
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Annemarie Voss
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Tania Schink
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.,Faculty of Human and Life Sciences, University of Bremen, Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Øystein Karlstad
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Lars J Kjerpeseth
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Olaf H Klungel
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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15
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Scholle O, Kollhorst B, Riedel O, Bachmann CJ. First-Time Users of ADHD Medication Among Children and Adolescents in Germany: An Evaluation of Adherence to Prescribing Guidelines Based on Claims Data. Front Psychiatry 2021; 12:653093. [PMID: 33935837 PMCID: PMC8081976 DOI: 10.3389/fpsyt.2021.653093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 01/13/2021] [Accepted: 03/11/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Drug utilization studies based on real-world data are vital for the identification of potentially needed improvements to rational prescribing. This is particularly important for the pharmacological treatment of children and adolescents with attention-deficit hyperactivity disorder (ADHD) due to the associated potential side effects and the frequent use. Whereas prevalent use is well-characterized, studies on first-time use of ADHD medication are scarce. This study aimed to evaluate off-label prescribing in first-time users of ADHD medication among children and adolescents in Germany based on three criteria: (i) lack of a documented ADHD diagnosis; (ii) first-time pharmacological treatment with a second-line drug; and (iii) patient age below 6 years. Methods: Based on German claims data, we included children and adolescents aged 0-17 years with a first-time dispensation of any ADHD medication in the period 2015-2017. These first-time users were characterized with regard to sex, age, specialty of the prescribing physician, documentation of an ADHD diagnosis, psychiatric hospitalization, psychiatric comorbidities, and history of other psychopharmacological drugs at first-time use. Results: The study population comprised 18,703 pediatric first-time users of ADHD medication. Of these, 9.8% had no documented ADHD diagnosis. Most of the ADHD drug users received first-line ADHD pharmacotherapy (methylphenidate, atomoxetine), whereas 2.6% were prescribed second-line ADHD medication (lisdexamfetamine, guanfacine, dexamfetamine, multiple ADHD drugs) as first drug. Overall, 1.2% of first-time users were aged below 6 years. A total of 12.7% of the study population met any off-label criterion. Conclusions: About 13% of pediatric first-time users of ADHD medication in Germany received an off-label pharmacotherapy at first-time use. Prescribing ADHD medication without a confirmed ADHD diagnosis was the most common of the three assessed off-label criteria. Off-label prescribing regarding drug choice and age of patients only occurred in a small percentage of initial pharmacological ADHD treatment. Our results suggest the need for improvement in rational prescribing, especially with regard to diagnostic requirements.
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Affiliation(s)
- Oliver Scholle
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Christian J Bachmann
- Department of Child & Adolescent Psychiatry, University Hospital Ulm, Ulm, Germany
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16
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March S, Andrich S, Drepper J, Horenkamp-Sonntag D, Icks A, Ihle P, Kieschke J, Kollhorst B, Maier B, Meyer I, Müller G, Ohlmeier C, Peschke D, Richter A, Rosenbusch ML, Scholten N, Schulz M, Stallmann C, Swart E, Wobbe-Ribinski S, Wolter A, Zeidler J, Hoffmann F. Good Practice Data Linkage (GPD): A Translation of the German Version. Int J Environ Res Public Health 2020; 17:ijerph17217852. [PMID: 33120886 PMCID: PMC7663300 DOI: 10.3390/ijerph17217852] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/16/2020] [Accepted: 10/22/2020] [Indexed: 12/14/2022]
Abstract
The data linkage of different data sources for research purposes is being increasingly used in recent years. However, generally accepted methodological guidance is missing. The aim of this article is to provide methodological guidelines and recommendations for research projects that have been consented to across different German research societies. Another aim is to endow readers with a checklist for the critical appraisal of research proposals and articles. This Good Practice Data Linkage (GPD) was already published in German in 2019, but the aspects mentioned can easily be transferred to an international context, especially for other European Union (EU) member states. Therefore, it is now also published in English. Since 2016, an expert panel of members of different German scientific societies have worked together and developed seven guidelines with a total of 27 practical recommendations. These recommendations include (1) the research objectives, research questions, data sources, and resources; (2) the data infrastructure and data flow; (3) data protection; (4) ethics; (5) the key variables and linkage methods; (6) data validation/quality assurance; and (7) the long-term use of data for questions still to be determined. The authors provide a rationale for each recommendation. Future revisions will include new developments in science and updates of data privacy regulations.
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Affiliation(s)
- Stefanie March
- Institute for Social Medicine and Health Systems Research (ISMHSR), Medical Faculty, Otto von Guericke University Magdeburg, 39120 Magdeburg, Germany; (S.M.); (C.S.); (E.S.)
- Department of Social Work, Health and Media, Magdeburg-Stendal University of Applied Sciences, 39114 Magdeburg, Germany
| | - Silke Andrich
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, 40225 Dusseldorf, Germany; (S.A.); (A.I.)
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, 40225 Dusseldorf, Germany
| | - Johannes Drepper
- TMF—Technology, Methods, and Infrastructure for Networked Medical Research, 10117 Berlin, Germany;
| | | | - Andrea Icks
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, 40225 Dusseldorf, Germany; (S.A.); (A.I.)
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, 40225 Dusseldorf, Germany
| | - Peter Ihle
- PMV Research Group, University of Cologne, 50931 Cologne, Germany; (P.I.); (I.M.)
| | - Joachim Kieschke
- Epidemiological Cancer Registry of Lower Saxony, Register Center, 26121 Oldenburg, Germany;
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology—BIPS Department Biometry and Data Management, 28359 Bremen, Germany;
| | - Birga Maier
- Berlin-Brandenburg Myocardial Infarction Registry e. V., 10317 Berlin, Germany;
| | - Ingo Meyer
- PMV Research Group, University of Cologne, 50931 Cologne, Germany; (P.I.); (I.M.)
| | - Gabriele Müller
- Center for Evidence-Based Healthcare (ZEGV), University Hospital and Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany;
| | | | - Dirk Peschke
- Institute for Public Health and Nursing Research (IPP), University of Bremen, 28359 Bremen, Germany;
- Department of Applied Health Sciences, University of Health Bochum, 44801 Bochum, Germany
| | - Adrian Richter
- Institute for Community Medicine, Department SHIP-KEF, Greifswald University Medical Center, 17475 Greifswald, Germany;
| | - Marie-Luise Rosenbusch
- Central Research Institute for Ambulatory Healthcare in Germany (Zi), Department of Data Science and Healthcare Analyses, 10587 Berlin, Germany; (M.-L.R.); (M.S.)
| | - Nadine Scholten
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences and Faculty of Medicine, University of Cologne, 50933 Cologne, Germany;
| | - Mandy Schulz
- Central Research Institute for Ambulatory Healthcare in Germany (Zi), Department of Data Science and Healthcare Analyses, 10587 Berlin, Germany; (M.-L.R.); (M.S.)
| | - Christoph Stallmann
- Institute for Social Medicine and Health Systems Research (ISMHSR), Medical Faculty, Otto von Guericke University Magdeburg, 39120 Magdeburg, Germany; (S.M.); (C.S.); (E.S.)
| | - Enno Swart
- Institute for Social Medicine and Health Systems Research (ISMHSR), Medical Faculty, Otto von Guericke University Magdeburg, 39120 Magdeburg, Germany; (S.M.); (C.S.); (E.S.)
| | - Stefanie Wobbe-Ribinski
- DAK Gesundheit, Health Services Research and Innovation, 20097 Hamburg, Germany; (S.W.-R.); (A.W.)
| | - Antke Wolter
- DAK Gesundheit, Health Services Research and Innovation, 20097 Hamburg, Germany; (S.W.-R.); (A.W.)
| | - Jan Zeidler
- Center for Health Economics Research Hanover (CHERH), Leibniz University Hanover, 30159 Hanover, Germany;
| | - Falk Hoffmann
- Faculty of Medicine and Health Sciences, Department of Healthcare Research, Carl von Ossietzky University Oldenburg, 26129 Oldenburg, Germany
- Correspondence:
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17
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Pisa FE, Reinold J, Kollhorst B, Haug U, Schink T. Individual Antidepressants and the Risk of Fractures in Older Adults: A New User Active Comparator Study. Clin Epidemiol 2020; 12:667-678. [PMID: 32606992 PMCID: PMC7319507 DOI: 10.2147/clep.s222888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 07/11/2019] [Accepted: 04/01/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To determine the risk of hip–pelvis and other non-vertebral fractures in older adults using antidepressants (ADs). Methods We conducted a case–control study nested in a cohort of new users of ADs aged ≥65 years without prior hip–pelvis or other non-vertebral fractures, identified in the German Pharmacoepidemiological Research Database (GePaRD) during 2005–2014. Cases were patients first hospitalized for hip–pelvis or other non-vertebral fractures. Up to 100 controls per case were selected using incidence density sampling. AD use was ascertained at index date (ID) based on the supply of last dispensing. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression with current users of mirtazapine as reference (active comparator). Results A total of 39,853 cases of hip–pelvis fracture (80% women, median age 81 years) and 31,577 cases of other fractures (84% women, median age 79 years) were matched to >3 million controls. For hip–pelvis fracture, aORs in current users were about 1.3 with little variation between individual ADs, ranging from 1.33 for citalopram (95% CI 1.27–1.39) to 1.28 for amitriptyline (1.21–1.35). For other fractures, the aORs were highest in current users of citalopram (1.50; 1.42–1.58) and duloxetine (1.54; 1.39–1.71) and lowest for amitriptyline (1.18; 1.11–1.26) and trimipramine (1.16; 1.03–1.29). For all examined ADs, the aORs were higher for other fractures than for hip–pelvis fracture. Conclusion The risk of fractures varies between ADs, but for most agents is higher than the risk for mirtazapine. When treating older adults with ADs, prescribers should carefully consider the risk profile of individual ADs regarding fractures, which are a major health problem in this population.
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Affiliation(s)
- Federica Edith Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Jonas Reinold
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Researchand Epidemiology - BIPS, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany.,Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Tania Schink
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
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18
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Fortuny J, Gilsenan A, Cainzos-Achirica M, Cantero OF, Flynn RWV, Garcia-Rodriguez L, Kollhorst B, Karlsson P, Linnér L, MacDonald TM, Plana E, Ruigómez A, Schink T, Ziemiecki R, Andrews EB. Study Design and Cohort Comparability in a Study of Major Cardiovascular Events in New Users of Prucalopride Versus Polyethylene Glycol 3350. Drug Saf 2020; 42:1167-1177. [PMID: 31134513 PMCID: PMC6739282 DOI: 10.1007/s40264-019-00836-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Introduction Given prior safety experience with other 5-HT4 agonists for chronic constipation, an observational, population-based cohort study in five data sources from Germany, Sweden, and the UK was conducted to evaluate the cardiovascular safety of prucalopride. Objectives Our objective is to describe the methods and resulting comparability of cohorts in a multi-database, multinational study of prucalopride initiators and polyethylene glycol 3350 (PEG) initiators following a harmonized protocol. Methods Prucalopride initiators were matched on age, sex, and index date to PEG initiators (1:5 ratio). Study exposures, cardiovascular risk factors, and other covariates were identified from healthcare utilization codes harmonized across databases. Cardiovascular outcomes were identified using database-specific algorithms based on diagnosis codes. The propensity score (PS) in each database was estimated using logistic regression, with prucalopride versus PEG as the outcome and including clinically relevant variables associated with major adverse cardiovascular events. Results In total, 12,030 prucalopride initiators and 59,985 PEG initiators were identified. After matching and trimming, cohorts from the UK and Sweden were well-balanced for cardiovascular risk factors and cancer. However, in Germany, PEG initiators remained older and sicker than prucalopride initiators. The prevalence of these characteristics also differed from those in the UK and Sweden. The pooled analyses included only data from the UK and Sweden. Conclusions Matching, trimming, and PS stratification yielded comparable cohorts in four of five data sources. Use of these methods could not achieve balance for key covariates within the German cohort, likely due to reimbursement differences in Germany. Electronic supplementary material The online version of this article (10.1007/s40264-019-00836-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Alicia Gilsenan
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709, USA.
| | - Miguel Cainzos-Achirica
- RTI Health Solutions, Barcelona, Spain.,Department of Cardiology, Hospital Universitari de Bellvitge, Feixa Llarga, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oscar F Cantero
- Centro Español de Investigación Farmacoepidemiológica, Madrid, Spain
| | | | | | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | | | | | | | | | - Ana Ruigómez
- Centro Español de Investigación Farmacoepidemiológica, Madrid, Spain
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Ryan Ziemiecki
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709, USA
| | - Elizabeth B Andrews
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709, USA
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19
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Gilsenan A, Fortuny J, Cainzos-Achirica M, Cantero OF, Flynn RWV, Garcia-Rodriguez L, Harding A, Kollhorst B, Karlsson P, Linnér L, MacDonald TM, Odsbu I, Plana E, Ruigómez A, Schink T, Ziemiecki R, Andrews EB. Cardiovascular Safety of Prucalopride in Patients with Chronic Constipation: A Multinational Population-Based Cohort Study. Drug Saf 2020; 42:1179-1190. [PMID: 31134512 PMCID: PMC6739451 DOI: 10.1007/s40264-019-00835-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Introduction The serotonin 5-HT4 receptor agonist prucalopride is approved in the European Union for the treatment of chronic constipation. This offered the unique opportunity to include real-world observational data on cardiovascular safety in the new drug application for approval of prucalopride in the USA. Methods This observational population-based cohort study (EUPAS9200) conducted in five data sources (three in the UK, one in Sweden, and one in Germany [which was subsequently excluded from the pooled analyses]) aimed to estimate the pooled adjusted incidence rate ratio for major adverse cardiovascular events (defined as hospitalization for non-fatal acute myocardial infarction or stroke, and in-hospital cardiovascular death) in adult initiators of prucalopride compared with initiators of polyethylene glycol 3350 (PEG) following a common protocol. Standardized incidence rates and incidence rate ratios of major adverse cardiovascular events were derived using propensity score stratification. Sensitivity analyses explored the impact of exposure definition, outcome categories, interim cancer, and unmeasured confounding. Results The pooled analyses included 5715 initiators of prucalopride and 29,372 initiators of PEG. Average duration of use was 175 days for prucalopride and 82 days for PEG. The pooled standardized incidence rate per 1000 person-years (95% confidence interval) of major adverse cardiovascular events was 6.57 (3.90–10.39) for patients initiating prucalopride and 10.24 (6.97–14.13) for PEG. The pooled adjusted incidence rate ratio for major adverse cardiovascular events was 0.64 (95% confidence interval 0.36–1.14). Results remained consistent in various sensitivity analyses. Conclusions The pooled incidence rate ratio estimate was consistent with no indication of an increased risk above the pre-specified safety threshold of 3.00 for major adverse cardiovascular events in patients with chronic constipation using prucalopride as compared with PEG.
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Affiliation(s)
- Alicia Gilsenan
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709, USA.
| | | | - Miguel Cainzos-Achirica
- RTI Health Solutions, Barcelona, Spain.,Department of Cardiology, Hospital Universitari de Bellvitge, Feixa Llarga, Hospitalet de Llobregat, Barcelona, Spain
| | - Oscar F Cantero
- Centro Español de Investigación Farmacoepidemiológica, Madrid, Spain
| | | | | | - Abenah Harding
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709, USA
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | | | | | | | | | | | - Ana Ruigómez
- Centro Español de Investigación Farmacoepidemiológica, Madrid, Spain
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Ryan Ziemiecki
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709, USA
| | - Elizabeth B Andrews
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709, USA
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20
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Abstract
OBJECTIVES To compare diclofenac use before and after implementation of European risk minimization measures in 2013, focusing on diclofenac initiators and prevalence of congestive heart failure (NYHA class II-IV), ischaemic heart disease, peripheral arterial disease and cerebrovascular disease (new contraindications) in these patients in Germany. METHODS We included adults with health insurance coverage on 1 January 2011 (cohort 2011) or 1 January 2014 (cohort 2014) and during a 1-year pre-observation period. We defined diclofenac initiators as persons filling a prescription of systemic diclofenac in 2011 (cohort 2011) or 2014 (cohort 2014) and without such a prescription during the respective pre-observation period. RESULTS Each cohort comprised >10 million persons. Between 2011 and 2014, the age-standardized proportion of persons initiating diclofenac decreased by 29% (from 8.2% to 5.8%) amongst female patients and by 26% (from 8.5% to 6.3%) amongst male patients; in the subgroup of persons with new contraindications, this proportion decreased by 33% (from 9.8% to 6.6%) amongst female patients and by 31% (from 10.0% to 6.7%) amongst male patients. Amongst diclofenac initiators, the proportion of those with new contraindications did not change between 2011 (12.0%) and 2014 (11.8%). CONCLUSION The overall decline of about 30% in diclofenac initiation between 2011 and 2014 was largely independent of the presence or absence of new contraindications. The proportion of diclofenac initiators with a new contraindication remained at a high level (more than one in ten patients), demonstrating the need for research at the prescriber level (e.g. interventional studies) and further measures to improve patient safety.
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Affiliation(s)
- O Scholle
- From the, Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - B Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - U Haug
- From the, Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.,Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
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21
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Scholle O, Fegert JM, Kollhorst B, Öztürk EE, Riedel O, Kölch M. Predictors for Receiving Medication and/or Psychotherapy in Children Newly Diagnosed With ADHD: A Longitudinal Population-Based Cohort Study. J Atten Disord 2020; 24:255-264. [PMID: 30522406 DOI: 10.1177/1087054718816172] [Citation(s) in RCA: 6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: The aim of this study is to identify characteristics predicting the use of medication and/or psychotherapy after a first ADHD diagnosis. Method: This cohort study was based on German claims data including 12,250 treatment-naïve children aged 5 to 12 years with an incident ADHD diagnosis in 2010. Logistic regression models were used to estimate associations between children's characteristics at first diagnosis and the chosen treatment within the following 5 years. Results: Medication use was associated with male sex, an ADHD diagnosis "with hyperactivity," comorbid depression, and comorbid developmental and conduct disorders. Male sex and comorbid neurotic and somatoform, conduct, and emotional disorders were associated with psychotherapy only. Receiving both treatments-instead of medication only-was associated with comorbid depression, neurotic and somatoform, conduct, and emotional disorders. Conclusion: In case of equal access to both treatment options, patients, for example, with externalizing symptoms were more prone to receive medication and/or psychotherapy than the average child diagnosed with ADHD.
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Affiliation(s)
- Oliver Scholle
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Jörg M Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Germany
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Eyyub E Öztürk
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Oliver Riedel
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Michael Kölch
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Germany.,Brandenburg Medical School Theodore Fontane, Neuruppin, Germany
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22
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Schmucker J, Fach A, Mata Marin LA, Retzlaff T, Osteresch R, Kollhorst B, Hambrecht R, Pohlabeln H, Wienbergen H. Efficacy and Safety of Ticagrelor in Comparison to Clopidogrel in Elderly Patients With ST-Segment-Elevation Myocardial Infarctions. J Am Heart Assoc 2019; 8:e012530. [PMID: 31538856 PMCID: PMC6818018 DOI: 10.1161/jaha.119.012530] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [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] [Indexed: 11/16/2022]
Abstract
Background Current guidelines recommend the new-generation P2Y12-inhibitor ticagrelor for patients with acute ST-segment-elevation myocardial infarctions (STEMIs). The aim of the present study was to assess efficacy and safety of ticagrelor for elderly patients with STEMI (≥75 years) in an all-comers STEMI registry. Methods and Results Patients with STEMI, aged ≥75 years, treated with primary percutaneous coronary intervention and documented in the Bremen STEMI Registry between 2006 and 2017 entered analysis. The primary efficacy outcome, major adverse cardiac and cerebrovascular events, was defined as a composite of death, myocardial reinfarction, and stroke. The safety outcome was defined as any significant bleeding event within 1 year. To estimate benefit/risk ratio, net adverse clinical events (major adverse cardiac and cerebrovascular events+bleedings) were calculated. Outcomes were estimated in propensity score-matched cohorts to adjust for possible confounders. Of a total of 7466 patients with STEMI, 1087, aged ≥75 years, were selected, of which 552 (51%) received clopidogrel and 535 (49%) received ticagrelor, with similar age (80.9±4.6 versus 80.9±4.6 years) and sex (51% versus 50% female) distributions between treatment arms. The primary efficacy outcome occurred in 32.4% of patients treated with clopidogrel versus 25.5% treated with ticagrelor (P=0.015), with the 1-year mortality rate at 26.8% versus 21.1% (P=0.035). Because there was no difference in the safety outcome (clopidogrel versus ticagrelor, 4.9% versus 5.1%; not significant), net adverse clinical events were higher for clopidogrel than for ticagrelor: 37.3% versus 30.6% (P=0.028). In a propensity score-matched model, the advantage for ticagrelor on major adverse cardiac and cerebrovascular events remained significant (hazard ratio, 0.69; 95% CI, 0.49-0.97; P=0.03), whereas 1-year-mortality (hazard ratio, 0.89; 95% CI, 0.67-1.27; P=0.5) and 1-year bleeding events (hazard ratio, 1.1; 95% CI, 0.4-2.3; P=0.8) did not differ. Conclusions These results from propensity score-matched registry data show that for elderly patients with STEMI, ticagrelor compared with clopidogrel was associated with a reduction in major adverse cardiac and cerebrovascular events without a significant increase in bleeding events within 1 year.
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Affiliation(s)
- Johannes Schmucker
- Bremer Institut für Herz- und Kreislaufforschung am Klinikum Links der Weser Bremen Germany
| | - Andreas Fach
- Bremer Institut für Herz- und Kreislaufforschung am Klinikum Links der Weser Bremen Germany
| | | | - Tina Retzlaff
- Bremer Institut für Herz- und Kreislaufforschung am Klinikum Links der Weser Bremen Germany
| | - Rico Osteresch
- Bremer Institut für Herz- und Kreislaufforschung am Klinikum Links der Weser Bremen Germany
| | - Bianca Kollhorst
- Leibniz-Institut für Präventionsforschung und Epidemiologie Bremen Germany
| | - Rainer Hambrecht
- Bremer Institut für Herz- und Kreislaufforschung am Klinikum Links der Weser Bremen Germany
| | - Hermann Pohlabeln
- Leibniz-Institut für Präventionsforschung und Epidemiologie Bremen Germany
| | - Harm Wienbergen
- Bremer Institut für Herz- und Kreislaufforschung am Klinikum Links der Weser Bremen Germany
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23
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March S, Andrich S, Drepper J, Horenkamp-Sonntag D, Icks A, Ihle P, Kieschke J, Kollhorst B, Maier B, Meyer I, Müller G, Ohlmeier C, Peschke D, Richter A, Rosenbusch ML, Scholten N, Schulz M, Stallmann C, Swart E, Wobbe-Ribinski S, Wolter A, Zeidler J, Hoffmann F. [Good Practice Data Linkage]. Gesundheitswesen 2019; 81:636-650. [PMID: 31394579 DOI: 10.1055/a-0962-9933] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Individual data linkage of different data sources for research purposes is being increasingly used in Germany in recent years. However, generally accepted methodological guidance is missing. The aim of this article is to define such methodological standards for research projects. Another aim is to provide readers with a checklist for critical appraisal of research proposals and articles. Since 2016, an expert panel of members of different German scientific societies have worked together and developed 7 guidelines with a total of 27 practical recommendations. These recommendations include (1) research aims, questions, data sources and resources, (2) infrastructure and data flow, (3) data privacy, (4) ethics, (5) key variables and type of linkage, (6) data validation/quality assurance and (7) long-term use for future research questions. The authors provide a rationale for each recommendation. Future revisions will include any new developments in science and data privacy.
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Affiliation(s)
- Stefanie March
- Institut für Sozialmedizin und Gesundheitsökonomie (ISMG), Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg, Magdeburg
| | - Silke Andrich
- Institut für Versorgungsforschung und Gesundheitsökonomie, Centre for Health and Society, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf.,Institut für Versorgungsforschung und Gesundheitsökonomie, Deutsches Diabetes-Zentrum (DDZ), Leibniz-Zentrum für Diabetes-Forschung an der Heinrich-Heine-Universität Düsseldorf, Düsseldorf
| | - Johannes Drepper
- TMF - Technologie- und Methodenplattform für die vernetzte medizinische Forschung e. V., Berlin
| | | | - Andrea Icks
- Institut für Versorgungsforschung und Gesundheitsökonomie, Centre for Health and Society, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf.,Institut für Versorgungsforschung und Gesundheitsökonomie, Deutsches Diabetes-Zentrum (DDZ), Leibniz-Zentrum für Diabetes-Forschung an der Heinrich-Heine-Universität Düsseldorf, Düsseldorf
| | - Peter Ihle
- PMV forschungsgruppe, Universität zu Köln, Köln
| | - Joachim Kieschke
- Epidemiologisches Krebsregister Niedersachsen, Registerstelle, Oldenburg
| | - Bianca Kollhorst
- Leibniz-Institut für Präventionsforschung und Epidemiologie - BIPS, Abteilung Biometrie und EDV, Bremen
| | - Birga Maier
- Berlin-Brandenburger Herzinfarktregister e. V., Berlin-Brandenburger Herzinfarktregister, Berlin
| | - Ingo Meyer
- PMV forschungsgruppe, Universität zu Köln, Köln
| | - Gabriele Müller
- Zentrum für Evidenzbasierte Gesundheitsversorgung (ZEGV), Universitätsklinikum und Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden
| | | | - Dirk Peschke
- Institut für Public Health und Pflegeforschung (IPP), Universität Bremen, Bremen.,Department für Angewandte Gesundheitswissenschaften, Studienbereich Physiotherapie, Hochschule für Gesundheit Bochum, Bochum
| | - Adrian Richter
- Institut für Community Medicine, Universitätsmedizin Greifswald, Greifswald
| | - Marie-Luise Rosenbusch
- Zentralinstitut für die kassenärztliche Versorgung in Deutschland (Zi), Fachbereich Versorgungsforschung, Systemanalyse und Data Science, Berlin
| | - Nadine Scholten
- Institut für Medizinsoziologie, Versorgungsforschung und Rehabilitationswissenschaft (IMVR), Humanwissenschaftliche Fakultät und Medizinische Fakultät, Universität zu Köln, Köln
| | - Mandy Schulz
- Zentralinstitut für die kassenärztliche Versorgung in Deutschland (Zi), Fachbereich Versorgungsforschung, Systemanalyse und Data Science, Berlin
| | - Christoph Stallmann
- Institut für Sozialmedizin und Gesundheitsökonomie (ISMG), Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg, Magdeburg
| | - Enno Swart
- Institut für Sozialmedizin und Gesundheitsökonomie (ISMG), Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg, Magdeburg
| | | | - Antke Wolter
- DAK Gesundheit, Vorstandsreferat Versorgungsforschung, Hamburg
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Hannover
| | - Falk Hoffmann
- Fakultät für Medizin und Gesundheitswissenschaften, Department für Versorgungsforschung, Carl von Ossietzky Universität Oldenburg, Oldenburg
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24
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Schäfer W, Princk C, Kollhorst B, Schink T. Antidepressants and the Risk of Hemorrhagic Stroke in the Elderly: a Nested Case–Control Study. Drug Saf 2019; 42:1081-1089. [DOI: 10.1007/s40264-019-00837-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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25
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Kollhorst B, Jobski K, Krappweis J, Schink T, Garbe E, Schmedt N. Antidepressants and the risk of death in older patients with depression: A population-based cohort study. PLoS One 2019; 14:e0215289. [PMID: 30986235 PMCID: PMC6464187 DOI: 10.1371/journal.pone.0215289] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 03/31/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Antidepressants are frequently used in older patients with depression, but little is known about the comparative safety of individual agents. The objective of the study was to determine the comparative risk of death of antidepressants in older patients with depression. METHODS AND FINDINGS We carried out a cohort study from 2004 to 2015 utilizing the German Pharmacoepidemiological Research Database, a population-based database supplied by statutory health insurance providers covering approximately 17% of the general population and all geographical regions. We included 376,846 patients aged 65+ years with a diagnosis of depression who initiated treatment with one of 13 antidepressants (ADs). In total 27,019 patients died during follow-up corresponding to a rate of 119.7 per 1,000 person years. We used proportional hazards models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for the risk of death for twelve ADs compared to citalopram. In the primary analysis, we found an increased risk of death associated with the use of amitriptyline (HR 1.15, 95%CI: 1.10-1.20). However, opipramol, trimipramine, doxepin, mirtazapine, fluoxetine, paroxetine, duloxetine, venlafaxine, and St. John's wort were found to be associated with a lower risk of death. The increased risk of amitriptyline diminished after exclusion of patients with a history of cancer (HR 0.88, 95%CI: 0.82-0.94) and after high-dimensional propensity score (HdPS) adjustment (HR 1.04, 95%CI: 0.95-1.14). In older patients and in those with dementia, differences in risk between most individual ADs and citalopram were smaller. After adjustment by HdPS, the decreased risks for fluoxetine, paroxetine, venlafaxine and mirtazapine compared to citalopram disappeared. CONCLUSIONS This study suggests that ADs recommended as first-line treatment in patients with depression have a similar safety profile with regard to the risk of death, especially in very old patients and in those with dementia. Further research is needed to investigate the risk of death for individual ADs in specific subgroups such as patients with cancer or cardiovascular disease.
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Affiliation(s)
- Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Bremen, Germany
- * E-mail:
| | - Kathrin Jobski
- Division of Outpatient Care and Pharmacoepidemiology, Carl von Ossietzky University Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Jutta Krappweis
- Federal Institute for Drugs and Medical Devices (BfArM), Kurt-Georg-Kiesinger-Allee, Bonn, Germany
| | - Tania Schink
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Bremen, Germany
| | - Edeltraut Garbe
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Bremen, Germany
| | - Niklas Schmedt
- InGef—Institute for Applied Health Research, Berlin, Berlin, Germany
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Pisa FE, Reinold J, Kollhorst B, Haug U, Schink T. Antidepressants and the risk of traumatic brain injury in the elderly: differences between individual agents. Clin Epidemiol 2019; 11:185-196. [PMID: 30858730 PMCID: PMC6386209 DOI: 10.2147/clep.s173667] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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] [Indexed: 11/23/2022] Open
Abstract
Objective To determine the association of individual antidepressants (ADs) with the risk of traumatic brain injury (TBI) in the elderly. Patients and methods We conducted a case-control study nested in a cohort of new users of ADs aged ≥65 years, identified in the German Pharmacoepidemiological Research Database during 2005-2014. Cases were patients first hospitalized for TBI. Up to 100 controls per case were selected using incidence density sampling. AD use was ascertained at the index date based on the supply of last dispensing (adding 150% of the defined daily doses [DDDs]; in sensitivity analysis, no additional DDDs were considered). We estimated adjusted ORs (aORs) and 95% CIs using conditional logistic regression. Results Among 701,309 cohort members, 16,750 cases were identified and matched to 1,673,320 controls (in both groups: 70.4% women; median age 80 years). Compared with remote users of the same AD, current users had an aOR (95% CI) of 1.87 (1.56-2.24) for duloxetine, 1.74 (1.41-2.15) for escitalopram, 1.70 (1.58-1.83) for citalopram, 1.66 (1.40-1.97) for sertraline, 1.64 (1.24-2.15) for fluoxetine and 1.57 (1.20-2.06) for paroxetine. The aOR was lower for amitriptyline (1.45; 1.32-1.58), trimipramine (1.17; 0.99-1.38) and opipramol (1.11; 0.99-1.25). Mirtazapine had an aOR of 1.03 (0.94-1.12). Sensitivity analysis confirmed the findings. Conclusion The large variability between individual ADs shows the importance of considering the safety of individual agents rather than focusing on class alone.
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Affiliation(s)
- Federica Edith Pisa
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany, .,Institute of Hygiene and Clinical Epidemiology, University Hospital of Udine, Udine, Italy,
| | - Jonas Reinold
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany,
| | - Bianca Kollhorst
- Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Ulrike Haug
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany, .,Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Tania Schink
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany,
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Masclee GMC, Straatman H, Arfè A, Castellsague J, Garbe E, Herings R, Kollhorst B, Lucchi S, Perez-Gutthann S, Romio S, Schade R, Schink T, Schuemie MJ, Scotti L, Varas-Lorenzo C, Valkhoff VE, Villa M, Sturkenboom MCJM. Risk of acute myocardial infarction during use of individual NSAIDs: A nested case-control study from the SOS project. PLoS One 2018; 13:e0204746. [PMID: 30383755 PMCID: PMC6211656 DOI: 10.1371/journal.pone.0204746] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [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] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 09/13/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Use of selective COX-2 non-steroidal anti-inflammatory drugs (NSAIDs) (coxibs) has been associated with an increased risk of acute myocardial infarction (AMI). However, the risk of AMI has only been studied for very few NSAIDs that are frequently used. OBJECTIVES To estimate the risk of AMI for individual NSAIDs. METHODS A nested case-control study was performed from a cohort of new NSAID users ≥18 years (1999-2011) matching cases to a maximum of 100 controls on database, sex, age, and calendar time. Data were retrieved from six healthcare databases. Adjusted odds ratios (ORs) of current use of individual NSAIDs compared to past use were estimated per database. Pooling was done by two-stage pooling using a random effects model (ORmeta) and by one-stage pooling (ORpool). RESULTS Among 8.5 million new NSAID users, 79,553 AMI cases were identified. The risk was elevated for current use of ketorolac (ORmeta 2.06;95%CI 1.83-2.32, ORpool 1.80; 1.49-2.18) followed, in descending order of point estimate, by indometacin, etoricoxib, rofecoxib, diclofenac, fixed combination of diclofenac with misoprostol, piroxicam, ibuprofen, naproxen, celecoxib, meloxicam, nimesulide and ketoprofen (ORmeta 1.12; 1.03-1.22, ORpool 1.00;0.86-1.16). Higher doses showed higher risk estimates than lower doses. CONCLUSIONS The relative risk estimates of AMI differed slightly between 28 individual NSAIDs. The relative risk was highest for ketorolac and was correlated with COX-2 potency, but not restricted to coxibs.
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Affiliation(s)
- Gwen M. C. Masclee
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, the Netherlands
| | | | - Andrea Arfè
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University Milano-Bicocca, Milano, Italy
| | | | - Edeltraut Garbe
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany
| | | | - Bianca Kollhorst
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany
| | | | | | - Silvana Romio
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University Milano-Bicocca, Milano, Italy
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - René Schade
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tania Schink
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany
| | - Martijn J. Schuemie
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lorenza Scotti
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University Milano-Bicocca, Milano, Italy
| | | | - Vera E. Valkhoff
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco Villa
- Local Health Authority ASL Cremona, Cremona, Italy
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Schink T, Kollhorst B, Varas Lorenzo C, Arfè A, Herings R, Lucchi S, Romio S, Schade R, Schuemie MJ, Straatman H, Valkhoff V, Villa M, Sturkenboom M, Garbe E. Risk of ischemic stroke and the use of individual non-steroidal anti-inflammatory drugs: A multi-country European database study within the SOS Project. PLoS One 2018; 13:e0203362. [PMID: 30231067 PMCID: PMC6145581 DOI: 10.1371/journal.pone.0203362] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [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] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 08/20/2018] [Indexed: 12/14/2022] Open
Abstract
Background and purpose A multi-country European study using data from six healthcare databases from four countries was performed to evaluate in a large study population (>32 million) the risk of ischemic stroke (IS) associated with individual NSAIDs and to assess the impact of risk factors of IS and co-medication. Methods Case-control study nested in a cohort of new NSAID users. For each case, up to 100 sex- and age-matched controls were selected and confounder-adjusted odds ratios for current use of individual NSAIDs compared to past use calculated. Results 49,170 cases of IS were observed among 4,593,778 new NSAID users. Use of coxibs (odds ratio 1.08, 95%-confidence interval 1.02–1.15) and use of traditional NSAIDs (1.16, 1.12–1.19) were associated with an increased risk of IS. Among 32 individual NSAIDs evaluated, the highest significant risk of IS was observed for ketorolac (1.46, 1.19–1.78), but significantly increased risks (in decreasing order) were also found for diclofenac, indomethacin, rofecoxib, ibuprofen, nimesulide, diclofenac with misoprostol, and piroxicam. IS risk associated with NSAID use was generally higher in persons of younger age, males, and those with a prior history of IS. Conclusions Risk of IS differs between individual NSAIDs and appears to be higher in patients with a prior history of IS or transient ischemic attack (TIA), in younger or male patients. Co-medication with aspirin, other antiplatelets or anticoagulants might mitigate this risk. The small to moderate observed risk increase (by 13–46%) associated with NSAIDs use represents a public health concern due to widespread NSAID usage.
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Affiliation(s)
- Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- * E-mail:
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | | | | | | | | | - Silvana Romio
- University Milano-Bicocca, Milano, Italy
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - René Schade
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Vera Valkhoff
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco Villa
- Local Health Authority ASL Cremona, Cremona, Italy
| | | | - Edeltraut Garbe
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
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Enders D, Kollhorst B, Engel S, Linder R, Pigeot I. Comparison of multiple imputation and two-phase logistic regression to analyse two-phase case–control studies with rich phase 1: a simulation study. J STAT COMPUT SIM 2018. [DOI: 10.1080/00949655.2018.1452926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Dirk Enders
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Susanne Engel
- Scientific Institute of TK for Benefit and Efficiency in Health Care – WINEG, Hamburg, Germany
| | - Roland Linder
- Scientific Institute of TK for Benefit and Efficiency in Health Care – WINEG, Hamburg, Germany
| | - Iris Pigeot
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- Faculty of Mathematics and Computer Science, University of Bremen, Bremen, Germany
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Jobski K, Kollhorst B, Garbe E, Schink T. The Risk of Ischemic Cardio- and Cerebrovascular Events Associated with Oxycodone-Naloxone and Other Extended-Release High-Potency Opioids: A Nested Case-Control Study. Drug Saf 2018; 40:505-515. [PMID: 28194654 DOI: 10.1007/s40264-017-0511-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION In Germany, an extended-release (ER) combination of the high-potency opioid (HPO) oxycodone and the antagonist naloxone was approved in 2006. In recent years, the cardio- and cerebrovascular safety of opioid antagonists and of opioids themselves has been discussed. OBJECTIVES The objective of this study was to estimate the risk of major ischemic cardio- and cerebrovascular events in patients receiving ER oxycodone-naloxone compared with those receiving other ER HPOs. METHODS We used the German Pharmacoepidemiological Research Database (GePaRD) to conduct a nested case-control study (2006-2011) within a cohort of ER HPO users. Cases were defined as patients hospitalized for acute myocardial infarction (MI) or ischemic stroke (IS). For each case, up to ten controls were selected by risk-set sampling. Using conditional logistic regression, confounder-adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were obtained for the risk of MI/IS associated with (1) current HPO treatment, (2) recent discontinuation, or (3) recent switch of HPO therapy compared with past treatment. RESULTS In 309,936 ER HPO users, 12,384 MI/IS events were detected, resulting in a crude incidence rate of 19.48 (95% CI 19.14-19.82) per 1000 person years. A small but significantly elevated aOR was found for morphine (1.12; 95% CI 1.04-1.22) but not for oxycodone-naloxone. Recent discontinuation and recent switch of any ER HPO also had a significant impact on the outcome (aOR 1.12; 95% CI 1.04-1.21 and 1.25; 95% CI 1.03-1.52, respectively). CONCLUSIONS Our study does not indicate an association between oxycodone-naloxone and ischemic cardio- or cerebrovascular events. However, our findings do suggest that every change in ER HPO therapy should be conducted with caution.
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Affiliation(s)
- Kathrin Jobski
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany. .,Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstrasse 140, 26129, Oldenburg, Germany.
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Edeltraut Garbe
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.,Core Scientific Area 'Health Sciences', University of Bremen, Bremen, Germany
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
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March S, Antoni M, Kieschke J, Kollhorst B, Maier B, Müller G, Sariyar M, Schulz M, Enno S, Zeidler J, Hoffmann F. [Quo Vadis Data Linkage in Germany? An Initial Inventory]. Gesundheitswesen 2018; 80:e20-e31. [PMID: 29462830 DOI: 10.1055/s-0043-125070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In recent years, linking different data sources, also called data linkage or record linkage, to address scientific questions, is being increasingly used in Germany. However, there are very few published reports and new projects develop the necessary tools independently of each other. Therefore, a team of researchers joined together to exchange their experiences on data linkage and to give suggestions on how linkage could be done for scientists, reviewers as well as members of data privacy boards and ethics committees. It is the aim of this article to assist future projects that want to link German data on an individual level. In addition to the legal framework conditions (data privacy), also examples of types of data linkage, their fields of application und potential pitfalls as well as the methods of preventing them will be described in an application-oriented fashion.
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Affiliation(s)
- Stefanie March
- Medizinische Fakultät, Institut für Sozialmedizin und Gesundheitsökonomie, Otto-von-Guericke-Universität Magdeburg, Magdeburg
| | - Manfred Antoni
- Institut für Arbeitsmarkt- und Berufsforschung der Bundesagentur für Arbeit (IAB), Nürnberg
| | - Joachim Kieschke
- Registerstelle, Epidemiologisches Krebsregister Niedersachsen, Oldenburg
| | - Bianca Kollhorst
- Abteilung Biometrie und EDV, Leibniz-Institut für Präventionsforschung und Epidemiologie - BIPS, Bremen
| | - Birga Maier
- Berlin-Brandenburger Herzinfarktregister e.V., Berlin
| | - Gabriele Müller
- Universitätsklinikum und Medizinische Fakultät Carl Gustav Carus, Zentrum für Evidenzbasierte Gesundheitsversorgung (ZEGV), TU Dresden, Dresden
| | - Murat Sariyar
- TMF - Technologie- und Methodenplattform für die vernetzte medizinische Forschung e.V., Berlin.,University of Applied Sciences Bern, Department of Medical Informatics, Bern
| | - Mandy Schulz
- Zentralinstitut für die kassenärztliche Versorgung in Deutschland (Zi), Fachbereich Versorgungsforschung und Risikostruktur, Berlin
| | - Swart Enno
- Medizinische Fakultät, Institut für Sozialmedizin und Gesundheitsökonomie, Otto-von-Guericke-Universität Magdeburg, Magdeburg
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Hannover
| | - Falk Hoffmann
- Department für Versorgungsforschung, Carl von Ossietzky Universität Oldenburg, Oldenburg
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Schröder C, Dörks M, Kollhorst B, Blenk T, Dittmann RW, Garbe E, Riedel O. Extent and Risks of Antipsychotic Off-Label Use in Children and Adolescents in Germany Between 2004 and 2011. J Child Adolesc Psychopharmacol 2017; 27:806-813. [PMID: 28618239 DOI: 10.1089/cap.2016.0202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Only little is known about antipsychotic (AP) off-label use (OLU) in pediatric populations. It was the aim of this study to examine the frequency as well as the risks of off-label AP use in underaged patients. METHODS To calculate the frequency of off-label AP prescriptions for the years 2004-2011, we used claims data of more than two million minors aged 0-17 years. Off-label prescriptions were analyzed with regard to type of OLU, physician specialty, and underlying diagnoses. Incidence rates of selected adverse events were calculated for on-label as well as for OLU. The risk of poisoning associated with on- or OLU was assessed in a nested case-control study. RESULTS The annual share of pediatric AP users with off-label prescriptions varied between 52.3% and 71.1%. OLU by indication (42.8%-66.5%) was the most common type of OLU. Of the subjects with OLU by indication, 52.5% had a diagnosis of hyperkinetic disorder. Adverse events were scarce (incidence rates between 0.8 and 8.6 per 10,000 person-years), and no significant difference was observed between on- and OLU. CONCLUSION Because of their frequent use in hyperkinetic disorder patients, APs are commonly prescribed off-label for minors. Since OLU by contraindication was rare and the risk of the adverse events under study was similarly small for on- and OLU, this is not necessarily an indication for inappropriate treatment. It rather indicates that further randomized studies are needed to examine efficacy and safety of pediatric AP use in this indication.
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Affiliation(s)
- Carsten Schröder
- 1 Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS , Bremen, Germany
| | - Michael Dörks
- 2 Department of Health Services Research, Carl von Ossietzky University Oldenburg , Oldenburg, Germany
| | - Bianca Kollhorst
- 3 Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology-BIPS , Bremen, Germany
| | - Tilo Blenk
- 1 Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS , Bremen, Germany
| | - Ralf W Dittmann
- 4 Paediatric Psychopharmacology, Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg , Mannheim, Germany
| | - Edeltraut Garbe
- 1 Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS , Bremen, Germany
| | - Oliver Riedel
- 1 Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS , Bremen, Germany
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Schröder C, Dörks M, Kollhorst B, Blenk T, Dittmann RW, Garbe E, Riedel O. Extent and risks of antidepressant off-label use in children and adolescents in Germany between 2004 and 2011. Pharmacoepidemiol Drug Saf 2017; 26:1395-1402. [DOI: 10.1002/pds.4289] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 06/01/2017] [Accepted: 07/18/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Carsten Schröder
- Department of Clinical Epidemiology; Leibniz Institute for Prevention Research and Epidemiology - BIPS; Bremen Germany
| | - Michael Dörks
- Department of Health Services Research; Carl von Ossietzky University Oldenburg; Oldenburg Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management; Leibniz Institute for Prevention Research and Epidemiology - BIPS; Bremen Germany
| | - Tilo Blenk
- Department of Clinical Epidemiology; Leibniz Institute for Prevention Research and Epidemiology - BIPS; Bremen Germany
| | - Ralf W. Dittmann
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim; University of Heidelberg; Mannheim Germany
| | - Edeltraut Garbe
- Department of Clinical Epidemiology; Leibniz Institute for Prevention Research and Epidemiology - BIPS; Bremen Germany
| | - Oliver Riedel
- Department of Clinical Epidemiology; Leibniz Institute for Prevention Research and Epidemiology - BIPS; Bremen Germany
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Thöne K, Kollhorst B, Schink T. Non-Steroidal Anti-Inflammatory Drug Use and the Risk of Acute Myocardial Infarction in the General German Population: A Nested Case-Control Study. Drugs Real World Outcomes 2017; 4:127-137. [PMID: 28676983 PMCID: PMC5567458 DOI: 10.1007/s40801-017-0113-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction Use of non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with an increased relative risk of acute myocardial infarction (AMI), but the label warnings refer particularly to patients with cardiovascular risk factors. The magnitude of relative AMI risk for patients with and without cardiovascular risk factors varies between studies depending on the drugs and doses studied. Objectives The aim of our study was to estimate population-based relative AMI risks for individual and widely used NSAIDs, for a cumulative amount of NSAID use, and for patients with and without a prior history of cardiovascular risk factors. Methods Based on data from the German Pharmacoepidemiological Research Database (GePaRD) of about 17 million insurance members from four statutory health insurance providers, for the years 2004–2009, a nested case–control study was conducted within a cohort of 3,476,931 new NSAID users classified into current, recent, or past users. Up to 100 controls were matched to each case by age, sex, and length of follow-up using risk set sampling. Multivariable conditional logistic regression was applied to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Duration of NSAID use was calculated by the cumulative amount of dispensed defined daily doses (DDDs), and stratified analyses were conducted for potential effect modifiers. Results Overall, 17,236 AMI cases were matched to 1,714,006 controls. Elevated relative AMI risks were seen for current users of fixed combinations of diclofenac with misoprostol (OR 1.76, 95% CI 1.26–2.45), indometacin (1.69, 1.22–2.35), ibuprofen (1.54, 1.43–1.65), etoricoxib (1.52, 1.24–1.87), and diclofenac (1.43, 1.34–1.52) compared with past use. A low cumulative NSAID amount was associated with a higher relative AMI risk for ibuprofen, diclofenac, and indometacin. The relative risk associated with current use of diclofenac, fixed combinations of diclofenac with misoprostol, etoricoxib, and ibuprofen was highest in the younger age group (<60 years) and similar for patients with or without major cardiovascular risk factors. Conclusion Relative AMI risk estimates differed among the 15 investigated individual NSAIDs. Diclofenac and ibuprofen, the most frequently used NSAIDs, were associated with a 40–50% increased relative risk of AMI, even for low cumulative NSAID amounts. The relative AMI risk in patients with and without cardiovascular risk factors was similarly elevated. Electronic supplementary material The online version of this article (doi:10.1007/s40801-017-0113-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kathrin Thöne
- Leibniz Institute for Prevention Research and Epidemiology, BIPS, Bremen, Germany
- University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology, BIPS, Bremen, Germany
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology, BIPS, Bremen, Germany
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Schröder C, Dörks M, Kollhorst B, Blenk T, Dittmann RW, Garbe E, Riedel O. Outpatient antipsychotic drug use in children and adolescents in Germany between 2004 and 2011. Eur Child Adolesc Psychiatry 2017; 26:413-420. [PMID: 27623818 DOI: 10.1007/s00787-016-0905-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/06/2016] [Indexed: 12/01/2022]
Abstract
Studies from different countries showed increasing use of antipsychotics in pediatric patients. However, these studies were methodologically limited and could not assess underlying diagnoses and off-label use sufficiently. This is the first study to examine antipsychotic prescriptions in a representative sample of minors over a long period, looking at changes regarding substances and drug classes, underlying diagnoses, and the rate of off-label use. Claims data of about two million pediatric subjects were used to calculate annual prevalences and incidence rates of antipsychotic prescriptions for the years 2004-2011. Analyses were stratified by sex, age, and drug type. Numbers of prescriptions, frequencies of diseases/disorders, the prescribing physicians' specialties, and the share of off-label prescriptions were examined. During the study period, the prevalence of antipsychotic prescriptions ranged between 2.0 and 2.6 per 1000 minors. Antipsychotic prescriptions in children younger than 6 years decreased from 2.42 per 1000 subjects in 2004 to 0.48 in 2011. Among antipsychotic users, 47.0 % had only one prescription and hyperkinetic disorder was, by far, the most frequent diagnosis. The annual share of off-label prescriptions varied between 61.0 and 69.5 %. Antipsychotics were mainly prescribed to manage aggressive and impulsive behaviors in hyperkinetic disorder patients. This explains the high share of off-label prescriptions but raises concerns, since efficacy and safety of antipsychotics in this indication have not been sufficiently investigated. The decreasing antipsychotic use in younger children and the high proportion of antipsychotic users with one-time prescriptions are striking and should be further investigated in the future.
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Affiliation(s)
- Carsten Schröder
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstr. 30, 28359, Bremen, Germany
| | - Michael Dörks
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26111, Oldenburg, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstr. 30, 28359, Bremen, Germany
| | - Tilo Blenk
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstr. 30, 28359, Bremen, Germany
| | - Ralf W Dittmann
- Paediatric Psychopharmacology, Department of Child and Adolescent Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, J 5, 68159, Mannheim, Germany
| | - Edeltraut Garbe
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstr. 30, 28359, Bremen, Germany
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstr. 30, 28359, Bremen, Germany.
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Schröder C, Dörks M, Kollhorst B, Blenk T, Dittmann RW, Garbe E, Riedel O. Outpatient antidepressant drug use in children and adolescents in Germany between 2004 and 2011. Pharmacoepidemiol Drug Saf 2016; 26:170-179. [PMID: 27868277 DOI: 10.1002/pds.4138] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 04/06/2016] [Revised: 10/24/2016] [Accepted: 10/24/2016] [Indexed: 11/11/2022]
Abstract
PURPOSE Recent studies on the utilization of antidepressant drugs in minors are scarce, methodologically limited, and do not factor in off-label use sufficiently. Beyond that, little is known about the short treatment durations that have been observed for many young antidepressant users. The present study examined antidepressant use in pediatric patients aged 0 to 17 years over time, investigated changes regarding the prescribed drugs, analyzed underlying diagnoses, and assessed the rate of off-label use. METHODS We used claims data of roughly two million individuals to calculate annual prevalence and incidence rates of antidepressant prescriptions for the years 2004 to 2011. Analyses were stratified by age, sex, and drug type. For antidepressant users, numbers of prescriptions, frequencies of disorders/diseases, and specialties of the prescribing physicians were examined. The share of off-label prescriptions was calculated for each year. RESULTS The prescription prevalence of antidepressants ranged between 1.7 and 2.1 per 1000 minors. The use of tricyclic antidepressants decreased from 0.9 to 0.6 prescriptions per 1000 minors, while the use of selective serotonin reuptake inhibitors increased from 0.5 to 1.1. Of the patients with an antidepressant prescription, 46.4% only received one prescription. Depression was by far the most frequent diagnosis among all antidepressant users as well as among subjects with only one prescription. In 2011, 36.3% of all prescriptions were off-label. CONCLUSIONS The high proportion of single prescriptions, even in patients with a diagnosed depression, and the high rate of off-label use are particularly noteworthy and should be further investigated in future studies. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Carsten Schröder
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Michael Dörks
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Tilo Blenk
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Ralf W Dittmann
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Edeltraut Garbe
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
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Arfè A, Scotti L, Varas-Lorenzo C, Nicotra F, Zambon A, Kollhorst B, Schink T, Garbe E, Herings R, Straatman H, Schade R, Villa M, Lucchi S, Valkhoff V, Romio S, Thiessard F, Schuemie M, Pariente A, Sturkenboom M, Corrao G. Non-steroidal anti-inflammatory drugs and risk of heart failure in four European countries: nested case-control study. BMJ 2016; 354:i4857. [PMID: 27682515 DOI: 10.1136/bmj.i4857] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [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] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the cardiovascular safety of non-steroidal anti-inflammatory drugs (NSAIDs) and estimate the risk of hospital admission for heart failure with use of individual NSAIDs. DESIGN Nested case-control study. SETTING Five population based healthcare databases from four European countries (the Netherlands, Italy, Germany, and the United Kingdom). PARTICIPANTS Adult individuals (age ≥18 years) who started NSAID treatment in 2000-10. Overall, 92 163 hospital admissions for heart failure were identified and matched with 8 246 403 controls (matched via risk set sampling according to age, sex, year of cohort entry). MAIN OUTCOME MEASURE Association between risk of hospital admission for heart failure and use of 27 individual NSAIDs, including 23 traditional NSAIDs and four selective COX 2 inhibitors. Associations were assessed by multivariable conditional logistic regression models. The dose-response relation between NSAID use and heart failure risk was also assessed. RESULTS Current use of any NSAID (use in preceding 14 days) was found to be associated with a 19% increase of risk of hospital admission for heart failure (adjusted odds ratio 1.19; 95% confidence interval 1.17 to 1.22), compared with past use of any NSAIDs (use >183 days in the past). Risk of admission for heart failure increased for seven traditional NSAIDs (diclofenac, ibuprofen, indomethacin, ketorolac, naproxen, nimesulide, and piroxicam) and two COX 2 inhibitors (etoricoxib and rofecoxib). Odds ratios ranged from 1.16 (95% confidence interval 1.07 to 1.27) for naproxen to 1.83 (1.66 to 2.02) for ketorolac. Risk of heart failure doubled for diclofenac, etoricoxib, indomethacin, piroxicam, and rofecoxib used at very high doses (≥2 defined daily dose equivalents), although some confidence intervals were wide. Even medium doses (0.9-1.2 defined daily dose equivalents) of indomethacin and etoricoxib were associated with increased risk. There was no evidence that celecoxib increased the risk of admission for heart failure at commonly used doses. CONCLUSIONS The risk of hospital admission for heart failure associated with current use of NSAIDs appears to vary between individual NSAIDs, and this effect is dose dependent. This risk is associated with the use of a large number of individual NSAIDs reported by this study, which could help to inform both clinicians and health regulators.
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Affiliation(s)
- Andrea Arfè
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Lorenza Scotti
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | | | - Federica Nicotra
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Antonella Zambon
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Bianca Kollhorst
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany
| | - Tania Schink
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany
| | - Edeltraut Garbe
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany
| | | | | | - René Schade
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Marco Villa
- Local Health Authority ASL Cremona, Cremona, Italy
| | | | - Vera Valkhoff
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Silvana Romio
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, Netherlands
| | | | - Martijn Schuemie
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, Netherlands
| | | | - Miriam Sturkenboom
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Giovanni Corrao
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
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Enders D, Kollhorst B, Engel S, Linder R, Verheyen F, Pigeot I. Comparative risk for cardiovascular diseases of dipeptidyl peptidase-4 inhibitors vs. sulfonylureas in combination with metformin: Results of a two-phase study. J Diabetes Complications 2016; 30:1339-46. [PMID: 27245402 DOI: 10.1016/j.jdiacomp.2016.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/07/2016] [Accepted: 05/16/2016] [Indexed: 12/25/2022]
Abstract
AIMS The aim was to assess whether the use of additional data from the Disease Management Program (DMP) diabetes mellitus type 2 to minimize the potential for residual confounding will alter the estimated risk of either myocardial infarction, ischemic stroke or heart failure in patients with type 2 diabetes using sulfonylureas compared to dipeptidyl peptidase-4 (DPP-4) inhibitors in addition to metformin based on routine health care data. METHODS We conducted a nested two-phase case-control study using claims data of one German health insurance from 2004 to 2013 (phase 1) and data of the DMP from 2010 to 2013 (phase 2). Adjusted odds ratios (ORs) for the combined cardiovascular event myocardial infarction, ischemic stroke or heart failure were calculated using a two-phase logistic regression. RESULTS Phase 1 comprised 3179 patients (289 cases; 2890 controls) and phase 2 comprised 1968 patients (168 cases; 1800 controls). We observed an adjusted OR of 0.83 for the combined cardiovascular event (95% CI: 0.61-1.13). CONCLUSIONS We observed a non-significantly reduced risk for cardiovascular diseases in patients using DPP-4 inhibitors compared to sulfonylureas in addition to metformin. This finding was not altered by the inclusion of additional information of the DMP in the analysis. However, due to the low power of this study, further studies are needed to reproduce our findings.
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Affiliation(s)
- Dirk Enders
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Susanne Engel
- Scientific Institute of TK for Benefit and Efficiency in Health Care, Hamburg, Germany
| | - Roland Linder
- Scientific Institute of TK for Benefit and Efficiency in Health Care, Hamburg, Germany
| | - Frank Verheyen
- Scientific Institute of TK for Benefit and Efficiency in Health Care, Hamburg, Germany
| | - Iris Pigeot
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.
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Schmedt N, Kollhorst B, Enders D, Jobski K, Krappweis J, Garbe E, Schink T. Comparative risk of death in older adults treated with antipsychotics: A population-based cohort study. Eur Neuropsychopharmacol 2016; 26:1390-1400. [PMID: 27475994 DOI: 10.1016/j.euroneuro.2016.07.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/21/2016] [Accepted: 07/02/2016] [Indexed: 11/15/2022]
Abstract
Although the use of antipsychotics has been associated with an increased risk of death, data on the safety of individual substances is scarce. We thus aimed to compare the risk of death in new users of individual antipsychotics aged =>65 years and conducted a cohort study in the German Pharmacoepidemiological Research Database between 2005 and 2011. Patients were followed from initiation of treatment until death, 90 days after cohort entry, end of insurance or the end of the study period. Multivariable cox regression was used to estimate confounder adjusted hazard ratios (aHR) of death for 14 individual antipsychotics compared to risperidone. In sensitivity analyses, we also applied high-dimensional propensity score (HDPS) methods to explore possible unmeasured confounding. In a cohort of 137,713 new users of antipsychotics, a higher risk of death was found for haloperidol (aHR: 1.45; 95% confidence interval: 1.35-1.55), levomepromazine (aHR: 1.34; 1.16-1.54), zuclopenthixol (aHR: 1.32; 1.02-1.72) and to a lesser extent for melperone (aHR: 1.13; 1.07-1.19) compared to risperidone. Lower risks were observed for quetiapine, prothipendyl, olanzapine, tiapride, clozapine, perazine and flupentixol. In subgroup analyses, levomepromazine and chlorprothixene were only associated with a higher risk of death in patients aged =>80 years and with dementia. The application of HDPS methods did not substantially change the results. In conclusion, our study suggests that initiation of haloperidol, levomepromazine, zuclopenthixol and chlorprothixene treatment is associated with an increased risk of death compared to risperidone and should be avoided in older patients except in palliative care when treatment alternatives are available.
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Affiliation(s)
- Niklas Schmedt
- Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Achterstraße 30, 28359 Bremen, Germany.
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Achterstraße 30, 28359 Bremen, Germany
| | - Dirk Enders
- Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Achterstraße 30, 28359 Bremen, Germany
| | - Kathrin Jobski
- Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Achterstraße 30, 28359 Bremen, Germany; Carl von Ossietzky University Oldenburg, Department of Health Services Research Oldenburg, Germany
| | - Jutta Krappweis
- Federal Institute for Drugs and Medical Devices (BfArM), Kurt-Georg-Kiesinger-Allee 3, 53175 Bonn, Germany
| | - Edeltraut Garbe
- Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Achterstraße 30, 28359 Bremen, Germany
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Achterstraße 30, 28359 Bremen, Germany
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Douros A, Jobski K, Kollhorst B, Schink T, Garbe E. Risk of venous thromboembolism in cancer patients treated with epoetins or blood transfusions. Br J Clin Pharmacol 2016; 82:839-48. [PMID: 27206325 DOI: 10.1111/bcp.13019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 09/14/2015] [Revised: 04/11/2016] [Accepted: 05/14/2016] [Indexed: 11/29/2022] Open
Abstract
AIMS Anaemia is common in cancer patients, with treatments including epoetins and blood transfusions. Although an increased risk of venous thromboembolism (VTE) has been associated with both therapeutics, studies comparing the risk of VTE between epoetins and transfusions in cancer patients are lacking. METHODS A nested case-control study investigated this risk using the German Pharmacoepidemiological Research Database. Cohort members were incident cancer patients receiving first time treatment with epoetin or transfusion. A subcohort including only patients receiving chemotherapy was created, since the formally approved indication of epoetins is chemotherapy-induced anaemia. Cases were defined as patients developing VTE. For each case up to 10 gender- and age-matched controls were selected from the cohort. Multiple confounder adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for VTE and recent treatment with epoetins or transfusions (last 28 days before index date) compared with past anti-anaemic treatment were calculated by conditional logistic regression. RESULTS Among 69 888 patients receiving first time treatment with epoetin or transfusion, 3316 VTE cases were identified. The aOR for VTE was 1.31 (95% CI 1.03, 1.65) for epoetins, 2.33 (95% CI 2.03, 2.66) for transfusions, and 2.24 (95% CI 1.34, 3.77) for epoetins and transfusions. Sensitivity analyses with a stricter VTE definition or an expanded time window yielded similar results. In the chemotherapy only subcohort the risk difference between epoetins and transfusions could not be verified (aOR 1.48, 95% CI 1.10, 1.98 vs. aOR 1.80, 95% CI 1.49, 2.19). Our study confirmed known VTE risk factors including previous VTE (aOR 14.76, 95% CI 12.79, 17.03) or surgery (aOR 1.83, 95% CI 1.67, 2.01). Epoetin-associated risk decreased after a safety warning by the European Medicines Agency setting maximum haemoglobin target values to 12 g dl(-1) . CONCLUSIONS Transfusions could be associated with a higher VTE risk than epoetins in cancer patients. Moreover, current prescribing patterns may have decreased the VTE risk for epoetins.
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Affiliation(s)
- Antonios Douros
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany.,Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kathrin Jobski
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany
| | - Bianca Kollhorst
- Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany
| | - Tania Schink
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany
| | - Edeltraut Garbe
- Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany.,Core Scientific Area 'Health Sciences' at the University of Bremen, Bremen, Germany
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Kollhorst B, Behr S, Enders D, Dippel FW, Theobald K, Garbe E. Comparison of basal insulin therapies with regard to the risk of acute myocardial infarction in patients with type 2 diabetes: an observational cohort study. Diabetes Obes Metab 2015; 17:1158-65. [PMID: 26279482 DOI: 10.1111/dom.12554] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/05/2015] [Accepted: 08/12/2015] [Indexed: 11/29/2022]
Abstract
AIMS To assess the risk of acute myocardial infarction (AMI) in patients with type 2 diabetes mellitus treated with long-acting insulin analogues in comparison with other basal insulin therapy. METHODS We used German insurance claims data from the years 2004-2009 to conduct a study in a retrospective cohort of patients with type 2 diabetes. Naïve insulin users were defined as patients who had an insulin-free history before the first prescription of long-acting analogue insulin, human NPH insulin or premixed insulin and who were pretreated with oral antidiabetic drugs. Adjusted hazard ratios (HRs) of AMI and corresponding 95% confidence intervals (CIs) were calculated using sex-stratified Cox models. Propensity-score-matched analyses were conducted as sensitivity analyses. RESULTS We identified 21,501 new insulin users. Patients treated with premixed insulin were older than patients treated with analogue or NPH insulin (mean age 70.7 vs. 64.1 and 61.6 years, respectively) and had more comorbidities. Regarding the risk of AMI, adjusted HRs showed no statistically significant difference between NPH and analogue insulin (HR 0.94, 95% CI 0.74-1.19), but a higher risk for premixed than for analogue insulin (HR 1.27, 95% CI 1.02-1.58). Contrary to the primary analysis, the propensity-score-matched analysis did not show an increased risk for premixed insulin. CONCLUSIONS In contrast to a former database study, no difference was observed for the risk of AMI between long-acting analogue and NPH insulin in this study. Neither long-acting analogue insulin nor premixed insulin appears to be associated with AMI in patients with type 2 diabetes.
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Affiliation(s)
- B Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - S Behr
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - D Enders
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - F-W Dippel
- Sanofi Aventis Deutschland GmbH, Berlin, Germany
| | - K Theobald
- Sanofi Aventis Deutschland GmbH, Berlin, Germany
| | - E Garbe
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
- Core Scientific Area 'Health Sciences', University of Bremen, Bremen, Germany
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Kollhorst B, Abrahamowicz M, Pigeot I. The proportion of all previous patients was a potential instrument for patients' actual prescriptions of nonsteroidal anti-inflammatory drugs. J Clin Epidemiol 2015; 69:96-106. [PMID: 26341022 DOI: 10.1016/j.jclinepi.2015.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 03/06/2015] [Revised: 07/24/2015] [Accepted: 08/24/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To investigate whether physician's prescribing preference is a valid instrumental variable (IV) for patients' actual prescription of selective cyclooxygenase-2 (COX-2) inhibitors in the German Pharmacoepidemiological Research Database (GePaRD). STUDY DESIGN AND SETTING We compared the effect of COX-2 inhibitors vs. traditional nonsteroidal anti-inflammatory drugs (tNSAIDs) on the risk of gastrointestinal complications using physician's preference as IV. We used different definitions of physician's preference for COX-2 inhibitors. A retrospective cohort of new users was built which was further restricted to subcohorts. We compared IV-based risk difference estimates, using a two-stage approach, to estimates from conventional multivariate models. RESULTS We observed only a small proportion of COX-inhibitor users (3.2%) in our study. All instruments, in the full cohort and in the subcohorts, reduced the imbalance in most of the covariates. However, the IV treatment effect estimates had a highly inflated variance. Compared to the most recent prescription, the proportion of previous patients was a stronger instrument and reduced the variance of the estimates. CONCLUSION The proportion of all previous patients is a potential IV for comparing COX-2 inhibitors vs. tNSAIDs in GePaRD. Our study demonstrates that valid instruments in one health care system may not be directly applicable to others.
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Affiliation(s)
- Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Department Biometry and Data Management, Achterstr. 30, Bremen 28359, Germany.
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal H3A 1A2, Québec, Canada; Division of Clinical Epidemiology, McGill University Health Centre Royal Victoria Hospital, 687 Pine Avenue West, Montreal H3A 1A1, Québec, Canada
| | - Iris Pigeot
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Department Biometry and Data Management, Achterstr. 30, Bremen 28359, Germany; Faculty of Mathematics and Computer Science, University of Bremen, Bibliothekstraße 1, Bremen 28359, Germany
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Jobski K, Kollhorst B, Schink T, Garbe E. The Risk of Opioid Intoxications or Related Events and the Effect of Alcohol-Related Disorders: A Retrospective Cohort Study in German Patients Treated with High-Potency Opioid Analgesics. Drug Saf 2015; 38:811-22. [PMID: 26119289 DOI: 10.1007/s40264-015-0312-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Intoxications involving prescription opioids are a major public health problem in many countries. When taken with opioids, alcohol can enhance the effects of opioids, particularly in the central nervous system. However, data quantifying the impact of alcohol involvement in opioid-related intoxications are limited. METHODS Using claims data from the German Pharmacoepidemiological Research Database (GePaRD), we conducted a retrospective cohort study based on users of high-potency opioid (HPO) analgesics during the years 2005-2009. HPO use was classified as extended-release, immediate-release or both. We calculated incidence rates (IRs) for opioid intoxications or related events as well as adjusted IR ratios (aIRR) comparing HPO-treated patients with alcohol-related disorders (ARDs) to those without ARDs overall and within each HPO category. RESULTS During the study period, 308,268 HPO users were identified with an overall IR of 340.4 per 100,000 person-years [95 % confidence interval (CI) 325.5-355.7]. The risk was highest when patients received concomitant treatment with extended- and immediate-release HPOs (IR 1093.8; 95 % CI 904.6-1310.9). ARDs increased the risk during HPO use by a factor of 1.7 and the highest aIRR was seen when comparing patients simultaneously exposed to extended- and immediate-release HPOs with ARDs to those without ARD also after excluding patients with potential improper/non-medical HPO use. CONCLUSIONS Physicians should be aware of these elevated risks in HPO patients with ARDs. Active patient education by healthcare providers regarding the risk of opioid intoxications or related events due to alcohol in conjunction with HPOs is warranted.
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Affiliation(s)
- K Jobski
- Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH, Achter Str. 30, 28359, Bremen, Germany
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Prager W, Wissmüller E, Kollhorst B, Williams S, Zschocke I. Comparison of two botulinum toxin type A preparations for treating crow's feet: a split-face, double-blind, proof-of-concept study. Dermatol Surg 2011; 36 Suppl 4:2155-60. [PMID: 21134046 DOI: 10.1111/j.1524-4725.2010.01798.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND This is the first double-blind, randomized, proof-of-concept study to compare the clinical effectiveness of botulinum toxin type A (BoNTA) free of complexing proteins with a BoNTA complex (BTXCo) in the treatment of crow's feet. PATIENTS AND METHOD Twelve U of each product were compared in an intra-individual study in 21 participants with a facial wrinkle scale (FWS) score of 2 to 3. Evaluations were done for up to 4 months. Subjects with an improvement of at least 1 point on the FWS were considered responders. RESULTS One month after treatment, the percentage of responders was slightly higher for the BoNTA side (95%) than the BTXCo side (90%). After 4 months, both sides still showed good efficacy, with an 84% response rate and greater than 30% FWS reduction (no statistically significant difference between the products). After 1 month, FWS score at rest was approximately 66% lower for BoNTA, versus 63% lower for BTXCo. After 4 months, FWS reduction was approximately 50%. CONCLUSION Both botulinum toxin A products displayed high efficacy and good tolerability at a dose ratio of 1:1, with no statistically significant differences between them. The high response rates observed after 4 months suggest a good effectiveness beyond this observation period.
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