Cardiovascular and renal diseases in type 2 diabetes patients: 5-year cumulative incidence of the first occurred manifestation and hospitalization cost: a cohort within the French SNDS nationwide claims database

BACKGROUND

Myocardial infarction (MI), stroke, peripheral arterial disease (PAD), heart failure (HF) and chronic kidney disease (CKD) are common cardiovascular renal diseases (CVRD) manifestations for type 2 diabetes. The objective was to estimate the incidence of the first occurring CVRD manifestation and cumulative hospitalization costs of each CVRD manifestation for type 2 diabetes without CVRD history.

METHODS

A cohort study of all type 2 diabetes free of CVRD as of January 1st 2014, was identified and followed-up for 5 years within the French SNDS nationwide claims database. The cumulative incidence of the first occurring CVRD manifestation was estimated using the cumulative incidence function, with death as a competing risk. Cumulative hospitalization costs of each CVRD manifestations were estimated from the perspective of all payers.

RESULTS

From 2,079,089 type 2 diabetes without cancer or transplantation, 76.5% were free of CVRD at baseline with a mean age of 65 years, 52% of women and 7% with microvascular complications history. The cumulative incidence of a first CVRD manifestation was 15.3% after 5 years of follow-up with a constant linear increase over time for all CVRD manifestations: The most frequent was CKD representing 40.6% of first occurred CVRD manifestation, followed by HF (23.0%), then PAD (13.5%), stroke (13.2%) and MI (9.7%). HF and CKD together reached about one patient out of ten after 5 years and represented 63.6% of first CVRD manifestations. The 5-year global cost of all CVRD hospitalizations was 3.9 billion euros (B€), i.e. 2,450€ per patient of the whole cohort, with an exponential increase over time for each specific CVRD manifestation. The costliest was CKD (2.0 B€), followed by HF (1.2 B€), then PAD (0.7 B€), stroke (0.6 B€) and MI (0.3 B€).

CONCLUSIONS/INTERPRETATION

While MI, stroke and PAD remain classic major risks of complications for CVRD-free type 2 diabetes, HF and CKD nowadays represent individually a higher risk and cost than each of these classic manifestations, and jointly represents a risk and a cost twice as high as these three classic manifestations all together. This should encourage the development of specific HF and CKD preventive strategies.

Cohort Event Monitoring of Adverse Reactions to COVID-19 Vaccines in Seven European Countries: Pooled Results on First Dose

INTRODUCTION

COVID-19 vaccines were rapidly authorised, thus requiring intense post-marketing re-evaluation of their benefit-risk profile. A multi-national European collaboration was established with the aim to prospectively monitor safety of the COVID-19 vaccines through web-based survey of vaccinees.

METHODS

A prospective cohort event monitoring study was conducted with primary consented data collection in seven European countries. Through the web applications, participants received and completed baseline and up to six follow-up questionnaires on self-reported adverse reactions for at least 6 months following the first dose of COVID-19 vaccine (Netherlands, France, Belgium, UK, Italy) and baseline and up to ten follow-up questionnaires for one year in Germany and Croatia. Rates of adverse reactions have been described by type (solicited, non-solicited; serious/non-serious; and adverse events of special interest) and stratified by vaccine brand. We calculated the frequency of adverse reaction after dose 1 and prior to dose 2 among all vaccinees who completed at least one follow-up questionnaire.

RESULTS

Overall, 117,791 participants were included and completed the first questionnaire in addition to the baseline: 88,196 (74.9%) from Germany, 27,588 (23.4%) from Netherlands, 984 (0.8%) from France, 570 (0.5%) from Italy, 326 (0.3%) from Croatia, 89 (0.1%) from the UK and 38 (0.03%) from Belgium. There were 89,377 (75.9%) respondents who had received AstraZeneca vaccines, 14,658 (12.4%) BioNTech/Pfizer, 11,266 (9.6%) Moderna and 2490 (2.1%) Janssen vaccines as a first dose. Median age category was 40-49 years for all vaccines except for Pfizer where median age was 70-79 years. Most vaccinees were female with a female-to-male ratio of 1.34, 1.96 and 2.50 for AstraZeneca, Moderna and Janssen, respectively. BioNtech/Pfizer had slightly more men with a ratio of 0.82. Fatigue and headache were the most commonly reported solicited systemic adverse reactions and injection-site pain was the most common solicited local reaction. The rates of adverse events of special interest (AESIs) were 0.1-0.2% across all vaccine brands.

CONCLUSION

This large-scale prospective study of COVID-19 vaccine recipients showed, for all the studied vaccines, a high frequency of systemic reactions, related to the immunogenic response, and local reactions at the injection site, while serious reactions or AESIs were uncommon, consistent with those reported on product labels. This study demonstrated the feasibility of setting up and conducting cohort event monitoring across multiple European countries to collect safety data on novel vaccines that are rolled out at scale in populations which may not have been included in pivotal trials.

Should dual antiplatelet therapy be maintained beyond one year after a myocardial infarction? A cohort study within the French SNDS nationwide claims database

Background

Dual antiplatelet therapy (DAPT), aspirin plus a P2Y12-i (clopidorel, prasugrel or ticagrelor), is recommended for one year after myocardial infarction (MI) for secondary prevention of cardiovascular disease (SP-CVD). Beyond one year maintaining DAPT is controversial.

Purpose

To compare the 3-year risk of a composite of MI, ischemic stroke (IS), major bleeding (MB) and death between DAPT and single antiplatelet therapy with aspirin (SAPT) beyond one year after MI.

Methods

All adults hospitalized in 2013 or 2014 for acute MI (trigger event) with intensive care unit stay were identified in the French SDNS nationwide claims database. Patients who survived at least one year without MI or MB, and with a DAPT medication possession ratio (MPR) ≥80% were included in a cohort study. All patients were followed for 3 years after the index date (defined 365 days after the MI trigger event), except right-censored observations for those who died or discontinued aspirin with a 60-day grace period. The 3-year hazard ratios (HR [95% CI]) were estimated using Cox proportional hazards risk model for outcomes including death, and Fine and Gray competing risks model for non-fatal outcomes, with a time-dependent variable for DAPT-SAPT exposure, and adjusted on a high-dimensional disease risk score (hdDRS) plus time dependent variables for SP-CVD drugs, oral antidiabetics, insulin, anticoagulants, NSAIDs, corticoids and proton pump inhibitors. HdDRS were estimated for the composite outcome, a composite of ischemic outcomes, and MB alone, and variables were selected using a combination of Principal Component Analysis and Lasso regression.

Results

From the 105,080 adults admitted in intensive care units for acute MI in 2013 or 2014, 53,399 were included in the cohort. The most common reasons for non-inclusion were death (n=12,012) and a DAPT MPR <80% (n=25,000). At index date, mean age was 65 years, with 74.6% men, 21.8% diabetes, 9.4% heart failure, 5.6% peripheral arterial disease, 72.2% with DAPT score ≤2, 61.9% Charlson index ≤1; 79.2% had a STEMI trigger event and 82.6% had cardiac revascularization (PCI 98.6%). P2Y12-i used at least once from the trigger event to the index date were clopidogrel (41.5%), ticagrelor (41.1%) and prasugrel (26.2%). Follow-up was 111,770 person-years and 4,268 composite outcomes were recorded. The 3-year HR of DAPT compared to SAPT was 1.21 [1.13–1.30] for the composite of MI, IS, MB and death, 1.22 [1.07–1.38] for MI, 0.98 [0.80–1.20] for IS, 1.89 [1.55–2.30] for MB and 1.16 [1.06–1.27] for death.

Conclusions

In this nationwide real-life population-based study in France, DAPT maintained beyond one year after MI is significantly associated with increased harm compared to SAPT with increased risks of 21% (IC95% [13–30]) for the composite of MI, IS, MB and death (net clinical benefit), 22% [7–38] for MI, 89% [55–130] for MB, 16% [6–27] for death, and no difference for IS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): French Ministry of Health (PHRCN-18-0745)

Cardiovascular or renal disease (CVRD) complication and mortality incidence for type 2 diabetics with a single or without CVRD comorbidity: a 5-year SNDS nationwide claims database cohort study

Background

Myocardial infarction (MI), stroke, peripheral arterial disease (PAD), heart failure (HF) and chronic kidney disease (CKD) are common cardiovascular renal disease (CVRD) complications for type 2 diabetes (T2D). However, for those with a single CVRD comorbidity, the incidence of a new CVRD complication and death is not well known.

Purpose

To assess the 5-year CVRD complication and mortality incidence for T2D patients with a single CVRD comorbidity or without CVRD at baseline.

Methods

A cohort study of all T2D patients with a single CVRD or without CVRD (disease-free) at baseline (January 1st, 2014) identified and followed-up for 5 years within the French SNDS nationwide claims database. Incidence rates were estimated for 5 years and the risk of all-cause death was compared to the disease-free population using Cox proportional hazards risk model: hazard ratio (HR) with [95% confidence interval].

Results

From about 2 million T2D patients without cancer or transplantation at baseline, 76.5% were disease-free, 7.9% with a single CVRD and the others having several CVRD comorbidities history. Five-year CVRD complication and mortality incidence rates for 1,000 patient-years are presented in the table. CKD and HF were the most frequent CVRD complications for the disease-free and all CVRD comorbid populations, far ahead of MI, stroke and PAD, except PAD complication for PAD population and to a lesser degree stroke complication for stroke population. The incidence rate of all-cause death was the highest for HF+CKD patients, followed by HF patients, then PAD, stroke and CKD patients. Compared to disease-free patients with same sex and age, the HR of death was 4.3 [4.2–4.5] higher for HF+CKD patients, 2.7 [2.7–2.8], 2.1 [2.0–2.1], 2.1 [2.0–2.1], 1.9 [1.9–1.9] and 1.4 [1.3–1.4] for HF, CKD, PAD, stroke and MI patients, respectively.

Conclusions

While MI, stroke and PAD comorbidities remain major risks of complications for T2D patients, HF and CKD nowadays represent a clearly higher risk of CVRD complications and death, that needs improved preventive strategies.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Study performed with unconditional funding from AstraZeneca

Patients with stable coronary artery disease and type 2 diabetes but without prior myocardial infarction or stroke and THEMIS-like patients: real-world prevalence and risk of major outcomes from the SNDS French nationwide claims database

AIM AND HYPOTHESES

The THEMIS randomized trial compared ticagrelor plus aspirin versus placebo plus aspirin for patients with stable coronary artery disease and type 2 diabetes mellitus (CAD-T2DM), and without prior myocardial infarction (MI) or stroke. The aim of the study was to quantify the size of the CAD-T2DM population without prior MI or stroke population in a real-world setting, and more specifically populations with similar THEMIS selection criteria (THEMIS-like and THEMIS-PCI-like populations), as well as their risk of major outcomes in current practice.

METHODS

A 2-year follow-up cohort study included all CAD-T2DM without MI/stroke prevalent patients on January 1st, 2014 in the SNDS French nationwide claims database. The THEMIS-like population concerned those ≥ 50 years of age with similar THEMIS inclusion and exclusion criteria. Prevalence was standardized to the European population. The cumulative incidence function was used to estimate the incidence of clinical outcomes (MI, ischemic stroke, and major bleeding according to the TIMI classification) with death as competing risk, and the Kaplan-Meier estimate for all-cause death and a composite outcome of MI, stroke and all-cause death.

RESULTS

From a population of about 50 million adults, the prevalence of CAD-T2DM without MI/stroke, THEMIS-like and THEMIS-PCI-like populations was respectively at 6.04, 1.50 and 0.27 per 1000 adults, with a mean age of 72.7, 72.3 and 70.9 years and less comorbidities and diabetic complications for the THEMIS-like and THEMIS-PCI-like population. The 2-year cumulative incidence was respectively 1.7%, 1.3% and 1.6% for MI, 1.7%, 1.5% and 1.4% for stroke, 4.8%, 3.1% and 2.9% for major bleeding, 13.6%, 9.7% and 6.8% for all-cause death, and 16.2%, 12.0% and 9.5% for the composite outcome.

CONCLUSION

THEMIS-like prevalence was estimated at 1.50 per 1,000 adults, representing about a quarter of CAD-T2DM without MI/stroke patients, and 0.27 per 1000 adults for the THEMIS-PCI-like populations. In current French practice, the median age of both these populations was about 5-6 years older than in the THEMIS trial, with a 2-year incidence of major outcomes between two or four time above the ones of the placebo arm of the THEMIS trial using very close definitions. Registration No. EUPAS27402 ( http://www.ENCEPP.eu ).

Reduced dose of rivaroxaban and dabigatran vs. vitamin K antagonists in very elderly patients with atrial fibrillation in a nationwide cohort study

AIMS

The real-life benefits and risks of the non-vitamin K antagonist oral anticoagulants for stroke prevention in very elderly patients with atrial fibrillation (AF) are still debated.

METHODS AND RESULTS

Cohorts of new users of rivaroxaban 15 mg, dabigatran 110 mg, or vitamin K antagonists (VKA) for AF ≥85 years old in 2013 or 2014 were identified in the nationwide French claims database and followed-up for 1 year. Cohorts were compared after 1:1 matching using high-dimensional propensity score. Compared to VKA use and considering 1-year cumulative incidences, risk of stroke, and systemic embolism was not different with rivaroxaban use [hazard ratio 1.14, 95% confidence interval (CI): 0.93-1.40] and lower with dabigatran use (0.77, 95% CI: 0.60-0.99), risk of major bleeding was not different with rivaroxaban use (0.91, 95% CI: 0.74-1.11) and with dabigatran use (0.81, 95% CI: 0.64-1.03), risk of all-cause death was borderline to significance lower with rivaroxaban use (0.91, 95% CI: 0.83-1.00), and lower with dabigatran use (0.87, 95% CI: 0.78-0.97). The risk for a composite of all events above was not different with rivaroxaban use (0.96, 95% CI: 0.88-1.04) and lower with dabigatran use (0.87, 95% CI: 0.79-0.96) as compared with VKA use. The risk for the composite of all events was not different with rivaroxaban use as compared with dabigatran use (1.09, 95% CI: 0.97-1.23).

CONCLUSION

This study shows for the first time in more than 25 000 new real-life anticoagulant users for AF aged ≥85 years a neutral overall benefit-risk of rivaroxaban 15 mg vs. VKA and a favourable overall benefit-risk of dabigatran 110 mg vs. VKA on relevant clinical events.

STUDY REGISTRATION

European Medicines Agency EUPAS14567 (www.encepp.eu) and Clinicaltrials.gov id NCT02864758.

Use of Nalmefene in Routine Practice: Results from a French Prospective Cohort Study and a National Database Analysis

Aims

Two complementary studies were used to assess the real-life use of nalmefene in alcohol-dependent patients and its impact on alcohol use health status.

Methods

USE-PACT was a prospective cohort study designed to evaluate the real-life effectiveness of nalmefene in the management of alcohol dependence, as assessed by total alcohol consumption (TAC) and number of heavy drinking days (HDD) at 1 year. USE-AM was a cohort study using data from the French nationwide claims database and was used to evaluate the external validity of the population in the prospective study.

Results

Overall, 256 of 700 new nalmefene users enrolled in the USE-PACT study had valid data at 1 year. After 1 year, patients treated with nalmefene showed a mean ± SD reduction from baseline in TAC (−41.5 ± 57.4 g/day) and number of HDD (−10.7 ± 11.7 days/4 weeks). Patients took a mean ± SD of 20.0 ± 12.0 tablets/4 weeks (median of 1 tablet/day) for the first 3 months and then reduced the dose. The proportion of patients who no longer took nalmefene gradually increased from 5% at 1 month to 52% at 1 year. The USE-AM study identified 486 patients with a first reimbursement for nalmefene in 2016; baseline characteristics confirmed external validity of the USE-PACT study. Overall, 46.3% of initial USE-AM prescriptions were made by GPs; most (91.8%) patients stopped treatment during follow-up. However, 15.2% of patients resumed treatment after stopping.

Conclusions

In this analysis of French routine practice, patients with alcohol dependence treated with nalmefene showed reduced alcohol consumption, and nalmefene was generally well tolerated.

Prevalence of type 2 diabetes with stable coronary artery disease but without prior myocardial infarction or stroke and THEMIS-like patients from the SNDS French nationwide claims database

Background

The THEMIS randomized controlled trial showed that patients with stable coronary artery disease and type 2 diabetes mellitus (CAD-T2DM), without prior myocardial infarction (MI) or stroke, and who received ticagrelor plus aspirin, had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. The number of patients concerned and their characteristics in current practice are not well known.

Purpose

To assess the characteristics of CAD-T2DM adults (≥18 years) without prior MI-stroke, and more specifically, of THEMIS-like patients in a real world setting.

Methods

Cohort within the main scheme of the SNDS (Système National des Données de Santé), the French nationwide claims database, representing about 86% of 66 million people. All CAD-T2DM prevalent patients without prior MI-stroke were identified on January 1st, 2014 (index date) based on a 5-year database history, and followed for two years. The THEMIS-like population included CAD-T2DM patients without prior MI-stroke ≥50 years at index date without renal failure with dialysis, cirrhosis or liver cancer history, as well as no intracranial and gastro-intestinal bleeding for the last 6 months, or anticoagulant or antiplatelet agent 2 months before and after index date. Study prevalence was standardized for the European population for 1,000 adults (‰) using sex and 5-year age classes from Eurostat statistics.

Results

From the 359,595 CAD-T2DM patients identified in the database, 71.8% had no prior MI-stroke (n=258,260), including 24.9% of THEMIS-like patients (n=64,334). CAD-T2DM without prior MI-stroke and THEMIS-like patients had the same mean age of 72 years, with 68% and 66% men, 26% and 25% with more than 4-year CAD and T2DM history, 79% and 76% of hypertension, 28% and 19% of revascularisation procedure, 19% and 11% of peripheral arterial disease, 16% and 9% of heart failure, and 39% and 32% of diabetes complications, respectively. The table below presents prevalence estimation per 1,000 European adults with differences according to both populations, as well as sex and age-classes.

Conclusions

The two populations had similar characteristics, although noting some differences in comorbidities. The THEMIS-like prevalence was estimated to 1.50‰ European adults, representing about a quarter of CAD-T2DM patients without prior MI-stroke.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Study performed with unconditional funding from AstraZeneca

Real world risk of major outcomes for type 2 diabetes with stable coronary artery disease without prior MI or stroke and THEMIS-like patients using the SNDS French nationwide claims database

Background

The THEMIS randomized controlled trial showed that patients with stable coronary artery disease and type 2 diabetes mellitus (CAD-T2DM), without a history of myocardial infarction (MI) or stroke, and who received ticagrelor plus aspirin, had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. After 3 years of follow-up, the incidence of major outcomes in the placebo arm was 1.8% for ischemic stroke, 3.3% for MI, 4.9% for all-cause death, 9.2% for a composite of all-cause-death, MI or stroke, and 0.38 per 100 patients-years for TIMI major bleedings. The risk of these outcomes is not well known in current practice.

Purpose

To estimate the incidence of major outcomes for CAD-T2DM patients without prior MI-stroke and more specifically for THEMIS-like patients in a real world setting.

Methods

Cohort within the main scheme of the SNDS (Système National des Données de Santé), the French nationwide claims database, representing about 86% of 66 million people. All CAD-T2DM prevalent patients without prior MI-stroke were identified on January 1st, 2014 (inclusion date), based on a 5-year database history, and followed for two years. The THEMIS-like population included CAD-T2DM patients without prior MI-stroke ≥50 years at inclusion date without renal failure with dialysis, cirrhosis or liver cancer history, as well as no intracranial and gastro-intestinal bleeding for the last 6 months, or anticoagulant or antiplatelet agent 2 months before and after inclusion date. The Kaplan-Meier method was used to estimate the 2-year cumulative incidence of all-cause death and a composite of all-cause death, MI and stroke, and the cumulative incidence function, taking into account death as competing risk for other clinical outcomes.

Results

From 258,260 CAD-T2DM patients without prior MI-stroke, 64,334 were included in the THEMIS-like population (24.9%) with the same median age of 72 years, with 68.3% and 65.7% men, respectively. The 2-year cumulative incidence for the CAD-T2DM without prior MI-stroke and THEMIS-like populations was 1.7% and 1.5% for ischemic stroke, 1.7% and 1.3% for MI, 9.5% and 5.3% for heart failure, 4.9% and 3.2% for major bleeding, 13.6% and 9.7% for all-cause death, and 16.2% and 12.0% for the composite outcome, respectively.

Conclusions

In current practice, the median age of the THEMIS-like population was 6 years older than in the THEMIS trial (i.e. 66 years), with an observed risk after 2 years of follow-up, about double for the composite outcome, triple for deaths and quadruple for major bleedings than those of the placebo arm of the trial (estimation after 2 years of follow-up in the THEMIS trial placebo arm assuming constant risk across time according to Kaplan-Meier graph).

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Study performed with unconditional funding from AstraZeneca

Comparative Real-Life Effectiveness and Safety of Dabigatran or Rivaroxaban vs. Vitamin K Antagonists: A High-Dimensional Propensity Score Matched New Users Cohort Study in the French National Healthcare Data System SNDS

BACKGROUND

Clinical trials have indicated that the direct-acting oral anticoagulants dabigatran and rivaroxaban have better risk/benefit profiles than do vitamin K antagonists (VKAs) for stroke prevention in non-valvular atrial fibrillation (NVAF).

OBJECTIVE

Our objective was to compare the 1-year real-life risk of major clinical events with dabigatran or rivaroxaban versus VKAs for NVAF.

METHODS

This was a high-dimensional propensity score (hdPS)-matched cohort study of new users of dabigatran, rivaroxaban or VKAs for NVAF in the French national healthcare systems database in 2013 followed-up for 1 year [22]. Hazard ratios (HRs) with 95% confidence intervals (CIs) for clinical events and death were determined during exposure.

RESULTS

In 2013, a total of 103,101 new anticoagulant users had definite NVAF: 44,653 VKA, 27,060 dabigatran, and 31,388 rivaroxaban. In matched populations, HRs were as follows for dabigatran versus VKAs (20,489 per group): stroke and systemic embolism (SSE) 0.75 (95% CI 0.63-0.88), clinically relevant bleeding (CRB) 0.58 (95% CI 0.51-0.66), hemorrhagic stroke (HS) 0.22 (95% CI 0.14-0.36), gastrointestinal bleeding (GIB) 0.98 (95% CI 0.80-1.19), acute coronary syndrome (ACS) 0.79 (95% CI 0.65-0.95), death 0.74 (95% CI 0.67-0.82), composite (any of the above) 0.71 (95% CI 0.66-0.76). For matched rivaroxaban versus VKA (23,053 per group) HRs were as follows: SSE 0.98 (95% CI 0.85-1.14), CRB 0.83 (95% CI 0.75-0.92), HS 0.65 (95% CI 0.49-0.87), GIB 1.08 (95% CI 0.90-1.30), ACS 0.84 (95% CI 0.71-1.00), death 0.77 (95% CI 0.71-0.84), composite 0.84 (95% CI 0.79-0.89). Numbers needed to treat to observe one fewer death were 49 ± 0.05 with dabigatran or rivaroxaban versus VKAs.

CONCLUSION

Consistent with results from clinical trials and other observational studies, dabigatran and rivaroxaban were at least as effective and safer than VKAs for the prevention of thromboembolic events in NVAF over 1 year in the French population.

STUDY REGISTRATION

European Medicines Agency EUPAS 13017 (www.encepp.eu) Clinicaltrials.gov id NCT02785354.

Use of benzodiazepines and z-drugs not compliant with guidelines and associated factors: a population-based study

Benzodiazepines and z-drugs are primarily indicated for the treatment of sleep disorders and anxiety symptoms. Their frequent long-term use contrasts with the international guidelines that limit treatment duration to a maximum of 4 weeks. The objective of this study was to assess the frequency of their use that was not in accordance with guidelines in the French general population between 2007 and 2012 and associated characteristics. A cohort of 67,550 benzodiazepine new users was set up in an exhaustive database for health-care reimbursements and representative of the French population. Benzodiazepine use not in accordance with guidelines was defined as the concomitant dispensation of several benzodiazepines, the dispensation of treatment over a period longer than recommended, or a new dispensing within the 2 months following the end of a previous treatment of maximum recommended duration, considering that French recommendations distinguish between hypnotic (4 weeks) and anxiolytic benzodiazepines (12 weeks). Benzodiazepine use not in accordance with guidelines was high, in about 30% of new hypnotic users and 20% of new anxiolytic users. Its frequency was stable over the study period. Associated characteristics were similar for new hypnotic or anxiolytic users, i.e.. older age, treatment initiation by a psychiatrist, presence of a chronic disease, hospitalization, or another psychotropic treatment. These findings provide a solid basis for establishing a public health policy to reduce benzodiazepine use not compliant with guidelines. They should be further explored in patients most at risk in the present study, e.g., patients treated by a psychiatrist.

Effectiveness and Safety of Rivaroxaban 15 or 20 mg Versus Vitamin K Antagonists in Nonvalvular Atrial Fibrillation

Supplemental Digital Content is available in the text.

We compared the 1-year safety and effectiveness of rivaroxaban 15 mg (R15) or rivaroxaban 20 mg (R20) to vitamin K antagonists (VKAs) in patients with nonvalvular atrial fibrillation.

Monitoring of drug misuse or potential misuse in a nationwide healthcare insurance database: A cross-sectional study in France

AIM OF THE STUDY

To provide a tool for drug misuse or potential misuse monitoring by using a healthcare insurance database.

METHODS

A cross-sectional study repeated quarterly from 2007 to 2014 was conducted using data from a 1/97th random sample of the French national healthcare reimbursement system. For each drug studied, ad hoc indicators were designed to assess drug misuse, defined as prescriptions that did not comply with the label stipulated in the summary of product characteristics, in terms of the drug (e.g., interactions) or the patient (age, medical history). We focused on specifically identified situations of drug misuse involving non-steroidal anti-inflammatory drugs (NSAIDs), antiemetics in patients with Parkinson's disease and antipsychotics in pediatrics; we also focused on direct anticoagulants, asthma and oral antidiabetic drugs but results for these latter are only shown in supplementary materials.

RESULTS

At-risk prescribing of NSAIDs in patients treated by diuretics or renin-angiotensin system inhibitors always remained higher than 14% over the study (maximum: 19%; 2014 quarter 4: 15.4%). Off-label prescribing of contraindicated anti-dopaminergic antiemetics with dopaminergic antiparkinson drugs was marginal (maximum: 2.2%; 2014 quarter 4: 0.5%) but represented at least 5.5% of antiemetic prescriptions. Despite the rise in antipsychotic prescriptions in pediatrics, no dramatic increase in misuse related to age was observed during the study period (2007 quarter 1: 16.1%; 2014 quarter 4: 11.1%). The highest degree of misuse was observed for aripiprazole and for second-generation antipsychotics other than risperidone and aripiprazole.

CONCLUSION

This study provides a simple tool to monitor drug misuse or potential misuse using information from a health insurance database. The results highlight the need for the Regulator to rethink risk management information campaigns and to modify the official information on products.

Effectiveness and safety of 110 or 150 mg dabigatran vs. vitamin K antagonists in nonvalvular atrial fibrillation

AIMS

We compared the 1-year safety and effectiveness of dabigatran 110 mg (D110) or 150 mg (D150) twice daily to vitamin K antagonists (VKA) in patients with nonvalvular atrial fibrillation.

METHODS

New user cohort study of patients dispensed D110 or D150 vs. VKA in 2013 for nonvalvular atrial fibrillation, followed 1 year in the French Système National des Données de Santé (66 million persons). D110 and D150 users were matched 1:1 with VKA users on sex, age, date of first drug dispensing and high-dimensional propensity score. Hazard ratios [HR (95% confidence intervals)] for stroke and systemic embolism (SSE), major bleeding (MB) and death were computed using Cox proportional hazards or Fine and Gray models during exposure.

RESULTS

In 14 442 matched D110 and VKA patients, mean age 79, 49% male, 91% with CHA₂ DS₂ -VASc ≥2 and 8% with HAS-BLED score >3, incidence rates of SSE were 1.9% and 2.6% person-years [HR 0.69 (0.56-0.84)], MB 1.8% and 2.9% [0.62 (0.51-0.76)], death 7.2% and 8.6% [0.84 (0.76-0.94)]. In 8389 matched D150 and VKA patients, mean age 67, 67% male, 65% with CHA₂ DS₂ -VASC ≥2; < 5% HAS-BLED >3, incidence rates were for SSE 1.4% and 1.9% [0.76 (0.56-1.04)], MB 0.6% and 1.9% [0.30 (0.20-0.46)], death 1.6% and 3.6% [0.46 (0.35-0.59)]. Numbers needed to treat to observe one fewer death were 78 for D110, 88 for D150.

CONCLUSION

In real life D110 and D150 were at least as effective, and safer than VKA.

Secondary prevention of acute coronary events with antiplatelet agents (SPACE-AA): One-year real-world effectiveness and safety cohort study in the French nationwide claims database

BACKGROUND AND AIMS

We aimed to compare the effectiveness of ticagrelor vs. clopidogrel or prasugrel on recurrence of acute coronary syndromes (ACS) in real-life conditions, as requested by regulatory authorities at the time of marketing.

METHODS

We performed a cohort study in SNDS, the French national healthcare database. All patients with a hospital admission for ACS in 2013 were followed one year. Patients on ticagrelor, clopidogrel or prasugrel were matched 1:1 using age, gender, index ACS type, and high-dimensional propensity scores (hdPS). Outcomes were ACS, stroke, all-cause death, and major bleeding, compared within matched groups using Cox proportional hazards models analysis during treatment.

RESULTS

54,048 ACS were hospitalized in 2013. At discharge, 19,796 were dispensed clopidogrel, 8242 prasugrel, and 13,916 ticagrelor. Per group, 9224 ticagrelor vs. clopidogrel, 6752 ticagrelor vs. prasugrel, and 4676 prasugrel vs. clopidogrel patients were matched. Compared to clopidogrel, ticagrelor was associated with a lower hazard ratio of death 0.73 [0.59-0.90] and composite criterion (0.88, 95% CI [0.79-0.99] but not ACS 0.92 [0.80-1.06], stroke (0.96 [017-5.53]) or major bleeding (1.02 [0.82-1.26]). Prasugrel was not different from ticagrelor or clopidogrel for any outcome, in matched patients.

CONCLUSIONS

Ticagrelor in real-life conditions in matched populations was associated with a lower risk of all-cause death than clopidogrel, and a lower risk of composite outcome, as in the main pivotal clinical trial. Ticagrelor and prasugrel were not different, nor were prasugrel and clopidogrel.

Outcomes in patients after myocardial infarction similar to those of the PEGASUS-TIMI 54 trial: A cohort study in the French national claims database

AIMS

The present study aims to describe real-life outcomes in stable patients after-myocardial infarction (MI) similar to those in the PEGASUS-TIMI 54 trial (PEGASUS), which found long-term benefits of ticagrelor in patients with a history of MI.

METHODS

One-year event-free post-MI patients were identified in the French claims database representative 1/97 sample (2005-2010) and followed for up to 3 years. A PEGASUS-like (PL) population included patients with age ≥ 65 years, or age ≥ 50 and diabetes, renal dysfunction or prior MI, without stroke, end-stage renal failure or oral anticoagulation. Outcomes were: a composite of all-cause death or hospital admission for MI or stroke; individual events; major bleeding.

RESULTS

There were 1585 post-MI patients totalling 3926 person-years including 865 PL patients (2114 PY); 68% were male; mean age was 66 (standard deviation 15) in post-MI, 74 (10) in PL. Outcomes per 100 person-years [95% confidence interval] were, respectively, in post-MI and PL 6.3 [5.6-7.1] and 7.8 [6.7-8.9] for the composite outcome; 5.1 [4.4-5.8] and 6.5 [5.5-7.6] for death; 1.0 [0.7-1.3] and 1.0 [0.6-1.4] for MI; 0.6 [0.4-0.9] and 0.9 [0.5-1.2] for stroke; 1.3 [0.9-1.6] and 1.4 [0.9-1.9] for major bleeding. Event rates were stable over the 3 study years. Placebo patients in the PEGASUS-TIMI54 Study were younger, more often male and had lower event rates, especially for all-cause death and major bleeding.

CONCLUSIONS

Patients selected using the criteria described in PEGASUS were older with more comorbidities, resulting in higher all-cause death and bleeding rates, but similar MI recurrence rates.

A population database study of outcomes associated with vitamin K antagonists in atrial fibrillation before DOAC

AIMS

This study aimed to describe the real-life incidence of bleeding, arterial thrombotic events and death during vitamin K antagonist (VKA) treatment in atrial fibrillation (AF).

METHODS

This was a cohort study in Echantillon Généraliste de Bénéficiaires, the 1/97 sample of the French national healthcare claims and hospitalization database, of new VKA users with definite or probable AF and no other indication, and of patients without AF, from 2007 to 2011. Prespecified outcomes were all-cause death, hospitalization for bleeding, arterial thrombotic event (ATE), or acute coronary syndrome (ACS) or any of the above (composite outcome).

RESULTS

Of 8894 new VKA users, 3345 had probable or certain AF, 51.7% were male, mean age was 75.1 years, 87.1% had a CHA2 DS2 -VASc score ≥ 2 and 11.6% a HAS-BLED score > 3. Among AF patients, during VKA exposure the incidence rate of bleeding was 2.8 [95% confidence interval (CI) 2.2, 3.4] per 100 patient-years, including 0.6 (95% CI 0.3, 0.8) cerebral, 1.0 (95% CI 0.7, 1.3) digestive and 1.4 (95% CI 1.0, 1.7) other bleeds. There were 1.6 (95% CI 1.2, 2.0) ACS, 1.5 (95% CI 1.1, 1.8) ATE and 3.8 (95% CI 3.2, 4.4) deaths per 100 patient-years. The incidence rate of the composite outcome was 9.1 per 100 patient-years (95% CI 8.2, 10.0). When patients stopped VKA, bleeding decreased (RR 0.67, 95% CI 0.43, 1.04)), but death or thrombosis increased (RR 3.06, 95% CI 2.46, 3.81 and 1.75, 95% CI 1.14, 2.70, respectively). During VKA exposure non-AF patients had similar rates of bleeding, but fewer deaths, ACS and ischaemic events.

CONCLUSIONS

Real-life rates for bleeding, arterial thrombotic events, ACS and deaths in AF patients treated with VKA were similar to those observed in clinical trials.

Parkinson's disease incidence and prevalence assessment in France using the national healthcare insurance database

BACKGROUND AND PURPOSE

The incidence and prevalence of Parkinson's disease are important for public health planning yet there is a lack of representative, up-to-date estimations for France.

METHODS

For this cross-sectional study, subjects with suspected Parkinson's were identified in the EGB database, a 1/97 random sample of the national healthcare insurance database, linked to the national hospital-discharge summary database. Incidence and prevalence were estimated using a specific definition that included those with a diagnosis (hospitalization or listed as a long-term chronic disease for full reimbursement) and a sensitive definition that also included those with an indicative drug reimbursement profile. Estimations were extrapolated to the national population, standardizing on age and gender.

RESULTS

According to either the specific or the sensitive definitions, the annual incidence of Parkinson's disease during the study period was respectively 36 and 49 per 100,000 person-years and prevalence in 2010 was 308-410 per 100,000 persons in the population as a whole. According to the age groups 55-64, 65-74, 75-84 and ≥85 years incidence was respectively 33-46, 139-172, 301-363 and 442-560 per 100,000 person-years amongst men and 32-55, 81-117, 203-270 and 251-313 per 100,000 person-years amongst women. The 2010 prevalence stratified by the same age groups was 293-376, 898-1161, 2524-3011 and 3760-4578 per 100,000 persons amongst men and 199-351, 618-889, 1910-2433 and 2504-3263 per 100,000 persons amongst women.

CONCLUSIONS

The specific and sensitive definitions of disease bracket the true values; the relatively small range indicates that the current study provides good estimations of incidence and prevalence of Parkinson's disease for recent years in France.

Continuation rates of levetiracetam in children from the EULEVp cohort study

BACKGROUND

Since indication extension to children data regarding the effectiveness of levetiracetam in paediatric patients remains limited.

AIMS

Investigate the real-life effectiveness of levetiracetam in paediatric patients.

METHODS

Epileptic children (<16 years) who had initiated levetiracetam between 1 October 2006 and 31 March 2007 were included and followed for 1 year by hospital or non-hospital neurologists practising in France.

RESULTS

Among the 156 identified children, 147 were analysed: 51.7% were female, and mean (SD) age was 9.2 years (4.2). Most patients had either partial symptomatic (30.6%) or partial cryptogenic (26.5%) epilepsy, 92.5% experienced seizures during the 6 months preceding levetiracetam initiation, and 19.2% were on levetiracetam alone at initiation. One-year levetiracetam continuation rate was estimated to be 72.0% (95%CI [63.8; 78.6]). Of the 104 children continuing levetiracetam treatment at end of study, 31.7% were seizure-free during the last six months of follow-up, and 23.1% on levetiracetam alone. Discontinuation of levetiracetam (n = 41) was mainly for insufficient efficacy (58.5% of those concerned).

CONCLUSIONS

In real-life clinical practice important treatment retention and non-negligible reduction of seizure frequency may be expected.

Insulin glargine and risk of cancer: a cohort study in the French National Healthcare Insurance Database

AIMS/HYPOTHESIS

Using the Echantillon Généraliste de Bénéficiaires: random 1/97 permanent sample of the French national healthcare insurance system database (EGB), we investigated whether, as previously suspected, the risk of cancer in insulin glargine (A21Gly,B31Arg,B32Arg human insulin) users is higher than in human insulin users. The investigation period was from 1 January 2003 to 30 June 2010.

METHODS

We used Cox proportional hazards time-dependent models that were stratified on propensity score quartiles for use of insulin glargine vs human insulin, and adjusted for insulin, biguanide and sulfonylurea possession rates to assess the risk of cancer or death in all or incident exclusive or predominant (≥ 80% use time) users of insulin glargine compared with equivalent human insulin users.

RESULTS

Only type 2 diabetic patients were studied. Exposure rates varied from 2,273 and 614 patient-years for incident exclusive users of insulin glargine or human insulin, respectively, to 3125 and 2341 patient-years for all patients predominantly using insulin glargine or human insulin, respectively. All-type cancer HRs with insulin glargine vs human insulin ranged from 0.59 (95% CI 0.28, 1.25) in incident exclusive users to 0.58 (95% CI 0.34, 1.01) in all predominant users. Cancer risk increased with exposure to insulin or sulfonylureas in these patients. Adjusted HRs for death or cancer associated with insulin glargine compared with human insulin ranged from 0.58 (95% CI 0.32, 1.06) to 0.56 (95% CI 0.36, 0.87).

CONCLUSIONS/INTERPRETATION

There was no excess risk of cancer in type 2 diabetic patients on insulin glargine alone compared with those on human insulin alone. The overall risk of death or cancer in patients on insulin glargine was about half that of patients on human insulin, thereby excluding a competitive risk bias.

The EULEV cohort study: rates of and factors associated with continuation of levetiracetam after 1 year

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Levetiracetam has shown good safety/tolerability and efficacy in regulatory trials. This was confirmed in observational investigations performed soon after marketing by using continuation or retention rates as a composite measure. When an anti-epileptic drug first becomes available; however, there is evidence of channelling to more severe patients than thereafter.

WHAT THIS STUDY ADDS

This study was performed several years after marketing of levetiracetam and found high rates of continuation. It also further explores this measure by determining the continuation in the absence of initiation of additional anti-epileptic drugs.

AIMS

To investigate real-life effectiveness of levetiracetam in patients initiating treatment in a stable market situation.

METHODS

Epileptic adults who had initiated levetiracetam between 1 January and 31 August in 2005 or 2006 were included and followed for 1 year by hospital or nonhospital neurologists practising in France. One-year continuation rates were estimated using Kaplan-Meier analysis. Among those still treated at end of study, treatment goals were investigated. Factors associated with discontinuation were investigated using Cox proportional hazards regression.

RESULTS

A total of 794 subjects were included in the cohort, and 753 subjects were followed up and included in the analysis. Among these, mean (SD) age was 42.6 (±17.0) years, 51.1% were female, 76.6% had partial epilepsy, 93.5% had seizures in the 6 months preceding levetiracetam initiation and 82.9% had at least one concomitant anti-epileptic drug when starting levetiracetam. One-year levetiracetam continuation rate was 83.5% (95% confidence interval, 80.5-86.0%). Of the 579 patients still using levetiracetam at end of study, 46.8% were seizure free during the last 6 months, and 24% were on levetiracetam monotherapy. Reasons for discontinuation (n= 122) were adverse events (45%), lack of efficacy (38%) or both (9%). Levetiracetam discontinuation was most strongly associated with previous exposure to more than four anti-epileptic drugs, whereas continuation was most strongly associated with presence of seizure-related falls in the 6 months preceding levetiracetam initiation.

CONCLUSIONS

This population-based cohort study in a stable market situation found a high 1 year levetiracetam continuation rate compared with previous studies done sooner after market introduction.