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Baillie S, Limdi JK, Bassi A, Fraser A, Parkes G, Scott G, Raine T, Lamb CA, Kennedy NA, Fumis N, Smith MA, Nicolaou A, Emms H, Wye J, Lehmann A, Carbery I, Goodhand J, Lees R, Beshyah W, Luthra P, Pollok R, Selinger C. Opioid use and associated factors in 1676 patients with inflammatory bowel disease: a multicentre quality improvement project. Frontline Gastroenterol 2023; 14:497-504. [PMID: 37854782 PMCID: PMC10579551 DOI: 10.1136/flgastro-2023-102423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/30/2023] [Indexed: 10/20/2023] Open
Abstract
Objective Despite its association with poorer outcomes, opioid use in inflammatory bowel disease (IBD) is not well characterised in the UK. We aimed to examine the extent of opioid use, the associated factors and the use of mitigation techniques such as pain-service review and opioid weaning plans among individuals with IBD. Methods Data were collected from consecutive patients attending IBD outpatient appointments at 12 UK hospitals. A predefined questionnaire was used to collect data including patient demographics, IBD history, opioid use in the past year (>2 weeks) and opioid-use mitigation techniques. Additionally, consecutive IBD-related hospital stays leading up to July 2019 were reviewed with data collected regarding opioid use at admission, discharge and follow-up as well as details of the admission indication. Results In 1352 outpatients, 12% had used opioids within the past 12 months. Over half of these individuals were taking opioids for non-IBD pain and less than half had undergone an attempted opioid wean.In 324 hospitalised patients, 27% were prescribed opioids at discharge from hospital. At 12 months postdischarge, 11% were using opioids. Factors associated with opioid use in both cohorts included female sex, Crohn's disease and previous surgery. Conclusions 1 in 10 patients with IBD attending outpatient appointments were opioid exposed in the past year while a quarter of inpatients were discharged with opioids, and 11% continued to use opioids 12 months after discharge. IBD services should aim to identify patients exposed to opioids, reduce exposure where possible and facilitate access to alternative pain management approaches.
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Affiliation(s)
- Samantha Baillie
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jimmy K Limdi
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Ash Bassi
- Department of Gastroenterology, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Aileen Fraser
- Department of Gastroenterology, University Hospitals Bristol and Weston Trust, Bristol, UK
| | - Gareth Parkes
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Glyn Scott
- Department of Gastroenterology, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christopher A Lamb
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter IBD Research Group, University of Exeter, Exeter, UK
| | - Natalia Fumis
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Melissa A Smith
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Andrew Nicolaou
- Pain Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Holly Emms
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - John Wye
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anouk Lehmann
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Isabel Carbery
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James Goodhand
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Robert Lees
- Department of Gastroenterology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Waleed Beshyah
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Pavit Luthra
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Richard Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christian Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Affiliation(s)
- Holly Emms
- Department of Paediatrics, St George's University, London, UK
| | - Richard Lee
- Department of Paediatrics, St George's University, London, UK
| | - Alison Thomas
- Department of Paediatrics, St George's University, London, UK
| | - Katja Doerholt
- Department of Paediatrics, St George's University, London, UK
| | - Kirsty Le Doare
- Department of Paediatrics, St George's University, London, UK
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Emms H, Farah G, Shine B, Boot C, Toole B, McFadden M, Lam L, Ou ZQ, Woollard G, Madhavaram H, Kyle C, Grossman AB. Falsely elevated plasma metanephrine in patients taking midodrine. Ann Clin Biochem 2018; 55:509-515. [DOI: 10.1177/0004563218755817] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Plasma metanephrines have become the biochemical test of choice for suspected phaeochromocytomas and paragangliomas in many institutions. We encountered two separate cases of significantly elevated plasma metanephrines in patients taking midodrine, a sympathomimetic drug used in the treatment of severe postural hypotension, in the absence of a diagnosis of phaeochromocytomas and paragangliomas. Upon stopping midodrine treatment, plasma metanephrine concentrations returned to normal in both patients. To explore the hypothesis that midodrine or its metabolite desglymidodrine might interfere with the metanephrines assay, we tested the interaction of midodrine with metanephrine assays from two different centres. High-performance liquid chromatography tandem mass spectrometry on plasma samples and on methanolic extract of midodrine demonstrated co-elution of the metabolite desglymidodrine with metanephrine. We conclude that patients taking midodrine may have falsely elevated plasma metanephrine as a result of analytical interference, and clinicians need to be aware of this problem.
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Affiliation(s)
- Holly Emms
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - George Farah
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Brian Shine
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford, UK
| | - Chris Boot
- Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Barry Toole
- Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Martin McFadden
- Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Leo Lam
- Department of Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Zong-Quan Ou
- Department of Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Gerald Woollard
- Department of Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Hima Madhavaram
- Department of Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Campbell Kyle
- Department of Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
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Emms H, Tsirou I, Cranston T, Tsagarakis S, Grossman AB. Do patients with incidentally discovered bilateral adrenal nodules represent an early form of ARMC5-mediated bilateral macronodular hyperplasia? Endocrine 2016; 53:801-8. [PMID: 27306888 DOI: 10.1007/s12020-016-0988-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 02/06/2016] [Accepted: 05/07/2016] [Indexed: 02/07/2023]
Abstract
Bilateral adrenal macronodular hyperplasia (BMAH) is a rare form of Cushing's syndrome characterised by the presence of bilateral secretory adrenal nodules and hypercortisolism. Familial studies support a genetic basis for BMAH, and the disease has been linked to mutations in ARMC5, a gene shown to have a tumour suppressor-like action in the development of adrenal nodules. This study aimed to investigate whether ARMC5 mutations play a role in the development of incidentally discovered bilateral adrenal nodules. We investigated 39 patients with incidentally discovered bilateral adrenal nodules >0.8 cm in diameter who underwent extensive biochemical testing to look for signs of subclinical hypercortisolism. Genomic DNA was analysed by Sanger sequencing, using primers targeted to ARMC5 transcripts. Of the 39 patients included in our study, three were identified as having variants in ARMC5. Two of these are unlikely to be clinically significant, but there is evidence that the third mutation, Chr16:g.31476122;c.1778G>C (p.Arg593Pro), may be pathogenic. Another variant, affecting the same amino-acid residue c.1777C>T (p.Arg593Trp), has been identified previously in two studies of BMAH patients, where it has been shown to segregate with disease in one BMAH family. This patient had biochemical evidence of hypercortisolism in the absence of overt Cushing's syndrome, and underwent bilateral adrenalectomy separated in time. The presence of a probably clinically significant mutation in ARMC5 in one patient with bilateral adrenal incidentalomas adds to the growing body of evidence in support of ARMC5 as a critical mediator of adrenal nodule development. In addition, the absence of significant ARMC5 mutations in 38 of our patients represents an important negative finding, demonstrating the degree of variability within the pathogenesis of adrenal nodule development.
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Affiliation(s)
- Holly Emms
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK.
- Green Templeton College, 43 Woodstock Road, Oxford, OX2 6HG, UK.
| | - Ioanna Tsirou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Treena Cranston
- Genetics Laboratories, Churchill Hospital, University of Oxford, Oxford, UK
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Ashley B Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
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Emms H, Lewis GP. The roles of prostaglandin endoperoxides, thromboxane A2 and adenosine diphosphate in collagen-induced aggregation in man and the rat. Br J Pharmacol 1986; 87:109-15. [PMID: 3082399 PMCID: PMC1916885 DOI: 10.1111/j.1476-5381.1986.tb10162.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The effects of aspirin, carboxyheptylimidazole (CHI) and creatine phosphate/creatine phosphokinase (CP/CPK) on platelet aggregation and thromboxane B2 (TxB2) formation induced by collagen have been examined in vitro. Platelets from two species, man and the rat, have been used. In man, aspirin and CHI abolished TxB2 production but only partially inhibited aggregation. CP/CPK partially inhibited aggregation and TxB2 formation. In the rat, aspirin and CHI abolished TxB2 formation but had no effect on aggregation. CP/CPK completely inhibited aggregation and partially inhibited TxB2 generation. In man, collagen-induced aggregation is largely dependent on ADP and to a lesser extent on arachidonate metabolites whereas, in the rat, ADP alone mediates aggregation induced by this agonist. The results with CP/CPK suggest that TxB2 formation is dependent either on the prior release of platelet ADP or on aggregation itself rather than being responsible for the aggregation response.
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Abstract
Platelet sensitivity to adenosine di-phosphate (ADP), thrombin, collagen, arachidonic acid and prostaglandin I2 (PGI2) and the activity of the coagulation system as measured by the activated partial thromboplastin time, prothrombin time, Russell's viper venom time and plasma fibrinogen have been examined in male and female rats, female rats during the oestrous cycle and female rats treated with oestrogen and a progestogen. Male rat platelets were less sensitive to thrombin and more sensitive to inhibition by PGI2 than those from females and fibrinogen levels in male rat plasma were approximately twice those seen in females. During the oestrous cycle, platelets were more sensitive to ADP and less sensitive to thrombin at dioestrus. Following 6 weeks treatment with 17 beta-oestradiol or ethynyl oestradiol, both platelet aggregation and release of granular ATP induced by collagen were significantly reduced. Platelet sensitivity to other agents, ADP, arachidonic acid, thrombin and PGI2 was, however, unchanged following oestrogen treatment. Activation of factor X by Russell's viper venom was accelerated in rats treated with ethynyl oestradiol, although this enhancement was not reflected in the overall clotting times.
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Emms H, Lewis GP. The effect of synthetic ovarian hormones on an in vivo model of thrombosis in the rat. Br J Pharmacol 1985; 84:243-8. [PMID: 4038891 PMCID: PMC1987224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The effects of endogenous and exogenous, synthetic ovarian hormones on thrombus formation have been examined using an in vivo model in the rat. Thrombus formation in female rats was greatest during the di-oestrus stage of the oestrous cycle. Thrombus formation in both male and female rats was reduced following 6 weeks treatment with the oestrogen, ethynyl oestradiol whilst in females the progestogen, norethindrone acetate had no effect. These findings are in contrast to the increased risk of thromboembolic disorders reported in women taking oral contraceptives. The inhibitory effect of ethynyl oestradiol was not due to changes in blood flow but was dependent on the heparin concentration, being greatest at the highest heparin concentration used. Thrombus formation was greater in male rats than in females, a sex difference which is consistent with the higher incidence of cardiovascular disease in men than in women.
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