CANNabinoid Drug Interaction Review (CANN-DIR™)

Non-prescription cannabidiol (CBD) and medical marijuana (cannabis) currently do not have US Food and Drug Administration (FDA)-approved prescribing information nor a dedicated resource to evaluate potential cannabinoid drug-drug interactions with other medications. The CANNabinoid Drug Interaction Review (CANN-DIR™) is a free web-based platform that has been developed to screen for potential drug-drug interactions from the perspective of how a cannabinoid delta-9-tetrahydrocannabinol (THC), CBD, or a combination of THC/CBD may affect the metabolism of another prescribed medication. CANN-DIR™ is based on FDA-approved prescribing information for the prescription cannabinoids (dronabinol, nabilone, nabiximols, and prescription CBD) and other FDA-approved prescribing information for medications sharing similar metabolic enzymes (e.g., the FDA "Drug Development and Drug Interactions: Table of Substrates, Inhibitors and Inducers"). The Summary of Product Characteristics (SmPC) was the source of drug-drug interaction information for the combined ∆⁹-THC & CBD product nabiximols (Sativex^®). CANN-DIR™ provides an expeditious review of cannabinoid drug-drug interaction information, and also a platform from which the patient and health care provider can print out the search results to either initiate a conversation, or for the health care provider to provide a written information sheet to supplement their verbal discussion. Additionally, to more effectively reach a global audience, the end user of CANN-DIR™ has the ability to currently navigate and print results in any of the following ten languages: Chinese, English, French, German, Nepali, Polish, Russian, Spanish, Swedish, and Vietnamese.

Drug-drug interaction between dexamethasone and direct-acting oral anticoagulants: a nested case-control study in the National COVID Cohort Collaborative (N3C)

OBJECTIVE

The goal of this work is to evaluate if there is an increase in the risk of thromboembolic events (TEEs) due to concomitant exposure to dexamethasone and apixaban or rivaroxaban. Direct oral anticoagulants (DOACs), as well as corticosteroid dexamethasone, are commonly used to treat individuals hospitalised with COVID-19. Dexamethasone induces cytochrome P450-3A4 enzyme that also metabolises DOACs apixaban and rivaroxaban. This raises a concern about possible interaction between dexamethasone and DOACs that may reduce the efficacy of the DOACs and result in an increased risk of TEE.

DESIGN

We used nested case-control study design.

SETTING

This study was conducted in the National COVID Cohort Collaborative (N3C), the largest electronic health records repository for COVID-19 in the USA.

PARTICIPANTS

Study participants were adults over 18 years who were exposed to a DOAC for 10 or more consecutive days. Exposure to dexamethasone was at least 5 or more consecutive days.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary exposure variable was concomitant exposure to dexamethasone for 5 or more days after exposure to either rivaroxaban or apixaban for 5 or more consecutive days. We used McNemar's Χ² test and adjusted logistic regression to evaluate association between concomitant use of dexamethasone with either apixaban or rivaroxaban.

RESULTS

McNemar's Χ² test did not find a discernible association of TEE in patients concomitantly exposed to dexamethasone and a DOAC (χ²=0.5, df=1, p=0.48). In addition, a conditional logistic regression model did not find an increase in the risk of TEE (adjusted OR 1.15, 95% CI 0.32 to 4.18).

CONCLUSION

This nested case-control study did not find evidence of an association between concomitant exposure to dexamethasone and a DOAC with an increase in risk of TEE. Due to small sample size, an association cannot be completely ruled out.

Use of Hydroxychloroquine, Remdesivir, and Dexamethasone Among Adults Hospitalized With COVID-19 in the United States : A Retrospective Cohort Study

BACKGROUND

Relatively little is known about the use patterns of potential pharmacologic treatments of COVID-19 in the United States.

OBJECTIVE

To use the National COVID Cohort Collaborative (N3C), a large, multicenter, longitudinal cohort, to characterize the use of hydroxychloroquine, remdesivir, and dexamethasone, overall as well as across individuals, health systems, and time.

DESIGN

Retrospective cohort study.

SETTING

43 health systems in the United States.

PARTICIPANTS

137 870 adults hospitalized with COVID-19 between 1 February 2020 and 28 February 2021.

MEASUREMENTS

Inpatient use of hydroxychloroquine, remdesivir, or dexamethasone.

RESULTS

Among 137 870 persons hospitalized with confirmed or suspected COVID-19, 8754 (6.3%) received hydroxychloroquine, 29 272 (21.2%) remdesivir, and 53 909 (39.1%) dexamethasone during the study period. Since the release of results from the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial in mid-June, approximately 78% to 84% of people who have had invasive mechanical ventilation have received dexamethasone or other glucocorticoids. The use of hydroxychloroquine increased during March 2020, peaking at 42%, and started declining by April 2020. By contrast, remdesivir and dexamethasone use gradually increased over the study period. Dexamethasone and remdesivir use varied substantially across health centers (intraclass correlation coefficient, 14.2% for dexamethasone and 84.6% for remdesivir).

LIMITATION

Because most N3C data contributors are academic medical centers, findings may not reflect the experience of community hospitals.

CONCLUSION

Dexamethasone, an evidence-based treatment of COVID-19, may be underused among persons who are mechanically ventilated. The use of remdesivir and dexamethasone varied across health systems, suggesting variation in patient case mix, drug access, treatment protocols, and quality of care.

PRIMARY FUNDING SOURCE

National Center for Advancing Translational Sciences; National Heart, Lung, and Blood Institute; and National Institute on Aging.

Delta-9-Tetrahydrocannabinol and Cannabidiol Drug-Drug Interactions

Although prescribing information (PI) is often the initial source of information when identifying potential drug-drug interactions, it may only provide a limited number of exemplars or only reference a class of medications without providing any specific medication examples. In the case of medical cannabis and medicinal cannabinoids, this is further complicated by the fact that the increased therapeutic use of marijuana extracts and cannabidiol oil will not have regulatory agency approved PI. The objective of this study was to provide a detailed and comprehensive drug-drug interaction list that is aligned with cannabinoid manufacturer PI. The cannabinoid drug-drug interaction information is listed in this article and online supplementary material as a PRECIPITANT (cannabinoid) medication that either INHIBITS/INDUCES the metabolism or competes for the same SUBSTRATE target (metabolic enzyme) of an OBJECT (OTHER) medication. In addition to a comprehensive list of drug-drug interactions, we also provide a list of 57 prescription medications displaying a narrow therapeutic index that are potentially impacted by concomitant cannabinoid use (whether through prescription use of cannabinoid medications or therapeutic/recreational use of cannabis and its extracts).

Comparison of Osteoporosis Pharmacotherapy Fracture Rates: Analysis of a MarketScan® Claims Database Cohort

BACKGROUND

Several different classes of medications have been shown to be efficacious at preventing fractures in patients with osteoporosis. No study has compared real world efficacy at preventing fractures between all currently approved medications.

OBJECTIVES

To directly compare the efficacy of all currently available osteoporosis medications by using a large population claims database.

METHODS

The Truven Health Analytics MarketScan^® database from 2008 - 2012 was used to identify all patients who started a new osteoporosis medication. Patients who experienced a fracture after at least 12 months of treatment were identified and risk factors for fracture for all patients were recorded. Logistic regression was used to account for and quantify the contribution of risk factors, and to make direct comparisons between different osteoporosis medications.

RESULTS

A total of 51649 patients were included in the cohort, with an average age of 56 years. The overall incidence rate of fracture was 1.55 per 100 person - years of treatment. Orally administered medications had the lowest fracture rates, led by raloxifene and alendronate (1.24 and 1.54 respectively), while parenterally administered medications including teriparatide and zolerdonic acid had the highest rates (3.90 and 1.98 respectively). No statistically significant differences found between oral or parenterally administered bisphosphonate medications.

CONCLUSIONS

While patients taking orally administered drugs including bisphosphonates had less frequent incident fracture no statistically significant differences were found between most drugs in head - to - head comparisons, even considering the route of administration of bisphosphonates. These findings support previous evidence that minimal differences in efficacy exist between different osteoporosis medications. This is the first study using a large database to compare all currently available osteoporosis treatments and will hopefully be augmented by further study to provide more evidence to make clinical decisions on osteoporosis medication use.

Use of Chronic Medications Among Patients with Non-Valvular Atrial Fibrillation

Background

Frequency of administration (once daily versus more than once daily) is believed to be an important consideration affecting drug choice.

Objective

The aim of this study was to describe the characteristics of patients with non-valvular atrial fibrillation (NVAF) and the extent to which they take chronic medications, other than anticoagulants, more frequently than once daily.

Methods

Using data from a large, national database of health insurance claims, patients with a diagnosis of NVAF between 1 July 2008 and 30 September 2011 were identified, along with their prescription medications, to determine the proportion of patients taking chronic medications more than once a day. Prescription medications, co-morbidities, and CHADS₂ and CHA₂DS₂-VASc scores were evaluated. CHADS₂ assesses the risk of stroke in NVAF patients with the following risk factors: Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, and history of prior Stroke or transient ischemic attack. The CHA₂DS₂-VASc score adds the following risk factors to the CHADS₂ score: Age 65–74 years, Vascular Disease, and Sex Category (Female).

Results

Overall, 324,172 patients with NVAF with mean CHADS₂ and CHA₂DS₂-VASc scores of 1.51 and 3.08, respectively, were included in the study. Of these patients, 299,716 (92.5 %) took chronic medications, with an average of 6.9 medications per patient, and 215,527 (66.5 % of all patients or 71.9 % of those taking chronic medications) took medications more than once per day.

Conclusion

Use of chronic medications other than anticoagulants is common among patients with NVAF, and medications are typically taken multiple times per day. The average number of medications per patient and multiple therapeutic classes prescribed underscore the clinical complexity of NVAF patients. Hence, the choice of a once daily anticoagulant versus a more than once daily anticoagulant may be less relevant in a real world NVAF population in terms of a potential convenience benefit.

Abstract 132: Comparing Time in Therapeutic Range between Point of Care and Tele-Management Patients

Introduction: A strong relationship exists between the Time in Therapeutic Range (TTR), bleeding and thromboembolic events. The TTR percentage can be calculated by the following three methods. The Rosendaal method assumes a linear relationship between two INR values, the Cross Section method uses INR values that are within a specified range and at a specific point in time, and the Fraction of INR Results method measures the number of INRs in a specified range over the total number of INRs.

Objectives: Compare the TTR between Point of Care (POC) and Tele-Management (TELE) Non-Valvular Atrial Fibrillation (NVAF) patients calculated by the Rosendaal, Cross Section, and Fraction of INR Results methods.

Methods: Data was collected retrospectively during the 2014 calendar year for 100 randomly selected patients ≥ 18 years, received warfarin without interruption, and were monitored by the Penn State Hershey Medical Center Anticoagulation Clinic. INR lab values were obtained 14 days after initiating warfarin therapy and the interval between 2 consecutive INR lab values was ≤ 56 days. All patients in this study had a target INR range of (2.0-3.0). There was a total number of 1,889 INR lab values collected for the POC (n=826) and TELE (n=1,063) cohort groups respectively. The mean TTR value was calculated for each patient. When comparing TTR between the POC and TELE cohorts, the two-sample t-test was used for both the Rosendaal and Fraction of INR Results methods and the Chi-Square test was used for the Cross Section method.

Results: Illustrated in Table 1, the mean TTR for the entire study sample (n=100) was (72.4%, 70.0%, and 67.6%) for the Rosendaal, Cross Section, and Fraction of INR Results methods respectively. When comparing between the POC and TELE cohorts, the TTR was 72.8% for the POC cohort and 72.0% for the TELE cohort by the Rosendaal method (p=0.81); the TTR was 64.0% for the POC cohort and 76.0% for the TELE cohort by the Cross Section method (p=0.19); and the TTR was 68.3% for the POC cohort and 67.0% for the TELE cohort by the Fraction of INR Results method (p=0.69).

Conclusion: The mean TTR percentage did not provide a consistent pattern among the different TTR calculation methods or between the POC and TELE cohort groups. The differences observed between the POC and TELE cohort groups were not statistically significant (all p > 0.05).

Abstract 215: Use of Chronic Medications among Patients with Non-Valvular Atrial Fibrillation

Introduction: Patients with non-valvular atrial fibrillation (NVAF) typically have other chronic comorbid conditions. However, little is known about the dosing regimens of medications that are prescribed to NVAF patients.

Objectives: Estimate the proportion of real world NVAF patients with at least 1 CHADS 2 risk factor for stroke that may take chronic medications more than once per day.

Methods: Using claims data from the Truven Health MarketScan® Commercial Claims and Encounters database, which contains health insurance claims data on a national sample of privately insured individuals, we identified NVAF patients with CHADS 2 ≥ 1 during the period January 1, 2008 through September 30, 2012. Chronic medications were identified as those for which the patient had at least a 90 day supply during the study period, excluding oral anticoagulants. A “medication portfolio” was developed for each NVAF patient characterizing the chronic prescription medications taken on a regular basis. Information from the medication’s FDA approved product label and pharmacy claims data were used to add detail to each patient’s medication list. This detail included the medication name, recommended dosage and administration, and prescribed strength, quantity, and days supply. Patients were identified as taking medications multiple times per day if they were prescribed a medication with a >1 time per day dosing regimen per the product label, or one medication typically taken in the morning and another medication typically taken in the evening, or, in cases where the typical administration was unclear from the label or from clinical practice, were prescribed more than 1 pill per day, while the total daily strength of the medication was equal to an available strength of a single pill. The proportion of NVAF patients that took medications multiple times per day was then determined.

Results: Overall, 324,172 NVAF patients were selected for the study. The mean age of the patients was 75.3 years and over half (54.6%) of the patients were male. Of these patients, 299,716 (92.5%) were prescribed chronic medications and 215,527 (66.5%) were identified as possibly taking medications more than once per day. Overall, among patients who were prescribed chronic medications, 71.9% were identified as possibly taking their medications more than once per day.

Conclusion: Patients with NVAF typically have other chronic conditions and a large proportion of these patients may be on treatment regimens that require taking medications more than once per day.