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Kim DH, Lee H, Pawar A, Lee SB, Park CM, Levin R, Metzger E, Bateman BT, Ely EW, Pandharipande PP, Pisani MA, Hohmann SF, Marcantonio ER, Inouye SK. Trends in use of antipsychotics and psychoactive drugs in older patients after major surgery. J Am Geriatr Soc 2023; 71:3755-3767. [PMID: 37676699 PMCID: PMC10841351 DOI: 10.1111/jgs.18580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/05/2023] [Accepted: 07/13/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Professional society guidelines recommend limiting the use of antipsychotics in older patients with postoperative delirium. How these recommendations affected the use of antipsychotics and other psychoactive drugs in the postoperative period has not been studied. METHODS This retrospective cohort study included patients 65 years or older without psychiatric diagnoses who underwent major surgery in community hospitals (CHs) and academic medical centers (AMCs) in the United States. The outcome was the rate of hospital days exposed to antipsychotics, antidepressants, antiepileptics, benzodiazepines, hypnotics, and selective alpha-2 receptor agonist dexmedetomidine in the postoperative period by hospital type. RESULTS The study included 4,098,431 surgical admissions from CHs (mean age 75.0 [standard deviation, 7.1] years; 50.8% female) during 2008-2018 and 2,310,529 surgical admissions from AMCs (75.0 [7.4] years; 49.4% female) during 2009-2018. In the intensive care unit (ICU) setting, the number of exposed days per 1000 hospital-days declined for haloperidol (CHs: 33-21 days [p < 0.01]; AMCs: 24-15 days [p < 0.01]) and benzodiazepines (CHs: 261-136 days [p < 0.01]; AMCs: 150-77 days [p < 0.01]). The use of atypical antipsychotics, antidepressants, antiepileptics, and dexmedetomidine increased, while hypnotic use varied by the hospital type. In the non-ICU setting, the rate declined for haloperidol in CHs but not in AMCs (CHs: 10-6 days [p < 0.01]; AMCs: 4-3 days [p = 0.52]) and for benzodiazepines in both settings (CHs: 126-56 days [p < 0.01]; AMCs: 30-27 days [p < 0.01]). The use of antiepileptics and antidepressants increased, while the use of atypical antipsychotics and hypnotics varied by the hospital type. CONCLUSIONS The use of haloperidol and benzodiazepines in the postoperative period declined at both CHs and AMCs. These trends coincided with the increasing use of other psychoactive drugs.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Eran Metzger
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - E. Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
| | - Pratik P. Pandharipande
- Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Margaret A. Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Samuel F. Hohmann
- Vizient, Inc. and Department of Health Systems Management, Rush University, Chicago, IL
| | - Edward R. Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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Kim DH, Lee SB, Park CM, Levin R, Metzger E, Bateman BT, Ely EW, Pandharipande PP, Pisani MA, Jones RN, Marcantonio ER, Inouye SK. Comparative Safety Analysis of Oral Antipsychotics for In-Hospital Adverse Clinical Events in Older Adults After Major Surgery : A Nationwide Cohort Study. Ann Intern Med 2023; 176:1153-1162. [PMID: 37665998 PMCID: PMC10625498 DOI: 10.7326/m22-3021] [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] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Antipsychotics are commonly used to manage postoperative delirium. Recent studies reported that haloperidol use has declined, and atypical antipsychotic use has increased over time. OBJECTIVE To compare the risk for in-hospital adverse events associated with oral haloperidol, olanzapine, quetiapine, and risperidone in older patients after major surgery. DESIGN Retrospective cohort study. SETTING U.S. hospitals in the Premier Healthcare Database. PATIENTS 17 115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018. INTERVENTIONS Haloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg). MEASUREMENTS The risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) were estimated after propensity score overlap weighting. RESULTS The weighted population had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%. Among the 4 antipsychotics, quetiapine was the most prescribed (53.0% of total exposure). There was no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group), olanzapine (2.8%; RR, 0.74 [95% CI, 0.42 to 1.27]), quetiapine (2.6%; RR, 0.70 [CI, 0.47 to 1.04]), and risperidone (3.3%; RR, 0.90 [CI, 0.53 to 1.41]). The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group. LIMITATION Residual confounding by delirium severity; lack of untreated group; restriction to oral low-to-moderate dose treatment. CONCLUSION These results suggest that atypical antipsychotics and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium who receive an oral low-to-moderate dose antipsychotic drug. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Eran Metzger
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - E. Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
| | - Pratik P. Pandharipande
- Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Margaret A. Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI
| | - Edward R. Marcantonio
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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Fu EL, Patorno E, Everett BM, Vaduganathan M, Solomon SD, Levin R, Schneeweiss S, Desai RJ. Sodium-glucose cotransporter 2 inhibitors vs. sitagliptin in heart failure and type 2 diabetes: an observational cohort study. Eur Heart J 2023; 44:2216-2230. [PMID: 37259575 PMCID: PMC10290872 DOI: 10.1093/eurheartj/ehad273] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 03/08/2023] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
AIMS The effectiveness of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in patients with heart failure (HF) in routine clinical practice is not extensively studied. This study aimed to evaluate the comparative effectiveness of SGLT2i vs. sitagliptin in older adults with HF and type 2 diabetes and to investigate whether there were any differences between agents within the SGLT2i class or for reduced and preserved ejection fraction. METHODS AND RESULTS Using Medicare claims data (April 2013 to December 2019), 16 253 SGLT2i initiators vs. 43 352 initiators of sitagliptin aged ≥65 years with type 2 diabetes and HF were included. The primary outcome was a composite of all-cause mortality, hospitalization for HF or urgent visit requiring intravenous diuretics; secondary outcomes included its individual components. Propensity score fine stratification weighted Cox regression was used to adjust for 100 pre-exposure characteristics. Mean age was 74 years; 49.8% were women. Initiation of SGLT2i vs. sitagliptin was associated with a lower risk of the primary composite outcome [adjusted hazard ratio (HR) 0.72; 95% confidence interval 0.67-0.77]. The adjusted HRs were 0.70 (0.63-0.78) for all-cause mortality, 0.64 (0.58-0.70) for hospitalization for HF, and 0.77 (0.69-0.86) for urgent visit requiring intravenous diuretics. Similar associations with the primary composite outcome were observed for all three agents within the SGLT2i class, for reduced and preserved ejection fraction, and subgroups based on demographics, comorbidities, and other HF treatments. Bias-calibrated HRs for the primary endpoint using negative and positive control outcomes ranged between 0.81 and 0.89, suggesting that the observed benefit could not be fully explained by residual confounding. CONCLUSION In routine US clinical practice, SGLT2i demonstrated robust clinical effectiveness in older adults with HF and type 2 diabetes compared with sitagliptin, with no evidence of heterogeneity across the SGLT2i class or across ejection fraction.
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Affiliation(s)
- Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, 1620 Tremont St., BC-3030, Boston, MA 02120, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, 1620 Tremont St., BC-3030, Boston, MA 02120, USA
| | - Brendan M Everett
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
- Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, 1620 Tremont St., BC-3030, Boston, MA 02120, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, 1620 Tremont St., BC-3030, Boston, MA 02120, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, 1620 Tremont St., BC-3030, Boston, MA 02120, USA
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Cromer SJ, Lauffenburger JC, Levin R, Patorno E. Deficits and Disparities in Early Uptake of Glucagon-Like Peptide 1 Receptor Agonists and SGLT2i Among Medicare-Insured Adults Following a New Diagnosis of Cardiovascular Disease or Heart Failure. Diabetes Care 2023; 46:65-74. [PMID: 36383481 PMCID: PMC9797651 DOI: 10.2337/dc22-0383] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 02/24/2022] [Accepted: 10/09/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the association of race/ethnicity and socioeconomic deprivation with initiation of guideline-recommended diabetes medications with cardiovascular benefit (glucagon-like peptide 1 receptor agonists [GLP1-RA] and sodium-glucose cotransporter 2 inhibitors [SGLT2i]) among older adults with type 2 diabetes (T2D) and either incident atherosclerotic cardiovascular disease (ASCVD) or congestive heart failure (CHF). RESEARCH DESIGN AND METHODS Using Medicare data (2016-2019), we identified 4,057,725 individuals age >65 years with T2D and either incident ASCVD or CHF. We estimated incidence rates and hazard ratios (HR) of GLP1-RA or SGLT2i initiation within 180 days by race/ethnicity and zip code-level Social Deprivation Index (SDI) using adjusted Cox proportional hazards models. RESULTS Incidence rates of GLP1-RA or SGLT2i initiation increased over time but remained low (<0.6 initiations per 100 person-months) in all years studied. Medication initiation was less common among those of Black or other race/ethnicity (HR 0.81 [95% CI 0.79-0.84] and HR 0.84 [95% CI 0.75-0.95], respectively) and decreased with increasing SDI (HR 0.96 [95% CI 0.96-0.97]). Initiation was higher in ASCVD than CHF (0.35 vs. 0.135 initiations per 100 person-months). Moderate (e.g., nephropathy, nonalcoholic fatty liver disease) but not severe (e.g., advanced chronic kidney disease, cirrhosis) comorbidities were associated with higher probability of medication initiation. CONCLUSIONS Among older adults with T2D and either ASCVD or CHF, initiation of GLP1-RA or SGLT2i was low, suggesting a substantial deficit in delivery of guideline-recommended care or treatment barriers. Individuals of Black and other race/ethnicity and those with higher area-level socioeconomic deprivation were less likely to initiate these medications.
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Affiliation(s)
- Sara J. Cromer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Julie C. Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Park CM, Inouye SK, Marcantonio ER, Metzger E, Bateman BT, Lie JJ, Lee SB, Levin R, Kim DH. Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery. JAMA Intern Med 2022; 182:1117-1127. [PMID: 36121671 PMCID: PMC9486639 DOI: 10.1001/jamainternmed.2022.3680] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/03/2022] [Indexed: 12/14/2022]
Abstract
Importance Gabapentin has been increasingly used as part of a multimodal analgesia regimen to reduce opioid use in perioperative pain management. However, the safety of perioperative gabapentin use among older patients remains uncertain. Objective To examine in-hospital adverse clinical events associated with perioperative gabapentin use among older patients undergoing major surgery. Design, Setting, and Participants This retrospective cohort study using data from the Premier Healthcare Database included patients aged 65 years or older who underwent major surgery at US hospitals within 7 days of hospital admission from January 1, 2009, to March 31, 2018, and did not use gabapentin before surgery. Data were analyzed from June 14, 2021, to May 23, 2022. Exposures Gabapentin use within 2 days after surgery. Main Outcomes and Measures The primary outcome was delirium, identified using diagnosis codes, and secondary outcomes were new antipsychotic use, pneumonia, and in-hospital death between postoperative day 3 and hospital discharge. To reduce confounding, 1:1 propensity score matching was performed. Risk ratios (RRs) and risk differences (RDs) with 95% CIs were estimated. Results Among 967 547 patients before propensity score matching (mean [SD] age, 76.2 [7.4] years; 59.6% female), the rate of perioperative gabapentin use was 12.3% (119 087 patients). After propensity score matching, 237 872 (118 936 pairs) gabapentin users and nonusers (mean [SD] age, 74.5 [6.7] years; 62.7% female) were identified. Compared with nonusers, gabapentin users had increased risk of delirium (4040 [3.4%] vs 3148 [2.6%]; RR, 1.28 [95% CI, 1.23-1.34]; RD, 0.75 [95% CI, 0.75 [0.61-0.89] per 100 persons), new antipsychotic use (944 [0.8%] vs 805 [0.7%]; RR, 1.17 [95% CI, 1.07-1.29]; RD, 0.12 [95% CI, 0.05-0.19] per 100 persons), and pneumonia (1521 [1.3%] vs 1368 [1.2%]; RR, 1.11 [95% CI, 1.03-1.20]; RD, 0.13 [95% CI, 0.04-0.22] per 100 persons), but there was no difference in in-hospital death (362 [0.3%] vs 354 [0.2%]; RR, 1.02 [95% CI, 0.88-1.18]; RD, 0.00 [95% CI, -0.04 to 0.05] per 100 persons). Risk of delirium among gabapentin users was greater in subgroups with high comorbidity burden than in those with low comorbidity burden (combined comorbidity index <4 vs ≥4: RR, 1.20 [95% CI, 1.13-1.27] vs 1.40 [95% CI, 1.30-1.51]; RD, 0.41 [95% CI, 0.28-0.53] vs 2.66 [95% CI, 2.08-3.24] per 100 persons) and chronic kidney disease (absence vs presence: RR, 1.26 [95% CI, 1.19-1.33] vs 1.38 [95% CI, 1.27-1.49]; RD, 0.56 [95% CI, 0.42-0.69] vs 1.97 [95% CI, 1.49-2.46] per 100 persons). Conclusion and Relevance In this cohort study, perioperative gabapentin use was associated with increased risk of delirium, new antipsychotic use, and pneumonia among older patients after major surgery. These results suggest careful risk-benefit assessment before prescribing gabapentin for perioperative pain management.
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Affiliation(s)
- Chan Mi Park
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Edward R. Marcantonio
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Eran Metzger
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jessica J. Lie
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Grinberg M, Levin R, Neuman H, Ziv O, Turjeman S, Gamliel G, Nosenko R, Koren O. Antibiotics increase aggression behavior and aggression-related pheromones and receptors in Drosophila melanogaster. iScience 2022; 25:104371. [PMID: 35620429 PMCID: PMC9127605 DOI: 10.1016/j.isci.2022.104371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 02/07/2022] [Accepted: 05/04/2022] [Indexed: 11/05/2022] Open
Abstract
Aggression is a behavior common in most species; it is controlled by internal and external drivers, including hormones, environmental cues, and social interactions, and underlying pathways are understood in a broad range of species. To date, though, effects of gut microbiota on aggression in the context of gut-brain communication and social behavior have not been completely elucidated. We examine how manipulation of Drosophila melanogaster microbiota affects aggression as well as the pathways that underlie the behavior in this species. Male flies treated with antibiotics exhibited significantly more aggressive behaviors. Furthermore, they had higher levels of cVA and (Z)-9 Tricosene, pheromones associated with aggression in flies, as well as higher expression of the relevant pheromone receptors and transporters OR67d, OR83b, GR32a, and LUSH. These findings suggest that aggressive behavior is, at least in part, mediated by bacterial species in flies. Aggression increases in flies that lack a microbiome Monocolonization with specific bacteria can mediate this effect We observed differences in aggression-related pheromone expression levels
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Warlick C, Levin R, Cantrill C, Regelman M, White M, Milbank A, Spilseth B, Dixon C. Transurethral Vapor Ablation (TUVA) of intermediate risk localized Prostate Cancer (PCa). Eur Urol 2022. [DOI: 10.1016/s0302-2838(22)00402-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Zakharia Y, Thomaidou D, Li B, Siu G, Levin R, Vlahiotis A, Zanotti G. 111P Real-world treatment modification of first-line axitinib + pembrolizumab in patients with metastatic renal cell carcinoma (mRCC). Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.10.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Gautam N, Bessette L, Pawar A, Levin R, Kim DH. Updating International Classification of Diseases 9th Revision to 10th Revision of a Claims-Based Frailty Index. J Gerontol A Biol Sci Med Sci 2021; 76:1316-1317. [PMID: 32529241 DOI: 10.1093/gerona/glaa150] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Nileesa Gautam
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lily Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Szmulewicz AG, Bateman BT, Levin R, Huybrechts KF. Risk of Overdose Associated With Co-prescription of Antipsychotics and Opioids: A Population-Based Cohort Study. Schizophr Bull 2021; 48:405-413. [PMID: 34582543 PMCID: PMC8886580 DOI: 10.1093/schbul/sbab116] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The US FDA issued a black-box warning against co-prescription of antipsychotic (AP) agents and opioids due to the risk of respiratory depression, but evidence on the comparative safety of sedating vs nonsedating APs is lacking. We classified APs as sedating (eg, quetiapine, olanzapine, and chlorpromazine) and nonsedating (eg, aripiprazole, haloperidol, and risperidone) based on their affinity to the histamine-1 neuroreceptor (Ki < or ≥20, respectively) and sought to compare the rate of overdose between patients using sedating vs nonsedating APs plus opioids. We constructed a population-based cohort nested in the IBM MarketScan database (2004-2017). Patients with concomitant use of sedating APs and prescription opioids ("exposed") were 1:1 matched to patients with concomitant use of nonsedating APs and prescription opioids ("referent") based on the propensity score (PS). The primary outcome was any hospitalization or emergency department visit due to an overdose within 30 days. The final cohort comprised 62 604 exposed and an equal number of PS-matched reference patients. Characteristics of matched exposed and reference patients were similar. There were 178 overdose events among the exposed (35.3 events per 1000 person-years [PY]) vs 133 among the reference group (26.4 events per 1000 PY), for an adjusted hazard ratio of 1.34 (95% CI: 1.07-1.68). This finding was consistent across sensitivity and subgroup analyses. Among patients receiving prescription opioids, concomitant use of sedating APs was associated with an increased risk of overdose compared with nonsedating APs. Caution is required when co-prescribing opioids and APs. If co-prescription is needed, choosing a nonsedating agent should be preferred whenever possible given the clinical context.
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Affiliation(s)
- Alejandro G Szmulewicz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA,To whom correspondence should be addressed; 677 Huntington Avenue, Boston, MA 02215, USA; tel: 617-432-1050, fax: (617)-232-8602 e-mail:
| | - Brian T Bateman
- Department of Medicine, Division of Pharmacoepidemiology & Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA,Department of Anaesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Raisa Levin
- Department of Medicine, Division of Pharmacoepidemiology & Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Krista F Huybrechts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA,Department of Medicine, Division of Pharmacoepidemiology & Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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Szmulewicz A, Bateman BT, Levin R, Huybrechts KF. The Risk of Overdose With Concomitant Use of Z-Drugs and Prescription Opioids: A Population-Based Cohort Study. Am J Psychiatry 2021; 178:643-650. [PMID: 33900810 DOI: 10.1176/appi.ajp.2020.20071038] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 11/30/2022]
Abstract
OBJECTIVE The Z-drugs (zolpidem, zopiclone, zaleplon) are widely used to treat insomnia in patients receiving prescription opioids, and the risk of overdose resulting from this coprescription has not been explored. The authors compared the rates of overdose among patients using opioids plus Z-drugs and patients using opioids alone. METHODS All individuals 15 to 85 years of age receiving prescription opioids, regardless of underlying indication and without evidence of cancer, were identified in the IBM MarketScan database (2004-2017). Patients with concomitant exposure to Z-drugs were matched 1:1 to patients with exposure to prescription opioids alone based on opioid prescribed, morphine equivalents, number of days' supply, and hospitalization within the past 30 days. The primary outcome was any hospitalization or emergency department visit due to an overdose within 30 days, using an intention-to-treat approach. Fine stratification on the propensity score was used to control for confounding. RESULTS A total of 510,529 exposed patients and an equal number of matched reference patients were analyzed. There were 217 overdose events among the exposed patients (52.5 events per 10,000 person-years) and 57 events among the reference patients (14.4 events per 10,000 person-years), corresponding to an unadjusted hazard ratio of 3.67 (95% CI=2.75, 4.90). Using fine stratification on the propensity score (c-statistic: 0.66), the adjusted hazard ratio was 2.29 (95% CI=1.79, 2.91). Results were consistent across sensitivity analyses. CONCLUSIONS Among patients receiving prescription opioids, after controlling for all confounding factors, concomitant treatment with Z-drugs was associated with a substantial relative increase in the risk of overdose. The potential implications are significant given the large number of opioid-treated patients receiving Z-drugs.
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Affiliation(s)
- Alejandro Szmulewicz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston (Szmulewicz, Huybrechts); Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (Bateman, Levin, Huybrechts), and Department of Anesthesiology, Perioperative and Pain Medicine (Bateman), Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Brian T Bateman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston (Szmulewicz, Huybrechts); Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (Bateman, Levin, Huybrechts), and Department of Anesthesiology, Perioperative and Pain Medicine (Bateman), Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Raisa Levin
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston (Szmulewicz, Huybrechts); Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (Bateman, Levin, Huybrechts), and Department of Anesthesiology, Perioperative and Pain Medicine (Bateman), Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Krista F Huybrechts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston (Szmulewicz, Huybrechts); Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (Bateman, Levin, Huybrechts), and Department of Anesthesiology, Perioperative and Pain Medicine (Bateman), Brigham and Women's Hospital and Harvard Medical School, Boston
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Desai RJ, Patorno E, Vaduganathan M, Mahesri M, Chin K, Levin R, Solomon SD, Schneeweiss S. Effectiveness of angiotensin-neprilysin inhibitor treatment versus renin-angiotensin system blockade in older adults with heart failure in clinical care. Heart 2021; 107:1407-1416. [PMID: 34088766 DOI: 10.1136/heartjnl-2021-319405] [Citation(s) in RCA: 15] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/17/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness of angiotensin receptor-neprilysin inhibitor (ARNI) versus renin-angiotensin system (RAS) blockade alone in older adults with heart failure with reduced ejection fraction (HFrEF). METHODS We conducted a cohort study using US Medicare fee-for-service claims data (2014-2017). Patients with HFrEF ≥65 years were identified in two cohorts: (1) initiators of ARNI or RAS blockade alone (ACE inhibitor, ACEI; or angiotensin receptor blocker, ARB) and (2) switchers from an ACEI to either ARNI or ARB. HR with 95% CI from Cox proportional hazard regression and 1-year restricted mean survival time (RMST) difference with 95% CI were calculated for a composite outcome of time to first worsening heart failure event or all-cause mortality after adjustment for 71 pre-exposure characteristics through propensity score fine-stratification weighting. All analyses of initiator and switcher cohorts were conducted separately and then combined using fixed effects. RESULTS 51 208 patients with a mean age of 76 years were included, with 16 193 in the ARNI group. Adjusted HRs comparing ARNI with RAS blockade alone were 0.92 (95% CI 0.84 to 1.00) among initiators and 0.79 (95% CI 0.74 to 0.85) among switchers, with a combined estimate of 0.84 (95% CI 0.80 to 0.89). Adjusted 1-year RMST difference (95% CI) was 4 days in the initiator cohort (-1 to 9) and 12 days (8 to 17) in the switcher cohort, resulting in a pooled estimate of 9 days (6 to 12) favouring ARNI. CONCLUSION ARNI treatment was associated with lower risk of a composite effectiveness endpoint compared with RAS blockade alone in older adults with HFrEF.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Heart and Vascular Center, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kristyn Chin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Scott D Solomon
- Heart and Vascular Center, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Desai RJ, Mahesri M, Chin K, Levin R, Lahoz R, Studer R, Vaduganathan M, Patorno E. Epidemiologic Characterization of Heart Failure with Reduced or Preserved Ejection Fraction Populations Identified Using Medicare Claims. Am J Med 2021; 134:e241-e251. [PMID: 33127370 DOI: 10.1016/j.amjmed.2020.09.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 08/26/2020] [Revised: 09/04/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Administrative claims do not contain ejection fraction information for heart failure patients. We recently developed and validated a claims-based model to predict ejection fraction subtype. METHODS Heart failure patients aged 65 years or above from US Medicare fee-for-service claims were identified using diagnoses recorded after a 6-month baseline period of continuous enrollment, which was used to identify predictors and to apply the claims-based model to distinguish heart failure with reduced or preserved ejection fraction (HFrEF or HFpEF). Patients were followed for the composite outcome of time to first worsening heart failure event (heart failure hospitalization or outpatient intravenous diuretic treatment) or all-cause mortality. RESULTS A total of 3,134,414 heart failure patients with an average age of 79 years were identified, of which 200,950 (6.4%) were classified as HFrEF. Among those classified as HFrEF, men comprised a larger proportion (68% vs 41%) and the average age was lower (76 vs 79 years) compared with HFpEF. History of myocardial infarction was more common in HFrEF (32% vs 13%), while hypertension was more common in HFpEF (71% vs 77%). One-year cumulative incidence of the composite endpoint was 42.6% for HFrEF and 36.9% for HFpEF. One-year all-cause mortality incidence was similar between the groups (27.4% for HFrEF and 26.4% for HFpEF), however, cardiovascular mortality was higher for HFrEF (15.6% vs 11.3%), whereas noncardiovascular mortality was higher for HFpEF (11.8% vs 15.1%). CONCLUSION We replicated well-documented differences in key patient characteristics and cause-specific outcomes between HFrEF and HFpEF in populations identified based on the application of a claims-based model.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, Mass.
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, Mass
| | - Kristyn Chin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, Mass
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, Mass
| | | | | | - Muthiah Vaduganathan
- Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, Mass
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Levin R, Sullivan A, Li B, Shetty V, Krulewicz S, Bartolome L. FP07.16 Trends in Biomarker Testing Among Advanced NSCLC Patients in Oncology Practice Settings in the US. J Thorac Oncol 2021. [DOI: 10.1016/j.jtho.2021.01.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Mahesri M, Schneeweiss S, Globe D, Mutebi A, Bohn R, Achebe M, Levin R, Desai RJ. Clinical outcomes following bone marrow transplantation in patients with sickle cell disease: A cohort study of US Medicaid enrollees. Eur J Haematol 2020; 106:273-280. [PMID: 33155319 DOI: 10.1111/ejh.13546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Bone marrow transplantation (BMT) is currently the only curative therapy available for patients with sickle cell disease (SCD), but clinical outcomes in routine care are not well understood. We describe the rates of vaso-occlusive crises (VOCs), transplant complications, and mortality in SCD patients after BMT. METHODS A cohort study of SCD patients who underwent BMT was designed using US Medicaid claims data (2000-2013). RESULTS A total of 204 SCD patients undergoing BMT were identified with a mean (SD) age of 10.6 (7.3) years, with 52.9% male and 67.6% African American. The overall VOC rate was 0.99 per person-year (95% CI: 0.91-1.07) over a median follow-up time of 2.1 years (IQR: 0.8-4.3 years). A total of 138 (67.6%) remained free of VOCs. The mortality rate was 1.7 (95% CI: 0.9-3.1) per 100 person-years, transplant-related complications occurred among 113 (55.4%) patients with an incidence rate of 38.2 (95% CI: 31.7-45.9) per 100 person-years, while 47 (23%) patients had GvHD with an incidence rate of 8.0 (95% CI: 6.0-10.7) per 100 person-years. CONCLUSION Two thirds of the BMT recipients remained VOC-free over 2 years of follow-up, but transplant-related complications, including GvHD occurred with high frequency. This highlights a continuing unmet need for alternative curative interventions in SCD.
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Affiliation(s)
- Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | | | - Alex Mutebi
- Vertex Pharmaceuticals Inc., Boston, MA, USA
| | | | - Maureen Achebe
- Hematology Division, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
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Desai RJ, Mahesri M, Globe D, Mutebi A, Bohn R, Achebe M, Levin R, Schneeweiss S. Clinical outcomes and healthcare utilization in patients with sickle cell disease: a nationwide cohort study of Medicaid beneficiaries. Ann Hematol 2020; 99:2497-2505. [DOI: 10.1007/s00277-020-04233-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023]
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Desai RJ, Levin R, Lin KJ, Patorno E. Bias Implications of Outcome Misclassification in Observational Studies Evaluating Association Between Treatments and All-Cause or Cardiovascular Mortality Using Administrative Claims. J Am Heart Assoc 2020; 9:e016906. [PMID: 32844711 PMCID: PMC7660765 DOI: 10.1161/jaha.120.016906] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background The bias implications of outcome misclassification arising from imperfect capture of mortality in claims‐based studies are not well understood. Methods and Results We identified 2 cohorts of patients: (1) type 2 diabetes mellitus (n=8.6 million), and (2) heart failure (n=3.1 million), from Medicare claims (2012–2016). Within the 2 cohorts, mortality was identified from claims using the following approaches: (1) all‐place all‐cause mortality, (2) in‐hospital all‐cause mortality, (3) all‐place cardiovascular mortality (based on diagnosis codes for a major cardiovascular event within 30 days of death date), or (4) in‐hospital cardiovascular mortality, and compared against National Death Index identified mortality. Empirically identified sensitivity and specificity based on observed values in the 2 cohorts were used to conduct Monte Carlo simulations for treatment effect estimation under differential and nondifferential misclassification scenarios. From National Death Index, 1 544 805 deaths (549 996 [35.6%] cardiovascular deaths) in the type 2 diabetes mellitus cohort and 1 175 202 deaths (523 430 [44.5%] cardiovascular deaths) in the heart failure cohort were included. Sensitivity was 99.997% and 99.207% for the all‐place all‐cause mortality approach, whereas it was 27.71% and 33.71% for the in‐hospital all‐cause mortality approach in the type 2 diabetes mellitus and heart failure cohorts, respectively, with perfect positive predicted values. For all‐place cardiovascular mortality, sensitivity was 52.01% in the type 2 diabetes mellitus cohort and 53.83% in the heart failure cohort with positive predicted values of 49.98% and 54.45%, respectively. Simulations suggested a possibility for substantial bias in treatment effects. Conclusions Approaches to identify mortality from claims had variable performance compared with the National Death Index. Investigators should anticipate the potential for bias from outcome misclassification when using administrative claims to capture mortality.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics Brigham and Women's Hospital & Harvard Medical School Boston MA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics Brigham and Women's Hospital & Harvard Medical School Boston MA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics Brigham and Women's Hospital & Harvard Medical School Boston MA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics Brigham and Women's Hospital & Harvard Medical School Boston MA
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Umarje S, Vaduganathan M, Levin R, Desai RJ. Medication Burden in Older Patients With Heart Failure: A Cohort Study of Medicare Beneficiaries. J Card Fail 2020; 26:742-744. [DOI: 10.1016/j.cardfail.2020.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/09/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
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Lee MP, Glynn RJ, Schneeweiss S, Lin KJ, Patorno E, Barberio J, Levin R, Evers T, Wang SV, Desai RJ. Risk Factors for Heart Failure with Preserved or Reduced Ejection Fraction Among Medicare Beneficiaries: Application of Competing Risks Analysis and Gradient Boosted Model. Clin Epidemiol 2020; 12:607-616. [PMID: 32606986 PMCID: PMC7304674 DOI: 10.2147/clep.s253612] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/16/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The differential impact of various demographic characteristics and comorbid conditions on development of heart failure (HF) with preserved (pEF) and reduced ejection fraction (rEF) is not well studied among the elderly. METHODS Using Medicare claims data linked to electronic health records, we conducted an observational cohort study of individuals ≥65 years of age without HF. A Cox proportional hazards model accounting for competing risk of HFrEF and HFpEF incidence was constructed. A gradient-boosted model (GBM) assessed the relative influence (RI) of each predictor in the development of HFrEF and HFpEF. RESULTS Among 138,388 included individuals, 9701 developed HF (incidence rate = 20.9 per 1000 person-years). Males were more likely to develop HFrEF than HFpEF (HR = 2.07, 95% CI: 1.81-2.37 vs. 1.11, 95% CI: 1.02-1.20, P for heterogeneity <0.01). Atrial fibrillation and pulmonary hypertension had stronger associations with the risk of HFpEF (HR = 2.02, 95% CI: 1.80-2.26 and 1.66, 95% CI: 1.23-2.22) while cardiomyopathy and myocardial infarction were more strongly associated with HFrEF (HR = 4.37, 95% CI: 3.21-5.97 and 1.94, 95% CI: 1.23-3.07). Age was the strongest predictor across all HF subtypes with RI from GBM >35%. Atrial fibrillation was the most influential comorbidity for the development of HFpEF (RI = 8.4%) while cardiomyopathy was the most influential comorbidity for the development of HFrEF (RI = 20.7%). CONCLUSION These findings of heterogeneous relationships between several important risk factors and heart failure types underline the potential differences in the etiology of HFpEF and HFrEF.
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Affiliation(s)
- Moa P Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA
| | - Julie Barberio
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA
| | | | - Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA
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Siddhanti S, Fanton C, Dixit N, Lu L, Chindalore V, Levin R, Diab I, Furie R, Zalevsky J, Kotzin B. THU0054 NKTR-358, A NOVEL IL-2 CONJUGATE, STIMULATES HIGH LEVELS OF REGULATORY T CELLS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Impaired IL-2 production and dysfunction of regulatory T cells (Tregs) have been identified as key immunological defects leading to the breakdown of immune self-tolerance in SLE. Low-dose IL-2 can expand Tregs, but the effect is limited by a narrow therapeutic window for Treg selectivity. Furthermore, the short half-life of IL-2 necessitates frequent administration. NKTR-358 is a polyethylene glycol (PEG) conjugate of recombinant human IL-2 (aldesleukin sequence) and is differentiated from native IL-2 by its altered binding to the IL-2 receptor and prolonged biological activity. NKTR-358 resulted in marked and selective stimulation of Tregs when administered as a single SC injection to healthy volunteers.Objectives:This multiple ascending dose study assessed the safety, tolerability, pharmacokinetics (PK), and immune effects of NKTR-358 in patients with SLE after repeated administration of SC doses. The time course and extent of changes in numbers and percentages of Tregs, conventional CD4+ and CD8+ T cells, NK cells, and cytokine levels in peripheral blood were investigated.Methods:In this double-blind, multiple ascending dose study, patients with mild to moderate SLE received 3 SC doses q2w in 4 cohorts ranging from 3.0 to 24.0 µg/kg (9 active:3 placebo per cohort); patients were followed for a total of 79 days.Results:There were no dose-limiting toxicities, deaths, or clinically significant abnormalities in either vital signs or electrocardiograms. Adverse events attributed to NKTR-358 were primarily limited to mild (grade 1) injection site reactions. At the highest dose, one subject had transient and mild (grade 1) symptoms of a flu-like syndrome after administration, without associated elevated cytokine levels, and another subject had dosing stopped due to elevated eosinophil levels. No other individual at any dose level had systemic signs or symptoms known to be associated with IL-2 therapy. No anti-drug antibodies were detected. NKTR-358 demonstrated dose-proportional PK with repeated dosing; plasma levels peaked 3-6 days post-dose and declined with a terminal half-life of ~10-13 days.The primary and consistent effect of NKTR-358 was seen on Tregs. In the four dose cohorts, dose-dependent and sustained increases in absolute numbers and percentages of circulating CD4+FoxP3+CD25brightTregs were observed. Treg levels remained elevated throughout the dosing period, peaking at Day 10 after the first administration of NKTR-358 and returning to baseline ~ 20-30 days following last administration. At 24.0 µg/kg, the mean peak increase in numbers of CD25brightTregs was 11-fold above baseline. In addition, there was an increase in Treg activation markers at doses ≥12.0 µg/kg. In contrast to effects on Tregs, no changes in percentages or numbers of conventional CD4+ or CD8+ T cells were observed at any dose tested. At the highest dose, there were low-level increases in the percentages and numbers of NK cells. Overall, NKTR-358 selectively induced Tregs, evidenced by a 12-fold increase in the mean peak Treg:CD8 ratio over baseline in the 24.0 µg/kg group.Conclusion:NKTR-358, an IL-2 conjugate Treg stimulator, was well tolerated when repeatedly administered (q2w) at doses up to 24 µg/kg. Its administration led to marked, selective, prolonged, and dose-dependent increases in circulating CD25brightTregs. This clinical study in SLE patients extends the previous results in healthy volunteers and provides strong support for continued testing of NKTR-358 as a new therapeutic in SLE and other inflammatory diseases.Disclosure of Interests:Suresh Siddhanti Shareholder of: Nektar Therapeutics, Employee of: Nektar Therapeutics, Christie Fanton Shareholder of: Nektar Therapeutics, Employee of: Nektar Therapeutics, Neha Dixit Shareholder of: Nektar Therapeutics, Employee of: Nektar Therapeutics, Lin Lu Shareholder of: Nektar Therapeutics, Employee of: Nektar Therapeutics, Vishala Chindalore Grant/research support from: Nektar Therapeutics for conducted studies, Speakers bureau: > 5 years ago, Robert Levin Grant/research support from: Payments for clinical research for industry-sponsored trials, Consultant of: Gilead, Exagen, Myriad Rheumatology, Speakers bureau: Sanofi/Genzyme, Regeneron, Bristol-Myers Squibb, AbbVie, Isam Diab: None declared, Richard Furie Grant/research support from: Nektar Therapeutics to Northwell Rheumatology to conduct this study, Consultant of: Nektar Therapeutics, Jonathan Zalevsky Shareholder of: Nektar Therapeutics, Employee of: Nektar Therapeutics, Brian Kotzin Shareholder of: Nektar Therapeutics, Employee of: Nektar Therapeutics
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Fralick M, Gagne JJ, Patorno E, Levin R, Kesselheim AS. Using Data From Routine Care to Estimate the Effectiveness and Potential Limitations of Outcomes-Based Contracts for Diabetes Medications. Value Health 2020; 23:434-440. [PMID: 32327160 DOI: 10.1016/j.jval.2019.11.004] [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] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/12/2019] [Accepted: 11/21/2019] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Outcomes-based contracts tie rebates and discounts for expensive drugs to outcomes. The objective was to estimate the utility of outcomes-based contracts for diabetes medications using real-world data and to identify methodologic limitations of this approach. METHODS A population-based cohort study of adults newly prescribed a medication for diabetes with a publicly announced outcomes-based contract (ie, exenatide microspheres ["exenatide"], dulaglutide, or sitagliptin) was conducted. The comparison group included patients receiving canagliflozin or glipizide. The primary outcome was announced in the outcomes-based contract: the percentage of adults with a follow-up hemoglobin A1C <8% up to 1 year later. Secondary outcomes included the percentage of patients diagnosed with hypoglycemia and the cost of a 1-month supply. RESULTS Thousands of adults newly filled prescriptions for exenatide (n = 5079), dulaglutide (n = 6966), sitagliptin (n = 40 752), canagliflozin (n = 16 404), or glipizide (n = 59 985). The percentage of adults subsequently achieving a hemoglobin A1C below 8% ranged from 83% (dulaglutide, sitagliptin) to 71% (canagliflozin). The rate of hypoglycemia was 25 per 1000 person-years for exenatide, 37 per 1000 person-years for dulaglutide, 28 per 1000 person-years for sitagliptin, 18 per 1000 person-years for canagliflozin, and 34 per 1000 person-years for glipizide. The cash price for a 1-month supply was $847 for exenatide, $859 for dulaglutide, $550 for sitagliptin, $608 for canagliflozin, and $14 for glipizide. CONCLUSION Outcomes-based pricing of diabetes medications has the potential to lower the cost of medications, but using outcomes such as hemoglobin A1C may not be clinically meaningful because similar changes in A1C can be achieved with generic medications at a far lower cost.
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Affiliation(s)
- Michael Fralick
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Sinai Health System, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Joshua J Gagne
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Huybrechts KF, Bateman BT, Pawar A, Bessette LG, Mogun H, Levin R, Li H, Motsko S, Scantamburlo Fernandes MF, Upadhyaya HP, Hernandez-Diaz S. Maternal and fetal outcomes following exposure to duloxetine in pregnancy: cohort study. BMJ 2020; 368:m237. [PMID: 32075794 PMCID: PMC7190016 DOI: 10.1136/bmj.m237] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the risk of adverse maternal and infant outcomes following in utero exposure to duloxetine. DESIGN Cohort study nested in the Medicaid Analytic eXtract for 2004-13. SETTING Publicly insured pregnancies in the United States. PARTICIPANTS Pregnant women 18 to 55 years of age and their liveborn infants. INTERVENTIONS Duloxetine exposure during the etiologically relevant time window, compared with no exposure to duloxetine, exposure to selective serotonin reuptake inhibitors, exposure to venlafaxine, and exposure to duloxetine before but not during pregnancy. MAIN OUTCOME MEASURES Congenital malformations overall, cardiac malformations, preterm birth, small for gestational age infant, pre-eclampsia, and postpartum hemorrhage. RESULTS Cohort sizes ranged from 1.3 to 4.1 million, depending on the outcome. The number of women exposed to duloxetine varied by cohort and exposure contrast and was around 2500-3000 for early pregnancy exposure and 900-950 for late pregnancy exposure. The base risk per 1000 unexposed women was 36.6 (95% confidence interval 36.3 to 36.9) for congenital malformations overall, 13.7 (13.5 to 13.9) for cardiovascular malformations, 107.8 (107.3 to 108.3) for preterm birth, 20.4 (20.1 to 20.6) for small for gestational age infant, 33.6 (33.3 to 33.9) for pre-eclampsia, and 23.3 (23.1 to 23.4) for postpartum hemorrhage. After adjustment for measured potential confounding variables, all baseline characteristics were well balanced for all exposure contrasts. In propensity score adjusted analyses versus unexposed pregnancies, the relative risk was 1.11 (95% confidence interval 0.93 to 1.33) for congenital malformations overall and 1.29 (0.99 to 1.68) for cardiovascular malformations. For preterm birth, the relative risk was 1.01 (0.92 to 1.10) for early exposure and 1.19 (1.04 to 1.37) for late exposure. For small for gestational age infants the relative risks were 1.14 (0.92 to 1.41) and 1.20 (0.83 to 1.72) for early and late pregnancy exposure, respectively, and for pre-eclampsia they were 1.12 (0.96 to 1.31) and 1.04 (0.80 to 1.35). The relative risk for postpartum hemorrhage was 1.53 (1.08 to 2.18). Results from sensitivity analyses were generally consistent with the findings from the main analyses. CONCLUSIONS On the basis of the evidence available to date, duloxetine is unlikely to be a major teratogen but may be associated with an increased risk of postpartum hemorrhage and a small increased risk of cardiac malformations. While continuing to monitor the safety of duloxetine as data accumulate over time, these potential small increases in risk of relatively uncommon outcomes must be weighed against the benefits of treating depression and pain during pregnancy in a given patient. TRIAL REGISTRATION EUPAS 15946.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Hu Li
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | | | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Desai RJ, Gopalakrishnan C, Dejene S, Sarpatwari AS, Levin R, Dutcher SK, Wang Z, Wittayanukorn S, Franklin JM, Gagne JJ. Comparative Outcomes of Treatment Initiation With Brand vs. Generic Warfarin in Older Patients. Clin Pharmacol Ther 2019; 107:1334-1342. [PMID: 31872419 DOI: 10.1002/cpt.1743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/02/2019] [Indexed: 01/05/2023]
Abstract
The anticoagulant response to warfarin, a narrow therapeutic index drug, increases with age, which may make older patients susceptible to adverse outcomes resulting from small differences in bioavailability between generic and brand products. Using US Medicare claims linked to electronic medical records from two large hospitals in Boston, we designed a cohort study of ≥ 65-year-old patients. Patients were followed for a composite effectiveness outcome of ischemic stroke or venous thromboembolism, a composite safety outcome, including major hemorrhage, and a 1-year all-cause mortality outcome. After propensity score fine-stratification and weighting to account for > 90 confounders, hazard ratios comparing brand vs. generic warfarin initiators (95% confidence intervals) for the effectiveness, safety, and all-cause mortality outcomes, were 0.97 (0.65-1.46), 0.94 (0.65-1.35), and 0.84 (0.62-1.13), respectively. Results from subgroup analyses of patients with atrial fibrillation, CHADS-VASc score ≥ 3, and HAS-BLED score ≥ 3 were consistent with the primary analysis.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Chandrasekar Gopalakrishnan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara Dejene
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ameet S Sarpatwari
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah K Dutcher
- Office of Research and Standards, Office of Generic Drugs, Center of Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Zhong Wang
- Office of Research and Standards, Office of Generic Drugs, Center of Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sara Wittayanukorn
- Office of Research and Standards, Office of Generic Drugs, Center of Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Vogelzang N, Gabrail N, Malik Z, Volterra F, Nordquist L, Levin R, Zhang P, Zhou K. The extended/phase II study of safety and tolerability of proxalutamide (GT0918) in subjects with metastatic castrate resistant prostate cancer (mCRPC) who failed either abiraterone (Abi) or enzalutamide (Enza). Ann Oncol 2019. [DOI: 10.1093/annonc/mdz248.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kundel Y, Brenner B, Perel G, Gordon N, Levin R. PO-0794 Postoperative Chemoradiotherapy in Gastric Cancer with Poor Response to Neoadjuvant Chemotherapy. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)31214-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
The present study was designed to investigate empirically the relationship between self-reports of nightmare frequency and ego strength and death anxiety in both men and women. In addition, the interrelations among these variables were assessed. 20 undergraduates with high frequencies of nightmares and 20 with low frequencies (10 men and 10 women per group) were administered the Barron Ego Strength Scale and a death anxiety scale. Significant differences were found between nightmare groups on the Barron scale for men and women but none on the death anxiety scale either by nightmare frequency or sex. A significant negative correlation of -.47 between death anxiety and ego strength was found for women and in one high frequency group. Women with high frequencies of nightmares showed the highest correlation, -.83. These data suggest that nightmare frequency may be a mediating factor in the relationship between ego strength, death anxiety, and sex of subject.
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Affiliation(s)
- R Levin
- State University of New York, Buffalo
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Gopalakrishnan C, Gagne JJ, Sarpatwari A, Dejene SZ, Dutcher SK, Levin R, Franklin JM, Schneeweiss S, Desai RJ. Evaluation of Socioeconomic Status Indicators for Confounding Adjustment in Observational Studies of Medication Use. Clin Pharmacol Ther 2019; 105:1513-1521. [PMID: 30659590 DOI: 10.1002/cpt.1348] [Citation(s) in RCA: 9] [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] [Received: 09/25/2018] [Accepted: 12/07/2018] [Indexed: 11/12/2022]
Abstract
Methodologic research evaluating confounding due to socioeconomic status (SES) in observational studies of medications is limited. We identified 7,109 patients who initiated brand or generic atorvastatin from Medicare claims (2011-2013) linked to electronic medical records and census data. We created a propensity score (PS) containing only claims-based covariates and augmented it with additional claims-based proxies for SES, ZIP code, and block group level SES. Cox models with PS fine-stratification and weighting were used to compare rates of a cardiovascular end point and emergency department visits. Adjustment with only claims-based variables substantially improved balance on all SES variables compared with the unadjusted. Although inclusion of SES in PS models further improved balance on SES variables compared with models with claims-based covariates only, it did not materially change point estimates for either outcome. Inclusion of claims-based proxies may mitigate confounding by SES when aggregate-level SES information is unavailable.
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Affiliation(s)
- Chandrasekar Gopalakrishnan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ameet Sarpatwari
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara Z Dejene
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah K Dutcher
- Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Desai RJ, Lin KJ, Patorno E, Barberio J, Lee M, Levin R, Evers T, Wang SV, Schneeweiss S. Development and Preliminary Validation of a Medicare Claims-Based Model to Predict Left Ventricular Ejection Fraction Class in Patients With Heart Failure. Circ Cardiovasc Qual Outcomes 2018; 11:e004700. [PMID: 30562067 DOI: 10.1161/circoutcomes.118.004700] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [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] [Indexed: 01/08/2023]
Abstract
BACKGROUND Ejection fraction (EF) class is an important predictor of treatment response in heart failure (HF); however, administrative claims databases lack information on EF, limiting their usefulness in clinical and health services research of HF. METHODS AND RESULTS We linked Medicare claims data to electronic medical records containing EF measurements for a cohort of 11 073 patients with HF from 2 academic medical centers. A a claims-based model predicting EF class was constructed using data from center 1 ("training sample") and validated using data from center 2 ("testing sample). Linear and logistic regression models with least absolute square shrinkage operator and Bayesian information criteria were developed to select the relevant predictor variables out of the total 57 candidate variables in the training sample. Higher accuracy was noted in the testing sample with models classifying patients into 2 EF classes (reduced EF <0.45) versus preserved EF (≥0.45) when compared with classifying patients into 3 EF classes (reduced, <0.40, moderately reduced, 0.40-0.49, or preserved, ≥0.50). In the testing sample, the most efficient model had 35 predictors and resulted in 83% of patients being correctly classified (95% CI, 82%-84%). The model had positive predictive value of 0.73 (95% CI, 0.68-0.78) and 0.84 (95% CI, 0.83-0.86) and sensitivity of 0.29 (95% CI, 0.25-0.32) and 0.97 (95% CI, 0.97-0.98) for reduced and preserved EF, respectively. In addition to HF-specific diagnosis codes, other factors including age, sex, medication use, and comorbidities, such as myocardial infarction and valve disorders, were important discriminators between EF classes. CONCLUSIONS The claims-based model developed in this study may be used to identify patient subgroups with specific EF class in studies evaluating the health outcomes, utilization patterns, and cost, of HF patients in routine care when EF measurements are not available.
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Affiliation(s)
- Rishi J Desai
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.J.D., K.J.L., E.P., J.B., M.L., R.L., S.V.W., S.S.)
| | - Kueiyu Joshua Lin
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.J.D., K.J.L., E.P., J.B., M.L., R.L., S.V.W., S.S.)
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (K.J.L.)
| | - Elisabetta Patorno
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.J.D., K.J.L., E.P., J.B., M.L., R.L., S.V.W., S.S.)
| | - Julie Barberio
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.J.D., K.J.L., E.P., J.B., M.L., R.L., S.V.W., S.S.)
| | - Moa Lee
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.J.D., K.J.L., E.P., J.B., M.L., R.L., S.V.W., S.S.)
| | - Raisa Levin
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.J.D., K.J.L., E.P., J.B., M.L., R.L., S.V.W., S.S.)
| | - Thomas Evers
- Market Access, Bayer AG, Wuppertal, Germany (T.E.)
| | - Shirley V Wang
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.J.D., K.J.L., E.P., J.B., M.L., R.L., S.V.W., S.S.)
| | - Sebastian Schneeweiss
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (R.J.D., K.J.L., E.P., J.B., M.L., R.L., S.V.W., S.S.)
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Affiliation(s)
- E Patorno
- Division of Pharmacoepidemiology, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - R J Glynn
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, USA
| | - R Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - K F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
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Kim DH, Mahesri M, Bateman BT, Huybrechts KF, Inouye SK, Marcantonio ER, Herzig SJ, Ely EW, Pisani MA, Levin R, Avorn J. Longitudinal Trends and Variation in Antipsychotic Use in Older Adults After Cardiac Surgery. J Am Geriatr Soc 2018; 66:1491-1498. [PMID: 30125337 PMCID: PMC6217828 DOI: 10.1111/jgs.15418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 03/22/2018] [Accepted: 03/27/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To evaluate temporal trends and between-hospital variation in off-label antipsychotic medication (APM) use in older adults undergoing cardiac surgery. DESIGN Retrospective cohort study. SETTING National administrative database including 465 U.S. hospitals. PARTICIPANTS Individuals aged 65 and older without known indications for APMs who underwent cardiac surgery from 2004 to 2014 (N=293,212). MEASUREMENTS Postoperative exposure to any APMs and potentially excessive dosing were examined. Hospital-level APM prescribing intensity was defined as the proportion of individuals newly treated with APMs in the postoperative period. RESULTS The rate of APM use declined from 8.8% in 2004 to 6.2% in 2014 (p<.001). Use of haloperidol (parenteral 7.0% to 4.5%, p<.001; oral: 1.9% to 0.5%, p<.001), and risperidone (1.1% to 0.3%, p<.001) declined, whereas quetiapine use tripled (0.6% to 1.9%, p=.03). Hospital APM prescribing intensity varied widely, from 0.3% to 35.6%, across 465 hospitals. Treated individuals at higher-prescribing hospitals were more likely to receive APMs on the day of discharge (highest vs lowest quintile: 15.1% vs 9.6%; p<.001) and for a longer duration (4.8 vs 3.7 days; p<.001) than those at lower-prescribing hospitals. Delirium was the strongest risk factor for APM exposure (odds ratio=9.73, 95% confidence interval=9.02-10.5), whereas none of the hospital characteristics were significantly associated. The rate of potentially excessive dosing declined (60.7% to 44.9%, p<.001), and risk factors for potentially excessive dosing were similar to those for any APM exposure. CONCLUSIONS Our findings suggest highly variable prescribing cultures and raise concerns about inappropriate use, highlighting the need for better evidence to guide APM prescribing in hospitalized older adults after cardiac surgery.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Sharon K. Inouye
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Edward R. Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Shoshana J. Herzig
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - E. Wesley Ely
- Division of Allergy, Pulmonology, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Veterans Affairs Tennessee Valley Geriatric Research Education Clinical Center, Nashville, TN
| | - Margaret A. Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale-New Haven Hospital, New Haven, CT
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Lo T, Piper I, Depreitere B, Meyfroidt G, Poca M, Sahuquillo J, Durduran T, Enblad P, Nilsson P, Ragauskas A, Kiening K, Morris K, Agbeko R, Levin R, Weitz J, Park C, Davis P. KidsBrainIT: A New Multi-centre, Multi-disciplinary, Multi-national Paediatric Brain Monitoring Collaboration. Acta Neurochir Suppl 2018; 126:39-45. [PMID: 29492529 DOI: 10.1007/978-3-319-65798-1_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVES Validated optimal cerebral perfusion pressure (CPP) treatment thresholds in children do not exist. To improve the intensive care unit (ICU) management of the paediatric traumatic brain injury (TBI) population, we are forming a new paediatric multi-centre collaboration to recruit standardised ICU data for running and reporting upon models for assessing autoregulation and optimal CCP (CPPopt). MATERIALS AND METHODS We are adapting the adult BrainIT group's approach to develop a new Paediatric Brain Monitoring and Information Technology Group (KidsBrainIT), which will include a repository to store prospectively collected high-resolution physiological, clinical, and outcome data. In the first phase of this project there are 7 UK Paediatric Intensive Care Units, 1 Spanish, 1 Belgium, and 1 Romanian Centre interested in participating. In subsequent phases, we plan to open recruitment to other centres both within Europe, US and abroad. We are collaborating with the Leuven Group and plan to use their LAx (low-frequency autoregulation index), DATACAR (dynamic adaptive target of active cerebral autoregulation), CPPopt and visualisation methodologies. We also plan to use the continuous diffuse optical monitoring and tomography technology developed in Barcelona as an acute surrogate end-point for optimising brain perfusion. This technology allows non-invasive continuous monitoring of deep tissue perfusion and oxygenation in adults but its clinical application in infants and children with TBI has not been studied previously. RESULTS We report on the current status of setting up this new collaboration and also on pilot analyses in two centres which are the basis of our rationale for the need for a prospective validation study of CPPopt in children. Specifically, we demonstrated that CPPopt varied with time for each patient during their paediatric intensive care unit (PICU) stay, and the median overall CPPopt levels for children aged 2-6 years, 7-11 years and 12-16 years were 68.83, 68.09, and 72.17 mmHg respectively. Among survivors and patients with favourable outcome (GOS 4 and 5), there were significantly higher proportions with CPP monitoring time within CPPopt (p = 0.04 and p = 0.01 respectively). CONCLUSIONS There is a need and an interest in forming a multi-centre PICU collaboration for acquiring data and performing analyses for determining validated CPPopt thresholds in the paediatric TBI population. KidsBrainIT is being formed to meet that need.
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Affiliation(s)
- T Lo
- Royal Hospital for Sick Children, Edinburgh, UK
| | - I Piper
- Queen Elizabeth University Hospital, Glasgow, UK.
| | | | | | - M Poca
- Val D'hebron University Hospital, Barcelona, Spain
| | - J Sahuquillo
- Val D'hebron University Hospital, Barcelona, Spain
| | - T Durduran
- Val D'hebron University Hospital, Barcelona, Spain
| | - P Enblad
- Uppsala University Hospital, Uppsala, Sweden
| | - P Nilsson
- Uppsala University Hospital, Uppsala, Sweden
| | - A Ragauskas
- Kaunas University of Technology, Kaunas, Lithuania
| | - K Kiening
- Heidelberg University Hospital, Heidelberg, Germany
| | - K Morris
- Birmingham Children's Hospital, Birmingham, UK
| | - R Agbeko
- Great Northern Children's Hospital, Newcastle Upon Tyne, UK
| | - R Levin
- Royal Hospital for Children, Glasgow, UK
| | - J Weitz
- Oxford Radcliffe Hospitals NHS Foundation Trust, Oxford, UK
| | - C Park
- Alder Hey Childrens NHS Foundation Trust, Liverpool, UK
| | - P Davis
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Rahmati MA, Homel P, Hoenich NA, Levin R, Kaysen GA, Levin NW. The Role of Improved Water Quality on Inflammatory Markers in Patients Undergoing Regular Dialysis. Int J Artif Organs 2018; 27:723-7. [PMID: 15478544 DOI: 10.1177/039139880402700811] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemodialysis utilizes large quantities of water for the preparation of dialysis fluid. Such water meets national standards and international standards but a considerable disparity exists between such standards with respect to microbiological purity. This study collated and retrospectively analyzed the impact of upgrading water systems from that specified in the US standards to those specified in European standards on clinical measures associated with inflammation in four metropolitan dialysis units for two periods. Two periods were compared, three months prior to and six months post upgrading the water treatment systems. The monthly total erythropoietin dosage and intravenous iron supplementation for each patient were also compared over these periods. Variables with significant pre-post differences were assessed using multivariate models to control for confounding factors. The results indicated significant increases in hemoglobin, ferritin and TSat (all p < 0.0001) and albumin (p = 0.0001) were associated with improvement in water quality. Decreases in CRP and creatinine (both p < 0.0001) were also noted. These findings suggest that the current regulations in the United States set the microbiological limits of water and dialysis fluid inappropriately high, and the limits should be revised downwards, since such an approach is reflected in improvement in markers of inflammation.
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Affiliation(s)
- M A Rahmati
- Division of Nephrology, Beth Israel Medical Center, New York, USA
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Mundkur ML, Rough K, Huybrechts KF, Levin R, Gagne JJ, Desai RJ, Patorno E, Choudhry NK, Bateman BT. Patterns of opioid initiation at first visits for pain in United States primary care settings. Pharmacoepidemiol Drug Saf 2017; 27:495-503. [PMID: 28971545 DOI: 10.1002/pds.4322] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 11/07/2022]
Abstract
PURPOSE The primary objective of this study was to characterize variation in patterns of opioid prescribing within primary care settings at first visits for pain, and to describe variation by condition, geography, and patient characteristics. METHODS 2014 healthcare utilization data from Optum's Clinformatics™ DataMart were used to evaluate individuals 18 years or older with an initial presentation to primary care for 1 of 10 common pain conditions. The main outcomes assessed were (1) the proportion of first visits for pain associated with an opioid prescription fill and (2) the proportion of opioid prescriptions with >7 days' supply. RESULTS We identified 205 560 individuals who met inclusion criteria; 9.1% of all visits were associated with an opioid fill, ranging from 4.1% (headache) to 28.2% (dental pain). Approximately half (46%) of all opioid prescriptions supplied more than 7 days, and 10% of prescriptions supplied ≥30 days. We observed a 4-fold variation in rates of opioid initiation by state, with highest rates of prescribing in Alabama (16.6%) and lowest rates in New York (3.7%). CONCLUSIONS In 2014, nearly half of all patients filling opioid prescriptions received more than 7 days' of opioids in an initial prescription. Policies limiting initial supplies have the potential to substantially impact opioid prescribing in the primary care setting.
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Affiliation(s)
- Mallika L Mundkur
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Kathryn Rough
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Abstract
Objectives To evaluate the risk of all cause mortality associated with initiating compared with not initiating benzodiazepines in adults, and to address potential treatment barriers and confounding related to the use of a non-active comparator group.Design Retrospective cohort study.Setting Large de-identified US commercial healthcare database (Optum Clinformatics Datamart).Participants 1:1 high dimensional propensity score matched cohort of benzodiazepine initiators, and randomly selected benzodiazepine non-initiators with a medical visit within 14 days of the start of benzodiazepine treatment (n=1 252 988), between July 2004 and December 2013. To address treatment barriers and confounding, patients were required to have filled one or more prescriptions for any medication in the 90 days and 91-180 days before the index date (ie, the date of starting benzodiazepine treatment for initiators and the date of the selected medical visit for benzodiazepine non-initiators) and the high dimensional propensity score was estimated on the basis of more than 300 covariates.Main outcome measure All cause mortality, determined by linkage with the Social Security Administration Death Master File.Results Over a six month follow-up period, 5061 and 4691 deaths occurred among high dimensional propensity score matched benzodiazepine initiators versus non-initiators (9.3 v 9.4 events per 1000 person years; hazard ratio 1.00, 95% confidence interval 0.96 to 1.04). A 4% (95% confidence interval 1% to 8%) to 9% (2% to 7%) increase in mortality risk was observed associated with the start of benzodiazepine treatment for follow-ups of 12 and 48 months and in subgroups of younger patients and patients initiating short acting agents. In secondary analyses comparing 1:1 high dimensional propensity score matched patients initiating benzodiazepines with an active comparator, ie, patients starting treatment with selective serotonin reuptake inhibitor antidepressants, benzodiazepine use was associated with a 9% (95% confidence interval 3% to 16%) increased risk.Conclusions This large population based cohort study suggests either no increase or at most a minor increase in risk of all cause mortality associated with benzodiazepine initiation. If a detrimental effect exists, it is likely to be much smaller than previously stated and to have uncertain clinical relevance. Residual confounding likely explains at least part of the small increase in mortality risk observed in selected analyses.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Moa P Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
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Vadas L, Bloch B, Levin R, Shalev I, Israel S, Uzefovsky F, Bachner-Melman R, Reshef A, Ebstein R, Kremer I. Sex-specific effect of intranasal vasopressin, but not oxytocin, on emotional recognition and perception in schizophrenia patients. Eur Psychiatry 2017. [DOI: 10.1016/j.eurpsy.2017.02.430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BackgroundImpairments in social behavior and cognition, such as the ability to identify others’ emotional state, are important features in schizophrenia. Arginine vasopressin (AVP) and oxytocin (OXT) and are nonapeptides that influence social cognition and behavior. Previous studies have shown that the administration of intranasal AVP or OXT may affect the ability to recognize facial emotions. The primary objective of this study was to investigate the effects of a single dose of AVP or OXT on social cognition in patients with schizophrenia. The secondary objective of the study was to test for sex-specific effects of intranasal AVP and OXT administration on social cognition.MethodsIn this double-blind, placebo-control, cross-over study, 34 patients diagnosed with schizophrenia or schizo-affective disorder, received a dose of AVP, OXT or placebo in three separate meetings. Forty-five minutes after administration, subjects performed facial emotion recognition tasks.ResultsThere were no significant main effects of hormone administration on the ability to recognize facial emotions between treatment conditions. However, AVP administration resulted in sex-specific differences in emotion recognition. Specifically, in men, AVP administration reduced the ability to recognize angry faces. In women, AVP administration reduced the ability to recognize sad faces and improved the ability to recognize fearful faces.ConclusionsThese findings indicate that intranasal AVP may affect the recognition of facial emotions differently in men and women. Thus, AVP may increase the differences between men and women on social cognition.Disclosure of interestThe authors have not supplied their declaration of competing interest.
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Kim DH, Huybrechts KF, Patorno E, Marcantonio ER, Park Y, Levin R, Abdurrob A, Bateman BT. Adverse Events Associated with Antipsychotic Use in Hospitalized Older Adults After Cardiac Surgery. J Am Geriatr Soc 2017; 65:1229-1237. [PMID: 28186624 DOI: 10.1111/jgs.14768] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To evaluate in-hospital adverse events associated with typical and atypical antipsychotic medications (APMs) after cardiac surgery. DESIGN Retrospective cohort study. SETTING Nationwide inpatient database, 2003 to 14. PARTICIPANTS Individuals (mean age 70) newly treated with oral atypical (n = 2,580) or typical (n = 1,126 APMs) after coronary artery bypass grafting or valve surgery (N = 3,706). MEASUREMENTS In-hospital mortality, arrhythmia, pneumonia, use of brain imaging (surrogate for oversedation and neurological events), and length of stay after drug initiation RESULTS: In the propensity score-matched cohort, median treatment duration was 3 days (interquartile range (IQR) 1-6 days) for atypical APMs and 2 days (IQR 1-3 days) for typical APMs. There were no large differences in in-hospital mortality (atypical 5.4%, typical 5.3%; risk difference (RD) = 0.1%, 95% confidence interval (CI) = -2.1 to 2.3%), arrhythmia (2.0% vs 2.2%; RD = 0.0%; 95% CI = -1.4 to 1.4%), pneumonia (16.1% vs 14.5%; RD = 1.6%, 95% CI = -1.9 to 5.0%), and length of stay (9.9 days vs 9.3 days; mean difference = 0.5 days, 95% CI = -1.2 to 2.2). Use of brain imaging was more common after initiating atypical APMs (17.3%) than after typical APMs (12.4%; RD = 4.9%, 95% CI = 1.4-8.4). CONCLUSION In hospitalized individuals who underwent cardiac surgery, short-term use of typical APMs was associated with risks of adverse events similar to those with atypical APMs. Moreover, greater use of brain imaging associated with atypical APMs suggests that these drugs may cause oversedation or adverse neurological events. Because of the low event rates, the analysis could not exclude modest differences in adverse events between atypical and typical APMs.
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Affiliation(s)
- Dae H Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edward R Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Yoonyoung Park
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Abdurrahman Abdurrob
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Burge DJ, Eisenman J, Byrnes-Blake K, Smolak P, Lau K, Cohen SB, Kivitz AJ, Levin R, Martin RW, Sherrer Y, Posada JA. Safety, pharmacokinetics, and pharmacodynamics of RSLV-132, an RNase-Fc fusion protein in systemic lupus erythematosus: a randomized, double-blind, placebo-controlled study. Lupus 2016; 26:825-834. [DOI: 10.1177/0961203316678675] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Blood-borne RNA circulating in association with autoantibodies is a potent stimulator of interferon production and immune system activation. RSLV-132 is a novel fully human biologic Fc fusion protein that is comprised of human RNase fused to the Fc domain of human IgG1. The drug is designed to remain in circulation and digest extracellular RNA with the aim of preventing activation of the immune system via Toll-like receptors and the interferon pathway. The present study describes the first clinical study of nuclease therapy in 32 subjects with systemic lupus erythematosus. The drug was well tolerated with a very favorable safety profile. The approximately 19-day serum half-life potentially supports once monthly dosing. There were no subjects in the study that developed anti-RSLV-132 antibodies. Decreases in B-cell activating factor correlated with decreases in disease activity in a subset of patients.
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Affiliation(s)
- D J Burge
- Resolve Therapeutics, LLC, Seattle, WA, USA
| | - J Eisenman
- Resolve Therapeutics, LLC, Seattle, WA, USA
| | | | - P Smolak
- Resolve Therapeutics, LLC, Seattle, WA, USA
| | - K Lau
- Resolve Therapeutics, LLC, Seattle, WA, USA
| | - S B Cohen
- Metroplex Clinical Research Center, Dallas, TX, USA
| | - A J Kivitz
- Altoona Center for Clinical Research, Duncansville, PA, USA
| | - R Levin
- Clinical Research of West Florida, Clearwater, FL, USA
| | - R W Martin
- Michigan State University, East Lansing, MI, USA
| | - Y Sherrer
- Center for Rheumatology, Immunology, and Arthritis, Ft. Lauderdale, FL, USA
| | - J A Posada
- Resolve Therapeutics, LLC, Seattle, WA, USA
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Donneyong MM, Bykov K, Bosco-Levy P, Dong YH, Levin R, Gagne JJ. Risk of mortality with concomitant use of tamoxifen and selective serotonin reuptake inhibitors: multi-database cohort study. BMJ 2016; 354:i5014. [PMID: 27694571 PMCID: PMC5044871 DOI: 10.1136/bmj.i5014] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To compare differences in mortality between women concomitantly treated with tamoxifen and selective serotonin reuptake inhibitors (SSRIs) that are potent inhibitors of the cytochrome-P450 2D6 enzyme (CYP2D6) versus tamoxifen and other SSRIs. DESIGN Population based cohort study. SETTING Five US databases covering individuals enrolled in private and public health insurance programs from 1995 to 2013. PARTICIPANTS Two cohorts of women who started taking tamoxifen. In cohort 1, women started taking an SSRI during tamoxifen treatment. In cohort 2, women were already taking an SSRI when they started taking tamoxifen. MAIN OUTCOME MEASURES All cause mortality in each cohort in women taking SSRIs that are potent inhibitors of CYP2D6 (paroxetine, fluoxetine) versus other SSRIs. Propensity scores were used to match exposure groups in a variable ratio fashion. Results were measured separately for each cohort and combined hazard ratios calculated from Cox regression models across the two cohorts with random effects meta-analysis. RESULTS There were 6067 and 8465 new users of tamoxifen in cohorts 1 and 2, respectively. Mean age was 55. A total of 991 and 1014 deaths occurred in cohorts 1 and 2 during a median follow-up of 2.2 (interquartile range 0.9-4.5) and 2.0 (0.8-3.9) years, respectively. The pooled hazard ratio for death for potent inhibitors (rate 58.6/1000 person years) compared with other SSRIs (rate 57.9/1000 person years) across cohorts 1 and 2 was 0.96 (95% confidence interval 0.88 to 1.06). Results were consistent across sensitivity analyses. CONCLUSION Concomitant use of tamoxifen and potent CYP2D6 inhibiting SSRIs versus other SSRIs was not associated with an increased risk of death.
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Affiliation(s)
- Macarius M Donneyong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA 02120
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA 02120 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA 02115
| | - Pauline Bosco-Levy
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA 02120
| | - Yaa-Hui Dong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA 02120
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA 02120
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA 02120 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA 02115
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Abstract
Background The malposition of endotracheal tubes (ETTs) can be associated with endo-bronchial intubation or accidental extubation. A variety of methods have been reported for predicting insertional length (IL) including weight, nasal-tragus length (NTL) and sternal length (STL) measurements. In our unit no consistent predictor method was being used. Aim To audit the proportion of endotracheal tubes that required a significant position change after oral intubation. Our standard set was that the endotracheal tube should be in a satisfactory position in >80% of cases. If not met, practice would then be re-audited after a consistent predictor method had been implemented. Methods Data regarding changes in endotracheal tube position were collected. Significant position changes were defined as adjustments>0.5 cm. Results Twenty two babies were included in the initial audit, and only 73% of endotracheal tubes had a satisfactory position. Thirty six babies were included in the re-audit and when the nasal-tragus length predictor was used, 94% of endotracheal tubes had a satisfactory position, meeting the standard. Conclusion The nasal-tragus length predictor improved the accuracy of endotracheal tube positioning after oral intubation. It is a simple, fast, reproducible method and can be used in everyday practice to help avoid significant endotracheal tube malposition.
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Affiliation(s)
- K L Whyte
- Neonatology Department, Princess Royal Maternity Hospital, 16 Alexandra Parade, Glasgow G31 2ER, UK.
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Affiliation(s)
- James A Baker
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts
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Huybrechts KF, Bateman BT, Palmsten K, Desai RJ, Patorno E, Gopalakrishnan C, Levin R, Mogun H, Hernandez-Diaz S. Antidepressant use late in pregnancy and risk of persistent pulmonary hypertension of the newborn. JAMA 2015; 313:2142-51. [PMID: 26034955 PMCID: PMC4761452 DOI: 10.1001/jama.2015.5605] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [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] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The association between selective serotonin reuptake inhibitor (SSRI) antidepressant use during pregnancy and risk of persistent pulmonary hypertension of the newborn (PPHN) has been controversial since the US Food and Drug Administration issued a public health advisory in 2006. OBJECTIVE To examine the risk of PPHN associated with exposure to different antidepressant medication classes late in pregnancy. DESIGN AND SETTING Cohort study nested in the 2000-2010 Medicaid Analytic eXtract for 46 US states and Washington, DC. Last follow-up date was December 31, 2010. PARTICIPANTS A total of 3,789,330 pregnant women enrolled in Medicaid from 2 months or fewer after the date of last menstrual period through at least 1 month after delivery. The source cohort was restricted to women with a depression diagnosis and logistic regression analysis with propensity score adjustment applied to control for potential confounders. EXPOSURES FOR OBSERVATIONAL STUDIES: SSRI and non-SSRI monotherapy use during the 90 days before delivery vs no use. MAIN OUTCOMES AND MEASURES Recorded diagnosis of PPHN during the first 30 days after delivery. RESULTS A total of 128,950 women (3.4%) filled at least 1 prescription for antidepressants late in pregnancy: 102,179 (2.7%) used an SSRI and 26,771 (0.7%) a non-SSRI. Overall, 7630 infants not exposed to antidepressants were diagnosed with PPHN (20.8; 95% CI, 20.4-21.3 per 10,000 births) compared with 322 infants exposed to SSRIs (31.5; 95% CI, 28.3-35.2 per 10,000 births), and 78 infants exposed to non-SSRIs (29.1; 95% CI, 23.3-36.4 per 10,000 births). Associations between antidepressant use and PPHN were attenuated with increasing levels of confounding adjustment. For SSRIs, odds ratios were 1.51 (95% CI, 1.35-1.69) unadjusted and 1.10 (95% CI, 0.94-1.29) after restricting to women with depression and adjusting for the high-dimensional propensity score. For non-SSRIs, the odds ratios were 1.40 (95% CI, 1.12-1.75) and 1.02 (95% CI, 0.77-1.35), respectively. Upon restriction of the outcome to primary PPHN, the adjusted odds ratio for SSRIs was 1.28 (95% CI, 1.01-1.64) and for non-SSRIs 1.14 (95% CI, 0.74-1.74). CONCLUSIONS AND RELEVANCE Evidence from this large study of publicly insured pregnant women may be consistent with a potential increased risk of PPHN associated with maternal use of SSRIs in late pregnancy. However, the absolute risk was small, and the risk increase appears more modest than suggested in previous studies.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts2Harvard Medical School, Boston, Massachusetts
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts2Harvard Medical School, Boston, Massachusetts3Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts
| | - Kristin Palmsten
- Department of Pediatrics, University of California, San Diego, La Jolla
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts2Harvard Medical School, Boston, Massachusetts
| | - Chandrasekar Gopalakrishnan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Park Y, Franklin JM, Schneeweiss S, Levin R, Crystal S, Gerhard T, Huybrechts KF. Antipsychotics and mortality: adjusting for mortality risk scores to address confounding by terminal illness. J Am Geriatr Soc 2015; 63:516-23. [PMID: 25752911 DOI: 10.1111/jgs.13326] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine whether adjustment for prognostic indices specifically developed for nursing home (NH) populations affect the magnitude of previously observed associations between mortality and conventional and atypical antipsychotics. DESIGN Cohort study. SETTING A merged data set of Medicaid, Medicare, Minimum Data Set (MDS), Online Survey Certification and Reporting system, and National Death Index for 2001 to 2005. PARTICIPANTS Dual-eligible individuals aged 65 and older who initiated antipsychotic treatment in a NH (N=75,445). MEASUREMENTS Three mortality risk scores (Mortality Risk Index Score, Revised MDS Mortality Risk Index, Advanced Dementia Prognostic Tool) were derived for each participant using baseline MDS data, and their performance was assessed using c-statistics and goodness-of-fit tests. The effect of adjusting for these indices in addition to propensity scores (PSs) on the association between antipsychotic medication and mortality was evaluated using Cox models with and without adjustment for risk scores. RESULTS Each risk score showed moderate discrimination for 6-month mortality, with c-statistics ranging from 0.61 to 0.63. There was no evidence of lack of fit. Imbalances in risk scores between conventional and atypical antipsychotic users, suggesting potential confounding, were much lower within PS deciles than the imbalances in the full cohort. Accounting for each score in the Cox model did not change the relative risk estimates: 2.24 with PS-only adjustment versus 2.20, 2.20, and 2.22 after further adjustment for the three risk scores. CONCLUSION Although causality cannot be proven based on nonrandomized studies, this study adds to the body of evidence rejecting explanations other than causality for the greater mortality risk associated with conventional antipsychotics than with atypical antipsychotics.
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Affiliation(s)
- Yoonyoung Park
- Department of Epidemiology, School of Public Health, Harvard University, Boston, Massachusetts; Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, Massachusetts
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Gerhard T, Huybrechts K, Olfson M, Schneeweiss S, Bobo WV, Doraiswamy PM, Devanand DP, Lucas JA, Huang C, Malka ES, Levin R, Crystal S. Comparative mortality risks of antipsychotic medications in community-dwelling older adults. Br J Psychiatry 2014; 205:44-51. [PMID: 23929443 DOI: 10.1192/bjp.bp.112.122499] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [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: 12/27/2022]
Abstract
BACKGROUND All antipsychotic medications carry warnings of increased mortality for older adults, but little is known about comparative mortality risks between individual agents. AIMS To estimate the comparative mortality risks of commonly prescribed antipsychotic agents in older people living in the community. METHOD A retrospective, claims-based cohort study was conducted of people over 65 years old living in the community who had been newly prescribed risperidone, olanzapine, quetiapine, haloperidol, aripiprazole or ziprasidone (n = 136 393). Propensity score-adjusted Cox proportional hazards models assessed the 180-day mortality risk of each antipsychotic compared with risperidone. RESULTS Risperidone, olanzapine and haloperidol showed a dose-response relation in mortality risk. After controlling for propensity score and dose, mortality risk was found to be increased for haloperidol (hazard ratio (HR) = 1.18, 95% CI 1.06-1.33) and decreased for quetiapine (HR = 0.81, 95% CI 0.73-0.89) and olanzapine (HR = 0.82, 95% CI 0.74-0.90). CONCLUSIONS Significant variation in mortality risk across commonly prescribed antipsychotics suggests that antipsychotic selection and dosing may affect survival of older people living in the community.
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Affiliation(s)
- T Gerhard
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - K Huybrechts
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - M Olfson
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - S Schneeweiss
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - W V Bobo
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - P M Doraiswamy
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - D P Devanand
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - J A Lucas
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - C Huang
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - E S Malka
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - R Levin
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - S Crystal
- Tobias Gerhard, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; Krista Huybrechts, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Mark Olfson, MD MPH, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Sebastian Schneeweiss, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; William V. Bobo, MD, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee; P. Murali Doraiswamy, MD, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; D. P. Devanand, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, New York; Judith A. Lucas, EdD RN, Cecilia Huang, PhD, Edmond S. Malka, PhD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey; Raisa Levin, MS, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Stephen Crystal, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
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Huybrechts KF, Palmsten K, Avorn J, Cohen LS, Holmes LB, Franklin JM, Mogun H, Levin R, Kowal M, Setoguchi S, Hernandez-Diaz S. Antidepressant use in pregnancy and the risk of cardiac defects. N Engl J Med 2014; 370:2397-407. [PMID: 24941178 PMCID: PMC4062924 DOI: 10.1056/nejmoa1312828] [Citation(s) in RCA: 212] [Impact Index Per Article: 21.2] [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] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whether the use of selective serotonin-reuptake inhibitors (SSRIs) and other antidepressants during pregnancy is associated with an increased risk of congenital cardiac defects is uncertain. In particular, there are concerns about a possible association between paroxetine use and right ventricular outflow tract obstruction and between sertraline use and ventricular septal defects. METHODS We performed a cohort study nested in the nationwide Medicaid Analytic eXtract for the period 2000 through 2007. The study included 949,504 pregnant women who were enrolled in Medicaid during the period from 3 months before the last menstrual period through 1 month after delivery and their liveborn infants. We compared the risk of major cardiac defects among infants born to women who took antidepressants during the first trimester with the risk among infants born to women who did not use antidepressants, with an unadjusted analysis and analyses that restricted the cohort to women with depression and that used propensity-score adjustment to control for depression severity and other potential confounders. RESULTS A total of 64,389 women (6.8%) used antidepressants during the first trimester. Overall, 6403 infants who were not exposed to antidepressants were born with a cardiac defect (72.3 infants with a cardiac defect per 10,000 infants), as compared with 580 infants with exposure (90.1 per 10,000 infants). Associations between antidepressant use and cardiac defects were attenuated with increasing levels of adjustment for confounding. The relative risks of any cardiac defect with the use of SSRIs were 1.25 (95% confidence interval [CI], 1.13 to 1.38) in the unadjusted analysis, 1.12 (95% CI, 1.00 to 1.26) in the analysis restricted to women with depression, and 1.06 (95% CI, 0.93 to 1.22) in the fully adjusted analysis restricted to women with depression. We found no significant association between the use of paroxetine and right ventricular outflow tract obstruction (relative risk, 1.07; 95% CI, 0.59 to 1.93) or between the use of sertraline and ventricular septal defects (relative risk, 1.04; 95% CI, 0.76 to 1.41). CONCLUSIONS The results of this large, population-based cohort study suggested no substantial increase in the risk of cardiac malformations attributable to antidepressant use during the first trimester. (Funded by the Agency for Healthcare Research and Quality and the National Institutes of Health.).
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Affiliation(s)
- Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Kristin Palmsten
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, United States
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Lee S. Cohen
- Center for Women’s Mental Health, Massachusetts General Hospital, Boston, MA, United States
| | - Lewis B. Holmes
- Medical Genetics Unit, MassGeneral Hospital for Children, Boston, MA, United States
| | - Jessica M. Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Mary Kowal
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Soko Setoguchi
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Duke University School of Medicine, Durham, NC, United States
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, United States
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Huybrechts KF, Gerhard T, Franklin JM, Levin R, Crystal S, Schneeweiss S. Instrumental variable applications using nursing home prescribing preferences in comparative effectiveness research. Pharmacoepidemiol Drug Saf 2014; 23:830-8. [PMID: 24664805 DOI: 10.1002/pds.3611] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 02/02/2014] [Accepted: 02/17/2014] [Indexed: 11/12/2022]
Abstract
PURPOSE Nursing home residents are of particular interest for comparative effectiveness research given their susceptibility to adverse treatment effects and systematic exclusion from trials. However, the risk of residual confounding because of unmeasured markers of declining health using conventional analytic methods is high. We evaluated the validity of instrumental variable (IV) methods based on nursing home prescribing preference to mitigate such confounding, using psychotropic medications to manage behavioral problems in dementia as a case study. METHODS A cohort using linked data from Medicaid, Medicare, Minimum Data Set, and Online Survey, Certification and Reporting for 2001-2004 was established. Dual-eligible patients ≥65 years who initiated psychotropic medication use after admission were selected. Nursing home prescribing preference was characterized using mixed-effects logistic regression models. The plausibility of IV assumptions was explored, and the association between psychotropic medication class and 180-day mortality was estimated. RESULTS High-prescribing and low-prescribing nursing homes differed by a factor of 2. Each preference-based IV measure described a substantial proportion of variation in psychotropic medication choice (β(IV → treatment): 0.22-0.36). Measured patient characteristics were well balanced across patient groups based on instrument status (52% average reduction in Mahalanobis distance). There was no evidence that instrument status was associated with markers of nursing home quality of care. CONCLUSION Findings indicate that IV analyses using nursing home prescribing preference may be a useful approach in comparative effectiveness studies, and should extend naturally to analyses including untreated comparison groups, which are of great scientific interest but subject to even stronger confounding.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Sternberg SA, Levin R, Dkaidek S, Edelman S, Resnick T, Menczel J. Frailty and osteoporosis in older women--a prospective study. Osteoporos Int 2014; 25:763-8. [PMID: 24002542 DOI: 10.1007/s00198-013-2471-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 07/23/2013] [Indexed: 01/13/2023]
Abstract
UNLABELLED Despite sharing common risk factors and biological pathways, the relationship between frailty and osteoporosis (OP) is not clear. This prospective study has shown that frailty defined by the Vulnerable Elders Survey can predict a decrease in bone mineral density after 1 year. Thus, frail older women should be assessed for osteoporosis. INTRODUCTION Frailty and OP share common risk factors such as age, sarcopenia, lack of physical activity, low body weight, and smoking. Despite shared risk factors and biological pathways, the relationship between frailty and OP is not clear. The purpose of our prospective study was to examine this relationship in a community sample of older women. METHODS A sample of 235 community-dwelling women was assessed for demographic, medical, frailty and OP status at baseline, and after at least 1 year. Frailty was assessed using the Cardiovascular Health study (CHS) frailty phenotype and using the Vulnerable Elders Survey (VES-13). OP was measured using dual photon absorptiometry bone mineral density (BMD). Descriptive statistics and regression models were used. RESULTS At baseline, 235 women with a mean age of 77.6 (SD = 5.4), body mass index (BMI) of 28.3 (SD = 5.2) kg/m(2), and BMD of 0.7 (SD = 0.2) g/cm(2)were assessed. No correlation was found between BMD and the CHS (BMD spine, r = 0.009, p = 0.889; BMD hips, r = 0.050, p = 0.473) or the VES-13 (BMD spine, r = 0.034, p = 0.605; BMD hips, r = -0.042, p = 0.537) frailty scales. One hundred fifty-two (63.9 %) women were assessed after 1 year. In a regression model, women who were frail at baseline (VES-13) were found to have a statistically significantly lower hip and spine BMD at follow-up (controlling for BMI) than women who were non-frail at baseline (p = 0.0393, hip; p = 0.0069, spine). CONCLUSIONS Frailty status as defined by the VES-13 predicts a decrease in BMD after 1 year.
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Choudhry NK, Glynn RJ, Avorn J, Lee JL, Brennan TA, Reisman L, Toscano M, Levin R, Matlin OS, Antman EM, Shrank WH. Untangling the relationship between medication adherence and post-myocardial infarction outcomes: medication adherence and clinical outcomes. Am Heart J 2014; 167:51-58.e5. [PMID: 24332142 DOI: 10.1016/j.ahj.2013.09.014] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients who adhere to medications experience better outcomes than their nonadherent counterparts. However, these observations may be confounded by patient behaviors. The level of adherence necessary for patients to derive benefit and whether adherence to all agents is important for diseases that require multiple drugs remain unclear. This study quantifies the relationship between medication adherence and post-myocardial infarction (MI) adverse coronary events. METHODS This is a secondary analysis of the randomized MI FREEE trial. Patients who received full prescription coverage were classified as adherent (proportion of days covered ≥80%) or not based upon achieved adherence in the 6 months after randomization. First major vascular event or revascularization rates were compared using multivariable Cox models adjusting for comorbidity and health-seeking behavior. RESULTS Compared with patients randomized to usual care, full coverage patients adherent to statin, β-blocker, or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker were significantly less likely to experience the study's primary outcome (hazard ratio [HR] range 0.64-0.81). In contrast, nonadherent patients derived no benefit (HR range 0.98-1.04, P ≤ .01 for the difference in HRs between adherent and nonadherent patients). Partially adherent patients had no reduction in clinical outcomes for any of the drugs evaluated, although their achieved adherence was higher than that among controls. CONCLUSION Achieving high levels of adherence to each and all guideline-recommended post-MI secondary prevention medication is associated with improved event-free survival. Lower levels of adherence appear less protective.
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Kulik A, Desai NR, Shrank WH, Antman EM, Glynn RJ, Levin R, Reisman L, Brennan T, Choudhry NK. Full prescription coverage versus usual prescription coverage after coronary artery bypass graft surgery: analysis from the post-myocardial infarction free Rx event and economic evaluation (FREEE) randomized trial. Circulation 2013; 128:S219-25. [PMID: 24030410 DOI: 10.1161/circulationaha.112.000337] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [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
BACKGROUND Eliminating out-of-pocket costs for patients after myocardial infarction (MI) improves adherence to preventive therapies and reduces clinical events. Because adherence to medical therapy is low among patients treated with coronary artery bypass graft surgery (CABG), we evaluated the impact of providing full prescription coverage to this patient subgroup. METHODS AND RESULTS The MI Free Rx Event and Economic Evaluation (FREEE) trial randomly assigned 5855 patients with MI to full prescription coverage or usual formulary coverage for all statins, β-blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. We assessed the impact of full prescription coverage on adherence, clinical outcomes, and healthcare costs using adjusted models among the 1052 patients who underwent CABG at the index hospitalization and 4803 who did not. CABG patients were older and had more comorbid illness (P<0.01). After MI, CABG patients were significantly more likely to receive β-blockers and statins but were less likely to receive angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy (P<0.01). Receiving full drug coverage increased rates of adherence to all preventative medications after CABG (all P<0.05). Full coverage was also associated with nonsignificant reductions in the rate of major vascular events or revascularization for patients treated with CABG (hazard ratio, 0.91; 95% confidence interval, 0.66-1.25) or without CABG (hazard ratio, 0.93; 95% confidence interval, 0.82-1.06), with no interaction noted (Pint=NS). After CABG, full prescription coverage significantly reduced patient out-of-pocket spending for drugs (P=0.001) without increasing overall health expenditures (P=NS). CONCLUSIONS Eliminating drug copayments after MI provides consistent benefits to patients treated with or without CABG, leading to increased medication adherence, trends toward improved clinical outcomes, and reduced patient out-of-pocket expenses.
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Affiliation(s)
- Alexander Kulik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.K., N.R.D., W.H.S., E.M.A., R.J.G., R.L., N.K.C.); Lynn Heart and Vascular Institute, Boca Raton Regional Hospital, Boca Raton, FL (A.K.); Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL (A.K.); Aetna, Hartford, CT (L.R.); and CVS Caremark, Woonsocket, RI (T.B.)
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Rybachuk O, Levin R, Кyryk V, Susarova D, Tsupykov O, Smozhanik E, Butenko G, Skibo G, Troshin P, Pivneva T. Effect of a water soluble derivative of fullerene C60 on the features neural progenitor cells in vitro. ACTA ACUST UNITED AC 2013. [DOI: 10.22494/cot.v1i1.49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
We studied the effect of a water soluble derivative of fullerene C60 on the behavior of cultured neural stem/progenitor cells. Addition of 20 nM of metal fullerenolate C60 (NaFL) into the cell culture increased the population of the cells almost twice in comparison with the control and also suppressed the formation of neurospheres. The obtained data allow us to suggest that NaFL has a positive effect on the proliferative activity of neural progenitors. The water-soluble fullerene nanostructures such as NaFL promoting the proliferation of neural stem cells might have numerous beneficent applications in cell biology and biotechnology.
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Cheung WY, Levin R, Setoguchi S. Appropriateness of cardiovascular care in elderly adult cancer survivors. Med Oncol 2013; 30:561. [DOI: 10.1007/s12032-013-0561-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 03/26/2013] [Indexed: 11/30/2022]
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