Predictors of Pancreatitis Among Patients with Inflammatory Bowel Disease Treated with Vedolizumab: Observation from a Large Global Safety Database

BACKGROUND

Patients with inflammatory bowel diseases (IBDs) are at increased risk of pancreatitis. Data from a global safety database (GSD) were queried to identify risk factors for pancreatitis in vedolizumab-treated patients with IBD.

METHODS

Takeda's GSD was retrospectively queried for case reports (CRs) of adverse events (AEs) following vedolizumab treatment, from licensure (May 20, 2014) through March 31, 2021. Unsolicited and solicited CRs of pancreatitis were coded using the Medical Dictionary for Regulatory Activities (MedDRA) High-Level Term "Acute and chronic pancreatitis." To examine factors associated with severe pancreatitis, serious CRs (serious AEs [SAEs]) were compared with SAEs from a comparator group of 600 random non-pancreatitis AEs. Comparisons were performed using t, χ2, and Fisher's exact tests. Logistic regression was performed to adjust for covariates allowing backward selection.

RESULTS

In total, 196 patients reported pancreatitis in > 700,000 patient-years of vedolizumab exposure. Pancreatitis was serious in 195 patients (99.5%), and non-pancreatitis AEs were serious in 195 of 600 (32.5%) in the random comparator group. In the pancreatitis group, 17 patients (8.7%) had a known history of pancreatitis versus none in the random comparator group. Younger age, vedolizumab indication of ulcerative colitis, concomitant medications (with a risk for pancreatitis), pancreatitis history, and comorbid conditions (especially ongoing pancreatitis) were associated with development of severe pancreatitis.

CONCLUSIONS

These analyses identified factors associated with pancreatitis SAEs in patients with IBD treated with vedolizumab, but do not suggest an increased risk of pancreatitis with vedolizumab. These findings will help inform which patients treated for IBD might have an elevated risk, regardless of treatment.

Design of a phase 3, randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of prucalopride in pediatric patients with functional constipation

Background

A previous phase 3 trial of prucalopride in pediatric patients (6 months-18 years old) with functional constipation (FC) demonstrated no efficacy versus placebo. We designed an additional phase 3 trial to further assess the efficacy, long-term safety and tolerability of prucalopride in children and adolescents.

Methods

This multicenter trial (ClinicalTrials.gov identifier: NCT04759833; EudraCT number: 2022-003221-22) comprises a 12-week, randomized, double-blind, placebo-controlled phase, followed by a 36-week, double-blind, safety extension phase. Approximately 240 toilet-trained patients aged 3-17 years will be randomized 1:1:1 to receive low- (0.04 mg/kg) or high-dose (0.08 mg/kg) prucalopride, or placebo once daily. Fifteen non-toilet-trained patients ≥6 months old with FC will be included in an exploratory efficacy and safety analysis.

Discussion

The efficacy endpoints used in this study will differ from those used in adults and in the previous pediatric phase 3 trial; they have been adapted to be more suitable for a wider age range of pediatric patients. Both study phases will be longer than in the previous pediatric study, providing a longer time period in which to assess the efficacy and safety of prucalopride. Study participants will be identified using the modified Rome IV criteria for FC, instead of the Rome III criteria, and non-toilet-trained patients will be included, which will broaden the population of pediatric patients assessed. Patients will undergo fecal disimpaction before randomization and undergo standardized continuous behavioral therapy throughout the trial. This pediatric study of prucalopride will aim to demonstrate the efficacy and long-term safety of this treatment.

The Association of Oral Stimulant Medication Adherence with Work Productivity among Adults with ADHD

OBJECTIVE

Examine associations between oral psychostimulant pharmacotherapy adherence, work productivity, and related indirect costs among US adults with ADHD.

METHODS

Medication adherence (Medication Adherence Reasons Scale [MAR-Scale]), work productivity and activity impairment (Work Productivity and Activity Impairment-General Health questionnaire), and ADHD symptom level (Adult ADHD Self-Report Scale version 1.1 Symptom Checklist) were assessed in this noninterventional online survey of adults who self-reported having an ADHD diagnosis and were currently receiving oral psychostimulant treatment for ≥3 months.

RESULTS

Of 602 respondents, 395 had low/medium adherence (LMA: MAR-Scale total score ≥1) and 207 had high adherence (HA: MAR-Scale total score 0). After adjusting for covariates, the LMA group had significantly greater levels of absenteeism, absenteeism-related indirect costs, and total indirect costs (all p < .01) than the HA group.

CONCLUSION

In adults with ADHD using oral psychostimulants, lower medication adherence was associated with greater absenteeism and indirect costs.

Epidemiology of status epilepticus in the United States: A systematic review

OBJECTIVES

Convulsive status epilepticus (CSE) is a life-threatening neurologic emergency, which is defined by the International League Against Epilepsy (ILAE) as bilateral tonic-clonic seizure activity lasting longer than 5 min, while absence status epilepticus (SE) and focal SE are specified as exceeding 10 min. Epidemiological evidence on SE is currently lacking, and the incidence is not well-known, especially in light of changes in the ILAE criteria for SE. The objectives of this systematic literature review were to describe the epidemiology of SE in the US population and the associated burden of illness.

METHODS

A systematic review, including literature and pragmatic searches, was conducted. Literature searches were performed using MEDLINE, Embase, BIOSIS, and Web of Science electronic databases from inception to February 2019. Pragmatic searches of the gray literature were carried out using Google, Google Scholar, conference proceedings, and ClinicalTrials.gov to identify additional sources. Only US-based studies or multinational studies reporting US data of interest were included.

RESULTS

In total, 69 sources were identified. The incidence of all SE in patients of all ages in the USA ranged from 18.3 to 41 per 100,000 people per year. Incidence of all-age CSE rose from 3.5 (1979) to 12.5 (2010) per 100,000 people per year. Status epilepticus incidence followed a bimodal (U-shaped) distribution, with the highest estimates in the first years of life (0-4 years) and after 60 years. Mortality associated with SE varied from 21% over 30 days to 31.2% over 10 years. For CSE, two studies reported similar in-hospital mortalities (9.2% and 10.7%). Median healthcare costs related to SE admission were approximately US$14,500 per adult (17-45 years) and US$8000 per child (0-16 years).

CONCLUSIONS

There is a lack of recent data on the epidemiology and healthcare burden associated with SE. Reports of SE incidence in the USA are highly variable and predate the 2015 ILAE definition of SE. However, the available data suggest a high burden of illness.

Burden of disease in patients with a history of status epilepticus and their caregivers

OBJECTIVE

Status epilepticus (SE) is a life-threatening neurological emergency with the potential for wide-ranging impact on patients and caregivers. In this study, the burden of disease in patients with a history of SE and their caregivers was assessed.

METHODS

Adult patients as well as caregivers of children, adolescents, and adults who had experienced ≥1 SE event in the past 24 months completed an online survey. Functional, social, emotional, and economic burden in patients and caregivers was assessed. Burden was measured through concept-targeted questionnaires, including the US Centers for Disease Control and Prevention (CDC) Health-Related Quality of Life 4 (HRQoL-4) and the Work Productivity and Activity Impairment (WPAI) instruments.

RESULTS

The 198 respondents comprised 49 adult patients, 51 caregivers of children, 47 caregivers of adolescents, and 51 caregivers of adults. Most patients (93.9%) were diagnosed with epilepsy. Patients' daily activities were highly affected, and many respondents reported a substantial long-term physical and mental impact on patients. The mean CDC HRQoL-4 score for unhealthy days per month ranged from 11.1 for caregivers of adults to 16.9 for caregivers of children. WPAI scores demonstrated a substantial impact on the ability of adult patients and all caregivers to work. Among respondents, caregivers of children reported the highest absenteeism from work (20%) and the lowest employment rate (33%). Proportions of caregivers reporting that their daily social life was impacted at least 'some of the time' ranged from 80% to 92%, with nearly half (47%) of caregivers of children responding that their social life was impacted 'all the time'.

CONCLUSIONS

Status epilepticus episodes place a high burden on patients and caregivers. Notably, the burden appeared high across a variety of domains. This study highlights that the burden of disease is pronounced and wide-reaching and goes beyond the immediate physical and medical impact of an SE episode.

Chronic Constipation in the United States: Results From a Population-Based Survey Assessing Healthcare Seeking and Use of Pharmacotherapy

OBJECTIVES

Chronic idiopathic constipation (CIC) is characterized by unsatisfactory defecation and difficult or infrequent stools. CIC affects 9%-20% of adults in the United States, and although prevalent, gaps in knowledge remain regarding CIC healthcare seeking and medication use in the community. We recruited a population-based sample to determine the prevalence and predictors of (i) individuals having discussed their constipation symptoms with a healthcare provider and (ii) the use of constipation therapies.

METHODS

We recruited a representative sample of Americans aged 18 years or older who had experienced constipation. Those who met the Rome IV criteria for irritable bowel syndrome and opioid-induced constipation were excluded. The survey included questions on constipation severity, healthcare seeking, and the use of constipation medications. We used multivariable regression methods to adjust for confounders.

RESULTS

Overall, 4,702 participants had experienced constipation (24.0% met the Rome IV CIC criteria). Among all respondents with previous constipation, 37.6% discussed their symptoms with a clinician (primary care provider 87.6%, gastroenterologist 26.0%, and urgent care/emergency room physician 7.7%). Age, sex, race/ethnicity, marital status, employment status, having a source of usual care, insurance status, comorbidities, locus of control, and constipation severity were associated with seeking care (P < 0.05). Overall, 47.8% of respondents were taking medication to manage their constipation: over-the-counter medication(s) only, 93.5%; prescription medication(s) only, 1.3%; and both over-the-counter medication(s) and prescription medication(s), 5.2%.

DISCUSSION

We found that 3 of 5 Americans with constipation have never discussed their symptoms with a healthcare provider. Furthermore, the use of prescription medications for managing constipation symptoms is low because individuals mainly rely on over-the-counter therapies.

Suicidal ideation and attempts in the United States of America among stimulant-treated, non-stimulant-treated, and untreated patients with a diagnosis of attention-deficit/hyperactivity disorder

BACKGROUND

Studies of the association between attention-deficit/hyperactivity disorder (ADHD) drug therapy and suicidal ideation and attempts (SIA) have conflicting results.

METHODS

Cohorts of patients with ADHD aged 6 years or older with at least one pharmacy claim for a central nervous system (CNS) stimulant or a non-stimulant, or with no claims for ADHD pharmacotherapy, were identified in the US IBM® MarketScan® Research Database from January 2008 to March 2018. Incidence density rates (IDRs) of SIA (i.e., claims for suicide and self-inflicted poisoning, suicide and self-inflicted injuries, or suicidal ideation) were calculated. Cohorts were compared (CNS stimulants vs non-stimulants; CNS stimulants vs no pharmacotherapy) using hazard ratios (HRs) estimated from Cox proportional hazards models. Inverse-probability-of-treatment weighting (IPTW) was used to control for confounding.

RESULTS

The study included 797,189 patients (CNS stimulants, 622,536; non-stimulants, 54,615; no pharmacotherapy, 120,038). IDRs of SIA (per 1000 patient-years) were: CNS stimulants, 5.8; non-stimulants, 10.5; and no pharmacotherapy, 10.0. The overall SIA risk was significantly lower with CNS stimulants than with non-stimulants (IPTW-adjusted HR = 0.70, 95% confidence interval = 0.61-0.81, p < 0.001) and no pharmacotherapy (0.62, 0.57-0.67, p < 0.001).

LIMITATIONS

SIA assessment was based on diagnostic codes; suicidal ideation may not have been reported; completed suicides were generally not captured; and treatment was not verified.

CONCLUSIONS

In this population-based study of patients with ADHD, SIA risk was significantly lower in those receiving CNS stimulants relative to those receiving non-stimulants or no pharmacotherapy, suggesting that CNS stimulants may attenuate SIA risk.

Eszopiclone treatment for insomnia: effect size comparisons in patients with primary insomnia and insomnia with medical and psychiatric comorbidity

OBJECTIVE

The purpose of this post hoc analysis was to compare the treatment effect size of eszopiclone 3 mg for insomnia in patients with a diagnosis of primary insomnia and in several of the psychiatric and medical conditions that are most commonly comorbid with insomnia.

METHOD

Data were analyzed from 5 large, multicenter, randomized, double-blind, placebo-controlled studies of adult outpatients of at least 1 month duration published between 2006 and 2009. Diary-derived indices of sleep and daytime functioning and the Insomnia Severity Index were compared for patients with primary insomnia (DSM-IV-TR criteria, n = 828) and for those with insomnia comorbid with major depressive disorder (MDD, DSM-IV-TR criteria, n = 545), generalized anxiety disorder (GAD, DSM-IV-TR criteria, n = 595), perimenopause/postmenopause (Stages of Reproductive Aging Workshop criteria, n = 410), and rheumatoid arthritis (American College of Rheumatology criteria, n = 153). Cohen d effect sizes were calculated for each individual study as the between-treatment difference score divided by the pooled standard deviation.

RESULTS

Effect sizes ranged from 0.40 to 0.69 (small-medium) as early as week 1 and were maintained at 0.26-0.63 at week 4 for sleep latency, wake time after sleep onset, and total sleep time. Sleep latency and total sleep time effect sizes increased from week 1 to week 4 in the primary insomnia group. At week 4, effect sizes on all 3 parameters and the Insomnia Severity Index tended to be highest for the primary insomnia patients and tended to be lowest for patients with comorbid GAD and MDD. The effect sizes for daytime functioning were small for all insomnia patient groups.

CONCLUSIONS

Eszopiclone 3 mg is an effective treatment for insomnia across 5 clinically diverse patient populations; however, magnitude of effect is mediated by underlying comorbidity and their treatments, with largest measures of effect seen in primary insomnia and lowest in MDD and GAD. These consistent results, and the fact that clinical trials were conducted in patients being treated as appropriate for their comorbid clinical conditions, support the results' real-world generalizability and utility to clinical practice.

Optimizing the Diagnosis and Treatment of Migraine

PURPOSE

To describe and discuss short headache questionnaires, which can simplify and improve the diagnosis of migraine.

DATA SOURCES

Review of the worldwide scientific literature on short diagnostic questionnaires for migraine.

CONCLUSIONS

A new three-question Headache Screen addressing disability due to recurring headaches, headache duration, and changes in headache characteristics and/or pattern over the previous 6 months displayed high sensitivity when used to survey >3000 migraineurs, correctly identifying 77% of migraineurs diagnosed by International Headache Society (IHS) criteria, clinical impression, or the presence of recurring, disabling headaches.

IMPLICATIONS FOR PRACTICE

The underdiagnosis and undertreatment of migraine are problems that may be attributed to many causes involving both patients and medical providers. These include stringent diagnostic criteria established by the IHS, which fail to easily classify many common migraine presentations, the lack of clear outcome measures of successful management of migraine, and failure to recognize the iatrogenic role of prescription and nonprescription medications as an etiologic factor in chronic daily headache. The recent development of reliable, clinically useful, short headache questionnaires that are focused on headache impact facilitates the understanding and diagnosis of migraine for both patients and healthcare professionals. As a diagnostic tool, the Headache Screen has the potential to expand appropriate medication use, leading to improved functional status and quality of life for migraineurs.

Cyclooxygenase-2 specific inhibitors and upper gastrointestinal tolerability in patients with osteoarthritis receiving concomitant low dose aspirin: pooled analysis of 2 trials

OBJECTIVE

To evaluate the relative gastrointestinal (GI) tolerability of celecoxib and rofecoxib in elderly hypertensive patients with osteoarthritis (OA) with or without coadministration of low dose aspirin (ASA) (< or = 325 mg daily).

METHODS

Two independently conducted, multicenter, double blind, randomized controlled trials designed to evaluate GI tolerability, in addition to cardiorenal study endpoints, in patients randomized to celecoxib 200 mg once daily (qd; n = 960) or rofecoxib 25 mg qd (n = 942) were analyzed. GI tolerability was assessed using investigator-reported GI symptoms, prespecified as abdominal pain, dyspepsia, and nausea. The pooled incidences of the 3 reported GI symptoms, regardless of severity (mild and moderate to severe), and the incidences of mild or moderate to severe GI symptoms individually were evaluated.

RESULTS

In the pooled population, the incidence of the 3 GI symptoms, regardless of severity, was not significantly different for patients receiving celecoxib or rofecoxib. In contrast, the aggregate incidence of moderate to severe GI symptoms for patients receiving rofecoxib (5.2%) was significantly greater than for those receiving celecoxib (3.2%; p < 0.05). Notably, the significant difference between the 2 arms was more pronounced in the population of patients receiving concomitant low dose ASA (rofecoxib 9.7% vs celecoxib 1.5%; p < 0.001). The incidence of moderate to severe GI symptoms was similar with rofecoxib (3.3%) and celecoxib (3.9%; p = 0.564) treatment in patients who did not receive low dose ASA.

CONCLUSION

While the GI tolerability was similar in the 2 arms of the entire pooled population, celecoxib 200 mg qd was associated with a significantly lower incidence of moderate to severe GI symptoms than rofecoxib 25 mg qd in patients receiving concomitant low dose ASA.

Simple and Efficient Recognition of Migraine With 3-Question Headache Screen

OBJECTIVE

To correlate the results of a new 3-question headache screen to 3 established methods of diagnosing migraine: the International Headache Society diagnostic criteria, physician's clinical impression, and presence of recurring disabling headaches.

BACKGROUND

A simple tool to recognize patients who experience migraine may facilitate diagnosis of this debilitating and frequently undiagnosed condition.

METHODS

Primary care physicians and neurologists in the United States enrolled 3014 adults with a diagnosis of migraine based on one of the following: International Headache Society criteria, an investigator's clinical impression, or presence of recurring disabling headaches. Each patient completed a 3-question headache screen: (1) Do you have recurrent headaches that interfere with work, family, or social functions? (2) Do your headaches last at least 4 hours? (3) Have you had new or different headaches in the past 6 months? A diagnosis of migraine was suggested by a yes answer to questions 1 and 2 and a no answer to question 3.

RESULTS

The 3-question headache screen identified migraine in 77% of the study population; including 78% of the patients enrolled based on International Headache Society criteria, 74% based on clinical impression, and 68% because of recurring disabling headaches.

CONCLUSIONS

Positive 3-question headache screen results agreed well with migraine diagnoses based on International Headache Society criteria, clinical impressions, and presence of recurring disabling headaches. These findings support use of the 3-question headache screen to recognize migraine.

Length of hospital stay and cost of Staphylococcus and Streptococcus infections among hospitalized patients

BACKGROUND

Staphylococcus (Staph) and Streptococcus (Strep) infections are important causes of morbidity and mortality worldwide. The economic burden of these infections is also significant, especially among hospitalized patients.

OBJECTIVE

The aim of this study was to estimate length of hospital stay (LOS) and total payments for hospital admissions for patients with Staph or Strep infection as a first (primary) or second or higher (comorbid) diagnosis.

METHODS

From the 1994-1997 MarketScan inpatient database, admissions with Staph (n = 2,042) or Strep (n = 1,401) infection (905 as primary and 2,538 as comorbid diagnosis) and 89,899 control admissions without a diagnosis of gram-positive infection were identified. Crude and category-specific mean LOS and anti-log mean total payments were compared between admissions with Staph or Strep infection and admissions without a diagnosis of any gram-positive infection within major diagnostic categories and principal surgical procedures (SPs).

RESULTS

For admissions with Staph or Strep infection as first (primary) diagnosis (n = 905), the mean LOS was 4.68 days (95% CI, 4.44-4.93) and 4.78 days (95% CI, 4.35-5.26), respectively. The mean total payments were $6,445 (95% CI, $6,045-$6,870) and $6,821 (95% CI, $6,149-$7,566), respectively. In contrast, the average LOS and total payment for the control group were 2.99 days (95% CI, 2.98-3.01) and $6,325 (95% CI, $6,284-$6,365). For admissions with infection as the comorbid diagnosis (n = 2,538), mean LOS and total payment were 4 days longer and $6,000 higher for Staph infections and 1.2 days longer and $1,200 higher for Strep infections than the control group. Within each SP, LOS and total payments were substantially higher for patients with Staph and Strep infections.

CONCLUSIONS

The results of this study indicate that infections with the pathogens Staph and Strep substantially increase LOS and total payments among hospitalized patients.