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Parab AZ, Kong A, Lee TA, Kim K, Nutescu EA, Malecki KC, Hoskins KF, Calip GS. Socioecologic Factors and Racial Differences in Breast Cancer Multigene Prognostic Scores in US Women. JAMA Netw Open 2024; 7:e244862. [PMID: 38568689 PMCID: PMC10993076 DOI: 10.1001/jamanetworkopen.2024.4862] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/06/2024] [Indexed: 04/05/2024] Open
Abstract
Importance Disproportionately aggressive tumor biology among non-Hispanic Black women with early-stage, estrogen receptor (ER)-positive breast cancer contributes to racial disparities in breast cancer mortality. It is unclear whether socioecologic factors underlie racial differences in breast tumor biology. Objective To examine individual-level (insurance status) and contextual (area-level socioeconomic position and rural or urban residence) factors as possible mediators of racial and ethnic differences in the prevalence of ER-positive breast tumors with aggressive biology, as indicated by a high-risk gene expression profile. Design, Setting, and Participants This retrospective cohort study included women 18 years or older diagnosed with stage I to II, ER-positive breast cancer between January 1, 2007, and December 31, 2015. All data analyses were conducted between December 2022 and April 2023. Main Outcomes and Measures The primary outcome was the likelihood of a high-risk recurrence score (RS) (≥26) on the Oncotype DX 21-gene breast tumor prognostic genomic biomarker. Results Among 69 139 women (mean [SD] age, 57.7 [10.5] years; 6310 Hispanic [9.1%], 274 non-Hispanic American Indian and Alaskan Native [0.4%], 6017 non-Hispanic Asian and Pacific Islander [8.7%], 5380 non-Hispanic Black [7.8%], and 51 158 non-Hispanic White [74.0%]) included in our analysis, non-Hispanic Black (odds ratio [OR], 1.33; 95% CI, 1.23-1.43) and non-Hispanic American Indian and Alaska Native women (OR, 1.38; 95% CI, 1.01-1.86) had greater likelihood of a high-risk RS compared with non-Hispanic White women. There were no significant differences among other racial and ethnic groups. Compared with non-Hispanic White patients, there were greater odds of a high-risk RS for non-Hispanic Black women residing in urban areas (OR, 1.35; 95% CI, 1.24-1.46), but not among rural residents (OR, 1.05; 95% CI, 0.77-1.41). Mediation analysis demonstrated that lack of insurance, county-level disadvantage, and urban vs rural residence partially explained the greater odds of a high-risk RS among non-Hispanic Black women (proportion mediated, 17%; P < .001). Conclusions and Relevance The findings of this cohort study suggest that the consequences of structural racism extend beyond inequities in health care to drive disparities in breast cancer outcome. Additional research is needed with more comprehensive social and environmental measures to better understand the influence of social determinants on aggressive ER-positive tumor biology among racial and ethnic minoritized women from disadvantaged and historically marginalized communities.
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Affiliation(s)
- Ashwini Z. Parab
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago
| | - Angela Kong
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago
| | - Todd A. Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago
| | - Kibum Kim
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago
| | - Edith A. Nutescu
- Department of Pharmacy Practice, University of Illinois, Chicago
- Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois, Chicago
| | - Kristen C. Malecki
- School of Public Health, University of Illinois, Chicago
- University of Illinois Cancer Center, Chicago
| | - Kent F. Hoskins
- University of Illinois Cancer Center, Chicago
- Division of Hematology and Oncology, University of Illinois College of Medicine, Chicago
| | - Gregory S. Calip
- Titus Family Department of Clinical Pharmacy, University of Southern California, Los Angeles
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Alobaidi A, Yan CH, Kopfman M, Naveed M, Sharp LK, Nutescu EA. The Relationship Between Signature Time and Functional Health Literacy: Results from a Prospective Study of an Urban Low-Income Population Receiving Long-Term Anticoagulation. Adv Ther 2023; 40:3926-3936. [PMID: 37389731 PMCID: PMC10427553 DOI: 10.1007/s12325-023-02556-4] [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: 03/02/2023] [Accepted: 05/16/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Low health literacy (HL) is consistently associated with worse health outcomes. Routine clinical screening with available instruments is impractical because of added time and effort. Prior findings suggested that signature time may be a reliable alternative measure of HL among general medicine patients. METHODS Our aim was to assess the screening performance of signature time and explore optimal thresholds for identifying patients with limited HL in a chronically anticoagulated population. English-speaking patients receiving long-term anticoagulation therapy were recruited. HL was assessed using the Short Test of Functional Health Literacy in Adults (STOFHLA). Signature time was measured using a stopwatch. Logistic regression models and receiver-operating characteristic (ROC) curves were used to evaluate the association and accuracy of signature time compared to HL, respectively. RESULTS Of 139 enrolled patients, mean age was 60.1 years, 70.5% were African-American, 48.9% reported < $25,000 income, and 27.3% had marginal or inadequate HL. Overall, median time to sign was 6.1 s. Signature time was longest with inadequate HL (median 9.5 s) compared to adequate HL (5.7 s; p < 0.01). Longer signature time was significantly associated with lower HL after adjusting for age and education (aOR 0.77, 95% CI: 0.68-0.88, p < 0.01). Signature time demonstrated high accuracy (area under the curve [AUC] > 0.8) in identifying HL levels. Thresholds of 5.1 s and 9.0 s showed appropriate screening performance in distinguishing patients with adequate vs. marginal and marginal vs. inadequate HL, respectively. CONCLUSION Signature time demonstrated strong screening performance and may offer a quick and practical approach to assessing HL among patients receiving long-term anticoagulation management.
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Affiliation(s)
- Ali Alobaidi
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, 833 S. Wood St., Chicago, IL, 60612, USA.
| | - Connie H Yan
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, 833 S. Wood St., Chicago, IL, 60612, USA
| | - Miranda Kopfman
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, 833 S. Wood St., Chicago, IL, 60612, USA
| | - Maryam Naveed
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, 833 S. Wood St., Chicago, IL, 60612, USA
| | - Lisa K Sharp
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, 833 S. Wood St., Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A Nutescu
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, 833 S. Wood St., Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
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Kim K, Duarte JD, Galanter WL, Han J, Lee JC, Cavallari LH, Nutescu EA. Pharmacist-guided pharmacogenetic service lowered warfarin-related hospitalizations. Pharmacogenomics 2023; 24:303-314. [PMID: 37166395 DOI: 10.2217/pgs-2023-0014] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
Background: The authors aimed to assess outcomes with a pharmacogenetic (PGx)-informed, pharmacist-guided, personalized consult service for warfarin dosing. Methods: This retrospective cohort study included patients admitted with thromboembolic events. Eligible subjects received either PGx-informed (n = 389) or historical non-PGx pharmacist-guided warfarin dosing (Hx; n = 308) before hospital discharge. The composite of admission with bleeding or thromboembolic events over 90 days after the discharge was compared between the PGx and Hx groups. Results: The rate ratio (95% CI) of the composite of bleeding or thromboembolic admissions for PGx versus Hx was 0.32 (0.12-0.82). The estimated hazard ratio was 0.43 (0.16-1.12). Conclusion: A PGx-informed warfarin dosing service was associated with decreased bleeding and thromboembolic encounters.
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Affiliation(s)
- Kibum Kim
- Department of Pharmacy Systems, Outcomes & Policy, University of Illinois Chicago, 833 S Wood St, Chicago, IL 60612, USA
- Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois Chicago, 833 S Wood St, Chicago, IL 60612, USA
| | - Julio D Duarte
- Department of Pharmacotherapy & Translational Research & Center for Pharmacogenomics & Precision Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - William L Galanter
- Department of Medicine, University of Illinois Chicago, 840 S Wood St, Chicago, IL 60612, USA
| | - Jin Han
- Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois Chicago, 833 S Wood St, Chicago, IL 60612, USA
- Department of Pharmacy Practice, University of Illinois Chicago, 833 Wood St, Chicago, IL 60612, USA
| | - James C Lee
- Department of Pharmacy Practice, University of Illinois Chicago, 833 Wood St, Chicago, IL 60612, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy & Translational Research & Center for Pharmacogenomics & Precision Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Edith A Nutescu
- Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois Chicago, 833 S Wood St, Chicago, IL 60612, USA
- Department of Pharmacy Practice, University of Illinois Chicago, 833 Wood St, Chicago, IL 60612, USA
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Chen T, O'Donnell PH, Middlestadt M, Ruhnke GW, Danahey K, van Wijk XMR, Choksi A, Knoebel R, Hartman S, Yeo KTJ, Friedman PN, Ratain MJ, Nutescu EA, O'Leary KJ, Perera MA, Meltzer DO. Implementation of pharmacogenomics into inpatient general medicine. Pharmacogenet Genomics 2023; 33:19-23. [PMID: 36729768 DOI: 10.1097/fpc.0000000000000487] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pharmacogenomics is a crucial piece of personalized medicine. Preemptive pharmacogenomic testing is only used sparsely in the inpatient setting and there are few models to date for fostering the adoption of pharmacogenomic treatment in the inpatient setting. We created a multi-institutional project in Chicago to enable the translation of pharmacogenomics into inpatient practice. We are reporting our implementation process and barriers we encountered with solutions. This study, 'Implementation of Point-of-Care Pharmacogenomic Decision Support Accounting for Minority Disparities', sought to implement pharmacogenomics into inpatient practice at three sites: The University of Chicago, Northwestern Memorial Hospital, and the University of Illinois at Chicago. This study involved enrolling African American adult patients for preemptive genotyping across a panel of actionable germline variants predicting drug response or toxicity risk. We report our approach to implementation and the barriers we encountered engaging hospitalists and general medical providers in the inpatient pharmacogenomic intervention. Our strategies included: a streamlined delivery system for pharmacogenomic information, attendance at hospital medicine section meetings, use of physician and pharmacist champions, focus on hospitalists' care and optimizing system function to fit their workflow, hand-offs, and dealing with hospitalists turnover. Our work provides insights into strategies for the initial engagement of inpatient general medicine providers that we hope will benefit other institutions seeking to implement pharmacogenomics in the inpatient setting.
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Affiliation(s)
- Thomas Chen
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Peter H O'Donnell
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA
| | - Gregory W Ruhnke
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA
| | | | - Anish Choksi
- Department of Pharmacy, The University of Chicago, Chicago, Illinois, USA
| | - Randall Knoebel
- Department of Pharmacy, The University of Chicago, Chicago, Illinois, USA
| | - Seth Hartman
- Department of Pharmacy, The University of Chicago, Chicago, Illinois, USA
| | | | - Paula N Friedman
- Department of Pharmacology, Northwestern University, Chicago, Illinois, USA
| | - Mark J Ratain
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kevin J O'Leary
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Minoli A Perera
- Department of Pharmacology, Northwestern University, Chicago, Illinois, USA
| | - David O Meltzer
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
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5
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Yang G, Alarcon C, Friedman P, Gong L, Klein T, O’Brien T, Nutescu EA, Tuck M, Meltzer D, Perera MA. The Role of Global and Local Ancestry on Clopidogrel Response in African Americans. Pac Symp Biocomput 2023; 28:221-232. [PMID: 36540979 PMCID: PMC9782753] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pharmacogenomics has long lacked dedicated studies in African Americans, resulting in a lack of indepth data in this populations. The ACCOuNT consortium has collected a cohort of 167 African American patients on steady state clopidogrel with the goal of discovering population specific variation that may contribute to the response of this anti-platelet agent. Here we analyze the role of both global and local ancestry on the clinical phenotypes of P2Y12 reaction units (PRU) and high on-treatment platelet reactivity (HTPR) in this cohort. We found that local ancestry at the TSS of three genes, IRS-1, ABCB1 and KDR were nominally associated with PRU, and local ancestry-adjusted SNP association identified variants in ITGA2 associated to increased PRU. These finding help to explain the variability in drug response seen in African Americans, especially as few studies on genes outside of CYP2C19 has been conducted in this population.
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Affiliation(s)
- Guang Yang
- Department of Pharmacology, Center for Pharmacogenomics, Feinherg School of Medicine, Northwestern University, Chicago, IL
| | - Cristina Alarcon
- Department of Pharmacology, Center for Pharmacogenomics, Feinherg School of Medicine, Northwestern University, Chicago, IL
| | - Paula Friedman
- Department of Pharmacology, Center for Pharmacogenomics, Feinherg School of Medicine, Northwestern University, Chicago, IL
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, CA
| | - Teri Klein
- Department of Biomedical Data Science and Department of Medicine, Stanford University, Stanford, CA
| | - Travis O’Brien
- Department of Pharmacology and Physiology, The George Washington University, School of Medicine and Health Sciences, Washington, DC
| | - Edith A. Nutescu
- Department of Pharmacy Practice and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois Chicago, College of Pharmacy, Chicago, IL
| | - Matthew Tuck
- Washington DC VA Medical Center, Washington, DC and The George Washington University, Washington, DC
| | - David Meltzer
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Minoli A Perera
- Department of Pharmacology, Center for Pharmacogenomics, Feinherg School of Medicine, Northwestern University, Chicago, IL
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6
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Deng H, Nutescu EA, DiDomenico RJ. Reversal of Oral Anticoagulants: A Survey of Contemporary Practice Trends (ReACT). Clin Appl Thromb Hemost 2023; 29:10760296231176808. [PMID: 37272034 PMCID: PMC10259145 DOI: 10.1177/10760296231176808] [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: 03/06/2023] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 06/06/2023] Open
Abstract
This study evaluated practice patterns and factors influencing treatment decisions regarding urgent or emergent reversal of oral anticoagulants (OACs). A 30-question survey was electronically distributed to anticoagulation members of the Anticoagulation Forum. Questions were designed to capture practice trends in the reversal of warfarin, factor Xa inhibitors, and factor IIa inhibitors. Continuous and categorical data were analyzed to generate descriptive statistics. Open-ended questions were summarized by thematic categories. 173 responses were collected most from US-based pharmacists with direct patient care responsibilities. The majority of the respondents' institutions (90.2%) utilized a guideline or protocol for OACs reversal. Vitamin K (91.3%), activated charcoal (80.4%), and fresh frozen plasma (72.8%) were the most common reversal agents on formulary without restrictions. Most institutions (87.0%) reported having 4-factor prothrombin complex concentrate (4F-PCC) and idarucizumab on formulary, but most commonly (52.2%) with restrictions. Andexanet alfa was only reported on formulary at 35.9% of institutions. In contrast to current guideline recommendations, vitamin K (98.8%) was preferred over 4F-PCC and 4F-PCC (71.6%) was preferred over andexanet alfa as first-line agents used to reverse warfarin and factor Xa inhibitors, respectively. Weight-based dosing strategies for 4F-PCC were commonly utilized for different reversals (41.2%-59.4%). Cost, efficacy, and safety of 4F-PCC were identified as top facilitators and barriers for 4F-PCC adoption in practice. Our findings revealed that guideline recommendations for reversal of warfarin and factor Xa and IIa inhibitors are not followed by a majority of institutions. Studies are needed to investigate strategies to overcome barriers for implementing and following guideline recommendations.
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Affiliation(s)
- Huiwen Deng
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago, Chicago, IL, USA
| | - Edith A. Nutescu
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL, USA
- Center for Pharmacoeconomic & Pharmacoepidemiology Research, University of Illinois Chicago, Chicago, IL, USA
| | - Robert J. DiDomenico
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL, USA
- Center for Pharmacoeconomic & Pharmacoepidemiology Research, University of Illinois Chicago, Chicago, IL, USA
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7
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Leonard CE, Brensinger CM, Bilker WB, Soprano SE, Dhopeshwarkar N, Hecht TEH, Kasner SE, Nutescu EA, Holbrook A, Carr M, Ashcroft DM, Chen C, Hennessy S. Thromboembolic Events in Users of Warfarin Treated with Different Skeletal Muscle Relaxants. Medicina (Kaunas) 2022; 58:medicina58091171. [PMID: 36143848 PMCID: PMC9501796 DOI: 10.3390/medicina58091171] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Warfarin and a skeletal muscle relaxant are co-treatments in nearly a quarter-million annual United States (US) office visits. Despite international calls to minimize patient harm arising from anticoagulant drug interactions, scant data exist on clinical outcomes in real-world populations. We examined effects of concomitant use of warfarin and individual muscle relaxants on rates of hospitalization for thromboembolism among economically disadvantaged persons. Materials and Methods: Using 1999−2012 administrative data of four US state Medicaid programs, we conducted 16 retrospective self-controlled case series studies: half included concomitant users of warfarin + one of eight muscle relaxants; half included concomitant users of an inhaled corticosteroid (ICS) + one of eight muscle relaxants. The ICS analyses served as negative control comparisons. In each study, we calculated incidence rate ratios (IRRs) comparing thromboembolism rates in the co-exposed versus warfarin/ICS-only exposed person-time, adjusting for time-varying confounders. Results: Among ~70 million persons, we identified 8693 warfarin-treated subjects who concomitantly used a muscle relaxant, were hospitalized for thromboembolism, and met all other inclusion criteria. Time-varying confounder-adjusted IRRs ranged from 0.31 (95% confidence interval: 0.13−0.77) for metaxalone to 3.44 (95% confidence interval: 1.53−7.78) for tizanidine. The tizanidine finding was robust after quantitatively adjusting for negative control ICS findings, and in numerous prespecified secondary analyses. Conclusions: We identified a potential >3-fold increase in the rate of hospitalized thromboembolism in concomitant users of warfarin + tizanidine vs. warfarin alone. Alternative explanations for this finding include confounding by indication, a native effect of tizanidine, or chance.
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Affiliation(s)
- Charles E. Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Correspondence: ; Tel.: +1-215-573-2663; Fax: +1-215-573-5315
| | - Colleen M. Brensinger
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Warren B. Bilker
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Neuropsychiatry Section, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Samantha E. Soprano
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Neil Dhopeshwarkar
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Todd E. H. Hecht
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Scott E. Kasner
- Division of Vascular Neurology, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edith A. Nutescu
- Department of Pharmacy Practice and Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Matthew Carr
- Center for Pharmacoepidemiology and Drug Safety, Division of Pharmacy & Optometry, School of Health Sciences, University of Manchester, Manchester M13, UK
| | - Darren M. Ashcroft
- Center for Pharmacoepidemiology and Drug Safety, Division of Pharmacy & Optometry, School of Health Sciences, University of Manchester, Manchester M13, UK
| | - Cheng Chen
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sean Hennessy
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Thomas A, Fang MC, Kogan S, Hubbard CC, Friedman PN, Gong L, Klein TE, Nutescu EA, O’Brien TJ, Tuck M, Perera MA, Schwartz JB. Apixaban Concentrations in Routine Clinical Care of Older Adults With Nonvalvular Atrial Fibrillation. JACC Adv 2022; 1:100039. [PMID: 37961076 PMCID: PMC10643025 DOI: 10.1016/j.jacadv.2022.100039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Direct-acting oral anticoagulants are first-line agents for prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF), but data are limited for the oldest patients, and with reduced dosing. OBJECTIVES To determine steady-state apixaban peak and trough concentrations during routine care of older adults with NVAF, compare concentrations to clinical trial concentrations, and explore factors associated with concentrations. METHODS A cross-sectional study of medically stable older adults with NVAF (≥75 years or ≥70 years if Black) receiving apixaban. Peak (2-4.4 hours post-dose) and trough (before next dose) concentrations were determined by anti-Xa activity calibrated chromogenic assay. Patient characteristics associated with concentrations were determined by multivariate modeling. RESULTS The median age of patients (n = 115) was 80 (interquartile range: 77-84) years. The cohort comprised 46 women and 69 men; of which 98 are White, 11 Black, and 6 Asian. With 5 mg twice daily per labelling (n = 88), peak concentrations were higher in women: 248 ± 105 vs 174 ± 67 ng/mL in men (P < 0.001) and exceeded expected 95% range in 6 of 30 vs 0 of 55 men (P = 0.002). With 2.5 mg twice daily per label (n = 11), concentrations were <5 mg twice daily (peak: 136 ± 87 vs 201 ± 90 ng/mL, P = 0.026; trough: 65 ± 28 vs 109 ± 56 ng/mL, P < 0.001), but not different than 2.5 mg twice daily without reduction criteria (n = 13; peak: 132 ± 88; trough: 65 ± 31 ng/mL). Covariates associated with concentrations included sex, number of daily medications, and creatinine clearance. CONCLUSIONS Older women had higher than expected peak apixaban concentrations, and 2.5 mg twice daily produced lower concentrations than standard dosing. Factors not currently included in dosing recommendations affected concentrations. The impact of apixaban concentrations on outcomes needs evaluation.
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Affiliation(s)
- Alveena Thomas
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Margaret C. Fang
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Scott Kogan
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Colin C. Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Paula N. Friedman
- Department of Pharmacology, Center for Pharmacogenomics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Teri E. Klein
- Department of Biomedical Data Science and Department of Medicine, Stanford University, Stanford, California, USA
| | - Edith A. Nutescu
- Department of Pharmacy Practice and Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Travis J. O’Brien
- Department of Pharmacology and Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Matthew Tuck
- Washington DC VA Medical Center, Washington, District of Columbia, USA
- Department of Medicine, The George Washington University, Washington, District of Columbia, USA
| | - Minoli A. Perera
- Department of Pharmacology, Center for Pharmacogenomics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Janice B. Schwartz
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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9
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Zolekar A, Kim K, Lee JC, Han J, Duarte JD, Galanter WL, Cavallari LH, Nutescu EA. Changing from mandatory to optional genotyping results in higher acceptance of pharmacist-guided warfarin dosing. Pharmacogenomics 2022; 23:85-95. [PMID: 35001645 DOI: 10.2217/pgs-2021-0109] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: We evaluated the clinical acceptance and feasibility of a pharmacist-guided personalized consult service following its transition from a mandatory (mPGx) to optional (oPGx) CYP2C9/VKORC1/CYP4F2 genotyping for warfarin. Methods: A total of 1105 patients were included. Clinical acceptance and feasibility outcomes were analyzed using bivariate and multivariable analyses. Results: After transitioning to optional genotyping, genotype testing was still ordered in a large segment of the eligible population (52.1%). Physician acceptance of pharmacist-recommended doses improved from 83.9% (mPGx) to 86.6% (oPGx; OR: 1.3; 95% CI: 1.1-1.5; p = 0.01) with a shorter median genotype result turnaround time (oPGX: 23.6 h vs mPGX: 25.1 h; p < 0.01). Conclusion: Ordering of genotype testing and provider acceptance of dosing recommendations remained high after transitioning to optional genotyping.
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Affiliation(s)
- Ashwini Zolekar
- Department of Pharmacy Systems, Outcomes & Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA
| | - Kibum Kim
- Department of Pharmacy Systems, Outcomes & Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA
| | - James C Lee
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA
| | - Jin Han
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA.,Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Julio D Duarte
- Department of Pharmacotherapy & Translational Research & Center for Pharmacogenomics & Precision Medicine, University of Florida College of Pharmacy, FL 32610, USA
| | - William L Galanter
- Department of Pharmacy Systems, Outcomes & Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA.,Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA.,Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL 60612, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy & Translational Research & Center for Pharmacogenomics & Precision Medicine, University of Florida College of Pharmacy, FL 32610, USA
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA.,Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL 60612, USA
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10
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Saulsberry L, Danahey K, Middlestadt M, O’Leary KJ, Nutescu EA, Chen T, Lee JC, Ruhnke GW, George D, House L, van Wijk XMR, Yeo KTJ, Choksi A, Hartman SW, Knoebel RW, Friedman PN, Rasmussen LV, Ratain MJ, Perera MA, Meltzer DO, O’Donnell PH. Applicability of Pharmacogenomically Guided Medication Treatment during Hospitalization of At-Risk Minority Patients. J Pers Med 2021; 11:1343. [PMID: 34945816 PMCID: PMC8709436 DOI: 10.3390/jpm11121343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/02/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 12/17/2022] Open
Abstract
Known disparities exist in the availability of pharmacogenomic information for minority populations, amplifying uncertainty around clinical utility for these groups. We conducted a multi-site inpatient pharmacogenomic implementation program among self-identified African-Americans (AA; n = 135) with numerous rehospitalizations (n = 341) from 2017 to 2020 (NIH-funded ACCOuNT project/clinicaltrials.gov#NCT03225820). We evaluated the point-of-care availability of patient pharmacogenomic results to healthcare providers via an electronic clinical decision support tool. Among newly added medications during hospitalizations and at discharge, we examined the most frequently utilized medications with associated pharmacogenomic results. The population was predominantly female (61%) with a mean age of 53 years (range 19-86). On average, six medications were newly prescribed during each individual hospital admission. For 48% of all hospitalizations, clinical pharmacogenomic information was applicable to at least one newly prescribed medication. Most results indicated genomic favorability, although nearly 29% of newly prescribed medications indicated increased genomic caution (increase in toxicity risk/suboptimal response). More than one of every five medications prescribed to AA patients at hospital discharge were associated with cautionary pharmacogenomic results (most commonly pantoprazole/suboptimal antacid effect). Notably, high-risk pharmacogenomic results (genomic contraindication) were exceedingly rare. We conclude that the applicability of pharmacogenomic information during hospitalizations for vulnerable populations at-risk for experiencing health disparities is substantial and warrants continued prospective investigation.
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Affiliation(s)
- Loren Saulsberry
- Department of Public Health Sciences, The University of Chicago, Chicago, IL 60637, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Center for Research Informatics, The University of Chicago, Chicago, IL 60637, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
| | - Kevin J. O’Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Edith A. Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, IL 60612, USA;
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois Chicago, Chicago, IL 60612, USA
| | - Thomas Chen
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - James C. Lee
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL 60612, USA;
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - David George
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
| | - Larry House
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
| | - Xander M. R. van Wijk
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Kiang-Teck J. Yeo
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Anish Choksi
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Seth W. Hartman
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Randall W. Knoebel
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Paula N. Friedman
- Center for Pharmacogenomics, Department of Pharmacology, Northwestern University, Chicago, IL 60611, USA; (P.N.F.); (M.A.P.)
| | - Luke V. Rasmussen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Mark J. Ratain
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Minoli A. Perera
- Center for Pharmacogenomics, Department of Pharmacology, Northwestern University, Chicago, IL 60611, USA; (P.N.F.); (M.A.P.)
| | - David O. Meltzer
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - Peter H. O’Donnell
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
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11
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Yan CH, Naveed M, Alobaidi A, Kopfman M, Nutescu EA, Sharp LK, Cannegieter DS. Association between transportation barriers and anticoagulation control among an inner-city, low-income population: A prospective observational cohort study. Res Pract Thromb Haemost 2021; 5:e12605. [PMID: 34755020 PMCID: PMC8558473 DOI: 10.1002/rth2.12605] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 09/09/2021] [Accepted: 09/20/2021] [Indexed: 11/06/2022] Open
Abstract
Background Anticoagulation with warfarin represents a transportation-sensitive treatment state. Transportation barrier is a common reason for not using health care services. Objective To assess the association between transportation barriers to anticoagulation clinic and anticoagulation control (AC) among an inner-city, low-income population. Patients/Methods Adults expected to be on chronic warfarin therapy were recruited from an ambulatory anticoagulation clinic. Participants completed a validated questionnaire that assessed transportation barriers to clinic, defined as self-reported trouble getting transportation to a clinic and a composite score of the presence of transportation barriers. Suboptimal AC was defined as time in therapeutic range (TTR) <60% over 6 months. Prevalence ratios with 95% confidence intervals (CIs), adjusted for age, sex, and annual household income, described the association of transportation trouble and barriers with AC. Results Of 133 participants, 42.9% had suboptimal AC. Mean age was 60.4 (SD, 13.6) years, and the majority of participants were women (62.2%). Participants with transportation trouble were more likely to report being disabled/unable to work (63.6%) and annual household income <$15 000 (45.5%). Mean TTR was significantly lower for participants with transportation trouble compared to those without (53.8% [SD, 24.7%] vs 64.7% [SD, 25.0%]; P = .03). Participants reporting transportation trouble or at least one transportation barrier were 1.60 (95% CI, 1.07-2.39) and 1.68 (95% CI, 1.01-2.80) times more likely, respectively, to have suboptimal AC compared to those without. Conclusion Inner-city, low-income individuals with transportation barriers were more likely to have suboptimal AC. Further research is warranted to evaluate the impact of alleviating patient-specific transportation barriers on anticoagulation outcomes.
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Affiliation(s)
- Connie H Yan
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy University of Illinois at Chicago Chicago IL USA
| | - Maryam Naveed
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy University of Illinois at Chicago Chicago IL USA
| | - Ali Alobaidi
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy University of Illinois at Chicago Chicago IL USA
| | - Miranda Kopfman
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy University of Illinois at Chicago Chicago IL USA
| | - Edith A Nutescu
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy University of Illinois at Chicago Chicago IL USA.,Center for Pharmacoepidemiology & Pharmacoeconomic Research University of Illinois at Chicago Chicago IL USA.,Department of Pharmacy Practice, College of Pharmacy University of Illinois at Chicago Chicago IL USA
| | - Lisa K Sharp
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy University of Illinois at Chicago Chicago IL USA.,Center for Pharmacoepidemiology & Pharmacoeconomic Research University of Illinois at Chicago Chicago IL USA
| | - Dr Suzanne Cannegieter
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy University of Illinois at Chicago Chicago IL USA.,Center for Pharmacoepidemiology & Pharmacoeconomic Research University of Illinois at Chicago Chicago IL USA.,Department of Pharmacy Practice, College of Pharmacy University of Illinois at Chicago Chicago IL USA
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12
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Bussey HI, Nutescu EA, Harper P. Can clinical pharmacists utilize telehealth to double the safety and efficacy of oral anticoagulation while reducing health care costs and improving patient satisfaction in patients with atrial fibrillation? J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Edith A. Nutescu
- Department of Pharmacy Practice, Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy University of Illinois at Chicago Chicago Illinois USA
| | - Paul Harper
- Consultant Hematologist Palmerston North Hospital Palmerston North New Zealand
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13
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Rahman S, Srisuwananukorn A, Molokie RE, Gowhari M, Njoku F, Hussain FA, Lee J, Nutescu EA, Gordeuk VR, Saraf SL, Han J. Evaluation of point-of-care International Normalized Ratio in sickle cell disease. Res Pract Thromb Haemost 2021; 5:e12533. [PMID: 34095734 PMCID: PMC8159702 DOI: 10.1002/rth2.12533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022] Open
Abstract
Background Point‐of‐care (POC) International Normalized Ratio (INR) measurement provides efficient monitoring of warfarin therapy; however, its reliability may be affected in patients with anemia, such as those with sickle cell disease (SCD). Objectives To evaluate the correlation of POC‐INR to clinical laboratory INR (CL‐INR) in SCD and use of a correction factor. Patient/Methods In this retrospective study, the accuracy of POC‐INR compared to CL‐INR was evaluated in a cohort of patients with SCD and in a non‐SCD Black cohort. Results Despite the difference in anemia, the SCD cohort showed a similar percentage of in‐range POC‐INR values as observed in the non‐SCD cohort (37% vs 42%). The SCD cohort was randomly divided to form discovery and validation cohorts. In the discovery cohort, 86% of POC‐INRs were in range when the POC‐INRs were ˂4.0, but only 24% were in range if POC‐INRs were ≥4.0. A linear regression of CL‐INR versus POC‐INR for POC‐INR values ≥4.0 yielded a coefficient of 0.72 (95% confidence interval, 0.69‐0.75); Multiplying POC‐INR by this correction factor, rounded to 0.7 for ease of use in clinical practice, improved the proportion of in‐range POC‐INR values ≥4.0 from 24% to 100% in the SCD discovery cohort and from 19% to 95% in the SCD validation cohort. Similar findings applied to analyses of the non‐SCD cohort. Conclusions POC‐INR and CL‐INR in patients with SCD are similar when POC‐INR is <4.0, and the accuracy of POC‐INR values ≥4.0 can be improved by applying an institution‐specific correction factor.
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Affiliation(s)
- Syeda Rahman
- Department of Pharmacy Practice College of Pharmacy University of Illinois at Chicago Chicago IL USA
| | | | - Robert E Molokie
- Comprehensive Sickle Cell Center Section of Hematology/Oncology Department of Medicine University of Illinois at Chicago Chicago IL USA.,Jesse Brown VA Medical Center Chicago IL USA
| | - Michel Gowhari
- Comprehensive Sickle Cell Center Section of Hematology/Oncology Department of Medicine University of Illinois at Chicago Chicago IL USA
| | - Franklin Njoku
- Comprehensive Sickle Cell Center Section of Hematology/Oncology Department of Medicine University of Illinois at Chicago Chicago IL USA
| | - Faiz Ahmed Hussain
- Comprehensive Sickle Cell Center Section of Hematology/Oncology Department of Medicine University of Illinois at Chicago Chicago IL USA
| | - James Lee
- Department of Pharmacy Practice College of Pharmacy University of Illinois at Chicago Chicago IL USA
| | - Edith A Nutescu
- Department of Pharmacy Practice College of Pharmacy University of Illinois at Chicago Chicago IL USA
| | - Victor R Gordeuk
- Comprehensive Sickle Cell Center Section of Hematology/Oncology Department of Medicine University of Illinois at Chicago Chicago IL USA
| | - Santosh L Saraf
- Comprehensive Sickle Cell Center Section of Hematology/Oncology Department of Medicine University of Illinois at Chicago Chicago IL USA
| | - Jin Han
- Department of Pharmacy Practice College of Pharmacy University of Illinois at Chicago Chicago IL USA.,Comprehensive Sickle Cell Center Section of Hematology/Oncology Department of Medicine University of Illinois at Chicago Chicago IL USA
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14
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Zhou J, Sweiss K, Nutescu EA, Han J, Patel PR, Ko NY, Lee TA, Chiu BCH, Calip GS. Racial Disparities in Intravenous Bisphosphonate Use Among Older Patients With Multiple Myeloma Enrolled in Medicare. JCO Oncol Pract 2021; 17:e294-e312. [PMID: 33449809 PMCID: PMC8257921 DOI: 10.1200/op.20.00479] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/07/2020] [Accepted: 10/13/2020] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Intravenous (IV) bisphosphonates reduce the risk of skeletal-related events in patients with multiple myeloma (MM). However, data describing racial differences in IV bisphosphonate utilization outside of clinical trial settings are limited. We evaluated population-level IV bisphosphonate initiation and discontinuation among patients of age ≥ 65 years with MM. METHODS We conducted a retrospective cohort study of patients of age ≥ 65 years diagnosed with first primary MM between 2001 and 2011. Patients were identified using the SEER-Medicare linked database and followed through December 2013. Cumulative incidences of IV bisphosphonate initiation and time to discontinuation among users were compared between racial and ethnic groups. In Fine and Gray competing risk models, we estimated subdistribution hazard ratios (SHRs) and 95% CIs for initiation and discontinuation. RESULTS We included 14,231 eligible patients with MM (median age, 76 years; 52% male). Over a median follow-up of 23.1 months, 54% of patients received at least one IV bisphosphonate dose. Our final analytical sample included 10,456 non-Hispanic (NH) Whites, 2,267 NH Blacks, 548 Asian and Pacific islanders, and 815 Hispanic and Latino patients. A higher proportion of White patients (56.1%) newly received IV bisphosphonates after MM diagnosis compared with NH Blacks (45.4%). Compared with White patients, NH Black patients were less likely to initiate IV bisphosphonates (SHR, 0.74; 95% CI, 0.70 to 0.79) and slightly more likely to discontinue treatment (SHR, 1.10; 95% CI, 1.01 to 1.19). CONCLUSION Approximately half of the patients with MM of age ≥ 65 years did not receive IV bisphosphonates, with significant delay among racial minority groups. These findings highlight the need for improvement of IV bisphosphonate uptake in patients with MM of age ≥ 65 years.
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Affiliation(s)
- Jifang Zhou
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
- University of Illinois at Chicago, Chicago, IL
| | | | | | - Jin Han
- University of Illinois at Chicago, Chicago, IL
| | | | - Naomi Y. Ko
- Boston University School of Medicine, Boston, MA
| | - Todd A. Lee
- University of Illinois at Chicago, Chicago, IL
| | | | - Gregory S. Calip
- University of Illinois at Chicago, Chicago, IL
- Flatiron Health, New York, NY
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15
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Zhou J, Calip GS, Nutescu EA, Han J, Walton SM, Srisuwananukorn A, Galanter WL. Type 2 diabetes mellitus burdens among adults with sickle cell disease: A 12‐year single health system‐based cohort analysis. eJHaem 2021; 2:94-98. [PMID: 35846078 PMCID: PMC9175929 DOI: 10.1002/jha2.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Jifang Zhou
- School of International Pharmaceutical BusinessChina Pharmaceutical UniversityNanjingChina
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Department of Pharmacy Systems, Outcomes and Policy, College of PharmacyUniversity of Illinois at ChicagoChicagoIllinoisUSA
| | - Gregory S. Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Department of Pharmacy Systems, Outcomes and Policy, College of PharmacyUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Flatiron HealthNew YorkNew YorkUSA
| | - Edith A. Nutescu
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Department of Pharmacy Systems, Outcomes and Policy, College of PharmacyUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Department of Pharmacy Practice, College of PharmacyUniversity of Illinois at ChicagoChicagoIllinoisUSA
| | - Jin Han
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Department of Pharmacy Practice, College of PharmacyUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Division of Hematology & Oncology, Department of Medicine, Comprehensive Sickle Cell CenterUniversity of Illinois at ChicagoChicagoIllinoisUSA
| | - Surrey M. Walton
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Department of Pharmacy Systems, Outcomes and Policy, College of PharmacyUniversity of Illinois at ChicagoChicagoIllinoisUSA
| | - Andrew Srisuwananukorn
- Division of Hematology & Oncology, Department of Medicine, Comprehensive Sickle Cell CenterUniversity of Illinois at ChicagoChicagoIllinoisUSA
| | - William L. Galanter
- Department of Pharmacy Systems, Outcomes and Policy, College of PharmacyUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Section of Academic Internal Medicine & GeriatricsDepartment of MedicineUniversity of Illinois at ChicagoChicagoIllinoisUSA
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16
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Zolekar A, Nabulsi NA, Asfaw AA, Zhou J, Sweiss K, Patel PR, Chiu BCH, Nutescu EA, Calip GS. Abstract 5748: Declines in health-related quality of life among older patients diagnosed with hematologic malignancies. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-5748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The diagnosis of cancer and its treatment have meaningful impacts on health-related quality of life (HRQOL). Although advances in novel therapy and stem cell transplantation have increased survival in patients with hematologic malignancies (HM), less evidence exists on the subsequent impacts of HM on HRQOL. The objective of this study was to evaluate changes in HRQOL following diagnosis of HM in a cohort of older Medicare beneficiaries.
Methods: This was a retrospective study utilizing the Surveillance, Epidemiology and End Results Medicare Health Outcomes Survey Data Resource, a linkage of longitudinal surveys and cancer registry data. We included patients ages ≥65 years diagnosed with first primary leukemia, lymphoma or multiple myeloma between 1998 and 2014 who completed at least one survey within two years pre- and post-diagnosis. HRQOL was measured using the Short Form Health Survey (SF-36) composite scores with a minimum clinically important difference of 2 points. We also measured self-reported general health, depressive symptoms, and the deficit-accumulation frailty index before and after HM diagnosis. Patients with HM were compared to up to four patients without cancer with exact matching on age, sex, race, marital status, smoking status, education, comorbid conditions, proxy response and calendar time of HM diagnosis. Comparisons of means were performed between groups using ANOVA with adjustment for survey type.
Results: Among 401 patients with HM included in our analysis, mean (SD) age of diagnosis was 75.98 (6.2) years and 26% were diagnosed with leukemia, 57% with lymphoma, and 17% with multiple myeloma. No significant differences in HRQOL, self-reported health, depressive symptoms, or frailty were observed between patients with HM and their non-cancer matches (n=1578) before diagnosis. Substantial declines in HRQOL were observed across all types of HM after cancer diagnosis. Mean decreases in composite SF-36 scores among patients with HM (physical component score [PCS] -7.1, 95% CI -8.8, -5.5; mental component score [MCS] -3.4, 95% CI -4.9, -1.8) were greater in magnitude compared to declines in matched non-cancer patients (PCS -1.6, 95% CI -2.4, -0.7; MCS -0.6, 95% CI -1.3, 0.1). During follow-up, patients with HM also had higher rates of low self-reported health (46% vs. 27%), depressive symptoms (34% vs. 25%) and frailty (56% vs. 43%).
Conclusion: Our study found decreases in HRQOL measures among older patients with HM that were more than three-fold higher than the minimum clinically important differences in the general population and twice that reported in older patients with common solid tumors. Prospective studies and clinical trials in patients with leukemia, lymphoma, and multiple myeloma should include measures that assess whether life-prolonging, novel therapies are also effective in preserving HRQOL.
Citation Format: Ashwini Zolekar, Nadia A. Nabulsi, Alemseged A. Asfaw, Jifang Zhou, Karen Sweiss, Pritesh R. Patel, Brian C.-H. Chiu, Edith A. Nutescu, Gregory S. Calip. Declines in health-related quality of life among older patients diagnosed with hematologic malignancies [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5748.
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Affiliation(s)
- Ashwini Zolekar
- 1University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Nadia A. Nabulsi
- 1University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | | | - Jifang Zhou
- 1University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | | | | | | | - Edith A. Nutescu
- 1University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Gregory S. Calip
- 1University of Illinois at Chicago College of Pharmacy, Chicago, IL
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Guadamuz JS, Durazo-Arvizu RA, Daviglus ML, Perreira KM, Calip GS, Nutescu EA, Gallo LC, Castaneda SF, Gonzalez F, Qato DM. Immigration Status and Disparities in the Treatment of Cardiovascular Disease Risk Factors in the Hispanic Community Health Study/Study of Latinos (Visit 2, 2014-2017). Am J Public Health 2020; 110:1397-1404. [PMID: 32673107 DOI: 10.2105/ajph.2020.305745] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To estimate treatment rates of high cholesterol, hypertension, and diabetes among Hispanic/Latino immigrants by immigration status (i.e., naturalized citizens, documented immigrants, or undocumented immigrants).Methods. We performed a cross-sectional analyses of the Hispanic Community Health Study/Study of Latinos (visit 2, 2014-2017). We restricted our analysis to Hispanic/Latino immigrants with high cholesterol (n = 3974), hypertension (n = 3353), or diabetes (n = 2406); treatment was defined as use of statins, antihypertensives, and antidiabetics, respectively.Results. When compared with naturalized citizens, undocumented and documented immigrants were less likely to receive treatment for high cholesterol (38.4% vs 14.1%; prevalence ratio [PR] = 0.37 [95% confidence interval [CI] = 0.27, 0.51] and 25.7%; PR = 0.67 [95% CI = 0.58, 0.76]), hypertension (77.7% vs 57.7%; PR = 0.74 [95% CI = 0.62, 0.89] and 68.1%; PR = 0.88 [95% CI = 0.82, 0.94]), and diabetes (60.3% vs. 50.4%; PR = 0.84 [95% CI = 0.68, 1.02] and 55.8%; PR = 0.93 [95% CI = 0.83, 1.03]); the latter did not reach statistical significance. Undocumented and documented immigrants had less access to health care, including insurance coverage or a usual health care provider, than naturalized citizens. Therefore, adjusting for health care access largely explained treatment disparities across immigration status.Conclusions. Preventing cardiovascular disease among Hispanic/Latino immigrants should focus on undertreatment of high cholesterol, hypertension, and diabetes by increasing health care access, especially among undocumented immigrants.
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Affiliation(s)
- Jenny S Guadamuz
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
| | - Ramon A Durazo-Arvizu
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
| | - Martha L Daviglus
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
| | - Krista M Perreira
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
| | - Gregory S Calip
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
| | - Edith A Nutescu
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
| | - Linda C Gallo
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
| | - Sheila F Castaneda
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
| | - Franklyn Gonzalez
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
| | - Dima M Qato
- Jenny S. Guadamuz and Martha L. Daviglus are with the Institute for Minority Health Research at the University of Illinois at Chicago. Gregory S. Calip, Edith A. Nutescu, and Dima M. Qato are with the Department of Pharmacy Systems, Outcomes, and Policy at the University of Illinois at Chicago. Ramon A. Durazo-Arvizu is with the Department of Public Health Sciences, Loyola University Chicago, Chicago, IL. Krista M. Perreira is with the Department of Social Medicine at the University of North Carolina at Chapel Hill. Linda C. Gallo and Sheila F. Castaneda are with the Department of Psychology, San Diego State University, San Diego, CA. Franklyn Gonzalez II is with the Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill
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Gor D, Gerber BS, Walton SM, Lee TA, Nutescu EA, Touchette DR. Antidiabetic drug use trends in patients with type 2 diabetes mellitus and chronic kidney disease: A cross-sectional analysis of the National Health and Nutrition Examination Survey. J Diabetes 2020; 12:385-395. [PMID: 31652390 DOI: 10.1111/1753-0407.13003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/25/2019] [Accepted: 10/13/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is little information on medication use, trends across time, and the impact of guidelines on appropriate use of antidiabetic drugs in participants with type 2 diabetes mellitus (T2DM) with chronic kidney disease (CKD). METHODS A cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) from 2005-2016 was carried out for participants with T2DM with and without CKD. Multivariate survey-weighted regression models were used to evaluate trends in antidiabetic drug use across the time periods and CKD severity. Guideline-discordant use of metformin and glyburide were assessed among those with glomerular filtration rate and serum creatinine-based contraindications. RESULTS Out of 3237 study participants with T2DM, 35.9% had CKD. Comparing 2013-2016 with 2005-2008, use of metformin (non-CKD: 69% vs 83.8%, CKD: 58.6% vs 68.2%) increased, whereas the use of sulfonylureas (non-CKD: 46.3% vs 27.2%, CKD: 54.7% vs 36.6%) and thiazolidinediones (non-CKD: 29.3% vs 3.9%, CKD: 24.6% vs 5.5%) decreased. In combined NHANES cycles and across stages of CKD severity, metformin use decreased (non-CKD, stage 1/2, stage 3, stage 4/5: 78.4%, 69.5%, 54.6%, 4.9%, respectively; P < .01), and insulin use increased (18.5%, 26.8%, 25%, 52.8%, respectively; P < .01) from non-CKD to progressed CKD. Guideline-discordant use of metformin and glyburide was observed in 8.3% and 2.8% of the participants, respectively, in 2013-2016. CONCLUSIONS Use of particular antidiabetic medications in patients with CKD changed noticeably over the years, most in accordance with guidelines and regulatory decisions. Gaps in quality of care still exist, which warrants increasing awareness and implementing programs to mitigate inappropriate use.
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Affiliation(s)
- Deval Gor
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Ben S Gerber
- Division of Academic Internal Medicine and Geriatrics, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Surrey M Walton
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Edith A Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
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19
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Guadamuz JS, Durazo-Arvizu RA, Daviglus ML, Calip GS, Nutescu EA, Qato DM. Citizenship Status and the Prevalence, Treatment, and Control of Cardiovascular Disease Risk Factors Among Adults in the United States, 2011-2016. Circ Cardiovasc Qual Outcomes 2020; 13:e006215. [PMID: 32151148 PMCID: PMC7100997 DOI: 10.1161/circoutcomes.119.006215] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jenny S. Guadamuz
- Department of Pharmacy Systems, Outcomes and Policy,
University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
- Institute of Minority Health Research, University of
Illinois at Chicago College of Medicine, Chicago, Illinois
- Centre de Recherche Politiques et Systèmes de
Santé, Université Libre de Bruxelles Ecole de Santé Publique,
Brussels, Belgium
| | | | - Martha L. Daviglus
- Institute of Minority Health Research, University of
Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Gregory S. Calip
- Department of Pharmacy Systems, Outcomes and Policy,
University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic
Research, University of Illinois at Chicago College of Pharmacy, Chicago,
Illinois
- Division of Public Health Sciences, Epidemiology Program,
Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Edith A. Nutescu
- Department of Pharmacy Systems, Outcomes and Policy,
University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic
Research, University of Illinois at Chicago College of Pharmacy, Chicago,
Illinois
- Department of Pharmacy Practice, University of Illinois at
Chicago College of Pharmacy, Chicago, Illinois
| | - Dima M Qato
- Department of Pharmacy Systems, Outcomes and Policy,
University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
- Division of Epidemiology and Biostatistics, University of
Illinois at Chicago School of Public Health, Chicago, Illinois
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20
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Zhou J, Nutescu EA, Han J, Calip GS. Clinical trajectories, healthcare resource use, and costs of long-term hematopoietic stem cell transplantation survivors: a latent class analysis. J Cancer Surviv 2020; 14:294-304. [PMID: 31897877 DOI: 10.1007/s11764-019-00842-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 07/07/2019] [Accepted: 11/28/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To identify patterns of healthcare utilization in allogeneic and autologous hematopoietic stem cell transplantation (HSCT) recipients and evaluate factors associated with high-need and high-cost post-transplantation care. METHODS Latent class analysis of a retrospective cohort of long-term allogeneic (n = 436) and autologous (n = 888) HSCT survivors within the Truven MarketScan database (2009-2014). We assessed factors associated with the latent classes by comparing post-transplantation healthcare utilization including inpatient admissions and length of stay, emergency room visits, specialist visits, and primary care provider visits. RESULTS Four utilization classes were identified in allogeneic and autologous HSCT recipients: (i) outpatient specialist care dominant (51.8% and 57.3%), (ii) outpatient primary care dominant (10.3% and 25.7%), (iii) outpatient/inpatient balanced (20.6% and 13.5%), and (iv) inpatient dominant (17.2% and 3.5%). Mean monthly healthcare expenditures in the inpatient dominant utilization class were $41,097 and $25,556 for allogeneic and autologous survivors, respectively, which were two to five times higher compared with other classes during the 2-year post-transplantation period. Factors associated with the high utilization class were transfusion (OR = 1.87, 95% CI 1.06-3.30) and 100-day post-transplant graft-versus-host-disease (OR = 1.76, 95% CI 1.05-2.94) in allogeneic HSCT; higher baseline Charlson comorbidity index (OR = 1.45, 95% CI 1.19-1.76) in autologous HSCT. CONCLUSION Based on distinct patterns of healthcare utilization following HSCT, we identified factors associated with higher resource utilization and greater healthcare related expenditures. IMPLICATIONS FOR CANCER SURVIVORS Earlier identification of high-cost and high-need HSCT long-term survivors could pave the way for clinicians to offer more continuous engagement in survivorship care delivery.
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Affiliation(s)
- Jifang Zhou
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A Nutescu
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Jin Han
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
- Comprehensive Sickle Cell Center, Section of Hematology/Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, 60607, USA
| | - Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA.
- Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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21
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Gor D, Lee TA, Schumock GT, Walton SM, Gerber BS, Nutescu EA, Touchette DR. Adherence and Persistence with DPP-4 Inhibitors Versus Pioglitazone in Type 2 Diabetes Patients with Chronic Kidney Disease: A Retrospective Claims Database Analysis. J Manag Care Spec Pharm 2020; 26:67-75. [PMID: 31880221 PMCID: PMC10390941 DOI: 10.18553/jmcp.2020.26.1.67] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 11/05/2022]
Abstract
BACKGROUND Adherence and persistence with diabetes medication play an important role in glycemic control and may differ by medication class. However, there is a lack of research comparing diabetes medications in patients with renal impairment, despite the challenges and higher burden associated with managing this population. OBJECTIVE To compare adherence and persistence among patients with type 2 diabetes mellitus (T2DM) and nondialysis chronic kidney disease (CKD) treated with dipeptidyl peptidase-4 (DPP-4) inhibitors versus pioglitazone. METHODS This retrospective cohort study used Truven MarketScan administrative claims databases from 2009 to 2015. One-year adherence for patients with T2DM and nondialysis CKD who initiated therapy with either a DPP-4 inhibitor or pioglitazone was measured by proportion of days covered (PDC) following an initial dispensing, and PDC ≥ 0.80 was coded as adherent. Persistence was calculated as the days between the index date and last day with the index medication on hand, based on the end of the last days supply or the end of follow-up (i.e., 365 days), whichever occurred first. Multivariate logistic regression and Cox proportional hazards models were used to estimate confounder-adjusted differences between the groups for adherence and persistence. RESULTS The final cohort included 9,019 patients (DPP-4 inhibitors: 7,002; pioglitazone: 2,017). In the adjusted analysis, DPP-4 inhibitor users demonstrated a 1.41 (95% CI = 1.25-1.59) higher odds of being adherent compared with pioglitazone users. Overall adjusted HR for persistence was 0.74 (95% CI = 0.69-0.79), which favored DPP-4 inhibitors compared with pioglitazone. Relative to 2010, persistence with pioglitazone decreased in 2011-2012 and then increased in 2013-2014. In the subgroup analysis, DPP-4 inhibitors first had lower (2010: OR = 0.78, 95% CI = 0.70-0.87; 2011-2012: OR = 0.60, 95% CI = 0.54-0.66) and then similar (2013-2014: OR = 1.03, 95% CI = 0.88-1.19) hazards of nonpersistence compared with pioglitazone. CONCLUSIONS Among patients with T2DM and nondialysis CKD, the use of DPP-4 inhibitors was associated with better adherence compared with pioglitazone. However, following the approval of generic pioglitazone and associated lower cost sharing after 2012, the magnitude of difference in adherence between the medication classes reduced. Similarly, safety warnings in 2011 and approval of generic products in 2012 may have affected pioglitazone persistence, leading to first higher and then similar hazards for nonpersistence with pioglitazone as compared with DPP-4 inhibitors. These shifts in the results for pioglitazone warrant further investigation and close monitoring of the population initiating this medication. DISCLOSURES No funding was received for this study. The authors have no conflicts of interest to disclose. An abstract for this study was presented as a podium presentation at the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) 2019 Annual Meeting; May 18-22, 2019; New Orleans, LA.
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MESH Headings
- Administrative Claims, Healthcare
- Aged
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/epidemiology
- Dipeptidyl-Peptidase IV Inhibitors/adverse effects
- Dipeptidyl-Peptidase IV Inhibitors/therapeutic use
- Disease Progression
- Drug Substitution
- Drug Utilization
- Drugs, Generic/adverse effects
- Drugs, Generic/therapeutic use
- Female
- Humans
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/therapeutic use
- Insurance, Pharmaceutical Services
- Male
- Medication Adherence
- Middle Aged
- Pioglitazone/adverse effects
- Pioglitazone/therapeutic use
- Practice Patterns, Physicians'
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/drug therapy
- Renal Insufficiency, Chronic/epidemiology
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Time Factors
- Treatment Outcome
- United States/epidemiology
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Affiliation(s)
- Deval Gor
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago
| | - Todd A. Lee
- Department of Pharmacy Systems, Outcomes and Policy, and Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago
| | - Glen T. Schumock
- Department of Pharmacy Systems, Outcomes and Policy, and Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago
| | - Surrey M. Walton
- Department of Pharmacy Systems, Outcomes and Policy, and Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago
| | - Ben S. Gerber
- Division of Academic Internal Medicine and Geriatrics, College of Medicine, University of Illinois at Chicago
| | - Edith A. Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, and Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago
| | - Daniel R. Touchette
- Department of Pharmacy Systems, Outcomes and Policy, and Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago
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22
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Lee I, Adimadhyam S, Nutescu EA, Zhou J, Asfaw AA, Sweiss K, Patel PR, Calip GS. Bevacizumab Use and the Risk of Arterial and Venous Thromboembolism in Patients with High-Grade Gliomas: A Nested Case-Control Study. Pharmacotherapy 2019; 39:921-928. [PMID: 31332810 PMCID: PMC7395667 DOI: 10.1002/phar.2310] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE Bevacizumab is used in the treatment of recurrent glioblastoma, but evidence is limited on the incidence of thromboembolic complications regarding the use of this drug in real-world settings. We evaluated the risk of arterial thromboembolism (ATE) and venous thromboembolism (VTE) associated with the use of bevacizumab among adults diagnosed with high-grade gliomas in a commercially insured U.S. POPULATION DESIGN Nested case-control study. DATA SOURCE Truven Health MarketScan Commercial and Medicare Supplemental health claims databases (2009-2015). PATIENTS A total of 2157 patients with high-grade gliomas who underwent incident (first-time) craniotomy, radiation, and concurrent temozolomide treatment between 2009 and 2015 were identified. Overall, 25 cases of ATE and 99 cases of VTE were each identified in this cohort, and each case was matched to up to 10 controls (170 for ATE and 819 for VTE) based on sex, age, quarter year of index time, and follow-up duration by using incidence density sampling without replacement from the overall cohort. Controls were at risk for the outcome of interest (ATE or VTE) at the time of case occurrence and survived at least as long as their referent case. MEASUREMENTS AND MAIN RESULTS Exposure to bevacizumab was determined during inpatient or outpatient encounters between the index date (date of the incident craniotomy) and the ATE or VTE event or corresponding matched control date. Multivariable conditional logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of ATE and VTE separately. A higher proportion of patients with ATE received bevacizumab compared with controls (28% vs 17%; adjusted OR 1.51, 95% CI 0.54-4.24), but this excess in odds was not statistically significant. Similarly, bevacizumab was not significantly associated with VTE (13% vs 9%; adjusted OR 1.40, 95% CI 0.71-2.75). CONCLUSION We found no significant association between the use of bevacizumab and the occurrence of thromboembolic events in patients with high-grade gliomas, although our study was limited by the small number of ATE events. Because the potential for complications from arterial thrombosis cannot be completely ruled out, further research is needed to confirm the thromboembolic safety of bevacizumab in a larger sample of patients with high-grade gliomas.
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Affiliation(s)
- Inyoung Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL
| | - Sruthi Adimadhyam
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL
| | - Edith A. Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL
- Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL
| | - Jifang Zhou
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL
| | - Alemseged A. Asfaw
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL
| | - Karen Sweiss
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL
| | - Pritesh R. Patel
- Division of Hematology Oncology, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Gregory S. Calip
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL
- Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL
- Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA
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23
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Zhou J, Han J, Nutescu EA, Galanter WL, Walton SM, Gordeuk VR, Saraf SL, Calip GS. Type 2 diabetes in adults with sickle cell disease: can we dive deeper? Response to Skinner et al. Br J Haematol 2019; 186:782-783. [PMID: 31066029 DOI: 10.1111/bjh.15949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jifang Zhou
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Jin Han
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.,Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.,Division of Hematology & Oncology, Department of Medicine, Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A Nutescu
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - William L Galanter
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.,Department of Medicine, Section of Academic Internal Medicine & Geriatrics, University of Illinois at Chicago, Chicago, IL, USA
| | - Surrey M Walton
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Victor R Gordeuk
- Division of Hematology & Oncology, Department of Medicine, Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Santosh L Saraf
- Division of Hematology & Oncology, Department of Medicine, Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.,Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Friedman PN, Shaazuddin M, Gong L, Grossman RL, Harralson AF, Klein TE, Lee NH, Miller DC, Nutescu EA, O'Brien TJ, O'Donnell PH, O'Leary KJ, Tuck M, Meltzer DO, Perera MA. The ACCOuNT Consortium: A Model for the Discovery, Translation, and Implementation of Precision Medicine in African Americans. Clin Transl Sci 2019; 12:209-217. [PMID: 30592548 PMCID: PMC6510376 DOI: 10.1111/cts.12608] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 11/26/2018] [Indexed: 01/06/2023] Open
Abstract
The majority of pharmacogenomic (PGx) studies have been conducted on European ancestry populations, thereby excluding minority populations and impeding the discovery and translation of African American–specific genetic variation into precision medicine. Without accounting for variants found in African Americans, clinical recommendations based solely on genetic biomarkers found in European populations could result in misclassification of drug response in African American patients. To address these challenges, we formed the Transdisciplinary Collaborative Center (TCC), African American Cardiovascular Pharmacogenetic Consortium (ACCOuNT), to discover novel genetic variants in African Americans related to clinically actionable cardiovascular phenotypes and to incorporate African American–specific sequence variations into clinical recommendations at the point of care. The TCC consists of two research projects focused on discovery and translation of genetic findings and four cores that support the projects. In addition, the largest repository of PGx information on African Americans is being established as well as lasting infrastructure that can be utilized to spur continued research in this understudied population.
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Affiliation(s)
- Paula N Friedman
- Department of Pharmacology, Center for Pharmacogenomics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Mohammed Shaazuddin
- Department of Pharmacology, Center for Pharmacogenomics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Robert L Grossman
- Department of Medicine and Computer Science, Center for Data Intensive Science, The University of Chicago, Chicago, Illinois, USA
| | - Arthur F Harralson
- Department of Pharmacogenomics, Shenandoah University, Inova Center for Personalized Health, Fairfax, Virginia, USA.,Department of Pharmacology and Physiology, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Teri E Klein
- Department of Biomedical Data Science and Department of Medicine, Stanford University, Stanford, California, USA
| | - Norman H Lee
- Department of Pharmacology and Physiology, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Doriane C Miller
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Edith A Nutescu
- Department of Pharmacy Systems, Outcomes, and Policy and Personalized Medicine Program, University of Illinois, College of Pharmacy, Chicago, Illinois, USA
| | - Travis J O'Brien
- Department of Pharmacology and Physiology, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Peter H O'Donnell
- Department of Medicine, Center for Personalized Therapeutics, Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA
| | - Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew Tuck
- Washington DC VA Medical Center, Washington, DC and The George Washington University, Washington, DC, USA
| | - David O Meltzer
- Department of Medicine, Center for Health and the Social Sciences, The University of Chicago, Chicago, Illinois, USA
| | - Minoli A Perera
- Department of Pharmacology, Center for Pharmacogenomics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Zhou J, Han J, Nutescu EA, Galanter WL, Walton SM, Gordeuk VR, Saraf SL, Calip GS. Similar burden of type 2 diabetes among adult patients with sickle cell disease relative to African Americans in the U.S. population: a six-year population-based cohort analysis. Br J Haematol 2019; 185:116-127. [PMID: 30714090 DOI: 10.1111/bjh.15773] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 10/05/2018] [Accepted: 11/29/2018] [Indexed: 12/15/2022]
Abstract
Conflicting evidence exists on the epidemiology of type 2 diabetes mellitus (T2DM) among patients with sickle cell disease (SCD). This study measured the prevalence, incidence and clinical outcomes associated with T2DM in a large US population of commercially-insured adults aged ≥20 years with SCD between 2009 and 2014. Among 7070 patients with SCD, the mean age (median) was 39 (37) years and 60·8% were female. The standardized prevalence of T2DM among patients with SCD showed a modest increase, from 15·7% to 16·5% (P trend = 0·026), and was comparable to African-American respondents to the National Health and Nutrition Examination Survey (18·2%). Over 17 024 person-years, the crude incidence rate for T2DM was 25·4 per 1000 person-years. Incident T2DM was associated with comorbid hypertension (hazard ratio [HR] = 1·45, 95% confidence interval [CI] 1·14-1·83), and dyslipidaemia (HR = 1·43, 95%CI 1·04-1·96). Compared to SCD patients without T2DM, more SCD patients with T2DM had diagnoses of nephropathy (28·0% vs. 9·5%; P < 0·001), neuropathy (17·7% vs. 5·2%; P < 0·001) and stroke (24·1% vs. 9·2%; P < 0·001). Prevalence of T2DM in SCD patients is similar to the general African American population with an increasing trend in recent years. These trends support routine screening for T2DM in aging patients with SCD, especially those with comorbid hypertension and/or dyslipidaemia.
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Affiliation(s)
- Jifang Zhou
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Jin Han
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.,Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.,Division of Hematology & Oncology, Department of Medicine, Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A Nutescu
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - William L Galanter
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.,Department of Medicine, Section of Academic Internal Medicine & Geriatrics, University of Illinois at Chicago, Chicago, IL, USA
| | - Surrey M Walton
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Victor R Gordeuk
- Division of Hematology & Oncology, Department of Medicine, Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Santosh L Saraf
- Division of Hematology & Oncology, Department of Medicine, Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.,Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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26
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Zhou J, Han J, Nutescu EA, Patel PR, Sweiss K, Calip GS. Discontinuation and Nonadherence to Medications for Chronic Conditions after Hematopoietic Cell Transplantation: A 6-Year Propensity Score-Matched Cohort Study. Pharmacotherapy 2019; 39:55-66. [PMID: 30485471 DOI: 10.1002/phar.2197] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Hematopoietic cell transplantation (HCT) is an established curative option for patients with hematological malignancies and other life-threatening conditions. Evidence on nonpersistence and nonadherence to oral medications for chronic conditions among patients following HCT is lacking. OBJECTIVES This study aims to examine patterns of oral medication use for chronic conditions following HCT in the U.S. POPULATION METHODS Nonpersistence and nonadherence to oral medications for diabetes, hypertension, and dyslipidemia among HCT recipients were assessed in a cohort that included 1382 autologous and 650 allogeneic HCT recipients with hematological malignancies using the Truven Health MarketScan Research Database between 2009 and 2014. Recipients of HCT were compared to propensity score-matched cancer patients receiving chemotherapy without transplantation. Multivariable Cox proportional hazards models and generalized estimating equations were used to determine characteristics associated with nonpersistence and nonadherence to oral chronic medications, respectively. RESULTS Recipients of HCT had higher risks of discontinuing medication for diabetes mellitus (allogeneic HCT hazard ratio [HR] = 1.93, 95% confidence interval [CI] 1.10-3.39; autologous HCT HR = 1.49, 95% CI 1.04-2.15); hypertension (allogeneic HCT HR = 1.75, 95% CI 1.21-2.53; autologous HCT HR = 1.32, 95% CI 1.07-1.62), and dyslipidemia (allogeneic HCT HR = 2.02, 95% CI 1.39-2.93; autologous HCT, HR = 1.26, 95% CI 0.98-1.61) compared to patients treated with only chemotherapy. Lower odds of adherence to antihypertensive medications (odds ratio [OR] = 0.58, 95% CI 0.38-0.89) and to lipid-lowering medications (OR = 0.38, 95% CI 0.22-0.65) were observed in allogeneic HCT recipients compared with propensity score-matched patients who underwent chemotherapy only. CONCLUSIONS Poor medication persistence and adherence to chronic disease medications are common after HCT. Further research to improve long-term outcomes following HCT should include management of medication therapy for chronic comorbid conditions.
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Affiliation(s)
- Jifang Zhou
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Jin Han
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois.,Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois
| | - Edith A Nutescu
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Pritesh R Patel
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Karen Sweiss
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois
| | - Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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27
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Manzoor BS, Bauman J, Shapiro NL, Stamos T, Galanter W, Nutescu EA. Outcomes of systematic anticoagulation management in pharmacist and nurse specialized clinics. J Am Coll Clin Pharm 2018. [DOI: 10.1002/jac5.1051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Beenish S. Manzoor
- Department of Pharmacy, Systems Outcomes and Policy; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
| | - Jerry Bauman
- Department of Pharmacy Practice; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
- Department of Medicine, Section of Cardiology; College of Medicine, University of Illinois at Chicago; Chicago Illinois
| | - Nancy L. Shapiro
- Department of Pharmacy Practice; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
| | - Thomas Stamos
- Department of Medicine, Section of Cardiology; College of Medicine, University of Illinois at Chicago; Chicago Illinois
| | - William Galanter
- Department of Pharmacy, Systems Outcomes and Policy; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
- Department of Pharmacy Practice; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
- Department of Medicine, Section of Academic Internal Medicine; College of Medicine, University of Illinois at Chicago; Chicago Illinois
| | - Edith A. Nutescu
- Department of Pharmacy, Systems Outcomes and Policy; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; College of Pharmacy, University of Illinois at Chicago; Chicago Illinois
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Manzoor BS, Walton SM, Sharp LK, Galanter WL, Lee TA, Nutescu EA. High number of newly initiated direct oral anticoagulant users switch to alternate anticoagulant therapy. J Thromb Thrombolysis 2018; 44:435-441. [PMID: 29027097 DOI: 10.1007/s11239-017-1565-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 01/23/2023]
Abstract
Real-world evidence focusing on medication switching patterns amongst direct oral anticoagulant (DOACs) has not been well studied. The objective of this study is to evaluate patterns of prescription switching in non-valvular atrial fibrillation (NVAF) patients initiated on a DOAC and previously naïve to anticoagulation (AC) therapy. Data was obtained from Truven Health MarketScan® Commercial and Medicare Supplemental database (2009-2013). AC naïve (those without prior anticoagulant use) NVAF patients initiated on a DOAC, with 6 months of continuous health plan enrollment before and after treatment initiation and maintained on continuous therapy for a minimum of 6 months were included. Of 34,022 AC naïve NVAF patients initiating a DOAC, 6613 (19.4%) patients switched from an index DOAC prescription to an alternate anticoagulant and 27,409 (80.6%) remained on the DOAC [age: 68.5 ± 11.7 vs. 67.1 ± 12.7 years, p < 0.001; males: 3781 (57.2%) vs. 17,160 (62.6%), p < 0.001]. Amongst those that switched medication, 3196 (48.3%) did so within the first 6 months of therapy. Overall, 2945 (44.5%) patients switched to warfarin, 2912 (44.0%) switched to another DOAC and 756 (11.4%) switched to an injectable anticoagulant. The highest proportion of patients switched from dabigatran to warfarin (N = 2320; 42.5%) or rivaroxaban (N = 2252; 41.3%). The median time to switch from the index DOAC to another DOAC was 309.5 days versus 118.0 days (p < 0.001) to switch to warfarin. In NVAF patients newly initiated on DOAC therapy, one in five patients switch to an alternate anticoagulant and one of every two patients do so within the first 6 months of therapy. Switching from an initial DOAC prescription to traditional anticoagulants occurs as frequently as switching to an alternate DOAC.
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Affiliation(s)
- Beenish S Manzoor
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
| | - Surrey M Walton
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Lisa K Sharp
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - William L Galanter
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Department of Academic Internal Medicine & Geriatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Todd A Lee
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A Nutescu
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA.
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
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Zhou J, Han J, Nutescu EA, Gordeuk VR, Saraf SL, Calip GS. Hydroxycarbamide adherence and cumulative dose associated with hospital readmission in sickle cell disease: a 6-year population-based cohort study. Br J Haematol 2018; 182:259-270. [PMID: 29767446 DOI: 10.1111/bjh.15396] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 02/06/2018] [Accepted: 03/31/2018] [Indexed: 01/19/2023]
Abstract
Sickle cell disease (SCD) is a congenital haemoglobinopathy that causes frequent acute care/emergency room visits and hospital admissions for affected individuals. Evidence from population-based studies demonstrating the role of hydroxycarbamide (HC, also termed hydroxyurea) in reducing hospital readmission rates is limited. Our objective was to describe the use of HC and its association with acute care utilization and readmission rates using a large, nationally-representative US health insurance claims database over a 6-year period between 2009 and 2014. We identified 20 721 SCD-related inpatient and acute care encounters. Patients had been exposed to HC within 6 months prior to admission in 4263 (21%) of SCD-related admission events. HC use was more common among children aged 10-17 years and young adults aged 18-29 years. HC was associated with lower 30-day all-cause readmission rates in adults treated with average daily doses ≥1 g (odds ratio [OR], 0·72, 95% confidence interval [CI] 0·52-0·99) and doses of 0·5-1 g (OR, 0·73, 95% CI 0·57-0·93), compared to HC treatment with average daily doses of <0·5 g; adherence to HC with proportion of days covered of ≥0·80 was also associated with significantly lower 30-day all-cause readmission risks (OR, 0·59, 95% CI 0·41-0·84). Optimal therapeutic dosing and adherence to HC treatment significantly reduces 30-day readmissions among patients with SCD.
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Affiliation(s)
- Jifang Zhou
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Jin Han
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.,Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.,Division of Hematology and Oncology, Department of Medicine, Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A Nutescu
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Victor R Gordeuk
- Division of Hematology and Oncology, Department of Medicine, Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Santosh L Saraf
- Division of Hematology and Oncology, Department of Medicine, Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.,Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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30
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Sharabiani A, Nutescu EA, Galanter WL, Darabi H. A New Approach towards Minimizing the Risk of Misdosing Warfarin Initiation Doses. Comput Math Methods Med 2018; 2018:5340845. [PMID: 29861781 PMCID: PMC5971298 DOI: 10.1155/2018/5340845] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/07/2018] [Accepted: 04/02/2018] [Indexed: 01/09/2023]
Abstract
It is a challenge to be able to prescribe the optimal initial dose of warfarin. There have been many studies focused on an efficient strategy to determine the optimal initial dose. Numerous clinical, genetic, and environmental factors affect the warfarin dose response. In practice, it is common that the initial warfarin dose is substantially different from the stable maintenance dose, which may increase the risk of bleeding or thrombosis prior to achieving the stable maintenance dose. In order to minimize the risk of misdosing, despite popular warfarin dose prediction models in the literature which create dose predictions solely based on patients' attributes, we have taken physicians' opinions towards the initial dose into consideration. The initial doses selected by clinicians, along with other standard clinical factors, are used to determine an estimate of the difference between the initial dose and estimated maintenance dose using shrinkage methods. The selected shrinkage method was LASSO (Least Absolute Shrinkage and Selection Operator). The estimated maintenance dose was more accurate than the original initial dose, the dose predicted by a linear model without involving the clinicians initial dose, and the values predicted by the most commonly used model in the literature, the Gage clinical model.
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Affiliation(s)
- Ashkan Sharabiani
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A. Nutescu
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - William L. Galanter
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Houshang Darabi
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, IL, USA
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Cavallari LH, Lee CR, Duarte JD, Nutescu EA, Weitzel KW, Stouffer GA, Johnson JA. Implementation of inpatient models of pharmacogenetics programs. Am J Health Syst Pharm 2018; 73:1944-1954. [PMID: 27864202 DOI: 10.2146/ajhp150946] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The operational elements essential for establishing an inpatient pharmacogenetic service are reviewed, and the role of the pharmacist in the provision of genotype-guided drug therapy in pharmacogenetics programs at three institutions is highlighted. SUMMARY Pharmacists are well positioned to assume important roles in facilitating the clinical use of genetic information to optimize drug therapy given their expertise in clinical pharmacology and therapeutics. Pharmacists have assumed important roles in implementing inpatient pharmacogenetics programs. This includes programs designed to incorporate genetic test results to optimize antiplatelet drug selection after percutaneous coronary intervention and personalize warfarin dosing. Pharmacist involvement occurs on many levels, including championing and leading pharmacogenetics implementation efforts, establishing clinical processes to support genotype-guided therapy, assisting the clinical staff with interpreting genetic test results and applying them to prescribing decisions, and educating other healthcare providers and patients on genomic medicine. The three inpatient pharmacogenetics programs described use reactive versus preemptive genotyping, the most feasible approach under the current third-party payment structure. All three sites also follow Clinical Pharmacogenetics Implementation Consortium guidelines for drug therapy recommendations based on genetic test results. CONCLUSION With the clinical emergence of pharmacogenetics into the inpatient setting, it is important that pharmacists caring for hospitalized patients are well prepared to serve as experts in interpreting and applying genetic test results to guide drug therapy decisions. Since genetic test results may not be available until after patient discharge, pharmacists practicing in the ambulatory care setting should also be prepared to assist with genotype-guided drug therapy as part of transitions in care.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL.
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC.,Center for Pharmacogenomics and Individualized Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julio D Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL.,Personalized Medicine Program, University of Illinois Hospital and Health Science System, Chicago, IL
| | - Edith A Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL.,Personalized Medicine Program, University of Illinois Hospital and Health Science System, Chicago, IL
| | - Kristin W Weitzel
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - George A Stouffer
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
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Lee YM, Manzoor BS, Cavallari LH, Nutescu EA. Facilitators and Barriers to the Adoption of Pharmacogenetic Testing in an Inner-City Population. Pharmacotherapy 2018; 38:205-216. [DOI: 10.1002/phar.2077] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Yee Ming Lee
- Department of Clinical Pharmacy; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora Colorado
| | - Beenish S. Manzoor
- Department of Pharmacy, Systems Outcomes, and Policy; College of Pharmacy; University of Illinois at Chicago; Chicago Illinois
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research; Center for Pharmacogenomics; College of Pharmacy; University of Florida; Gainesville Florida
| | - Edith A. Nutescu
- Department of Pharmacy, Systems Outcomes, and Policy; College of Pharmacy; University of Illinois at Chicago; Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; College of Pharmacy; University of Illinois at Chicago; Chicago Illinois
- Personalized Medicine Program; The University of Illinois at Chicago Hospital & Health Sciences System (UI-Health); Chicago Illinois
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Lefebvre P, Nutescu EA, Duh M, LaMori J, Bookhart BK, Olson WH, Dea K, Hossou Y, Schein J, Kaatz S, Laliberté F. All-cause and disease-related health care costs associated with recurrent venous thromboembolism. Thromb Haemost 2017; 110:1288-97. [DOI: 10.1160/th13-05-0425] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 08/12/2013] [Indexed: 11/05/2022]
Abstract
SummaryIt was the objective of this study to quantify the risk of complications and the incremental health care costs associated with recurrent VTE events. Health care insurance claims from the Ingenix IMPACT database from 01/2004−09/2008 were analysed. Subjects aged ≥18 years on the date of first recurrent VTE diagnosis with ≥12 months of baseline observation prior to the index recurrent VTE were matched 1:1 with no-recurrent VTE patients based on propensity scores. The risk of developing post-thrombotic syndrome (PTS) and other disease-related diagnoses (thrombocytopenia, superficial venous thrombosis, venous ulcer, pulmonary hypertension, stasis dermatitis, and venous insufficiency) was compared between the recurrent and no-recurrent VTE groups for up to one year. All-cause and disease-related costs per patient per year (PPPY) were calculated. The recurrent VTE and no-recurrent VTE cohorts (8,001 subjects in each group) were matched with respect to age, gender, and comorbidities. The risk ratios (RRs) indicated that the risk of developing post-event complications was significantly higher for the recurrent VTE group compared to the no-recurrent VTE group (RR [95% CI]: PTS: 2.7 [2.4 − 2.9], p-value <0.01). Patients with recurrent VTE had significantly higher average PPPY all-cause costs compared to no-recurrent VTE patients ($86,744 versus $37,525, cost difference: $49,219 [€33,617]; 95% CI= 46,253−51,989). Corresponding disease-related health care costs PPPY were also significantly higher for the recurrent VTE group ($11,120 vs $1,262, cost difference: $9,858 [€6,733]; 95% CI= $9,081-$10,476). In conclusion, in this large matched-cohort study, recurrent VTE patients had significantly higher risk of complications and health care costs compared to no-recurrent VTE patients.Note: Parts of this manuscript were presented at the American College of Clinical Pharmacy (ACCP) Annual Meeting 2012, October 21–24, Hollywood, Florida and at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 18th Annual International Meeting 2013, May 18–22, New Orleans, LA, USA.
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Cavallari LH, Lee CR, Beitelshees AL, Cooper-DeHoff RM, Duarte JD, Voora D, Kimmel SE, McDonough CW, Gong Y, Dave CV, Pratt VM, Alestock TD, Anderson RD, Alsip J, Ardati AK, Brott BC, Brown L, Chumnumwat S, Clare-Salzler MJ, Coons JC, Denny JC, Dillon C, Elsey AR, Hamadeh IS, Harada S, Hillegass WB, Hines L, Horenstein RB, Howell LA, Jeng LJB, Kelemen MD, Lee YM, Magvanjav O, Montasser M, Nelson DR, Nutescu EA, Nwaba DC, Pakyz RE, Palmer K, Peterson JF, Pollin TI, Quinn AH, Robinson SW, Schub J, Skaar TC, Smith DM, Sriramoju VB, Starostik P, Stys TP, Stevenson JM, Varunok N, Vesely MR, Wake DT, Weck KE, Weitzel KW, Wilke RA, Willig J, Zhao RY, Kreutz RP, Stouffer GA, Empey PE, Limdi NA, Shuldiner AR, Winterstein AG, Johnson JA. Multisite Investigation of Outcomes With Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2017; 11:181-191. [PMID: 29102571 DOI: 10.1016/j.jcin.2017.07.022] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [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: 05/22/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVES This multicenter pragmatic investigation assessed outcomes following clinical implementation of CYP2C19 genotype-guided antiplatelet therapy after percutaneous coronary intervention (PCI). BACKGROUND CYP2C19 loss-of-function alleles impair clopidogrel effectiveness after PCI. METHODS After clinical genotyping, each institution recommended alternative antiplatelet therapy (prasugrel, ticagrelor) in PCI patients with a loss-of-function allele. Major adverse cardiovascular events (defined as myocardial infarction, stroke, or death) within 12 months of PCI were compared between patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy. Risk was also compared between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy. Cox regression was performed, adjusting for group differences with inverse probability of treatment weights. RESULTS Among 1,815 patients, 572 (31.5%) had a loss-of-function allele. The risk for major adverse cardiovascular events was significantly higher in patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy (23.4 vs. 8.7 per 100 patient-years; adjusted hazard ratio: 2.26; 95% confidence interval: 1.18 to 4.32; p = 0.013). Similar results were observed among 1,210 patients with acute coronary syndromes at the time of PCI (adjusted hazard ratio: 2.87; 95% confidence interval: 1.35 to 6.09; p = 0.013). There was no difference in major adverse cardiovascular events between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy (adjusted hazard ratio: 1.14; 95% confidence interval: 0.69 to 1.88; p = 0.60). CONCLUSIONS These data from real-world observations demonstrate a higher risk for cardiovascular events in patients with a CYP2C19 loss-of-function allele if clopidogrel versus alternative therapy is prescribed. A future randomized study of genotype-guided antiplatelet therapy may be of value.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida.
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Julio D Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Deepak Voora
- Department of Medicine, Center for Applied Genomics & Precision Medicine, Duke University, Durham, North Carolina
| | - Stephen E Kimmel
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Chintan V Dave
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida
| | - Victoria M Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - R David Anderson
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Jorge Alsip
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amer K Ardati
- Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Brigitta C Brott
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lawrence Brown
- Veterans Administration Medical Center, Baltimore, Maryland
| | - Supatat Chumnumwat
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Michael J Clare-Salzler
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - James C Coons
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joshua C Denny
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Issam S Hamadeh
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Shuko Harada
- Department of Pathology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - William B Hillegass
- Heart South Cardiovascular Group, Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsay Hines
- Department of Neuropsychology, University of North Dakota, Fargo, North Dakota
| | | | - Lucius A Howell
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Linda J B Jeng
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Mark D Kelemen
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Yee Ming Lee
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Oyunbileg Magvanjav
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - May Montasser
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - David R Nelson
- College of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois; Department of Pharmacy Systems, Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Devon C Nwaba
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Ruth E Pakyz
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Kathleen Palmer
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Josh F Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Toni I Pollin
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Alison H Quinn
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Shawn W Robinson
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Jamie Schub
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Todd C Skaar
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - D Max Smith
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Vindhya B Sriramoju
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Tomasz P Stys
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James M Stevenson
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nicholas Varunok
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark R Vesely
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Dyson T Wake
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Karen E Weck
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kristin W Weitzel
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Russell A Wilke
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James Willig
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard Y Zhao
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nita A Limdi
- Department of Neurology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan R Shuldiner
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida; Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
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Manzoor BS, Lee TA, Sharp LK, Walton SM, Galanter WL, Nutescu EA. Real-World Adherence and Persistence with Direct Oral Anticoagulants in Adults with Atrial Fibrillation. Pharmacotherapy 2017; 37:1221-1230. [DOI: 10.1002/phar.1989] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Beenish S. Manzoor
- Department of Pharmacy, Systems Outcomes and Policy; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
| | - Todd A. Lee
- Department of Pharmacy, Systems Outcomes and Policy; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
| | - Lisa K. Sharp
- Department of Pharmacy, Systems Outcomes and Policy; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
| | - Surrey M. Walton
- Department of Pharmacy, Systems Outcomes and Policy; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
| | - William L. Galanter
- Department of Pharmacy, Systems Outcomes and Policy; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
- Department of Medicine, Section of Academic Internal Medicine & Geriatrics; University of Illinois at Chicago, College of Medicine; Chicago Illinois
| | - Edith A. Nutescu
- Department of Pharmacy, Systems Outcomes and Policy; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; University of Illinois at Chicago, College of Pharmacy; Chicago Illinois
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Manzoor BS, Cheng WH, Lee JC, Uppuluri EM, Nutescu EA. Quality of Pharmacist-Managed Anticoagulation Therapy in Long-Term Ambulatory Settings: A Systematic Review. Ann Pharmacother 2017; 51:1122-1137. [PMID: 28735551 DOI: 10.1177/1060028017721241] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [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: 12/27/2022] Open
Abstract
OBJECTIVE To perform a systematic review to evaluate the quality of warfarin anticoagulation control in outpatient pharmacist-managed anticoagulation services (PMAS) compared with routine medical care (RMC). DATA SOURCES MEDLINE, SCOPUS, EMBASE, IPA, CINAHL, and Cochrane CENTRAL, from inception to May 2017. Search terms employed: ("pharmacist-managed" OR "pharmacist-provided" OR "pharmacist-led" OR "pharmacist-directed") AND ("anticoagulation services" OR "anticoagulation clinic" OR "anticoagulation management" OR "anticoagulant care") AND ("quality of care" OR "outcomes" OR "bleeding" OR "thromboembolism" OR "mortality" OR "hospitalization" OR "length of stay" OR "emergency department visit" OR "cost" OR "patient satisfaction"). STUDY SELECTION AND DATA EXTRACTION Criteria used to identify selected articles: English language; original studies (comments, letters, reviews, systematic reviews, meta-analyses, editorials were excluded); warfarin use; outpatient setting; comparison group present; time in therapeutic range (TTR) included as a measure of quality of anticoagulant control; study design was not a case report. DATA SYNTHESIS Of 177 articles identified, 25 met inclusion criteria. Quality of anticoagulation control was better in the PMAS group compared with RMC in majority of the studies (N = 23 of 25, 92.0%). Clinical outcomes were also favorable in the PMAS group as evidenced by lower or equal risk of major bleeding (N = 10 of 12, 83.3%) or thromboembolic events (N = 9 of 10, 90.0%), and lower rates of hospitalization or emergency department visits (N = 9 of 9, 100%). When reported, PMAS have also resulted in cost-savings in all (N=6 of 6, 100%) of studies. CONCLUSIONS Compared with routine care, pharmacist-managed outpatient-based anticoagulation services attained better quality of anticoagulation control, lower bleeding and thromboembolic events, and resulted in lower health care utilization.
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Affiliation(s)
| | - Wei-Han Cheng
- 2 University of Southern California, Los Angeles, CA, USA
| | - James C Lee
- 1 University of Illinois at Chicago, Chicago, IL, USA
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Spinler SA, Nutescu EA, Smythe MA, Wittkowsky AK. Anticoagulation Monitoring Part 1: Warfarin and Parenteral Direct Thrombin Inhibitors. Ann Pharmacother 2017; 39:1049-55. [PMID: 15855245 DOI: 10.1345/aph.1e118] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 11/27/2022] Open
Abstract
OBJECTIVE: To review the availability, mechanisms, limitations, and clinical application of point-of-care (POC) devices used in the management of warfarin and parenteral direct thrombin inhibitors. DATA SOURCES: Scientific articles were identified through a MEDLINE search (1966–August 2004), manufacturer Web sites, additional references listed in articles and Web sites, and abstracts from scientific meetings. STUDY SELECTION AND DATA EXTRACTION: English-language literature from clinical trials was reviewed to evaluate the accuracy, reliability, and clinical application of POC monitoring devices. DATA SYNTHESIS: The prothrombin time expressed as the international normalized ratio (PT—INR) is a well-established test for monitoring warfarin anticoagulation. Multiple devices are available for POC testing. Because there is no universally accepted standard, the performance of each device is typically tested against a standard test performed in a reference laboratory. Performance of currently available devices, as measured by correlations to a standard reference laboratory PT—INR, may be considered very good and acceptable for use in patient care. Utilization of patient self-testing and patient self-monitoring of warfarin anticoagulation using POC devices is increasing. Parenteral direct thrombin inhibitors are typically monitored using a standard laboratory activated partial thromboplastin time. Some research has shown that POC monitoring of direct thrombin inhibitors using the ecarin clotting time is helpful for patients undergoing cardiopulmonary bypass surgery, although that test is not readily available. CONCLUSIONS: POC testing for anticoagulation therapy has been available for >20 years. Multiple POC devices are available to monitor warfarin. There is some variability in results between devices and between reagents used in the same device. Despite these limitations, POC monitoring of warfarin via the PT—INR is an integral part of clinical practice. Additional research evaluating POC monitoring of direct thrombin inhibitors is necessary.
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Affiliation(s)
- Sarah A Spinler
- Cardiovascular Division, Department of Medicine, Philadelphia College of Pharmacy, University of Pennsylvania, Philadelphia, PA 19104-4495, USA.
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Arwood MJ, Deng J, Drozda K, Pugach O, Nutescu EA, Schmidt S, Duarte JD, Cavallari LH. Anticoagulation endpoints with clinical implementation of warfarin pharmacogenetic dosing in a real-world setting: A proposal for a new pharmacogenetic dosing approach. Clin Pharmacol Ther 2016; 101:675-683. [PMID: 28032893 DOI: 10.1002/cpt.558] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 10/20/2016] [Accepted: 10/20/2016] [Indexed: 02/03/2023]
Abstract
Achieving therapeutic anticoagulation efficiently with warfarin is important to reduce thrombotic and bleeding risks and is influenced by genotype. Utilizing data from a diverse population of 257 patients who received VKORC1 and CYP2C9 genotype-guided warfarin dosing, we aimed to examine genotype-associated differences in anticoagulation endpoints and derive a novel pharmacogenetic nomogram to more optimally dose warfarin. We observed significant differences across patients with 0, 1, or ≥2 reduced-function VKORC1 or CYP2C9 alleles, respectively, in time to achieve therapeutic international normalized ratio (INR) (7.8 ± 5.8, 7.2 ± 4.7, and 5.4 ± 4.6 days, P = 0.0004) and mean percentage of time in therapeutic range in the first 28 days (22.2, 27.8, and 32.2%, P = 0.0127) with use of existing pharmacogenetic algorithms. These data suggest that more aggressive dosing is necessary for patients with 0 to 1 VKORC1/CYP2C9 variants to more efficiently achieve therapeutic anticoagulation. Herein, we provide a novel kinetic/pharmacodynamic-derived dosing nomogram optimized for a heterogeneous patient population.
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Affiliation(s)
- M J Arwood
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida, Gainesville, Florida, USA
| | - J Deng
- Center for Pharmacometrics and Systems Pharmacology, University of Florida at Lake Nona, Orlando, Florida, USA
| | - K Drozda
- Genomics and Targeted Therapy, Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - O Pugach
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - E A Nutescu
- Personalized Medicine Program, University of Illinois at Chicago, Chicago, Illinois, USA.,Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA.,Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois, USA
| | - S Schmidt
- Center for Pharmacometrics and Systems Pharmacology, University of Florida at Lake Nona, Orlando, Florida, USA
| | - J D Duarte
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida, Gainesville, Florida, USA
| | - L H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida, Gainesville, Florida, USA
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Takahashi H, Ohara M, Shibata S, Lee MTM, Cavallari LH, Nutescu EA, Scordo MG, Pengo V, Padrini R, Atsuda K, Matsubara H, Chen YT, Echizen H. Correlations between the enantio- and regio-selective metabolisms of warfarin. Pharmacogenomics 2016; 18:133-142. [PMID: 27995809 DOI: 10.2217/pgs-2016-0149] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To clarify whether the activities of multiple CYPs associated with warfarin metabolism would be correlated with each other. METHODS Oral clearances (CLpo) of warfarin enantiomers were estimated in 378 Chinese, Caucasians and African-Americans. The partial metabolic clearances (CLm) for 7-hydroxywarfarin enantiomers were also measured. In addition, CLpo and CLm were determined in a patient on warfarin and rifampicin. RESULTS Correlations between CLpo for warfarin enantiomers existed across the three populations. In addition, there was a significant correlation between the CLm for 7-hydroxylation of warfarin enantiomers. Under induced conditions by rifampicin, there were significant correlations between the enantio- and regio-selective metabolisms of warfarin. CONCLUSION Metabolic activities of CYP2C9, CYP1A2 and CYP3A4 may be regulated by common transcriptional mechanism(s).
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Affiliation(s)
- Harumi Takahashi
- Department of Biopharmaceutics, Meiji Pharmaceutical University, Tokyo, Japan
| | - Minami Ohara
- Department of Biopharmaceutics, Meiji Pharmaceutical University, Tokyo, Japan
| | - Soichi Shibata
- Department of Pharmacy, Kitasato Institute Hospital, Kitasato University, Tokyo, Japan
| | - Ming Ta Michael Lee
- Geisinger Health System, Danville, PN, USA.,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Larisa H Cavallari
- Department of Pharmacotherapy & Translational Research & Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Maria G Scordo
- Department of Medical Sciences, Clinical Pharmacology, Uppsala University Hospital, Uppsala, Sweden
| | - Vittorio Pengo
- Department of Cardiothoracic & Vascular Sciences, University of Padova, Padova, Italy
| | - Roberto Padrini
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Koichiro Atsuda
- Department of Pharmacy, Kitasato University Hospital, Kanagawa, Japan
| | - Hajime Matsubara
- Department of Pharmacy, Kitasato Institute Hospital, Kitasato University, Tokyo, Japan
| | - Yuan Tsong Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Hirotoshi Echizen
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Tokyo, Japan
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Nutescu EA, Wittkowsky AK, Dobesh PP, Hawkins DW, Dager WE. Choosing the Appropriate Antithrombotic Agent for the Prevention and Treatment of VTE: A Case-Based Approach. Ann Pharmacother 2016; 40:1558-71. [PMID: 16912250 DOI: 10.1345/aph.1g577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 11/27/2022] Open
Abstract
Objective: To review the risk of venous thromboembolism (VTE) in various patient populations and evaluate the agents available for the prevention and treatment of VTE using a case-based approach. Data Sources: A MEDLINE search (1995–July 2006) was conducted to identify relevant literature. Additional references were reviewed from selected articles. Study Selection and Data Extraction: Articles related to the prevention of VTE in orthopedic surgery, general surgery, and medically ill patients, as well as the treatment of VTE, were reviewed. Data Synthesis: Pharmacologic options for the prevention and treatment of VTE include warfarin, unfractionated heparin (UFH), low-molecular-weight heparins (LMWH), and fondaparinux. Current guidelines support the use of warfarin, LMWH, or fondaparinux for VTE prophylaxis following lower limb major orthopedic surgery. For VTE prophylaxis in hospitalized medical patients or patients undergoing general surgery, use of UFH and LMWH is supported; however, recent data on fondaparinux suggest that it is also effective in these patient populations. The use of UFH or LMWH (both in conjunction with warfarin) for treatment of acute deep venous thrombosis or nonmassive pulmonary embolism is recommended. Recent data suggest that fondaparinux (in conjunction with warfarin) is also effective for the treatment of VTE. A variety of pharmacokinetic, pharmacodynamic, and pharmacoeconomic factors differentiate each agent for the various indications. Conclusions: Currently, a “one-size-fits-all” anticoagulant is not available for treatment of VTE. A variety of patient factors, including type of surgery, medical indication, thrombotic risk factors, bleeding risk, history of heparin-induced thrombocytopenia, and a variety of comorbid conditions can affect the safety, efficacy, and selection of appropriate VTE therapy.
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Affiliation(s)
- Edith A Nutescu
- Antithrombosis Center, Department of Pharmacy Practice, College of Pharmacy, The University of Illinois at Chicago, Chicago, IL 60612-7230, USA.
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Abstract
Anticoagulant drugs are the foundation of therapy for patients with VTE. While effective therapeutic agents, anticoagulants can also result in hemorrhage and other side effects. Thus, anticoagulant therapy selection should be guided by the risks, benefits and pharmacologic characteristics of each agent for each patient. Safe use of anticoagulants requires not only an in-depth knowledge of their pharmacologic properties but also a comprehensive approach to patient management and education. This paper will summarize the key pharmacologic properties of the anticoagulant agents used in the treatment of patients with VTE.
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Affiliation(s)
- Edith A Nutescu
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology & Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
| | - Allison Burnett
- Inpatient Antithrombosis Services, University of New Mexico Hospital, University of New Mexico College of Pharmacy, Albuquerque, NM, USA
| | - John Fanikos
- Brigham and Women's Hospital, Massachusetts College of Pharmacy, Boston, MA, USA
| | - Sarah Spinler
- Philadelphia College of Pharmacy and Science, Philadelphia, PA, USA
| | - Ann Wittkowsky
- University of Washington School of Pharmacy, Seattle, WA, USA
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Arwood MJ, Chumnumwat S, Cavallari LH, Nutescu EA, Duarte JD. Implementing Pharmacogenomics at Your Institution: Establishment and Overcoming Implementation Challenges. Clin Transl Sci 2016; 9:233-245. [PMID: 27214750 PMCID: PMC5121089 DOI: 10.1111/cts.12404] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/12/2016] [Indexed: 12/21/2022] Open
Affiliation(s)
- M J Arwood
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - S Chumnumwat
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Rajathevi, Bangkok, Thailand
| | - L H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - E A Nutescu
- Personalized Medicine Program, University of Illinois College of Pharmacy, Chicago, Illinois, USA.,Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois College of Pharmacy, Chicago, Illinois, USA.,Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois College of Pharmacy, Chicago, Illinois, USA
| | - J D Duarte
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, Florida, USA
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Stone RH, Bress AP, Nutescu EA, Shapiro NL. Upper-Extremity Deep-Vein Thrombosis: A Retrospective Cohort Evaluation of Thrombotic Risk Factors at a University Teaching Hospital Antithrombosis Clinic. Ann Pharmacother 2016; 50:637-44. [PMID: 27189014 DOI: 10.1177/1060028016649601] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Upper-extremity deep-vein thrombosis (UEDVT) causes significant morbidity and mortality and is not well characterized in the existing literature, particularly in underrepresented minorities such as African Americans. OBJECTIVE To describe the characteristics of a cohort of patients with UEDVT seen at an urban academic medical center. METHODS This was a retrospective cohort study among patients with a confirmed UEDVT at the University of Illinois Hospital and Health Sciences System between 1996 and 2011. Patients were identified by ICD-9 code for UEDVT. Variables collected include thrombotic risk factors and outcomes, including recurrent thrombosis and bleeding. RESULTS We identified 229 patients with UEDVT; 71% were African American, and 11% were diagnosed with sickle cell disease. The average number of UEDVT risk factors was 4.40 ± 1.5, the most common being central venous catheter (CVC) use (178, 78%). In the year following UEDVT, 13% experienced recurrent thrombosis, and 6% experienced major bleeding. Of 181 patients receiving warfarin after an UEDVT, 36% of international normalized ratio (INR) values were therapeutic. Patients with sickle cell disease had a lower proportion of INRs within the target range (25% vs 38%, P < 0.01), and were more likely to be lost to follow-up (67% vs 46%, P = 0.05) and experience a recurrent thrombotic event (29% vs 11%, P = 0.02). CONCLUSION A CVC is the most common risk factor for UEDVT; however, patients with sickle cell disease demonstrate additional unique demographics and risk factors. Patients included in this underrepresented demographic cohort had a low quality of anticoagulation control, particularly those with sickle cell disease.
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Abstract
Anticoagulant drugs are the foundation of therapy for patients with VTE. While effective therapeutic agents, anticoagulants can also result in hemorrhage and other side effects. Thus, anticoagulant therapy selection should be guided by the risks, benefits and pharmacologic characteristics of each agent for each patient. Safe use of anticoagulants requires not only an in-depth knowledge of their pharmacologic properties but also a comprehensive approach to patient management and education. This paper will summarize the key pharmacologic properties of the anticoagulant agents used in the treatment of patients with VTE.
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Affiliation(s)
- Edith A Nutescu
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology & Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
| | - Allison Burnett
- Inpatient Antithrombosis Services, University of New Mexico Hospital, University of New Mexico College of Pharmacy, Albuquerque, NM, USA
| | - John Fanikos
- Brigham and Women's Hospital, Massachusetts College of Pharmacy, Boston, MA, USA
| | - Sarah Spinler
- Philadelphia College of Pharmacy and Science, Philadelphia, PA, USA
| | - Ann Wittkowsky
- University of Washington School of Pharmacy, Seattle, WA, USA
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Nagai R, Ohara M, Cavallari LH, Drozda K, Patel SR, Nutescu EA, Perera MA, Hernandez W, Kaneko N, Hibiya M, Takahashi H. Factors influencing pharmacokinetics of warfarin in African-Americans: implications for pharmacogenetic dosing algorithms. Pharmacogenomics 2015; 16:217-25. [PMID: 25712185 DOI: 10.2217/pgs.14.160] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
AIM This study attempted to identify predictors of S-warfarin clearance (CL[S]) and to make a pharmacokinetic evaluation of genotype-based dosing algorithms in African-Americans. METHODS Using plasma S-warfarin concentration (Cp[S]) at a steady state and eight SNPs previously shown to influence warfarin dose in African-Americans, CL(S) and its predictors were estimated by population pharmacokinetic analysis in 60 African-Americans. The time courses of Cp(S) following either the loading dose or maintenance dose were simulated using the population pharmacokinetic estimates. RESULTS CYP2C9*8 and body surface area or body weight were predictors of CL(S) (-30 and -5% per -0.1 m(2)/-10 kg reduction in CL[S], respectively) in African-Americans. Simulations of Cp(S) showed that Cp(S) at steady state was 1.4-times higher in patients with CYP2C9*8 than in those with CYP2C9*1/*1, irrespective of the algorithm for loading dose or maintenance dose. CONCLUSION African-Americans possess independent predictors of CL(S), possibly leading to a prediction error of any dosing algorithm that excludes African-specific variant(s). Original submitted 3 September 2014; Revision submitted 3 November 2014.
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Affiliation(s)
- Rui Nagai
- Department of Biopharmaceutics, Meiji Pharmaceutical University, Kiyose, Tokyo 204 8588, Japan
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Nutescu EA, Wittkowsky AK, Witt DM, Kaatz S, Ansell J, Burnett A, Garcia D, Lopes RD, Oertel L, Schnurr T, Streiff M, Wirth D, Crowther M. Integrating electronic health records in the delivery of optimized anticoagulation therapy. Ann Pharmacother 2015; 49:125-6. [PMID: 25524928 DOI: 10.1177/1060028014548570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Integration of accepted practice standards into electronic health record systems can facilitate standardization of anticoagulation care delivery and result in improved anticoagulation safety. However, the majority of commonly used electronic health record systems are lacking the specialized features necessary for optimal anticoagulation management. The Task Force on Electronic Health Records of the New York State Anticoagulation Coalition provides such a Consensus Statement in this issue of the journal. The Anticoagulation Forum endorses these recommendations and advises the electronic health record industry and health information technology programmers at the institutional level to adopt these recommendations in a comprehensive and timely manner.
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Affiliation(s)
- Edith A Nutescu
- University of Illinois at Chicago, IL, USA University of Illinois Hospital and Health Sciences System, IL, USA
| | | | | | - Scott Kaatz
- Hurley Medical Center, Flint Township, MI, USA
| | - Jack Ansell
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Allison Burnett
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - David Garcia
- University of Washington School of Medicine, Seattle, WA, USA
| | | | - Lynn Oertel
- Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Mark Crowther
- St Joseph's Healthcare Hamilton, ON, Canada McMaster University, Hamilton, ON, Canada
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Hellenbart E, Drambarean B, Lee J, Nutescu EA. The evolving role of dabigatran etexilate in clinical practice. Expert Opin Pharmacother 2015; 16:2053-72. [PMID: 26245513 DOI: 10.1517/14656566.2015.1074179] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Stroke and venous thromboembolism (VTE) affect millions of patients. The vitamin K antagonist, warfarin, has been the main oral anticoagulant used to treat these conditions despite many limitations associated with its use. Recently, multiple novel oral anticoagulants have been approved and are reshaping how patients with atrial fibrillation (AF) at risk of stroke and patients with VTE are treated. The direct thrombin inhibitor, dabigatran etexilate , is among these novel agents that have been developed to overcome limitations with warfarin. AREAS COVERED In this article, authors describe the pharmacokinetic and pharmacodynamic properties of dabigatran etexilate and summarize the clinical evidence and controversy surrounding its use in the US, Canada and Europe. EXPERT OPINION Dabigatran has demonstrated similar efficacy and safety to enoxaparin for VTE prevention in patients undergoing hip and knee arthroplasty, and to warfarin for the treatment of VTE. Dabigatran (110 mg) is noninferior and dabigatran (150 mg) is superior to warfarin for stroke prevention in patients with nonvalvular AF, with a lower rate of intracranial hemorrhage reported at both doses. Apixaban, rivaroxaban and edoxaban provide alternate anticoagulant options to dabigatran. While there are many similarities, there are also significant differences to consider in agent selection based on patient-specific characteristics.
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Affiliation(s)
- Erika Hellenbart
- University of Illinois at Chicago College of Pharmacy , 833 South Wood Street, Suite 164, MC 886, Chicago, IL 60612 , USA
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Barta AL, Nutescu EA, Thompson PA, Bussey HI, Gulseth MP. Relationship between time spent at extreme International Normalized Ratios and time in therapeutic range with bleeding and thrombosis in warfarin-treated patients. Am J Health Syst Pharm 2015; 72:1188-94. [DOI: 10.2146/ajhp140752] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Ashley L. Barta
- Sanford USD Medical Center, Sioux Falls, SD; when this project was conducted she was Postgraduate Year 1 Resident, Sanford USD Medical Center
| | - Edith A. Nutescu
- Department of Pharmacy Systems Outcomes and Policy, and Co-Director, Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy, Chicago
| | - Paul A. Thompson
- Methodology and Data Analysis Center, and Professor, Department of Pediatrics, Sanford School of Medicine, Sanford Research, Sioux Falls
| | - Henry I. Bussey
- ClotCare.org, San Antonio, TX, and President, Genesis Clinical Research, San Antonio
| | - Michael P. Gulseth
- Sanford USD Medical Center, and Adjunct Assistant Professor, College of Pharmacy, South Dakota State University, Sioux Falls
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Nordstrom BL, Evans MA, Murphy BR, Nutescu EA, Schein JR, Bookhart BK. Risk of recurrent venous thromboembolism among deep vein thrombosis and pulmonary embolism patients treated with warfarin. Curr Med Res Opin 2015; 31:439-47. [PMID: 25495136 DOI: 10.1185/03007995.2014.998814] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [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: 11/23/2022]
Abstract
OBJECTIVE Guidelines for warfarin treatment of venous thromboembolism (VTE) recommend targeting an international normalized ratio (INR) level of 2-3. This study examines the association between INR levels and VTE recurrence among warfarin-treated patients. METHODS A retrospective cohort study in the MedMining electronic health record database included adults treated with warfarin for VTE in 2004-2011. INR levels during warfarin use were categorized as below therapeutic range (<2), in range (2-3), or above range (>3), with time in each category estimated using the Rosendaal method. Recurrent VTE was noted from 30 days after the initial VTE to end of follow-up, which ranged up to 8 years. The incidence of recurrent VTE was calculated, and association with time-varying INR levels estimated using Cox models. RESULTS Of 1753 qualifying patients, 867 had deep vein thrombosis, and 886 had pulmonary embolism. Mean age was 58 years, and 50.7% were female. Across all follow-up time, VTE recurrences were observed in 134 (7.6%) patients, at a rate of 3.2 (95% confidence interval [CI]: 0.7-9.1) events per 100 person-years. The risk of VTE recurrence was greater during time spent with INR <2 than with INR in the therapeutic range (hazard ratio [HR]: 3.37; 95% CI: 2.16-5.27). Low platelet counts also predicted greater risk of VTE recurrence (HR: 2.13; 95% CI: 1.24-3.67). LIMITATIONS Exposure to warfarin and other anticoagulants was estimated based on prescription data and may be inaccurate. The study data include care within a single health system; thus, care received outside of the health system may be missing, and results may not be generalizable to the broader US population. CONCLUSIONS Approximately 8% of patients experienced a recurrent VTE during follow-up. Subtherapeutic INR levels were associated with a more than three-fold increased risk of VTE recurrence.
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