Effects of iloprost in patients with critical limb ischemia: Results of a cohort study from the COPART registry

BACKGROUND

Iloprost has been proposed as an alternative to amputation in Critical Limb Ischemia (CLI) patients when revascularization was unsuccessful or not possible. Nonetheless, there is limited evidence of its benefit. The main objective was to evaluate the effectiveness of iloprost and the secondary objective was to evaluate its safety.

METHODS

In this cohort study including CLI patients from the COPART registry from 2006/10 to 2021/01, patients exposed to iloprost were matched with up to three unexposed patients according to age, sex, and Propensity Score (PS) for exposure to iloprost. The main outcome combined the occurrence of all-cause death and major amputations; survival was assessed over one-year using Kaplan-Meier estimates and Cox model analyses. Major Adverse Cardiovascular Events (MACE) were chosen as the safety outcome; the association with iloprost was estimated using a logistic regression model.

RESULTS

Among 1850 CLI patients, 201 were exposed to iloprost (71.6% men; median age: 72 years vs. 72.1%; 75 years for unexposed). In 134 exposed patients matched to 375 unexposed patients, 14 major amputations and 24 deaths occurred in exposed patients (28.4%) vs. 33 and 46 respectively in the unexposed patients (20.9%). The hazard ratio (HR) was of 1.49 (95% Confidence Interval: 1.01-2.20). The association remained in the subgroup of "no option" patients (HR: 1.74; [1.01-2.20]). Regarding safety, 21/201 (10.7%) exposed patients experienced MACE vs. 146/1649 (9.41%) unexposed patients (unadjusted Odds Ratio [OR]: 1.17 [0.72-1.90]; adjusted OR: 1.23 [0.72-2.11]).

CONCLUSION

The study did not find any benefit of iloprost in CLI patients and even suggested a deleterious effect.

Increase in hospitalisation-associated methadone intoxication in France following first COVID-19 lockdown

OBJECTIVES

At the beginning of the COVID-19 pandemic, the French Addictovigilance Network drew attention to the need to facilitate access to methadone while ensuring its safe use, in order to avoid the occurrence of overdoses and deaths. The objectives of the study were to assess the impact of the lockdowns on the incidence of methadone-use-related hospitalisations (MUHs) and describe the characteristics of patients and hospitalisations.

STUDY DESIGN

An interrupted time series using the unobserved components model was performed to predict the monthly incidence of MUHs in 2020 on the basis of previous years' data and compared with MUHs observed. Data were presented with prediction intervals (PI95%).

METHODS

This retrospective study was conducted on patients hospitalised in France for methadone between 2014 and 2020, using the French national database hospital discharge database. Patients' characteristics and hospitalisations were described over four periods: before lockdown, first lockdown, after first lockdown, and second lockdown.

RESULTS

Compared to the predictions, a higher incidence of MUH was found during the first lockdown, especially in March 2020 (66 cases vs. 51.3; PI95%: 34-65), and there was a large increase during the month following the end of the first lockdown (79 cases vs. 61; PI95%: 46-75). Coconsumptions (alcohol, cannabis, cocaine) were more frequent during the first lockdown, whereas patients aged over 30 years were more concerned thereafter. The second lockdown did not present any particularity.

CONCLUSIONS

The first lockdown had a significant impact on the incidence of MUHs. These results confirm the data from the reinforced national monitoring during first lockdown published in 2020, where methadone was the primary substance involved in overdoses and deaths.

General hospital admissions in young and middle-aged people who use psychoactive substances: Impact of Covid-19 lockdowns

BACKGROUNDS

The Covid-19 pandemic offered a unique opportunity to investigate trends in hospitalizations related to psychoactive substance intoxication, since the usual health burden of social use at parties and gatherings was likely to be decreased during lockdowns and curfew periods. Since young adults are the main users of psychoactive substances for experimental and recreational purposes, this study identified and compared hospitalization trends in young adults and adults over 30 years old.

METHODS

This national cohort study was conducted using the French hospital discharge database. An interrupted time-series analysis for the period between 2014 and 2020 was performed in two groups: young (age 18-29) and other adults (30+) to ascertain the trends in the monthly incidence of hospitalization related to psychoactive substance intoxication (opiates, cocaine, benzodiazepines, psychostimulants, alcohol and cannabis). Hospitalization characteristics during the first and second lockdown and the period between them were compared to the reference period (from 01/01/2014 to 29/02/2020).

RESULTS

Among 1,358,007 stays associated with psychoactive substance intoxication, 215,430 concerned young adults. Compared with adults 30+, hospitalization trends in young adults showed a greater decrease in the number of stays during lockdown, with a maximum decrease of -39% during the first lockdown (1,566 vs. 2,576; CI95%: 2,285-2,868) versus -20% (10,212 vs. 12,894; CI95%: 12,001-13,787) in the second lockdown. Presentations for alcohol intoxication decreased throughout the pandemic, particularly during the second lockdown, while admissions for benzodiazepine intoxication increased during both lockdowns. Admissions for cannabis intoxication increased throughout the entire period.

CONCLUSIONS

Lockdowns were associated with fewer hospitalizations related to psychoactive substance intoxication in both age groups, especially among young adults, which might reflect a decrease in social use. Recreational use might therefore be an important target for prevention and risk minimization.

Risk of discontinuation of antipsychotic long-acting injections vs. oral antipsychotics in real-life prescribing practice: a community-based study

OBJECTIVE

To compare the risk of discontinuation of ambulatory antipsychotic treatment in persons treated with antipsychotic long-acting injections (LAIs) or by oral antipsychotics (OAPs).

METHODS

The study was performed in a representative sample of persons newly treated with OAPs (n = 6904) affiliated to the French Insurance Healthcare system. The risk of all-cause discontinuation was compared in patients prescribed OAPs (n = 246) vs. matched patients prescribed LAIs (n = 246) using multivariate survival analyses. Confounding by indication was minimized by matching on type of antipsychotic drug and by the high-dimensional propensity score method.

RESULTS

Discontinuation was more frequent with OAPs (69%) compared to LAIs (57%) [adjusted relative risk (aRR) = 1.6, 95% CI 1.23-2.07]. Risk of discontinuation was higher for first-generation (FGA) OAPs vs. FGA LAIs (aRR = 1.94, 95% CI 1.22-3.08) as well as for second-generation (SGA) OAPs vs. SGA LAIs (aRR = 1.58, 95% CI 1.15-2.17). Over the 6-month period after discontinuation of LAIs, a new antipsychotic drug was dispensed in 58% of patients, the most frequent pattern being dispensing of the same LAI as that prescribed before discontinuation.

CONCLUSIONS

Although less frequent than with OAPs, the rate of ambulatory treatment discontinuation was high with LAIs. Prescription of LAIs should be associated with intervention strategies aimed at promoting medication adherence.