Pub Date : 2012-12-01DOI: 10.1016/j.amjopharm.2012.11.001
Connie Marras MD, PhD , Nathan Herrmann MD , Geoffrey M. Anderson MD, PhD , Hadas D. Fischer MSc, MD , Xuesong Wang MSc , Paula A. Rochon MD, MPH
Background
Differences between atypical antipsychotics in their potential to cause parkinsonism and risk factors for antipsychotic-induced parkinsonism are not well established. There is a particular paucity of information on this in real-world use of these drugs, outside of clinical trial settings.
Objective
We compared the incidence of parkinsonism after new treatment with risperidone, olanzapine, or quetiapine in patients with dementia and examined the effects of dose and sex on the risk of parkinsonism.
Methods
Administrative data from Ontario, Canada between 2002 and 2010 were used to compare the incidence of a diagnostic code for parkinsonism or prescription of an anti-Parkinson medication among patients with dementia who were newly prescribed quetiapine, olanzapine, or risperidone.
Results
From 15,939 person-years of observation, 421 patients developed parkinsonism. Using low-dose risperidone as the reference group, the adjusted hazard ratios for developing parkinsonism were 0.49 (95% CI, 0.07–3.53) for low-dose olanzapine and 1.18 (95% CI, 0.84–1.66) for low-dose quetiapine. Comparing across drugs within the most commonly prescribed dose ranges, the incidence of parkinsonism was higher in the medium-dose olanzapine group compared with the low-dose risperidone group (hazard ratio 1.66; 95% CI 23–2.23). The adjusted hazard ratio for developing parkinsonism for men (compared with women) was 2.29 (95% CI, 1.88– 2.79).
Conclusions
We found no evidence that the risk of drug-induced parkinsonism in older adults with dementia was different among quetiapine, olanzapine, or risperidone, challenging the notion that the drugs differed in their propensity to cause parkinsonism. Men appeared to be at higher risk of parkinsonism as a adverse event than women.
{"title":"Atypical Antipsychotic Use and Parkinsonism in Dementia: Effects of Drug, Dose, and Sex","authors":"Connie Marras MD, PhD , Nathan Herrmann MD , Geoffrey M. Anderson MD, PhD , Hadas D. Fischer MSc, MD , Xuesong Wang MSc , Paula A. Rochon MD, MPH","doi":"10.1016/j.amjopharm.2012.11.001","DOIUrl":"10.1016/j.amjopharm.2012.11.001","url":null,"abstract":"<div><h3>Background</h3><p>Differences between atypical antipsychotics in their potential to cause parkinsonism and risk factors for antipsychotic-induced parkinsonism are not well established. There is a particular paucity of information on this in real-world use of these drugs, outside of clinical trial settings.</p></div><div><h3>Objective</h3><p>We compared the incidence of parkinsonism after new treatment with risperidone, olanzapine, or quetiapine in patients with dementia and examined the effects of dose and sex on the risk of parkinsonism.</p></div><div><h3>Methods</h3><p>Administrative data from Ontario, Canada between 2002 and 2010 were used to compare the incidence of a diagnostic code for parkinsonism or prescription of an anti-Parkinson medication among patients with dementia who were newly prescribed quetiapine, olanzapine, or risperidone.</p></div><div><h3>Results</h3><p>From 15,939 person-years of observation, 421 patients developed parkinsonism. Using low-dose risperidone as the reference group, the adjusted hazard ratios for developing parkinsonism were 0.49 (95% CI, 0.07–3.53) for low-dose olanzapine and 1.18 (95% CI, 0.84–1.66) for low-dose quetiapine. Comparing across drugs within the most commonly prescribed dose ranges, the incidence of parkinsonism was higher in the medium-dose olanzapine group compared with the low-dose risperidone group (hazard ratio 1.66; 95% CI 23–2.23). The adjusted hazard ratio for developing parkinsonism for men (compared with women) was 2.29 (95% CI, 1.88– 2.79).</p></div><div><h3>Conclusions</h3><p>We found no evidence that the risk of drug-induced parkinsonism in older adults with dementia was different among quetiapine, olanzapine, or risperidone, challenging the notion that the drugs differed in their propensity to cause parkinsonism. Men appeared to be at higher risk of parkinsonism as a adverse event than women.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 6","pages":"Pages 381-389.e3"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.11.001","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"31104543","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-12-01DOI: 10.1016/j.amjopharm.2012.09.006
Parinaz K. Ghaswalla PhD , Spencer E. Harpe PharmD, PhD, MPH , Daniel Tassone PharmD , Patricia W. Slattum PharmD, PhD
Background
Several classes of drugs, such as antibiotics, may interact with warfarin to cause an increase in wafarins anticoagulant activity and the clinical relevance of warfarin–antibiotic interactions in older adults is not clear.
Objective
The aim of this study was to determine the effect of oral antibiotics, such as amoxicillin, azithromycin, cephalexin, ciprofloxacin, levofloxacin, and moxifloxacin, on the international normalized ratio (INR) in patients ≥65 years on stable warfarin therapy. The secondary objective was to compare the effect of warfarin–antibiotic interactions on outcomes of overanticoagulation.
Methods
Data for this retrospective cohort study were collected through a medical record review of patients in an outpatient anticoagulation clinic of a Veterans Affairs medical center. Patients aged ≥65 years on stable warfarin therapy and with at least 1 prescription of an oral antibiotic of interest during the period from January 1, 2003 to March 1, 2011 were included. A mixed-effects repeated-measures ANOVA model was used to determine the effect of antibiotics on the mean change in patients' INR. The Fisher exact test was used to determine the association between the antibiotics and secondary outcomes of overanticoagulation, using cephalexin as the control. Statistical significance was defined as a P value <0.05.
Results
A total of 205 patients had 364 prescriptions for warfarin and antibiotics concomitantly, and there was a significant interaction between antibiotic and time (F15, 358 = 1.9; P = 0.0221). Antibiotics with a significant increase in INR were amoxicillin (P = 0.0019), azithromycin (P < 0.0001), ciprofloxacin (P = 0.002), levofloxacin (P < 0.0001) and moxifloxacin (P < 0.0001). There was a significant association between type of antibiotic and secondary outcomes of overanticoagulation.
Conclusions
In older patients on stable warfarin therapy, antibiotics may lead to an increase in INR. However, this may not result in clinically significant outcomes of bleeding or hospitalization, suggesting that antibiotics may be prescribed for older adults taking warfarin as long as their INR is being routinely monitored.
{"title":"Warfarin–Antibiotic Interactions in Older Adults of an Outpatient Anticoagulation Clinic","authors":"Parinaz K. Ghaswalla PhD , Spencer E. Harpe PharmD, PhD, MPH , Daniel Tassone PharmD , Patricia W. Slattum PharmD, PhD","doi":"10.1016/j.amjopharm.2012.09.006","DOIUrl":"10.1016/j.amjopharm.2012.09.006","url":null,"abstract":"<div><h3>Background</h3><p>Several classes of drugs<span>, such as antibiotics, may interact with warfarin to cause an increase in wafarins anticoagulant activity and the clinical relevance of warfarin–antibiotic interactions in older adults is not clear.</span></p></div><div><h3>Objective</h3><p><span><span><span>The aim of this study was to determine the effect of oral antibiotics, such as amoxicillin, </span>azithromycin, </span>cephalexin<span>, ciprofloxacin<span><span>, levofloxacin, and </span>moxifloxacin, on the international normalized ratio (INR) </span></span></span>in patients ≥65 years on stable warfarin therapy. The secondary objective was to compare the effect of warfarin–antibiotic interactions on outcomes of overanticoagulation.</p></div><div><h3>Methods</h3><p><span><span><span>Data for this retrospective cohort study were collected through a </span>medical record review of patients in an outpatient anticoagulation clinic of a </span>Veterans Affairs<span><span> medical center. Patients aged ≥65 years on stable warfarin therapy and with at least 1 prescription of an oral antibiotic of interest during the period from January 1, 2003 to March 1, 2011 were included. A mixed-effects repeated-measures ANOVA model was used to determine the effect of antibiotics on the mean change in patients' INR. The </span>Fisher exact test was used to determine the association between the antibiotics and secondary outcomes of overanticoagulation, using cephalexin as the control. Statistical significance was defined as a </span></span><em>P</em> value <0.05.</p></div><div><h3>Results</h3><p>A total of 205 patients had 364 prescriptions for warfarin and antibiotics concomitantly, and there was a significant interaction between antibiotic and time (<em>F</em><sub>15, 358</sub> = 1.9; <em>P</em> = 0.0221). Antibiotics with a significant increase in INR were amoxicillin (<em>P</em> = 0.0019), azithromycin (<em>P</em> < 0.0001), ciprofloxacin (<em>P</em> = 0.002), levofloxacin (<em>P</em> < 0.0001) and moxifloxacin (<em>P</em> < 0.0001). There was a significant association between type of antibiotic and secondary outcomes of overanticoagulation.</p></div><div><h3>Conclusions</h3><p>In older patients on stable warfarin therapy, antibiotics may lead to an increase in INR. However, this may not result in clinically significant outcomes of bleeding or hospitalization, suggesting that antibiotics may be prescribed for older adults taking warfarin as long as their INR is being routinely monitored.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 6","pages":"Pages 352-360"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.09.006","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30994496","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-12-01DOI: 10.1016/j.amjopharm.2012.09.005
Richard H. Stanford PharmD, MS , Christopher M. Blanchette PhD , Melissa H. Roberts MS , Hans Petersen MS , Anne L. Fuhlbrigge MD, MS
Background
National asthma treatment guidelines recommend either the use of inhaled corticosteroids (ICS) or ICS in combination with a long-acting bronchodilator for the treatment of moderate to severe asthma. Even though asthma is common among older adults, few studies have assessed the differences in effectiveness between these two recommended therapies in patients over 65 years of age.
Objective
The aim of this study was to assess the association of the fluticasone-salmeterol combination (FSC) or ICS initiation on asthma-related events in Medicare-eligible asthma patients.
Methods
This was a retrospective observational study using a large health claims database (July 1, 2001 to June 30, 2008). Subjects 65 to 79 years of age with 12-month preindex and 3- to 12-month postindex eligibility, an asthma diagnosis (ICD-493.xx), and with 1 or more FSC or ICS claims at index were included. Subjects with an FSC or ICS claim in the preindex and any claim for chronic obstructive pulmonary disease were excluded. Subjects were observed until they had an event (emergency department [ED] inpatient hospitalization [IP], combined IP/ED or oral corticosteroid [OCS] use) or were no longer eligible in the database, whichever came first. Cox proportional hazards regression was used to assess risk of an asthma-related event (IP, ED, or IP/ED). Baseline characteristics (age, sex, region, index season, comorbidities, preindex use of short-acting β-agonists, OCS, other asthma controllers, and asthma-related ED/IP visits) were independent covariates in the model.
Results
A total of 10,837 met the criteria (4843 ICS and 5994 FSC). Age (70.4 and 70.5 years, respectively) and the percentage of female subjects (65.5% and 64.8%, respectively) were similar. Asthma-related events were also similar at baseline. Postindex unadjusted rates occurring after >30 days were ED (1.8% vs 1.5%, P = 0.18), IP (2.7% vs 1.7%, P < 0.001), and ED/IP (4.1% vs 2.8%, P < 0.001) for ICS and FSC, respectively. Subjects who received FSC were associated with a 32% (adjusted HR = 0.68; 95% CI, 0.51–0.91) lower risk of experiencing an IP visit and a 22% (HR = 0.78; 95% CI, 0.62–0.98) lower risk of experiencing an ED/IP visit. No differences were observed for ED visits (HR = 0.94; 95% CI, 0.68–1.29).
Conclusions
In Medicare-eligible asthma patients, FSC use was associated with lower rates of asthma-related serious exacerbations compared with ICS.
背景:国家哮喘治疗指南推荐使用吸入皮质类固醇(ICS)或ICS联合长效支气管扩张剂治疗中度至重度哮喘。尽管哮喘在老年人中很常见，但很少有研究评估这两种推荐疗法在65岁以上患者中的有效性差异。目的本研究的目的是评估氟替卡松-沙美特罗联合用药(FSC)或ICS启动与符合医疗保险条件的哮喘患者哮喘相关事件的关系。方法采用大型健康声明数据库(2001年7月1日至2008年6月30日)进行回顾性观察性研究。受试者年龄65 - 79岁，指数前12个月和指数后3- 12个月符合条件，哮喘诊断(ICD-493.xx)，指数时有1次或1次以上FSC或ICS索赔。在前指数中有FSC或ICS索赔和任何慢性阻塞性肺疾病索赔的受试者被排除在外。受试者一直观察到他们发生事件(急诊科[ED]住院住院[IP]， IP/ED联合使用或口服皮质类固醇[OCS]使用)或不再符合数据库中的条件，以先到者为准。采用Cox比例风险回归评估哮喘相关事件(IP、ED或IP/ED)的风险。基线特征(年龄、性别、地区、指数季节、合并症、指数前使用短效β激动剂、OCS、其他哮喘控制者和哮喘相关ED/IP就诊)是模型中的独立协变量。结果10837例符合标准，其中ICS 4843例，FSC 5994例。年龄(分别为70.4岁和70.5岁)和女性比例(分别为65.5%和64.8%)相似。哮喘相关事件在基线时也相似。30天后发生的指数后未调整率为ED (1.8% vs 1.5%， P = 0.18)， IP (2.7% vs 1.7%， P <0.001)， ED/IP (4.1% vs 2.8%， P <ICS和FSC分别为0.001)。接受FSC的受试者与32%(调整后HR = 0.68;95% CI, 0.51-0.91)，经历IP访问的风险降低22% (HR = 0.78;95% CI, 0.62-0.98)经历ED/IP访问的风险降低。急诊科就诊无差异(HR = 0.94;95% ci, 0.68-1.29)。结论在符合医疗保险条件的哮喘患者中，与ICS相比，FSC的使用与哮喘相关严重恶化的发生率较低相关。
{"title":"Effect of Combination Fluticasone Propionate and Salmeterol or Inhaled Corticosteroids on Asthma-Related Outcomes in a Medicare-Eligible Population","authors":"Richard H. Stanford PharmD, MS , Christopher M. Blanchette PhD , Melissa H. Roberts MS , Hans Petersen MS , Anne L. Fuhlbrigge MD, MS","doi":"10.1016/j.amjopharm.2012.09.005","DOIUrl":"10.1016/j.amjopharm.2012.09.005","url":null,"abstract":"<div><h3>Background</h3><p><span><span>National asthma treatment<span> guidelines recommend either the use of inhaled corticosteroids (ICS) or ICS in combination with a long-acting bronchodilator for the treatment of moderate to </span></span>severe asthma. Even though asthma is common among older adults, few studies have assessed the differences in effectiveness between these two recommended therapies </span>in patients over 65 years of age.</p></div><div><h3>Objective</h3><p>The aim of this study was to assess the association of the fluticasone-salmeterol combination (FSC) or ICS initiation on asthma-related events in Medicare-eligible asthma patients.</p></div><div><h3>Methods</h3><p>This was a retrospective observational study using a large health claims database (July 1, 2001 to June 30, 2008). Subjects 65 to 79 years of age with 12-month preindex and 3- to 12-month postindex eligibility, an asthma diagnosis (ICD-493.xx), and with 1 or more FSC or ICS claims at index were included. Subjects with an FSC or ICS claim in the preindex and any claim for chronic obstructive pulmonary disease<span> were excluded. Subjects were observed until they had an event (emergency department [ED] inpatient hospitalization [IP], combined IP/ED or oral corticosteroid [OCS] use) or were no longer eligible in the database, whichever came first. Cox proportional hazards regression was used to assess risk of an asthma-related event (IP, ED, or IP/ED). Baseline characteristics (age, sex, region, index season, comorbidities, preindex use of short-acting β-agonists, OCS, other asthma controllers, and asthma-related ED/IP visits) were independent covariates in the model.</span></p></div><div><h3>Results</h3><p>A total of 10,837 met the criteria (4843 ICS and 5994 FSC). Age (70.4 and 70.5 years, respectively) and the percentage of female subjects (65.5% and 64.8%, respectively) were similar. Asthma-related events were also similar at baseline. Postindex unadjusted rates occurring after >30 days were ED (1.8% vs 1.5%, <em>P</em> = 0.18), IP (2.7% vs 1.7%, <em>P</em> < 0.001), and ED/IP (4.1% vs 2.8%, <em>P</em> < 0.001) for ICS and FSC, respectively. Subjects who received FSC were associated with a 32% (adjusted HR = 0.68; 95% CI, 0.51–0.91) lower risk of experiencing an IP visit and a 22% (HR = 0.78; 95% CI, 0.62–0.98) lower risk of experiencing an ED/IP visit. No differences were observed for ED visits (HR = 0.94; 95% CI, 0.68–1.29).</p></div><div><h3>Conclusions</h3><p>In Medicare-eligible asthma patients, FSC use was associated with lower rates of asthma-related serious exacerbations compared with ICS.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 6","pages":"Pages 343-351"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.09.005","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30991431","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-12-01DOI: 10.1016/j.amjopharm.2012.11.002
Edeltraut Kröger PhD , Mieke Berkers MSc , Pierre-Hugues Carmichael MSc , Patrick Souverein PhD , Rob van Marum MD , Toine Egberts PhD
Background
Two cholinesterase inhibitors (ChEIs), rivastigmine and galantamine, are used to treat Alzheimer disease in the Netherlands. Several adverse cardiac events have been reported for these medications.
Objective
We aimed to assess if the use of ChEIs increased the risk of cardiac events in the Netherlands.
Methods
A cohort crossover study of the PHARMO Record Linking System database included patients who initiated ChEIs at age 50 years or older, had at least 1 dispensing of a ChEI drug between 1998 and 2008, a 1-year history in PHARMO, and 1 subsequent dispensing of any medication. Two outcomes were assessed: a first hospitalization for syncope or atrioventricular block. Poisson and Cox regression were used to calculate incidence densities and hazard ratios for cardiac events during periods with ChEI use, compared with periods without ChEI use.
Results
During the complete observation period of 8.9 years (interquartile range 6.7 to 10.2) there were 132 first hospitalizations for atrioventricular block and 17 first hospitalizations for syncope among 3358 patients. The adjusted incidence densities were significantly increased during ChEI exposure for syncope and atrioventricular block, when compared with the background incidence densities in the roughly 5 years before the last year before ChEI initiation. However, when exposed periods were compared with the unexposed periods 1 year before ChEI initiation and times after exposure, the adjusted hazard ratios remained increased for syncope and atrioventricular block, but increases were not significant anymore.
Conclusions
Exposure to ChEIs might increase the risk of adverse cardiac events, but small numbers of cases limit conclusions about the risk in this population and research on larger study samples is needed.
{"title":"Use of Rivastigmine or Galantamine and Risk of Adverse Cardiac Events: A Database Study from the Netherlands","authors":"Edeltraut Kröger PhD , Mieke Berkers MSc , Pierre-Hugues Carmichael MSc , Patrick Souverein PhD , Rob van Marum MD , Toine Egberts PhD","doi":"10.1016/j.amjopharm.2012.11.002","DOIUrl":"10.1016/j.amjopharm.2012.11.002","url":null,"abstract":"<div><h3>Background</h3><p>Two cholinesterase inhibitors<span><span> (ChEIs), rivastigmine<span> and galantamine, are used to treat </span></span>Alzheimer disease in the Netherlands. Several adverse cardiac events have been reported for these medications.</span></p></div><div><h3>Objective</h3><p>We aimed to assess if the use of ChEIs increased the risk of cardiac events in the Netherlands.</p></div><div><h3>Methods</h3><p>A cohort crossover study of the PHARMO Record Linking System database included patients who initiated ChEIs at age 50 years or older, had at least 1 dispensing of a ChEI drug<span><span> between 1998 and 2008, a 1-year history in PHARMO, and 1 subsequent dispensing of any medication. Two outcomes were assessed: a first hospitalization for syncope or atrioventricular block. Poisson and </span>Cox regression were used to calculate incidence densities and hazard ratios for cardiac events during periods with ChEI use, compared with periods without ChEI use.</span></p></div><div><h3>Results</h3><p>During the complete observation period of 8.9 years (interquartile range 6.7 to 10.2) there were 132 first hospitalizations for atrioventricular block and 17 first hospitalizations for syncope among 3358 patients. The adjusted incidence densities were significantly increased during ChEI exposure for syncope and atrioventricular block, when compared with the background incidence densities in the roughly 5 years before the last year before ChEI initiation. However, when exposed periods were compared with the unexposed periods 1 year before ChEI initiation and times after exposure, the adjusted hazard ratios remained increased for syncope and atrioventricular block, but increases were not significant anymore.</p></div><div><h3>Conclusions</h3><p>Exposure to ChEIs might increase the risk of adverse cardiac events, but small numbers of cases limit conclusions about the risk in this population and research on larger study samples is needed.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 6","pages":"Pages 373-380"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.11.002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"31102974","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-12-01DOI: 10.1016/j.amjopharm.2012.11.003
Gregory Reardon RPh, PhD , Naushira Pandya MD , Edith A. Nutescu PharmD , Joyce Lamori MHS, MBA , Chandrasekhar V. Damaraju PhD , Jeff Schein DrPH, MPH , Brahim K. Bookhart MBA, MPH
Background
Treatment of venous thromboembolism (VTE) in long-term care (LTC) settings has received little empirical study.
Objective
Among residents with VTE in nursing homes, this analysis evaluated frequency of anticoagulant use, the proportion of residents newly started on warfarin who persisted on therapy (≥3 months), and the association of key resident characteristics, including bleeding risk, with warfarin use and persistence.
Methods
Using the AnalytiCare LTC database (US), eligible residents had deep vein thrombosis or pulmonary embolism coded in the Minimum Data Set (MDS) 2.0 during the uptake period April 1, 2007 through December 31, 2008 (earliest VTE was index date) and had 1 or more MDS assessment(s) over the 90-day preindex period, each negative for VTE. Logistic regression evaluated the association of resident characteristics with warfarin use. Cox regression evaluated persistence with warfarin therapy.
Results
The median age of residents with VTE included in the analysis (N = 489) was 80 years; 73% received anticoagulant therapy and 66% were prescribed warfarin ±45 days of the index date. Multivariate logistic regression identified several factors significantly associated with warfarin use: location in South Central region (odds ratio [OR] = 1.94, P = 0.019) and the Western region (OR = 2.53, P = 0.005) [both vs reference South Atlantic]; body mass index categories normal (OR = 2.73, P = 0.045), overweight (OR = 4.21, P = 0.005), and obese (OR = 3.82, P = 0.010) (both vs reference underweight); Alzheimer's/dementia (OR = 0.52, P = 0.024); cancer (OR = 0.39, P = 0.008); and moderate-dependent versus independent physical functioning (OR = 2.59, P = 0.003). Of residents newly started on warfarin therapy with no history of cancer (n = 149), 28% discontinued warfarin within 90 days of initiation. Peripheral vascular disease (PVD) (OR = 4.07, P < 0.001), Alzheimer's disease/dementia (OR = 2.55, P = 0.046), and antipsychotic use (OR = 4.60, P < 0.001) were all significantly associated with discontinuation.
Conclusions
Patients in specific geographic regions who were underweight, had Alzheimer's disease/dementia or cancer, or had independent physical functioning were less likely to receive warfarin. Nonpersistence of warfarin therapy was strongly related to antipsychotic use, presence of dementia, or PVD.
背景:长期护理(LTC)环境下静脉血栓栓塞(VTE)的治疗很少得到实证研究。目的:分析疗养院静脉血栓栓塞患者使用抗凝剂的频率、新开始华法林治疗并持续治疗(≥3个月)的比例，以及住院患者出血风险等关键特征与华法林使用和持续治疗的关系。方法使用AnalytiCare LTC数据库(美国)，在2007年4月1日至2008年12月31日期间(最早VTE为索引日期)，符合条件的居民在最小数据集(MDS) 2.0中编码有深静脉血栓形成或肺栓塞，并在90天的索引前期间进行了1次或多次MDS评估，每次VTE均为阴性。Logistic回归评估住院特征与华法林使用的关系。Cox回归评估华法林治疗的持续性。结果纳入分析的静脉血栓栓塞患者(N = 489)的中位年龄为80岁;73%的患者接受了抗凝治疗，66%的患者在指标日期±45天内服用华法林。多因素logistic回归确定了与华法林使用显著相关的几个因素:位于中南部地区(比值比[OR] = 1.94, P = 0.019)和西部地区(OR = 2.53, P = 0.005)[均与南大西洋对照];体重指数分类为正常(OR = 2.73, P = 0.045)、超重(OR = 4.21, P = 0.005)和肥胖(OR = 3.82, P = 0.010)(均与参考体重过轻相比);阿尔茨海默病/痴呆(OR = 0.52, P = 0.024);癌症(OR = 0.39, P = 0.008);中度依赖与独立的身体功能差异(OR = 2.59, P = 0.003)。在新开始华法林治疗且无癌症史的居民中(149例)，28%在开始治疗90天内停用华法林。外周血管疾病(PVD) (OR = 4.07, P <0.001)、阿尔茨海默病/痴呆(OR = 2.55, P = 0.046)和抗精神病药物使用(OR = 4.60, P <0.001)均与停药显著相关。结论在特定的地理区域，体重过轻、患有阿尔茨海默病/痴呆或癌症或具有独立身体功能的患者接受华法林的可能性较低。华法林治疗不持续与抗精神病药物使用、痴呆或PVD的存在密切相关。
{"title":"Use of Warfarin Therapy Among Residents Who Developed Venous Thromboembolism in the Nursing Home","authors":"Gregory Reardon RPh, PhD , Naushira Pandya MD , Edith A. Nutescu PharmD , Joyce Lamori MHS, MBA , Chandrasekhar V. Damaraju PhD , Jeff Schein DrPH, MPH , Brahim K. Bookhart MBA, MPH","doi":"10.1016/j.amjopharm.2012.11.003","DOIUrl":"10.1016/j.amjopharm.2012.11.003","url":null,"abstract":"<div><h3>Background</h3><p>Treatment<span> of venous thromboembolism (VTE) in long-term care (LTC) settings has received little empirical study.</span></p></div><div><h3>Objective</h3><p>Among residents with VTE in nursing homes, this analysis evaluated frequency of anticoagulant use, the proportion of residents newly started on warfarin who persisted on therapy (≥3 months), and the association of key resident characteristics, including bleeding risk, with warfarin use and persistence.</p></div><div><h3>Methods</h3><p><span>Using the AnalytiCare LTC database (US), eligible residents had deep vein thrombosis<span> or pulmonary embolism coded in the Minimum Data Set (MDS) 2.0 during the uptake period April 1, 2007 through December 31, 2008 (earliest VTE was index date) and had 1 or more MDS assessment(s) over the 90-day preindex period, each negative for VTE. </span></span>Logistic regression<span> evaluated the association of resident characteristics with warfarin use. Cox regression evaluated persistence with warfarin therapy.</span></p></div><div><h3>Results</h3><p><span>The median age of residents with VTE included in the analysis (N = 489) was 80 years; 73% received anticoagulant therapy and 66% were prescribed warfarin ±45 days of the index date. Multivariate logistic regression identified several factors significantly associated with warfarin use: location in South Central region (odds ratio [OR] = 1.94, </span><em>P</em> = 0.019) and the Western region (OR = 2.53, <em>P</em><span> = 0.005) [both vs reference South Atlantic]; body mass index categories normal (OR = 2.73, </span><em>P</em> = 0.045), overweight (OR = 4.21, <em>P</em> = 0.005), and obese (OR = 3.82, <em>P</em> = 0.010) (both vs reference underweight); Alzheimer's/dementia (OR = 0.52, <em>P</em> = 0.024); cancer (OR = 0.39, <em>P</em> = 0.008); and moderate-dependent versus independent physical functioning (OR = 2.59, <em>P</em><span> = 0.003). Of residents newly started on warfarin therapy with no history of cancer (n = 149), 28% discontinued warfarin within 90 days of initiation. Peripheral vascular disease (PVD) (OR = 4.07, </span><em>P</em> < 0.001), Alzheimer's disease/dementia (OR = 2.55, <em>P</em><span> = 0.046), and antipsychotic use (OR = 4.60, </span><em>P</em> < 0.001) were all significantly associated with discontinuation.</p></div><div><h3>Conclusions</h3><p>Patients in specific geographic regions who were underweight, had Alzheimer's disease/dementia or cancer, or had independent physical functioning were less likely to receive warfarin. Nonpersistence of warfarin therapy was strongly related to antipsychotic use, presence of dementia, or PVD.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 6","pages":"Pages 361-372"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.11.003","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"31102973","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-12-01DOI: 10.1016/j.amjopharm.2012.09.004
Christine K. O'Neil PharmD , Joseph T. Hanlon PharmD, MS , Zachary A. Marcum PharmD, MS
Background
Osteoarthritis (OA) is the most common cause of disability in older adults, and although analgesic use can be helpful, it can also result in adverse drug events.
Objective
To review the recent literature to describe potential adverse drug events associated with analgesics commonly used by older adults with OA.
Methods
To identify articles for this review, a systematic search of the English-language literature from January 2001 to June 2012 was conducted using PubMed, MEDLINE, EBSCO, and the Cochrane Database of Systematic Reviews for publications related to the medical management of OA. Search terms used were “analgesics,” “acetaminophen,” “nonsteroidal anti-inflammatory drugs” (NSAIDs), “opioids,” “pharmacokinetics,” “pharmacodynamics,” and “adverse drug events.” The search was restricted to those articles that concerned humans aged ≥65 years. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that examined analgesic use in older adults.
Results
There are limited data to suggest that non-frail elders are more likely than their younger counterparts to develop acetaminophen-induced hepatotoxicity. However, decreased hepatic phase II metabolism in frail elders may result in increased risk of hepatotoxicity. It is now well established that older adults are at higher risk of NSAID-induced gastrointestinal toxicity and renal insufficiency. Insofar as opioids, the data that suggest an increased risk of falls, fractures, or delirium need to be tempered by the potential risk of inadequately treating severe chronic OA-related pain.
Conclusions
Acetaminophen is the mainstay frontline analgesic for treating OA-related pain in older adults. NSAIDs should be limited to short-term use only, and for moderate to severe OA-related pain, opioids may be preferable in individuals without substance abuse or dependence issues.
{"title":"Adverse Effects of Analgesics Commonly Used by Older Adults With Osteoarthritis: Focus on Non-Opioid and Opioid Analgesics","authors":"Christine K. O'Neil PharmD , Joseph T. Hanlon PharmD, MS , Zachary A. Marcum PharmD, MS","doi":"10.1016/j.amjopharm.2012.09.004","DOIUrl":"10.1016/j.amjopharm.2012.09.004","url":null,"abstract":"<div><h3>Background</h3><p>Osteoarthritis<span> (OA) is the most common cause of disability in older adults, and although analgesic<span> use can be helpful, it can also result in adverse drug events.</span></span></p></div><div><h3>Objective</h3><p>To review the recent literature to describe potential adverse drug events associated with analgesics commonly used by older adults with OA.</p></div><div><h3>Methods</h3><p><span>To identify articles for this review, a systematic search of the English-language literature from January 2001 to June 2012 was conducted using PubMed, MEDLINE, EBSCO, and the Cochrane Database of Systematic Reviews for publications related to the medical management of OA. Search terms used were “</span><em>analgesics</em>,” “<span><em>acetaminophen</em></span>,” “<em>nonsteroidal anti-inflammatory drugs</em>” (NSAIDs), “<em>opioids</em>,” “<span><em>pharmacokinetics</em></span>,” “<span><em>pharmacodynamics</em></span>,” and “<em>adverse drug events</em>.” The search was restricted to those articles that concerned humans aged ≥65 years. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that examined analgesic use in older adults.</p></div><div><h3>Results</h3><p>There are limited data to suggest that non-frail elders are more likely than their younger counterparts to develop acetaminophen-induced hepatotoxicity<span>. However, decreased hepatic phase II metabolism in frail elders may result in increased risk of hepatotoxicity. It is now well established that older adults are at higher risk of NSAID-induced gastrointestinal toxicity and renal insufficiency. Insofar as opioids, the data that suggest an increased risk of falls, fractures, or delirium need to be tempered by the potential risk of inadequately treating severe chronic OA-related pain.</span></p></div><div><h3>Conclusions</h3><p>Acetaminophen is the mainstay frontline analgesic for treating OA-related pain in older adults. NSAIDs should be limited to short-term use only, and for moderate to severe OA-related pain, opioids may be preferable in individuals without substance abuse or dependence issues.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 6","pages":"Pages 331-342"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.09.004","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30954068","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-10-01DOI: 10.1016/j.amjopharm.2012.08.003
Shih-Yin Chen PhD , Julie Vanderpoel PharmD, MPA , Samir Mody PharmD, MBA , Winnie W. Nelson PharmD, MS , Jeffrey Schein DrPH, MPH , Preethi Rao BA , Luke Boulanger MA, MBA
Background
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and disproportionately affects the elderly.
Objective
This study describes patient characteristics and caregiver assistance among Medicare beneficiaries with AF and examines factors associated with receiving anticoagulant treatment.
Methods
Patients with AF and age/gender-matched controls were identified from Medicare Current Beneficiary Survey data from 2001 to 2006. A logistic regression model was used to assess factors associated with receiving anticoagulants in a subgroup of patients with AF whose treatment pattern was established for 2 consecutive years. Sample weights were applied to obtain nationally representative estimates.
Results
A total of 2990 patients with AF and 5980 control patients were included in the burden of disease analysis, and 1481 patients with AF were included in the anticoagulant predictor analysis. Patients with AF had a higher level of comorbidity (Charlson Comorbidity Index: 3.3 vs 1.5; P < 0.05), worse self-perceived health status (P < 0.001), and greater level of disability (P < 0.001) than their matched counterparts. A greater proportion of patients with AF required caregiver assistance (62.8% vs 51.5%; P < 0.001). Logistic regression found that higher Charlson Comorbidity Index scores, difficulty in obtaining necessary health care, older age, being widowed, a history of psychiatric disorders, and being underweight decreased the likelihood of receiving anticoagulant therapy.
Conclusions
In a Medicare population, a greater need for caregiver assistance was observed in patients with AF. Subgroups characterized by frailty or inability for self-care were identified as being less likely to receive anticoagulant therapy. The need for caregiver assistance among patients with AF, as well as the patient subgroups identified as less likely to receive anticoagulant therapy, should be considered when making treatment decisions.
房颤(AF)是最常见的持续性心律失常，对老年人的影响尤为严重。目的:本研究描述了AF医疗保险受益人的患者特征和护理人员的帮助，并探讨了接受抗凝治疗的相关因素。方法从2001年至2006年的医疗保险受益人调查数据中确定房颤患者和年龄/性别匹配的对照组。采用logistic回归模型评估连续2年治疗模式确定的房颤亚组患者接受抗凝治疗的相关因素。使用样本权重来获得具有全国代表性的估计。结果共有2990例房颤患者和5980例对照患者被纳入疾病负担分析，1481例房颤患者被纳入抗凝预测分析。房颤患者的合并症水平更高(Charlson共病指数:3.3 vs 1.5;P & lt;0.05)，自我感觉健康状况较差(P <0.001)和更大程度的残疾(P <0.001)。房颤患者需要护理人员帮助的比例更高(62.8% vs 51.5%;P & lt;0.001)。逻辑回归发现，较高的Charlson合并症指数评分、难以获得必要的医疗保健、年龄较大、丧偶、有精神疾病史和体重过轻降低了接受抗凝治疗的可能性。结论:在医疗保险人群中，观察到AF患者对护理人员帮助的需求更大。以虚弱或无法自我护理为特征的亚组被认为不太可能接受抗凝治疗。在做出治疗决定时，应考虑房颤患者以及不太可能接受抗凝治疗的患者亚组对护理人员帮助的需求。
{"title":"Caregiver Assistance Among Medicare Beneficiaries With Atrial Fibrillation and Factors Associated With Anticoagulant Treatment","authors":"Shih-Yin Chen PhD , Julie Vanderpoel PharmD, MPA , Samir Mody PharmD, MBA , Winnie W. Nelson PharmD, MS , Jeffrey Schein DrPH, MPH , Preethi Rao BA , Luke Boulanger MA, MBA","doi":"10.1016/j.amjopharm.2012.08.003","DOIUrl":"10.1016/j.amjopharm.2012.08.003","url":null,"abstract":"<div><h3>Background</h3><p>Atrial fibrillation<span> (AF) is the most common sustained cardiac arrhythmia and disproportionately affects the elderly.</span></p></div><div><h3>Objective</h3><p>This study describes patient characteristics<span> and caregiver assistance among Medicare beneficiaries with AF and examines factors associated with receiving anticoagulant treatment.</span></p></div><div><h3>Methods</h3><p>Patients with AF and age/gender-matched controls were identified from Medicare Current Beneficiary Survey data from 2001 to 2006. A logistic regression<span> model was used to assess factors associated with receiving anticoagulants<span> in a subgroup of patients with AF whose treatment pattern was established for 2 consecutive years. Sample weights were applied to obtain nationally representative estimates.</span></span></p></div><div><h3>Results</h3><p>A total of 2990 patients with AF and 5980 control patients were included in the burden of disease analysis, and 1481 patients with AF were included in the anticoagulant predictor analysis. Patients with AF had a higher level of comorbidity (Charlson Comorbidity Index: 3.3 vs 1.5; <em>P</em> < 0.05), worse self-perceived health status (<em>P</em> < 0.001), and greater level of disability (<em>P</em> < 0.001) than their matched counterparts. A greater proportion of patients with AF required caregiver assistance (62.8% vs 51.5%; <em>P</em><span> < 0.001). Logistic regression found that higher Charlson Comorbidity Index<span> scores, difficulty in obtaining necessary health care, older age, being widowed, a history of psychiatric disorders, and being underweight decreased the likelihood of receiving anticoagulant therapy.</span></span></p></div><div><h3>Conclusions</h3><p><span>In a Medicare population, a greater need for caregiver assistance was observed in patients with AF. Subgroups characterized by </span>frailty or inability for self-care were identified as being less likely to receive anticoagulant therapy. The need for caregiver assistance among patients with AF, as well as the patient subgroups identified as less likely to receive anticoagulant therapy, should be considered when making treatment decisions.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 5","pages":"Pages 273-283"},"PeriodicalIF":0.0,"publicationDate":"2012-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.08.003","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30906154","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-10-01DOI: 10.1016/j.amjopharm.2012.09.002
Adrienne M. Gilligan MSc, Daniel C. Malone PhD, RPh, Terri L. Warholak PhD, RPh, Edward P. Armstrong PharmD
Background
Treatment disparities in Alzheimer's disease (AD) have received little attention. Determining whether disparities exist in this subpopulation is an important health policy issue.
Objective
The aim was to determine whether an association existed between race/ethnicity and exposure to AD pharmacotherapy across 4 state Medicaid populations.
Methods
Data from the Centers for Medicare and Medicaid Services (CMS) were used in this retrospective study. Persons with AD enrolled in California, Florida, New Jersey, or New York Medicaid programs on January 1, 2004, and remained in that program for 1 year. Individuals had an AD diagnosis based on the ICD-9-CM code 331.0. Outcomes of interest were exposure to a cholinesterase inhibitor (ChEI) or memantine. Multivariate logistic regression was used to test for the association between race/ethnicity and exposure to a ChEI or memantine. Variables of interest included demographic characteristics and resource utilization factors. The Oaxaca-Blinder decomposition method was used to test for disparities to determine whether exposure to AD pharmacotherapy was influenced by race.
Results
Race, age, long-term care admittance, inpatient care admittance, state of residence, and sex were significant predictors of AD pharmacotherapy exposure (P < 0.0001 for all variables). Racial/ethnic disparities were observed with respect to exposure to a ChEI or memantine between non-Hispanic whites and Hispanics (in favor of Hispanics) in Florida (P < 0.0001), between non-Hispanic blacks and Hispanics (in favor of Hispanics) in California (P < 0.0001) and Florida (P < 0.0001), between non-Hispanic blacks and non-Hispanic others (in favor of non-Hispanic others) in California (P < 0.0001) and New York (P < 0.0001), and between Hispanics and non-Hispanic others (in favor of non-Hispanic others) in California (P = 0.001) and New York (P < 0.0001).
Conclusions
Disparities in AD pharmacotherapy exposure among minority populations are just as prevalent, if not of greater magnitude, than minority/white disparities.
{"title":"Racial and Ethnic Disparities in Alzheimer's Disease Pharmacotherapy Exposure: An Analysis Across Four State Medicaid Populations","authors":"Adrienne M. Gilligan MSc, Daniel C. Malone PhD, RPh, Terri L. Warholak PhD, RPh, Edward P. Armstrong PharmD","doi":"10.1016/j.amjopharm.2012.09.002","DOIUrl":"10.1016/j.amjopharm.2012.09.002","url":null,"abstract":"<div><h3>Background</h3><p><span><span>Treatment </span>disparities in </span>Alzheimer's disease (AD) have received little attention. Determining whether disparities exist in this subpopulation is an important health policy issue.</p></div><div><h3>Objective</h3><p>The aim was to determine whether an association existed between race/ethnicity and exposure to AD pharmacotherapy across 4 state Medicaid populations.</p></div><div><h3>Methods</h3><p><span>Data from the Centers for Medicare and Medicaid Services (CMS) were used in this retrospective study. Persons with AD enrolled in California, Florida, New Jersey, or New York Medicaid programs on January 1, 2004, and remained in that program for 1 year. Individuals had an AD diagnosis based on the ICD-9-CM code 331.0. Outcomes of interest were exposure to a </span>cholinesterase inhibitor<span><span> (ChEI) or memantine. Multivariate </span>logistic regression was used to test for the association between race/ethnicity and exposure to a ChEI or memantine. Variables of interest included demographic characteristics and resource utilization factors. The Oaxaca-Blinder decomposition method was used to test for disparities to determine whether exposure to AD pharmacotherapy was influenced by race.</span></p></div><div><h3>Results</h3><p>Race, age, long-term care admittance, inpatient care admittance, state of residence, and sex were significant predictors of AD pharmacotherapy exposure (<em>P</em> < 0.0001 for all variables). Racial/ethnic disparities were observed with respect to exposure to a ChEI or memantine between non-Hispanic whites and Hispanics (in favor of Hispanics) in Florida (<em>P</em> < 0.0001), between non-Hispanic blacks and Hispanics (in favor of Hispanics) in California (<em>P</em> < 0.0001) and Florida (<em>P</em> < 0.0001), between non-Hispanic blacks and non-Hispanic others (in favor of non-Hispanic others) in California (<em>P</em> < 0.0001) and New York (<em>P</em> < 0.0001), and between Hispanics and non-Hispanic others (in favor of non-Hispanic others) in California (<em>P</em> = 0.001) and New York (<em>P</em> < 0.0001).</p></div><div><h3>Conclusions</h3><p>Disparities in AD pharmacotherapy exposure among minority populations are just as prevalent, if not of greater magnitude, than minority/white disparities.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 5","pages":"Pages 303-312"},"PeriodicalIF":0.0,"publicationDate":"2012-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.09.002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30974770","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-10-01DOI: 10.1016/j.amjopharm.2012.08.002
Kalpana P. Padala MD, MS , Prasad R. Padala MD, MS , Dennis P. McNeilly PsyD , Jenenne A. Geske PhD , Dennis H. Sullivan MD , Jane F. Potter MD
Background
Statins are well-known for their cardiovascular benefits. However, the cognitive effects of statins are not well understood. We hypothesized that individuals with preexisting dementia would be more vulnerable to statin-related cognitive effects.
Objective
The aim of this study was to evaluate the impact on cognition of 3-hydroxy-3-methylglutaryl–coenzyme A reductase inhibitor (statin) discontinuation and rechallenge in individuals with Alzheimer's dementia (AD) on statins at baseline.
Methods
A 12-week prospective, open-label study was conducted in a geriatric clinic setting. Eighteen older subjects underwent a 6-week withdrawal phase of statins followed by a 6-week rechallenge. The primary outcome measure was cognition, measured by the Mini-Mental State Examination (MMSE); secondary outcome measures were the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery, Activities of Daily Living (ADL) scale, Instrumental ADL (IADL) scale, and fasting cholesterol. The change in outcome measures was assessed using repeated-measures ANOVA and paired t tests.
Results
At the end of the intervention, there was a significant difference across time for MMSE score (P = 0.018), and total cholesterol (P = 0.0002) and a trend toward change across time for ADL (P = 0.07) and IADL (P = 0.06) scale scores. Further analyses using paired t tests indicated improvement in MMSE scores (Δ1.9 [3.0], P = 0.014) with discontinuation of statins and a decrease in MMSE scores (Δ1.9 [2.7], P = 0.007) after rechallenge. Total cholesterol increased with statin discontinuation (P = 0.0003) and decreased with rechallenge (P = 0.0007). The CERAD score did not show a change across time (P = 0.31). There was a trend toward improvement in ADL (P = 0.07) and IADL (P = 0.06) scale scores with discontinuation of statins, but no change with rechallenge.
Conclusions
This pilot study found an improvement in cognition with discontinuation of statins and worsening with rechallenge. Statins may adversely affect cognition in patients with dementia.
{"title":"The Effect of HMG-CoA Reductase Inhibitors on Cognition in Patients With Alzheimer's Dementia: A Prospective Withdrawal and Rechallenge Pilot Study","authors":"Kalpana P. Padala MD, MS , Prasad R. Padala MD, MS , Dennis P. McNeilly PsyD , Jenenne A. Geske PhD , Dennis H. Sullivan MD , Jane F. Potter MD","doi":"10.1016/j.amjopharm.2012.08.002","DOIUrl":"10.1016/j.amjopharm.2012.08.002","url":null,"abstract":"<div><h3>Background</h3><p>Statins are well-known for their cardiovascular benefits. However, the cognitive effects of statins are not well understood. We hypothesized that individuals with preexisting dementia would be more vulnerable to statin-related cognitive effects.</p></div><div><h3>Objective</h3><p><span>The aim of this study was to evaluate the impact on cognition of 3-hydroxy-3-methylglutaryl–coenzyme A reductase inhibitor (statin) discontinuation and rechallenge in individuals with </span>Alzheimer's dementia (AD) on statins at baseline.</p></div><div><h3>Methods</h3><p><span><span>A 12-week prospective, open-label study was conducted in a geriatric clinic setting. Eighteen older subjects underwent a 6-week withdrawal phase of statins followed by a 6-week rechallenge. The primary outcome measure was cognition, measured by the Mini-Mental State Examination (MMSE); secondary outcome measures were the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery, Activities of Daily Living (ADL) scale, Instrumental </span>ADL (IADL) scale, and fasting cholesterol. The change in outcome measures was assessed using repeated-measures ANOVA and paired </span><em>t</em> tests.</p></div><div><h3>Results</h3><p><span>At the end of the intervention, there was a significant difference across time for MMSE score (</span><em>P</em> = 0.018), and total cholesterol (<em>P</em> = 0.0002) and a trend toward change across time for ADL (<em>P</em> = 0.07) and IADL (<em>P</em> = 0.06) scale scores. Further analyses using paired <em>t</em> tests indicated improvement in MMSE scores (Δ1.9 [3.0], <em>P</em> = 0.014) with discontinuation of statins and a decrease in MMSE scores (Δ1.9 [2.7], <em>P</em><span> = 0.007) after rechallenge. Total cholesterol increased with statin discontinuation (</span><em>P</em> = 0.0003) and decreased with rechallenge (<em>P</em> = 0.0007). The CERAD score did not show a change across time (<em>P</em> = 0.31). There was a trend toward improvement in ADL (<em>P</em> = 0.07) and IADL (<em>P</em> = 0.06) scale scores with discontinuation of statins, but no change with rechallenge.</p></div><div><h3>Conclusions</h3><p>This pilot study found an improvement in cognition with discontinuation of statins and worsening with rechallenge. Statins may adversely affect cognition in patients with dementia.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 5","pages":"Pages 296-302"},"PeriodicalIF":0.0,"publicationDate":"2012-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.08.002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30856939","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-10-01DOI: 10.1016/j.amjopharm.2012.09.003
Jennifer Tjia MD, MSCE , Terry S. Field DSc , Kathleen M. Mazor EdD , Jennifer L. Donovan PharmD , Abir O. Kanaan PharmD , George Reed PhD , Peter Doherty BA , Leslie R. Harrold MD, MPH , Jerry H. Gurwitz MD
Background
Little attention has been focused on the safety of medications administered to treat non illnesses in nursing home residents with dementia. It is unclear whether this population is at increased risk of adverse drug events.
Objectives
To test the hypotheses that in nursing home residents with dementia prescribed warfarin have less time in therapeutic range and a higher incidence of nonpreventable and preventable adverse warfarin events compared to nursing home residents without dementia after controlling for facility and patient characteristics.
Methods
A prospective cohort embedded in a clinical trial of nursing home residents prescribed warfarin in 26 nursing homes in Connecticut was observed for up to 12 months. The primary outcome measures included adverse warfarin events (AWEs) (injuries resulting from warfarin use), potential AWEs (INR [international normalized ratio] >4.5 and management error), and AWE preventability based on physician reviews of medical record abstractions. Potential confounders included nursing home structural characteristics (eg, number of beds and for-profit status), nursing staff time, and nursing home regulatory deficiencies (pharmacy, administrative, quality of care, and all other deficiencies). Multivariable Poisson regression analysis was used to determine the independent association of dementia with potential and preventable AWEs using generalized estimating equations to account for clustering within nursing homes.
Results
Residents with dementia had no difference in the number of INR monitoring tests or percentage of days in the therapeutic range, but did have an increased risk of AWEs (adjusted incidence rate ratio [IRR], 1.47; 95% confidence interval [CI], 1.20–1.82), and preventable or potential AWEs (adjusted IRR, 1.36; 95% CI, 1.06–1.76) after adjustment for patient characteristics, nursing home quality, and case mix. Greater nursing staff time was protective for preventable and potential AWEs (adjusted IRR, 0.66; 95% CI, 0.48–0.90) but not for nonpreventable AWEs.
Conclusion
A diagnosis of dementia was associated with increased risk of nonpreventable and preventable or potential AWEs. Greater nursing staff time was associated with lower risk of preventable AWEs. These findings have implications for quality-of-care reporting and patient safety.
{"title":"Dementia and Risk of Adverse Warfarin-Related Events in the Nursing Home Setting","authors":"Jennifer Tjia MD, MSCE , Terry S. Field DSc , Kathleen M. Mazor EdD , Jennifer L. Donovan PharmD , Abir O. Kanaan PharmD , George Reed PhD , Peter Doherty BA , Leslie R. Harrold MD, MPH , Jerry H. Gurwitz MD","doi":"10.1016/j.amjopharm.2012.09.003","DOIUrl":"10.1016/j.amjopharm.2012.09.003","url":null,"abstract":"<div><h3>Background</h3><p>Little attention has been focused on the safety of medications administered to treat non illnesses in nursing home residents with dementia. It is unclear whether this population is at increased risk of adverse drug events.</p></div><div><h3>Objectives</h3><p>To test the hypotheses that in nursing home residents with dementia prescribed warfarin have less time in therapeutic range and a higher incidence of nonpreventable and preventable adverse warfarin events compared to nursing home residents without dementia after controlling for facility and patient characteristics.</p></div><div><h3>Methods</h3><p>A prospective cohort embedded in a clinical trial<span><span> of nursing home residents prescribed warfarin in 26 nursing homes in Connecticut was observed for up to 12 months. The primary outcome measures included adverse warfarin events (AWEs) (injuries resulting from warfarin use), potential AWEs (INR [international normalized ratio] >4.5 and management error), and AWE preventability based on physician reviews of medical record abstractions. Potential </span>confounders included nursing home structural characteristics (eg, number of beds and for-profit status), nursing staff time, and nursing home regulatory deficiencies (pharmacy, administrative, quality of care, and all other deficiencies). Multivariable Poisson regression analysis was used to determine the independent association of dementia with potential and preventable AWEs using generalized estimating equations to account for clustering within nursing homes.</span></p></div><div><h3>Results</h3><p>Residents with dementia had no difference in the number of INR monitoring tests or percentage of days in the therapeutic range, but did have an increased risk of AWEs (adjusted incidence rate ratio [IRR], 1.47; 95% confidence interval [CI], 1.20–1.82), and preventable or potential AWEs (adjusted IRR, 1.36; 95% CI, 1.06–1.76) after adjustment for patient characteristics, nursing home quality, and case mix. Greater nursing staff time was protective for preventable and potential AWEs (adjusted IRR, 0.66; 95% CI, 0.48–0.90) but not for nonpreventable AWEs.</p></div><div><h3>Conclusion</h3><p>A diagnosis of dementia was associated with increased risk of nonpreventable and preventable or potential AWEs. Greater nursing staff time was associated with lower risk of preventable AWEs. These findings have implications for quality-of-care reporting and patient safety.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 5","pages":"Pages 323-330"},"PeriodicalIF":0.0,"publicationDate":"2012-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.09.003","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9776511","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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