Prescription Of Nonsteroidal Anti-inflammatory Drugs Research Articles

PMU38 ASSOCIATION OF PRESCRIPTION NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) WITH DEPRESSION AMONG ADULTS WITH INFLAMMATORY CHRONIC CONDITIONS IN THE UNITED STATES

The study objective was to assess the association between prescription NSAIDs and depression among adults with inflammatory chronic conditions. Some randomized clinical trials have demonstrated that non-steroidal anti-inflammatory drugs (NSAIDs) can be beneficial in reducing depressive symptoms among adults with depression. As depression is often considered as an inflammatory disease, NSAIDs may also reduce the risk of depression by reducing inflammation. We used a retrospective cross-sectional design. Data were derived from 2015 Medical Expenditure Panel Survey (MEPS), a nationally representative sample of the US non-institutionalized civilian population. Inflammatory conditions included arthritis, asthma, cancer, cardiovascular disease, chronic obstructive pulmonary disease (COPD), and diabetes. The dependent variable was the presence or absence of depression and the key independent variable was prescription NSAIDs use. Logistic regression models were used to examine the adjusted associations between NSAIDs and depression. In these regressions, other independent variables (biological, sociocultural, socio-economic, access to healthcare services, medical conditions, behavioral and environmental factors) that may affect the relationship between NSAIDs and depression were also included. All analyses accounted for the complex survey design of MEPS. The study sample consisted of 11,714 adults, representing approximately 124.5 million adults with inflammatory conditions. Overall, 18.2% reported depression and 21% used prescription NSAIDs. A higher percentage of adults using NSAIDs reported depression compared to those without NSAIDS use (23.5% vs 16%;OR=1.59;95%CI=1.40,1.82). In the fully-adjusted logistic regression model, with controls for biological (sex, age, race/ethnicity), sociocultural, socio-economic, access to healthcare services, medical conditions including pain, behavioral and environmental factors, adults using prescription NSAIDs had higher odds of depression (AOR=1.24;95%CI=[1.07,1.43]) compared to those without NSAIDs. In this first real-world study of all adults (with and without depression) in the US, we observed a positive association between prescription NSAIDs and the presence of depression.

Effects of pharmacist participation in chronic kidney disease (CKD) network and CKD manual distribution on drug-related kidney injury.

Renin-angiotensin system (RAS) inhibitors carry a risk of normotensive ischemic acute kidney injury in dehydration and concurrent nonsteroidal anti-inflammatory drug (NSAID) use. Although the estimated number of patients with chronic kidney disease (CKD) is 20000, Fujieda, Japan, has only three nephrologists. On 25 March 2016, we reorganized the CKD network to include pharmacists and distributed a CKD manual. We assessed effects of pharmacist participation in the CKD network and CKD manual distribution on patient hospitalizations because of drug-related kidney injury. Changes in the prevalence of RAS inhibitor-related estimated glomerular filtration rate (eGFR) declines of greater than or equal to 30% and hyperkalemia of greater than or equal to 6.0mEq/L in 129 hospitalized CKD patients, drug prescriptions of 14150 hospitalized patients, and annual medical checkup data in 36042 citizens were investigated before and after pharmacist participation. After pharmacist participation, patient hospitalizations due to RAS inhibitor-related eGFR declines decreased (71.4% to 38.1%, P=.03) and hyperkalemia declined (38.1% to 9.5%, P=.03). Pharmacist participation influenced the decrease in RAS inhibitor-related eGFR declines (P=.03). NSAID prescriptions decreased (13.4% to 11.8%, P=.003) and acetaminophen prescriptions increased (6.6% to 8.0%, P=.002) among 14150 hospitalized patients, whereas RAS inhibitor prescriptions decreased (43.2% to 39.4%, P=.002) among 6930 hospitalized patients with eGFR less than 60mL/min/1.73m2 . A significant number of citizens shifted from CKD stage G3a-3b to G1-2. Pharmacist participation in the CKD network and CKD manual distribution decreased both hospitalizations due to RAS inhibitor-related kidney injury and citizens with CKD stage G3a-3b.

Treatment Interventions for the Management of Intestinal Permeability: A Cross-Sectional Survey of Complementary and Integrative Medicine Practitioners.

Objectives: This study aims to explore the treatment interventions complementary and integrative medicine (CIM) practitioners use in the management of an emerging health condition, increased intestinal permeability (IP), and the association these methods have on the observed time to resolve this condition. Design and setting: A cross-sectional survey of Australian naturopaths, nutritionists, and Western herbal medicine practitioners was undertaken (n = 227) through the Practitioner Research and Collaboration Initiative (PRACI) network. Outcome measures: Frequencies and percentages of the treatment methods, including chi-square analysis to examine the associations between treatment methods and observed time to resolve IP. Results: Thirty-six CIM practitioners responded to the survey (response rate 15.9%). CIM practitioners were found to use a multimodal approach in the management of IP with 92.6% of respondents using three or more categories of treatment interventions (nutritional, herbal, dietary, and lifestyle) with a mean total of 43.0 ± 24.89 single treatment interventions frequently prescribed. The main treatments prescribed in the management of IP were zinc (85.2%), probiotics: multistrain (77.8%), vitamin D (75.0%), glutamine (73.1%), Curcuma longa (73.1%), and Saccharomyces boulardii (70.4%). CIM practitioners also advocate patients with IP to reduce alcohol (96.3%), gluten (85.2%), and dairy (75.0%) consumption. Evaluation of antibiotics (75.0%) and nonsteroidal anti-inflammatory drugs (73.1%) prescriptions were frequently advised by CIM practitioners. A longer observed time to resolve IP was seen in CIM practitioners who did not reduce intense exercise in the management of IP (p = 0.02). Conclusions: This study represents the first survey of the treatments prescribed by CIM practitioners for IP and suggests that CIM practitioners use numerous integrative treatment methods for the management of IP. The treatment interventions frequently prescribed by CIM practitioners align with preclinical research, suggesting that CIM practitioners prescribe in accordance with the published literature. The findings of this study contribute to the implementation of clinical research in the management of IP, which considers multiple concurrent treatments.

Nonsteroidal anti-inflammatory drug use and risk of acute kidney injury and hyperkalemia in older adults: a population-based study.

Clinical guidelines caution against nonsteroidal anti-inflammatory drug (NSAID) use in older adults. The study objective was to quantify the 30-day risk of acute kidney injury (AKI) and hyperkalemia in older adults after NSAID initiation and to develop a model to predict these outcomes. We conducted a population-based retrospective cohort study in Ontario, Canada from 2007 to 2015 of patients ≥66 years. We matched 46107 new NSAID users with 46107 nonusers with similar baseline health. The primary outcome was 30-day risk of AKI and secondary outcomes were hyperkalemia and all-cause mortality. NSAID use versus nonuse was associated with a higher 30-day risk of AKI {380 [0.82%] versus 272 [0.59%]; odds ratio (OR) 1.41 [95% confidence interval (CI) 1.20-1.65]} and hyperkalemia [184 (0.40%) versus 123 (0.27%); OR 1.50 (95% CI 1.20-1.89); risk difference 0.23% (95% CI 0.13-0.34)]. There was no association between NSAID use and all-cause mortality. A prediction model incorporated six predictors of AKI or hyperkalemia: older age, male gender, lower baseline estimated glomerular filtration rate, higher baseline serum potassium, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use or diuretic use. This model had moderate discrimination [C-statistic 0.72 (95% CI 0.70-0.74)] and good calibration. In older adults, new NSAID use compared with nonuse was associated with a higher 30-day risk of AKI and hyperkalemia but not all-cause mortality. Prescription NSAID use among many older adults may be safe, but providers should use caution and assess individual risk.

Regional Variation in Nonoperative Therapy Utilization for Symptomatic Lumbar Stenosis and Spondylolisthesis: A 2-Year Costs Analysis.

Study Design:Retrospective cohort study.Objectives:To characterize regional variations in maximal nonoperative therapy (MNT) costs in patients suffering from lumbar stenosis or spondylolisthesis.Methods:Medical records from patients with symptomatic lumbar stenosis or spondylolisthesis undergoing primary ≤3-level lumbar decompression and fusion procedures from 2007 to 2016 were gathered from a large insurance database. Geographic regions (Midwest, Northeast, South, and West) reflected the US Census Bureau definitions. Records were searchable by International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and insurance-specific generic drug codes. Utilization of MNT, defined as cost billed, prescriptions written, and number of units disbursed, within 2-years prior to index surgery was assessed.Results:A total of 27 877 patients underwent 1-, 2-, or 3-level lumbar decompression and fusion surgery. Regional breakdown of the study cohort was as follows: South 62.3%, Midwest 25.2%, West 10.4%, Northeast 2.1%. Regional variations in the number of patients using nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .0001), opioids (P < .0001), muscle relaxants (P < .0001), and lumbar steroid injections (P < .0001) were detected. A significant difference was identified in the regional MNT failure rates (P < .0001). The total cost associated with MNT prior to index surgery was $48 411 125 ($1736.60/patient), with the Midwest ($1943.83/patient) responsible for the greatest average spending. Despite comprising 62.3% of the cohort, the South was accountable for 67.5% of NSAID prescriptions, 64.6% of opioid prescriptions, and 71.2% of muscle relaxant prescriptions.Conclusions:Regional differences exist in the costs of MNT in patients with lumbar stenosis and spondylolisthesis prior to surgery. Future studies should focus on identifying patients likely to fail prolonged nonoperative management.

Does Insurance Coverage Affect Use of Tests and Treatments for Working Age Individuals With Carpal Tunnel Syndrome in the United States? Analysis of the National Ambulatory Medical Care Survey (2005-2014)

ObjectiveCarpal tunnel syndrome (CTS) is frequently seen as a work-related disorder. Few studies have examined the treatment of CTS by insurance coverage, and none have used a large, population-based dataset. This study examined the extent to which the use of CTS tests and treatments varied for those on workers’ compensation insurance (WCI) vs private insurance and Medicaid, controlling for patient and provider characteristics. DesignAnalysis of 10 years of data (2005-2014) from the National Ambulatory Medical Care Survey. SettingUnited States office-based physician practices. ParticipantsAdults 18-64 years who had a physician visit for CTS (N=23,236,449). InterventionsNot applicable. Main Outcome MeasuresWe examined use of 2 diagnostic tests, imaging and electromyography, and 7 treatments: casting, splinting, occupational therapy (OT), physical therapy (PT), carpal tunnel release surgery, steroid injections, and nonsteroidal anti-inflammatory drug (NSAID). ResultsIndividuals who sought care for CTS were more likely to be covered by private insurance (56.9%) than WCI (9.8%) or Medicaid (6.5%). The most commonly prescribed treatment for all types of insurance coverage was splints, followed by NSAID prescription, and OT or PT therapies. Steroid injections (1.2%) and CTS surgery (4.5%) were used significantly less than other treatment types. Patients on WCI were less likely to receive diagnostic tests, and more likely to receive OT or PT than those on other types of insurance coverage. ConclusionPatients with CTS who seek ambulatory care are most likely to be covered by private insurance. Insurance coverage appears to play a role in treatment and diagnostic choices for CTS.

Non-steroidal anti-inflammatory drug prescriptions from the 6th month of pregnancy: impact of advice from health authorities.

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used drugs. On June 2008 and February 2009, Dear Doctor Letters (DDLs) were sent by the French Health Authorities (AFSSAPS) to remind practitioners of risks with NSAIDs after the fifth month of pregnancy. The aim of this study was to evaluate the impact of these letters on NSAID prescriptions during late pregnancy. EFEMERIS is a French database that registers drugs prescribed and reimbursed during pregnancy and outcomes between 2004 and 2015. We performed a descriptive study and a 'before-and-after' comparison of NSAID prescriptions between 3 June 2006 and 3 June 2008 ('before group'), and between 1 March 2010 and 1 March 2012 ('after group'). We carried out a Cochran Armitage trend test to check whether the rate of women exposed to NSAIDs varies linearly over time. We identified 948 (4.38%) pregnant women in the 'before group' and 678 (2.73%) in the 'after group' receiving at least one NSAID prescription in late pregnancy (P<0.0001). Between 2006 and 2012, mainly prescriptions for morniflumate/niflumic acid (1.7% vs. 0.9%; P<0.0001), ibuprofen (0.8% vs. 0.6%; P=0.01) and ketoprofen (0.7% vs. 0.3%; P<0.0001) fell significantly after DDLs. The Cochran Armitage trend test shows that the percentage of women exposed to NSAIDs in late pregnancy decreased significantly during the study period (P<0.0001). This study highlighted a significant decrease in the percentage of women receiving NSAID prescriptions during late pregnancy after DDLs. This decrease is not linked to a specific women's profile or prescriber's medical discipline.

Management of hip and knee osteoarthritis in general practice: a systematic review

Purpose: Osteoarthritis (OA) management by general practitioners (GPs) is aimed at improving quality of life, self-management and preventing further progression of the disease. Understanding GP reported clinical practice is key when trying to improve adherence to the well-established management guidelines. The aim of this study was to summarise GP reported management of hip and knee OA, including pharmacological and non-pharmacological management, referrals, diagnostic tools and assessment patterns. Methods: Databases (Embase, MEDLINE, CINHAL and Cochrane Central Register for Controlled Trial) were searched using the keywords “general practice”, “treatment” and “osteoarthritis” from inception to June 2018. Published studies that comprised GP reported management for people with hip and knee OA were identified. Risk of bias was assessed based on predetermined measures of informativeness and internal validity. Results: Out of a total of 13,930 records identified through the databases search, 14 original articles were included in this review, all of which used a prospective cross-sectional design. Results were collected from ∼19,446 GPs; response rates ranged from 17% to 90%. Of the included studies, seven studies reported respondents’ male percentage (mean (SD) 72% (18)), six reported respondents’ practice location (urban 60% (18) versus rural 40% (14)) and five reported respondents’ time since graduation (20 years (8)). Overall, studies scored high in most internal validity measures including reproducibility of results and standardising GP management definitions across cohorts. However, eight of the included studies did not adjust analyses for confounding factors such as patients and GPs’ characteristics. Informativeness rated low as seven included studies lacked data on respondents’ baseline characteristics. Pharmacological management: Twelve of the 14 studies included data on GP reported management with non-steroidal anti-inflammatory drugs (NSAIDs) with prescription rates ranging from 15% to 84%. NSAID prescription rates differed by stages of disease severity (stage 1: 43%, stage 2 and 3 >70%) and before and after treatment (19% before, 9.3% after). Paracetamol prescription rates ranged from 7% to 91%, as reported in 10 out of the 14 studies. One Australian study showed that for every 100 patients treated for hip and knee OA, 23 were prescribed paracetamol. Prescription of NSAIDs combined with paracetamol was reported in one study, while prescription of NSAIDs combined with analgesics was reported in three out of the 14 included studies. The rates ranged from 1.4% to 42.8%. Non-pharmacological management: GP reported non-pharmacological management of OA using exercise prescription and/or weight reduction advice was reported in 10 of the 14 studies. The percentages of GPs recommending general exercise ranged from 15% to 87%. Four of the 10 studies which included data on exercise prescription showed that types of recommended exercise included walking, swimming, cycling and hydrotherapy. Weight reduction advice rates ranged from 32% to 68%, as reported in nine of the 14 studies. Five of the 14 included studies reported on management using intra-articular steroid injections and rates were low ranging from 4% to 25%. There was a low percentage of GPs recommending the use of walking sticks in early-stage OA (25% as reported in two studies) and this percentage increased to 45% in the case of acute exacerbation. Referrals: Referral rates to allied health professionals (physiotherapists, exercise physiologists and/or nutritionists) ranged from 0.1% to 62.7%, as reported in seven of the 14 included studies. Referral to orthopaedic surgeons ranged from 7% to 75%, as reported in three studies. GPs also referred to other health care practitioners (6% to 18%), secondary care (13%), rheumatologists (5%) and clinical specialists (46%). Diagnostic tools and assessment patterns Five of the 14 studies reported data on GPs’ use of diagnostic tools when assessing patients with knee or hip OA. Across these studies, 35% to 85% of GPs reported requesting plain radiography (X-ray). One study reported that 28% of GPs would request additional imaging even if patients had previously undergone radiography within the past six months. Two studies reported that >50% of GPs request blood tests to investigate erythrocyte sedimentation rate and blood count. Conclusions: Pharmacological management largely concentrated on NSAIDs and paracetamol, with similar prescription rates for both. Non-pharmacological management using exercise and/or weight reduction and referral to allied health professionals varies widely but appears to be underutilised. Diagnostic imaging use appears high, given OA can be diagnosed clinically, suggesting that GPs over investigate the diagnosis. More work needs to be done to support GPs’ implementation of evidence-based management of hip and knee OA.

Research roundup

Journal of Kidney CareVol. 4, No. 2 Research Roundupresearch roundupPublished Online:27 Mar 2019https://doi.org/10.12968/jokc.2019.4.2.116AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleAbstractIn this section, Nikki Welyczko provides a brief synopsis of a selection of recently published research papers of potential interest to professionals in the kidney community. This research roundup aims to provide an overview, rather than a detailed critique, of the research that is presented. A full reference is provided with each study, should you wish to look at any of the papers in greater detail. References Nelson DA, Marks ES, Deuster PA et al.. Association of nonsteroidal anti-inflammatory drug prescriptions with kidney disease among active young and middle-aged adults. JAMA Network Open. 2019; 2(2):e187896. https://doi.org/10.1001/jamanetworkopen.2018.7896 Google ScholarSaglimbene VM, Wong G, Ruospo M et al.. Fruit and vegetable intake and mortality in adults undergoing maintenance haemodialysis. Clin J Am Soc Nephrol. 2019; 14(2):1-2. https://doi.org/10.2215/CJN.08580718 Google ScholarThongprayoon C, Cheungpasitporn W, Mao MA et al.. Elevated admission serum calcium phosphate produce as an independent risk factor for acute kidney injury in hospitalized patients. Hospital Pract. 2019; https://doi.org/10.1080/21548331.2019.1568719 Google ScholarHong YS, Ryu S, Chang Y et al.. Hepatitis B virus infection and development of chronic kidney disease: a cohort study. BMC Nephrol. 2018; 19:353. https://doi.org/10.1186%2Fs12882-018-1154-4 Google Scholar FiguresReferencesRelatedDetails 2 March 2019Volume 4Issue 2ISSN (print): 2397-9534ISSN (online): 2397-9542 Metrics History Published online 27 March 2019 Published in print 2 March 2019 Information© MA Healthcare LimitedPDF download

Evaluation of Opioid Prescriptions After Urogynecologic Surgery Within a Large Health Care Organization: How Much Are We Prescribing?

Data regarding postoperative opioid prescriptions for patients undergoing urogynecologic surgery are sparse. Our objective was to quantify surgeon prescribing patterns for patients undergoing surgery for pelvic organ prolapse or stress urinary incontinence. Patients who underwent surgery for pelvic organ prolapse or SUI within a large health care maintenance organization were identified by procedural codes within the electronic medical record. Medical records were reviewed for demographic and clinical data. Our primary objective was to describe initial postoperative morphine milligram equivalent (MME) dosages for patients undergoing various urogynecologic surgeries. Secondary objectives were to evaluate rates of postoperative non-opioid analgesic prescriptions, presence of additional postoperative opioid prescriptions within 90 days of surgery, and to characterize prescribing patterns of surgeons from different specialties. We evaluated 855 patients undergoing 7 urogynecologic surgeries. There was wide variation in the quantity of MME prescribed to patients undergoing different urogynecologic surgeries, and the mean MME ranged from 137.6 mg after a colpocleisis to 214.1 mg after a laparoscopic uterosacral ligament suspension. Less than two thirds of patients received a postoperative nonsteroidal anti-inflammatory drug (NSAID) prescription, and rates of NSAID prescriptions varied widely between surgeons from different specialties. Thirty-nine (4.6%) patients received an additional postoperative opioid prescription specifically for the indication of persistent postoperative pain. There is wide variation in the range of MME prescribed postoperatively to patients undergoing common urogynecologic surgeries. Less than two thirds of patients received a postoperative NSAID prescription, which was found to be independently associated with a higher postoperative opioid prescription dose.

Prescribing of Non-Steroidal Anti-Inflammatory Drugs to Patients with Diabetes Mellitus in Portugal

Portugal presents the highest incidence of stage 5 chronic kidney disease in Europe. It is speculated that a high consumption of non-steroidal anti-inflammatory drugs (NSAIDS) may contribute to this high incidence. Our aim was to characterize the prescription of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus in Portugal. We analyzed the national prescription database in triennium 2015 - 2017. In patients with diabetes mellitus, we evaluated the prescription of non-steroidal anti-inflammatory drugs according to age, gender and region of the patient and specialty of the prescribing physician. We evaluated the prescription of non-steroidal anti-inflammatory drugs in all patients with diabetes mellitus, in patients with presumed renal impairment, and in those with concomitant prescription of angiotensin converting enzyme inhibitors or angiotensin receptor antagonists. We analyzed 23 320 620 prescriptions, corresponding to 610 157 adults, including 104 306 patients with diabetes mellitus. The most prescribed non-steroidal anti-inflammatory drugs were ibuprofen (20.1%), metamizole (14.7%), and diclofenac (11.4%). The prescription of non-steroidal anti-inflammatory drugs was higher in females, in patients aged 51 - 70 years and in the Alentejo region. Non-steroidal anti-inflammatory drugs were prescribed to 70.6% of patients with diabetes mellitus, from which 10.6% were prescribed ≥ 10 packages during the three years. Among patients with diabetes mellitus on angiotensin converting enzyme inhibitors/angiotensin receptor antagonists and with presumed reduction in kidney function, 69.3% were prescribed non-steroidal anti-inflammatory drugs and 11.5% were prescribed ≥ 10 packages during the three years. The level of prescribing of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus is high. The concern of reducing non-steroidal anti-inflammatory drugs prescription to patients already on angiotensin converting enzyme inhibitors/angiotensin receptor antagonists and/or decreased renal function does not seem to exist. In Portugal, the level of prescribing of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus should be reduced, particularly in the subgroups identified with higher prescription and with higher risk of progression to stage 5 chronic kidney disease.

Association of Nonsteroidal Anti-inflammatory Drug Prescriptions With Kidney Disease Among Active Young and Middle-aged Adults

Concern about the renal effects of nonsteroidand al anti-inflammatory drugs (NSAIDs) among young, healthy adults has been limited, but more attention may be warranted given the prevalent use of these agents. To test for associations between dispensed NSAIDs and incident acute kidney injury and chronic kidney disease while controlling for other risk factors. This retrospective, longitudinal cohort study used deidentified medical and administrative data on 764 228 active-duty US Army soldiers serving between January 1, 2011, and December 31, 2014. Analysis was conducted from August 1 to November 30, 2018. All individuals new to Army service were included in the analysis. Persons already serving in January 2011 were required to have at least 7 months of observable time to eliminate those with kidney disease histories. Mean total defined daily doses of prescribed NSAIDs dispensed per month in the prior 6 months. Incident outcomes were defined by diagnoses documented in health records and a military-specific digital system. Among the 764 228 participants (655 392 [85.8%] men; mean [SD] age, 28.6 [7.9] years; median age, 27.0 years [interquartile range, 22.0-33.0 years]), 502 527 (65.8%) were not dispensed prescription NSAIDs in the prior 6 months, 137 108 (17.9%) were dispensed 1 to 7 mean total defined daily doses per month, and 124 594 (16.3%) received more than 7 defined daily doses per month. There were 2356 acute kidney injury outcomes (0.3% of participants) and 1634 chronic kidney disease outcomes (0.2%) observed. Compared with participants who received no medication, the highest exposure level was associated with significantly higher adjusted hazard ratios (aHRs) for acute kidney injury (aHR, 1.2; 95% CI, 1.1-1.4) and chronic kidney disease (aHR, 1.2; 95% CI, 1.0-1.3), with annual outcome excesses per 100 000 exposed individuals totaling 17.6 cases for acute kidney injury and 30.0 cases for chronic kidney disease. Modest but statistically significant associations were noted between the highest observed doses of NSAID exposure and incident kidney problems among active young and middle-aged adults.

Prescription of potentially inappropriate medications in geriatric patients: data from a single dental institution

The Beers criteria and the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) are consensus-driven lists of potentially inappropriate medications (PIMs) in geriatric patients. The primary objective was to determine the frequency of PIMs prescribed to geriatric patients at Tufts University School of Dental Medicine. The secondary aim was to determine the American Society of Anesthesiologists (ASA) status of these patients and suggest that Beers/STOPP guidelines should be implied with consideration to the patient's ASA status. Beers/STOPP criteria were studied and PIMs thus identified. A retrospective electronic chart review of patients at TUSDM aged 65 and older was performed for calendar years 2013, 2014, and 2015. Search queries were generated for ASA status, along with PIMs prescribed. Out of 15,569 geriatric patients, more than half of patients between 65-74 years were classified as ASA I. Over a 3-year period, 895 (5.75%) and 840 (5.4%) received new prescriptions for opioids or nonsteroidal anti-inflammatory drugs, respectively. New prescriptions for muscle relaxants, benzodiazepines, and tricyclic antidepressants were given to 65 (0.42%), 44 (0.28%), and 38 (0.24%) patients, respectively. PIMs are prescribed at low percentages to geriatric patients. However, prescription of opioids, benzodiazepines, and nonsteroidal anti-inflammatory drugs across undergraduate and postgraduate clinics is not uncommon. The majority of Tufts University School of Dental Medicine geriatric patients fall within the category of ASA I-II. ASA classification must be taken into consideration when PIMs are prescribed to geriatric patients rather than relying solely on chronologic age.

Analgesic prescribing trends in a national sample of older veterans with osteoarthritis: 2012-2017.

Few investigations examine patterns of opioid and nonopioid analgesic prescribing and concurrent pain intensity ratings before and after institution of safer prescribing programs such as the October 2013 Veterans Health Administration system-wide Opioid Safety Initiative (OSI) implementation. We conducted a quasi-experimental pre-post observational study of all older U.S. veterans (≥50 years old) with osteoarthritis of the knee or hip. All associated outpatient analgesic prescriptions and outpatient pain intensity ratings from January 1, 2012 to December 31, 2016, were analyzed with segmented regression of interrupted time series. Standardized monthly rates for each analgesic class (total, opioid, nonsteroidal anti-inflammatory drug, acetaminophen, and other study analgesics) were analyzed with segmented negative binomial regression models with overall slope, step, and slope change. Similarly, segmented linear regression was used to analyze pain intensity ratings and percentage of those reporting pain. All models were additionally adjusted for age, sex, and race. Before OSI implementation, total analgesic prescriptions showed a steady rise, abruptly decreasing to a flat trajectory after OSI implementation. This trend was primarily due to a decrease in opioid prescribing after OSI. Total prescribing after OSI implementation was partially compensated by continuing increased prescribing of other study analgesics as well as a significant rise in acetaminophen prescriptions (post-OSI). No changes in nonsteroidal anti-inflammatory drug prescribing were seen. A small rise in the percentage of those reporting pain but not mean pain intensity ratings continued over the study period with no changes associated with OSI. Changes in analgesic prescribing trends were not paralleled by changes in reported pain intensity for older veterans with osteoarthritis.

Integrating Risk-Based Care for Patients With Chronic Kidney Disease in the Community: Study Protocol for a Cluster Randomized Trial.

Background:A risk-based model of care for managing patients with chronic kidney disease (CKD) using the Kidney Failure Risk Equation (KFRE) has been successfully integrated into nephrology care pathways in several jurisdictions. However, as most patients with CKD can be managed in primary care, the next pertinent steps would be to integrate the KFRE into primary care pathways.Objective:Using a risk-based approach for guiding CKD care in the primary care setting, the objective of the study is to develop, implement, and evaluate tools that can be used by patients and providers.Design:This study is a multicenter cluster randomized control trial.Setting:Thirty-two primary care clinics belonging to the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) across Manitoba and Alberta.Patients:All patients at least 18 years old or older with CKD categories G3-G5 attending the participating clinics; we estimate each clinic will have an average of 185 patients with CKD.Methods:Thirty-two primary care clinics will be randomized to receive either an active knowledge translation intervention or no intervention. The intervention involves the addition of the KFRE and decision aids to clinics’ Data Presentation Tool (DPT), as well as patient-facing visual aids, a medical detailing visit, and sentinel feedback reports. Control clinics will only be exposed to current guidelines for CKD management, without active dissemination.Measurements:Data from the CPCSSN repository will be used to assess whether a risk-based care approach affected management of CKD. Primary outcomes are as follows: the proportion of patients with measured urine albumin-to-creatinine ratio, and the proportion of patients being appropriately treated with angiotensin-converting enzyme inhibitor or angiotensin receptor blockers. Secondary outcomes are as follows: the optimal management of diabetes (hemoglobin A1C <8.5%, and the use of sodium-glucose cotransporter-2 inhibitors in CKD G3 patients), hypertension (office blood pressure <130/80 for patients with diabetes, 140/90 for those without), and cardiovascular risk (statin prescription); prescriptions of nonsteroidal anti-inflammatory drugs; and decline in estimated glomerular filtration rate (eGFR). In addition, in a substudy, we will measure CKD-specific health literacy and trust in physician care via surveys administered in the clinic post-visit. At the provider level, we will measure satisfaction with the risk prediction tools. Lastly, at the health system level, outcomes include cost of CKD care, and appropriate referrals for patients at high risk of kidney failure based on provincial guidelines. Primary and secondary outcomes will be measured at the patient level and enumerated at the clinic level 1 year after the intervention implementation, except for decline in eGFR, which will be measured 2 years postintervention.Limitations:Limitations include scalability of the proposal in other health care systems.Conclusions:If successful, this intervention has the potential to improve the management of patients with CKD within Canadian primary care settings, leading to health and economic benefits, and influencing practice guidelines.Trial Registration:ClinicalTrials.gov identifier: NCT03365063

Economic impact of potentially inappropriate prescribing and related adverse events in older people: a cost-utility analysis using Markov models

ObjectivesTo determine the economic impact of three drugs commonly involved in potentially inappropriate prescribing (PIP) in adults aged ≥65 years, including their adverse effects (AEs): long-term use of non-steroidal anti-inflammatory...

Effectiveness of an academic detailing intervention in primary care on the prescribing of non-steroidal anti-inflammatory drugs

PurposeThe objective of this study was to examine the impact of an academic detailing programme in primary care in Norway on the prescribing rate of diclofenac, naproxen and non-steroidal anti-inflammatory drugs (NSAIDs) in total.MethodsAn academic detailing programme was delivered to general practitioners (GPs) in two Norwegian cities. The key message was to avoid diclofenac and COX-2 inhibitors and to use naproxen as the NSAID of choice. We analysed prescription data for 12 months before and after the programme to estimate its impact, using interrupted time series to control for underlying trends, and using the rest of Norway as a comparator. The primary outcome was change in the proportion of the population filling a prescription for diclofenac; secondary outcomes were change in naproxen prescribing and change in total NSAID prescribing.ResultsControlling for baseline trends, and relative to changes in the rest of Norway, there was a statistically significant reduction in the prescribing rate of diclofenac in both cities (− 18% and − 16%, respectively) immediately after the intervention. The impact of the programme on prescribing of diclofenac was maintained by the end of the 12 month follow-up period. An increase in the prescribing of naproxen was observed in both cities. The programme had no impact on the overall rate of prescribing of NSAIDs.ConclusionAcademic detailing was effective in changing the choice of prescribed NSAID amongst Norwegian GPs. Academic detailing is potentially an important method for providing GPs with independent, evidence-based updates on pharmacotherapy to improve prescribing.

Monitoring of drug misuse or potential misuse in a nationwide healthcare insurance database: A cross-sectional study in France

To provide a tool for drug misuse or potential misuse monitoring by using a healthcare insurance database. A cross-sectional study repeated quarterly from 2007 to 2014 was conducted using data from a 1/97th random sample of the French national healthcare reimbursement system. For each drug studied, ad hoc indicators were designed to assess drug misuse, defined as prescriptions that did not comply with the label stipulated in the summary of product characteristics, in terms of the drug (e.g., interactions) or the patient (age, medical history). We focused on specifically identified situations of drug misuse involving non-steroidal anti-inflammatory drugs (NSAIDs), antiemetics in patients with Parkinson's disease and antipsychotics in pediatrics; we also focused on direct anticoagulants, asthma and oral antidiabetic drugs but results for these latter are only shown in supplementary materials. At-risk prescribing of NSAIDs in patients treated by diuretics or renin-angiotensin system inhibitors always remained higher than 14% over the study (maximum: 19%; 2014 quarter 4: 15.4%). Off-label prescribing of contraindicated anti-dopaminergic antiemetics with dopaminergic antiparkinson drugs was marginal (maximum: 2.2%; 2014 quarter 4: 0.5%) but represented at least 5.5% of antiemetic prescriptions. Despite the rise in antipsychotic prescriptions in pediatrics, no dramatic increase in misuse related to age was observed during the study period (2007 quarter 1: 16.1%; 2014 quarter 4: 11.1%). The highest degree of misuse was observed for aripiprazole and for second-generation antipsychotics other than risperidone and aripiprazole. This study provides a simple tool to monitor drug misuse or potential misuse using information from a health insurance database. The results highlight the need for the Regulator to rethink risk management information campaigns and to modify the official information on products.

Pain Management in Hemophilia Α: Analysis of a Large US Insurance Claims Database

Introduction: Persons with hemophilia A (PwHA) can develop pain resulting from joint and/or muscle bleeding over time, which can be debilitating and decrease quality of life. Hemophilia A guidelines recommend medications and other interventions to manage pain, however, little is known about how PwHA in the US use different interventions to manage pain. This study aims to describe interventions for pain management in PwHA in the US.Methods: This retrospective cross-sectional analysis identified PwHA between 2006-2015 using data from Truven Health Analytics MarketScan® Commercial Database. PwHA were identified using a previously validated claims-based algorithm with high sensitivity and specificity (Lyons et al. Value Health 2018). PwHA with pain were identified if they had at least one medical claim for pain as identified by the International Classification of Diseases, Ninth and Tenth Revision codes (ICD-9 & ICD-10). Pharmacologic treatment alternatives, including prescription opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and adjuvant therapies(including antirheumatics, anticonvulsants, muscle relaxants, topical pain products, and corticosteroids), were identified using national drug codes from pharmacy claims and/or J-codes from medical claims. Non-pharmacologic physical therapy services, regardless of the reason for the procedure, were included and identified using common procedural terminology codes in medical claims. Data on over-the-counter pain medications were not available in the database and were not included in the study. Demographic and clinical characteristics of PwHA with evidence of pain were examined. Descriptive rates were reported for pharmacologic and non-pharmacologic pain interventions in PwHA with any pain and joint pain. Patterns of pain management by age subgroups were also described.Results: We identified 2295 PwHA; of those, 1258 (54.8%) had evidence of any pain. The mean (standard deviation [SD]) age of PwHA was 21.9 (±15.3) years, with 99.7% males, mean (SD) Charlson Comorbidity Index (CCI) score of 0.27 (± 0.9); 44.9% had evidence of arthropathy, 8.9% of fracture, and 3.5% of joint replacement surgery. PwHA with evidence of pain were numerically older (23.4 ± 16.0 years), had higher mean CCI (0.32 ± 1.0) and a higher proportion of arthropathy (81.5%), fractures (14.5%), and joint replacement surgery (6.3%). Of the PwHA with evidence of any pain, 43.8% had at least one claim for physical therapy, 20.1% for prescription opioids, and 17.1% for NSAIDs. Similarly, physical therapy was the most common treatment recorded among patients with evidence of joint pain (46.1%), followed by prescription opioids (20.5%) and NSAIDs (19.0%). Approximately 39% of PwHA with evidence of any pain and joint pain received adjuvant therapies; however, the use of these agents cannot be completely attributed to pain management (Table 1). About a fifth of pediatric patients (<12 years) with any pain or joint pain had evidence of receiving prescription opioids (18.7% and 19.3%) and NSAIDs (6.9% and 8.2%), respectively, and these proportions increased with age. Among adults with evidence of any pain or joint pain, 25.1% and 26.1% of those in the age group of 45-64 years had received prescription opioids, and 26.8% and 28.8% had received NSAIDs, respectively.Conclusions: Over half of the PwHA had evidence of any pain. Nearly half of PwHA with pain received physical therapy services for any reason, while approximately a fifth of PwHA with pain received prescription opioids and NSAIDs. These findings suggest a high prevalence of pain and pain management interventions in hemophilia A. [Display omitted] DisclosuresRaimundo:Genentech Inc: Employment, Other: Ownership interests PLC. Patel:Genentech Inc: Employment. Ko:F. Hoffmann-La Roche Ltd: Other: Ownership interests non-PLC; Genentech Inc: Employment.

Association of Inpatient Opioid Utilization and Readmission Risk in Sickle Cell Disease

Abstract Background: Vaso-occlusive crisis (VOC) is the hallmark complication of sickle cell disease (SCD). The majority of SCD-related healthcare costs in the United States, estimated at $2.4 billion annually, are attributed to frequent healthcare utilization due to recurrent VOC (1-3). Risk factors such as the prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) only without opioids, older age, and steroid treatment have been identified to be associated with readmissions in pediatric SCD patients (4, 5), but limited data exist about potential predictors for readmission in adults (6). The impact of inpatient opioid utilization on readmission was evaluated in this study. Methods: Seventy SCD adults treated at the University of Illinois Hospital from 2012-2016 had at least one hospitalization for uncomplicated VOC that was followed by a 30-day readmission (30-DR) and at least one hospitalization without a 30-DR. One hospitalization with a 30-DR and one hospitalization without a 30-DR from each patient were used to form the discovery cohort (a total of 140 hospitalizations from 70 unique patients). Patient characteristics, inpatient laboratory values, outpatient daily opioid use before admission, and inpatient daily opioid use were collected from the electronic medical records, and the ratio of the last inpatient day opioid dose/home opioid dose before admission was calculated. Among the 70 patients in the discovery cohort, 22 patients had more than one hospitalization with a 30-DR. The additional hospitalizations with a 30-DR and matched hospitalizations from the same patient without a 30-DR were used to form a validation cohort (a total of 62 hospitalizations from 22 unique patients). A Wilcoxon signed-rank test was performed to compare the ones with a 30-DR to the ones without. The study was approved by the Institutional Review Board prior to the initiation of chart review. Results: Among the 70 SCD patients identified, the median (IQR) age was 32.5 (25-44) years by the time of the first admission included in this cohort, and 67% were females, 76% were HbSS or Sbeta0 genotype, and 46% were on hydroxyurea before admission. The median (IQR) dose of daily outpatient opioids before the first admission was 170 (64-280) mg oral morphine equivalents (OME). When the hospitalizations without a 30-DR were compared to the ones with in the discovery cohort (Table 1), the ratio of last inpatient day opioid dose/home opioid dose was lower (1.5 vs. 1.9, p=0.024), whereas other relevant clinical variables including length of stay, pain score upon discharge, and hemoglobin or WBC upon discharge were not significantly different between the two groups (Table 1). The proportion of patients who used patient controlled analgesia (PCA) during admission, or underwent opioid dose tapering during hospitalizations, or converted IV opioids to oral ones before discharge was also comparable. In the validation cohort (Table 1), the ratio of last inpatient day opioid dose/home opioid dose in the group without a 30-DR was also lower than the ones with a 30-DR (1.4 vs. 2.0, p=0.033), whereas other clinical variables were comparable. Summary: Here we showed that a high ratio of last inpatient day opioid dose/home opioid dose is associated with readmission risk for sickle cell patients treated for uncomplicated VOC. The results suggest that proper tapering of inpatient opioid dose in reference to patient's home opioid dose before discharge may reduce the readmission risk. Reference: K. L. Hassell, Am J Prev Med38, S512 (Apr, 2010). S. Lanzkron, C. P. Carroll, C. Haywood, Jr., Am J Hematol85, 797 (Oct, 2010). T. L. Kauf, T. D. Coates, L. Huazhi, N. Mody-Patel, A. G. Hartzema, Am J Hematol84, 323 (Jun, 2009). L. M. Okorji, D. S. Muntz, R. I. Liem, Pediatr Blood Cancer64, (May, 2017). A. Sobota, D. A. Graham, E. J. Neufeld, M. M. Heeney, Pediatr Blood Cancer58, 61 (Jan, 2012). M. A. Brodsky et al., Am J Med130, 601 e9 (May, 2017). Disclosures No relevant conflicts of interest to declare.