Preventive Pharmacological Therapy Research Articles

Unsatisfactory response to acute medications does not affect the medication overuse headache development in pediatric chronic migraine

BackgroundChronic migraine (CM) negatively impacts the quality of life of 2 to 4% of pediatric patients. In adults, CM is frequently linked to medication overuse headache (MOH), but there is a much lower prevalence of MOH in children. A suboptimal response to acute therapies may lead to their reduced use, thus preventing MOH development in children and adolescents. The frequency of patients with CM who do not respond to acute therapies was examined in the present study. We investigated whether the prevalence of MOH was different between responders and non-responders. We also examined whether patients receiving prophylactic therapy had an improved response to acute therapy. Finally, we investigated if there was a difference in the frequency of psychiatric comorbidities between responders and non-responders.MethodsWe retrospectively analysed clinical data of all chronic pediatric migraineurs under the age of 18 referred to the Headache Centre at Bambino Gesù Children Hospital in June 2021 and February 2023. ICHD3 criteria were used to diagnose CM and MOH. We collected demographic data, including the age at onset of migraine and the age of the CM course. At baseline and after 3 months of preventive treatment, we evaluated the response to acute medications. Neuropsychiatric comorbidities were referred by the children’s parents during the first attendance evaluation.ResultsSeventy patients with CM were assessed during the chosen period. Paracetamol was tried by 41 patients (58.5%), NSAIDs by 56 patients (80.0%), and triptans by 1 patient (1.4%). Fifty-one participants (73%) were non-responder to the abortive treatment. The presence of MOH was detected in 27.1% of the whole populations. Regarding our primary aim, MOH was diagnosed in 29% of non-responder patients and 22% of responders (p > 0.05). All patients received preventative treatment. After 3 months of preventive pharmacological therapy, 65.4% of patients who did not respond to acute medications achieved a response, while 34.6% of patients who were non-responder remain non-responder (p < 0.05). Prophylactic therapy was also effective in 69% of patients who responded to acute medication (p < 0.05). Psychiatric comorbidities were detected in 68.6% of patients, with no difference between responders and non-responders (72.2% vs. 67.3%; p = 0.05).ConclusionsDespite the high prevalence of unresponsiveness to acute therapies in pediatric CM, it does not act as a protective factor for MOH. Moreover, responsiveness to acute drugs is improved by pharmacological preventive treatment and it is not affected by concomitant psychiatric comorbidities.

Real-World Effectiveness of Preventive Pharmacological Therapy in Patients With Urolithiasis: A Retrospective Cohort Study

Data supporting the efficacy of preventive pharmacological therapy (PPT) to reduce urolithiasis recurrence are based on clinical trials with composite outcomes that incorporate imaging findings and which have uncertain clinical significance. This study sought to evaluate if the use of PPT leads to fewer symptomatic stone events. Retrospective cohort study. & Participants: Medicare enrollees with urolithiasis who completed 24-hour urine collections that revealed hypercalciuria, hypocitraturia, low urine pH, or hyperuricosuria. PPT (thiazide diuretics for hypercalciuria, alkali for hypocitraturia or low urine pH, or uric acid lowering drugs for hyperuricosuria) categorized as, 1) adherent to guideline-concordant PPT, 2) nonadherent to guideline-concordant PPT, or 3) untreated. Symptomatic stone event occurrence (emergency department [ED] visit or hospitalization for urolithiasis or stone-directed surgery). Cox proportional hazards regression. Among 13,942 patients, 31.0% were prescribed PPT. Compared to no treatment, concordant/adherent PPT use was associated with a significantly lower hazard of symptomatic stone events for patients with hypercalciuria (hazard ratio [HR], 0.736 [95% confidence interval (CI), 0.593 to 0.915]) and low urine pH (HR, 0.804 [CI, 0.650 to 0.996]) but not for patients with hypocitraturia or hyperuricosuria. These associations were largely driven by significantly lower rates of ED visits after initiating PPT among the concordant/adherent group versus untreated patients. Patients with hypercalciuria had adjusted two-year predicted probabilities of a visit of 3.8% [95% CI, 2.5% to 5.2%%] and 6.9% [95% CI, 6.0% to 7.7%] for the concordant/adherent PPT and no-treatment groups, respectively. Among patients with low urine pH, these probabilities were 4.3% [95% CI, 2.9% to 5.7%] and 7.3% [95% CI, 6.5% to 8.0%] for the concordant/adherent PPT and no-treatment groups, respectively. Potential bias from the possibility that patients prescribed PPT had more severe disease than untreated patients. Patients with urolithiasis and hypercalciuria who were adherent to treatment with thiazide diuretics as well as those with low urine pH adherent to prescribed alkali therapy had fewer symptomatic stone events than untreated patients.

Preventive Pharmacological Therapy and Risk of Recurrent Urinary Stone Disease.

Urinary stone disease is a prevalent condition associated with a high recurrence risk. Preventive pharmacological therapy has been proposed to reduce recurrent stone episodes. However, limited evidence exists regarding its effectiveness, contributing to its underutilization by physicians. This study aimed to evaluate the association between preventive pharmacological therapy (thiazide diuretics, alkali therapy, and uric acid-lowering medications) and clinically significant urinary stone disease recurrence. Using data from the Veterans Health Administration, adults with an index episode of urinary stone disease from 2012 through 2019 and at least one urinary abnormality (hypercalciuria, hypocitraturia, or hyperuricosuria) on 24-hour urine collection were included. The primary outcome was a composite variable representing recurrent stone events that resulted in emergency department visits, hospitalizations, or surgery for urinary stone disease. Cox proportional hazards regression was performed to estimate the association between preventive pharmacological therapy use and recurrent urinary stone disease while adjusting for relevant baseline patient characteristics. Among the cohort of patients with urinary abnormalities ( n =5637), treatment with preventive pharmacological therapy was associated with a significant 19% lower risk of recurrent urinary stone disease during the 12-36-month period after the initial urine collection (hazard ratio, 0.81; 95% confidence interval, 0.65 to 1.00; P = 0.0496). However, the effectiveness of preventive pharmacological therapy diminished over longer follow-up periods (12-48 and 12-60 months after the urine collection) and did not reach statistical significance. When examining specific urinary abnormalities, only alkali therapy for hypocitraturia was associated with a significant 26% lower recurrence risk within the 12-36-month timeframe (hazard ratio, 0.74; 95% confidence interval, 0.56 to 0.97; P = 0.03). When considering all urinary abnormalities together, this study demonstrates that the use of preventive pharmacological therapy is associated with a lower risk of clinically significant recurrent episodes of urinary stone disease in the 12-36 month timeframe after urine collection, although only the association with the use of alkali therapy for hypocitraturia was significant when individual abnormalities were examined.

Comparison of Class-Specific Side Effects Across Preventative Pharmacologic Therapies for Kidney Stone Disease.

Clinical guidelines recommend monitoring for metabolic derangements while on preventive pharmacologic therapy for kidney stone disease. The study objective was to compare the frequency of side effects among patients receiving alkali citrate, thiazides, and allopurinol. Using claims data from working-age adults with kidney stone disease (2008-2019), we identified those with a new prescription for alkali citrate, thiazide, or allopurinol within 12 months after their index stone-related diagnosis or procedure. We fit multivariable logistic regression models, adjusting for cohort characteristics like comorbid illness and medication adherence, to estimate 2-year measured frequencies of claims-based outcomes of acute kidney injury, falls/hip fracture, gastritis, abnormal liver function tests/hepatitis, hypercalcemia, hyperglycemia/diabetes, hyperkalemia, hypokalemia, hyponatremia, and hypotension. Our cohort consisted of 1776 (34%), 2767 (53%), and 677 (13%) patients prescribed alkali citrate, thiazides, or allopurinol, respectively. Comparing unadjusted rates of incident diagnoses, thiazides compared to alkali citrate and allopurinol were associated with the highest rates of hypercalcemia (2.3% vs 1.5% and 1.0%, respectively, P = .04), hypokalemia (6% vs 3% and 2%, respectively, P < .01), and hyperglycemia/diabetes (17% vs 11% and 16%, respectively, P < .01). No other differences with the other outcomes were significant. In adjusted analyses, compared to alkali citrate, thiazides were associated with a higher odds of hypokalemia (OR=2.01, 95% CI 1.44-2.81) and hyperglycemia/diabetes (OR=1.52, 95% CI 1.26-1.83), while allopurinol was associated with a higher odds of hyperglycemia/diabetes (OR=1.34, 95% CI 1.02-1.75). These data provide evidence to support clinical guidelines that recommend periodic serum testing to assess for adverse effects from preventive pharmacologic therapy.

Understanding the Barriers to Preventive Pharmacological Therapy Use in Older Patients With Urinary Stone Disease.

Despite compelling clinical trial evidence and professional society guideline recommendations, prescription rates of preventative pharmacological therapy (PPT) for urinary stone disease are low. We sought to understand how patient- and clinician-level factors contribute to the decision to prescribe PPT after an index stone event. We identified Medicare beneficiaries with urinary stone disease who had a 24-hour urine collection processed by a central laboratory. Among the subset with a urine chemistry abnormality (ie, hypercalciuria, hypocitraturia, hyperuricosuria, or low urine pH), we determined whether PPT was prescribed within 6 months of their collection. After assigning patients to the clinicians who ordered their collection, we fit multilevel models to determine how much of the variation in PPT prescription was attributable to patient vs clinician factors. Of the 11,563 patients meeting inclusion criteria, 33.6% were prescribed PPT. There was nearly sevenfold variation between the treating clinician with the lowest prescription rate (11%) and the one with the highest (75%). Nineteen percent of this variation was attributable to clinician factors. After accounting for measured patient differences and clinician volume, patients had twice the odds of being prescribed PPT if they were treated by a nephrologist (odds ratio [OR], 2.15; 95% CI, 1.79-2.57) or a primary care physician (OR, 1.78; 95% CI, 1.22-2.58) compared to being treated by a urologist. These findings suggest that the type of clinician whom a patient sees for his stone care determines, to a large extent, whether PPT will be prescribed.

Associations Between Provider Specialty and Use of Follow-up Testing Among Patients on Preventive Pharmacological Therapy for Urinary Stone Disease.

The AUA Medical Management of Kidney Stones guideline outlines recommendations on follow-up testing for patients prescribed preventive pharmacological therapy. We evaluated adherence to these recommendations by provider specialty. Using claims data from working-age adults with urinary stone disease (2008-2019), we identified patients prescribed a preventive pharmacological therapy agent (a thiazide diuretic, alkali citrate therapy, allopurinol, or a combination thereof) and the specialty of the prescribing physician (urology, nephrology, and general practice). Next, we identified patients who completed a 24-hour urine collection prior to their prescription fill. We then measured adherence to 3 recommendations outlined in the AUA guideline. Finally, we fit multivariable logistic regression models evaluating associations between prescribing provider specialty and adherence to recommended follow-up testing. Among 2,600 patients meeting study criteria, 1,523 (59%) adhered to ≥1 follow-up testing recommendation, with a significant increase over the study period. Nephrologists had higher odds of adherence to ≥1 follow-up test compared to urologists (odds ratio, 1.52; 95% confidence interval, 1.19-1.94; P < .01). Significant differences in adherence to the 3 individual guideline recommendations were also observed by specialty. Following initiation of preventive pharmacological therapy, adherence to guideline-recommended follow-up testing was low overall. There exist meaningful specialty-specific differences in the use of this testing.

MP10-09 THE REAL-WORLD EFFECTIVENESS OF PREVENTIVE PHARMACOLOGICAL THERAPY

You have accessJournal of UrologyCME1 Apr 2023MP10-09 THE REAL-WORLD EFFECTIVENESS OF PREVENTIVE PHARMACOLOGICAL THERAPY John Hollingsworth, Mary Oerline, Ryan Hsi, Joseph Crivelli, Noah Krampe, John Asplin, and Vahakn Shahinian John HollingsworthJohn Hollingsworth More articles by this author , Mary OerlineMary Oerline More articles by this author , Ryan HsiRyan Hsi More articles by this author , Joseph CrivelliJoseph Crivelli More articles by this author , Noah KrampeNoah Krampe More articles by this author , John AsplinJohn Asplin More articles by this author , and Vahakn ShahinianVahakn Shahinian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003225.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Most efficacy results supporting preventive pharmacological therapy (PPT) used to reduce kidney stone recurrence are based on composite outcomes largely driven by imaging findings. Because these findings are surrogates for things about which patients and their clinicians care, we conducted an observational study to determine whether PPT use led to fewer symptomatic kidney stone events, requiring emergency department (ED) visit, hospitalization, or surgery. METHODS: We identified a cohort of Medicare enrollees who had a 24-hour urine collection processed by a large central laboratory (2011-2016). We linked their clinical data with their pharmacy and medical claims. Among the subset with at least one biochemistry abnormality, we distinguished those who were prescribed guideline-concordant PPT (i.e., thiazides for hypercalciuria, alkali citrate therapy for hypocitraturia or low urine pH, uric acid lowering agents for hyperuricosuria) from those who were not. We differentiated between adherent and nonadherent PPT users based on the proportion of days covered method. We fit multivariate Cox models to estimate the hazard of a symptomatic stone event as a function of PPT use. RESULTS: In total, 7,230 patients met criteria, 55% of whom had hypocitraturia. Sixty-nine percent were untreated, and 31% were prescribed concordant PPT (alkali citrate therapy was used in 66%). Compared to untreated patients, those prescribed concordant therapy and adhered to their medication had a 38% lower hazard of ED visit (P<0.01) and a 46% lower hazard of hospitalization (P=0.04). Put differently, compared to untreated patients, concordant/adherent patients had lower 2-year predicted probabilities of ED visit (4.6% vs. 7.3%) and hospitalization (1.1% vs. 2.0%) (P<0.05 for each comparison). A similar pattern was noted for stone directed surgery but was not significant (Figure 1). CONCLUSIONS: Our findings help strengthen the evidence base for PPT use, providing real-world data on its clinical effectiveness. Source of Funding: National Institute of Diabetes and Digestive and Kidney Diseases R01DK121709 (to J.H.) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e117 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Hollingsworth More articles by this author Mary Oerline More articles by this author Ryan Hsi More articles by this author Joseph Crivelli More articles by this author Noah Krampe More articles by this author John Asplin More articles by this author Vahakn Shahinian More articles by this author Expand All Advertisement PDF downloadLoading ...

The real-world effectiveness of preventive pharmacological therapy

The real-world effectiveness of preventive pharmacological therapy

The necessity of improving cardiovascular health in commercial motor vehicle drivers

Commercial motor vehicle (CMV) drivers have an increased risk for cardiometabolic risk factors and higher rates of cardiovascular disease relative to the general population. Lifestyle factors, including the sedentary nature of driving and lack of access to healthy foods, contribute to the disproportionately high cardiovascular disease (CVD) risk among commercial vehicle (CMV) drivers. Occupational physicals represent an important opportunity to reach populations with a high prevalence and incidence of coronary artery disease who may not otherwise seek preventive care. These visits are an opportunity to discuss primary and secondary prevention, including lifestyle topics such as diet and exercise, and potentially recommend or implement preventive medical therapy when indicated. Future iterations of licensing guidelines for drivers should seek to incorporate updated recommendations regarding diet, physical activity, and preventive pharmacologic therapies.

PD05-01 ASSOCIATION BETWEEN ON-TREATMENT FOLLOW-UP TESTING AND MEDICATION ADHERENCE AMONG PATIENTS PRESCRIBED PREVENTIVE PHARMACOLOGIC THERAPY FOR URINARY STONE DISEASE

You have accessJournal of UrologyCME1 May 2022PD05-01 ASSOCIATION BETWEEN ON-TREATMENT FOLLOW-UP TESTING AND MEDICATION ADHERENCE AMONG PATIENTS PRESCRIBED PREVENTIVE PHARMACOLOGIC THERAPY FOR URINARY STONE DISEASE Joseph Crivelli, Phyllis Yan, Ryan Hsi, Vahakn Shahinian, Brian Denton, and John Hollingsworth Joseph CrivelliJoseph Crivelli More articles by this author , Phyllis YanPhyllis Yan More articles by this author , Ryan HsiRyan Hsi More articles by this author , Vahakn ShahinianVahakn Shahinian More articles by this author , Brian DentonBrian Denton More articles by this author , and John HollingsworthJohn Hollingsworth More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002524.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Guidelines on medical management for urinary stone disease (USD) recommend that clinicians obtain a 24-hour urine specimen within six months of initiating preventive pharmacological therapy (PPT) to assess therapeutic response. We examined whether there are beneficial spillover effects associated with this testing, specifically increased PPT adherence. METHODS: Using claims data from working-age, commercially insured adults with USD (2008 to 2019), we identified those who were prescribed PPT (i.e., a thiazide diuretic, alkali citrate therapy, or allopurinol). Next, we sorted patients into three groups: 1) those who did not complete any 24-hour urine testing, 2) those who completed only a baseline 24-hour urine collection prior to initiating PPT, and 3) those who completed both baseline testing and on-treatment follow-up testing within six months of initiating PPT. We defined PPT adherence based on percentage days covered using pharmacy claims and assessed this over 0 to 180 days and 180 to 360 days following the initial prescription fill. Finally, we fit multivariable logistic regression models to evaluate the association between on-treatment follow-up testing and PPT adherence. RESULTS: Among a cohort of 5,072 patients receiving PPT for USD, 3,517 (69.3%) did not complete 24-hour urine testing, 1,214 (23.9%) completed a baseline collection only, and 341 (6.7%) completed both baseline and on-treatment follow-up testing. Adjusted adherence rates based on results from multivariable logistic regression are shown in the Figure. There were no significant differences in adherence rates between patients without any 24-hour urine testing and those who performed a baseline urine collection only; however, compared to patients without any 24-hour urine testing, rates of PPT adherence were significantly higher for those who completed both baseline and on-treatment follow-up testing (45.9% vs. 24.7% at 0 to 180 days [P<0.01] and 29.5% vs. 15.7% at 180 to 360 days [P<0.01]). CONCLUSIONS: On-treatment follow-up testing for patients with USD managed with PPT was associated with higher rates of medication adherence. Further research is needed to understand how the timing of on-treatment follow-up testing can be optimized to maximize PPT adherence. Source of Funding: NIH 5R01DK121709 (JH) © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e86 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph Crivelli More articles by this author Phyllis Yan More articles by this author Ryan Hsi More articles by this author Vahakn Shahinian More articles by this author Brian Denton More articles by this author John Hollingsworth More articles by this author Expand All Advertisement PDF DownloadLoading ...

Comparison of Selective vs Empiric Pharmacologic Preventive Therapy of Kidney Stone Recurrence With High-Risk Features

ObjectiveTo compare the frequency of stone-related events among subgroups of high-risk patients with and without 24-hour urine testing before preventive pharmacological therapy (PPT) prescription. While recent studies show, on average, no benefit to a selective approach to PPT for urinary stone disease (USD), there could be heterogeneity in treatment effect across patient subgroups. Materials and MethodsUsing medical claims data from working-age adults and their dependents with USD (2008-2019), we identified those with a prescription fill for a PPT agent (thiazide diuretic, alkali therapy, or allopurinol). We then stratified patients into subgroups based on the presence of a concomitant condition or other factors that raised their stone recurrence risk. Finally, we fit multivariable regression models to measure the association between stone-related events (emergency department visit, hospitalization, and surgery) and 24-hour urine testing before PPT prescription by high-risk subgroup. ResultsOverall, 8369 adults with USD had a concomitant condition that raised their recurrence risk. Thirty-three percent (n = 2722) of these patients were prescribed PPT after 24-hour urine testing (median follow-up, 590 days), and 67% (n = 5647) received PPT empirically (median follow-up, 533 days). Compared to patients treated empirically, those with a history of recurrent USD had a significantly lower hazard of a subsequent stone-related event if they received selective PPT (hazard ratio, 0.83; 95% confidence interval, 0.71-0.96). No significant associations were noted for selective PPT in the other high-risk subgroups. ConclusionPatients with a history of recurrent USD benefit from PPT when guided by findings from 24-hour urine testing.

PD14-09 THE BENEFIT OF OBTAINING 24-HOUR URINE TESTING BEFORE PRESCRIBING PREVENTIVE PHARMACOLOGICAL THERAPY TO PATIENTS WITH HIGH-RISK URINARY STONE DISEASE

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation I (PD14)1 Sep 2021PD14-09 THE BENEFIT OF OBTAINING 24-HOUR URINE TESTING BEFORE PRESCRIBING PREVENTIVE PHARMACOLOGICAL THERAPY TO PATIENTS WITH HIGH-RISK URINARY STONE DISEASE Ryan Hsi, Phyllis Yan, Joseph Crivelli, Vahakn Shahinian, and John Hollingsworth Ryan HsiRyan Hsi More articles by this author , Phyllis YanPhyllis Yan More articles by this author , Joseph CrivelliJoseph Crivelli More articles by this author , Vahakn ShahinianVahakn Shahinian More articles by this author , and John HollingsworthJohn Hollingsworth More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001990.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recent studies show no benefit to a selective approach to preventive pharmacological therapy (PPT) for patients with urinary stone disease (i.e., obtaining 24-hour urine testing before prescribing). Because selective PPT may produce nonrandom differences in outcomes based on individual recurrence risk, we compared the frequency of stone-related events among patients with and without 24-hour urine testing before PPT use in high-risk subgroups. METHODS: Using medical claims data (2008 to 2019), we identified adults with urinary stone disease who had a prescription fill for a thiazide diuretic, alkali therapy, or allopurinol. We stratified them into subgroups based on the presence of a concomitant condition or other factors that raise stone recurrence risk, including (children, urinary tract infection, gout, bone disease, intestinal malabsorption, hyperparathyroidism, staghorn calculus, renal anomalies, sarcoidosis, cystinuria, and prior stone recurrence). We fit multivariable regression models to compare the frequency of a stone-related event (emergency department visit, hospitalization, and surgery) among patients with and without 24-hour urine testing before PPT prescription in these subgroups. RESULTS: Among 5,275 patients with urinary stone disease who had a concomitant high-risk condition, 37% (n=1,954) were prescribed PPT after 24-hour urine testing (median follow-up, 631 days), while 63% (3,321) received PPT empirically (median follow-up, 623 days). Patients with prior stone recurrence had a significantly lower hazard of a subsequent stone-related event if they received selective PPT (hazard ratio, 0.83; 95% confidence interval, 0.71 to 0.96). The adjusted predicted probability of a stone-related event among patients in this group was five percentage points lower at two years of follow-up for those on selective versus empiric PPT. No significant associations were noted for selective PPT in the other high-risk subgroups. CONCLUSIONS: Patients with a history of recurrent urinary stone disease benefit from PPT when guided by findings from 24-hour urine testing. These data highlight the importance of examining for heterogeneity in treatment effect when comparing stone prevention approaches. Source of Funding: NIH 1R01DK121709-01A1 © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e219-e219 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Hsi More articles by this author Phyllis Yan More articles by this author Joseph Crivelli More articles by this author Vahakn Shahinian More articles by this author John Hollingsworth More articles by this author Expand All Advertisement Loading ...

PD21-04 THE FREQUENCY OF METABOLIC ABNORMALITIES FOLLOWING INITIATION OF PREVENTIVE PHARMACOLOGIC THERAPY FOR URINARY STONE DISEASE

You have accessJournal of UrologyStone Disease: Medical & Dietary Therapy (PD21)1 Sep 2021PD21-04 THE FREQUENCY OF METABOLIC ABNORMALITIES FOLLOWING INITIATION OF PREVENTIVE PHARMACOLOGIC THERAPY FOR URINARY STONE DISEASE Joseph Crivelli, Phyllis Yan, Ryan Hsi, and John Hollingsworth Joseph CrivelliJoseph Crivelli More articles by this author , Phyllis YanPhyllis Yan More articles by this author , Ryan HsiRyan Hsi More articles by this author , and John HollingsworthJohn Hollingsworth More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002010.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While thiazide diuretics, alkali citrate therapy, and allopurinol—collectively referred to as preventive pharmacologic therapy (PPT)—are a mainstay of urinary stone disease (USD) prevention, their adverse effect profiles remain poorly characterized. Physicians must often extrapolate from data on other conditions (e.g., hypertension, gout) for which these medications are also prescribed, even though the dosing can differ. In this context, we assessed the frequency of metabolic abnormalities following initiation of PPT in a cohort of patients with USD. METHODS: Using medical claims data from working-age adults with USD (2008 to 2017), we identified patients who were prescribed a PPT agent and had at least three years of continuous insurance coverage following their first prescription fill. We measured the frequency of class-specific metabolic abnormalities among these patients: hyperkalemia for alkali citrate therapy; hypokalemia, hyponatremia, hyperglycemia, or hypercalcemia for thiazide diuretics; and elevated liver function tests for allopurinol. We then fit a multivariable logistic regression model to evaluate for an association between the occurrence of a metabolic abnormality and the PPT drug class prescribed. RESULTS: Among a cohort of 3914 patients with USD who were prescribed a PPT agent, 54.3%, 34.5%, and 20.7% received a thiazide diuretic, alkali citrate therapy, and allopurinol, respectively. Overall, 708 patients (18.1%) had at least one metabolic abnormality during a three-year period after PPT prescription. Hyperglycemia after initiating a thiazide diuretic was most frequent, while thiazide-induced hyponatremia was least frequent (Table). Compared to patients prescribed alkali citrate therapy, those prescribed a thiazide diuretic (odds ratio [OR], 11.95; 95% confidence interval [CI], 8.40 to 17.00) or allopurinol (OR, 3.35; 95% CI, 2.16 to 5.20) had significantly higher odds of experiencing a metabolic abnormality. CONCLUSIONS: Nearly one in five patients prescribed PPT for USD prevention will experience a medication-induced metabolic abnormality. These data can be used to counsel patients prior to prescribing PPT. Furthermore, they highlight the importance of guideline-recommended follow-up serum testing after the initiation of PPT. Source of Funding: National Institutes of Health 1R01DK121709-01A1 © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e375-e375 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph Crivelli More articles by this author Phyllis Yan More articles by this author Ryan Hsi More articles by this author John Hollingsworth More articles by this author Expand All Advertisement Loading ...

Comparison of Selective Versus Empiric Pharmacologic Preventative Therapy With Kidney Stone Recurrence

ObjectiveTo assess the effectiveness of an empiric approach to metabolic stone prevention. MethodsUsing medical claims from a cohort of working age adults with kidney stone diagnoses (2008-2017), we identified the subset who were prescribed thiazides, alkali therapy, or allopurinol—collectively known as preventive pharmacologic therapy (PPT). We distinguished between those who had 24-hour urine testing prior to initiating PPT (selective therapy) from those without it (empiric therapy). We conducted a survival analysis for time to first recurrence for stone-related events, including ED visits, hospitalizations, and surgery, up to 2 years after initiating PPT. ResultsOf 10,125 patients identified, 2744 (27%) and 7381 (73%) received selective and empiric therapy, respectively. The overall frequency of any stone-related event was 11%, and this did not differ between the 2 groups on bivariate analysis (P = .29). After adjusting for sociodemographic factors, comorbidities, medication class, and adherence, there was no difference in the hazard of a stone-related event between the selective and empiric therapy groups (hazard ratio, 0.97; 95% confidence interval, 0.84-1.12). When considered individually, the frequency of ED visits, hospitalizations, and surgeries did not differ between groups. Greater adherence to PPT and older age were associated with a lower hazard of a stone-related event (both P < .05). ConclusionCompared to empiric therapy, PPT guided by 24-hour urine testing, on average, is not associated with a lower hazard of a stone-related event. These results suggest a need to identify kidney stone patients who benefit from 24-hour urine testing.

The Immediate, Intermediate, and Long-Term Effects of Osteopathic Manipulative Treatment on Pulmonary Function in Adults with Asthma

Abstract Context Asthma is a common chronic obstructive lung disease with increasing prevalence and economic burden. The effect of osteopathic manipulative treatment (OMT) has been studied in patients with several lung diseases, including asthma; however, no clinical trials have studied effects beyond the immediate time period in adults with asthma using spirometry. Objective To examine the immediate, intermediate, and long-term effects of OMT on objective pulmonary function and subjective quality of life in asthmatic adults. Methods Twenty-five adults with asthma were recruited from the Des Moines University community. Standardized Asthma Quality of Life Questionnaire (AQLQ(S)) surveys and spirometry measures including forced expiratory volume in one second (FEV1), forced vital capacity (FVC), the FEV1/FVC ratio, and peak expiratory flow (PEF) were collected at baseline. Spirometry testing was performed immediately after and 3 days after each of 3 weekly standardized OMT sessions. Spirometry and AQLQ(S) surveys were collected again 4 weeks after the final OMT session. Spirometry results were analyzed using a repeated measure, linear mixed-effect model, and survey results were analyzed using paired t-tests. Results The study demonstrated statistically significant changes to the spirometry results, including the PEF and FEV1/FVC ratio. The PEF measurements increased 3 days after the first treatment and remained elevated through the completion of the study. The FEV1/FVC ratio decreased by 0.01 at 4 weeks post-OMT compared to baseline. There were no significant differences observed in the immediate, intermediate or long-term FEV1 and FVC measurements post-OMT. However, there was a significant increase in the overall score and all 4 domains of the AQLQ(S), including Symptoms, Activity Limitations, Emotional Function, and Environmental Stimuli. Conclusion The results of this pilot study suggest that OMT may improve the quality of life in adults with asthma. Spirometry testing revealed a significant change in some measures of pulmonary function and participants reported an improvement in asthma-specific quality of life. The authors suggest that, in combination with preventive measures and pharmacologic therapy, OMT may offer additional benefit in the treatment of adults with asthma. The results also suggest a need for further study of the effects of OMT on respiratory function in asthmatic adults.

Abstract P446: Hispanics/Latinos With Prediabetes are Eligible for Diabetes Prevention Intervention: Findings From the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Background: Hispanics/Latinos in the US are at high risk of type 2 diabetes mellitus (T2D). The American Diabetes Association (ADA) consensus statement recommends prediabetes screening in persons with body mass index (BMI) ≥ 25 kg/m 2 from at-risk racial/ethnic groups and/or with additional T2D risk factors to identify those who may benefit from lifestyle and/or pharmacological (metformin) therapy to prevent T2D. Little is known about the proportion of diverse Hispanics/Latinos who have prediabetes and may benefit from such preventive measures. Objectives: This study examined prediabetes prevalence in Hispanics/Latinos by BMI categories to estimate the proportion eligible for preventive therapy per ADA guidelines. Methods: The HCHS/SOL is a prospective, multi-center, population-based study that enrolled 16,415 diverse Hispanic/Latino adults aged 18-74 years from four US communities in 2008 – 2011. Prediabetes was defined per ADA criteria as any of the following: fasting plasma glucose 100-125 mg/dL, oral glucose tolerance test 140-199 mg/dL, or hemoglobin A1C 5.7%-6.4%. Prevalence of prediabetes age-standardized to the 2010 US population was examined in persons aged 18-74 years with BMI ≥ 25 kg/m 2 who were free of diabetes and not taking anti-glycemic medication (n=9393) and a sub-sample of those aged 18-60 with BMI ≥ 35 kg/m 2 (n=1528) to determine eligibility for preventive lifestyle and pharmacological therapy, respectively. Overall and heritage specific prevalence estimates (95% confidence intervals) were computed. Analyses were weighted for sampling probability and non-response. Results: Among individuals with BMI ≥ 25 kg/m 2 , 50.9% (49.6 - 52.3) had prediabetes, i.e., could benefit from preventive lifestyle measures. Prevalence was highest in those of Mexican heritage (53.1%; 50.8 – 55.4), followed by Puerto Rican (49.8%; 46.2 – 53.4) and Central American (49.8%; 45.5 – 54.1) heritage. Persons of South American heritage had the lowest prevalence (45.6%; 41.4 – 49.6) (p=0.29 for overall differences across groups). Among persons with BMI ≥ 35 kg/m 2 , 55.7% (52.2 – 59.2) had prediabetes, i.e., could benefit from metformin therapy; prevalence was highest in persons of South American heritage (62.2%; 48.3 – 76.1). Of those who met the criteria for lifestyle measures, about 64% were age 18-44, 69% had at least a high school education, 41% had income &lt;$20,000, and 40% had family history of diabetes. Over 60% of those eligible for preventive metformin therapy were women. Conclusions: Among Hispanics/Latinos who are overweight/obese, over half of those of Mexican heritage and almost half of those of Puerto Rican and Central American heritage need intensive lifestyle measures to prevent progression to diabetes. Among those who are obese, six out of ten individuals of South American heritage met criteria for preventive metformin therapy.

Understanding migraine and psychiatric comorbidity.

This article describes recent trends in our understanding of the role of psychiatric disorders in the experience and treatment of migraine, and the role of migraine in the experience and treatment of psychiatric disorders. Although the majority of studies evaluating psychiatric comorbidity in migraine have focused on depression, anxiety, and bipolar disorders are highly associated with migraine and relevant for prognosis and treatment planning. Comorbid psychiatric disorders may be associated with poorer treatment response for some acute pharmacotherapies; however, people with comorbid migraine and mood or anxiety disorders can achieve large responses to preventive pharmacologic and behavioral therapies. Emerging research is developing and evaluating behavioral treatments designed to manage cooccurring migraine and mood or anxiety disorders. Stigma related to psychiatric disorders has been well characterized, and could exacerbate extant migraine-related stigma. Anxiety and mood disorders are prevalent in people with migraine, although not ubiquitous. Psychiatric comorbidity is associated with greater migraine symptoms and disability; however, people with comorbid depression or anxiety are amenable to preventive migraine treatment. Research regarding migraine treatment strategies optimized for people with comorbid psychiatric disorders is critical to advancing care and reducing stigma for this important subpopulation of people with migraine.

Factors Associated With Preventive Pharmacological Therapy Adherence Among Patients With Kidney Stones

To determine adherence patterns for thiazide diuretics, alkali citrate therapy, and allopurinol, collectively referred to as preventive pharmacological therapy (PPT), among patients with kidney stones. Using medical claims data, we identified adults diagnosed with kidney stones between 2002 and 2006. Through National Drug Codes, we determined those with one or more prescription fills for a PPT agent. We measured adherence to PPT (as determined by the proportion of days covered formula) within the first 6 months of starting therapy and performed multivariate analysis to evaluate patient factors associated with PPT adherence. Among 7980 adults with kidney stones who were prescribed PPT, less than one third (30.2%) were adherent to their regimen (indicated by proportion of days covered ≥ 80%). Among those on monotherapy, rates of adherence differed by the type of PPT agent prescribed: 42.5% for thiazides, 40.0% for allopurinol, and 13.4% for citrate therapy. Factors that were independently associated with lower odds of PPT adherence included combination therapy receipt, female gender, less generous health insurance, and residence in the South or Northeast. In contrast, older patients and those with salaried employment had a higher probability of PPT adherence. Adherence to PPT is low. These findings help providers identify patients where PPT adherence will be problematic. Moreover, they suggest possible targets for quality improvement efforts in the secondary prevention of kidney stones.

PD47-09 FOLLOW-UP CARE AFTER ED VISITS FOR KIDNEY STONES—A MISSED OPPORTUNITY

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II1 Apr 2016PD47-09 FOLLOW-UP CARE AFTER ED VISITS FOR KIDNEY STONES—A MISSED OPPORTUNITY Amy Luckenbaugh, MD Phyllis Yan, MA J. Stuart Wolf, MD Khurshid Ghani, MBChB, MS Brent Hollenbeck, andMD, MS John HollingsworthMD, MS Amy LuckenbaughAmy Luckenbaugh More articles by this author , Phyllis YanPhyllis Yan More articles by this author , J. Stuart WolfJ. Stuart Wolf More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , Brent HollenbeckBrent Hollenbeck More articles by this author , and John HollingsworthJohn Hollingsworth More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2697AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The emergency department (ED) serves as the entry point for many patients with kidney stones into the healthcare system. When patients with acute renal colic are discharged from the ED, they are typically given instructions for urologic or primary care follow-up. However, data suggest that many do not comply with these recommendations. In doing so, patients may miss an opportunity for secondary stone prevention. To test this hypothesis, we examined patterns of post-ED follow-up care among adults with kidney stones. METHODS We used MarketScan's Commercial Claims and Encounters Database (2003-2006) to identify adults age 18 to 64 years with an ED visit for kidney stones. Next, we determined which patients received post-ED follow-up care, defined as a physician office visit or surgery for kidney stones within 90 days of the index ED claim. We then compared patients who received post-ED follow-up care and those who did not over a variety of sociodemographic characteristics. Finally, we fit multivariable logistic regression models to evaluate the association between receipt of post-ED follow-up care and subsequent secondary stone prevention (i.e., 24-hour urine testing and/or prescription of a preventive pharmacological therapy agent). RESULTS We identified 70,294 patients with an ED visit for kidney stones, of which 53% had follow-up care within 90 days. Among those with post-ED follow-up care, 66% were seen by a urologist. Compared to patients who received follow-up care, those who did not were more likely to be young (P<0.001), have non-salaried employment (P<0.001), and live in a rural area (P<0.001). After controlling for these differences we found that, relative to patients who did not receive follow-up care, those who did were significantly more likely to undergo 24-hour urine testing and be prescribed a preventive pharmacological therapy agent (Figure). Overall, post-ED follow-up care was associated with 36% higher odds of receiving secondary prevention (OR, 1.36; 95% CI, 1.30 to 1.43). CONCLUSIONS A substantial proportion of patients seen acutely in the ED for kidney stones do not have follow-up care for the kidney stone. Given that post-ED follow-up is associated with greater use of secondary prevention, efforts to enhance linkages across settings are needed in order to provide patients with kidney stones more comprehensive care. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1173 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Amy Luckenbaugh More articles by this author Phyllis Yan More articles by this author J. Stuart Wolf More articles by this author Khurshid Ghani More articles by this author Brent Hollenbeck More articles by this author John Hollingsworth More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

This Month in Adult Urology

No AccessJournal of UrologyThis Month in Adult Urology1 Mar 2016This Month in Adult Urology Joseph A. Smith Joseph A. SmithJoseph A. Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.11.032AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Adult Urology." The Journal of Urology, 195(3), pp. 537–538 References 1 : Impact of the Cell Cycle Progression test on physician and patient treatment selection for localized prostate cancer. J Urol2016; 195: 612. Link, Google Scholar 2 : Evaluating the role of operative repair of extraperitoneal bladder rupture following blunt pelvic trauma. J Urol2016; 195: 661. Link, Google Scholar 3 : Surgical salvage of thermal ablation failures for renal cell carcinoma. J Urol2016; 195: 594. Link, Google Scholar 4 : Percutaneous kidney biopsy for a small renal mass: a critical appraisal of results. J Urol2016; 195: 568. Link, Google Scholar 5 : Active surveillance for renal neoplasms with oncocytic features is safe. J Urol2016; 195: 581. Link, Google Scholar 6 : Medication nonadherence and effectiveness of preventive pharmacological therapy for kidney stones. J Urol2016; 195: 648. Link, Google Scholar © 2016 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 195Issue 3March 2016Page: 537-538 Advertisement Copyright & Permissions© 2016 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph A. Smith More articles by this author Expand All Advertisement PDF downloadLoading ...