1
|
Kanning JP, Abtahi S, Schnier C, Klungel OH, Geerlings MI, Ruigrok YM. Prescribed Drug Use and Aneurysmal Subarachnoid Hemorrhage Incidence: A Drug-Wide Association Study. Neurology 2024; 102:e209479. [PMID: 38838229 DOI: 10.1212/wnl.0000000000209479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Current benefits of invasive intracranial aneurysm treatment to prevent aneurysmal subarachnoid hemorrhage (aSAH) rarely outweigh treatment risks. Most intracranial aneurysms thus remain untreated. Commonly prescribed drugs reducing aSAH incidence may provide leads for drug repurposing. We performed a drug-wide association study (DWAS) to systematically investigate the association between commonly prescribed drugs and aSAH incidence. METHODS We defined all aSAH cases between 2000 and 2020 using International Classification of Diseases codes from the Secure Anonymised Information Linkage databank. Each case was matched with 9 controls based on age, sex, and year of database entry. We investigated commonly prescribed drugs (>2% in study population) and defined 3 exposure windows relative to the most recent prescription before index date (i.e., occurrence of aSAH): current (within 3 months), recent (3-12 months), and past (>12 months). A logistic regression model was fitted to compare drug use across these exposure windows vs never use, controlling for age, sex, known aSAH risk factors, and health care utilization. The family-wise error rate was kept at p < 0.05 through Bonferroni correction. RESULTS We investigated exposure to 205 commonly prescribed drugs between 4,879 aSAH cases (mean age 61.4, 61.2% women) and 43,911 matched controls. We found similar trends for lisinopril and amlodipine, with a decreased aSAH risk for current use (lisinopril odds ratio [OR] 0.63, 95% CI 0.44-0.90, amlodipine OR 0.82, 95% CI 0.65-1.04) and an increased aSAH risk for recent use (lisinopril OR 1.30, 95% CI 0.61-2.78, amlodipine OR 1.61, 95% CI 1.04-2.48). A decreased aSAH risk in current use was also found for simvastatin (OR 0.78, 95% CI 0.64-0.96), metformin (OR 0.58, 95% CI 0.43-0.78), and tamsulosin (OR 0.55, 95% CI 0.32-0.93). By contrast, an increased aSAH risk was found for current use of warfarin (OR 1.35, 95% CI 1.02-1.79), venlafaxine (OR 1.67, 95% CI 1.01-2.75), prochlorperazine (OR 2.15, 95% CI 1.45-3.18), and co-codamol (OR 1.31, 95% CI 1.10-1.56). DISCUSSION We identified several drugs associated with aSAH, of which 5 drugs (lisinopril and possibly amlodipine, simvastatin, metformin, and tamsulosin) showed a decreased aSAH risk. Future research should build on these signals to further assess the effectiveness of these drugs in reducing aSAH incidence. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that some commonly prescribed drugs are associated with subsequent development of aSAH.
Collapse
Affiliation(s)
- Jos P Kanning
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Shahab Abtahi
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Christian Schnier
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Olaf H Klungel
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Mirjam I Geerlings
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Ynte M Ruigrok
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| |
Collapse
|
5
|
Marcucci M, Iorio A, Nobili A, Tettamanti M, Pasina L, Marengoni A, Salerno F, Corrao S, Mannucci PM. Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards. Eur J Intern Med 2010; 21:516-23. [PMID: 21111937 DOI: 10.1016/j.ejim.2010.07.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 07/14/2010] [Accepted: 07/17/2010] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Current guidelines for ischemic stroke prevention in atrial fibrillation or flutter (AFF) recommend Vitamin K antagonists (VKAs) for patients at high-intermediate risk and aspirin for those at intermediate-low risk. The cost-effectiveness of these treatments was demonstrated also in elderly patients. However, there are several reports that emphasize the underuse of pharmacological prophylaxis of cardio-embolism in patients with AFF in different health care settings. AIMS To evaluate the adherence to current guidelines on cardio-embolic prophylaxis in elderly (> 65 years old) patients admitted with an established diagnosis of AFF to the Italian internal medicine wards participating in REPOSI registry, a project on polypathologies/polytherapies stemming from the collaboration between the Italian Society of Internal Medicine and the Mario Negri Institute of Pharmacological Research; to investigate whether or not hospitalization had an impact on guidelines adherence; to test the role of possible modifiers of VKAs prescription. METHODS We retrospectively analyzed registry data collected from January to December 2008 and assessed the prevalence of patients with AFF at admission and the prevalence of risk factors for cardio-embolism. After stratifying the patients according to their CHADS(2) score the percentage of appropriateness of antithrombotic therapy prescription was evaluated both at admission and at discharge. Univariable and multivariable logistic regression models were employed to verify whether or not socio-demographic (age >80years, living alone) and clinical features (previous or recent bleeding, cranio-facial trauma, cancer, dementia) modified the frequency and modalities of antithrombotic drugs prescription at admission and discharge. RESULTS Among the 1332 REPOSI patients, 247 were admitted with AFF. At admission, CHADS(2) score was ≥ 2 in 68.4% of patients, at discharge in 75.9%. Among patients with AFF 26.5% at admission and 32.8% at discharge were not on any antithrombotic therapy, and 43.7% at admission and 40.9% at discharge were not taking an appropriate therapy according to the CHADS(2) score. The higher the level of cardio-embolic risk the higher was the percentage of antiplatelet- but not of VKAs-treated patients. At admission or at discharge, both at univariable and at multivariable logistic regression, only an age >80 years and a diagnosis of cancer, previous or active, had a statistically significant negative effect on VKAs prescription. Moreover, only a positive history of bleeding events (past or present) was independently associated to no VKA prescription at discharge in patients who were on VKA therapy at admission. If heparin was considered as an appropriate therapy for patients with indication for VKAs, the percentage of patients admitted or discharged on appropriate therapy became respectively 43.7% and 53.4%. CONCLUSION Among elderly patients admitted with a diagnosis of AFF to internal medicine wards, an appropriate antithrombotic prophylaxis was taken by less than 50%, with an underuse of VKAs prescription independently of the level of cardio-embolic risk. Hospitalization did not improve the adherence to guidelines.
Collapse
Affiliation(s)
- M Marcucci
- Department of Internal Medicine, University of Perugia, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
van Aart L, Eijkhout HW, Kamphuis JS, Dam M, Schattenkerk ME, Schouten TJ, Ploeger B, Strengers PFW. Individualized dosing regimen for prothrombin complex concentrate more effective than standard treatment in the reversal of oral anticoagulant therapy: An open, prospective randomized controlled trial. Thromb Res 2006; 118:313-20. [PMID: 16182346 DOI: 10.1016/j.thromres.2005.08.005] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2005] [Revised: 08/03/2005] [Accepted: 08/06/2005] [Indexed: 11/28/2022]
Abstract
Prothrombin Complex Concentrate (PCC) is indicated for the acute reversal of oral anticoagulation therapy. To compare the efficacy of a "standard" dosage of 20 ml PCC equivalent to about 500 IU factor IX (group A), and an "individualized" dosage based on a target-INR of 2.1 or 1.5, the initial-INR and the patient's body weight (group B), we performed an open, prospective, randomized, controlled trial. The in vivo response and in vivo recovery of factor II, VII, IX and X in these patients on oral anticoagulation was determined. Ninety three patients (group A: 47; group B: 46) with major bleedings or admitted for urgent (surgical) interventions were enrolled. PCC and Vitamin K (10 mg) were administered intravenously. We evaluated the effect of treatment by the decrease of INR and the clinical outcome. The number of patients reaching the target-INR 15 min after the dosage of PCC was significantly higher in the group treated with an "individualized" dosage, compared to the group treated with a standard dose, (89% versus 43%; p<0.001). So, we conclude that for the acute reversal of oral anticoagulant therapy, an "individualized" dosage regimen of PCC based on the target-INR, the initial-INR, and body weight of the patient, is significantly more effective in reaching the target-INR than a "standard" dosage. The in vivo response and in vivo recovery found in this study was higher then in patients with isolated factor deficiencies. This suggests that the pharmacokinetics in patients on oral anticoagulants may be different.
Collapse
|
11
|
Taylor CT, Chester EA, Byrd DC, Stephens MA. Vitamin K to reverse excessive anticoagulation: a review of the literature. Pharmacotherapy 1999; 19:1415-25. [PMID: 10600090 DOI: 10.1592/phco.19.18.1415.30896] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We conducted an extensive literature review to evaluate the appropriate use, route, and dose of vitamin K to reverse excessive anticoagulation. Issues such as sample size, study design, different patient populations, and various study end points confounded results. Of 18 studies published, 8 enrolled 229 patients to evaluate parenteral vitamin K administration. Nine studies with 288 patients evaluated oral administration, and only 2 retrospective studies (280 patients) compared routes of administration. Reductions in international normalized ratios at 24 hours ranged from 21-42%, 47-86%, 25-67%, and 40-75% for temporary warfarin discontinuation alone, and intravenous, subcutaneous, and oral routes of vitamin K administration, respectively. Methodologically weak studies and indeterminate results plague interpretation of the literature on vitamin K. In general, results of this review support current guidelines for reversing excessive warfarin anticoagulation. However, it is important to realize that the quality of literature on which these recommendations are based is poor and that optimal dose and route of vitamin K administration remain unclear. Large, well-designed, randomized, controlled trials are necessary to define optimum management strategies for excessively anticoagulated patients.
Collapse
Affiliation(s)
- C T Taylor
- Department of Pharmacy Practice, Auburn University School of Pharmacy, Tuscaloosa, Alabama 35487, USA
| | | | | | | |
Collapse
|