Core Concepts in Pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data

Healthcare and psychiatric drug utilization after a suicide attempt in patients with depression: a register-based Swedish cohort study

BACKGROUND

Suicide attempts (SA) are common in depression, yet little is known about healthcare utilization (HCU) and psychiatric drug utilization (PDU) following a SA. This study assesses and compares HCU and PDU patterns in patients with depression with and without a SA.

METHODS

We retrieved data from population-based registers on 359,276 patients with incident depression. Patients with a first-time SA (n = 16,748), were matched with comparators (n = 330,764). Patients with a history of SA (n = 11,764) were analyzed separately. Inpatient days, outpatient visits, and the amount of psychiatric medications were measured until five years after the SA.

RESULTS

Patients with a first-time SA had four times higher psychiatric inpatient HCU (ratio 3.8 [95 % CI 3.6-4.0]) and twice higher outpatient HCU (ratio 1.7 [95 % CI 1.7-1.8]) than comparators in the year following the SA. PDU was higher for most drug classes in the SA patients, with the largest difference observed for anxiolytics and sedatives (ratio 1.9 [95 % CI 1.8-1.9]). Higher HCU and PDU in SA patients persisted throughout the five-year follow-up period.

LIMITATIONS

Our data did not include depressed patients from primary care, indicating that the findings may be more generalizable to patients with moderate or severe depression.

CONCLUSIONS

Patients with depression who attempted suicide had higher HCU and PDU than comparators during the five-year follow-up period. The association between SA and increased HCU and PDU underscores the ongoing suffering of these individuals as well as the substantial burden placed on the healthcare system.

General practice-related variation in oral anticoagulant treatment of atrial fibrillation: a nationwide cohort study

BACKGROUND

Guideline-adherent oral anticoagulant (OAC) treatment in atrial fibrillation (AF) remains a challenge. In Denmark, most patients with AF are treated in general practice. Nevertheless, determinants of OAC prescription in primary care are poorly understood.

AIM

To investigate variation in OAC treatment adherence between general practice clinics and to identify clinic characteristics associated with a lower propensity to prescribe OAC treatment.

DESIGN & SETTING

Nationwide register-based cohort study including prevalent and incident patients with AF and CHA2DS2-VASc score ≥2 (n = 165 731) listed with Danish general practice clinics (n = 1666) in 2021.

METHOD

The main outcome was OAC treatment adherence assessed as proportion of days covered (PDC). We used clinic OAC propensity to evaluate variation. OAC propensity was quantified as ratios between observed and expected adherence. Expected adherence was estimated based on the composition of the clinic patient populations. Sampled reference populations were constructed to account for random variation. Linear regression models examined associations between OAC propensity and clinic characteristics.

RESULTS

The PDC with OAC treatment in the AF population was 78%. OAC propensity in clinics in the 90th percentile was 20% higher compared with clinics in the 10th percentile; however, this difference was reduced to 3% when accounting for random variation. Modest associations were observed between clinic characteristics and OAC propensity. The most significant difference was in the correlation between geographic location and OAC propensity, showing an 8% gap between top and bottom-performing regions.

CONCLUSION

The study suggests persistent underutilisation of OAC treatment in patients with AF and little variation in OAC prescription patterns across general practice clinics.

Analysis of medication management system data to determine potentially inappropriate medication use and hospitalization among older adults living in residential care homes for the elderly population

OBJECTIVES

Many older adults living in Resident Care Homes for the Elderly (RCHEs) are at risk of polypharmacy and the use of potentially inappropriate medication (PIM). Few studies have evaluated the prevalence and consequences of PIM use among older adults living in RCHEs. The objectives of this study are (1) to evaluate the prevalence of PIM use in 29 RCHEs in Hong Kong, and (2) to investigate the association between PIM use and hospitalization in this population.

METHODS

This is a prospective, observational, cohort study which utilized final-administered medication data from RCHEs that participated in a medication management program. Data on the medications administered to all residents living in the participating RCHEs were extracted from the SafeMed Medication Management System (SMMS®), which is a purpose-built Information Technology supporting the entire medication management process at RCHEs. The outcome of interest is the 12-month period prevalence of PIM use (January 1 to December 31, 2023), which was obtained by comparing the medication data with the 2023 Beers criteria. Hospital admissions during the study period were extracted from the SMMS®.Multivariable logistic regression was conducted to investigate the association between PIM use and hospital admissions.

RESULTS

We included 6,346 residents (age 82.9 ± 8.6 years; female 61.9%). The average number of current medications was 6.8 ± 7.4. Over half (51.5%) of residents had polypharmacy (≥ 5 medications). The 12-month period prevalence of PIM use was 34.5%. Among the residents with PIMs, 65.1%, 25.5% and 9.4% used 1, 2 and > 2 PIMs, respectively. Residents with PIMs were associated with higher rates of hospitalization (Odds Ratio [OR] 1.73, 95% confidence interval [CI] 1.54 to 1.69), after adjusting for age, sex and comorbidities. The number of PIMs was significantly associated with higher risk of hospitalization (OR: 2.17, 95% CI: 1.82 to 2.59 for > 1 PIMs vs. 0).

CONCLUSIONS

The use of PIM was observed in one-third of older adults living in RCHEs, and was associated with an increased risk of hospitalization. Our findings highlighted the urgent need for strategies to improve clinicians' awareness of PIMs and their adverse impact, and to implement pharmacist-led medication reviews in RCHEs.

Treatment Persistence and Variations in Prescribing Oral, Injectable, and Inhaled Corticosteroids: A Population-Based Drug Utilisation Study

PURPOSE

To examine variation in oral, injectable, and inhaled corticosteroid (CS) prescribing in primary care, exploring treatment persistence and coverage.

METHODS

We examined patient-level electronic health records from English general practices in the Clinical Practice Research Datalink Aurum database. We delineated a cohort of new users of oral, injectable, or inhaled CS with prescriptions issued between January 1, 2000, and June 30, 2021. Lorenz curves assessed potential prescribing skewness, and Kaplan-Meier (KM) plots estimated treatment persistence. The Proportion of Patients Covered (PPC) method estimated the proportion of patients still covered by treatment 1 year after initiation.

RESULTS

We observed 1 942 571 CS users across 1471 general practices, with 20% of oral and inhaled CS users accounting for almost 80% of total CS use. Older patients with comorbidities including respiratory diseases (13.5%), skin conditions (5.8%), or inflammatory bowel diseases (1.6%) were more likely to be prescribed higher doses. The KM plots showed that 20% of oral and 50% of inhaled CS users were persistent after one and 2 months, respectively. The PPC method indicated that 30% of oral and 60% of inhaled CS users were covered by treatment 6 months post-initiation. Some variation was observed when different grace periods were applied. Combined use of oral and inhaled CS was observed for 6.9% of patients.

CONCLUSION

A fifth of patients receiving CS accounted for over 80% of oral and inhaled CS prescribing in primary care. Identifying these patients is crucial for targeting future interventions to promote patient safety and cost-effective CS use.

Trends in gabapentinoid prescribing: A nationwide Danish drug utilization study

AIMS

Pregabalin and gabapentin are increasingly used for pain and other conditions. Concerns exist about overuse as well as potential misuse and abuse. To guide rational prescribing practices, we provide detailed nationwide data on the use of gabapentinoids in Denmark.

METHODS

We conducted a nationwide descriptive drug utilization study using the Danish healthcare registries to describe the use of gabapentinoids among Danish adults 2010-2023. We described overall use patterns, temporal trends, user characteristics, skewness of use, treatment duration and concomitant medication use.

RESULTS

The prevalence of gabapentinoid use increased almost four-fold from 11 per 1000 adults in 2010 to 41 in 2023 with the highest use among individuals aged 80+ years (96 per 1000 in 2023). Gabapentin and pregabalin were used equally. The median age of users increased from 58 years in 2010 to 63 years in 2023, while a decline was observed in the proportion with concomitant use of other drug classes, including benzodiazepines or opioids. Only 7% of patients were continuously treated for 3 years following initiation, while 22% were currently treated after 3 years (allowing treatment breaks). The use of gabapentinoids were somewhat skewed with 1% of users accounting for 7.3% of use in 2023.

CONCLUSION

The use of gabapentinoids has increased dramatically in recent years, in particular, among the elderly, and adherence was low. Increased attention to the increasing use of gabapentinoids is warranted to ensure rational use of this drug class.

Long-term adherence to anti-osteoporosis medication and determinants of adherence in the population-based screening trial ROSE

Screening initiatives for osteoporosis must facilitate treatment of those at elevated fracture risk. In a randomized controlled trial of 24,229 women, those in the screening group with FRAX ≥ 15% were invited for DXA with AOM treatment offered as per national guidelines. Treatment initiation in the following year was 9.5 times higher compared with controls.

PURPOSE

To determine if screened individuals have lower adherence to anti-osteoporotic medication (AOM) than unscreened and to examine determinants for low treatment adherence.

METHOD

In 2010/2011, women aged 65-80 (N = 34,229) in the Region of Southern Denmark were invited to the risk-stratified osteoporosis strategy evaluation (ROSE) randomized study. Women in the screening group with moderate to high 10-year fracture risk (FRAX® ≥ 15%) were invited for dual-energy x-ray absorptiometry with AOM treatment as per national guidelines. Screened, controls, and an age-matched general population sample were compared for adherence to AOM using 10-year follow-up data on prescription and hospital records.

RESULTS

Among ROSE participants with FRAX ≥ 15%, 5864 screened and 5790 controls were eligible for analysis, along with an equal number from the general population. AOM initiation in the first year was 9.5 times higher in screened compared to controls (HR 9.50, 7.16; 12.61). There was no difference in implementation assessed as medication possession ratio. The 5-year persistence rates were similar in screened and controls (51-52%), but lower in the general population (44%). FRAX risk factors partly influenced AOM initiation in the screened, with different patterns in other groups. Immobilization, comorbidities, and co-medications were key determinants of discontinuation in both the short and long term.

CONCLUSION

The ROSE screening programme significantly increased treatment initiation in postmenopausal women. Screened women showed similar treatment adherence levels to non-screened once they started medication. However, frail women were more prone to treatment discontinuation, highlighting the need for targeted support in this subgroup.

TRIAL REGISTRATION

The original ROSE trial is registered at ClinicalTrials.gov (NCT01388244). The study protocol has been published in Rubin et al. The risk-stratified osteoporosis strategy evaluation study (ROSE): a randomized prospective population-based study. Design and baseline characteristics. Calcif Tissue Int. 2015;96(2):167-79.

In utero exposure to methylphenidate, amphetamines and atomoxetine and offspring neurodevelopmental disorders - a population-based cohort study and meta-analysis

The use of Attention-Deficit/Hyperactivity Disorder (ADHD) medications during pregnancy is increasing, raising concerns about potential long-term effects on offspring. This study investigates in utero exposure to methylphenidate, amphetamines and atomoxetine and risk of offspring neurodevelopmental disorders (NDDs). The population-based cohort study identified from Swedish registers included 861,650 children born by 572,731 mothers from 2008-2017. We categorized exposure based on redeemed medication during pregnancy and compared exposed children to those whose mothers discontinued medication before conception. Main outcomes were any NDD, including ADHD and autism spectrum disorder (ASD). Cox proportional hazards regression estimated hazard ratios (HRs), adjusting for maternal psychiatric and sociodemographic factors. Sensitivity analyses included stratifications by medication type, timing, and duration of exposure, and sibling comparisons. We also performed a meta-analysis combining data from the present study with those from a previous Danish study. Results showed no increased risk for any NDD (HRadjusted 0.95, 95% CI 0.82-1.11), ADHD (HRadjusted 0.92, 95% CI 0.78-1.08), or ASD (HRadjusted 0.86, 95% CI 0.63-1.18). Sensitivity analyses showed consistent patterns of no increased risks across different exposure durations, medication types and between siblings. Meta-analyses further supported the findings (pooled HR for any NDD 1.00, 95% CI 0.83;1.20). Our study provides evidence that in utero exposure to ADHD medications does not increase the risk of long-term NDDs in offspring. This study replicates safety data for methylphenidate and extends it with new safety data on amphetamines and atomoxetine. These findings are crucial for informing clinical guidelines and helping healthcare providers and expectant mothers make informed decisions.

Medication nonadherence - definition, measurement, prevalence, and causes: reflecting on the past 20 years and looking forwards

In 2003, Sabate's World Health Organisation report defined medication nonadherence as a phenomenon where individuals' behaviour does not correspond to prescribed treatment recommendations from their healthcare provider. This concept of nonadherence evolved beyond a categorisation of patients as adherent or nonadherent. Rather, nonadherence varies within the same individual and treatment over time, and between treatments and individuals. The type and patterns of nonadherence are key determinants of outcome with individuals with the same percentage nonadherence having different outcomes depending on their pattern of nonadherence. Often the poorest clinical outcomes occur in individuals who do not initiate medication or discontinue early, but much of the nonadherence literature remains focused on implementation. This paper provides a nuanced discussion of nonadherence which has been enabled in part by the growing availability of technologies such as electronic nonadherence monitors, new biomarkers for adherence and greater access to 'big data' (e.g., on prescription refills). These allow granular assessment of nonadherence that can be linked with biophysical markers captured using technologies such as wearables. More validated self-report measures have also become available to profile nonadherence in research and practice. Together, in-depth data on dosing and clinical measures provide an opportunity to explore complex interactions between medications, therapeutic effects and clinical outcomes. This variation in measurement and definition means that there is a more fine-grained understanding of the prevalence of nonadherence and a greater recognition of the prevalence of nonadherence, with growing evidence suggesting that approximately a fifth of patients do not initiate treatment, of those initiating treatment approximately 30%-50% of patients do not implement their treatment as prescribed and that, over long follow-up periods in some conditions 80%-100% of patients discontinue. There is potential too to better understand causes of nonadherence. New behavioural models synthesise determinants of nonadherence previously considered separately. Frameworks like the COM-B (considering individual capability, opportunity, and motivation factors) and MACO (focusing on Medication Adherence Contexts and Outcomes) emphasize the multifaceted nature of nonadherence determinants. Greater focus on dynamic processes with interplay between individual, social, and environmental influences is needed. Addressing these complexities could lead to more effective and personalised support for patients.

Associating regulatory actions on diclofenac use with Danish trends in utilization by route of administration 1999-2023

AIMS

With the growing evidence of cardiovascular risks associated with diclofenac use, regulatory measures governing its application and sales have intensified since 2008. We evaluated the association between central regulatory actions and trends in diclofenac use in Denmark from 1999 to 2023, according to different dosage forms and routes of administration.

METHODS AND RESULTS

Data on diclofenac sales in Denmark from 1999 to 2023 were retrieved from the publicly available web database MEDSTAT, based on the Danish Register of Medicinal Products Statistics. The annual sales of various diclofenac dosage forms, including systemic (tablets, modified-release dosage forms, and suppositories) and topical (nonspecific and ophthalmic) dosage forms, were calculated and displayed by sales unit. From 1999 to 2008, sales of all systemically administered diclofenac forms increased: tablets by 51% (2000-2008), modified-release dosage forms by 40% (2003-2007), and suppositories by 44% (1999-2008). Thereafter, sales of tablets declined by 86% and modified-release dosage forms by 90% through 2023. The sales of suppositories declined somewhat lesser, by 34%, during 2008 to 2018 and then increased by 67% through 2023. Sales of nonspecific topical diclofenac increased by several thousandfold from 2005, although with brief periods of decline.

CONCLUSION

Sales of systemically administered diclofenac dosage forms, particularly tablets and modified-release drugs, declined by approximately 90% from about 2008 to 2023, indicating compliance with Danish and international regulatory actions. Conversely, sales of topically administered diclofenac increased heavily from 2005 to 2023, denoting a policy-driven shift toward these lower risk dosage forms.

Prescription drug use in Danish children and adolescents 2005-2023

Continuous monitoring of pediatric drug utilization is important for ensuring rational use and prioritizing research. This study provides an overview of pediatric prescription drug use among Danish children and adolescents from 2005-2023. Using Danish nationwide individual-level dispensing data, we identified all redeemed prescriptions for individuals < 18 years from January 2005-December 2023. We computed overall annual prevalence proportions of users and mean number of prescriptions per child. For all non-antibiotic drugs, we further determined the quantity of drug use measured in defined daily doses (DDDs) and stratified all analyses by age and Anatomical Therapeutic Chemical classification first and forth level. During the study period, the overall yearly prevalence of prescription drug use decreased due to reductions in antibiotic prescribing. When antibiotic prescriptions were disregarded, the prevalence of children with at least one prescription increased from 38% in 2005 to 42% in 2023, while the mean number of prescriptions and DDDs increased from 1.2 prescriptions per child and 51.2 million DDDs in 2005 to 1.5 prescriptions per child and 76.5 million DDDs in 2023. This increase was primarily driven by prescribing of central nervous system drugs to adolescents 12-17 years, with a substantial increase in centrally acting sympathomimetics and melatonin use. Overall pediatric drug prescribing is decreasing due to reduced antibiotic use. Non-antibiotic drug use is, however, rising, especially among adolescents and notably for psychotropic drugs. These findings underscore the importance of ongoing monitoring and call for further research into underlying causes and prescription practices for psychotropics.

Trends in initial pharmacological COPD treatment in primary care (2010-2021): a population-based study using the PHARMO Data Network

BACKGROUND

Pharmacological treatment is a cornerstone of chronic obstructive pulmonary disease (COPD) management, with general practitioners providing the most care. However, the lack of data on prescribing trends in initial pharmacotherapy in primary care hinders the understanding of how scientific and technical developments impact patient care and may also perpetuate suboptimal practices. Hence, this study aims to analyze trends in the initial pharmacological treatment of newly diagnosed COPD patients in Dutch primary care from 2010 to 2021.

METHODS

A repeated cross-sectional study was conducted via the PHARMO GP Database. Data were extracted from the electronic health records of individuals managed by general practitioners in the Netherlands within the PHARMO Data Network. Individuals aged ≥ 40 years at diagnosis with an International Classification of Primary Care code for COPD (R95) were included. Initial pharmacological treatment was identified based on the first prescription issued within 90 days postdiagnosis. The annual proportions of individuals receiving a specific treatment among those diagnosed were calculated and directly standardized by age and sex according to the 2021 Dutch population structure. Trend analysis was performed via joinpoint regression.

RESULTS

A total of 54,628 COPD patients were included (median [IQR] age: 65 [57-73]; 53.7% male), with 36.4% not receiving respiratory medication within 90 days of diagnosis, and 4.2% on other treatments. Trend analysis revealed that LAMA monotherapy increased from 13.4% in 2010 to 15.1% in 2015 and then declined to 11.0% by 2021. Moreover, LABA-ICS decreased from 17.6% to 8.5% between 2010 and 2018, after which it plateaued. In contrast, LABA-LAMA sharply increased, from 0.6% in 2010 to 9.6% in 2021. LABA monotherapy increased from 2.6% in 2010 to 5.7% in 2021. Triple therapy has remained constant. For reliever-only therapies, SABA increased from 8.5% in 2010 to 14.3% in 2018 and then stabilized, whereas SAMA and SABA-SAMA remained low throughout.

CONCLUSIONS

Shifts in initial pharmacological COPD treatment from 2010 to 2021 likely reflect the introduction of new inhalers and updated management strategies. However, a significant proportion of patients remain without GP prescriptions, which warrants further investigation.

Prevalence of central nervous system-active polypharmacy in a cohort of older adults in Argentina

BACKGROUND

Central nervous system (CNS)-active polypharmacy is frequent and potentially harmful in older patients. Data on its burden outside the USA and European countries remain limited.

AIMS

To estimate the period prevalence of and factors associated with out-of-hospital CNS-active polypharmacy in older adults.

METHOD

We used data from a cohort of out-patients aged ≥60 years affiliated to the Hospital Italiano de Buenos Aires' health maintenance organisation on 1 January 2021. A CNS-active polypharmacy event was defined as the concurrent exposure to ≥3 CNS-active medications (i.e. antidepressants, anti-epileptics, antipsychotics, benzodiazepines, Z-drugs and opioids) through filled out-of-hospital prescriptions. We calculated the period prevalence of CNS-active polypharmacy for 2021. We identified factors associated with CNS-active polypharmacy using a multivariable logistic regression model to estimate odds ratios and 95% confidence intervals (CI).

RESULTS

We included 63 857 patients. Pre-existing mental health diagnoses included anxiety (21%), depressive (14%) and sleep (11%) disorders. CNS-active polypharmacy occurred in 4535 patients, for a period prevalence of 7.1% (95% CI: 6.9-7.3%). The combination of an antidepressant, an antipsychotic and a benzodiazepine accounted for 21% of the CNS-active polypharmacy events. Frontotemporal dementia (odds ratio: 14.67; 95% CI: 4.47-48.20), schizophrenia (odds ratio: 7.93; 95% CI: 4.64-13.56), bipolar disorder (odds ratio: 7.20; 95% CI: 5.45-9.50) and depressive disorder (odds ratio: 3.50; 95% CI: 3.26-3.75) were associated with CNS-active polypharmacy.

CONCLUSIONS

One in 14 adults aged 60 years and older presented out-of-hospital CNS-active polypharmacy. Future studies should evaluate measures to reduce CNS-active medication use in this population.

Screening for Hypoglycaemia Risk and Medication Changes in Diabetes Patients Using Pharmacy Dispensing Data

Background: To improve hypoglycaemia management in primary care, more insight is needed into the opportunities to screen for hypoglycaemia risk and subsequent treatment modification using routinely available data. Our primary aim was to assess the number of diabetes patients with an estimated high risk of hypoglycaemia and describe the treatment changes in these patients using pharmacy dispensing data. Additionally, our aim was to investigate patient characteristics associated with such treatment changes. Methods: A drug utilisation cohort study with a 1-year follow-up using the IADB.nl pharmacy database was conducted. Patients aged 35 years or older who received at least two glucose-lowering medication dispensings in 2019 were included. Hypoglycaemia risk was determined using a validated algorithm based on patient demographics and dispensing data. The hypoglycaemia risk score ranged between 0 and 1. The anniversary method was used to evaluate treatment changes after 1 year. Factors associated with treatment changes were assessed by multinomial logistic regression. Results: Around one-quarter (26.9%) of the 36,628 included patients had a hypoglycaemia score of 0.6 or more. After a 1-year follow-up, the majority of these patients (88.9%) experienced no diabetes treatment changes. De-intensification was observed for 8.8% and intensification for 2.3%. Having a high-risk score, being female, and being younger in age were associated with de-intensification. Conclusions: A substantial number of primary care patients using glucose-lowering medications appear at risk of hypoglycaemia, whereas few of them undergo medication de-intensification. Pharmacy dispensing data can be helpful in screening for diabetes patients in whom a review of treatment is indicated.

Short-acting β2-agonists (SABA) overuse in asthma and patients' perceptions for this behavior

BACKGROUND

Short-acting β2-agonists (SABA) overuse is associated with poor asthma control. The Global Initiative for Asthma (GINA) 2019-updated strategy report has therefore taken a paradigm shift in reliever therapy recommendations.

OBJECTIVES

(I) To investigate the status of SABA overuse and medication dispensing patters in asthma in the Netherlands (II) validate dispensing data for SABA overuse identification and (III) understand patients' perspectives towards this SABA-taking behavior to inform future improvement strategies.

METHODS

An annually repeated cross-sectional study was conducted from 2017 to 2021 using pharmacy dispensing data in a real-world setting, including asthma patients aged 18-45 with ≥1 inhaler. A following qualitative study was performed in identified SABA overusing patients with a questionnaire and semi-structured interviews, supported by theoretical frameworks.

RESULTS

Dispensing data was available from 87 % of all community pharmacies (n = 1994) in 2017 and 95 % (n = 2005) in 2021. SABA overuse prevalence was constant for the five study-years with 20.6 % (±0.5 %). Increased ICS-formoterol and decreased SABA dispenses were observed in starters of inhalation therapy in 2021. 53 asthma patients completed the questionnaire of whom 43 patients confirmed SABA overuse, generating a positive predictive value of 81 %. Key behavioral drivers covered 7 themes regarding capability (knowledge; skills; memory, attention and decision process) motivation (emotion; beliefs about-capabilities; consequences) and opportunity (environmental context).

CONCLUSION

SABA overuse remains in one-fifth of asthma patients across the Netherlands, requiring careful attention from healthcare professionals. Dispensing data is a valid measure for SABA overuse in a clinical setting, facilitating patient selection. To meet patients' varied supporting needs, integration of tailored behavioral interventions is essential.

Prevalent and new use of common drugs for the incidence of community-acquired acute kidney injury: cohort and case-crossover study

Although community-acquired acute kidney injury (CA-AKI) represents a significant subset of all AKI incidence, evidence is limited due to the lack of comprehensive data prior to diagnosis. Here, we examined the risk of drug use for CA-AKI by using exhaustive pre-diagnostic prescription data. We included 78,754 working-age healthy individuals who underwent an annual health checkup program. We conducted a cohort study to assess the association between prevalent drug use and subsequent CA-AKI incidence using the Cox proportional hazard model. Subsequently, we conducted a case-crossover study to compare the new drug use in the case period directly before the CA-AKI incidence (- 3 to 0 months) with that in the control period far before the CA-AKI incidence (- 15 to - 12 months and - 9 to - 6 months) using the conditional Poisson regression model. The prevalent use of renin-angiotensin-aldosterone system (RAAS) inhibitors was associated with an increased CA-AKI incidence, but the new use was not. The new use of diuretics, anti-infectious drugs, and contrast medium was also associated with an increased CA-AKI incidence. These results suggest we need to pay attention for the incidence of AKI among the general population taking those common drugs.

Oxycodone initiation in Australia (2014-2018): Sociodemographic factors and preceding health service use

AIMS

Oxycodone is the most commonly prescribed strong opioid in Australia. This study describes health service antecedents and sociodemographic factors associated with oxycodone initiation.

METHODS

Population-based new user cohort study linking medicine dispensings, hospitalizations, emergency department visits, medical services and cancer notifications from New South Wales (NSW) for 2014-2018. New users had no dispensings of any opioid in the preceding year. We analysed health service use in the 5 days preceding initiation and proportion of people on treatment over 1 year and fitted an area-based, multivariable initiation model with sociodemographic covariates.

RESULTS

Oxycodone accounted for 30% of opioid initiations. Annually, 3% of the NSW population initiated oxycodone, and 5-6% were prevalent users; the new user cohort comprised 830 963 people. Discharge from hospital (39.3%), therapeutic procedures (21.4%) and emergency department visits (19.7%) were common; a hospital admission for injury (6.0%) or a past-year history of cancer (7.2%) were less common. At 1 year after initiation, 4.6% of people were using oxycodone. In the multivariable model, new use of oxycodone increased with age and was higher for people outside major cities, for example, an incidence rate ratio of 1.43 (95% confidence interval 1.36-1.51) for inner regional areas relative to major cities; there was no evidence of variation in rates of new use by social disadvantage.

CONCLUSION

About half of new oxycodone use in NSW was preceded by a recent episode of hospital care or a therapeutic procedure. Higher rates of oxycodone initiation in rural and regional areas were not explained by sociodemographic factors.

Impact of COVID-19 pandemic on prescription of psychotropic medications in the Italian paediatric population during 2020

BACKGROUND

There is a global perception that psychotropic utilization in children and adolescents is increasing, especially with the onset of COVID-19 pandemic. Available literature data on paediatric psychotropic medication prescriptions in Italy are limited to one or few regions and not updated. The aim of this study was to provide updated data on psychotropic prescriptions referred to the whole Italian paediatric population, as overall and by subgroups of medications and to evaluate if the COVID-19 pandemic during 2020 had an impact on prescription rates.

METHODS

A descriptive study on psychotropic drug utilization in children and adolescents (< 18 years) resident in all Italian regions during 2020 was performed. Patients registered in the Pharmaceutical Prescriptions database with at least one prescription/dispensing of a psychotropic medication (antipsychotics-N05A), (antidepressants-N06A) and (psychostimulants-N06BA) during the study period were considered. The indicators used were the prescription rate (number of prescriptions per 1000 children) and prevalence of use (proportion of the paediatric population with at least one prescription in the relevant year).

RESULTS

During the 2020 the prevalence of psychotropic drug use in the paediatric population was 0.3%, increased of 7.8% if compared to 2019. The same trend was observed for the prescription rate, which recorded an average of 28.2 per 1000 children with an increase of 11.6% if compared to previous year, representing the 0.6% of the overall drug use in this age group. The data showed a growing trend prescription by age, reaching the peak in adolescents aged 12-17 years old, with a prescription rate of 65 per 1000 children and a prevalence of 0.71%. Considering the subgroups of psychotropic medications, the highest prevalence of use was found for antipsychotic drugs, received by the 0.19% of the paediatric population during 2020.

CONCLUSIONS

Psychotropic drug utilization in children and adolescents has grown during 2020 in Italy and worldwide, raising alarms from health care clinicians and patient advocates about the increase of burden of mental diseases in paediatric population during the COVID-19 pandemic. A more systematic monitoring of the use of psychotropic medications should be implemented in all countries for collecting relevant information about children and adolescents taking psychotropic drugs, in order to address the present and the future of the mental health of the paediatric population.

Evaluating the effect of inequalities in oral anti-coagulant prescribing on outcomes in people with atrial fibrillation

Aims

Whilst anti-coagulation is typically recommended for thromboprophylaxis in atrial fibrillation (AF), it is often never prescribed or prematurely discontinued. The aim of this study was to evaluate the effect of inequalities in anti-coagulant prescribing by assessing stroke/systemic embolism (SSE) and bleeding risk in people with AF who continue anti-coagulation compared with those who stop transiently, permanently, or never start.

Methods and results

This retrospective cohort study utilized linked Scottish healthcare data to identify adults diagnosed with AF between January 2010 and April 2016, with a CHA2DS2-VASC score of ≥2. They were sub-categorized based on anti-coagulant exposure: never started, continuous, discontinuous, and cessation. Inverse probability of treatment weighting-adjusted Cox regression and competing risk regression was utilized to compare SSE and bleeding risks between cohorts during 5-year follow-up. Of an overall cohort of 47 427 people, 26 277 (55.41%) were never anti-coagulated, 7934 (16.72%) received continuous anti-coagulation, 9107 (19.2%) temporarily discontinued, and 4109 (8.66%) permanently discontinued. Lower socio-economic status, elevated frailty score, and age ≥ 75 were associated with a reduced likelihood of initiation and continuation of anti-coagulation. Stroke/systemic embolism risk was significantly greater in those with discontinuous anti-coagulation, compared with continuous [subhazard ratio (SHR): 2.65; 2.39-2.94]. In the context of a major bleeding event, there was no significant difference in bleeding risk between the cessation and continuous cohorts (SHR 0.94; 0.42-2.14).

Conclusion

Our data suggest significant inequalities in anti-coagulation prescribing, with substantial opportunity to improve initiation and continuation. Decision-making should be patient-centred and must recognize that discontinuation or cessation is associated with considerable thromboembolic risk not offset by mitigated bleeding risk.

Prescriptions of antidepressants and anxiolytics in France 2012-2022 and changes with the COVID-19 pandemic: interrupted time series analysis

BACKGROUND

Depression and anxiety have increased in prevalence since the start of the COVID-19 pandemic.

OBJECTIVE

To evaluate the consumption of antidepressants and anxiolytics from 2012 to 2022 and the pandemic's potential impact in France.

METHODS

We conducted an interrupted time series analysis of routine drug sales data (Medic'AM) from all French outpatient pharmacies from 2012 to 2022. We investigated trends in defined daily doses of antidepressants and anxiolytics sold per 1000 inhabitants (DDD/TID) and related expenditures before and after pandemic onset and in relation with stringency of pandemic mitigation measures. Analyses were performed descriptively and using segmented linear regression, autoregressive and autoregressive integrated moving average models.

FINDINGS

From 2012 to 2019, overall monthly antidepressant sales increased (+0.02 DDD/TID) while monthly anxiolytic sales decreased (-0.07 DDD/TID). With pandemic onset, there was a relevant and persisting trend increase (+0.20 DDD/TID per month) for antidepressant sales overall, with an estimated excess of 112.6 DDD/TID sold from May 2020 until December 2022. Anxiolytic sales were elevated from February 2020 throughout the pandemic but returned to expected levels by December 2022, with an estimated excess of 33.8 DDD/TID. There was no evident association between stringency and antidepressant or anxiolytic sales.

CONCLUSIONS

This study showed a protracted trend increase in the consumption of antidepressants since pandemic onset, while increases in anxiolytic consumption were temporary.

CLINICAL IMPLICATIONS

We provide evidence that the COVID-19 pandemic may have had long-lasting consequences on the prevalence and treatment of depression and anxiety disorders, requiring further actions by researchers and policy-makers to address this potential public mental health crisis.

Association between Prescribing and Intoxication Rates for Selected Psychotropic Drugs: A Longitudinal Observational Study

Psychotropic prescription drugs are commonly involved in intoxication events. The study's aim was to determine a comparative risk for intoxication in relation to prescribing rates for individual drugs. This was a nationwide observational study in Slovenian adults between 2015 and 2021. Intoxication events with psychotropic drugs were collected from the National Register of intoxications. Dispensing data, expressed in defined daily doses, were provided by the Health Insurance Institute of Slovenia. Intoxication/prescribing ratio values were calculated. The correlation between trends in prescribing and intoxication rates was assessed using the Pearson correlation coefficient. In total, 2640 intoxication cases with psychotropic prescription drugs were registered. Anxiolytics and antipsychotics were the predominant groups. Midazolam, chlormethiazole, clonazepam, sulpiride, and quetiapine demonstrated the highest risk of intoxication, while all antidepressants had a risk several times lower. The best trend correlation was found for the prescribing period of 2 years before the intoxication events. An increase of 1,000,000 defined daily doses prescribed resulted in an increase of fifty intoxication events for antipsychotics, twenty events for antiepileptics, and five events for antidepressants. Intoxication/prescribing ratio calculation allowed for a quantitative comparison of the risk for intoxication in relation to the prescribing rates for psychotropic drugs, providing additional understanding of their toxicoepidemiology.

Estimating Type 2 Diabetes Prevalence: A Model of Drug Consumption Data

Observational, cross-sectional prevalence studies are costly and time-consuming. The development of indirect methods estimating prevalence used to obtain faster, less-expensive, and more robust results would be an advantage for several healthcare applications. This study aimed to use the drug dispensing data from community pharmacies to estimate the prevalence of Type 2 Diabetes mellitus (T2DM) in the Portuguese population. A cross-sectional study was conducted using a database of dispensed medicines with an indication for Diabetes mellitus in 2018 and 2021, stratified by geographic region. The methodology was based on a sequential method of acquiring prevalence estimates obtained through exposure to medicines using the daily doses defined per thousand inhabitants per day and adjusted to the rate of adherence to therapy, prescription patterns, and concomitance of antidiabetic drugs. The estimated overall T2DM prevalence in 2018 was 13.9%, and it was 14.2% for 2021. The results show the increased consumption of antidiabetic drugs, with fixed-dose combination antidiabetics and new antidiabetics being particularly important in 2021. This work allowed for the development of a model to obtain the estimated prevalence of T2DM based on drug consumption, using a simple, fast, and robust method that is in line with the available evidence. However, with the recent expanding indications for new antidiabetics, the inclusion of further data in the model needs to be studied.

Drug Utilization Studies in Pregnant Women for Newly Licensed Medicinal Products: A Contribution from IMI ConcePTION

Purpose

Studies focusing on safety outcomes typically require large populations to comprehensively characterise the patient groups exposed to the medicines under investigation. However, there is often less information for subpopulations, such as pregnant or breastfeeding women, particularly when new medicines are considered. It is important to understand what information can be obtained from drug utilization studies (DUS) involving pregnant women in the early years postmarketing to provide supportive information for safety studies. The aims of this literature review are to (1) identify and review DUS for new medicines in pregnancy and breastfeeding and (2) list and summarise key information items to be reported in a DUS for new medicines in pregnancy.

Methods

To identify postmarketing DUS of new prescription medicines or enantiomers in pregnancy, a systematic literature review was undertaken in PubMed and Embase between January 2015 and June 2022. In addition, the complete database of the ENCePP EU PAS Register was systematically searched to June 2022.

Results

We identified 11 published DUS on new medicines in pregnancy from the ENCePP EU PAS Register and none from other sources. No studies on breastfeeding were identified. The 11 identified publications reported the medicine's use for the first 3 to 5 years after marketing approval. No reports assessed utilization in the first 3 years of approval. It was usual to issue interim reports annually (7 studies). All studies concerned conditions managed in ambulatory care (primary care and outpatient facilities) and included some primary care prescribing. Most (n = 8) only had prescribing/dispensing data available at individual level for ambulatory care; outpatient prescribing was included in three of these studies Three studies held a limited amount of in-hospital prescribing data. A DUS can confirm at an early stage whether there are sufficient exposed pregnancies in available data sources to ensure a safety study is powered to detect a difference in the prevalence of adverse pregnancy or infant outcomes or if additional data from other databases are needed. A DUS may also help address methodological considerations such as selection of comparators. DUS can be performed embedded in a DUS in the general population, in a cohort of women of childbearing age, or in a cohort of pregnant women.

Conclusion

This review summarises key aspects of a DUS for new medicines in pregnancy. DUS for new medicines in pregnancy should be planned before marketing, scheduled for the first 3 to 5 years after release, with annual interim/progress reports, and reported in peer-reviewed journals. By offering detailed information on data sources, exposure timing, prevalence and location, coprescribing, comorbidities, coexposures, and demographics, a DUS will offer a firm foundation for safety studies and will help to contextualize spontaneous reporting of serious adverse events.

Noninterventional studies in the COVID-19 era: methodological considerations for study design and analysis

The global COVID-19 pandemic has generated enormous morbidity and mortality, as well as large health system disruptions including changes in use of prescription medications, outpatient encounters, emergency department admissions, and hospitalizations. These pandemic-related disruptions are reflected in real-world data derived from electronic medical records, administrative claims, disease or medication registries, and mobile devices. We discuss how pandemic-related disruptions in healthcare utilization may impact the conduct of noninterventional studies designed to characterize the utilization and estimate the effects of medical interventions on health-related outcomes. Using hypothetical studies, we highlight consequences that the pandemic may have on study design elements including participant selection and ascertainment of exposures, outcomes, and covariates. We discuss the implications of these pandemic-related disruptions on possible threats to external validity (participant selection) and internal validity (for example, confounding, selection bias, missing data bias). These concerns may be amplified in populations disproportionately impacted by COVID-19, such as racial/ethnic minorities, rural residents, or people experiencing poverty. We propose a general framework for researchers to carefully consider during the design and analysis of noninterventional studies that use real-world data from the COVID-19 era.