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Hauta-Aho M, Teperi S, Korhonen MJ, Bell JS, Farinola N, Johns S, Shakib S, Huupponen R. Frailty and Co-Prescribing of Potentially Interacting Drugs in New Users of Warfarin. Drugs Aging 2020; 37:373-382. [PMID: 32147805 PMCID: PMC7190596 DOI: 10.1007/s40266-020-00755-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Warfarin is underutilised in frail older people because of the fear of bleeding complications. Drug interactions are an independent bleeding risk factor. However, the extent to which potential drug interactions are taken into account at warfarin therapy initiation in frail patients is not known. Objective The objective of this study was to investigate the use of potentially interacting drugs increasing the bleeding risk before and after warfarin initiation in frail and non-frail patients. Methods We conducted an observational study including inpatients aged ≥ 60 years initiated on warfarin in a tertiary hospital in Adelaide, South Australia. Frailty status was assessed with the Reported Edmonton Frail Scale. Medication charts were reviewed before and after warfarin initiation. Results In total, 151 patients (102 non-frail and 49 frail) were included. Before warfarin initiation, the use of clopidogrel and acetaminophen was more common in frail patients compared with non-frail patients (25.5% vs 10.2%, p = 0.0135, 63.8% vs 35.7% p = 0.0014, respectively). The use of non-steroidal anti-inflammatory drugs, 9.2% in non-frail patients and 6.4% in frail patients before warfarin initiation, was completely stopped after warfarin initiation in both groups. The use of antiplatelet drugs decreased from 56.1% in non-frail patients and 66.0 % in frail patients to 12.2% and 14.9%, respectively. Instead, the use of drugs affecting the metabolism of warfarin or vitamin K increased in both groups. No statistically significant difference was seen in the exposure to interacting drugs between study groups after warfarin initiation. Acetaminophen, senna glycosides and cytochrome P450 2C9 inhibiting drugs were the most common interacting drugs at discharge used in 49.0%, 18.4% and 20.4% of non-frail patients and 53.2%, 29.8% and 19.1% of frail patients, respectively. Conclusions The overall frequency of potential drug interactions was moderate and frail patients were not exposed to warfarin drug interactions more often than non-frail patients. Further studies in larger study populations are required to verify these results. Electronic supplementary material The online version of this article (10.1007/s40266-020-00755-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Milka Hauta-Aho
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland. .,Clinical Pharmacology Unit, Turku University Hospital, Turku, Finland. .,Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Simo Teperi
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Maarit J Korhonen
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland.,Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
| | - J Simon Bell
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia.,NHMRC Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
| | - Nicholas Farinola
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sally Johns
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia.,Department of Clinical Pharmacology, Faculty of Health Science, University of Adelaide, Adelaide, SA, Australia
| | - Risto Huupponen
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland.,Clinical Pharmacology Unit, Turku University Hospital, Turku, Finland
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Leblanc A, Petitpain N, Pereira O, Adssi HE, Latarche C, Gillet P, Colnat-Coulbois S. [Intracranial hemorrhage and oral anticoagulants of patients treated between 2011 and 2013 at the Nancy Regional University Hospital]. Neurochirurgie 2017; 63:302-307. [PMID: 28882608 DOI: 10.1016/j.neuchi.2017.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 01/03/2017] [Accepted: 02/21/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To perform a descriptive analysis of intracranial hemorrhages of patients treated with an antivitamin K (fluindione, acenocoumarol or warfarin) or a direct oral anticoagulant (dabigatran, rivaroxaban or apixaban) at the Nancy Regional University Hospital. MATERIAL AND METHOD The study period was from January 2011 to December 2013 and the computerized data (Programme de Médicalisation des Systèmes d'Information) of our hospital was accessed to identify the patients. Clinical data were obtained from the patients' files. Regional healthcare system was queried for reimbursement data. RESULTS Among the 157 identified cases of intracranial hemorrhage, 153 were related to antivitamin K, primarily fluindione (n=127), and only 4 to a direct oral anticoagulant (3 dabigatran and 1 rivaroxaban). During the same period, regional data indicated that 65,345 patients had had at least one reimbursement of antivitamin K and 20,983 patients one reimbursement of an oral direct anticoagulant. In our series, the most frequent intracranial hemorrhages were subdural hematoma (chronic in 65 cases, acute in 50 cases) and intraparenchymal hemorrhage (20 cases). The global mortality rate was 20.2% but varied with the site of hemorrhage. In multivariate analysis, the two risk factors of fatal outcome were coma on admission (OR 6.2; 95%CI: 2.6-15.0) and a history of previous intracranial hemorrhage (OR 13,4; 95% CI: 1,6-114,9). CONCLUSION During the 2011-2013 period, antivitamin K, especially fluindione, was the most frequently involved anticoagulants in intracranial hemorrhages with hospitalization at our Regional University Hospital. Coma on admission and a history of previous intracranial hemorrhage were the two main risk factors for fatal outcome.
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Affiliation(s)
- A Leblanc
- Centre régional de pharmacovigilance de Lorraine, hôpital Central, CHRU de Nancy, 29, avenue de Lattre-de-Tassigny, 54035 Nancy, France
| | - N Petitpain
- Centre régional de pharmacovigilance de Lorraine, hôpital Central, CHRU de Nancy, 29, avenue de Lattre-de-Tassigny, 54035 Nancy, France.
| | - O Pereira
- Direction régionale du service médical du Nord-Est, 54000 Nancy, France
| | - H El Adssi
- Département d'information médicale, hôpital St-Julien, CHRU de Nancy, 54000 Nancy, France
| | - C Latarche
- Coordination qualité risques et vigilances, CHRU de Nancy, 54000 Nancy, France
| | - P Gillet
- Centre régional de pharmacovigilance de Lorraine, hôpital Central, CHRU de Nancy, 29, avenue de Lattre-de-Tassigny, 54035 Nancy, France
| | - S Colnat-Coulbois
- Service de neurochirurgie, hôpital Central, CHRU de Nancy, 54000 Nancy, France
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Hansen PW, Clemmensen L, Sehested TSG, Fosbøl EL, Torp-Pedersen C, Køber L, Gislason GH, Andersson C. Identifying Drug-Drug Interactions by Data Mining: A Pilot Study of Warfarin-Associated Drug Interactions. Circ Cardiovasc Qual Outcomes 2016; 9:621-628. [PMID: 28263937 DOI: 10.1161/circoutcomes.116.003055] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 10/17/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Knowledge about drug-drug interactions commonly arises from preclinical trials, from adverse drug reports, or based on knowledge of mechanisms of action. Our aim was to investigate whether drug-drug interactions were discoverable without prior hypotheses using data mining. We focused on warfarin-drug interactions as the prototype. METHODS AND RESULTS We analyzed altered prothrombin time (measured as international normalized ratio [INR]) after initiation of a novel prescription in previously INR-stable warfarin-treated patients with nonvalvular atrial fibrillation. Data sets were retrieved from clinical work. Random forest (a machine-learning method) was set up to predict altered INR levels after novel prescriptions. The most important drug groups from the analysis were further investigated using logistic regression in a new data set. Two hundred and twenty drug groups were analyzed in 61 190 novel prescriptions. We rediscovered 2 drug groups having known interactions (β-lactamase-resistant penicillins [dicloxacillin] and carboxamide derivatives) and 3 antithrombotic/anticoagulant agents (platelet aggregation inhibitors excluding heparin, direct thrombin inhibitors [dabigatran etexilate], and heparins) causing decreasing INR. Six drug groups with known interactions were rediscovered causing increasing INR (antiarrhythmics class III [amiodarone], other opioids [tramadol], glucocorticoids, triazole derivatives, and combinations of penicillins, including β-lactamase inhibitors) and two had a known interaction in a closely related drug group (oripavine derivatives [buprenorphine] and natural opium alkaloids). Antipropulsives had an unknown signal of increasing INR. CONCLUSIONS We were able to identify known warfarin-drug interactions without a prior hypothesis using clinical registries. Additionally, we discovered a few potentially novel interactions. This opens up for the use of data mining to discover unknown drug-drug interactions in cardiovascular medicine.
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Affiliation(s)
- Peter Wæde Hansen
- From the Danish Heart Foundation, Copenhagen, Denmark (P.W.H., T.S.G.S., E.L.F., G.H.G.); DTU Compute, Technical University of Denmark, Lyngby (L.C.); The Heart Centre, Rigshospitalet (E.L.F., L.K.), and Department of Clinical Medicine (G.H.G.), University of Copenhagen, Denmark; Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.); The National Institute of Public Health, University of Southern Denmark, Copenhagen (G.H.G.); University of Copenhagen, Denmark; and Department of Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Denmark (C.A.).
| | - Line Clemmensen
- From the Danish Heart Foundation, Copenhagen, Denmark (P.W.H., T.S.G.S., E.L.F., G.H.G.); DTU Compute, Technical University of Denmark, Lyngby (L.C.); The Heart Centre, Rigshospitalet (E.L.F., L.K.), and Department of Clinical Medicine (G.H.G.), University of Copenhagen, Denmark; Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.); The National Institute of Public Health, University of Southern Denmark, Copenhagen (G.H.G.); University of Copenhagen, Denmark; and Department of Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Denmark (C.A.)
| | - Thomas S G Sehested
- From the Danish Heart Foundation, Copenhagen, Denmark (P.W.H., T.S.G.S., E.L.F., G.H.G.); DTU Compute, Technical University of Denmark, Lyngby (L.C.); The Heart Centre, Rigshospitalet (E.L.F., L.K.), and Department of Clinical Medicine (G.H.G.), University of Copenhagen, Denmark; Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.); The National Institute of Public Health, University of Southern Denmark, Copenhagen (G.H.G.); University of Copenhagen, Denmark; and Department of Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Denmark (C.A.)
| | - Emil Loldrup Fosbøl
- From the Danish Heart Foundation, Copenhagen, Denmark (P.W.H., T.S.G.S., E.L.F., G.H.G.); DTU Compute, Technical University of Denmark, Lyngby (L.C.); The Heart Centre, Rigshospitalet (E.L.F., L.K.), and Department of Clinical Medicine (G.H.G.), University of Copenhagen, Denmark; Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.); The National Institute of Public Health, University of Southern Denmark, Copenhagen (G.H.G.); University of Copenhagen, Denmark; and Department of Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Denmark (C.A.)
| | - Christian Torp-Pedersen
- From the Danish Heart Foundation, Copenhagen, Denmark (P.W.H., T.S.G.S., E.L.F., G.H.G.); DTU Compute, Technical University of Denmark, Lyngby (L.C.); The Heart Centre, Rigshospitalet (E.L.F., L.K.), and Department of Clinical Medicine (G.H.G.), University of Copenhagen, Denmark; Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.); The National Institute of Public Health, University of Southern Denmark, Copenhagen (G.H.G.); University of Copenhagen, Denmark; and Department of Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Denmark (C.A.)
| | - Lars Køber
- From the Danish Heart Foundation, Copenhagen, Denmark (P.W.H., T.S.G.S., E.L.F., G.H.G.); DTU Compute, Technical University of Denmark, Lyngby (L.C.); The Heart Centre, Rigshospitalet (E.L.F., L.K.), and Department of Clinical Medicine (G.H.G.), University of Copenhagen, Denmark; Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.); The National Institute of Public Health, University of Southern Denmark, Copenhagen (G.H.G.); University of Copenhagen, Denmark; and Department of Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Denmark (C.A.)
| | - Gunnar H Gislason
- From the Danish Heart Foundation, Copenhagen, Denmark (P.W.H., T.S.G.S., E.L.F., G.H.G.); DTU Compute, Technical University of Denmark, Lyngby (L.C.); The Heart Centre, Rigshospitalet (E.L.F., L.K.), and Department of Clinical Medicine (G.H.G.), University of Copenhagen, Denmark; Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.); The National Institute of Public Health, University of Southern Denmark, Copenhagen (G.H.G.); University of Copenhagen, Denmark; and Department of Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Denmark (C.A.)
| | - Charlotte Andersson
- From the Danish Heart Foundation, Copenhagen, Denmark (P.W.H., T.S.G.S., E.L.F., G.H.G.); DTU Compute, Technical University of Denmark, Lyngby (L.C.); The Heart Centre, Rigshospitalet (E.L.F., L.K.), and Department of Clinical Medicine (G.H.G.), University of Copenhagen, Denmark; Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.); The National Institute of Public Health, University of Southern Denmark, Copenhagen (G.H.G.); University of Copenhagen, Denmark; and Department of Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Denmark (C.A.)
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Lindh JD, Andersson ML, Mannheimer B. Adherence to guidelines for avoiding drug interactions associated with warfarin--a Nationwide Swedish Register Study. PLoS One 2014; 9:e97388. [PMID: 24830709 PMCID: PMC4022627 DOI: 10.1371/journal.pone.0097388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/17/2014] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To investigate the extent to which clinicians avoid well-established drug-drug interactions associated with warfarin. We hypothesised that clinicians would avoid combining non-steroidal anti-inflammatory drugs (NSAIDs), tramadol and sulfamethoxazole with warfarin. METHODS A cross-sectional analysis of nationwide dispensing data was performed in Swedish individuals 18 years or older (n = 7,563,649). Odds ratios of interacting NSAIDs, tramadol and sulfamethoxazole versus respective prevalence of comparator drugs codeine, and ciprofloxacin in patients co-dispensed interacting warfarin versus patients unexposed was calculated. RESULTS The odds of receiving an interacting NSAID versus the comparator codeine was markedly lower in patients with warfarin than in the remaining population (adjusted OR 0.21; 95% CI 0.20 - 0.22). Also, the interacting drugs tramadol and sulfamethoxazole were less common among patients dispensed warfarin as compared to the remaining population, although the decrease was much more modest (adjusted OR 0.83; CI 0.80-0.87 and 0.81; CI 0.73 - 0.90). CONCLUSIONS In conclusion, Swedish doctors in the vast majority of cases refrain from prescribing NSAIDs to patients already on warfarin. Tramadol and sulfamethoxazole are however rarely avoided.
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Affiliation(s)
- Jonatan D. Lindh
- Dept of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Marine L. Andersson
- Dept of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Buster Mannheimer
- Karolinska Institutet, Department of Clinical Science and Education at Södersjukhuset, Stockholm, Sweden
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Abadie D, Durrieu G, Roussin A, Montastruc JL. ["Serious" adverse drug reactions with tramadol: a 2010-2011 pharmacovigilance survey in France]. Therapie 2013; 68:77-84. [PMID: 23773348 DOI: 10.2515/therapie/2013021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 02/15/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Tramadol is a weak opioid used as a step 2 analgesic, approved in France for moderate to severe pain. After dextropropoxyphene withdrawal, a national pharmacovigilance follow-up of tramadol was decided by the French Drug Agency. METHODS All Serious Adverse Drug Reactions (SADR) notified with tramadol to the French PharmacoVigilance Centres (CRPV) and pharmaceutical companies between August 1(st), 2010 and July 31(th), 2011 were analyzed. RESULTS During the study period, 296 cases of SADR were notified to CRPV and 59 to pharmaceutical companies. Apart from opiate-related SADR, tramadol induced serotoninergic SADR, including seizures or serotoninergic syndromes. Several « unlabelled » SADR were also identified: some of them, like hyponatremia or hypoglycemia, are poorly known by health professionals. Other were never published: peripheral edema or pancreatitis. CONCLUSION This study shows that besides well-known opioid or serotoninergic ADR, tramadol can also induce 2 other relatively unknown ADR: hypoglycemia and hyponatremia.
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Affiliation(s)
- Delphine Abadie
- Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de Pharmacovigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, et Centre Midi-Pyrénées d'Évaluation et d'Information sur la Pharmacodépendance-Addictovigilance, Université de Toulouse, Faculté de Médecine, Centre hospitalier universitaire, Toulouse, France.
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