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Smith SM, Winterstein AG, Gurka MJ, Walsh MG, Keshwani S, Libby AM, Hogan WR, Pepine CJ, Cooper‐DeHoff RM. Initial Antihypertensive Regimens in Newly Treated Patients: Real World Evidence From the OneFlorida+ Clinical Research Network. J Am Heart Assoc 2022; 12:e026652. [PMID: 36565195 PMCID: PMC9973585 DOI: 10.1161/jaha.122.026652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Knowledge of real-world antihypertensive use is limited to prevalent hypertension, limiting our understanding of how treatment evolves and its contribution to persistently poor blood pressure control. We sought to characterize antihypertensive initiation among new users. Methods and Results Using Medicaid and Medicare data from the OneFlorida+ Clinical Research Consortium, we identified new users of ≥1 first-line antihypertensives (angiotensin-converting enzyme inhibitor, calcium channel blocker, angiotensin receptor blocker, thiazide diuretic, or β-blocker) between 2013 and 2021 among adults with diagnosed hypertension, and no antihypertensive fill during the prior 12 months. We evaluated initial antihypertensive regimens by class and drug overall and across study years and examined variation in antihypertensive initiation across demographics (sex, race, and ethnicity) and comorbidity (chronic kidney disease, diabetes, and atherosclerotic cardiovascular disease). We identified 143 054 patients initiating 188 995 antihypertensives (75% monotherapy; 25% combination therapy), with mean age 59 years and 57% of whom were women. The most commonly initiated antihypertensive class overall was angiotensin-converting enzyme inhibitors (39%) followed by β-blockers (31%), calcium channel blockers (24%), thiazides (19%), and angiotensin receptor blockers (11%). With the exception of β-blockers, a single drug accounted for ≥75% of use of each class. β-blocker use decreased (35%-26%), and calcium channel blocker use increased (24%-28%) over the study period, while initiation of most other classes remained relatively stable. We also observed significant differences in antihypertensive selection across demographic and comorbidity strata. Conclusions These findings indicate that substantial variation exists in initial antihypertensive prescribing, and there remain significant gaps between current guideline recommendations and real-world implementation in early hypertension care.
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Affiliation(s)
- Steven M. Smith
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL,Division of Cardiovascular Medicine, Department of Medicine, College of MedicineUniversity of FloridaGainesvilleFL,Center for Integrative Cardiovascular and Metabolic DiseaseUniversity of FloridaGainesvilleFL
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Matthew J. Gurka
- Department of Health Outcomes and Biomedical Informatics, College of MedicineUniversity of FloridaGainesvilleFL
| | - Marta G. Walsh
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Shailina Keshwani
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Anne M. Libby
- Department of Emergency Medicine, School of MedicineUniversity of Colorado DenverAuroraCO
| | - William R. Hogan
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Carl J. Pepine
- Division of Cardiovascular Medicine, Department of Medicine, College of MedicineUniversity of FloridaGainesvilleFL
| | - Rhonda M. Cooper‐DeHoff
- Division of Cardiovascular Medicine, Department of Medicine, College of MedicineUniversity of FloridaGainesvilleFL,Center for Integrative Cardiovascular and Metabolic DiseaseUniversity of FloridaGainesvilleFL,Department of Pharmacotherapy and Translational Research, College of PharmacyUniversity of FloridaGainesvilleFL
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Anderson TS, Ayanian JZ, Zaslavsky AM, Souza J, Landon BE. National Trends in Antihypertensive Treatment Among Older Adults by Race and Presence of Comorbidity, 2008 to 2017. J Gen Intern Med 2022; 37:4223-4232. [PMID: 35474502 PMCID: PMC9708992 DOI: 10.1007/s11606-022-07612-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/12/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND In 2014, hypertension guidelines for older adults endorsed increased use of fixed-dose combinations, prioritized thiazide diuretics and calcium channel blockers (CCBs) for Black patients, and no longer recommend beta-blockers as first-line therapy. OBJECTIVE To evaluate older adults' antihypertensive use following guideline changes. DESIGN Time series analysis. PATIENTS Twenty percent national sample of Medicare Part D beneficiaries aged 66 years and older with hypertension. INTERVENTION Eighth Joint National Committee (JNC8) guidelines MAIN MEASURES: Quarterly trends in prevalent and initial antihypertensive use were examined before (2008 to 2013) and after (2014 to 2017) JNC8. Analyses were conducted among all beneficiaries with hypertension, beneficiaries without chronic conditions that might influence antihypertensive selection (hypertension-only cohort), and among Black patients, given race-based guideline recommendations. KEY RESULTS The number of beneficiaries with hypertension increased from 1,978,494 in 2008 to 2,809,680 in 2017, the proportions using antihypertensives increased from 80.3 to 81.2%, and the proportion using multiple classes and fixed-dose combinations declined (60.8 to 58.1% and 20.7 to 15.1%, respectively, all P<.01). Prior to JNC8, the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and CCBs was increasing. Use of CCBs as initial therapy increased more rapidly following JNC8 (relative change in quarterly trend 0.15% [95% CI, 0.13-0.18%), especially among Black beneficiaries (relative change 0.44% [95% CI, 0.21-0.68%]). Contrary to guidelines, the use of thiazides and combinations as initial therapy consistently decreased in the hypertension-only cohort (13.8 to 8.3% and 25.1 to 15.7% respectively). By 2017, 65.9% of Black patients in the hypertension-only cohort were initiated on recommended first-line or combination therapy compared to 80.3% of non-Black patients. CONCLUSIONS Many older adults, particularly Black patients, continue to be initiated on antihypertensive classes not recommended as first-line, indicating opportunities to improve the effectiveness and equity of hypertension care and potentially reduce antihypertensive regimen complexity.
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Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02246, USA.
- Harvard Medical School, Boston, MA, USA.
| | - John Z Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jeffrey Souza
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Bruce E Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02246, USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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3
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Sandhu AT, Kohsaka S, Lin S, Woo CY, Goldstein MK, Heidenreich PA. Renin-angiotensin-aldosterone system inhibitors and SARS-CoV-2 infection: an analysis from the veteran's affairs healthcare system. Am Heart J 2021; 240:46-57. [PMID: 34126079 PMCID: PMC8196226 DOI: 10.1016/j.ahj.2021.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 06/07/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are known to impact the functional receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The association between chronic therapy with these medications and infection risk remains unclear. OBJECTIVES The objective was to determine the association between prior ACEI or ARB therapy and SARS-CoV-2 infection among patients with hypertension in the U.S. Veteran's Affairs health system. METHODS We compared the odds of SARS-CoV-2 infection among three groups: patients treated with ACEI, treated with ARB, or treated with alternate first-line anti-hypertensives without ACEI/ARB. We excluded patients with alternate indications for ACEI or ARB therapy. We performed an augmented inverse propensity weighted analysis with adjustment for demographics, region, comorbidities, vitals, and laboratory values. RESULTS Among 1,724,723 patients with treated hypertension, 659,180 were treated with ACEI, 310,651 with ARB, and 754,892 with neither. Before weighting, patients treated with ACEI or ARB were more likely to be diabetic and use more anti-hypertensives. There were 13,278 SARS-CoV-2 infections (0.8%) between February 12, 2020 and August 19, 2020. Patients treated with ACEI had lower odds of SARS-CoV-2 infection (odds ratio [OR] 0.93; 95% CI: 0.89-0.97) while those treated with ARB had similar odds (OR 1.02; 95% CI: 0.96-1.07) compared with patients treated with alternate first-line anti-hypertensives without ACEI/ARB. In falsification analyses, patients on ACEI did not have a difference in their odds of unrelated outcomes. CONCLUSIONS Our results suggest the safety of continuing ACEI and ARB therapy. The association between ACEI therapy and lower odds of SARS-CoV-2 infection requires further investigation.
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Affiliation(s)
- Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA.
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shoutzu Lin
- Medical Service, VA Palo Alto Health Care System, Palo Alto, CA
| | | | - Mary K Goldstein
- Medical Service, VA Palo Alto Health Care System, Palo Alto, CA; Center for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford, CA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA; Medical Service, VA Palo Alto Health Care System, Palo Alto, CA
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4
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Helgeson SA, Waddle MR, Burnside RC, Debella YT, Lee AS, Burger CD, Li Z, Johnson PW, Patel NM. Association between Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers and Lung Cancer. South Med J 2021; 114:607-613. [PMID: 34480196 DOI: 10.14423/smj.0000000000001293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are the most commonly prescribed antihypertensives, with prior studies identifying a possible association between long-term use and increased rates of lung cancer. This study evaluated this potential association in a large population using propensity matching. METHODS This was a population-based cohort study in a large healthcare system in three regions of the United States. Pairwise propensity score matching was performed using demographics and comorbidities. All of the adult patients in the healthcare system from January 1, 2000 to April 30, 2018 with at least 1 year of follow-up were included. RESULTS In total, 3,253,811 patients with a median age of 59 (range 18-103) years were included. The ACEI group had a higher freedom from lung cancer versus controls at 15 years (98.47%, 95% confidence interval [CI] 98.41-98.54) versus 98.26%, (95% CI 98.20-98.33), whereas ARBs had similar rates versus controls at all time points. For patients diagnosed as having lung cancer, median all-cause survival was significantly higher in the ACEI (34.7 months, 95% CI 32.8-36.6) and ARB (30.9 months, 95% CI 28.1-33.8) groups than the control group (20.6 months, 95% CI 20.1-21.1). CONCLUSIONS This study showed lower rates of lung cancer with ACEI use and no difference in risk with ARBs. In addition, use of these medications was found to be associated with increased survival in those diagnosed as having lung cancer. This study supports the continued use of these medications without concern for increasing the risk of lung cancer.
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Affiliation(s)
- Scott A Helgeson
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Mark R Waddle
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Rebecca C Burnside
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Yalew T Debella
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Augustine S Lee
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Charles D Burger
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Zhuo Li
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Patrick W Johnson
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Neal M Patel
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
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5
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Foti KE, Appel LJ, Matsushita K, Coresh J, Alexander GC, Selvin E. Digit Preference in Office Blood Pressure Measurements, United States 2015-2019. Am J Hypertens 2021; 34:521-530. [PMID: 33246327 DOI: 10.1093/ajh/hpaa196] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/09/2020] [Accepted: 11/20/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Blood pressure (BP) measurement error may lead to under- or overtreatment of hypertension. One common source of error is terminal digit preference, most often a terminal digit of "0." The objective was to evaluate national trends in terminal digit preference in office BP measurements among adults with treated hypertension. METHODS Data were from IQVIA's National Disease and Therapeutic Index, a nationally representative, serial cross-sectional survey of office-based physicians. The analysis included office visits from 2015 to 2019 among adults aged ≥18 years receiving antihypertensive treatment. Annual trends were examined in the percent of systolic and diastolic BP measurements ending in zero by patient sex, age, and race/ethnicity, physician specialty, and first or subsequent hypertension treatment visit. RESULTS From 2015 to 2019, there were ~60 million hypertension treatment visits annually (unweighted N: 5,585-9,085). There was a decrease in the percent of visits with systolic (41.7%-37.7%) or diastolic (42.7%-37.8%) BP recordings ending in zero. Trends were similar by patient characteristics. However, a greater proportion of measurements ended in zero among patients aged ≥80 (vs. 15-59 or 60-79) years, first (vs. subsequent) treatment visits, visits to cardiologists (vs. primary care physicians), and visits with systolic BP ≥140 or diastolic BP ≥90 (vs. <140/90) mm Hg. CONCLUSIONS Despite modest improvement, terminal digit preference remains a common problem in office BP measurement in the United States. Without bias, 10%-20% of measurements are expected to end in zero. Reducing digit preference is a priority for improving BP measurement accuracy and hypertension management.
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Affiliation(s)
- Kathryn E Foti
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lawrence J Appel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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6
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Zou X, He J, Zhao D, Zhang M, Xie Y, Dai C, Wang C, Li C. Structural Changes and Evolution of Peptides During Chill Storage of Pork. Front Nutr 2020; 7:151. [PMID: 33072793 PMCID: PMC7536345 DOI: 10.3389/fnut.2020.00151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
In this work, we investigated changes in protein structures in vacuum-packed pork during chill storage and its impact on the in vitro protein digestion. Longissimus dorsi muscles were vacuum packed and stored at 4°C for 3 days. Samples were subjected to Raman spectroscopy, in vitro digestion and nano LC-MS/MS. The 3 d samples had lower α-helix content, but higher β-sheet, β-turn, and random coil contents than the 0 d samples (P < 0.05). SDS-PAGE revealed significant protein degradation in the 3 d samples and the differences in digested products across the storage time. Proteome analysis indicated that the 3 d samples had the higher susceptibility to digestion. Increasing protein digestibility was mainly attributed to the degradation of myofibrillar proteins. Thus, exposure of more enzymatic sites in loose protein structure during chill storage could increase protein degradation in meat.
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Affiliation(s)
- Xiaoyu Zou
- Key Laboratory of Meat Processing and Quality Control, Ministry of Education, Nanjing Agricultural University, Nanjing, China.,Jiangsu Collaborative Innovation Center of Meat Production and Processing, Quality and Safety Control, Nanjing Agricultural University, Nanjing, China.,Key Laboratory of Meat Processing, Ministry of Agriculture and Rural Affairs, Nanjing Agricultural University, Nanjing, China
| | - Jing He
- Key Laboratory of Meat Processing and Quality Control, Ministry of Education, Nanjing Agricultural University, Nanjing, China.,Jiangsu Collaborative Innovation Center of Meat Production and Processing, Quality and Safety Control, Nanjing Agricultural University, Nanjing, China.,Key Laboratory of Meat Processing, Ministry of Agriculture and Rural Affairs, Nanjing Agricultural University, Nanjing, China
| | - Di Zhao
- Key Laboratory of Meat Processing and Quality Control, Ministry of Education, Nanjing Agricultural University, Nanjing, China.,Jiangsu Collaborative Innovation Center of Meat Production and Processing, Quality and Safety Control, Nanjing Agricultural University, Nanjing, China.,Key Laboratory of Meat Processing, Ministry of Agriculture and Rural Affairs, Nanjing Agricultural University, Nanjing, China
| | - Min Zhang
- Key Laboratory of Meat Processing and Quality Control, Ministry of Education, Nanjing Agricultural University, Nanjing, China.,Jiangsu Collaborative Innovation Center of Meat Production and Processing, Quality and Safety Control, Nanjing Agricultural University, Nanjing, China.,Key Laboratory of Meat Processing, Ministry of Agriculture and Rural Affairs, Nanjing Agricultural University, Nanjing, China
| | - Yunting Xie
- Key Laboratory of Meat Processing and Quality Control, Ministry of Education, Nanjing Agricultural University, Nanjing, China.,Jiangsu Collaborative Innovation Center of Meat Production and Processing, Quality and Safety Control, Nanjing Agricultural University, Nanjing, China.,Key Laboratory of Meat Processing, Ministry of Agriculture and Rural Affairs, Nanjing Agricultural University, Nanjing, China
| | - Chen Dai
- Experimental Teaching Center of Life Science, Nanjing Agricultural University, Nanjing, China
| | - Chong Wang
- Key Laboratory of Meat Processing and Quality Control, Ministry of Education, Nanjing Agricultural University, Nanjing, China.,Jiangsu Collaborative Innovation Center of Meat Production and Processing, Quality and Safety Control, Nanjing Agricultural University, Nanjing, China.,Key Laboratory of Meat Processing, Ministry of Agriculture and Rural Affairs, Nanjing Agricultural University, Nanjing, China
| | - Chunbao Li
- Key Laboratory of Meat Processing and Quality Control, Ministry of Education, Nanjing Agricultural University, Nanjing, China.,National Center for International Research on Animal Gut Nutrition, Nanjing Agricultural University, Nanjing, China.,Joint International Research Laboratory of Animal Health and Food Safety, Ministry of Education, Nanjing Agricultural University, Nanjing, China
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7
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LaVallee C, Rascati KL, Gums TH. Antihypertensive agent utilization patterns among patients with uncontrolled hypertension in the United States. J Clin Hypertens (Greenwich) 2020; 22:2084-2092. [PMID: 32951318 DOI: 10.1111/jch.14041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 08/06/2020] [Accepted: 08/09/2020] [Indexed: 11/27/2022]
Abstract
Hypertension affects approximately one-third of the US adults. This study investigated antihypertensive utilization patterns among hypertensive patients who were prescribed treatment, yet still experienced uncontrolled hypertension. Data from the Decision Resources Group Real World Evidence Data Repository US database (2015-2016) were used to construct a cohort of uncontrolled hypertension patients to observe antihypertensive utilization patterns. Results for 5059 patients, with an average age of 57.8 (SD = 13.7), who had, on average 2.4 agents prescribed. Approximately half (51.9%) were female, and most were White (86.8%). More than one-third (N = 1877; 37.1%) of patients were diagnosed with diabetes mellitus (DM) or chronic kidney disease (CKD) that could independently contribute to increased cardiovascular complications. Overall, the most common treatments prescribed, as percent of agents and as percent of patients, respectively, were diuretics (24.9%; 59.6%), followed by angiotensin-converting enzyme inhibitors (ACEIs) (23.8%; 56.9%), beta-blockers (BBs) (18.7%; 44.8%), calcium channel blockers (CCBs) (15.4%; 36.8%), and angiotensin II receptor blockers (ARBs) (13.5%; 32.3%). Approximately one-tenth (10.5%) of the prescriptions were written for fixed-dose combination therapies. Among patients diagnosed with DM and CKD (N = 200), the order of the most common agents was the same as the overall cohort. Only 5.6% of prescriptions written for these patients were fixed-dose combination therapy. Based on clinical guidelines, which suggest using ACEIs, ARBs, or CCBs as first-line therapy, and fixed-dose combination therapy to increase adherence, this indicates over-prescribing of BBs and under-prescribing of fixed-dose combination therapy. These findings illustrate the need to further investigate challenges faced by patients and providers in treatment decision-making.
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Affiliation(s)
- Chris LaVallee
- Division of Health Outcomes and Pharmacy Practice, College of Pharmacy, University of Texas, Austin, Texas, USA.,Decision Resources Group, Health Outcomes, Boston, Massachusetts, USA
| | - Karen L Rascati
- Division of Health Outcomes and Pharmacy Practice, College of Pharmacy, University of Texas, Austin, Texas, USA
| | - Tyler H Gums
- Division of Health Outcomes and Pharmacy Practice, College of Pharmacy, University of Texas, Austin, Texas, USA
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8
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Miano TA, Shashaty MGS, Yang W, Brown JR, Zuppa A, Hennessy S. Effect of Renin-Angiotensin System Inhibitors on the Comparative Nephrotoxicity of NSAIDs and Opioids during Hospitalization. ACTA ACUST UNITED AC 2020; 1:604-613. [PMID: 33163971 DOI: 10.34067/kid.0001432020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Nonsteroidal anti-inflammatory drugs (NSAIDS) are increasingly important alternatives to opioids for analgesia during hospitalization as health systems implement opioid-minimization initiatives. Increasing NSAID use may increase AKI rates, particularly in patients with predisposing risk factors. Inconclusive data in outpatient populations suggests that NSAID nephrotoxicity is magnified by renin-angiotensin system inhibitors (RAS-I). No studies have tested this in hospitalized patients. Methods Retrospective, active-comparator cohort study of patients admitted to four hospitals in Philadelphia, Pennsylvania. To minimize confounding by indication, NSAIDs were compared to oxycodone, and RAS-I were compared to amlodipine. We tested synergistic NSAID+RAS-I nephrotoxicity by comparing the difference in AKI rate between NSAID versus oxycodone in patients treated with RAS-I to the difference in AKI rate between NSAID versus oxycodone in patients treated with amlodipine. In a secondary analysis, we restricted the cohort to patients with baseline diuretic treatment. AKI rates were adjusted for 71 baseline characteristics with inverse probability of treatment-weighted Poisson regression. Results The analysis included 25,571 patients who received a median of 2.4 days of analgesia. The overall AKI rate was 23.6 per 1000 days. The rate difference (RD) for NSAID versus oxycodone in patients treated with amlodipine was 4.1 per 1000 days (95% CI, -2.8 to 11.1), and the rate difference for NSAID versus oxycodone in patients treated with RAS-I was 5.9 per 1000 days (95% CI, 1.9 to 10.1), resulting in a nonsignificant interaction estimate: 1.85 excess AKI events per 1000 days (95% CI, -6.23 to 9.92). Analysis in patients treated with diuretics produced a higher, albeit nonsignificant, interaction estimate: 9.89 excess AKI events per 1000 days (95% CI, -5.04 to 24.83). Conclusions Synergistic nephrotoxicity was not observed with short-term NSAID+RAS-I treatment in the absence of concomitant diuretics, suggesting that RAS-I treatment may not be a reason to choose opioids in lieu of NSAIDs in this population. Synergistic nephrotoxicity cannot be ruled out in patients treated with diuretics.
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Affiliation(s)
- Todd A Miano
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremiah R Brown
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.,Department of Epidemiology, Geisel School of Medicine, Hanover, New Hampshire.,Department of Biomedical Data Science, Geisel School of Medicine, Hanover, New Hampshire
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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9
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ACE inhibitor-mediated angioedema. Int Immunopharmacol 2019; 78:106081. [PMID: 31835086 DOI: 10.1016/j.intimp.2019.106081] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/19/2019] [Accepted: 11/23/2019] [Indexed: 02/07/2023]
Abstract
Angioedema (AE) occurring during ACE inhibitor therapy (ACEi-AE) is a rare complication involving between 0.1 and 0.7% of treated patients. AE can also complicate other therapeutic regimens that block the renin-angiotensin aldosterone system. Other drugs, such as immune suppressors, some type of antidiabetics or calcium antagonists, can increase the likelihood of ACEi-AE when associated to ACEi. There is a clear ethnic predisposition, since African-Americans or Hispanics show a higher prevalence of this condition compared to Caucasians. At least in African-Americans the genetic predisposition accounts for a general higher prevalence of AE, independently from the cause. People that experience ACEi-AE may have some recurrence when they are switched to an angiotensin-receptor blocker (ARB); however, epidemiological studies on large cohorts have shown that angiotensin receptor blockers (ARB) do not increase the likelihood of AE compared to other antihypertensives. Clinical manifestations consist of edema of face, lips, tongue, uvula and upper airways, requiring intubation or tracheotomy in severe cases. Attacks last for 48-72 h and require hospital admission in most cases. Intestinal involvement with sub-occlusive symptoms has also been reported. The pathogenesis of ACEi-AE depends mainly on a reduced catabolism and accumulation of bradykinin, which is normally metabolized by ACE. Genetic studies have shown that some single nucleotide polymorphisms at genes encoding relevant molecules for bradykinin metabolism and action may be involved in ACEi-AE, giving a basis for the ethnic predisposition. Treatment of ACEi-AE is still a matter of debate. Corticosteroids and antihistamines do not show efficacy. Some therapeutic attempts have shown some efficacy for fresh frozen plasma or C1 inhibitor concentrate infusion. Interventional studies with the specific bradykinin receptor antagonist icatibant have shown conflicting results; there might be a different ethnic predisposition to icatibant efficacy which has been proven in caucasian but not in black patients.
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10
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Lim S, Choo EH, Choi IJ, Ihm SH, Kim HY, Ahn Y, Chang K, Jeong MH, Seung KB. Angiotensin Receptor Blockers as an Alternative to Angiotensin-Converting Enzyme Inhibitors in Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention. J Korean Med Sci 2019; 34:e289. [PMID: 31760711 PMCID: PMC6875434 DOI: 10.3346/jkms.2019.34.e289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/24/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEIs) are the first choice for the treatment of acute myocardial infarction (AMI), and angiotensin receptor blockers (ARBs) should be considered in patients intolerant to ACEIs. Although previous studies support the use of ARBs as an alternative to ACEIs, these studies showed inconsistent results. The objective of this study was to demonstrate the clinical impact of ARBs as an alternative to ACEIs in patients with AMI undergoing percutaneous coronary intervention (PCI). METHODS The CardiOvascular Risk and idEntificAtion of potential high-risk population in AMI (COREA-AMI) registry enrolled all consecutive patients with AMI undergoing PCI. The primary endpoint was the composite of cardiovascular death, myocardial infarction, stroke, or hospitalization due to heart failure. RESULTS Of the 3,328 eligible patients, ARBs replaced ACEIs in 816 patients, while 824 patients continued to use ACEIs and 826 patients continued to use ARBs. The remaining 862 patients did not receive ACEIs/ARBs. After the adjustment with inverse probability weighting, the primary endpoints in the first groups were similar (7.5% vs. 8.0%, hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.75-1.05; P = 0.164). Composite events were less frequent in the ACEI to ARB group than no ACEI/ARB group (7.5% vs. 11.8%, HR, 0.76; 95% CI, 0.64-0.90; P = 0.002). CONCLUSION The alternative use of ARBs following initial treatment with ACEIs demonstrates comparable clinical outcomes to those with continued use of ACEIs and is associated with an improved rate of composite events compared to no ACEI/ARB use in patients with AMI undergoing PCI. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02385682.
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Affiliation(s)
- Sungmin Lim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ik Jun Choi
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hyun Ihm
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Yeol Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youngkeun Ahn
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Ki Bae Seung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Shah SJ, Stafford RS. Current Trends of Hypertension Treatment in the United States. Am J Hypertens 2017; 30:1008-1014. [PMID: 28531239 DOI: 10.1093/ajh/hpx085] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 04/29/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To examine current patterns of hypertension (HTN) treatment in the United States, including blood pressure (BP) control, prevalence of different antihypertensive agents, and variations in treatment associated with patient and physician characteristics. METHODS We used data from the National Disease and Therapeutic Index (NDTI), a nationally representative physician survey produced by QuintilesIMS. We selected patients with a diagnosis of HTN and identified those prescribed antihypertensive therapies. We analyzed the type of antihypertensive agents prescribed. Extent of BP control, and associated patient and physician characteristics. We calculated 95% confidence intervals that accounted for the multistage NDTI sampling design. RESULTS Among those treated for HTN in 2014, BP control varied: systolic BP (SBP) ≥160 (15%) vs. SBP 150-159 (9%) vs. SBP 140-149 (19%) vs. SBP 130-139 (26%) vs. SBP <130 (32%). Of those treated for HTN, 29% used of angiotensin-converting enzyme inhibitors (ACEIs); 24%, thiazide-like diuretics; 22%, angiotensin receptor blockers (ARBs), 21%, calcium-channel blockers (CCBs); and 19% beta-blockers. Newer drugs had very limited uptake; no drugs approved after 2002 were used in more than 5% of patients. Selection of agents varied only modestly by patient and physician characteristics. CONCLUSIONS The treatment of HTN in 2014 predominantly involved older medications in 5 major classes of drugs: ACEIs, thiazide diuretics, ARBs, CCBs, and beta-blockers. Selection of antihypertensive agents showed limited variation by age, gender, race, and insurance type. Although 58% of treated patients had SBP <140, 24% had poorly controlled HTN with SBP ≥150, indicating the need for improved treatment.
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Affiliation(s)
- Shreya J Shah
- Department of Medicine, Stanford University, Palo Alto, California, USA
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Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011. JAMA Intern Med 2016; 176:473-82. [PMID: 26998708 PMCID: PMC5024734 DOI: 10.1001/jamainternmed.2015.8581] [Citation(s) in RCA: 356] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Prescription and over-the-counter medicines and dietary supplements are commonly used, alone and together, among older adults. However, the effect of recent regulatory and market forces on these patterns is not known. OBJECTIVES To characterize changes in the prevalence of medication use, including concurrent use of prescription and over-the-counter medications and dietary supplements, and to quantify the frequency and types of potential major drug-drug interactions. DESIGN, SETTING, AND PARTICIPANTS Descriptive analyses of a longitudinal, nationally representative sample of community-dwelling older adults 62 to 85 years old. In-home interviews with direct medication inspection were conducted in 2005-2006 and again in 2010-2011. The dates of the analysis were March to November 2015. We defined medication use as the use of at least 1 prescription or over-the-counter medication or dietary supplement at least daily or weekly and defined concurrent use as the regular use of at least 2 medications. We used Micromedex to identify potential major drug-drug interactions. MAIN OUTCOMES AND MEASURES Population estimates of the prevalence of medication use (in aggregate and by therapeutic class), concurrent use, and major drug-drug interactions. RESULTS The study cohort comprised 2351 participants in 2005-2006 and 2206 in 2010-2011. Their mean age was 70.9 years in 2005-2006 and 71.4 years in 2010-2011. Fifty-three percent of participants were female in 2005-2006, and 51.6% were female in 2010-2011. The use of at least 1 prescription medication slightly increased from 84.1% in 2005-2006 to 87.7% in 2010-2011 (P = .003). Concurrent use of at least 5 prescription medications increased from 30.6% to 35.8% (P = .02). While the use of over-the-counter medications declined from 44.4% to 37.9%, the use of dietary supplements increased from 51.8% to 63.7% (P < .001 for both). There were clinically significant increases in the use of statins (33.8% to 46.2%), antiplatelets (32.8% to 43.0%), and omega-3 fish oils (4.7% to 18.6%) (P < .05 for all). In 2010-2011, approximately 15.1% of older adults were at risk for a potential major drug-drug interaction compared with an estimated 8.4% in 2005-2006 (P < .001). Most of these interacting regimens involved medications and dietary supplements increasingly used in 2010-2011. CONCLUSIONS AND RELEVANCE In this study, the use of prescription medications and dietary supplements, and concurrent use of interacting medications, has increased since 2005, with 15% of older adults potentially at risk for a major drug-drug interaction. Improving safety with the use of multiple medications has the potential to reduce preventable adverse drug events associated with medications commonly used among older adults.
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Affiliation(s)
- Dima M Qato
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago2Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health
| | - Jocelyn Wilder
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago2Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health
| | - L Philip Schumm
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Victoria Gillet
- currently a medical student at the School of Medicine, University of Chicago, Chicago, Illinois
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland6Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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