Evaluation of Adverse Effects of Topical Glaucoma Medications on Trabeculectomy Outcomes Using the Glaucoma Medications Intensity Index

Introduction

Trabeculectomy is commonly performed for glaucoma when medications are unable to control disease progression or have intolerable adverse effects. Previous studies have suggested that a higher number of and/or longer treatment duration with preoperative topical glaucoma medications are associated with a higher risk of trabeculectomy failure, but most of these studies lack quantification of exposure. The aim of this study was to investigate the relationship between preoperative exposure to topical glaucoma medications and trabeculectomy outcome, using a new method for quantifying accumulated exposure.

Methods

Consecutive patients with primary open-angle glaucoma (POAG) or normal-tension glaucoma (NTG) who underwent primary trabeculectomy between 2013 and 2017 were retrospectively reviewed. The Glaucoma Medications Intensity Index (GMII) was calculated for each eye by multiplying the number of drops per week by duration of use (in years). The relationship between the GMII and postoperative outcome in terms of 1- and 2-year success rates and survival time was analyzed.

Results

A total of 55 eyes from 40 subjects were analyzed, all with follow-up > 6 months (mean 2.72 ± 1.46 years). The GMII for eyes with successful (n = 41) and failed (n = 14) outcome at last visit was 111.71 ± 78.59 and 167.41 ± 85.04, respectively, and significantly higher in failed eyes (P = 0.03). Univariate regression analysis of age, gender, cup–disc ratio, previous phacoemulsification, diabetes, hypertension, dyslipidemia, preoperative number of glaucoma medications/treatment duration/intraocular pressure (IOP), and GMII showed age and GMII to be possible predictors of treatment failure. On subsequent multivariate analysis, only GMII was correlated with failure (odds ratio 1.021, 95% confidence interval 1.00–1.05; P = 0.05). When GMII ≥ 80, the postoperative survival time was shorter (P = 0.02), the 1-year IOP, number of glaucoma medications, and number of needlings performed were higher (P = 0.03, P  < 0.01, P  < 0.03, respectively), and reduction in glaucoma medication was less (P = 0.02).

Conclusion

The GMII can be used to predict eyes at higher risk for trabeculectomy that may benefit from additional perioperative intervention or treatment. It can also help the surgeon time the surgery before the GMII becomes too high, thereby optimizing the patient’s postoperative outcome.

A comprehensive review on non-clinical methods to study transfer of medication into breast milk - A contribution from the ConcePTION project

Breastfeeding plays a major role in the health and wellbeing of mother and infant. However, information on the safety of maternal medication during breastfeeding is lacking for most medications. This leads to discontinuation of either breastfeeding or maternal therapy, although many medications are likely to be safe. Since human lactation studies are costly and challenging, validated non-clinical methods would offer an attractive alternative. This review gives an extensive overview of the non-clinical methods (in vitro, in vivo and in silico) to study the transfer of maternal medication into the human breast milk, and subsequent neonatal systemic exposure. Several in vitro models are available, but model characterization, including quantitative medication transport data across the in vitro blood-milk barrier, remains rather limited. Furthermore, animal in vivo models have been used successfully in the past. However, these models don't always mimic human physiology due to species-specific differences. Several efforts have been made to predict medication transfer into the milk based on physicochemical characteristics. However, the role of transporter proteins and several physiological factors (e.g., variable milk lipid content) are not accounted for by these methods. Physiologically-based pharmacokinetic (PBPK) modelling offers a mechanism-oriented strategy with bio-relevance. Recently, lactation PBPK models have been reported for some medications, showing at least the feasibility and value of PBPK modelling to predict transfer of medication into the human milk. However, reliable data as input for PBPK models is often missing. The iterative development of in vitro, animal in vivo and PBPK modelling methods seems to be a promising approach. Human in vitro models will deliver essential data on the transepithelial transport of medication, whereas the combination of animal in vitro and in vivo methods will deliver information to establish accurate in vitro/in vivo extrapolation (IVIVE) algorithms and mechanistic insights. Such a non-clinical platform will be developed and thoroughly evaluated by the Innovative Medicines Initiative ConcePTION.

Fall Risk-Increasing Drugs, Polypharmacy, and Falls Among Low-Income Community-Dwelling Older Adults

Background and Objectives

Medication exposure is a potential risk factor for falls and subsequent death and functional decline among older adults. However, controversy remains on the best way to assess medication exposure and which approach best predicts falls. The objective of the current study was to examine the association between different measures of medication exposure and falls risk among community-dwelling older adults.

Research Design and Methods

This retrospective cohort study was conducted using Falls Free PA program data and a linked prescription claims data from Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program. Participants were community-dwelling older adults living in Pennsylvania, United States. Three measures of medication exposure were assessed: (a) total number of regular medications (polypharmacy); (b) counts of potentially inappropriate medications derived from current prescription guidance tools (Fall Risk-Increasing Drugs [FRIDs], Beers Criteria); and (c) medication burden indices based on pharmacologic mechanisms (Anticholinergic Cognitive Burden, Drug Burden Index) all derived from claims data. The associations between the different medication risk measures and self-reported falls incidence were examined with univariate and multivariable negative binomial regression models to estimate incidence rate ratios (IRRs).

Results

Overall 343 older adults were included and there were 236 months with falls during 2,316 activity-adjusted person-months (10.2 falls per 100 activity-adjusted person-months). Of the 6 measures of medication risk assessed in multivariate models, only the use of 2 or more FRIDs (adjusted IRR 1.67 [95% CI: 1.04-2.68]) independently predicted falls risk. Among the 13 FRID drug classes, the only FRID class associated with an increased fall risk was antidepressants.

Discussion and Implications

The presence of multiple FRIDs in a prescription is an independent risk factor for falls, even in older adults with few medications. Further investigation is required to examine whether deprescribing focused on FRIDs effectively prevents falls among this population.

Drugs as risk factors of acute kidney injury in critically ill children

BACKGROUND

Acute kidney injury (AKI) is a serious condition in critically ill children. Nephrotoxic medication exposure is a common contributing factor to AKI, but little literature is available in pediatrics. The aim of the present study was to assess potential associations between drugs and the risk of developing AKI.

METHODS

We performed a retrospective case-control study in a pediatric intensive care unit (PICU). Cases were patients who developed AKI during PICU stay. Patients without AKI served as controls and were matched to cases by age and gender in a one-to-one ratio.

RESULTS

One hundred case-control pairs were included. Cases were not statistically different from controls with regard to median weight and main diagnoses, but differed with regard to the need for mechanical ventilation, severity of illness, and median length of PICU stay. Multivariate models revealed a statistically significant higher risk of developing AKI for patients treated with metamizole, morphine, paracetamol, and tropisetron. A similar risk could be shown for medication groups, namely glucocorticoids, betalactam antibiotics, opioids, and non-steroidal anti-inflammatory drugs.

CONCLUSIONS

The results suggest that drugs are associated with acute renal dysfunction in critically ill children, but the multifactorial causes of AKI should be kept in mind.