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Lee S, Hetherington E, Leigh R, Ramage K, Metcalfe A. Impact of Asthma Medications During Pregnancy on Asthma Exacerbation, Maternal, and Neonatal Outcomes. J Allergy Clin Immunol Pract 2024:S2213-2198(24)00173-9. [PMID: 38530680 DOI: 10.1016/j.jaip.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 02/04/2024] [Accepted: 02/08/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Asthma affects 5% to 13% of pregnant women, and many require daily pharmacotherapy to achieve asthma control; however, adherence to medication during pregnancy often decreases. OBJECTIVE To understand the association between the use of or adherence to asthma medication with asthma exacerbation and maternal/neonatal outcomes. METHODS Using linked population-based administrative databases from Alberta, Canada (2012-2018), pregnant women with asthma were categorized based on asthma medication use 1 year before pregnancy: short-acting β-agonists (SABA), inhaled corticosteroids (ICS), and ICS with long-acting β-agonists (ICS+LABA). Women on ICS+LABA were grouped by trajectory of adherence during pregnancy using group-based trajectory modeling. Logistic regressions were used to estimate the associations between the use of or trajectories of adherence to asthma medication during pregnancy with asthma exacerbation and maternal/neonatal outcomes. RESULTS Overall, 13,509 of 238,751 (5.7%) pregnant women had asthma before pregnancy (SABA: 24.7%; ICS: 12.5%; ICS+LABA: 25.1%; none: 36.1%). The use of SABA (adjusted odds ratio [aOR]: 1.79, 95% confidence interval [CI]: 1.21, 2.64), ICS (aOR: 3.37, 95% CI: 2.10, 5.39), and ICS+LABA (aOR: 3.64, 95% CI: 2.57, 5.17) had greater odds of disease exacerbation than no asthma medication during pregnancy. ICS+LABA adherence groups during pregnancy included low (79.8%), moderate-to-decreasing (14.0%), and moderate-to-increasing (6.2%). The moderate-to-decreasing (aOR: 1.45, 95% CI: 1.14, 1.84) and moderate-to-increasing (aOR: 2.06, 95% CI: 1.50, 2.83) adherence groups had greater odds of disease exacerbation than the low adherence group. ICS use during pregnancy decreased odds of preterm birth (aOR: 0.62; 95% CI: 0.39, 0.99) and neonatal intensive care unit admission (aOR: 0.66; 95% CI: 0.45, 0.97). Other group comparisons were not statistically significant. CONCLUSIONS Our study shows the importance of continuing asthma maintenance medication during pregnancy to improve outcomes. Future research should study the postpartum and long-term outcomes with asthma medication during pregnancy.
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Affiliation(s)
- Sangmin Lee
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Erin Hetherington
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Richard Leigh
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kaylee Ramage
- School of Public Health, San Diego State University, San Diego, Calif
| | - Amy Metcalfe
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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van Dijkman SC, Yorgancıoğlu A, Pavord I, Brusselle G, Pitrez PM, Oosterholt S, Fumali S, Majumdar A, Della Pasqua O. Effect of Individual Patient Characteristics and Treatment Choices on Reliever Medication Use in Moderate-Severe Asthma: A Poisson Analysis of Randomised Clinical Trials. Adv Ther 2024; 41:1201-1225. [PMID: 38296921 PMCID: PMC10879282 DOI: 10.1007/s12325-023-02774-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/15/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Even though increased use of reliever medication, including short-acting beta agonists (SABA), provides an indirect measure of symptom worsening, there have been limited efforts to assess how different patterns of reliever use correlate with symptom control and future risk of exacerbations. Here, we evaluate the effect of individual baseline characteristics on reliever use in patients with moderate-severe asthma on regular maintenance therapy with fluticasone propionate (FP) or combination therapy with fluticasone propionate/salmeterol (FP/SAL) or budesonide/formoterol (BUD/FOR). METHODS A drug-disease model describing the number of 24-h puffs and overnight occasions was developed with data from five clinical studies (N = 6212). The model was implemented using a nonlinear mixed effects approach and a Poisson function, considering clinical and demographic baseline characteristics. Goodness of fit and model predictive performance were assessed. Heatmaps were created to summarise the effect of concurrent baseline factors on reliever utilisation. RESULTS The final model accurately described individual patterns of reliever use, which is significantly increased with time since diagnosis, smoking, higher Asthma Control Questionnaire (ACQ-5) score and higher body mass index (BMI) at baseline. Whilst the number of puffs decreases slowly after an initial drop relative to the start of treatment, exacerbating patients utilise significantly more reliever than those who do not exacerbate. The mean effect of FP/SAL (median dose: 250/50 μg BID) on reliever use was slightly higher than that of BUD/FOR (median dose: 160/4.5 μg BID), i.e. a 75.3% vs 69.3% reduction in reliever use, respectively. CONCLUSIONS The availability of individual-level patient data in conjunction with a parametric approach enabled the characterisation of interindividual differences in the patterns of reliever use in patients with moderate-severe asthma. Taken together, individual demographic and clinical characteristics, as well as exacerbation history, can be considered an indicator of the degree of asthma control. High SABA reliever use suggests suboptimal clinical management of patients on maintenance therapy.
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Affiliation(s)
| | | | - Ian Pavord
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Paulo M Pitrez
- Hospital Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | - Sean Oosterholt
- Clinical Pharmacology Modelling and Simulation, GSK, London, UK
| | - Sourabh Fumali
- GSK, Global Classic and Established Medicines, Worli, India
| | - Anurita Majumdar
- GSK, Global Classic and Established Medicines, Singapore, Singapore
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, University College London, BMA House, Tavistock Square, London, WC1H 9JP, UK.
- GSK House, 980 Great West Rd, London, TW8 9GS, UK.
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Misra SN, Sperling MR, Rao VR, Peters JM, Penovich P, Wheless J, Hogan RE, Davis CS, Carrazana E, Rabinowicz AL. Analyses of patients who self-administered diazepam nasal spray for acute treatment of seizure clusters. Epilepsy Behav Rep 2024; 25:100644. [PMID: 38274142 PMCID: PMC10808926 DOI: 10.1016/j.ebr.2024.100644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/15/2023] [Accepted: 01/01/2024] [Indexed: 01/27/2024] Open
Abstract
For acute treatment of seizure clusters in patients with epilepsy, intranasal administration of acute seizure therapies has been shown to provide accessibility and ease of use to care partners as well as the potential for self-administration by patients. Diazepam nasal spray (Valtoco®) was approved by the US Food and Drug Administration for acute treatment of intermittent, stereotypic episodes of frequent seizure activity (ie, seizure clusters, acute repetitive seizures) in patients with epilepsy aged ≥6 years. Self-administration consistent with the prescribing information is feasible and was reported by a subgroup of patients (n = 27 of 163) in a long-term phase 3 safety study. Data regarding self-administration among these patients with seizure clusters are examined here to explore the safety profiles and measures of effectiveness, as well as the quality of life of those who self-treated. In addition, this focused look at patients who self-administered diazepam nasal spray may offer some insights into the characteristics of patients who may be appropriate for self-administration.
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Affiliation(s)
- Sunita N Misra
- Formerly of Neurelis, Inc., 3430 Carmel Mountain Rd, Ste 300, San Diego, CA 92121, USA
| | | | - Vikram R. Rao
- University of California, San Francisco, 400 Parnassus Ave Fl 8, San Francisco, CA 94143, USA
| | - Jurriaan M. Peters
- Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 20115, USA
| | | | - James Wheless
- Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, 49 N Dunlap St, FOB Room 393, Memphis, TN 38105, USA
| | - R. Edward Hogan
- Washington University in St. Louis, 4921 Parkview Pl, St. Louis, MO 63110, USA
| | - Charles S. Davis
- CSD Biostatistics, Inc., 1005 W Soft Wind Pl, Oro Valley, AZ 85737, USA
| | - Enrique Carrazana
- John A. Burns School of Medicine, University of Hawaii, 651 Ilalo St., Honolulu, HI 96813, USA
- Neurelis, Inc., 3430 Carmel Mountain Rd, Ste 300, San Diego, CA, 92121, USA
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Leviton A, Patel AD, Loddenkemper T. Self-management education for children with epilepsy and their caregivers. A scoping review. Epilepsy Behav 2023; 144:109232. [PMID: 37196451 DOI: 10.1016/j.yebeh.2023.109232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/19/2023]
Abstract
Self-management education programs have been highly successful in preparing people to manage medical conditions with recurring events. A detailed curriculum for epilepsy patients, and their caretakers, is lacking. Here we assess what is available for patients who have disorders with recurring events and offer an approach to developing a potential self-care curriculum for patients with seizures and their caregivers. Among the anticipated components are a baseline efficacy assessment and training tailored to increasing self-efficacy, medication compliance, and stress management. Those at risk of status epilepticus will also need guidance in preparing a personalized seizure action plan and training in how to decide when rescue medication is appropriate and how to administer the therapy. Peers, as well as professionals, could teach and provide support. To our knowledge, no such programs are currently available in English. We encourage their creation, dissemination, and widespread use.
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Affiliation(s)
- Alan Leviton
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Anup D Patel
- Nationwide Children's Hospital, 700 Childrens Drive, Columbus, OH 43205, USA.
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Meng TC, Szaflarski JP, Chen L, Brunnert M, Campos R, Van Ess P, Pullman WE, Fakhoury T. Psychosocial outcomes of repeated treatment of seizure clusters with midazolam nasal spray: Results of a phase 3, open-label extension trial. Epilepsy Behav 2023; 138:108989. [PMID: 36410152 DOI: 10.1016/j.yebeh.2022.108989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/25/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate treatment satisfaction, level of anxiety, confidence about traveling with midazolam nasal spray (MDZ-NS), and health-related quality of life in patients with seizure clusters and their caregivers after repeated, intermittent use of MDZ-NS in the outpatient setting. METHODS We analyzed the psychosocial outcome data from a phase 3, open-label extension trial (ARTEMIS-2; P261-402; NCT01529034) in patients 12 years of age and older with seizure clusters on a stable regimen of antiseizure medications. Caregivers administered MDZ-NS 5 mg when patients experienced a seizure cluster. A second dose could be given if seizures did not terminate within 10 min or recurred from 10 min to 6 h. Treatment Satisfaction Questionnaire for Medication (TSQM), the Intranasal Therapy Impact Questionnaire (ITIQ), and the Short Form-12 Health Survey version 2 (SF-12v2) were self-administered by patients and/or caregivers at prespecified visits. RESULTS Of the one hundred and seventy-five patients enrolled in ARTEMIS-2, 161 (92.0%) received ≥ 1 dose of MDZ-NS and had a post-treatment seizure-related assessment and were included in the Efficacy Evaluable Set in this analysis, with a total of 1,998 treated seizure clusters over a median duration of 16.8 months. All TSQM scales showed improvement from the baseline of the double-blind ARTEMIS-1 trial (NCT01390220) to the last visit in ARTEMIS-2, indicating greater satisfaction with MDZ-NS across all domains, with a mean change from baseline of 8.8, 6.1, 4.3, and 6.2 for effectiveness (n = 135), side effects (n = 139), convenience (n = 139), and global satisfaction (n = 138), respectively. Change from baseline in TSQM scores generally increased with repeated MDZ-NS use. In both patients and caregivers, anxiety generally lessened with repeated MDZ-NS use, with a mean improvement in ITIQ scores in patients' anxiety since receiving MDZ-NS from 2.5 (n = 138) to 3.5 (n = 145) from visit 1 to the last visit (and from 2.6 [n = 156] to 3.6 [n = 160] for caregivers), respectively. From visit 1 (screening and enrollment in ARTEMIS-2) to visit 10 (after 16 seizure cluster episodes treated with MDZ-NS), the proportions of patients and caregivers who answered "strongly agree" or "agree" for confidence about traveling with an intranasal spray remained ≥ 79% and generally increased over repeated MDZ-NS use. Small positive mean changes in SF-12v2 scores from baseline to the last visit were observed in both patients and caregivers, respectively, for the domains of physical functioning (0.9, 1.1), role-physical (2.4, 0.3), bodily pain (1.7, 0.3), general health (0.6, 1.2), and role-emotional (2.1, 0.3), and in the physical health component (1.6, 1.0). CONCLUSION Patients and caregivers perceived MDZ-NS favorably, with improvement from baseline on perceived effectiveness, side effects, convenience, and global satisfaction in the TSQM. This is supported by progressively lower anxiety and higher confidence levels about traveling with MDZ-NS over repeated intermittent use in the ITIQ. The positive mean changes observed in SF-12v2 scores from baseline to the last visit were small in magnitude. Limitations of this exploratory analysis include the open-label trial design and that these questionnaires have not been directly validated in epilepsy to identify clinically important changes; however, this does not mean these findings are not clinically meaningful. Overall, MDZ-NS is a socially acceptable drug device for outpatient treatment of seizure clusters that has the potential to improve quality of life and overall independence.
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Affiliation(s)
- Tze-Chiang Meng
- Proximagen LLC, 605 Highway 169 N, Suite 240, Plymouth, MN 55441, USA.
| | - Jerzy P Szaflarski
- Departments of Neurology, Neurobiology, and Neurosurgery, Comprehensive Neuroscience Center, University of Alabama at Birmingham Heersink School of Medicine, 1719 6th Ave South, CIRC 312, Birmingham, AL 35294, USA.
| | - Linda Chen
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
| | - Marcus Brunnert
- UCB Pharma, Alfred-Nobel-Straße 10, 40789 Monheim am Rhein, Germany.
| | - Rita Campos
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
| | - Peter Van Ess
- Proximagen LLC, 605 Highway 169 N, Suite 240, Plymouth, MN 55441, USA.
| | - William E Pullman
- Proximagen LLC, 605 Highway 169 N, Suite 240, Plymouth, MN 55441, USA.
| | - Toufic Fakhoury
- St. Joseph Health System, 1401 Harrodsburg Road, Suite B-280, Lexington, KY 40504, USA.
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Jafarpour S, Fong MWK, Detyniecki K, Khan A, Jackson-Shaheed E, Wang X, Lewis S, Benjamin R, Gaínza-Lein M, O'Bryan J, Hirsch LJ, Loddenkemper T. Prevalence and Predictors of Seizure Clusters in Pediatric Patients With Epilepsy: The Harvard-Yale Pediatric Seizure Cluster Study. Pediatr Neurol 2022; 137:22-29. [PMID: 36208614 DOI: 10.1016/j.pediatrneurol.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Determine the prevalence of seizure clusters (two or more seizures in six hours), use of rescue medications, and adverse outcomes associated with seizure clusters in pediatric patients with a range of epilepsy severities, and identify risk factors predictive of seizure clusters. METHODS Prospective observational two-center study, including phone call and seizure diary follow-up for 12 months in patients with epilepsy aged one month to 18 years. We classified patients into three risk groups based on seizures within the prior year: high, seizure cluster (two or more seizures within one day); intermediate, at least one seizure but no days with two or more seizures; low, no seizures. RESULTS One-third (32.3%; high risk, 72.4%; intermediate risk, 30.4%; low risk, 3.1%) of 297 patients had a seizure cluster during the study, including half (46.2%) of the patients with active seizures at baseline (intermediate- and high-risk groups combined). Emergency room visits or injuries were no more likely due to a seizure cluster than an isolated seizure. Rescue medications were utilized in 15.8% of patients in the high-risk group and 19.2% in the intermediate-risk group. History of status epilepticus (adjusted odds ratio [aOR], 2.13; confidence interval [CI], 1.09 to 4.16]), seizure frequency greater than four per month (aOR, 4.27; CI, 1.92 to 9.50), and high-risk group status (aOR, 6.42; CI, 2.97 to 13.87) were associated with greater odds of seizure cluster. CONCLUSIONS Seizure clusters are common in pediatric patients with epilepsy. High seizure frequency was the strongest predictor of clusters. Rescue medications were underutilized. Future studies should evaluate the applicability and effectiveness of these medications for optimization of pediatric seizure cluster treatment and reduction of seizure-related emergency department visits, injuries, and mortality.
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Affiliation(s)
- Saba Jafarpour
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Neurology, Children's Hospital of Los Angeles, Los Angeles, California
| | - Michael W K Fong
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; TY Nelson Department of Neurology, The Children's Hospital at Westmead, Sydney, Australia; Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Kamil Detyniecki
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; Comprehensive Epilepsy Center, Department of Neurology, University of Miami, Miami, Florida
| | - Ambar Khan
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; Larkin Community Hospital, South Miami, Florida
| | - Ebony Jackson-Shaheed
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Xiaofan Wang
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Lewis
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Robert Benjamin
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Instituto dr Pediatria, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Jane O'Bryan
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Wu D, Hua Y, Zhao Z, Huang X, Rao Q, Liu L, Xiao Y, Chen Q, Sun JL. Patient Preferences for Rescue Medications in the Treatment of Breakthrough Cancer Pain. J Pain Symptom Manage 2022; 64:521-531. [PMID: 36002122 DOI: 10.1016/j.jpainsymman.2022.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The discrete choice experiment (DCE) is conducted in this study to discuss Chinese cancer patients' risk-benefit preferences for rescue medications (RD) and their willingness to pay (WTP) in the treatment of breakthrough cancer pain (BTcP). METHOD Through literature reviews, specialist consultation, and patient surveys, this work finally included five attributes in the DCE questionnaire, i.e., the remission time of breakthrough pain, adverse reactions of the digestive system, adverse reactions of the neuropsychiatric system, administration routes, and drug costs (estimating patients' WTP). The alternative-specific conditional logit model is used to analyze patients' preferences and WTP for each attribute and its level and to assess the sociodemographic impact and clinical characteristics. RESULTS A total of 134 effective questionnaires were collected from January, 1 to April, 5 in 2022. Results show that the five attributes all have a significant impact on cancer patients' choice of "rescue medications" (P<0.05). Among these attributes, the remission time after drug administration (10.0; 95%CI 8.5-11.5) is the most important concern for patients, followed by adverse reactions of the digestive system (8.5; 95%CI 7.0-10.0), adverse reactions of the neuropsychiatric system (2.9; 95%CI 1.4-4.3), and administration routes (0.9; 95%CI 0-1.8). The respondents are willing to spend 1182 yuan (95%CI 605-1720 yuan) per month for "rescue medications" to take effect within 15 minutes and spend 1002 yuan (95%CI 605-1760 yuan) per month on reducing the incidence of drug-induced adverse reactions in the digestive system to 5%. CONCLUSION For Chinese cancer patients, especially those with moderate/severe cancer pain, the priority is to relieve the BTcP more rapidly and reduce adverse drug reactions more effectively. This study indicates these patients' expectations for the quick control of breakthrough pain and their emphasis on the reduction of adverse reactions. These findings are useful for doctors, who are encouraged to communicate with cancer patients about how to better alleviate the BTcP.
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Affiliation(s)
- Dan Wu
- Department of Anesthesiology (D.W., J-L.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, P.R. China; Department of Pain Medicine (D.W., Z.Z., X.H., Q.R., L.L., Q.C.), Lishui Hospital, Zhejiang University School of Medicine, Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui, Zhejiang Province, P.R. China
| | - Yingjie Hua
- Department of Pain Medicine (D.W., Z.Z., X.H., Q.R., L.L., Q.C.), Lishui Hospital, Zhejiang University School of Medicine, Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui, Zhejiang Province, P.R. China
| | - Zhongwei Zhao
- Department of Pain Medicine (D.W., Z.Z., X.H., Q.R., L.L., Q.C.), Lishui Hospital, Zhejiang University School of Medicine, Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui, Zhejiang Province, P.R. China
| | - Xufang Huang
- Department of Pain Medicine (D.W., Z.Z., X.H., Q.R., L.L., Q.C.), Lishui Hospital, Zhejiang University School of Medicine, Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui, Zhejiang Province, P.R. China
| | - Qiaoying Rao
- Department of Pain Medicine (D.W., Z.Z., X.H., Q.R., L.L., Q.C.), Lishui Hospital, Zhejiang University School of Medicine, Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui, Zhejiang Province, P.R. China
| | - Lu Liu
- Department of Pain Medicine (D.W., Z.Z., X.H., Q.R., L.L., Q.C.), Lishui Hospital, Zhejiang University School of Medicine, Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui, Zhejiang Province, P.R. China
| | - Yangrui Xiao
- Department of Radiology (Y.X.), Lishui Hospital, Zhejiang University School of Medicine, Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui, Zhejiang Province, P.R. China
| | - Qiaoyan Chen
- Department of Pain Medicine (D.W., Z.Z., X.H., Q.R., L.L., Q.C.), Lishui Hospital, Zhejiang University School of Medicine, Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui, Zhejiang Province, P.R. China
| | - Jian-Liang Sun
- Department of Anesthesiology (D.W., J-L.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, P.R. China.
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Tepper SJ, Ailani J, Ray S, Hirman J, Shrewsbury SB, Aurora SK. Variability in recurrence rates with acute treatments for migraine: why recurrence is not an appropriate outcome measure. J Headache Pain 2022; 23:148. [PMID: 36414952 PMCID: PMC9682643 DOI: 10.1186/s10194-022-01519-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Headache recurrence is a common feature of acute therapies, whether approved or still in development, and continues to be a significant problem for both the patient and the clinician. Further complicating this issue is lack of standardization in definitions of recurrence used in clinical trials, as well as disparity in patient characteristics, rendering a comparison of different acute medications challenging. Recurrence has serious clinical implications, which can include an increased risk for new-onset chronic migraine and/or development of medication overuse headache. The aim of this review is to illustrate variability of recurrence rates depending on prevailing definitions in the literature for widely used acute treatments for migraine and to emphasize sustained response as a clinically relevant endpoint for measuring prolonged efficacy. BODY: A literature search of PubMed for articles of approved acute therapies for migraine that reported recurrence rates was performed. Study drugs of interest included select triptans, gepants, lasmiditan, and dihydroergotamine mesylate. An unpublished post hoc analysis of an investigational dihydroergotamine mesylate product that evaluated recurrence rates using several different definitions of recurrence common in the literature is also included. Depending on the criteria established by the clinical trial and the definition of recurrence used, rates of recurrence vary considerably across different acute therapies for migraine, making it difficult to compare results of different trials to assess the sustained (i.e., over a single attack) and the prolonged (i.e., over multiple attacks) efficacy of a particular study medication. CONCLUSION A standardized definition of recurrence is necessary to help physicians evaluate recurrence rates of different abortive agents for migraine. Sustained pain relief or freedom may be more comprehensive efficacy outcome measures than recurrence. Future efficacy studies should be encouraged to use the recommended definition of sustained pain freedom set by the International Headache Society.
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Affiliation(s)
| | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Joe Hirman
- Pacific Northwest Statistical Consulting, Inc, Woodinville, WA, USA
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Hasvik E, Gran JM, Haugen AJ, Grøvle L. Strategies to manage auxiliary pain medications in chronic pain trials: a topical review. Eur J Clin Pharmacol 2022; 78:1377-1384. [PMID: 35842457 PMCID: PMC9365733 DOI: 10.1007/s00228-022-03355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
Chronic pain trials commonly allow auxiliary pain medications such as rescue and concomitant analgesics in addition to the randomized treatment. Changes in auxiliary pain medications after randomization represent intercurrent events that may affect either the interpretation or the existence of the measurements associated with the clinical question of interest, complicating the assessment of treatment efficacy. In chronic pain trials, pain intensity typically varies and patients may take the auxiliary medications 1 day but not the next or increase and decrease the dosages temporarily while continuing their randomized study medication. This distinctive feature of auxiliary pain medications as an intercurrent event has received little attention in the literature. Further clarifications on how to manage these issues are therefore pressing. Here we provide perspectives on issues related to auxiliary pain medication-related intercurrent events in randomized controlled chronic pain trials considering the strategies suggested in the E9(R1) addendum to the ICH guideline on statistical principles for clinical trials.
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Affiliation(s)
- Eivind Hasvik
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, 1714, Grålum, Norway.
| | - Jon Michael Gran
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | | | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, Grålum, Norway
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Andersen ASS, Heinskou TB, Asghar MS, Rossen B, Noory N, Smilkov EA, Bendtsen L, Maarbjerg S. Intravenous fosphenytoin as treatment for acute exacerbation of trigeminal neuralgia: A prospective systematic study of 15 patients. Cephalalgia 2022; 42:1138-1147. [PMID: 35469443 DOI: 10.1177/03331024221094536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Intravenous fosphenytoin is widely used for acute exacerbation of trigeminal neuralgia, however, few studies have investigated this treatment. We aimed to examine the efficacy and side effects of initial intravenous fosphenytoin plus oral tapering of phenytoin for exacerbation of trigeminal neuralgia. METHODS Consecutive patients with primary trigeminal neuralgia were included in this prospective observational 90-days follow-up study. Data were collected using standardized interviews before, at 24 hours, day 7, 30 and 90 post loading dose. The primary outcome was the proportion of responders defined as a 50% reduction in pain intensity 24 hours post loading dose. RESULTS We included 15 patients. Nine patients (60%) were responders. Pain intensity 24 hours post loading dose was reduced by 5.00 points on the numerical rating scale (p < 0.001), and at day 7 by 5.5 points (p < 0.001). The most common side effects were hypotension and dizziness. CONCLUSION Intravenous fosphenytoin relieves trigeminal neuralgia pain in most patients and provides a window for titrating prophylactic trigeminal neuralgia medications or planning neurosurgery. The decision to administer intravenous fosphenytoin should be taken with support from trigeminal neuralgia experts and involves considerations of co-morbidities and other treatment options for acute exacerbation of trigeminal neuralgia.Clinical Trial: Preregistered (ClinicalTrials.gov Identifier: NCT03712254.
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Affiliation(s)
| | - Tone Bruvik Heinskou
- Danish Headache Center, Department of Neurology, Rigshospitalet - Glostrup, Denmark
| | | | - Birgitte Rossen
- Department of Anaesthesiology, Rigshospitalet - Glostrup, Denmark
| | - Navid Noory
- Danish Headache Center, Department of Neurology, Rigshospitalet - Glostrup, Denmark
| | | | - Lars Bendtsen
- Danish Headache Center, Department of Neurology, Rigshospitalet - Glostrup, Denmark
| | - Stine Maarbjerg
- Danish Headache Center, Department of Neurology, Rigshospitalet - Glostrup, Denmark
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Schubert-Bast S, Kay L, Simon A, Wyatt G, Holland R, Rosenow F, Strzelczyk A. Epidemiology, healthcare resource use, and mortality in patients with probable Dravet syndrome: A population-based study on German health insurance data. Epilepsy Behav 2022; 126:108442. [PMID: 34864381 DOI: 10.1016/j.yebeh.2021.108442] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Ten-year retrospective study to assess burden of illness in patients with probable Dravet syndrome (DS) identified from German healthcare data. METHODS In the absence of an International Classification of Diseases code, patients with probable DS were identified using a selection algorithm considering diagnoses and drug prescriptions. Primary analyses were prevalence and demographics; secondary analyses included healthcare costs, annual hospitalization rate (AHR) and length of stay (LOS), medication use, and mortality. RESULTS In the final study year, 64 patients with probable DS (mean [range] age: 33.2 [3-82] years; male: 48%) were identified. Prevalence: 4.7 per 100,000 people. During the study, 160 patients with probable DS were identified and followed up for 1,261 patient-years. Mean cost of healthcare was €11,048 per patient-year (PPY), mostly attributable to inpatient care (47%), medication (26%), and services and devices (19%). Annual healthcare costs were significantly greater for those with prescribed rescue medication (15% of patient-years) vs. without (€16,123 vs. €10,125 PPY, p < 0.001). Mean (standard deviation [SD]) AHR and LOS were 1.1 (1.7) and 17.5 (33.5) days PPY. AHR was significantly greater in patients with prescribed rescue medication vs. without (1.6 [2.0] vs. 1.0 [1.6] PPY, p < 0.001). Mean (SD) number of antiseizure medications prescribed was 2.6 (1.2) PPY and 5.0 (2.5) over the entire observable time for each patient. Mortality rate was significantly higher for probable DS vs. matched controls (11.88% [19 events] vs. 1.19% [172 events], p < 0.001). CONCLUSION Probable DS is associated with substantial healthcare costs in Germany.
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Affiliation(s)
- Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital and Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Lara Kay
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital and Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | | | - Geoffrey Wyatt
- Market Access and Health Economics and Outcomes Research, GW Pharma Ltd, London, UK.
| | - Rowena Holland
- Market Access and Health Economics and Outcomes Research, GW Pharma Ltd, London, UK.
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital and Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital and Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
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Vogelmeier CF, Jones PW, Kerwin EM, Boucot IH, Maltais F, Tombs L, Compton C, Lipson DA, Bjermer LH. Efficacy of umeclidinium/vilanterol according to the degree of reversibility of airflow limitation at screening: a post hoc analysis of the EMAX trial. Respir Res 2021; 22:279. [PMID: 34711232 DOI: 10.1186/s12931-021-01859-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
Background In patients with chronic obstructive pulmonary disease (COPD), the relationship between short-term bronchodilator reversibility and longer-term response to bronchodilators is unclear. Here, we investigated whether the efficacy of long-acting bronchodilators is associated with reversibility of airflow limitation in patients with COPD with a low exacerbation risk not receiving inhaled corticosteroids. Methods The double-blind, double-dummy EMAX trial randomised patients to umeclidinium/vilanterol 62.5/25 µg once daily, umeclidinium 62.5 µg once daily, or salmeterol 50 µg twice daily. Bronchodilator reversibility to salbutamol was measured once at screening and defined as an increase in forced expiratory volume in 1 s (FEV1) of ≥ 12% and ≥ 200 mL 10−30 min post salbutamol. Post hoc, fractional polynomial (FP) modelling was conducted using the degree of reversibility (mL) at screening as a continuous variable to investigate its relationship to mean change from baseline in trough FEV1 and self-administered computerised-Transition Dyspnoea Index (SAC-TDI) at Week 24, Evaluating Respiratory Symptoms-COPD (E-RS) at Weeks 21–24, and rescue medication use (puffs/day) over Weeks 1–24. Analyses were conducted across the full range of reversibility (−850–896 mL); however, results are presented for the range −100–400 mL because there were few participants with values outside this range. Results The mean (standard deviation) reversibility was 130 mL (156) and the median was 113 mL; 625/2425 (26%) patients were reversible. There was a trend towards greater improvements in trough FEV1, SAC-TDI, E-RS and rescue medication use with umeclidinium/vilanterol with higher reversibility. Improvements in trough FEV1 and reductions in rescue medication use were greater with umeclidinium/vilanterol compared with either monotherapy across the range of reversibility. Greater improvements in SAC-TDI and E-RS total scores were observed with umeclidinium/vilanterol versus monotherapy in the middle of the reversibility range. Conclusions FP analyses suggest that patients with higher levels of reversibility have greater improvements in lung function and symptoms in response to bronchodilators. Improvements in lung function and rescue medication use were greater with umeclidinium/vilanterol versus monotherapy across the full range of reversibility, suggesting that the dual bronchodilator umeclidinium/vilanterol may be an appropriate treatment for patients with symptomatic COPD, regardless of their level of reversibility. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01859-w.
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Shankar R, Goodwin M, Toland J, Boyle A, Grant A, Pearson J, Storer A, Higgins R, Hudson S, Reuber M. Oro-mucosal midazolam maleate: Use and effectiveness in adults with epilepsy in the UK. Epilepsy Behav 2021; 123:108242. [PMID: 34371288 DOI: 10.1016/j.yebeh.2021.108242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/14/2021] [Accepted: 07/24/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Oro-mucosal midazolam maleate (OMM) with suitable training to family and carers is being increasingly recognized as the treatment of choice to mitigate the development of status epilepticus in non-hospital community settings. There are no studies to describe the use, effectiveness, and suitable dosing of OMM in adults with epilepsy in community settings. PURPOSE To describe the use, effectiveness, and dosing of OMM in the emergency treatment of epileptic seizures in community settings. METHODS A retrospective observational study (2016-17) design was used with participant recruitment from four UK NHS secondary care outpatient clinics providing epilepsy management. Study sample was of adult people with epilepsy (PWE) having had a recent seizure requiring OMM. Data on patient demographics, patient care plans, details of a recent seizure requiring emergency medication, and dose of OMM were collected from medical records. RESULTS Study data from 146 PWE were included. The mean age of PWE was 41.0 years (SD 15.2) and mean weight was 64.8Kg (SD 18.2). Fifty-three percent of PWE were recorded as having intellectual disability. The most frequently used concomitant medications were lamotrigine (43%). The majority of seizures occurred at people's homes (n = 92, 63%). OMM was most often administered by family/professional care-givers (n = 75, 48.4%). Generalized (tonic/clonic) seizures were recorded in most people (n = 106, 72.6%). The most common initial dose of OMM was 10 mg (n = 124, 84.9%). The mean time to seizure cessation after administration of this initial dose was 5.5 minutes (SD = 4.5, Median 5.0, IQR 2.1-5.0). Only a minority of seizures led to ambulance callouts (n = 18, 12.3%) or hospital admissions (n = 13, 9%). CONCLUSION This is the first observational study describing the use and effectiveness of OMM in adults in community settings. Minimal hospital admissions were reported in this cohort and the treatment was effective in ending seizures in adults in community settings.
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Tittensor P, Tittensor S, Chisanga E, Bagary M, Jory C, Shankar R. UK framework for basic epilepsy training and oromucosal midazolam administration. Epilepsy Behav 2021; 122:108180. [PMID: 34252835 DOI: 10.1016/j.yebeh.2021.108180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/11/2021] [Accepted: 06/11/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND UK wide Oromucosal Midazolam is used as an emergency treatment in community for seizures administered by family/carers with the right training. The Joint Epilepsy Council (JEC) UK which produced the training guidelines disbanded in 2016. PURPOSE Provide standards for basic epilepsy education and rescue medication (Midazolam) administration. METHODS The Epilepsy Nurses Association (ESNA), The International League against Epilepsy, British Chapter (ILAE) and the Royal college of Psychiatrists (RCPsych), used the Delphi process to update guidelines for the administration of oromucosal midazolam including developing a voluntary on-line test for carers. During 2017-2019 a facilitator worked with two ESNA committees to update the existing guidance and another to develop a question-bank. Both committee outputs were circulated to the ESNA membership, then ILAE and RCPsych for review. Patient-facing organizations and charities' opinions were solicited. All feedback was assimilated. A private provider was contracted to deliver the test. RESULTS A consensus process involving two task and finish groups of 19 people each compared, reflected, debated, and engaged with stakeholders across three stages. The updated ratified guidelines were circulated nationally. The Delphi process highlighted many regions and individuals had local assessment tools and procedures in place, while others (around 50%) had no assessment provision. 278 carers with a 95% pass-rate and 100% positive feedback have undertaken the online test (10/2020). CONCLUSION The UK-wide care provision gap in basic epilepsy-training and safe rescue medication administration is now addressed. A two-yearly update to the guidelines and test is planned.
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Affiliation(s)
- Phil Tittensor
- Royal Wolverhampton NHS Trust United Kingdom, United Kingdom; University of Wolverhampton United Kingdom, United Kingdom
| | - Sarah Tittensor
- University Hospitals Birmingham NHS Foundation Trust United Kingdom, United Kingdom
| | - Erica Chisanga
- Cambridge University Hospital NHS Foundation Hospital Trust United Kingdom, United Kingdom
| | - Manny Bagary
- Birmingham and Solihull Mental Health Foundation Trust, United Kingdom
| | - Caryn Jory
- Cornwall Partnership NHS Foundation Trust United Kingdom, United Kingdom
| | - Rohit Shankar
- Cornwall Partnership NHS Foundation Trust United Kingdom, United Kingdom; Cornwall Institute of Intellectual Disability Equity Research (CIDER), Peninsula School of Medicine, University of Plymouth, United Kingdom.
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15
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Tang M, Chen M, Bruera E, Hui D. Association among rescue neuroleptic use, agitation, and perceived comfort: secondary analysis of a randomized clinical trial on agitated delirium. Support Care Cancer 2021. [PMID: 34184130 DOI: 10.1007/s00520-021-06384-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Few studies have examined how the use of rescue medications could be used to inform on the efficacy of interventions in delirium clinical trials. The objective of this study was to determine the association among rescue medication use, Richmond Agitation-Sedation Scale (RASS), and perceived comfort by the nurses and caregivers. METHODS This was a pre-planned secondary analysis of a double-blind, randomized clinical trial comparing the use of a single dose of lorazepam plus haloperidol versus placebo plus haloperidol in patients with agitated delirium. Rescue medications were considered the gold standard for this analysis. The optimal cutoff for RASS analysis was calculated by using general linear regression models and determining the area of the curve and using the top left approach. We used 2 × 2 tables to examine the association between rescue medication use and perceived comfort. RESULTS Fifty-eight patients received the study medications and 52 (89%) completed the 8-h observation period. There were 26 (50%) patients in each arm. The lorazepam/haloperidol arm required fewer rescue doses (4/26 (15%)) vs. 16/26 (62%), p = 0.004). Patients with a greater initial RASS reduction required fewer rescue doses. The cutoff value for RASS improvement was 4 points, area under the curve (AUC) 0.64 (95% CI 0.49-0.79) for those who required no rescue doses, and 3 points, AUC 0.74 (95% CI 0.52-0.96) for those who required more than one rescue dose. CONCLUSIONS Rescue medication use was responsive to change and associated with both RASS scores and perceived patient comfort by the nurse and caregiver.
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Langenbruch L, Strippel C, Görlich D, Elger CE, Möddel G, Meuth SG, Kellinghaus C, Wiendl H, Kovac S. Occurrence of status epilepticus in persons with epilepsy is determined by sex, epilepsy classification, and etiology: a single center cohort study. J Neurol 2021; 268:4816-4823. [PMID: 34021409 PMCID: PMC8563665 DOI: 10.1007/s00415-021-10600-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/28/2022]
Abstract
Background Status epilepticus (SE) can occur in persons with or without epilepsy and is associated with high morbidity and mortality. Methods This survey aimed to record self-reported frequency of SE in persons with epilepsy, its association with clinical characteristics and patient level of information on SE and rescue medication. 251 persons with epilepsy at a tertiary epilepsy center were included in the study. Results 87 (35%) had a history of SE defined as seizure duration of more than 5 min. These patients were less likely to be seizure-free, and had a higher number of present and past anti-seizure medication. Female sex, cognitive disability, younger age at epilepsy onset, defined epilepsy etiology, and focal epilepsy were associated with a history of SE. On Cox regression analysis, female sex, defined etiology and focal classification remained significant. 67% stated that they had information about prolonged seizures, and 75% knew about rescue medication. 85% found it desirable to receive information about SE at the time of initial diagnosis of epilepsy, but only 16% had been offered such information at the time. Conclusion SE is frequent among persons with epilepsy and there remain unmet needs regarding patient education.
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Affiliation(s)
- Lisa Langenbruch
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Christine Strippel
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Christian E Elger
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Gabriel Möddel
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, University of Düsseldorf, Düsseldorf, Germany
| | | | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
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Strzelczyk A, Schubert-Bast S, Simon A, Wyatt G, Holland R, Rosenow F. Epidemiology, healthcare resource use, and mortality in patients with probable Lennox-Gastaut syndrome: A population-based study on German health insurance data. Epilepsy Behav 2021; 115:107647. [PMID: 33358132 DOI: 10.1016/j.yebeh.2020.107647] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This retrospective study examined patients with probable Lennox-Gastaut syndrome (LGS) identified from German healthcare data. METHODS This 10-year study (2007-2016) assessed healthcare insurance claims information from the Vilua Healthcare research database. A selection algorithm considering diagnoses and drug prescriptions identified patients with probable LGS. To increase the sensitivity of the identification algorithm, two populations were defined: all patients with probable LGS (broadly defined) and only those with a documented epilepsy diagnosis before 6 years of age (narrowly defined). This specific criterion was used as LGS typically has a peak seizure onset between age 3 and 5 years. Primary analyses were prevalence and demographics; secondary analyses included healthcare costs, hospitalization rate and length of stay (LOS), medication use, and mortality. RESULTS In the final year of the study, 545 patients with broadly defined probable LGS (mean [range] age: 31.4 [2-89] years; male: 53%) were identified. Using the narrowly defined probable LGS definition, the number of patients was reduced to 102 (mean [range] age: 7.4 [2-14] years; male: 52%). Prevalence of broadly defined and narrowly defined probable LGS was 39.2 and 6.5 per 100,000 people. During the 10-year study, 208 patients with narrowly defined probable LGS were identified and followed up for 1379 patient-years. The mean annual cost of healthcare was €22,787 per patient-year (PPY); greatest costs were attributable to inpatient care (33%), home nursing care (13%), and medication (10%). Mean annual healthcare costs were significantly greater for those with prescribed rescue medication (45% of patient-years) versus those without (€33,872 vs. €13,785 PPY, p < 0.001). Mean (standard deviation [SD]) annual hospitalization rate was 1.6 (2.0) PPY with mean (SD) annual LOS of 22.7 (46.0) days. Annual hospitalization rate was significantly greater in those who were prescribed rescue medication versus those who were not (2.2 [2.3] vs. 1.1 [1.6] PPY, p < 0.001). The mean (SD) number of different medications prescribed was 11.3 (7.3) PPY and 33.8 (17.0) over the entire observable time per patient (OET); antiepileptic drugs only accounted for 2.1 (1.1) of the medications prescribed PPY and 3.8 (2.0) OET. Over the 10-year study period, mortality in patients with narrowly defined probable LGS was significantly higher than the matched control population (six events [2.88%] vs. oneevent [0.01%], p < 0.001). CONCLUSION Annual healthcare costs incurred by patients with probable LGS in Germany were substantial, and mostly attributable to inpatient care, home nursing care, and medication. Patients prescribed with rescue medication incurred significantly greater costs than those who were not. Patients with narrowly defined probable LGS had a higher mortality rate versus control populations.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | | | - Geoffrey Wyatt
- Market Access and Health Economics and Outcomes Research, GW Pharma Ltd, London, UK.
| | - Rowena Holland
- Market Access and Health Economics and Outcomes Research, GW Pharma Ltd, London, UK.
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
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Bert F, Pompili E, Gualano MR, Venuti S, Minniti D, Siliquini R. Empowering seizure management skills: Knowledge, attitudes, and experiences of school staff trained in administering rescue drugs in Northern Italy. Epilepsy Behav 2021; 114:107362. [PMID: 33041219 DOI: 10.1016/j.yebeh.2020.107362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/10/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The administration of rescue medication at school concerns students for which it may be essential, on doctor's prescription, to take therapy during school hours. In this case, since the parents are absent, the first rescuer is necessarily the school staff, who should be properly trained because prolonged seizures can cause severe harm and even death. METHODS Every year, the Local Health Unit "TO3" in Northern Italy, provides training for school staff to administrate rescue medication at school. From December 2019 to February 2020, the same questionnaire was administered to school staff trained for seizures at the end of the course, while the staff trained for other diseases completed it before the course. RESULTS About 60% of the sample (N = 123) had been trained in seizure management at least once in their lifetime. Median knowledge score in subjects with no seizures training was 7 (Q25/Q75: 5/8), while it was 9 (Q25/Q75: 6/10) in subjects with seizures training (p < 0.001). The self-reported level of confidence in their skills to administer rescue medication was high in 10.2% of subjects not trained for seizures and in 62.9% of those trained (p < 0.001). CONCLUSION Results suggest that medical training for school staff increases knowledge scores and levels of self-confidence relating to the administration of rescue medication. Moreover, after the training, the school staff changed attitude toward seizures, no longer considering them a problem, and became more aware, less fearful, and more inclined to act in case of need, making school a better place for all students.
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Affiliation(s)
- Fabrizio Bert
- Department of Public Health Sciences, University of Turin, Italy; Molinette Hospital, AOU City of Health and Science of Turin, Italy
| | - Erika Pompili
- Department of Public Health Sciences, University of Turin, Italy
| | | | | | | | - Roberta Siliquini
- Department of Public Health Sciences, University of Turin, Italy; Molinette Hospital, AOU City of Health and Science of Turin, Italy
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De Jong HJI, Voorham J, Scadding GK, Bachert C, Canonica GW, Smith P, Wahn U, Ryan D, Castillo JA, Carter VA, Murray RB, Price DB. Evaluating the real-life effect of MP-AzeFlu on asthma outcomes in patients with allergic rhinitis and asthma in UK primary care. World Allergy Organ J 2020; 13:100490. [PMID: 33376573 PMCID: PMC7753940 DOI: 10.1016/j.waojou.2020.100490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 12/18/2022] Open
Abstract
Background MP-AzeFlu (Dymista®; spray of azelastine/fluticasone propionate) is the most effective allergic rhinitis (AR) treatment available. Its effect on asthma outcomes in patients with AR and asthma is unknown. Methods This pre-post historical cohort study, using the Optimum Patient Care Research Database, included patients aged ≥12 years, from UK general practice with active asthma (defined as a recorded diagnosis, with ≥1 prescription for reliever or controller inhaler) in the year before or at the initiation date. The primary study outcome was change in number of acute respiratory events (i.e. exacerbation or antibiotic course for a respiratory event) between baseline and outcome years. The effect size of MP-AzeFlu was quantified as the difference in % of patients that improved and worsened. Results Of the 1,188 patients with AR and asthma included, many had a record of irreversible obstruction (67%), and uncontrolled asthma (70.4%), despite high mean daily doses of reliever/controller therapy and acute oral corticosteroid use, in the year pre-MP-AzeFlu initiation. MP-AzeFlu initiation was associated with fewer acute respiratory events (effect size (e) = 5.8%, p = 0.0129) and a reduction in daily use of short-acting β2-agonists, with fewer patients requiring >2 SABA puffs/week (e = 7.7% p < 0.0001). More patients had well-controlled asthma 1-year post-MP-AzeFlu initiation (e = 4.1%; p = 0.0037), despite a reduction in inhaled corticosteroids (e = 4.8%; p = 0.0078). Conclusions This study provides the first direct evidence of the beneficial effect of MP-AzeFlu on asthma outcomes in co-morbid patients in primary care in the United Kingdom. Trial registration EUPAS30940. Registered August 13, 2019.
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Key Words
- ADEPT, Anonymized data ethics & protocol transparency
- AR, Allergic rhinitis
- ATS, American Thoracic society
- BEC, Blood eosinophil count
- CRS, Chronic rhinosinusitis
- Control
- ERS, European respiratory society
- Exacerbations
- FEV1, forced expiratory volume in 1 s
- FVC, Forced vital capacity
- GERD, Gastroesophageal reflux disease
- GINA, Global initiative for asthma
- ICS, Inhaled corticosteroid
- INS, Intranasal corticosteroid
- NP, Nasal polyps
- OAC, Overall asthma control
- OAH, Oral anti-histamine
- OCS, Oral corticosteroid
- OPCRD, Optimum patient care research database
- OTC, Over the counter
- PEF, Peak expiratory flow rate
- RCT, Randomized controlled trial
- RDAC, Risk domain asthma control
- Rescue medication
- SABA, Short-acting β2-agonist
- SMD, Standardised mean difference
- UK, United Kingdom
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Affiliation(s)
| | - Jaco Voorham
- Observational and Pragmatic Research Institute, Singapore
| | - Glenis K Scadding
- Royal National Throat, Nose and Ear Hospital, University College London School of Medicine, London, UK
| | | | - Giorgio Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic, Humanitas University & Research Hospital, SANI-Severe Asthma Network, Milan, Italy
| | - Peter Smith
- Griffith University, Southport, QLD, Australia
| | | | - Dermot Ryan
- Usher Institute, University of Edinburgh, Edinburgh, UK.,Optimum Patient Care, Cambridge, UK
| | | | | | | | - David B Price
- Observational and Pragmatic Research Institute, Singapore.,Optimum Patient Care, Cambridge, UK.,Academic Primary Care, University of Aberdeen, Aberdeen, UK
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Woltermann S, Jeschke S, Herziger B, Müller RM, Kiess W, Bertsche T, Bertsche A, Neininger MP. Anticonvulsant long-term and rescue medication: The children's perspective. Eur J Paediatr Neurol 2020; 28:180-185. [PMID: 32727667 DOI: 10.1016/j.ejpn.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/17/2020] [Accepted: 06/21/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Little is known about children's perspectives and attitudes towards their long-term and rescue anticonvulsant medication. METHODS We interviewed paediatric patients aged 6-18 years in two university hospitals concerning their anticonvulsant treatment based on a structured questionnaire. We also asked them to draw a picture titled "Me and my medication". RESULTS We interviewed 100 patients with anticonvulsant long-term medication. 87/100 patients considered their medication to be helpful. 66/100 patients gave an explanation on why a regular medication intake is important, e.g. "Reduction/prevention of seizures", "Otherwise I have to go to hospital", "I don't want to die" or "Kill the virus which is causing epilepsy". Of 92 patients with a prescribed rescue medication, 22 (24%) did not know about it. Of the remaining 70, 39 (56%) stated they always carry it with them. When asked to imagine being the physician and to inform about the medication, the children would use illustrative (e.g. brochures) or demonstration material (e.g. "real tablets") to aid their consultation (47/100). 55/100 would stress the necessity of a regular intake. 52 participants drew a picture related to the given topic. Of those, only 1 depicted rescue medication. CONCLUSION Paediatric patients mostly have a positive attitude towards their medication. However, misconceptions exist and participants expressed the desire for more interactive support in the medical counselling. Children are not sufficiently aware of their rescue medication in everyday life. Consequently, physicians should consider the children's needs in their consultations and put more focus on potentially life-saving rescue medication.
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Affiliation(s)
- Sarah Woltermann
- University Hospital for Children and Adolescents, Centre for Pediatric Research, Liebigstrasse 20a, 04103 Leipzig, Germany; Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University and Drug Safety Center, Leipzig University and University Hospital, Bruederstrasse 32, 04103 Leipzig, Germany.
| | - Sarah Jeschke
- University Hospital for Children and Adolescents, Neuropediatrics, Ernst-Heydemann-Strasse 8, 18057 Rostock, Germany.
| | - Birthe Herziger
- University Hospital for Children and Adolescents, Neuropediatrics, Ernst-Heydemann-Strasse 8, 18057 Rostock, Germany.
| | - Ruth Melinda Müller
- University Hospital for Children and Adolescents, Neuropediatrics, Ernst-Heydemann-Strasse 8, 18057 Rostock, Germany.
| | - Wieland Kiess
- University Hospital for Children and Adolescents, Centre for Pediatric Research, Liebigstrasse 20a, 04103 Leipzig, Germany.
| | - Thilo Bertsche
- Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University and Drug Safety Center, Leipzig University and University Hospital, Bruederstrasse 32, 04103 Leipzig, Germany.
| | - Astrid Bertsche
- University Hospital for Children and Adolescents, Centre for Pediatric Research, Liebigstrasse 20a, 04103 Leipzig, Germany; University Hospital for Children and Adolescents, Neuropediatrics, Ernst-Heydemann-Strasse 8, 18057 Rostock, Germany.
| | - Martina Patrizia Neininger
- Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University and Drug Safety Center, Leipzig University and University Hospital, Bruederstrasse 32, 04103 Leipzig, Germany.
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Chis Ster AM, Cornelius V, Cro S. Current approaches to handling rescue medication in asthma and eczema randomized controlled trials are inadequate: a systematic review. J Clin Epidemiol 2020; 125:148-157. [PMID: 32504781 PMCID: PMC7482905 DOI: 10.1016/j.jclinepi.2020.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 05/05/2020] [Accepted: 05/28/2020] [Indexed: 01/10/2023]
Abstract
Objectives The objective of this study was to examine how rescue medication is defined, reported, and accounted for in randomized controlled trials (RCTs) in eczema and asthma populations. Study Design and Setting This is a systematic review of phase II/III RCTs evaluating monoclonal antibodies for treating chronic eczema or asthma. A search of EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials was conducted to identify eligible RCTs. Results Sixty published RCTs were identified, of which 60 (100%) allowed use of rescue medication but only 28 (47%) reported its use. Twenty-seven (45%) articles summarized rescue use by arm, with an average of 25% (95% CI (17%, 36%)) greater use in the placebo arm. Nine (15%) trials undertook an analysis that adjusted the primary treatment effect estimate for rescue medication use, but 8 of these used a suboptimal approach using single imputation, including 4 which used “last observation carried forward” after setting postrescue data to missing. Conclusion Rescue medication use in eczema and asthma trials evaluating monoclonal antibodies is often permitted, but not routinely reported. There is evidence of imbalance in rescue use between arms, but few articles attempted to estimate a rescue-adjusted treatment effect. In trials that did, the methods used were suboptimal which could introduce bias.
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Affiliation(s)
- Anca Maria Chis Ster
- Imperial College London, Imperial College Clinical Trials Unit, 1st Floor Stadium House, 68 Wood Lane, London W12 7RH, UK
| | - Victoria Cornelius
- Imperial College London, Imperial College Clinical Trials Unit, 1st Floor Stadium House, 68 Wood Lane, London W12 7RH, UK
| | - Suzie Cro
- Imperial College London, Imperial College Clinical Trials Unit, 1st Floor Stadium House, 68 Wood Lane, London W12 7RH, UK.
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van Dijk BCP, Svedsater H, Heddini A, Nelsen L, Balradj JS, Alleman C. Relationship between the Asthma Control Test (ACT) and other outcomes: a targeted literature review. BMC Pulm Med 2020; 20:79. [PMID: 32245451 PMCID: PMC7118934 DOI: 10.1186/s12890-020-1090-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 02/17/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The Asthma Control Test (ACT) has been used to assess asthma control in both clinical trials and clinical practice. However, the relationships between ACT score and other measures of asthma impact are not fully understood. Here, we evaluate how ACT scores relate to other clinical, patient-reported, or economic asthma outcomes. METHODS A targeted literature search of online databases and conference abstracts was performed. Data were extracted from articles reporting ACT score alongside one or more of: Asthma Control Questionnaire (ACQ) score; rescue medication use; exacerbations; lung function; health-/asthma-related quality of life (QoL); sleep quality; work and productivity; and healthcare resource use (HRU) and costs. RESULTS A total of 1653 publications were identified, 74 of which were included in the final analysis. Of these, 69 studies found that improvement in ACT score was related to improvement in outcome(s), either as correlation or by association. The level of evidence for each relationship differed widely between outcomes: substantial evidence was identified for relationships between ACT score and ACQ score, lung function, and asthma-related QoL; moderate evidence was obtained for relationships between ACT score and rescue medication use, exacerbations, sleep quality, and work and productivity; limited evidence was identified for relationships between ACT score and general health-related QoL, HRU, and healthcare costs. CONCLUSIONS Findings of this review suggest that the ACT is an appropriate measure for overall asthma impact and support its use in clinical trial settings. GlaxoSmithKline plc. study number HO-17-18170.
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Affiliation(s)
| | - Henrik Svedsater
- Value Evidence and Outcomes, GlaxoSmithKline plc., Brentford, UK
| | - Andreas Heddini
- Medical Affairs, GlaxoSmithKline Nordic Region, Stockholm, Sweden
| | - Linda Nelsen
- Value Evidence and Outcomes, GlaxoSmithKline plc., Collegeville, PA, USA
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Kirkham FJ, Vigevano F, Raspall-Chaure M, Wilken B, Lee D, Le Reun C, Werner-Kiechle T, Lagae L. Health-related quality of life and the burden of prolonged seizures in noninstitutionalized children with epilepsy. Epilepsy Behav 2020; 102:106340. [PMID: 31733569 DOI: 10.1016/j.yebeh.2019.04.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/09/2019] [Accepted: 04/13/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aimed to provide information on the burden of illness and health-related quality of life (HRQoL) in children with epilepsy who experience prolonged acute convulsive seizures (PACS) in the community setting, and to investigate factors that may predict poor HRQoL in this population. METHODS Noninstitutionalized children (aged 3-16 years) who had experienced at least one PACS within the past year and had currently prescribed PACS rescue medication were enrolled in a cross-sectional study in Germany, Italy, Spain, and the United Kingdom (Practices in Emergency and Rescue medication For Epilepsy managed with Community-administered Therapy 3 [PERFECT-3]). Clinicians, parents/guardians, and patients completed web-based questionnaires regarding clinical characteristics, PACS frequency, and day-to-day impairment. Patients' HRQoL was rated by clinicians, parents/guardians, and patients themselves using the 5-dimension EuroQol questionnaire (EQ-5D) and summarized as a utility score. Potential predictors of poor HRQoL were tested in individual univariate generalized linear models and a global multivariable model. RESULTS Enrolled children (N = 286) had experienced 1-400 PACS (median: 4) in the past year. Clinicians reported that 216/281 patients (76.9%) had learning disabilities of varying severity. Mean EQ-5D utility scores rated by clinicians (n = 279), parents (n = 277), and patients (n = 85) were 0.52 (standard deviation: 0.41), 0.51 (0.39), and 0.74 (0.29), respectively. Increasing PACS frequency, increasing severity of learning disability, and specialist school attendance were significantly associated with decreasing EQ-5D utility score. In the multivariable model, having learning disabilities was the best predictor of poor HRQoL. SIGNIFICANCE Health-related quality of life was very poor in many children with epilepsy whose PACS were managed with rescue medication in the community, with learning disability being the most powerful predictor of patients' HRQoL. Mean EQ-5D utility scores were lower (worse) than published values for many other chronic disorders, indicating that optimal treatment should involve helping children and their families to manage learning disabilities and day-to-day impairments, in addition to preventing seizures.
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Affiliation(s)
- Fenella J Kirkham
- Department of Child Health, University Hospital Southampton NHS Trust, Southampton, United Kingdom; Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom.
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Miquel Raspall-Chaure
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Bernd Wilken
- Department of Pediatric Neurology, Klinikum Kassel, Kassel, Germany
| | - Dawn Lee
- BresMed Health Solutions, Sheffield, United Kingdom
| | | | - Tamara Werner-Kiechle
- Global Medical Affairs, Shire (a member of the Takeda group of companies), Zug, Switzerland
| | - Lieven Lagae
- Department of Pediatric Neurology, University Hospitals, Katholieke Universiteit Leuven, Leuven, Belgium
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Calzetta L, Matera MG, Goldstein MF, Fairweather WR, Howard WW, Cazzola M, Rogliani P. A long-term clinical trial on the efficacy and safety profile of doxofylline in Asthma: The LESDA study. Pulm Pharmacol Ther 2019; 60:101883. [PMID: 31884206 DOI: 10.1016/j.pupt.2019.101883] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/23/2019] [Accepted: 12/23/2019] [Indexed: 12/15/2022]
Abstract
Doxofylline, an oral methylxanthine with bronchodilator and anti-inflammatory activities, offers a promising alternative to theophylline due to its superior efficacy/safety profile. No long-term studies on the efficacy and safety of doxofylline are currently available in asthma. The aim of the Long-term clinical trial on the Efficacy and Safety profile of Doxofylline in Asthma (LESDA) study was to investigate the safety and efficacy profile of doxofylline administered for one year in asthmatic patients. LESDA was a multicenter, open-label, Phase III, clinical trial in which adult asthmatic patients received the same treatment (oral doxofylline 400 mg t.i.d.) for one year. Efficacy was assessed through periodic pulmonary function tests and by having the subjects keep monthly records of asthma events rates and use of salbutamol as rescue medication. The rate of adverse events (AEs) was recorded during the study. Three-hundred nine patients were screened and allocated in the study. Doxofylline significantly improved the change from baseline in forced expiratory volume in 1 s (FEV1) (+16.90 ± 1.81%, P < 0.001 vs. baseline). Doxofylline also significantly improved the rate of asthma events (events/day: -0.57 ± 0.18, P < 0.05 vs. baseline) and the use of salbutamol as rescue medication (puffs/day: -1.48 ± 0.25, P < 0.01 vs. baseline). The most common AEs were nausea (14.56%), headache (14.24%), insomnia (10.68%), and dyspepsia (10.03%). There were neither serious AEs nor deaths during or shortly after the study. Concluding, doxofylline is effective and well tolerated when administered chronically in asthmatic patients.
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Affiliation(s)
- Luigino Calzetta
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | | | | | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Kivitz AJ, Conaghan PG, Cinar A, Lufkin J, Kelley SD. Rescue Analgesic Medication Use by Patients Treated with Triamcinolone Acetonide Extended-Release for Knee Osteoarthritis Pain: Pooled Analysis of Three Phase 2/3 Randomized Clinical Trials. Pain Ther 2019; 8:271-80. [PMID: 31066021 DOI: 10.1007/s40122-019-0125-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In clinical trials for knee osteoarthritis (OAK), rescue medication is commonly provided to manage uncontrolled index-knee pain. The impact of treatment on rescue medication utilization provides important information on the robustness of analgesic effect. In randomized controlled OAK trials (NCT01487161, NCT02116972, NCT02357459), intra-articular (IA) triamcinolone acetonide extended-release (TA-ER) demonstrated substantial, prolonged analgesia versus saline-placebo and TA crystalline solution (TAcs) as assessed by patient-reported pain scales. This pooled analysis assessed the impact of TA-ER on rescue medication use. METHODS Patients (N = 798) with OAK (American College of Rheumatology criteria; Kellgren-Lawrence grade 2/3) and baseline average daily pain intensity score ≥ 5 to ≤ 9 (0-10 numeric rating scale) received a single IA injection of TA-ER (N = 324), saline-placebo (N = 262), or TAcs (N = 212). Acetaminophen/paracetamol tablets were provided to treat uncontrolled pain (knee or otherwise). Rescue medication consumption was monitored through a daily diary; pill counts were confirmed at the clinical site. Differences in rescue medication use were measured by least-squares mean (LSM) differences, number of rescue medication tablets used per day, and in area under the effect (AUE) curves of rescue medication tablets used per week. RESULTS The overall number of rescue medication tablets used per day through week 24 was significantly less (p ≤ 0.05) for TA-ER versus saline-placebo (LSM difference, - 0.43) and TAcs (- 0.24). Rescue medication use was significantly (p ≤ 0.05) lower following TA-ER versus saline-placebo across weeks 1-12 (AUEweeks1-12; LSM difference, - 24.5) and weeks 1-24 (AUEweeks1-24; - 51.6) and versus TAcs across weeks 1-12 (AUEweeks1-12; - 21.1). CONCLUSIONS In patients with painful OAK, reduced rescue medication use may be a potential benefit of TA-ER and further supports its analgesic efficacy. Additional research is needed to assess whether TA-ER impacts the use of other common oral analgesics (nonsteroidal anti-inflammatory drugs, opioids) for patients with OAK. FUNDING Flexion Therapeutics, Inc., Burlington, MA, USA. Plain language summary available for this article.
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Detyniecki K, O'Bryan J, Choezom T, Rak G, Ma C, Zhang S, Bonito J, Hirsch LJ. Prevalence and predictors of seizure clusters: A prospective observational study of adult patients with epilepsy. Epilepsy Behav 2018; 88:349-356. [PMID: 30344026 DOI: 10.1016/j.yebeh.2018.09.035] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 09/24/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this prospective observational study was to describe the prevalence and adverse outcomes associated with seizure clusters (defined as ≥2 seizures in a 6-hour period) in a large sample of adult patients with a range of epilepsy severities and to identify clinical characteristics predictive of clustering. METHODS Patients maintained a seizure diary and were contacted monthly to verify compliance and data accuracy. Logistic regression models were utilized to test associations between individual patient demographic/clinical characteristics and seizure clustering. Fisher's exact test was utilized to test associations between rescue medication use and adverse seizure-related outcomes. RESULTS A total of 300 patients were followed prospectively for one year; 247 patients qualified for final analysis. Six-hour seizure clusters occurred in 45.8% of patients with active epilepsy at enrollment, including 62.7% of those with prior day-clusters and 30.0% of those without prior day-clusters. The odds of clustering were markedly greater among patients who reported a higher seizure frequency (>4 seizures per year vs. 1-4 seizures per year) (adjusted odds ratio (OR): 8.9; 95% confidence interval (CI): 3.2-24.6; p < 0.0001) and among patients with prior day-clusters (adjusted OR: 11.0; 95% CI: 1.2-104.2; p = 0.036). Rescue medication use was associated with significantly fewer injuries and emergency department visits, but rescue medication was underutilized. CONCLUSIONS Seizure clusters are common, occurring in nearly half of adult patients with active epilepsy followed prospectively over one year, and are more frequent in those with higher seizure frequencies and prior day-clusters. Although underutilized, rescue medication was associated with fewer injuries and emergency department visit.
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Affiliation(s)
- Kamil Detyniecki
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America.
| | - Jane O'Bryan
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America
| | - Tenzin Choezom
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America; Yale Cancer Center, New Haven, CT, United States of America
| | - Grzegorz Rak
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America; Second Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Chanthia Ma
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America; Department of Molecular, Cellular and Developmental Biology, Yale University, New Haven, CT, United States of America
| | - Shiliang Zhang
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America; David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States of America
| | - Jennifer Bonito
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America
| | - Lawrence J Hirsch
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America
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Grazzi L, Tassorelli C, de Tommaso M, Pierangeli G, Martelletti P, Rainero I, Geppetti P, Ambrosini A, Sarchielli P, Liebler E, Barbanti P. Practical and clinical utility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: a post hoc analysis of the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain 2018; 19:98. [PMID: 30340460 PMCID: PMC6742918 DOI: 10.1186/s10194-018-0928-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 10/03/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The PRESTO study of non-invasive vagus nerve stimulation (nVNS; gammaCore®) featured key primary and secondary end points recommended by the International Headache Society to provide Class I evidence that for patients with an episodic migraine, nVNS significantly increases the probability of having mild pain or being pain-free 2 h post stimulation. Here, we examined additional data from PRESTO to provide further insights into the practical utility of nVNS by evaluating its ability to consistently deliver clinically meaningful improvements in pain intensity while reducing the need for rescue medication. METHODS Patients recorded pain intensity for treated migraine attacks on a 4-point scale. Data were examined to compare nVNS and sham with regard to the percentage of patients who benefited by at least 1 point in pain intensity. We also assessed the percentage of attacks that required rescue medication and pain-free rates stratified by pain intensity at treatment initiation. RESULTS A significantly higher percentage of patients who used acute nVNS treatment (n = 120) vs sham (n = 123) reported a ≥ 1-point decrease in pain intensity at 30 min (nVNS, 32.2%; sham, 18.5%; P = 0.020), 60 min (nVNS, 38.8%; sham, 24.0%; P = 0.017), and 120 min (nVNS, 46.8%; sham, 26.2%; P = 0.002) after the first attack. Similar significant results were seen when assessing the benefit in all attacks. The proportion of patients who did not require rescue medication was significantly higher with nVNS than with sham for the first attack (nVNS, 59.3%; sham, 41.9%; P = 0.013) and all attacks (nVNS, 52.3%; sham, 37.3%; P = 0.008). When initial pain intensity was mild, the percentage of patients with no pain after treatment was significantly higher with nVNS than with sham at 60 min (all attacks: nVNS, 37.0%; sham, 21.2%; P = 0.025) and 120 min (first attack: nVNS, 50.0%; sham, 25.0%; P = 0.018; all attacks: nVNS, 46.7%; sham, 30.1%; P = 0.037). CONCLUSIONS This post hoc analysis demonstrated that acute nVNS treatment quickly and consistently reduced pain intensity while decreasing rescue medication use. These clinical benefits provide guidance in the optimal use of nVNS in everyday practice, which can potentially reduce use of acute pharmacologic medications and their associated adverse events. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02686034 .
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Affiliation(s)
- Licia Grazzi
- Neuroalgology Unit, Carlo Besta Neurological Institute and Foundation, Milan, Italy
- Department of Fondazione IRCCS Istituto Neurologico C. Besta, U.O. Neurologia III – Cefalee e Neuroalgologia, Via Celoria 11, 20133 Milan, Italy
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS C. Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Marina de Tommaso
- Neurophysiology and Pain Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giulia Pierangeli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | | | | | - Paola Sarchielli
- Neurologic Clinic, Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
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Gao F, Zeng D, Wei H, Wang X, Ibrahim JG. Estimating Treatment Effects for Recurrent Events in the Presence of Rescue Medications: An Application to the Immune Thrombocytopenia Study. Stat Biosci 2018; 10:473-489. [PMID: 30298095 DOI: 10.1007/s12561-016-9164-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In many clinical studies, patients may experience the same type of event of interest repeatedly over time. However, the assessment of treatment effects is often complicated by the rescue medication uses due to ethical reasons. For example, in the motivating trial in studying the Immune Thrombocytopenia (ITP), when the interest lies in evaluating the treatment benefit of investigational product (IP) on reducing patient's repeated bleeding, rescue medication such as platelet transfusions may be allowed to raise platelet counts. Both the intention-to-treat analysis and treating the intermediate rescue medication as covariate tend to attenuate the treatment benefit, and the estimates can be biased if interpreted as causal. In this paper, we propose a general causal framework when intermediate rescue medications are informative. We adopt the inverse weighted estimation approach to estimate the treatment effect, where weights are constructed to reflect time-dependent medication use probabilities. The proposed estimators are shown to be asymptotically normal and are demonstrated to perform well in small-sample simulation studies. The application to the ITP studies reveals a stronger benefit of using IP in reducing bleeding.
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Affiliation(s)
- Fei Gao
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Donglin Zeng
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Helen Wei
- Global Biostatistical Science, Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 91320, USA
| | - Xuena Wang
- Global Biostatistical Science, Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 91320, USA
| | - Joseph G Ibrahim
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27599, USA
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Azhar A, Kim YJ, Haider A, Hui D, Balankari VR, Epner MC, Park M, Liu DD, Williams J, Frisbee-Hume SE, Allo JA, Bruera E. Response to Oral Immediate-Release Opioids for Breakthrough Pain in Patients with Advanced Cancer with Adequately Controlled Background Pain. Oncologist 2018; 24:125-131. [PMID: 30254187 DOI: 10.1634/theoncologist.2017-0583] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 05/31/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is limited evidence about the response of breakthrough pain (BTP) to the most commonly used oral immediate-release (IR) opioids. Our aim was to determine response rate to oral IR opioids for BTP control in patients with advanced cancer. MATERIALS AND METHODS In this prospective study, palliative care outpatients, with advanced cancer and adequately managed background pain, were asked to complete a self-administered survey. We assessed patients' baseline demographics, pain characteristics, alcoholism (CAGE questionnaire), tobacco and substance abuse, and Edmonton Symptom Assessment Scores (ESAS). We determined the effectiveness of oral IR BTP opioids by using a 7-point Likert scale ranging from "very ineffective" to "very effective." "Effective" and "very effective" were defined a priori as a good response to IR opioids for BTP. RESULTS Of 592 evaluable patients, 192 (32%) had background pain of ≤3 (ESAS pain scale 0-10). Among these 192 patients, 152 (79%) reported BTP, 143/152 (94%) took oral IR opioids for BTP, and 127/143 (89%) responded to a median dose of 10% of the total morphine equivalent daily dose. In univariate logistic regression analysis, younger age (odds ratio [OR], 0.94 per year; p = .008), higher ESAS scores for pain (OR, 1.32; p = .012), anxiety (OR, 1.24; p = .017), and dyspnea (OR, 1.31; p = .007) had statistically significant association with poor response to IR opioids for BTP. In multicovariate logistic regression, adjusted for age, a higher ESAS dyspnea score was significantly associated with poor response to oral IR opioids (OR, 1.44; p = .002). CONCLUSION The vast majority of patients with advanced cancer with adequately controlled background pain reported a good response to oral IR opioids for BTP, supporting their use in clinical practice. IMPLICATIONS FOR PRACTICE Oral immediate-release opioids are standard treatment for cancer breakthrough pain. However, information regarding treatment response to these commonly used opioids is limited. This study provides information that the vast majority of patients with advanced cancer, with adequately controlled background pain, reported good response to oral immediate release opioids for managing their breakthrough pain episodes. Results of this study support the use of conventional oral immediate release opioids that are relatively inexpensive and readily available for management of breakthrough pain in patients with advanced cancer.
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Affiliation(s)
- Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vishidha R Balankari
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Margeaux Chiou Epner
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janet Williams
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan E Frisbee-Hume
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julio A Allo
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Chen W, FitzGerald JM, Lynd LD, Sin DD, Sadatsafavi M. Long-Term Trajectories of Mild Asthma in Adulthood and Risk Factors of Progression. J Allergy Clin Immunol Pract 2018; 6:2024-2032.e5. [PMID: 29746917 DOI: 10.1016/j.jaip.2018.04.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 04/19/2018] [Accepted: 04/26/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Most patients with asthma have mild disease. However, the clinical course of mild asthma and risk factors for progression are not well studied. OBJECTIVE To examine the long-term trajectories of mild asthma and the effects of early-stage risk factors on the subsequent disease course. METHODS From the administrative health data of British Columbia, Canada, we identified patients aged 14 to 45 years with newly diagnosed mild asthma between January 1997 and December 2012. For each follow-up year, we categorized a patient's asthma severity into mild/dormant, moderate, or severe on the basis of the intensity of asthma medications and occurrence of exacerbations. Ordinal logistic regression was used to estimate the probability of severity or all-cause death in the next year as a function of a patient's severity history in the past 3 years and selected baseline risk factors. RESULTS The study included 70,829 patients with incident mild asthma (62% women; mean age, 31 years). Over 10 years, 8% of these patients transitioned to moderate or severe asthma. Inappropriate use of rescue medications and older age were the most influential determinants for progression from mild asthma (odds ratios, 1.79; 95% CI, 1.68-1.90; P < .001; 1.24 per 10-year increase in age; 95% CI, 1.22-1.27; P < .001), whereas the presence of allergic rhinitis had no significant effects (odds ratio, 0.95; 95% CI, 0.91-1.00; P = .063). CONCLUSIONS Mild asthma remains largely stable over time. However, potentially modifiable factors such as inappropriate use of rescue medications are associated with a worsened prognosis.
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Affiliation(s)
- Wenjia Chen
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - J Mark FitzGerald
- Institute for Heart and Lung Health, Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, BC, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation and Outcome Sciences, Providence Health, St Paul's Hospital, Vancouver, BC, Canada
| | - Don D Sin
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, BC, Canada; Division of Respiratory Medicine, Department of Medicine, The UBC Centre for Heart Lung Innovation, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Mohsen Sadatsafavi
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, BC, Canada.
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Vigevano F, Kirkham FJ, Wilken B, Raspall-Chaure M, Grebla R, Lee D, Werner-Kiechle T, Lagae L. Effect of rescue medication on seizure duration in non-institutionalized children with epilepsy. Eur J Paediatr Neurol 2018; 22:56-63. [PMID: 29289522 DOI: 10.1016/j.ejpn.2017.07.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 06/06/2017] [Accepted: 07/10/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Characterize the real-world management of and outcomes for children with epilepsy receiving rescue medication for prolonged acute convulsive seizures (PACS) in the community. METHODS PERFECT-3 (Practices in Emergency and Rescue medication For Epilepsy managed with Community-administered Therapy 3) was a European, retrospective observational study. Eligible patients were non-institutionalized children with epilepsy aged 3-16 years who had experienced ≥1 PACS in the past year and had ≥1 currently prescribed PACS rescue medication. Investigators provided clinical assessments and parents/guardians completed questionnaires. Statistical tests were post hoc; p values are descriptive. RESULTS At enrollment (N = 286), most patients had prescriptions for diazepam (69.2%) and/or midazolam (55.9%); some had two (26.6%) or three (2.4%) prescribed rescue medications. Most patients experienced PACS despite regular anti-epilepsy medication. According to parents, the average duration of their child's seizures without rescue medication was <5 min in 35.7% of patients, 5-<20 min in 42.6%, and ≥20 min in 21.7% (n = 258); with rescue medication seizure duration was <5 min in 69.4% of patients, 5-<20 min in 25.6%, and ≥20 min in 5.0%. Rescue medication use was significantly associated with average seizures lasting <5 min (χ2 = 58.8; p < 0.0001). At the time of their most recent PACS, 58.5-67.8% of children reportedly received rescue medication within 5 min of seizure onset, and 85.4-94.1% within 10 min. CONCLUSION This study provides the first real-world data that rescue medications administered in the community reduce the duration of PACS in children with epilepsy. Study limitations including potential recall bias are acknowledged.
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Affiliation(s)
- Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Fenella J Kirkham
- Department of Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Bernd Wilken
- Neuropaediatrics, Klinikum Kassel, Kassel, Germany
| | - Miquel Raspall-Chaure
- Department of Paediatric Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Regina Grebla
- Global Health Economics and Outcomes Research, Shire, Lexington, MA, USA
| | - Dawn Lee
- BresMed Health Solutions, Sheffield, UK
| | | | - Lieven Lagae
- Pediatric Neurology, University Hospitals, Katholieke Universiteit Leuven, Leuven, Belgium
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Dumeier HK, Neininger MP, Bernhard MK, Merkenschlager A, Kiess W, Bertsche T, Bertsche A. Providing teachers with education on epilepsy increased their willingness to handle acute seizures in children from one to 10 years of age. Acta Paediatr 2017; 106:1811-1816. [PMID: 28561263 DOI: 10.1111/apa.13938] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 05/29/2017] [Indexed: 01/27/2023]
Abstract
AIM In Germany, preschool teachers supervise children up to six years of age and are also responsible for supervising older pupils after school. This study explored the impact of a teaching session on epilepsy for teachers in charge of children from 1 to 10 years of age. METHODS We evaluated the benefit of a teaching session offered to all preschool teachers in Leipzig, Germany, in 2014-2015, by asking them to complete the same questionnaire 12-24 months pre-intervention, and 12 months postintervention. RESULTS Both questionnaires were completed by 123 teachers. The number of teachers who felt they were prepared to handle an acute seizure rose from 36 (29%) pre-intervention to 65 (53%) post-intervention (p < 0.001) and their willingness to administer a prescribed rescue medication rose from 66 (54%) to 93 (76%, p < 0.001). The session also increased the number of teachers who were prepared to take children with epilepsy on excursions under any circumstance from 38 (31%) to 52 (42%, p < 0.05). In addition, the number of teachers who would place a solid object in the child's mouth during an attack fell from 16 (13%) to seven (6%) (p < 0.05). CONCLUSION Providing a teaching session on epilepsy increased the teachers' knowledge and willingness to act and reduced obsolete, counterproductive measures.
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Affiliation(s)
| | | | - Matthias Karl Bernhard
- Centre of Pediatric Research; University Hospital for Children and Adolescents; Leipzig Germany
| | - Andreas Merkenschlager
- Centre of Pediatric Research; University Hospital for Children and Adolescents; Leipzig Germany
| | - Wieland Kiess
- Centre of Pediatric Research; University Hospital for Children and Adolescents; Leipzig Germany
| | - Thilo Bertsche
- Department of Clinical Pharmacy; Drug Safety Center; Leipzig University; Leipzig Germany
| | - Astrid Bertsche
- Centre of Pediatric Research; University Hospital for Children and Adolescents; Leipzig Germany
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Singla NK, Meske DS, Desjardins PJ. Exploring the Interplay between Rescue Drugs, Data Imputation, and Study Outcomes: Conceptual Review and Qualitative Analysis of an Acute Pain Data Set. Pain Ther 2017; 6:165-175. [PMID: 28676997 PMCID: PMC5693805 DOI: 10.1007/s40122-017-0074-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Indexed: 11/01/2022] Open
Abstract
In placebo-controlled acute surgical pain studies, provisions must be made for study subjects to receive adequate analgesic therapy. As such, most protocols allow study subjects to receive a pre-specified regimen of open-label analgesic drugs (rescue drugs) as needed. The selection of an appropriate rescue regimen is a critical experimental design choice. We hypothesized that a rescue regimen that is too liberal could lead to all study arms receiving similar levels of pain relief (thereby confounding experimental results), while a regimen that is too stringent could lead to a high subject dropout rate (giving rise to a preponderance of missing data). Despite the importance of rescue regimen as a study design feature, there exist no published review articles or meta-analysis focusing on the impact of rescue therapy on experimental outcomes. Therefore, when selecting a rescue regimen, researchers must rely on clinical factors (what analgesics do patients usually receive in similar surgical scenarios) and/or anecdotal evidence. In the following article, we attempt to bridge this gap by reviewing and discussing the experimental impacts of rescue therapy on a common acute surgical pain population: first metatarsal bunionectomy. The function of this analysis is to (1) create a framework for discussion and future exploration of rescue as a methodological study design feature, (2) discuss the interplay between data imputation techniques and rescue drugs, and (3) inform the readership regarding the impact of data imputation techniques on the validity of study conclusions. Our findings indicate that liberal rescue may degrade assay sensitivity, while stringent rescue may lead to unacceptably high dropout rates.
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Affiliation(s)
- Neil K Singla
- Lotus Clinical Research, Huntington Hospital, Department of Anesthesiology, Pasadena, CA, USA.
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Kaune A, Schumacher PM, Hoppe SC, Syrbe S, Bernhard MK, Frontini R, Merkenschlager A, Kiess W, Neininger MP, Bertsche A, Bertsche T. Administration of anticonvulsive rescue medication in children-discrepancies between parents' self-reports and limited practical performance. Eur J Pediatr 2016; 175:1139-46. [PMID: 27370405 DOI: 10.1007/s00431-016-2750-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/20/2016] [Accepted: 06/26/2016] [Indexed: 10/21/2022]
Abstract
UNLABELLED Quality of parents' performance in administering anticonvulsive rescue medication to their children suffering from seizures is unknown. After obtaining ethical approval, we used a questionnaire to ask parents of children with seizures, who had been prescribed rescue medications, about their experience in administering those. To assess the frequency of actually committed drug-handling errors, we let them administer rescue medications to dummy dolls. An expert panel rated the clinical risk of handling errors from "1" (lowest) to "6" (highest). Eighty-one parents completed the study. In the questionnaire, 85 % (100 %) of parents that already conducted rectal (buccal) administration reported that they had never experienced problems. The number of rectal administrations with at least one handling error (97 %, 58/60) was higher than in buccal administration (58 %; 14/24; p < 0.001). According to logistic regressions, previous use of rescue medication was not a predictor of the number of committed errors per process (n. s.). All errors were rated with a high clinical risk (class 4-6). CONCLUSION By observing parents' administration of rescue medication to dummy dolls, we found a high frequency of clinically relevant drug-handling errors. Most parents, however, self-reported to have never experienced problems while administering rescue medications to their children. WHAT IS KNOWN • For seizures with duration of more than 5 min, the administration of anticonvulsive rescue medication is recommended. • Outside the hospital, the administration of rescue medication to children is performed most frequently by their parents. What is New: • Most of the parents reported that they had never experienced problems in handling anticonvulsive rescue medication. • But in the observed drug-handling performances, identified errors committed by parents were alarmingly frequent and pose a high clinical risk according to an expert panel.
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Calverley PMA, Rennard SI, Clerisme-Beaty E, Metzdorf N, Zubek VB, ZuWallack R. Effect of tiotropium on night-time awakening and daily rescue medication use in patients with COPD. Respir Res 2016; 17:27. [PMID: 26971242 PMCID: PMC4789269 DOI: 10.1186/s12931-016-0340-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 02/25/2016] [Indexed: 12/16/2022] Open
Abstract
Background Several small studies found night-time awakenings due to COPD symptoms were associated with decreased health status. In this study, night-time awakenings in patients with COPD were examined and effects of tiotropium therapy evaluated. Methods This study was a post hoc, exploratory, pooled analysis of twin, multicenter, double-blind, randomized, placebo-controlled, parallel-group trials. Patients with stable moderate-to-severe COPD were randomized to tiotropium HandiHaler® (n = 550) or placebo (n = 371) and followed for 13 weeks. During a 2-week, pre-treatment baseline period and for 13 weeks on treatment, self-reported night-time awakenings due to COPD symptoms, rescue medication (albuterol) use, and morning and evening peak expiratory flow rate (PEFR) were recorded daily. Nightly, COPD-related awakenings were scored: 0 = no awakenings; 1 = 1 awakening; 2 = 2–3 awakenings; or 3 = awake most of the night. Health-related quality-of-life (HRQoL) and energy–fatigue questionnaires were completed at baseline and during treatment. Results Patients were aged 65.2 ± 8.7 years (mean ± SD), with a mean pre-bronchodilator FEV1 of 36.1 ± 13.5 % predicted normal at baseline. Data for night-time awakenings and albuterol use were available for 543 (99 %) patients on tiotropium and 352 (95 %) on placebo. At baseline, 280 (51.5 %) patients on tiotropium and 179 (50.1 %) on placebo reported ≥1 COPD-related night-time awakening per week. Over the 13-weeks’ treatment, tiotropium was associated with fewer night-time awakenings, with mean ± SE overall awakening scores per week of 0.356 ± 0.006 compared with 0.421 ± 0.007 for placebo (p < 0.001); means were significantly lower for tiotropium versus placebo in patients with baseline awakenings (p < 0.001), but not for those without baseline awakenings. COPD-related night-time awakenings were associated with increased nocturnal rescue medication use and lower HRQoL ratings in both treatment arms. Following start of treatment, tiotropium decreased patients’ use of rescue medication compared with placebo, and morning and evening adjusted means for PEFR were higher for tiotropium compared with placebo. Conclusions Tiotropium is associated with decreased COPD-related night-time awakenings. Night-time awakenings are associated with increased nocturnal rescue medication use and may be a surrogate marker of symptom control in patients with COPD. Electronic supplementary material The online version of this article (doi:10.1186/s12931-016-0340-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Peter M A Calverley
- Clinical Science Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.
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