1
|
Chen C, Hennessy S, Brensinger CM, Miano TA, Bilker WB, Dublin S, Chung SP, Horn JR, Tiwari A, Leonard CE. Comparative Risk of Injury with Concurrent Use of Opioids and Skeletal Muscle Relaxants. Clin Pharmacol Ther 2024. [PMID: 38482733 DOI: 10.1002/cpt.3248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 03/02/2024] [Indexed: 05/04/2024]
Abstract
Concurrent use of skeletal muscle relaxants (SMRs) and opioids has been linked to an increased risk of injury. However, it remains unclear whether the injury risks differ by specific SMR when combined with opioids. We conducted nine retrospective cohort studies within a US Medicaid population. Each cohort consisted exclusively of person-time exposed to both an SMR and one of the three most dispensed opioids-hydrocodone, oxycodone, and tramadol. Opioid users were further divided into three cohorts based on the initiation order of SMRs and opioids-synchronically triggered, opioid-triggered, and SMR-triggered. Within each cohort, we used Cox proportional hazard models to compare the injury rates for different SMRs compared to methocarbamol, adjusting for covariates. We identified 349,543, 139,458, and 218,967 concurrent users of SMRs with hydrocodone, oxycodone, and tramadol, respectively. In the oxycodone-SMR-triggered cohort, the adjusted hazard ratios (HRs) were 1.86 (95% CI, 1.23-2.82) for carisoprodol and 1.73 (1.09-2.73) for tizanidine. In the tramadol-synchronically triggered cohort, the adjusted HRs were 0.69 (0.49-0.97) for metaxalone and 0.62 (0.42-0.90) for tizanidine. In the tramadol-SMR-triggered cohort, the adjusted HRs were 1.51 (1.01-2.26) for baclofen and 1.48 (1.03-2.11) for cyclobenzaprine. All other HRs were statistically nonsignificant. In conclusion, the relative injury rate associated with different SMRs used concurrently with the three most dispensed opioids appears to vary depending on the specific opioid and the order of combination initiation. If confirmed by future studies, clinicians should consider the varying injury rates when prescribing SMRs to individuals using hydrocodone, oxycodone, and tramadol.
Collapse
Affiliation(s)
- Cheng Chen
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sean Hennessy
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colleen M Brensinger
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Todd A Miano
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Warren B Bilker
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
| | | | - John R Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Anika Tiwari
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles E Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
2
|
Wang J, Ritchey ME, Reynolds K, Carbonneau M, Carrera A, Goti N, Horn JR, Girman CJ. Assessment of Codispensing Patterns of Mirabegron and Prespecified CYP2D6 Substrates in Patients with Overactive Bladder. Drugs Real World Outcomes 2023; 10:439-446. [PMID: 37219800 PMCID: PMC10491567 DOI: 10.1007/s40801-023-00370-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Patients with overactive bladder (OAB) experience sudden, intense urges to urinate, which may include urge urinary incontinence and nocturia. Pharmacotherapy includes β3-adrenergic receptor agonists such as mirabegron; however, mirabegron contains a label warning for cytochrome P450 (CYP) 2D6 inhibition, making coadministration with CYP2D6 substrates require monitoring and dose adjustment to avoid unintended increases in substrate concentration. OBJECTIVE To understand the codispensing patterns of mirabegron among patients using ten predefined CYP2D6 substrates with and before mirabegron dispensing. METHODS This retrospective claims database analysis used the IQVIA PharMetrics® Plus Database to assess codispensing of mirabegron with ten predefined CYP2D6 substrate groups identified on the basis of medications most frequently prescribed in the United States, those with high susceptibility to CYP2D6 inhibition, and those with evidence for exposure-related toxicity. Patients had to be ≥ 18 years old before initiation of the CYP2D6 substrate episode that overlapped with mirabegron. The cohort entry period was November 2012 to September 2019, and the overall study period was 1 January 2011 to 30 September 2019. Comparisons of patient profiles at dispensing were made between time periods with and before mirabegron use in the same patient. Descriptive statistics were used to assess the number of exposure episodes, total duration of exposure, and median duration of exposure of CYP2D6 substrate dispensing with and before mirabegron. RESULTS CYP2D6 substrate exposure periods totaling ≥ 9000 person-months were available before overlapping exposure to mirabegron for all ten CYP2D6 substrate cohorts. Median codispensing duration for chronically administered CYP2D6 substrates was 62 (interquartile range [IQR] 91) days for citalopram/escitalopram, 71 (105) days for duloxetine/venlafaxine, and 75 (115) days for metoprolol/carvedilol; median codispensing duration for acutely administered CYP2D6 substrates was 15 (33) days for tramadol and 9 (18) days for hydrocodone. CONCLUSIONS In this claims database analysis, the dispensing patterns of CYP2D6 substrates with mirabegron displayed frequent overlapping of exposure. Thus, a need exists to better understand the outcomes experienced by patients with OAB who are at increased risk for drug‒drug interactions when taking multiple CYP2D6 substrates concurrently with a CYP2D6 inhibitor.
Collapse
Affiliation(s)
| | | | - Kamika Reynolds
- CERobs Consulting, LLC, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Adam Carrera
- Urovant Sciences, 5281 California Ave, Suite 100, Irvine, CA, 92617, USA.
| | - Noelia Goti
- Urovant Sciences, 5281 California Ave, Suite 100, Irvine, CA, 92617, USA
| | - John R Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
3
|
Hansten PD, Tan MS, Horn JR, Gomez-Lumbreras A, Villa-Zapata L, Boyce RD, Subbian V, Romero A, Gephart S, Malone DC. Colchicine Drug Interaction Errors and Misunderstandings: Recommendations for Improved Evidence-Based Management. Drug Saf 2023; 46:223-242. [PMID: 36522578 PMCID: PMC9754312 DOI: 10.1007/s40264-022-01265-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Abstract
Colchicine is useful for the prevention and treatment of gout and a variety of other disorders. It is a substrate for CYP3A4 and P-glycoprotein (P-gp), and concomitant administration with CYP3A4/P-gp inhibitors can cause life-threatening drug-drug interactions (DDIs) such as pancytopenia, multiorgan failure, and cardiac arrhythmias. Colchicine can also cause myotoxicity, and coadministration with other myotoxic drugs may increase the risk of myopathy and rhabdomyolysis. Many sources of DDI information including journal publications, product labels, and online sources have errors or misleading statements regarding which drugs interact with colchicine, as well as suboptimal recommendations for managing the DDIs to minimize patient harm. Furthermore, assessment of the clinical importance of specific colchicine DDIs can vary dramatically from one source to another. In this paper we provide an evidence-based evaluation of which drugs can be expected to interact with colchicine, and which drugs have been stated to interact with colchicine but are unlikely to do so. Based on these evaluations we suggest management options for reducing the risk of potentially severe adverse outcomes from colchicine DDIs. The common recommendation to reduce the dose of colchicine when given with CYP3A4/P-gp inhibitors is likely to result in colchicine toxicity in some patients and therapeutic failure in others. A comprehensive evaluation of the almost 100 reported cases of colchicine DDIs is included in table form in the electronic supplementary material. Colchicine is a valuable drug, but improvements in the information about colchicine DDIs are needed in order to minimize the risk of serious adverse outcomes.
Collapse
Affiliation(s)
| | - Malinda S Tan
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - John R Horn
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Ainhoa Gomez-Lumbreras
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | | | - Richard D Boyce
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Vignesh Subbian
- College of Engineering, University of Arizona, Tucson, AZ, USA
| | - Andrew Romero
- Department of Pharmacy, Tucson Medical Center, Tucson, AZ, USA
| | - Sheila Gephart
- College of Nursing, University of Arizona, Tucson, AZ, USA
| | - Daniel C Malone
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
4
|
Chen C, Hennessy S, Brensinger CM, Bilker WB, Dublin S, Chung SP, Horn JR, Bogar KF, Leonard CE. Antidepressant drug-drug-drug interactions associated with unintentional traumatic injury: Screening for signals in real-world data. Clin Transl Sci 2022; 16:326-337. [PMID: 36415144 PMCID: PMC9926061 DOI: 10.1111/cts.13452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/23/2022] [Accepted: 10/27/2022] [Indexed: 11/24/2022] Open
Abstract
Antidepressants are associated with traumatic injury and are widely used with other medications. It remains unknown how drug-drug-drug interactions (3DIs) between antidepressants and two other drugs may impact potential injury risks associated with antidepressants. We aimed to generate hypotheses regarding antidepressant 3DI signals associated with elevated injury rates. Using 2000-2020 Optum's de-identified Clinformatics Data Mart, we performed a self-controlled case series study for each drug triad consisting of an antidepressant + codispensed drug (base-pair) with a candidate interacting medication (precipitant). We included persons aged greater than or equal to 16 years who (1) experienced an injury and (2) used a candidate precipitant, during base-pair therapy. We compared injury rates during observation time exposed to the drug triad versus the base-pair only, adjusting for time-varying covariates. We calculated adjusted rate ratios (RRs) using conditional Poisson regression and accounted for multiple comparisons via semi-Bayes shrinkage. Among 147,747 eligible antidepressant users with an injury, we studied 120,714 antidepressant triads, of which 334 (0.3%) were positively associated with elevated injury rates and thus considered potential 3DI signals. Adjusted RRs for signals ranged from 1.31 (1.04-1.65) for sertraline + levothyroxine with tramadol (vs. without tramadol) to 6.60 (3.23-13.46) for escitalopram + simvastatin with aripiprazole (vs. without aripiprazole). Nearly half of the signals (137, 41.0%) had adjusted RRs greater than or equal to 2, suggesting strong associations with injury. The identified signals may represent antidepressant 3DIs of potential clinical concern and warrant future etiologic studies to test these hypotheses.
Collapse
Affiliation(s)
- Cheng Chen
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sean Hennessy
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Department of Systems Pharmacology and Translational Therapeutics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Colleen M. Brensinger
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Warren B. Bilker
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Department of Psychiatry, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA,Department of Epidemiology, School of Public HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Sophie P. Chung
- Epocrates Medical InformationAthenaHealth, Inc.WatertownMassachusettsUSA
| | - John R. Horn
- Department of Pharmacy, School of PharmacyUniversity of WashingtonSeattleWashingtonUSA
| | - Kacie F. Bogar
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Charles E. Leonard
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| |
Collapse
|
5
|
Chen C, Hennessy S, Brensinger CM, Dawwas GK, Acton EK, Bilker WB, Chung SP, Dublin S, Horn JR, Miano TA, Pham Nguyen TP, Soprano SE, Leonard CE. Skeletal muscle relaxant drug-drug-drug interactions and unintentional traumatic injury: Screening to detect three-way drug interaction signals. Br J Clin Pharmacol 2022; 88:4773-4783. [PMID: 35562168 PMCID: PMC9560998 DOI: 10.1111/bcp.15395] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/27/2022] Open
Abstract
AIM The aim of this study was to identify skeletal muscle relaxant (SMR) drug-drug-drug interaction (3DI) signals associated with increased rates of unintentional traumatic injury. METHODS We conducted automated high-throughput pharmacoepidemiologic screening of 2000-2019 healthcare data for members of United States commercial and Medicare Advantage health plans. We performed a self-controlled case series study for each drug triad consisting of an SMR base-pair (i.e., concomitant use of an SMR with another medication), and a co-dispensed medication (i.e., candidate interacting precipitant) taken during ongoing use of the base-pair. We included patients aged ≥16 years with an injury occurring during base-pair-exposed observation time. We used conditional Poisson regression to calculate adjusted rate ratios (RRs) with 95% confidence intervals (CIs) for injury with each SMR base-pair + candidate interacting precipitant (i.e., triad) versus the SMR-containing base-pair alone. RESULTS Among 58 478 triads, 29 were significantly positively associated with injury; confounder-adjusted RRs ranged from 1.39 (95% CI = 1.01-1.91) for tizanidine + omeprazole with gabapentin to 2.23 (95% CI = 1.02-4.87) for tizanidine + diclofenac with alprazolam. Most identified 3DI signals are new and have not been formally investigated. CONCLUSION We identified 29 SMR 3DI signals associated with increased rates of injury. Future aetiologic studies should confirm or refute these SMR 3DI signals.
Collapse
Affiliation(s)
- Cheng Chen
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Colleen M. Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Ghadeer K. Dawwas
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
| | - Emily K. Acton
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Warren B. Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | | | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute (Seattle, WA, US)
- Department of Epidemiology, School of Public Health, University of Washington (Seattle, WA, US)
| | - John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington (Seattle, WA, US)
| | - Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Thanh Phuong Pham Nguyen
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Samantha E. Soprano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
| |
Collapse
|
6
|
Nguyen TPP, Soprano SE, Hennessy S, Brensinger CM, Bilker WB, Miano TA, Acton EK, Horn JR, Chung SP, Dublin S, Oslin DW, Wiebe DJ, Leonard CE. Population-based signals of benzodiazepine drug interactions associated with unintentional traumatic injury. J Psychiatr Res 2022; 151:299-303. [PMID: 35526445 PMCID: PMC9513701 DOI: 10.1016/j.jpsychires.2022.04.033] [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: 12/16/2021] [Revised: 04/19/2022] [Accepted: 04/25/2022] [Indexed: 10/18/2022]
Abstract
Benzodiazepine receptor agonists and related medications, such as Z-drugs and dual orexin receptor antagonists (BZDs), have been associated with unintentional traumatic injury due to their central nervous system (CNS)-depressant effects. Drug-drug interactions (DDIs) may contribute to the known relationship between BZD use and unintentional traumatic injury, yet evidence is still lacking. We conducted high-throughput pharmacoepidemiologic screening using the self-controlled case series design in a large US commercial health insurance database to identify potentially clinically relevant DDI signals among new users of BZDs. We used conditional Poisson regression to estimate rate ratios (RRs) between each co-exposure (vs. not) and unintentional traumatic injury (primary outcome), typical hip fracture (secondary outcome), and motor vehicle crash (secondary outcome). We identified 48 potential DDI signals (1.1%, involving 39 unique co-dispensed drugs), i.e., with statistically significant elevated adjusted RRs for injury. Signals were strongest for DDI pairs involving zolpidem, lorazepam, temazepam, alprazolam, eszopiclone, triazolam, and clonazepam. We also identified four potential DDI signals for typical hip fracture, but none for motor vehicle crash. Many signals have biologically plausible explanations through additive or synergistic pharmacodynamic effects of co-dispensed antidepressants, opioids, or muscle relaxants on CNS depression, impaired psychomotor and cognitive function, and/or somnolence. While other signals that lack an obvious mechanism may represent true associations that place patients at risk of injury, it is also prudent to consider the roles of chance, reverse causation, and/or confounding by indication, which merit further exploration. Given the high-throughput nature of our investigation, findings should be interpreted as hypothesis generating.
Collapse
Affiliation(s)
- Thanh Phuong Pham Nguyen
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US),Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Samantha E. Soprano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US),Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US),Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US),Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US),Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
| | - Colleen M. Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US),Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Warren B. Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US),Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US),Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US),Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Emily K. Acton
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US),Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US),Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington (Seattle, WA, US)
| | | | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington (Seattle, WA, US),Department of Epidemiology, School of Public Health, University of Washington (Seattle, WA, US)
| | - David W. Oslin
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US),Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US),Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Administration Medical Center (Philadelphia, PA, US)
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US),Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US),Penn Injury Science Center, University of Pennsylvania (Philadelphia, PA, US)
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US),Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US),Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
| |
Collapse
|
7
|
Villa Zapata L, Subbian V, Boyce RD, Hansten PD, Horn JR, Gephart SM, Romero A, Malone DC. Overriding Drug-Drug Interaction Alerts in Clinical Decision Support Systems: A Scoping Review. Stud Health Technol Inform 2022; 290:380-384. [PMID: 35673040 DOI: 10.3233/shti220101] [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] [Indexed: 06/15/2023]
Abstract
Ineffective computerized alerts for potential Drug-Drug Interactions (DDI) is a longstanding informatics issue. Prescribing clinicians often ignore or override such alerts due to lack of context and clinical relevance, among various other reasons. In this study, we reveiwed published data on the rate of DDI alert overrides and medications involved in the overrides. We identified 34 eligible studies from sites across Asia, Europe, the United States, and the United Kingdom. The override rate of DDI alerts ranged from 55% to 98%, with more than half of the studies reporting the most common drug pairs or medications involved in acceptance or overriding of alerts. The high prevalance of alert overrides highlights the need for decision support systems that take user, drug, and institutional factors into consideration, as well as actionable metrics to better characterize harm associated with overrides.
Collapse
Affiliation(s)
- Lorenzo Villa Zapata
- Department of Pharmacy Practice, College of Pharmacy, Mercer University, Atlanta, Georgia, USA
| | - Vignesh Subbian
- College of Engineering, The University of Arizona, Tucson, Arizona, USA
| | - Richard D Boyce
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip D Hansten
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - John R Horn
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Sheila M Gephart
- College of Nursing, The University of Arizona, Tucson, Arizona, USA
| | - Andrew Romero
- Department of Pharmacy, Banner University Medical Center, Tucson, Arizona, USA
| | - Daniel C Malone
- College of Pharmacy, L.S. Skaggs Research Institute, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
8
|
Villa Zapata L, Boyce RD, Chou E, Hansten PD, Horn JR, Gephart SM, Subbian V, Romero A, Malone DC. QTc Prolongation with the Use of Hydroxychloroquine and Concomitant Arrhythmogenic Medications: A Retrospective Study Using Electronic Health Records Data. Drugs Real World Outcomes 2022; 9:415-423. [PMID: 35665910 PMCID: PMC9167427 DOI: 10.1007/s40801-022-00307-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Hydroxychloroquine can induce QT/QTc interval prolongation for some patients; however, little is known about its interactions with other QT-prolonging drugs. Objective The purpose of this retrospective electronic health records study was to evaluate changes in the QTc interval in patients taking hydroxychloroquine with or without concomitant QT-prolonging medications. Methods De-identified health records were obtained from the Cerner Health Facts® database. Variables of interest included demographics, diagnoses, clinical procedures, laboratory tests, and medications. Patients were categorized into six cohorts based on exposure to hydroxychloroquine, methotrexate, or sulfasalazine alone, or the combination of any those drugs with any concomitant drug known to prolong the QT interval. Tisdale QTc risk score was calculated for each patient cohort. Two-sample paired t-tests were used to test differences between the mean before and after QTc measurements within each group and ANOVA was used to test for significant differences across the cohort means. Results A statistically significant increase in QTc interval from the last measurement prior to concomitant exposure of 18.0 ms (95% CI 3.5–32.5; p < 0.05) was found in the hydroxychloroquine monotherapy cohort. QTc changes varied considerably across cohorts, with standard deviations ranging from 40.9 (hydroxychloroquine monotherapy) to 57.8 (hydroxychloroquine + sulfasalazine). There was no difference in QTc measurements among cohorts. The hydroxychloroquine + QTc-prolonging agent cohort had the highest average Tisdale Risk Score compared with those without concomitant exposure (p < 0.05). Conclusion Our analysis of retrospective electronic health records found hydroxychloroquine to be associated with a moderate increase in the QTc interval compared with sulfasalazine or methotrexate. However, the QTc was not significantly increased with concomitant exposure to other drugs known to increase QTc interval.
Collapse
Affiliation(s)
- Lorenzo Villa Zapata
- Department of Pharmacy Practice, College of Pharmacy, Mercer University, Atlanta, GA, USA
| | - Richard D Boyce
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, The Offices@Baum, 5607 Baum Blvd, Pittsburgh, PA, 15202, USA.
| | - Eric Chou
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, The Offices@Baum, 5607 Baum Blvd, Pittsburgh, PA, 15202, USA
| | | | - John R Horn
- Department of Pharmacy Practice, School of Pharmacy and Pharmacy Services UW Medicine, University of Washington, Seattle, WA, USA
| | - Sheila M Gephart
- Community and Health Systems Science, College of Nursing, The University of Arizona, Tucson, AZ, USA
| | - Vignesh Subbian
- Department of Biomedical Engineering and Department of Systems and Industrial Engineering, College of Engineering, The University of Arizona, Tucson, AZ, USA
| | - Andrew Romero
- Department of Pharmacy, Banner University Medical Center, Tucson, AZ, USA
| | - Daniel C Malone
- College of Pharmacy, L.S. Skaggs Research Institute, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
9
|
Acton EK, Hennessy S, Brensinger CM, Bilker WB, Miano TA, Dublin S, Horn JR, Chung S, Wiebe DJ, Willis AW, Leonard CE. Opioid Drug-Drug-Drug Interactions and Unintentional Traumatic Injury: Screening to Detect Three-Way Drug Interaction Signals. Front Pharmacol 2022; 13:845485. [PMID: 35620282 PMCID: PMC9127150 DOI: 10.3389/fphar.2022.845485] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/18/2022] [Indexed: 12/02/2022] Open
Abstract
Growing evidence suggests that drug interactions may be responsible for much of the known association between opioid use and unintentional traumatic injury. While prior research has focused on pairwise drug interactions, the role of higher-order (i.e., drug-drug-drug) interactions (3DIs) has not been examined. We aimed to identify signals of opioid 3DIs with commonly co-dispensed medications leading to unintentional traumatic injury, using semi-automated high-throughput screening of US commercial health insurance data. We conducted bi-directional, self-controlled case series studies using 2000-2015 Optum Data Mart database. Rates of unintentional traumatic injury were examined in individuals dispensed opioid-precipitant base pairs during time exposed vs unexposed to a candidate interacting precipitant. Underlying cohorts consisted of 16-90-year-olds with new use of opioid-precipitant base pairs and ≥1 injury during observation periods. We used conditional Poisson regression to estimate rate ratios adjusted for time-varying confounders, and semi-Bayes shrinkage to address multiple estimation. For hydrocodone, tramadol, and oxycodone (the most commonly used opioids), we examined 16,024, 8185, and 9330 drug triplets, respectively. Among these, 75 (0.5%; hydrocodone), 57 (0.7%; tramadol), and 42 (0.5%; oxycodone) were significantly positively associated with unintentional traumatic injury (50 unique base precipitants, 34 unique candidate precipitants) and therefore deemed potential 3DI signals. The signals found in this study provide valuable foundations for future research into opioid 3DIs, generating hypotheses to motivate crucially needed etiologic investigations. Further, this study applies a novel approach for 3DI signal detection using pharmacoepidemiologic screening of health insurance data, which could have broad applicability across drug classes and databases.
Collapse
Affiliation(s)
- Emily K. Acton
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Colleen M. Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Warren B. Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, United States
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States
| | - John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Sophie Chung
- AthenaHealth, Inc., Watertown, MA, United States
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, United States
| | - Allison W. Willis
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
10
|
Dawwas GK, Hennessy S, Brensinger CM, Acton EK, Bilker WB, Chung S, Dublin S, Horn JR, Manis MM, Miano TA, Oslin DW, Pham Nguyen TP, Soprano SE, Wiebe DJ, Leonard CE. Signals of Muscle Relaxant Drug Interactions Associated with Unintentional Traumatic Injury: A Population-Based Screening Study. CNS Drugs 2022; 36:389-400. [PMID: 35249204 PMCID: PMC9375100 DOI: 10.1007/s40263-022-00909-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Use of muscle relaxants is rapidly increasing in the USA. Little is understood about the role of drug interactions in the known association between muscle relaxants and unintentional traumatic injury, a clinically important endpoint causing substantial morbidity, disability, and death. OBJECTIVE We examined potential associations between concomitant drugs (i.e., precipitants) taken with muscle relaxants (affected drugs, i.e., objects) and hospital presentation for unintentional traumatic injury. METHODS In a series of self-controlled case series studies, we screened to identify drug interaction signals for muscle relaxant + precipitant pairs and unintentional traumatic injury. We used Optum's de-identified Clinformatics® Data Mart Database, 2000-2019. We included new users of a muscle relaxant, aged 16-90 years, who were dispensed at least one precipitant drug and experienced an unintentional traumatic injury during the observation period. We classified each observation day as precipitant exposed or precipitant unexposed. The outcome was an emergency department or inpatient discharge diagnosis for unintentional traumatic injury. We used conditional Poisson regression to estimate rate ratios adjusting for time-varying confounders and then accounted for multiple estimation via semi-Bayes shrinkage. RESULTS We identified 74,657 people who initiated muscle relaxants and experienced an unintentional traumatic injury, in whom we studied concomitant use of 2543 muscle relaxant + precipitant pairs. After adjusting for time-varying confounders, 16 (0.6%) pairs were statistically significantly and positively associated with injury, and therefore deemed signals of a potential drug interaction. Among signals, semi-Bayes shrunk, confounder-adjusted rate ratios ranged from 1.29 (95% confidence interval 1.04-1.62) for baclofen + sertraline to 2.28 (95% confidence interval 1.14-4.55) for methocarbamol + lamotrigine. CONCLUSIONS Using real-world data, we identified several new signals of potential muscle relaxant drug interactions associated with unintentional traumatic injury. Only one among 16 signals is currently reported in a major drug interaction knowledge base. Future studies should seek to confirm or refute these signals.
Collapse
Affiliation(s)
- Ghadeer K. Dawwas
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA,Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen M. Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily K. Acton
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Warren B. Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA,Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Melanie M. Manis
- Department of Pharmacy Practice, McWhorter School of Pharmacy, Samford University, Birmingham, AL, USA
| | - Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David W. Oslin
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA, USA
| | - Thanh Phuong Pham Nguyen
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Samantha E. Soprano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA,Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
11
|
Villa Zapata L, Hansten PD, Horn JR, Boyce RD, Gephart S, Subbian V, Romero A, Malone DC. Evidence of Clinically Meaningful Drug-Drug Interaction With Concomitant Use of Colchicine and Clarithromycin. Drug Saf 2021; 43:661-668. [PMID: 32274687 DOI: 10.1007/s40264-020-00930-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Colchicine is currently approved for the treatment of gout and familial Mediterranean fever, among other conditions. Clarithromycin, a strong inhibitor of CYP3A4 and P-glycoprotein, dramatically increases colchicine's half-life, augmenting the risk of a life-threatening adverse reaction when used inadvertently with colchicine. OBJECTIVES The aim of this study was to examine the evidence and clinical implications of concomitant use of colchicine and clarithromycin. METHODS Case reports of colchicine-clarithromycin co-administration were searched using the FDA's Adverse Event Reporting System (FAERS) database. PubMed, EMBASE, and Web of Science electronic databases were also searched from January 2005 through November 2019 for articles reporting colchicine-clarithromycin concomitant use. Individual reports were reviewed to identify consequences of coadministration, dose, days to onset of interaction, symptoms, evidence of renal disease, time to resolution of symptoms, and Drug Interaction Probability Scale (DIPS) rating. RESULTS The FAERS search identified 58 reported cases, nearly 53% of which were from patients aged between 65 and 85 years. Of 30 reported deaths, 11 occurred in males, and 19 in females. Other frequent complications reported in FAERS included diarrhea (31%), pancytopenia (22%), bone marrow failure (14%), and vomiting (14%). From published literature, we identified 20 case reports of concomitant exposure, 19 of which were rated 'probable' and one 'possible' according to DIPS rating. Of these cases, four 'probable' patients expired. The documented onset of colchicine toxicity occurred within 5 days of starting clarithromycin, and death within 2 weeks of concomitant exposure. CONCLUSION Clinical manifestations of colchicine-clarithromycin interaction may resemble other systemic diseases and may be life threatening. Understanding this clinically meaningful interaction can help clinicians avoid unsafe medication combinations.
Collapse
Affiliation(s)
- Lorenzo Villa Zapata
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Center for Pharmaceutical Outcomes Research, University of Colorado, Aurora, CO, USA
| | | | - John R Horn
- Department of Pharmacy Practice, School of Pharmacy and Associate Director, Pharmacy Services UW Medicine, University of Washington, Seattle, WA, USA
| | - Richard D Boyce
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sheila Gephart
- Community and Health Systems Science, College of Nursing, The University of Arizona, Tucson, AZ, USA
| | - Vignesh Subbian
- Department of Biomedical Engineering and Department of Systems and Industrial Engineering, College of Engineering, The University of Arizona, Tucson, AZ, USA
| | - Andrew Romero
- Department of Pharmacy, Banner University Medical Center, Tucson, AZ, USA
| | - Daniel C Malone
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA.
| |
Collapse
|
12
|
Leonard CE, Brensinger CM, Acton EK, Miano TA, Dawwas GK, Horn JR, Chung S, Bilker WB, Dublin S, Soprano SE, Phuong Pham Nguyen T, Manis MM, Oslin DW, Wiebe DJ, Hennessy S. Population-Based Signals of Antidepressant Drug Interactions Associated With Unintentional Traumatic Injury. Clin Pharmacol Ther 2021; 110:409-423. [PMID: 33559153 PMCID: PMC8316258 DOI: 10.1002/cpt.2195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 10/22/2020] [Accepted: 01/14/2021] [Indexed: 11/11/2022]
Abstract
Antidepressants are very widely used and associated with traumatic injury, yet little is known about their potential for harmful drug interactions. We aimed to identify potential drug interaction signals by assessing concomitant medications (precipitant drugs) taken with individual antidepressants (object drugs) that were associated with unintentional traumatic injury. We conducted pharmacoepidemiologic screening of 2000-2015 Optum Clinformatics data, identifying drug interaction signals by performing self-controlled case series studies for antidepressant + precipitant pairs and injury. We included persons aged 16-90 years codispensed an antidepressant and ≥ 1 precipitant drug(s), with an injury during antidepressant therapy. We classified antidepressant person-days as either precipitant-exposed or precipitant-unexposed. The outcome was an emergency department or inpatient discharge diagnosis for unintentional traumatic injury. We used conditional Poisson regression to calculate confounder adjusted rate ratios (RRs) and accounted for multiple estimation via semi-Bayes shrinkage. We identified 330,884 new users of antidepressants who experienced an injury. Among such persons, we studied concomitant use of 7,953 antidepressant + precipitant pairs. Two hundred fifty-six (3.2%) pairs were positively associated with injury and deemed potential drug interaction signals; 22 of these signals had adjusted RRs > 2.00. Adjusted RRs ranged from 1.06 (95% confidence interval: 1.00-1.12, P = 0.04) for citalopram + gabapentin to 3.06 (1.42-6.60) for nefazodone + levonorgestrel. Sixty-five (25.4%) signals are currently reported in a seminal drug interaction knowledgebase. We identified numerous new population-based signals of antidepressant drug interactions associated with unintentional traumatic injury. Future studies, intended to test hypotheses, should confirm or refute these potential interactions.
Collapse
Affiliation(s)
- Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Center for Therapeutic Effectiveness Research, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
| | - Colleen M. Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Emily K. Acton
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Ghadeer K. Dawwas
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
| | - John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington (Seattle, WA, US)
| | | | - Warren B. Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute (Seattle, WA, US)
- Department of Epidemiology, School of Public Health, University of Washington (Seattle, WA, US)
| | - Samantha E. Soprano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Thanh Phuong Pham Nguyen
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Melanie M. Manis
- Department of Pharmacy Practice, McWhorter School of Pharmacy, Samford University (Birmingham, AL, US)
| | - David W. Oslin
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Administration Medical Center (Philadelphia, PA, US)
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
- Penn Injury Science Center, University of Pennsylvania (Philadelphia, PA, US)
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Center for Therapeutic Effectiveness Research, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| |
Collapse
|
13
|
Villa-Zapata L, Carhart BS, Horn JR, Hansten PD, Subbian V, Gephart S, Tan M, Romero A, Malone DC. Serum potassium changes due to concomitant ACEI/ARB and spironolactone therapy: A systematic review and meta-analysis. Am J Health Syst Pharm 2021; 78:2245-2255. [PMID: 34013341 PMCID: PMC8194784 DOI: 10.1093/ajhp/zxab215] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To provide evidence of serum potassium changes in individuals taking angiotensin-converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs) concomitantly with spironolactone compared to ACEI/ARB therapy alone. Methods PubMed, Embase, Scopus, and Web of Science were searched for studies including exposure to both spironolactone and ACEI/ARB therapy compared to ACEI/ARB therapy alone. The primary outcome was serum potassium change over time. Main effects were calculated to estimate average treatment effect using random effects models. Heterogeneity was assessed using Cochran’s Q and I 2. Risk of bias was assessed using the revised Cochrane risk of bias tool. Results From the total of 1,225 articles identified, 20 randomized controlled studies were included in the meta-analysis. The spironolactone plus ACEI/ARB group included 570 patients, while the ACEI/ARB group included 547 patients. Treatment with spironolactone and ACEI/ARB combination therapy compared to ACEI/ARB therapy alone increased the mean serum potassium concentration by 0.19 mEq/L (95% CI, 0.12-0.26 mEq/L), with intermediate heterogeneity across studies (Q statistic = 46.5, P = 0.004; I 2 = 59). Sensitivity analyses showed that the direction and magnitude of this outcome did not change with the exclusion of individual studies, indicating a high level of reliability. Reporting risk of bias was low for 16 studies (80%), unclear for 3 studies (15%) and high for 1 study (5%). Conclusion Treatment with spironolactone in combination with ACEI/ARB therapy increases the mean serum potassium concentration by less than 0.20 mEq/L compared to ACEI/ARB therapy alone. However, serum potassium and renal function must be monitored in patients starting combination therapy to avoid changes in serum potassium that could lead to hyperkalemia.
Collapse
Affiliation(s)
- Lorenzo Villa-Zapata
- Department of Pharmacy Practice, College of Pharmacy, Mercer University, Atlanta, GA, USA
| | | | - John R Horn
- Department of Pharmacy Practice, School of Pharmacy, University of Washington, Seattle, WA, and Pharmacy Services, UW Medicine, Seattle, WA, USA
| | | | - Vignesh Subbian
- Department of Biomedical Engineering and Department of Systems & Industrial Engineering, College of Engineering, The University of Arizona, Tucson, AZ, USA
| | - Sheila Gephart
- Community and Health Systems Science, College of Nursing, The University of Arizona, Tucson, AZ, USA
| | - Malinda Tan
- College of Pharmacy, L.S. Skaggs Research Institute, University of Utah, Salt Lake City, UT, USA
| | - Andrew Romero
- Department of Pharmacy, Banner University Medical Center, Tucson, AZ, USA
| | - Daniel C Malone
- College of Pharmacy, L.S. Skaggs Research Institute, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
14
|
Rutman MP, Horn JR, Newman DK, Stefanacci RG. Overactive Bladder Prescribing Considerations: The Role of Polypharmacy, Anticholinergic Burden, and CYP2D6 Drug‒Drug Interactions. Clin Drug Investig 2021; 41:293-302. [PMID: 33713027 PMCID: PMC8004492 DOI: 10.1007/s40261-021-01020-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2021] [Indexed: 12/11/2022]
Abstract
Overactive bladder (OAB) is a common disorder in the general population, and the prevalence increases with age. Adults with OAB typically have a greater number of comorbid conditions, such as hypertension, depression, and dementia, compared with adults without OAB. Subsequent to an increased number of comorbidities, adults with OAB take a greater number of concomitant medications, which may increase the risk of potentially harmful drug‒drug interactions. There are two important considerations for many of the medications approved for the treatment of OAB in the USA: anticholinergic burden and potential for drug‒drug interactions, notably related to cytochrome P450 (CYP) 2D6, which is responsible for the metabolism of approximately 25% of all drugs. A substantial number of drugs used for the treatment of OAB and comorbid conditions (e.g., cardiovascular and neurologic disorders) are CYP2D6 substrates or inhibitors. Furthermore, a substantial number of drugs with CYP2D6 properties also have strong anticholinergic properties. Here, we review polypharmacy associated with OAB and its common comorbidities, identify drugs with reported anticholinergic properties, and provide an overview of clinically relevant drug‒drug interactions in the treatment of OAB as they relate to CYP2D6 metabolism. This review aims to provide clinicians with essential information necessary for making treatment decisions when managing OAB.
Collapse
Affiliation(s)
- Matthew P Rutman
- Columbia University, 11th Floor, HIP, 161 Ft. Washington Avenue, New York, NY, 10032, USA.
| | - John R Horn
- School of Pharmacy, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Diane K Newman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard G Stefanacci
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
15
|
Chou E, Boyce RD, Balkan B, Subbian V, Romero A, Hansten PD, Horn JR, Gephart S, Malone DC. Designing and evaluating contextualized drug-drug interaction algorithms. JAMIA Open 2021; 4:ooab023. [PMID: 33763631 PMCID: PMC7976224 DOI: 10.1093/jamiaopen/ooab023] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 01/28/2021] [Accepted: 03/09/2021] [Indexed: 11/12/2022] Open
Abstract
Objective Alert fatigue is a common issue with off-the-shelf clinical decision support. Most warnings for drug-drug interactions (DDIs) are overridden or ignored, likely because they lack relevance to the patient's clinical situation. Existing alerting systems for DDIs are often simplistic in nature or do not take the specific patient context into consideration, leading to overly sensitive alerts. The objective of this study is to develop, validate, and test DDI alert algorithms that take advantage of patient context available in electronic health records (EHRs) data. Methods Data on the rate at which DDI alerts were triggered but for which no action was taken over a 3-month period (override rates) from a single tertiary care facility were used to identify DDIs that were considered a high-priority for contextualized alerting. A panel of DDI experts developed algorithms that incorporate drug and patient characteristics that affect the relevance of such warnings. The algorithms were then implemented as computable artifacts, validated using a synthetic health records data, and tested over retrospective data from a single urban hospital. Results Algorithms and computable knowledge artifacts were developed and validated for a total of 8 high priority DDIs. Testing on retrospective real-world data showed the potential for the algorithms to reduce alerts that interrupt clinician workflow by more than 50%. Two algorithms (citalopram/QT interval prolonging agents, and fluconazole/opioid) showed potential to filter nearly all interruptive alerts for these combinations. Conclusion The 8 DDI algorithms are a step toward addressing a critical need for DDI alerts that are more specific to patient context than current commercial alerting systems. Data commonly available in EHRs can improve DDI alert specificity.
Collapse
Affiliation(s)
- Eric Chou
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Richard D Boyce
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Baran Balkan
- College of Engineering, University of Arizona, Tucson, Arizona, USA
| | - Vignesh Subbian
- College of Engineering, University of Arizona, Tucson, Arizona, USA
| | - Andrew Romero
- Banner University Medical Center, Tucson, Arizona, USA
| | - Philip D Hansten
- Department of Pharmacy, University of Washington, Seattle, Washington, USA
| | - John R Horn
- Department of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Sheila Gephart
- College of Nursing, University of Arizona, Tucson, Arizona, USA
| | - Daniel C Malone
- Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
16
|
Shah SN, Seger DL, Fiskio JM, Horn JR, Bates DW. Comparison of Medication Alerts from Two Commercial Applications in the USA. Drug Saf 2021; 44:661-668. [PMID: 33616888 PMCID: PMC8184526 DOI: 10.1007/s40264-021-01048-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/17/2022]
Abstract
Introduction Medication organizations across the USA have adopted electronic health records, and one of the most anticipated benefits of these was improved medication safety, but alert fatigue has been a major issue. Objective We compared the appropriateness of medication-related clinical decision support alerts triggered by two commercial applications: EPIC and Seegnal’s platform. Methods This was a retrospective comparison of two commercial applications. We provided Seegnal with deidentified inpatient, outpatient, and inpatient genetic electronic medical record (EMR)-extracted datasets for 657, 2731, and 413 patients, respectively. Seegnal then provided the alerts that would have triggered, which we compared with those triggered by EPIC in clinical care. A random sample of the alerts triggered were reviewed for appropriateness, and the positive predictive value (PPV) and negative predictive value (NPV) were calculated. We also reviewed all the inpatient and outpatient charts for patients within our cohort who were receiving ten or more concomitant medications with alerts we found to be appropriate to assess whether any adverse events had occurred and whether Seegnal’s platform could have prevented them. Results Results from EPIC and the Seegnal platform were compared based on alert load, PPV, NPV, and potential adverse events. Overall, compared with EPIC, the Seegnal platform triggered fewer alerts in the inpatient (1697 vs. 27,540), outpatient (2341 vs. 35,134), and inpatient genetic (1493 vs. 20,975) cohorts. The Seegnal platform had higher specificity in the inpatient (99 vs. 0.3%; p < 0.0001), outpatient (99 vs. 0.3%; p < 0.0001), and inpatient genetic (97.9 vs. 1.2%; p < 0.0001) groups and higher sensitivity in the inpatient (100 vs. 68.8%; p < 0.0001) and outpatient (88.6 vs.78.3%; p < 0.0001) groups but not in the inpatient genetic cohort (81 vs. 78.5%; p = 0.11). We identified 16 adverse events that occurred in the inpatient setting, 11 (69%) of which potentially could have been prevented with the Seegnal platform. Conclusions Overall, the Seegnal platform triggered 94% fewer alerts than EPIC in the inpatient setting and 93% fewer in the outpatient setting, with much higher sensitivity and specificity. This application could substantially reduce alert fatigue and improve medication safety at the same time. Supplementary Information The online version of this article (10.1007/s40264-021-01048-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sonam N Shah
- Department of General Internal Medicine, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, Office 103, Boston, MA, 02115, USA. .,Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.
| | - Diane L Seger
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, USA
| | - Julie M Fiskio
- Department of General Internal Medicine, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, Office 103, Boston, MA, 02115, USA
| | - John R Horn
- University of Washington Medicine Pharmacy Services, Seattle, WA, USA
| | - David W Bates
- Department of General Internal Medicine, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, Office 103, Boston, MA, 02115, USA.,Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, USA.,Harvard Medical School, Boston, MA, USA
| |
Collapse
|
17
|
Leonard CE, Brensinger CM, Pham Nguyen TP, Horn JR, Chung S, Bilker WB, Dublin S, Soprano SE, Dawwas GK, Oslin DW, Wiebe DJ, Hennessy S. Screening to identify signals of opioid drug interactions leading to unintentional traumatic injury. Biomed Pharmacother 2020; 130:110531. [PMID: 32739738 DOI: 10.1016/j.biopha.2020.110531] [Citation(s) in RCA: 12] [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] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/07/2020] [Accepted: 07/11/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Efforts to minimize harms from opioid drug interactions may be hampered by limited evidence on which drugs, when taken concomitantly with opioids, result in adverse clinical outcomes. OBJECTIVE To identify signals of opioid drug interactions by identifying concomitant medications (precipitant drugs) taken with individual opioids (object drugs) that are associated with unintentional traumatic injury DESIGN: We conducted pharmacoepidemiologic screening of Optum Clinformatics Data Mart, identifying drug interaction signals by performing confounder-adjusted self-controlled case series studies for opioid + precipitant pairs and injury. SETTING Beneficiaries of a major United States-based commercial health insurer during 2000-2015 PATIENTS: Persons aged 16-90 years co-dispensed an opioid and ≥1 precipitant drug(s), with an unintentional traumatic injury event during opioid therapy, as dictated by the case-only design EXPOSURE: Precipitant-exposed (vs. precipitant-unexposed) person-days during opioid therapy. OUTCOME Emergency department or inpatient International Classification of Diseases discharge diagnosis for unintentional traumatic injury. We used conditional Poisson regression to generate confounder adjusted rate ratios. We accounted for multiple estimation via semi-Bayes shrinkage. RESULTS We identified 25,019, 12,650, and 10,826 new users of hydrocodone, tramadol, and oxycodone who experienced an unintentional traumatic injury. Among 464, 376, and 389 hydrocodone-, tramadol-, and oxycodone-precipitant pairs examined, 20, 17, and 16 (i.e., 53 pairs, 34 unique precipitants) were positively associated with unintentional traumatic injury and deemed potential drug interaction signals. Adjusted rate ratios ranged from 1.23 (95 % confidence interval: 1.05-1.44) for hydrocodone + amoxicillin-clavulanate to 4.21 (1.88-9.42) for oxycodone + telmisartan. Twenty (37.7 %) of 53 signals are currently reported in a major drug interaction knowledgebase. LIMITATIONS Potential for reverse causation, confounding by indication, and chance CONCLUSIONS: We identified previously undescribed and/or unappreciated signals of opioid drug interactions associated with unintentional traumatic injury. Subsequent etiologic studies should confirm (or refute) and elucidate these potential drug interactions.
Collapse
Affiliation(s)
- Charles E Leonard
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Therapeutic Effectiveness Research, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Colleen M Brensinger
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Thanh Phuong Pham Nguyen
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - John R Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Sophie Chung
- AthenaHealth, Inc., Watertown, MA, United States
| | - Warren B Bilker
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States; Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States
| | - Samantha E Soprano
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Ghadeer K Dawwas
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - David W Oslin
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA, United States
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Injury Science Center, University of Pennsylvania, Philadelphia, PA, United States
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Therapeutic Effectiveness Research, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
18
|
Villa Zapata L, Hansten PD, Panic J, Horn JR, Boyce RD, Gephart S, Subbian V, Romero A, Malone DC. Risk of Bleeding with Exposure to Warfarin and Nonsteroidal Anti-Inflammatory Drugs: A Systematic Review and Meta-Analysis. Thromb Haemost 2020; 120:1066-1074. [PMID: 32455439 DOI: 10.1055/s-0040-1710592] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Warfarin use can trigger the occurrence of bleeding independently or as a result of a drug-drug interaction when used in combination with nonsteroidal anti-inflammatory drugs (NSAIDs). OBJECTIVES This article examines the risk of bleeding in individuals exposed to concomitant warfarin and NSAID compared with those taking warfarin alone (Prospero Registry ID 145237). METHODS PubMed, EMBASE, Scopus, and Web of Science were searched. The primary outcome of interest was gastrointestinal bleeding and general bleeding. Summary effects were calculated to estimate average treatment effect using random effects models. Heterogeneity was assessed using Cochran's Q and I 2. Risk of bias was also assessed using the Agency for Healthcare Research and Quality bias assessment tool. RESULTS A total of 651 studies were identified, of which 11 studies met inclusion criteria for meta-analysis. The odds ratio (OR) for gastrointestinal bleeding when exposed to warfarin and an NSAID was 1.98 (95% confidence interval [CI]: 1.55-2.53). The risk of gastrointestinal bleeding was also significantly elevated with exposure to a COX-2 inhibitor and warfarin relative to warfarin alone (OR = 1.90, 95% CI: 1.46-2.46). There was an increased risk of general bleeding with the combination of warfarin with NSAIDs (OR = 1.58, 95% CI: 1.18-2.12) or COX-2 inhibitors (OR = 1.54, 95% CI: 0.86-2.78) compared with warfarin alone. CONCLUSION Risk of bleeding is significantly increased among persons taking warfarin and a NSAID or COX-2 inhibitor together as compared with taking warfarin alone. It is important to caution patients about taking these medications in combination.
Collapse
Affiliation(s)
- Lorenzo Villa Zapata
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Center for Pharmaceutical Outcomes Research, University of Colorado, Denver, Colorado, United States
| | - Philip D Hansten
- School of Pharmacy, University of Washington, Seattle, Washington, United States
| | - Jennifer Panic
- Marshfield Clinic Health System, Marshfield, Wisconsin, United States
| | - John R Horn
- Department of Pharmacy Practice, School of Pharmacy, Pharmacy Services UW Medicine, University of Washington, Seattle, Washington, United States
| | - Richard D Boyce
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Sheila Gephart
- Community and Health Systems Science, College of Nursing, The University of Arizona, Tucson, Arizona, United States
| | - Vignesh Subbian
- Department of Biomedical Engineering, College of Engineering, The University of Arizona, Tucson, Arizona, United States
| | - Andrew Romero
- Department of Pharmacy, Banner-University Medical Center Tucson, Tucson, Arizona, United States
| | - Daniel C Malone
- College of Pharmacy, L. S. Skaggs Research Institute, University of Utah, Salt Lake City, Utah, United States
| |
Collapse
|
19
|
Chen KF, Chan LN, Senn TD, Oelschlager BK, Flum DR, Shen DD, Horn JR, Lin YS. The Impact of Proximal Roux-en-Y Gastric Bypass Surgery on Acetaminophen Absorption and Metabolism. Pharmacotherapy 2020; 40:191-203. [PMID: 31960977 DOI: 10.1002/phar.2368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Indexed: 12/20/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGBS), a surgery that creates a smaller stomach pouch and reduces the length of small intestine, is one of the most common medical interventions for the treatment of obesity. AIM The aim of this study was to determine how RYGBS affects the absorption and metabolism of acetaminophen. MATERIALS AND METHODS Ten morbidly obese patients received 1.5 g of liquid acetaminophen (APAP) orally on three separate pharmacokinetic study days (i.e., pre-RYGBS baseline and 3 and 12 months post-RYGBS). Plasma was collected at pre-specified timepoints over 24 hours, and the samples were analyzed using liquid chromatography-mass spectrometry for APAP, APAPglucuronide (APAP-gluc), APAP-sulfate (APAP-sulf), APAP-cysteine (APAP-cys), and APAP-Nacetylcysteine (APAP-nac). RESULT Following RYGBS, peak APAP concentrations at the 3-month and 12-month visits increased by 2.0-fold compared to baseline (p=0.0039 and p=0.0078, respectively) and the median time to peak concentration decreased from 35 to 10 minutes. In contrast, peak concentrations of APAP-gluc, APAP-sulf, APAP-cys, and APAP-nac were unchanged following RYGBS. The apparent oral clearance of APAP and the ratios of metabolite area under the curve (AUC)-to-APAP AUC for all four metabolites decreased at 3 and 12 months post-RYGBS compared to the presurgical baseline. In a simulation of expected steady-state plasma concentrations following multiple dosing of 650 mg APAP every 4 hours, post-RYGBS patients had higher steady-state peak APAP concentrations compared to healthy individuals and obese pre-RYGBS patients, though APAP exposure was unchanged compared to healthy individuals. CONCLUSION Following RYGBS, the rate and extent of APAP absorption increased and decreased formation of APAP metabolites was observed, possibly due to downregulation of Phase II and cytochrome P450 2E1 enzymes.
Collapse
Affiliation(s)
- Kuan-Fu Chen
- Department of Pharmaceutics, University of Washington, Seattle, Washington
| | | | - Taurence D Senn
- Department of Medicinal Chemistry, University of Washington, Seattle, Washington
| | | | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington
| | - Danny D Shen
- Department of Pharmaceutics, University of Washington, Seattle, Washington
| | - John R Horn
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Yvonne S Lin
- Department of Pharmaceutics, University of Washington, Seattle, Washington
| |
Collapse
|
20
|
Clark NP, Hoang K, Delate T, Horn JR, Witt DM. Warfarin Interaction With Hepatic Cytochrome P-450 Enzyme-Inducing Anticonvulsants. Clin Appl Thromb Hemost 2017; 24:172-178. [PMID: 28118749 DOI: 10.1177/1076029616687849] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 11/16/2022] Open
Abstract
Initiation of cytochrome P-450 (CYP)-inducing anticonvulsant medications during warfarin therapy may decrease anticoagulant effect and necessitate frequent warfarin dose adjustments to maintain therapeutic response measured by the international normalized ratio (INR). Clinical information regarding interactions between warfarin and these medications is limited. This study investigated warfarin dose and INR response following CYP-inducing anticonvulsant initiation among chronic warfarin users. This retrospective, pre-post study included patients ≥18 years who were receiving chronic warfarin therapy and who initiated carbamazepine, oxcarbazepine, phenobarbital, or phenytoin between January 1, 2006, and December 31, 2013. Mean weekly warfarin dose/INR ratio and mean weekly warfarin dose were compared in the 90 days pre- and days post-anticonvulsant initiation periods. Of the 57 included patients, 34 (60%), 15 (26%), 6 (11%), and 2 (3%) patients purchased a prescription for carbamazepine, phenytoin, oxcarbazepine, and phenobarbital, respectively. Mean age was 70 years, 59% were female, and the majority were receiving chronic warfarin therapy for atrial fibrillation (39%) or venous thromboembolism (26%). The ratio of mean warfarin dose and INR increased significantly between the pre- and post-anticonvulsant initiation periods (from 13 mg/INR to 18 mg/INR, respectively, P ≤ .001) as did the mean weekly warfarin dose (from 33 mg to 37 mg, P = <.001). Warfarin dose and dose/INR ratio significantly increased after carbamazepine initiation (both P < .001), while oxcarbazepine, phenobarbital, and phenytoin initiation did not significantly affect warfarin dosing. Our results support the presence of a clinically meaningful interaction between warfarin and carbamazepine. Frequent INR monitoring and warfarin dose escalation are recommended in this setting.
Collapse
Affiliation(s)
- Nathan P Clark
- 1 Kaiser Permanente Colorado, Aurora, CO, USA.,2 University of Colorado Denver Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kim Hoang
- 3 Evans Army Community Hospital, Fort Carson, CO, USA
| | - Thomas Delate
- 1 Kaiser Permanente Colorado, Aurora, CO, USA.,2 University of Colorado Denver Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - John R Horn
- 4 University of Washington School of Pharmacy, Seattle, WA, USA
| | - Daniel M Witt
- 5 University of Utah College of Pharmacy, Salt Lake City, UT, USA
| |
Collapse
|
21
|
Abstract
The assessment of causation for a potential drug interaction requires thoughtful consideration of the properties of both the object and precipitant drugs, patient-specific factors, and the possible contribution of other drugs that the patient may be taking. The Naranjo nomogram was designed to evaluate single-drug adverse events, not drug–drug interactions. Several of the questions on the Naranjo nomogram do not apply to potential drug–drug interactions, while others do not specify object or precipitant drug. Nevertheless, it has been inappropriately used to evaluate drug–drug interactions. The Drug Interaction Probability Scale (DIPS) was developed to provide a guide to evaluating drug interaction causation in a specific patient. It is intended to be used to assist practitioners in the assessment of drug interaction–induced adverse outcomes. The DIPS uses a series of questions relating to the potential drug interaction to estimate a probability score. An accurate assessment using the DIPS requires knowledge of the pharmacologic properties of both the object and precipitant drugs. Inadequate knowledge of either the drugs involved or the basic mechanisms of interaction will be a limitation for some users. The DIPS can also serve as a guide in the preparation of articles describing case reports of drug interactions, as well as in the evaluation of published case reports.
Collapse
Affiliation(s)
- John R Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA 98195, USA.
| | | | | |
Collapse
|
22
|
Hochheiser H, Ning Y, Hernandez A, Horn JR, Jacobson R, Boyce RD. Using Nonexperts for Annotating Pharmacokinetic Drug-Drug Interaction Mentions in Product Labeling: A Feasibility Study. JMIR Res Protoc 2016; 5:e40. [PMID: 27066806 PMCID: PMC4844909 DOI: 10.2196/resprot.5028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 11/25/2015] [Accepted: 12/19/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Because vital details of potential pharmacokinetic drug-drug interactions are often described in free-text structured product labels, manual curation is a necessary but expensive step in the development of electronic drug-drug interaction information resources. The use of nonexperts to annotate potential drug-drug interaction (PDDI) mentions in drug product label annotation may be a means of lessening the burden of manual curation. OBJECTIVE Our goal was to explore the practicality of using nonexpert participants to annotate drug-drug interaction descriptions from structured product labels. By presenting annotation tasks to both pharmacy experts and relatively naïve participants, we hoped to demonstrate the feasibility of using nonexpert annotators for drug-drug information annotation. We were also interested in exploring whether and to what extent natural language processing (NLP) preannotation helped improve task completion time, accuracy, and subjective satisfaction. METHODS Two experts and 4 nonexperts were asked to annotate 208 structured product label sections under 4 conditions completed sequentially: (1) no NLP assistance, (2) preannotation of drug mentions, (3) preannotation of drug mentions and PDDIs, and (4) a repeat of the no-annotation condition. Results were evaluated within the 2 groups and relative to an existing gold standard. Participants were asked to provide reports on the time required to complete tasks and their perceptions of task difficulty. RESULTS One of the experts and 3 of the nonexperts completed all tasks. Annotation results from the nonexpert group were relatively strong in every scenario and better than the performance of the NLP pipeline. The expert and 2 of the nonexperts were able to complete most tasks in less than 3 hours. Usability perceptions were generally positive (3.67 for expert, mean of 3.33 for nonexperts). CONCLUSIONS The results suggest that nonexpert annotation might be a feasible option for comprehensive labeling of annotated PDDIs across a broader range of drug product labels. Preannotation of drug mentions may ease the annotation task. However, preannotation of PDDIs, as operationalized in this study, presented the participants with difficulties. Future work should test if these issues can be addressed by the use of better performing NLP and a different approach to presenting the PDDI preannotations to users during the annotation workflow.
Collapse
Affiliation(s)
- Harry Hochheiser
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| | | | | | | | | | | |
Collapse
|
23
|
Scheife RT, Hines LE, Boyce RD, Chung SP, Momper JD, Sommer CD, Abernethy DR, Horn JR, Sklar SJ, Wong SK, Jones G, Brown ML, Grizzle AJ, Comes S, Wilkins TL, Borst C, Wittie MA, Malone DC. Consensus recommendations for systematic evaluation of drug-drug interaction evidence for clinical decision support. Drug Saf 2015; 38:197-206. [PMID: 25556085 DOI: 10.1007/s40264-014-0262-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Healthcare organizations, compendia, and drug knowledgebase vendors use varying methods to evaluate and synthesize evidence on drug-drug interactions (DDIs). This situation has a negative effect on electronic prescribing and medication information systems that warn clinicians of potentially harmful medication combinations. OBJECTIVE The aim of this study was to provide recommendations for systematic evaluation of evidence for DDIs from the scientific literature, drug product labeling, and regulatory documents. METHODS A conference series was conducted to develop a structured process to improve the quality of DDI alerting systems. Three expert workgroups were assembled to address the goals of the conference. The Evidence Workgroup consisted of 18 individuals with expertise in pharmacology, drug information, biomedical informatics, and clinical decision support. Workgroup members met via webinar 12 times from January 2013 to February 2014. Two in-person meetings were conducted in May and September 2013 to reach consensus on recommendations. RESULTS We developed expert consensus answers to the following three key questions. (i) What is the best approach to evaluate DDI evidence? (ii) What evidence is required for a DDI to be applicable to an entire class of drugs? (iii) How should a structured evaluation process be vetted and validated? CONCLUSION Evidence-based decision support for DDIs requires consistent application of transparent and systematic methods to evaluate the evidence. Drug compendia and clinical decision support systems in which these recommendations are implemented should be able to provide higher-quality information about DDIs.
Collapse
|
24
|
Chan LN, Lin YS, Tay-Sontheimer JC, Trawick D, Oelschlager BK, Flum DR, Patton KK, Shen DD, Horn JR. Proximal Roux-en-Y gastric bypass alters drug absorption pattern but not systemic exposure of CYP3A4 and P-glycoprotein substrates. Pharmacotherapy 2015; 35:361-9. [PMID: 25757445 DOI: 10.1002/phar.1560] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 12/26/2022]
Abstract
STUDY OBJECTIVES To evaluate the effect of Roux-en-Y gastric bypass surgery (RYGB) on the pharmacokinetics of midazolam (a CYP3A4 substrate) and digoxin (a P-glycoprotein substrate). DESIGN Prospective, nonblinded, longitudinal, single-dose pharmacokinetic study in three phases: presurgery baseline and postoperative assessments at 3 and 12 months. PATIENTS Twelve obese patients meeting current standards for bariatric surgery. MEASUREMENTS AND MAIN RESULTS At each study visit, patients received a single dose of oral digoxin and midazolam at 8 a.m. Blood samples were collected at regular intervals for 24 hours after dosing. Continuous 12-lead electrocardiogram (EKG), heart rate, blood pressure, and respiratory rate were monitored, and pharmacokinetic parameters from the three visits were compared. The peak plasma concentration (Cmax ) of midazolam increased by 66% and 71% at 3- and 12-month post-RYGB (p=0.017 and p=0.001, respectively), whereas the median time to peak concentration (Tmax ) was reduced by 50%. The mean Cmax for 1'-hydroxymidazolam increased by 87% and 80% at 3 and 12 months (p=0.001 and p<0.001, respectively). However, neither the area under the concentration-time curve (AUC) for midazolam nor the metabolite-to-parent AUC ratio changed significantly over time. For digoxin, the median Tmax decreased from 40 minutes at baseline to 30 and 20 minutes at 3 and 12 months, respectively. The mean AUC for digoxin, heart rate, and EKG patterns were similar across the three study phases. CONCLUSION Contemporary proximal RYGB increases the rate of drug absorption without significantly changing the overall exposure to midazolam and digoxin. The Cmax of a CYP3A4 substrate with a high extraction ratio was substantially increased after RYGB.
Collapse
Affiliation(s)
- Lingtak-Neander Chan
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Wood MD, Delate T, Clark M, Clark N, Horn JR, Witt DM. An evaluation of the potential drug interaction between warfarin and levothyroxine. J Thromb Haemost 2014; 12:1313-9. [PMID: 24913218 DOI: 10.1111/jth.12626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 05/26/2014] [Indexed: 08/31/2023]
Abstract
BACKGROUND Drug interaction references report that initiation of levothyroxine potentiates the effects of warfarin, and recommend more frequent International Normalized Ratio (INR) monitoring, but the mechanism is not well understood. OBJECTIVE To assess the impact of levothyroxine initiation on INR response. PATIENTS/METHODS A retrospective, self-controlled study was performed on patients aged ≥ 18 years receiving chronic warfarin therapy who were started on levothyroxine between 1 January 2006 and 30 June 2013, and who were followed for 90 days prior to and after levothyroxine initiation. The included patients had at least one elevated thyroid-stimulating hormone laboratory value in the pre-period, continuous warfarin therapy for 100 days prior to levothyroxine initiation, no purchases of medications known to interact with warfarin, no procedures requiring warfarin interruption, and no bleeding or thromboembolic event during the study period. The primary outcome was a comparison of the warfarin dose/INR ratio recorded before the initiation of levothyroxine with the ratio recorded during the post-period after two consecutive INRs with no warfarin dose change. RESULTS One hundred and two patients were included in the primary outcome. The mean warfarin dose/INR ratios in the pre-period and post-period were equivalent (P = 0.825). Although the mean warfarin dose was numerically lower in the post-period than in the pre-period, this difference did not reach statistical significance (P = 0.068). CONCLUSION No difference in the mean warfarin dose/INR ratio before and after initiation of levothyroxine was detected. The results suggest that there is not a clinically significant interaction between warfarin and levothyroxine, and so additional monitoring may not be necessary.
Collapse
Affiliation(s)
- M D Wood
- Kaiser Permanente Colorado, Aurora, CO, USA
| | | | | | | | | | | |
Collapse
|
26
|
Horn JR, Gumpper KF, Hardy JC, McDonnell PJ, Phansalkar S, Reilly C. Clinical decision support for drug-drug interactions: improvement needed. Am J Health Syst Pharm 2013; 70:905-9. [PMID: 23640353 DOI: 10.2146/ajhp120405] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- John R Horn
- School of Pharmacy, University of Washington Medicine, Seattle, WA 98195, USA.
| | | | | | | | | | | |
Collapse
|
27
|
Boyce RD, Horn JR, Hassanzadeh O, Waard AD, Schneider J, Luciano JS, Rastegar-Mojarad M, Liakata M. Dynamic enhancement of drug product labels to support drug safety, efficacy, and effectiveness. J Biomed Semantics 2013; 4:5. [PMID: 23351881 PMCID: PMC3698101 DOI: 10.1186/2041-1480-4-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [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: 03/27/2012] [Accepted: 12/27/2012] [Indexed: 12/04/2022] Open
Abstract
Out-of-date or incomplete drug product labeling information may increase the risk of otherwise preventable adverse drug events. In recognition of these concerns, the United States Federal Drug Administration (FDA) requires drug product labels to include specific information. Unfortunately, several studies have found that drug product labeling fails to keep current with the scientific literature. We present a novel approach to addressing this issue. The primary goal of this novel approach is to better meet the information needs of persons who consult the drug product label for information on a drug's efficacy, effectiveness, and safety. Using FDA product label regulations as a guide, the approach links drug claims present in drug information sources available on the Semantic Web with specific product label sections. Here we report on pilot work that establishes the baseline performance characteristics of a proof-of-concept system implementing the novel approach. Claims from three drug information sources were linked to the Clinical Studies, Drug Interactions, and Clinical Pharmacology sections of the labels for drug products that contain one of 29 psychotropic drugs. The resulting Linked Data set maps 409 efficacy/effectiveness study results, 784 drug-drug interactions, and 112 metabolic pathway assertions derived from three clinically-oriented drug information sources (ClinicalTrials.gov, the National Drug File - Reference Terminology, and the Drug Interaction Knowledge Base) to the sections of 1,102 product labels. Proof-of-concept web pages were created for all 1,102 drug product labels that demonstrate one possible approach to presenting information that dynamically enhances drug product labeling. We found that approximately one in five efficacy/effectiveness claims were relevant to the Clinical Studies section of a psychotropic drug product, with most relevant claims providing new information. We also identified several cases where all of the drug-drug interaction claims linked to the Drug Interactions section for a drug were potentially novel. The baseline performance characteristics of the proof-of-concept will enable further technical and user-centered research on robust methods for scaling the approach to the many thousands of product labels currently on the market.
Collapse
Affiliation(s)
- Richard D Boyce
- Department of Biomedical Informatics, University of Pittsburgh, Offices at Baum, 5607 Baum Blvd, Pittsburgh, PA, USA
| | - John R Horn
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | | | | | - Jodi Schneider
- Digital Enterprise Research Institute, National University of Ireland, Galway, Ireland
| | - Joanne S Luciano
- Tetherless World Constellation, Rensselaer Polytechnic Institute, Troy, NY, USA
| | | | - Maria Liakata
- Department of Computer Science, Aberystwyth University, Wales, UK
- Text mining group, EBI-EMBL, Hinxton, Cambridge, UK
| |
Collapse
|
28
|
Boyce RD, Collins C, Clayton M, Kloke J, Horn JR. Inhibitory metabolic drug interactions with newer psychotropic drugs: inclusion in package inserts and influences of concurrence in drug interaction screening software. Ann Pharmacother 2012; 46:1287-98. [PMID: 23032655 DOI: 10.1345/aph.1r150] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Food and Drug Administration (FDA) regulations mandate that package inserts (PIs) include observed or predicted clinically significant drug-drug interactions (DDIs), as well as the results of pharmacokinetic studies that establish the absence of effect. OBJECTIVE To quantify how frequently observed metabolic inhibition DDIs affecting US-marketed psychotropics are present in FDA-approved PIs and what influence the source of DDI information has on agreement between 3 DDI screening programs. METHODS The scientific literature and PIs were reviewed to determine all drug pairs for which there was rigorous evidence of a metabolic inhibition interaction or noninteraction. The DDIs were tabulated noting the source of evidence and the strength of agreement over chance. Descriptive statistics were used to examine the influence of source of DDI information on agreement among 3 DDI screening tools. Logistic regression was used to assess the influence of drug class, indication, generic status, regulatory approval date, and magnitude of effect on agreement between the literature and PI as well as agreement among the DDI screening tools. RESULTS Thirty percent (13/44) of the metabolic inhibition DDIs affecting newer psychotropics were not mentioned in PIs. Drug class, indication, regulatory approval date, generic status, or magnitude of effect did not appear to be associated with more complete DDI information in PIs. DDIs found exclusively in PIs were 3.25 times more likely to be agreed upon by all 3 DDI screening tools than were those found exclusively in the literature. Generic status was inversely associated with agreement among the DDI screening tools (odds ratio 0.11; 95% CI 0.01 to 0.89). CONCLUSIONS The presence in PIs of DDI information for newer psychotropics appears to have a strong influence on agreement among DDI screening tools. Users of DDI screening software should consult more than 1 source when considering interactions involving generic psychotropics.
Collapse
Affiliation(s)
- Richard D Boyce
- Department of Biomedical Informatics, University of Pittsburgh, PA, USA.
| | | | | | | | | |
Collapse
|
29
|
Horn JR, Mantione MM, Johanson JF. OTC polyethylene glycol 3350 and pharmacists' role in managing constipation. J Am Pharm Assoc (2003) 2012; 52:372-80. [DOI: 10.1331/japha.2012.10161] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
30
|
Horn JR, Hansten PD, Osborn JD, Wareham P, Somani S. Customizing clinical decision support to prevent excessive drug-drug interaction alerts. Am J Health Syst Pharm 2012; 68:662-4. [PMID: 21460171 DOI: 10.2146/ajhp100465] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- John R Horn
- School of Pharmacy, University of Washington (UW), Box 357630, 1959 NE Pacific Street, Seattle, WA 98195-7630, USA.
| | | | | | | | | |
Collapse
|
31
|
Horn JR, Hansten PD. Careful scrutiny of the evidence for drug-drug interactions in clinical decision support systems is necessary. J Manag Care Pharm 2011; 17:713. [PMID: 22050397 PMCID: PMC10437417 DOI: 10.18553/jmcp.2011.17.9.713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- John R. Horn
- UW Medicine Health System, University of Washington. USA.
| | | |
Collapse
|
32
|
Horn JR, Hansten PD. Comment: evaluation of contraindicated drug-drug interaction alerts in a hospital setting. Ann Pharmacother 2011; 45:826; author reply 826-7. [PMID: 21672901 DOI: 10.1345/aph.1p533a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
33
|
Horn JR. Hard-stops for drug interactions. Arch Intern Med 2011; 171:706-707. [PMID: 21482852 DOI: 10.1001/archinternmed.2011.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
|
34
|
Wright AJ, Gomes T, Mamdani MM, Horn JR, Juurlink DN. The risk of hypotension following co-prescription of macrolide antibiotics and calcium-channel blockers. CMAJ 2011; 183:303-7. [PMID: 21242274 DOI: 10.1503/cmaj.100702] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The macrolide antibiotics clarithromycin and erythromycin may potentiate calcium-channel blockers by inhibiting cytochrome P450 isoenzyme 3A4. However, this potential drug interaction is widely underappreciated and its clinical consequences have not been well characterized. We explored the risk of hypotension or shock requiring hospital admission following the simultaneous use of calcium-channel blockers and macrolide antibiotics. METHODS We conducted a population-based, nested, case-crossover study involving people aged 66 years and older who had been prescribed a calcium-channel blocker between Apr. 1, 1994, and Mar. 31, 2009. Of these patients, we included those who had been admitted to hospital for the treatment of hypotension or shock. For each antibiotic, we estimated the risk of hypotension or shock associated with the use of a calcium blocker using a pair-matched analytic approach to contrast each patient's exposure to each macrolide antibiotic (erythromycin, clarithromycin or azithromycin) in a seven-day risk interval immediately before admission to hospital and in a seven-day control interval one month earlier. RESULTS Of the 7100 patients admitted to hospital because of hypotension while receiving a calcium-channel blocker, 176 had been prescribed a macrolide antibiotic during either the risk or control intervals. Erythromycin (the strongest inhibitor of cytochrome P450 3A4) was most strongly associated with hypotension (odds ratio [OR] 5.8, 95% confidence interval [CI] 2.3-15.0), followed by clarithromycin (OR 3.7, 95% CI 2.3-6.1). Azithromycin, which does not inhibit cytochrome P450 3A4, was not associated with an increased risk of hypotension (OR 1.5, 95% CI 0.8-2.8). We found similar results in a stratified analysis of patients who received only dihydropyridine calcium-channel blockers. INTERPRETATION In older patients receiving a calcium-channel blocker, use of erythromycin or clarithromycin was associated with an increased risk of hypotension or shock requiring admission to hospital. Preferential use of azithromycin should be considered when a macrolide antibiotic is required for patients already receiving a calcium-channel blocker.
Collapse
|
35
|
Horn JR. Analysis of purported erythromycin–warfarin interaction. Am J Health Syst Pharm 2010; 67:966; author reply 966, 968. [DOI: 10.2146/ajhp100015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- John R. Horn
- Department of Pharmacy Box 357630 School of Pharmacy University of Washington Seattle, WA 98195
| |
Collapse
|
36
|
Affiliation(s)
| | | | - Joan M Korth-Bradley
- Clinical Pharmacology, SpecialtyCare BusinessUnit. Pfizer Inc., Collegeville, PA
| |
Collapse
|
37
|
Elston Lafata J, Simpkins J, Kaatz S, Horn JR, Raebel MA, Schultz L, Smith DH, Yood MU. What Do Medical Records Tell Us About Potentially Harmful Co-Prescribing? Jt Comm J Qual Patient Saf 2007; 33:395-400. [PMID: 17711141 DOI: 10.1016/s1553-7250(07)33045-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Previous efforts document drug-drug interactions in ambulatory care. Yet little is known about medical record documentation or clinical management when interacting medications are received. METHODS The study population was identified from the HMO Research Network's Centers for Education and Research on Therapeutics (n = 2,020,037). A random subsample of patients > or = 18 years of age with drug coverage in 2000 initiating a co-dispensing for (1) warfarin with a nonsteroidal anti-inflammatory drug (n = 97), (2) digoxin with verapamil or diltiazem (n = 100), or (3) lovastatin/simvastatin with diltiazem or verapamil (n = 89) was identified. RESULTS The majority (63%-74%) of patients had documentation indicating receipt of both drugs during a single office visit. Documentation of risks and patient education was less common (< or = 14%, with all corresponding upper bounds of the 95% CIs < 23%). Clinical management changes were more frequently documented, ranging from 64% (95% CI: 47-81%) for lovastatin/simvastatin patients to 79% (95% CI: 60-99%) for warfarin patients. CONCLUSIONS The findings, although indicating that clinicians are likely aware of concomitant receipt of interacting medications, call into question the adequacy of medical record documentation as well as clinical management when interacting drugs are co-prescribed in the ambulatory setting.
Collapse
|
38
|
Lafata JE, Schultz L, Simpkins J, Chan KA, Horn JR, Kaatz S, Long C, Platt R, Raebel MA, Smith DH, Xi H, Yood MU. Potential Drug–Drug Interactions in the Outpatient Setting. Med Care 2006; 44:534-41. [PMID: 16708002 DOI: 10.1097/01.mlr.0000215807.91798.25] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although medication safety research has tended to focus on inpatients, the safety of drug use among outpatients is also a concern. OBJECTIVE We estimate the frequency of potentially interacting concomitant medication dispensing among outpatients. RESEARCH DESIGN We report the number and percent of patients annually dispensed an object drug of interest (ie, warfarin, digoxin, cyclosporine, or lovastatin/simvastatin) with a potentially interacting drug among a random sample of insured adults receiving care from 10 integrated delivery systems. We use 2 definitions of concomitant dispensing: medications dispensed: 1) during the time period for which the patient had the other medication available ('days supply') and 2) on the same day. We also estimate the number of insured U.S. population codispensed these medication pairs. RESULTS Among patients dispensed a drug of interest, between 17.8% (95% confidence interval [CI]=17.1-18.6%) and 28.0% (95% CI=24.0-32.1%) were concomitantly dispensed a potentially interacting drug using the "days supply" definition, and between 7.1% (95% CI=6.6-7.7%) and 17.7% (95% CI=14.4-21.1%) using the "same day" definition. Extrapolating to the insured U.S. population, between 1.29 (95% CI=1.25-1.33; same day) and 2.67 (95% CI=2.62-2.72; days supply) million insured adults are dispensed 1 of these 4 potentially interacting pairs. CONCLUSIONS We found evidence of potentially interacting concomitant medication dispensing among outpatients. An opportunity exists to better understand how such dispensing translates into adverse events and ultimately to improved medication safety.
Collapse
Affiliation(s)
- Jennifer Elston Lafata
- Henry Ford Health System, Detroit, Michigan 48202, Channing Laboratory, Brigham and Women's Hospital, and Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
Proton-pump inhibitors are acid-labile, and require an enteric coating to protect them from degradation in the stomach when given orally. However, this leads to delayed absorption and onset of action of the proton-pump inhibitor. This article aims to review the similarities and differences between the various formulations of delayed release proton-pump inhibitors. Delayed-release omeprazole and delayed-release lansoprazole have been suspended in sodium bicarbonate for tube administration; however, for omeprazole, absorption is further impaired and antisecretory effects are disappointing. Although such formulations may be more convenient for clinical use in certain patient groups, absorption of the proton-pump inhibitor is still influenced by residual enteric coating. There are few differences among the currently available delayed-release proton-pump inhibitors with respect to their pharmacodynamic effects during chronic administration. There are minor formulation-based pharmacokinetic differences among these agents, primarily reflected in their bioavailability following the first few doses. Differences in bioavailability may explain slight differences in the rate of onset of maximal antisecretory effect. However, minor pharmacodynamic and pharmacokinetic differences are not associated with meaningful differences in clinical outcomes.
Collapse
Affiliation(s)
- J R Horn
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
40
|
Barone JA, Horn JR. Comparative pharmacology of proton pump inhibitors. Manag Care 2001; 10:11-6. [PMID: 11729442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The PPIs are the most effective therapy to suppress gastric acid secretion. These agents decrease acid secretion by inhibiting parietal cell proton pumps. From chemical and pharmacodynamic points of view, subtle differences that exist among the PPIs may influence clinical activity.
Collapse
Affiliation(s)
- J A Barone
- Rutgers University College of Pharmacy, Department of Pharmacy Practice and Administration, 160 Frelinghuysen Road, Piscataway, N.J. 08854-8020, USA.
| | | |
Collapse
|
41
|
Abstract
OBJECTIVE To evaluate the performance of computerized drug-drug interaction (DDI) software in identifying clinically important drug-drug interactions. DESIGN One-time performance test of computer systems using a standard set of prescriptions. SETTING Community pharmacies or central corporate locations with pharmacy terminals identical to those used in actual pharmacies. PARTICIPANTS Chain and health maintenance organization (HMO) pharmacies with seven or more practice sites in Washington State. A total of nine different DDI software programs were installed in 516 community pharmacies represented by these chains and HMOs. MAIN OUTCOME MEASURES Sensitivity, specificity, and positive and negative predictive values of software in detecting 16 well-established DDIs contained within six fictitious patient profiles. RESULTS The software systems failed to detect clinically relevant DDIs one-third of the time. Sensitivity of the software programs ranged from 0.44 to 0.88, with 1.00 being perfect; specificity ranged from 0.71 to 1.00; positive predictive value ranged from 0.67 to 1.00; and negative predictive value ranged from 0.69 to 0.90. For software packages that were installed at different locations, between-installation differences were observed. CONCLUSION The performance of most DDI-detecting software programs tested in this study was suboptimal. Improvement is needed to advance their contribution to detection of DDIs.
Collapse
Affiliation(s)
- T K Hazlet
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle 98195-7630, USA.
| | | | | | | |
Collapse
|
42
|
Affiliation(s)
- P D Hansten
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, USA
| | | | | |
Collapse
|
43
|
Horn JR, Russell D, Lewis EA, Murphy KP. Van't Hoff and calorimetric enthalpies from isothermal titration calorimetry: are there significant discrepancies? Biochemistry 2001; 40:1774-8. [PMID: 11327839 DOI: 10.1021/bi002408e] [Citation(s) in RCA: 153] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The enthalpy of a reaction is most often determined through one of two means; it can be determined directly using calorimetry or indirectly by measuring the temperature dependence of the equilibrium constant (i.e., the van't Hoff method). Recently, discrepancies have been noted between the enthalpy measured by calorimetry, and the enthalpy determined by the van't Hoff method,. This has been suggested to indicate that the binding reaction is more complex than the simple one-to-one binding model used to describe the data. To better understand possible discrepancies between and, we have undertaken both experimental studies using isothermal titration calorimetry to measure the binding energetics of Ba(2+) binding 18-crown-6 ether and 2'-CMP binding RNase A, along with a simulation of a system involving a molecule in conformational equilibrium coupled with binding. We find that when experimental setup and analysis are correctly performed, no statistically significant discrepancies between and exist even for the linked system.
Collapse
Affiliation(s)
- J R Horn
- Department of Biochemistry, University of Iowa College of Medicine, Iowa City, IA 52242, USA
| | | | | | | |
Collapse
|
44
|
Abstract
Cyclosporine-drug interactions in adult transplant patients and the impact of age were studied. The medical records of transplant patients receiving cyclosporine therapy were identified. Data on patient demographics, cyclosporine dosages, dosage form, blood trough concentrations, clinical laboratory test values, and concurrent medications were collected. One-compartment models for oral and i.v. administration were used to fit cyclosporine concentration data to population pharmacokinetic and statistical models. Nonlinear mixed-effect modeling (NONMEM) software was used. The influence of covariates, including but not limited to concomitant medications and age, on cyclosporine pharmacokinetics was evaluated. The records of 100 patients (36 women and 64 men) were reviewed. A mean +/- S.D. of 9 +/- 2 and 9 +/- 1 medications per day were consumed by patients < 60 and > or = 60 years old, respectively. Mean population pharmacokinetic values of 0.407 L/hr/kg for clearance, 4.0 L/kg for volume of distribution, 31% for bioavailability, and 10.6 hours for half-life were determined on the basis of 569 blood cyclosporine levels. Twelve medications (sertraline, losartan, valsartan, quinine, atorvastatin, simvastatin, pravastatin, fluvastatin, alendronate, digoxin, acyclovir, and oxycodone) with previously unconfirmed pharmacokinetic interactions with cyclosporine were identified as interacting. There was no correlation between age and interactions. Patients taking cyclosporine were at risk for pharmacokinetic drug interactions when cyclosporine was used in combination with sertraline, losartan, valsartan, quinine, atorvastatin, simvastatin, pravastatin, fluvastatin, alendronate, digoxin, acyclovir, and oxycodone. Transplant patients 60-75 years of age had cyclosporine-drug interactions similar to those in younger patients.
Collapse
Affiliation(s)
- J Lill
- University of Washington Medical Center, Seattle 98195-6015, USA
| | | | | | | |
Collapse
|
45
|
Bauer LA, Horn JR, Maxon MS, Easterling TR, Shen DD, Strandness DE. Effect of metoprolol and verapamil administered separately and concurrently after single doses on liver blood flow and drug disposition. J Clin Pharmacol 2000; 40:533-43. [PMID: 10806607 DOI: 10.1177/00912700022009152] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nine healthy males participated in a double-blind, placebo-controlled, randomized, crossover study to determine the effects of verapamil and metoprolol administered alone and concurrently on blood flow through the hepatic artery and portal and hepatic veins and to detect a possible drug interaction between the two agents. Single oral doses of placebo/placebo, metoprolol (50 mg)/placebo, verapamil (80 mg)/placebo, or verapamil/metoprolol were separated by at least 14 days. Liver blood flow through individual hepatic vessels was measured up to 8 hours after dosage administration using a duplex Doppler ultrasound technique. Cardiac output, heart rate, blood pressure, stroke volume, and total peripheral resistance were measured for 3 hours after drug doses were given. In 5 subjects, pharmacokinetic parameters for total drug as well as S- and R-enantiomers were also measured. Verapamil given alone caused a rapid and intense increase in liver blood flow (hepatic artery = 50%, portal vein = 42%, hepatic vein = 55%) 0.75 to 1 hour after administration because of a decrease in total peripheral resistance and an increase in heart rate, stroke volume, and cardiac output. Metoprolol given alone caused a slow but prolonged decrease in liver blood flow (maximum decrease: hepatic artery = -54%, portal vein = -21%, hepatic vein = -27%) 4 hours after administration because of a decrease in heart rate and cardiac output. When the two agents were given together, a composite of the changes noted after separate administration was noted: a brief peak increase in liver blood flow at 0.33 to 1 hour followed by a slow, prolonged decrease that reached its maximum decline 4 to 5 hours postdose. During the combined phase, metoprolol and its enantiomers had an increased AUC and Cmax, while verapamil and its enantiomers had an increased AUC and t1/2. These pharmacokinetic changes were consistent with the magnitude and time course of liver blood flow changes through the hepatic artery and portal or hepatic veins.
Collapse
Affiliation(s)
- L A Bauer
- Department of Pharmacy, University of Washington, Seattle 98195-7630, USA
| | | | | | | | | | | |
Collapse
|
46
|
Lill JS, O'Sullivan T, Bauer LA, Horn JR, Carithers R, Strandness DE, Lau H, Chan K, Thakker K. Pharmacokinetics of diclofenac sodium in chronic active hepatitis and alcoholic cirrhosis. J Clin Pharmacol 2000; 40:250-7. [PMID: 10709153 DOI: 10.1177/00912700022008919] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to assess the pharmacokinetics of diclofenac sodium and its five metabolites following administration of a 150 mg oral dose to healthy subjects and patients with either chronic active hepatitis of varying morphology or alcoholic cirrhosis. Six healthy subjects, 6 chronic active hepatitis patients, and 6 alcoholic cirrhosis patients were enrolled in this prospective, open-label, parallel study. Blood samples were drawn at 0, 0.25, 0.5, 0.75, 1, 2, 4, 6, 8, 12, 24, 48, 72, 144, 312, and 480 hours, and urine samples were collected for 144 hours after administration of a single oral dose of diclofenac sodium. The mean area under the serum concentration-time curve extrapolated to infinity, oral clearance, half-life, maximal concentration, and time to peak concentration for diclofenac and its metabolites were determined and compared using analysis of variance. Cirrhotics had a mean +/- SD diclofenac AUC value (19,114 +/- 6806 ng.h/ml) significantly different (p < 0.02) from hepatitis patients (6071 +/- 1867 ng.h/ml) and healthy subjects (7008 +/- 2006 ng.h/ml), whereas healthy subjects and hepatitis patients had similar values. Comparable results were found for 4'-hydroxydiclofenac. The AUC values for 3'-hydroxydiclofenac and 3'-hydroxy-4'methoxydiclofeanc were significantly different when healthy subjects were compared to cirrhotics. However, hepatitis subjects were not significantly different from either group. The results indicate that hepatitis does not alter the pharmacokinetics of diclofenac. Alcoholic cirrhosis increased the mean diclofenac AUC approximately three times compared to normal subjects, indicating that one-third of the usual dose in cirrhotics would produce equivalent AUC values in normal subjects and subjects with alcoholic cirrhosis. However, since pharmacodynamic measurements were not made and no increase in untoward or side effects was noted in the alcoholic cirrhosis patients after a single dose, maintenance doses should be titrated to patients response.
Collapse
Affiliation(s)
- J S Lill
- University of Washington, Department of Pharmacy, Seattle 98195-7630, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Harrington RD, Woodward JA, Hooton TM, Horn JR. Life-threatening interactions between HIV-1 protease inhibitors and the illicit drugs MDMA and gamma-hydroxybutyrate. Arch Intern Med 1999; 159:2221-4. [PMID: 10527300 DOI: 10.1001/archinte.159.18.2221] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Human immunodeficiency virus 1 (HIV-1) protease inhibitors have dramatically reduced the morbidity and mortality due to HIV-1 infection. However, most of these antiretrovirals are also potent inhibitors (and occasionally inducers) of hepatic and intestinal cytochrome P450 systems and, therefore, have the potential to alter the elimination of any substance that utilizes these metabolic pathways. We describe a patient infected with HIV-1 who was treated with ritonavir and saquinavir and then experienced a prolonged effect from a small dose of methylenedioxymetamphetamine (MDMA or ecstacy) and a nearly fatal reaction from a small dose of gamma-hydroxybutyrate (GHB). We also discuss the potential for HIV-1 protease inhibitors to alter the metabolism of other abusable prescribed and illicit substances.
Collapse
Affiliation(s)
- R D Harrington
- Department of Medicine, School of Medicine, University of Washington, Seattle, USA.
| | | | | | | |
Collapse
|
48
|
Abstract
The use of prokinetic agents by pediatric patients, geriatric patients, and patients taking other drugs that may affect or be affected by the prokinetic agent is reviewed. The use of such agents to treat motility disorders has expanded over the past few years. These agents may be administered to patients who have special physiologic considerations, have other diseases, or require concomitant drug therapy. The appropriate use of prokinetic agents in these groups requires an understanding of the unique dosage considerations that may be necessary to ensure safe, effective therapy.
Collapse
Affiliation(s)
- J R Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle 98185, USA
| |
Collapse
|
49
|
Affiliation(s)
- John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Health Sciences Building, 1959 NE Pacific Street. Seattle, WA 98185
| |
Collapse
|
50
|
Abstract
Nitroglycerin has been reported to reduce activated partial thromboplastin time (aPTT) values in patients treated with concurrent heparin and nitroglycerin. However, in vivo studies have yielded conflicting results. In this in vitro evaluation, nitroglycerin was added to samples of pooled plasma from normal volunteers in concentrations of 0, 1, 10, 50, 100, 150, and 200 ng/mL. Preservative-free heparin was then added to the samples to produce final concentrations of 0, 0.3, and 0.6 U/mL. Activated partial thromboplastin time (aPTT) was determined for each sample using a single reagent. There were no significant differences in aPTT values among increasing nitroglycerin concentrations for any of the three levels of heparinization. No direct effect of nitroglycerin on the anticoagulant effect of heparin was observed, as measured by aPTT.
Collapse
Affiliation(s)
- A D Barnes
- University of Washington School of Pharmacy, Seattle Washington, USA
| | | | | |
Collapse
|