Statin use and lung cancer risk in chronic obstructive pulmonary disease patients: a population-based cohort study.

BACKGROUND: Patients living with chronic obstructive pulmonary disease (COPD) are at an increased risk of lung cancer. A common comorbidity of COPD is cardiovascular disease; as such, COPD patients often receive statins. This study sought to understand the association between statin exposure and lung cancer risk in a population-based cohort of COPD patients. METHODS: We identified a population-based cohort of COPD patients based on having filled at least three prescriptions for an anticholinergic or short-acting beta-agonist (SABA). We used an array of methods of defining medication exposure including three conventional methods (ever statin exposure, cumulative duration of use, and cumulative dose) and two novel methods (recency-weighted cumulative duration of use and recency-weighted cumulative dose). To assess residual confounding, a negative control exposure was used to test the validity of our results. All exposure variables were time-dependent. RESULTS: The population-based cohort of COPD had 39,879 patients with mean age of 70.6 (SD: 11.2) years and, of which, 53.5% were female. There were 12,469 patients who received at least one statin prescription. Results from the reference case multivariable analysis indicated a reduced risk from statin exposure (HR: 0.85 (95% CI: 0.73-1.00) in COPD patients, but this result not statistically significant. Using the two recency-weighted modelling approaches, statin exposure was associated with a statistically significant reduction in lung cancer risk (recency-weighted cumulative dose, HR: 0.85 (95% CI: 0.77-0.93) and recency-weighted cumulative duration of use, HR: 0.97 (95% CI: 0.96-0.99). Multivariable analysis incorporating the negative control exposure was not statistically significant (HR: 0.89 (95% CI: 0.75-1.10). CONCLUSIONS: The results of this population-based analysis indicate that statin use in COPD patients may reduce the risk of lung cancer. While the effect was not statistically significantly across all exposure definitions, the overall results support the hypothesis that COPD patients might benefit from statin therapy.

Household food insecurity and dietary diversity as correlates of maternal and child undernutrition in rural Cambodia.

OBJECTIVES: To assess household food insecurity and dietary diversity as correlates of maternal and child anthropometric status and anemia in rural Cambodia. METHODS: Trained interviewers administered a survey to 900 households in four rural districts of Prey Veng, Cambodia. The Household Food Insecurity Access Scale (HFIAS) and Household Dietary Diversity Score (HDDS) were used to assess household food insecurity and dietary diversity. The height, weight and hemoglobin concentration of the mother and youngest child under 5 years in each household were measured. Multivariate logistic regression models were constructed to assess the association between household food insecurity and dietary diversity, and child stunting and wasting, maternal thinness, maternal and child anemia. RESULTS: The mean (s.d.) HFIAS and HDDS scores were 5.3 (3.9) and 4.7 (1.6), respectively. The respective prevalences of mild, moderate and severe food insecurity were 33, 37 and 12%. Maternal thinness, child stunting and child wasting were present in 14.6, 25.4 and 8.1% of respondents, respectively. The risk of maternal thinness, but not child stunting or wasting, increased as the severity of household food insecurity increased. Household food insecurity was also positively associated with maternal, but not child, anemia. Household dietary diversity status was not significantly associated with any of the outcomes we assessed. CONCLUSIONS: Efforts to improve household food security are important as a means of promoting maternal nutritional status; however, additional research is needed to better understand the role of other factors that are driving the burden of child undernutrition in Cambodia.

Low-molecular-weight heparin versus unfractionated heparin for prophylaxis of venous thromboembolism in medicine patients--a pharmacoeconomic analysis.

BACKGROUND: Prevention of in-hospital venous thromboembolism (VTE) is identified internationally as a priority to improve patient safety. Advocated alternatives include low-dose unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Although LMWHs are as effective as UFH, less frequent administration and potentially safer adverse effect profile associated with LMWHs might off-set greater drug acquisition costs. The objective of this study was to determine the most cost-effective thromboprophylaxis strategy for hospitalized medicine patients and specific subgroups in Canada. METHODS: A decision-analytic model assessed costs and outcomes of LMWH compared to UFH for thromboprophylaxis in at-risk hospitalized medicine patients from an institutional perspective. The outcome of interest was the incremental cost-effectiveness ratio (ICER) for preventing deep vein thrombosis (DVT) and combined untoward events (pulmonary embolism [PE], major bleed, and death). The time horizon of the model was the hospital stay. RESULTS: In the base-case analysis, LMWH thromboprophylaxis resulted in higher costs ($7.40), but 3.6 and 1.1 fewer DVT and untoward events per 1000 patients, respectively, with associated ICERs of $2042 and $6832. Results remained predominantly stable when alternative assumptions were evaluated in the sensitivity analysis. Low-molecular-weight heparin had the most favorable economic profile in patients with a history of DVT. In the probabilistic sensitivity analysis, in 33% of simulations LMWH was less costly and more effective, whereas the reverse was true for UFH only in 13% of simulations. CONCLUSIONS: Low-molecular-weight heparin administration is a cost-effective alternative for thromboprophylaxis strategy in Canadian hospitalized medicine patients.

The impact of low family income on self-reported health outcomes in patients with rheumatoid arthritis within a publicly funded health-care environment.

OBJECTIVE: Self-rated health (SRH) is an independent, strong predictor of morbidity and mortality. Socio-economic status (SES) is strongly associated with SRH. This study investigated the relationship between SES and SRH outcomes in a sample of patients with rheumatoid arthritis (RA) in Canada. METHODS: Both generic preference-based [Health Utilities Index Mark 3 (HUI3) and Short Form 6D (SF-6D)] and non-preference-based [disease-specific (Rheumatoid Arthritis Quality of Life, RAQoL) and a functional status (Health Assessment Questionnaire, HAQ)] SRH questionnaires were administered to 313 RA patients. Both proximate (education and annual household income) and contextual (neighbourhood income, education and unemployment) measures of SES were captured. Ordinary least squares (OLS) regression was used to adjust for RA severity while assessing the relationship between SRH and SES measures. Two-stage least-squares (TSLS) regression was used to determine if there was an inter-relationship between SES and SRH measures. RESULTS: The sample was well distributed across RA severity and SES measures. Contextual and proximate measures of SES were poorly correlated. Lower levels of proximate SES measures (but not contextual) were associated with poorer SRH outcomes. The OLS regressions showed significant associations between the HUI3 and the SF-6D overall scores and the HAQ for self-reported income. The RAQoL did not differ significantly across SES. TSLS regression confirmed the finding that self-reported income was similarly associated with the SRH measures. CONCLUSIONS: Even in a country with universal access to health-care, the impact of a chronic disease such as RA on SRH is associated with self-reported income. The finding that preference-based measures vary with income independently of RA severity could bias economic evaluation.

Double trouble: impact of inappropriate use of asthma medication on the use of health care resources.

BACKGROUND: There is considerable controversy about the regular use of short-acting beta-agonists for the treatment of asthma. Although case-control studies have suggested that excessive use of these drugs may worsen asthma control and increase the risk of fatal or near-fatal asthma, the controversy remains unresolved because of the confounding that exists among disease control, disease severity and the use of short-acting beta-agonists. Whatever the cause-and-effect relation between the use of short-acting beta-agonists and disease severity, we hypothesized that their excessive use, in conjunction with underuse of inhaled corticosteroids, would be a marker for poorly controlled asthma and excessive use of health care resources. METHODS: To characterize the pattern of health services utilization among asthmatic patients taking various doses of inhaled beta-agonists and corticosteroids in British Columbia, we linked the relevant health administrative databases. All patients between 5 and 50 years of age for whom a prescription for a short-acting beta-agonist was filled in 1995 and whose prescription data were captured through the provincial drug plan were included in a retrospective analysis of prescriptions for asthma drugs, physician prescribing patterns and health services utilization. Patients' use of asthma medication was classified as appropriate (low doses of short-acting beta-agonist and high doses of inhaled corticosteroid) or inappropriate (high doses of short-acting beta-agonist and low doses of inhaled corticosteroid), and the 2 resulting groups were compared, by means of logistic, Poisson and gamma regression, for differences in prescribing patterns, physician visits and use of hospital resources. RESULTS: A total of 23,986 patients were identified as having filled a prescription for a short-acting beta-agonist (for inhalation) in 1995. Of these, 3069 (12.8%) filled prescriptions for 9 or more canisters of beta-agonist, and of this group of high-dose beta-agonist users, 763 (24.9%) used no more than 100 micrograms/day of inhaled beclomethasone. On average, those with inappropriate use of beta-agonists visited significantly more physicians for their prescriptions (1.8 v. 1.4), and each of these physicians on average wrote significantly more prescriptions for asthma medications per patient than the physicians who prescribed to appropriate users (5.2 v. 2.5 prescriptions). Patients with inappropriate use were more likely to be admitted to hospital (adjusted relative risk [RR] 1.68, 95% confidence interval [CI] 1.25-2.26), were admitted to hospital more frequently (adjusted RR 1.81, 95% CI 1.41-2.32) and were more likely to require emergency admission (adjusted RR 1.93, 95% CI 1.35-2.77). INTERPRETATION: Despite the widespread distribution of guidelines for asthma pharmacotherapy, inappropriate use of asthma medications persists (specifically excessive use of inhaled short-acting beta-agonists combined with underuse of inhaled corticosteroids). Not only are patients who use medication inappropriately at higher risk for fatal or near-fatal asthma attacks, but, as shown in this study, they use significantly more health care resources than patients with appropriate medication use.

Selective serotonin-reuptake inhibitor-induced movement disorders.

OBJECTIVE: To compile and evaluate all available data suggesting an association between selective serotonin-reuptake inhibitor (SSRI) administration and the occurrence of movement disorders, and to characterize these reactions in terms of onset, duration, treatment and outcome, and potential predisposing factors. METHODOLOGY: Reports of movement disorders were identified by conducting a comprehensive literature search that included tertiary adverse drug reaction resources, MEDLINE, EmBASE, Biological Abstracts, Current Contents, Reactions, ClinAlert, and International Pharmaceutical Abstracts. In addition, reports were solicited from the Canadian proprietary manufacturers of SSRIs, and from the Therapeutic Products Program of Health Canada. Each case was then classified according to the description of the movement disorder, based on predefined diagnostic criteria. RESULTS: A total of 127 published reports of SSRI-induced movement disorders were identified involving akathisia (n = 30), dystonia (19), dyskinesia (12), tardive dyskinesia (6), parkinsonism (25), and 15 cases of mixed disorders. Ten isolated cases of bruxism were identified. Ten additional reports could not be classified. Manufacturers of SSRIs provided 49 reports of akathisia, 44 of dystonia, 208 of dyskinesia, 76 of tardive dyskinesia, 516 of parkinsonism, and 60 of bruxism. Treatment strategies included discontinuation of the SSRI; dosage reduction; or the addition of a benzodiazepine, beta-blocker, or anticholinergic agent. CONCLUSIONS: SSRI use appears to be associated with the development of movement disorders, as either a direct result of the drug or exacerbation of an underlying condition. Predisposing factors may include the use of neuroleptics, existing neurologic diagnoses, or preexisting movement disorders. Clinicians should be cognizant of the potential for these reactions, as prompt recognition and management is essential in preventing potentially significant patient morbidity.

Sumatriptan contraindications and the serotonin syndrome.

OBJECTIVE: To determine the risk for serotonin syndrome associated with the concomitant use of sumatriptan and the currently contraindicated therapies, that is, the monoamine oxidase inhibitors (MAOIs), serotonin selective-reuptake inhibitors (SSRIs), and lithium. METHODOLOGY: A comprehensive search for reports of serotonin syndrome associated with sumatriptan use was conducted by using tertiary drug interaction literature, MEDLINE, EmBASE, Biological Abstracts, Current Contents, Reactions, ClinAlert, and the International Pharmaceutical Abstracts. In addition, related reports from the proprietary manufacturers, the Health Protection Branch of Health Canada, and the World Health Organization Collaborative Centre for International Drug Monitoring were also solicited. RESULTS: The concurrent use of sumatriptan with an SSRI or lithium has been reported to cause symptoms suggestive of serotonin syndrome in 16 and 2 cases, respectively. There were no reports involving MAOIs. In general, the reports indicated a mild-to-moderate, self-limited course with some features consistent with the serotonin syndrome. We found published reports of sumatriptan use without adverse events involving 148 patients receiving SSRIs, 31 patients taking MAOIs, and a small number using lithium. CONCLUSIONS: Clinical evidence supporting the strict contraindication of MAOIs, SSRIs and lithium was not identified. The balance of documented clinical experience pertaining to the use of sumatriptan concurrently with SSRIs or lithium suggests that most patients tolerate this combination without incident. Because there is little reliable experience with sumatriptan in combination with MAOIs, we suggest that sumatriptan should continue to be avoided in patients taking these agents until further data demonstrating safety become available.

Drug and poison information resources on the Internet, Part 2: Identification and evaluation.

The Internet is a potential source of information for practitioners and researchers of pharmaceutical sciences. Despite its explosive growth and popularity, pharmacists and other health care providers have been slow to use the Internet as a source of clinical information. We have identified and evaluated several sites available on the Internet that are devoted to providing information related to professional practice, pharmacotherapy, and toxicology. We have concerns, however, regarding the quality of the available information and advise users to be cautious in using the data they obtain.

Drug and poison information resources on the Internet, Part 1: An introduction.

The Internet is an excellent source of drug and poison information. Despite the relative case and minimal costs associated with accessing the Internet, many pharmacists and other health care professionals have been slow to adopt this new technology.