This document examines the cardiovascular risk of various non-steroidal anti-inflammatory drugs (NSAIDs) and the inclusion of those drugs on essential medicines lists and patterns of sales in 15 countries. It finds that diclofenac and etoricoxib, which are ranked highest for cardiovascular risk based on meta-analyses, together account for about one-third of total NSAID usage globally despite evidence of their risks for years. Diclofenac in particular is the most commonly used NSAID worldwide despite having similar cardiovascular risk as rofecoxib, which was withdrawn due to toxicity. National essential medicines lists and usage patterns have not reflected the evidence on relative cardiovascular safety of NSAIDs.
This document summarizes research on potential adverse effects of herbal medicine use in cardiac patients taking prescription medications. It reviews 5 studies that explored interactions between common herbal medicines (e.g. cranberry, garlic) and cardiac drugs (e.g. warfarin). The studies found that certain herbal medicines can increase or decrease the effects of drugs like warfarin when taken together, potentially causing issues like abnormal bleeding or clotting in patients. However, many of the studies had limitations like small sample sizes. Overall, more research is still needed but the document suggests herbal medicine use should be carefully monitored in cardiac patients on multiple medications.
Psychotropic medication in a randomly selected group of citizens receiving re...Anne Kathrine Helnæs
This study analyzed the medication lists of 214 citizens receiving residential or home care to summarize patterns of psychotropic medication (PM) use. The key findings were:
1) 64.5% of citizens were prescribed one or more PMs, most commonly antidepressants (43.5%) and anxiolytics/hypnotics (27.1%).
2) Citizens receiving antipsychotics were often also prescribed antidepressants (52.9%), anxiolytics/hypnotics (35.3%), and anti-dementia drugs (20.9%).
3) While improvements have been made regarding doses and drug choices compared to past studies, PM use among the elderly is still not fully aligned with recommendations
Neglected and rare diseases traditionally have not been the focus of large pharmaceutical company research as biotech and academia have primarily been involved in drug discovery efforts for such diseases. This area certainly represents a new opportunity as the pharmaceutical industry investigates new markets. One approach to speed up drug discovery is to examine new uses for existing approved drugs; this is termed drug repositioning or drug repurposing and has become increasingly popular in recent years. Analysis of the literature reveals that using high-throughput screening there have been many examples of FDA approved drugs found to be active against additional targets that can be used to therapeutic advantage for repositioning for other diseases. To date there are far fewer such examples where in silico approaches have allowed for the derivation of new uses. It is suggested that with current technologies and databases of chemical compounds (drugs) and related data, as well as close integration with in vitro screening data, improved opportunities for drug repurposing will emerge. In this publication a review of the literature will highlight several proof of principle examples from areas such as finding new inhibitors for drug transporters with 3D pharmacophores and uncovering molecules active against Mycobacterium tuberculosis (Mtb) using Bayesian models of compound libraries. Research into neglected or rare/orphan diseases can likely benefit from in silico drug repositioning approaches and accelerate drug discovery for these diseases.
This study evaluated drug prescription patterns among medical specialties in West Azerbaijan, Iran between 2014-2015. A total of over 500,000 prescriptions were analyzed using prescription software. The results showed that antibiotics were most prescribed by ENT, gynecology, infectious disease, urology and general surgery specialists. Neurosurgeons, GPs and ENT specialists prescribed the most corticosteroids. Neurosurgeons, orthopedists and cardiologists prescribed most central nervous system drugs. Overall, antibiotics and corticosteroids were overprescribed compared to guidelines. The study concludes certain specialties prescribed drugs outside their expertise and some specialists overprescribed antibiotics and corticosteroids.
This study analyzed 150 prescriptions of patients with rheumatoid arthritis treated at a tertiary care hospital in India. The study found:
1. Hydroxychloroquine was the most commonly prescribed drug (20.1%), followed by paracetamol (18.6%). Combination therapy using 3 or more drugs was preferred over monotherapy.
2. The majority of patients were female (91.3%) and the average age was 50 years old. Common comorbidities included hypertension (60%), diabetes (26.6%), and asthma (13.3%).
3. A total of 552 drugs were prescribed and 221 drug-drug interactions were identified. The highest number of interactions occurred with
1. Adverse drug reactions (ADRs) are a major public health problem, causing over 2 million serious reactions, 100,000 deaths, and up to 440,000 preventable medical deaths per year in the US. ADRs are one of the leading causes of death ahead of other illnesses.
2. Older adults are particularly at risk of ADRs due to changes in body composition, decreased liver and kidney function, and increased drug sensitivity with age. Over 6.6 million older adults per year receive inappropriate prescriptions putting them at risk.
3. In addition to deaths, ADRs cause over 1.5 million hospitalizations per year and additional hospitalizations when patients experience reactions after
This systematic review and meta-analysis analyzed 19 studies comprising over 326,000 patients to investigate the effect of digoxin use on mortality in patients with atrial fibrillation (AF) or congestive heart failure (CHF). The analysis found that digoxin use was associated with an increased relative risk of all-cause mortality, with a 29% higher mortality risk seen in AF patients and a 14% higher risk in CHF patients. The results suggest that digoxin therapy may increase mortality risk, particularly in patients with AF. However, significant heterogeneity was seen between the individual studies.
This document summarizes research on potential adverse effects of herbal medicine use in cardiac patients taking prescription medications. It reviews 5 studies that explored interactions between common herbal medicines (e.g. cranberry, garlic) and cardiac drugs (e.g. warfarin). The studies found that certain herbal medicines can increase or decrease the effects of drugs like warfarin when taken together, potentially causing issues like abnormal bleeding or clotting in patients. However, many of the studies had limitations like small sample sizes. Overall, more research is still needed but the document suggests herbal medicine use should be carefully monitored in cardiac patients on multiple medications.
Psychotropic medication in a randomly selected group of citizens receiving re...Anne Kathrine Helnæs
This study analyzed the medication lists of 214 citizens receiving residential or home care to summarize patterns of psychotropic medication (PM) use. The key findings were:
1) 64.5% of citizens were prescribed one or more PMs, most commonly antidepressants (43.5%) and anxiolytics/hypnotics (27.1%).
2) Citizens receiving antipsychotics were often also prescribed antidepressants (52.9%), anxiolytics/hypnotics (35.3%), and anti-dementia drugs (20.9%).
3) While improvements have been made regarding doses and drug choices compared to past studies, PM use among the elderly is still not fully aligned with recommendations
Neglected and rare diseases traditionally have not been the focus of large pharmaceutical company research as biotech and academia have primarily been involved in drug discovery efforts for such diseases. This area certainly represents a new opportunity as the pharmaceutical industry investigates new markets. One approach to speed up drug discovery is to examine new uses for existing approved drugs; this is termed drug repositioning or drug repurposing and has become increasingly popular in recent years. Analysis of the literature reveals that using high-throughput screening there have been many examples of FDA approved drugs found to be active against additional targets that can be used to therapeutic advantage for repositioning for other diseases. To date there are far fewer such examples where in silico approaches have allowed for the derivation of new uses. It is suggested that with current technologies and databases of chemical compounds (drugs) and related data, as well as close integration with in vitro screening data, improved opportunities for drug repurposing will emerge. In this publication a review of the literature will highlight several proof of principle examples from areas such as finding new inhibitors for drug transporters with 3D pharmacophores and uncovering molecules active against Mycobacterium tuberculosis (Mtb) using Bayesian models of compound libraries. Research into neglected or rare/orphan diseases can likely benefit from in silico drug repositioning approaches and accelerate drug discovery for these diseases.
This study evaluated drug prescription patterns among medical specialties in West Azerbaijan, Iran between 2014-2015. A total of over 500,000 prescriptions were analyzed using prescription software. The results showed that antibiotics were most prescribed by ENT, gynecology, infectious disease, urology and general surgery specialists. Neurosurgeons, GPs and ENT specialists prescribed the most corticosteroids. Neurosurgeons, orthopedists and cardiologists prescribed most central nervous system drugs. Overall, antibiotics and corticosteroids were overprescribed compared to guidelines. The study concludes certain specialties prescribed drugs outside their expertise and some specialists overprescribed antibiotics and corticosteroids.
This study analyzed 150 prescriptions of patients with rheumatoid arthritis treated at a tertiary care hospital in India. The study found:
1. Hydroxychloroquine was the most commonly prescribed drug (20.1%), followed by paracetamol (18.6%). Combination therapy using 3 or more drugs was preferred over monotherapy.
2. The majority of patients were female (91.3%) and the average age was 50 years old. Common comorbidities included hypertension (60%), diabetes (26.6%), and asthma (13.3%).
3. A total of 552 drugs were prescribed and 221 drug-drug interactions were identified. The highest number of interactions occurred with
1. Adverse drug reactions (ADRs) are a major public health problem, causing over 2 million serious reactions, 100,000 deaths, and up to 440,000 preventable medical deaths per year in the US. ADRs are one of the leading causes of death ahead of other illnesses.
2. Older adults are particularly at risk of ADRs due to changes in body composition, decreased liver and kidney function, and increased drug sensitivity with age. Over 6.6 million older adults per year receive inappropriate prescriptions putting them at risk.
3. In addition to deaths, ADRs cause over 1.5 million hospitalizations per year and additional hospitalizations when patients experience reactions after
This systematic review and meta-analysis analyzed 19 studies comprising over 326,000 patients to investigate the effect of digoxin use on mortality in patients with atrial fibrillation (AF) or congestive heart failure (CHF). The analysis found that digoxin use was associated with an increased relative risk of all-cause mortality, with a 29% higher mortality risk seen in AF patients and a 14% higher risk in CHF patients. The results suggest that digoxin therapy may increase mortality risk, particularly in patients with AF. However, significant heterogeneity was seen between the individual studies.
TRENDS AND PATTERNS OF GEOGRAPHIC VARIATIONS IN OPIOID PRESCRIBINGwith Wind
The document analyzes trends in opioid prescribing practices across US states from 2006 to 2017. It finds that while the total amount of opioids prescribed decreased over this period, the duration of prescriptions increased. Specifically:
- The total amount of opioids prescribed per person decreased 12.8% on average nationally, though there was significant variation between states.
- The mean duration of opioid prescriptions increased 37.6% nationally, with increases in every state.
- Prescriptions for durations of 30 days or longer, which are more likely to treat chronic pain, increased 37.7% nationally, with increases in 39 states.
- However, prescribing rates decreased for high dosages, short durations,
2016: Considerations on Polypharmacy and Adverse Drug Events-WatanabeSDGWEP
The document discusses issues related to polypharmacy and adverse drug events in older adults. It notes that polypharmacy is common in seniors, putting them at higher risk for adverse drug events, hospitalizations, and costs. The document also reviews tools that can help reduce inappropriate polypharmacy and prescribing, such as Beers criteria, STOPP criteria, and comprehensive medication reviews.
This document proposes developing a pharmacogenetic-guided warfarin dosing regimen for Puerto Rican patients starting anticoagulation therapy. It summarizes previous research showing genetics like CYP2C9 and VKORC1 genotypes influence warfarin dosing. The study aims to predict initial doses for 175 Puerto Rican veterans using a pharmacokinetic-pharmacogenetic model and develop a customized dosing algorithm incorporating genotypes and patient factors. Preliminary results show the model predicted doses for 121 patients with few outside the therapeutic range, and the customized algorithm had superior predictability compared to other models for Puerto Ricans.
After starting blood pressure medication, most let other lifestyle changes sl...Δρ. Γιώργος K. Κασάπης
Although physicians recommend that those who take blood pressure medications also keep up with lifestyle changes such as eating healthily and exercising, a large new study suggests that those who start on the drugs may not be adhering to the other advice. Looking at data from a Finnish cohort of nearly 9,000 patients over the age of 40 who started BP treatment, scientists found that these individuals were 82% more likely to become obese and 8% more likely to be physically inactive than those not on treatment.
Still, these people experienced a decline in their average alcohol consumption and were 26% more likely to quit smoking. Doctors ought to continue to emphasize the importance of lifestyle changes even as people start taking BP medication, the authors suggest.
This study examined the association between initial opioid prescribing patterns and the likelihood of long-term opioid use among patients who were opioid-naïve. The study used prescription drug monitoring program data from Oregon to identify over 500,000 patients who filled their first opioid prescription between 2012-2013. It found that receiving multiple prescriptions or higher total morphine milligram equivalents in the first 30 days was associated with greater odds of long-term opioid use (defined as 6 or more fills) in the following year. Patients who started on long-acting opioids also had higher risk than those starting on short-acting drugs. The associations remained after excluding patients likely using opioids for cancer or end-of-life care.
This document summarizes the key points from a conference on managing risk in the workplace by addressing substance abuse issues. The conference objectives are to identify signs of drug addiction, describe employer procedures for substance abuse, and explain potential liabilities. It discusses the opioid epidemic, prescription drug abuse trends, and provides statistics on prescription drug use. Guidelines are presented for screening employees, using urine drug testing, identifying aberrant behaviors, and establishing treatment plans when substance abuse is suspected.
This document provides a literature review on opioid use for chronic noncancer pain. It discusses how opioid prescriptions and related harms have increased substantially in recent decades. Several studies highlighted found higher opioid doses were associated with greater risks of overdose and other adverse outcomes. The document also reviews literature on risk evaluation strategies like urine drug testing and treatment agreements. It identifies a need for more research on nurse practitioner-specific guidelines and long-term opioid effectiveness for chronic pain.
This document contains a PowerPoint presentation with images and figures about Thailand's national antiretroviral treatment program from 2000-2007. It discusses the expansion of the program over time, including increasing enrollment numbers across provinces. It also analyzes patient characteristics and survival rates based on baseline CD4 count and enrollment year. The presentation contains copyright information and requires permission for reuse or distribution.
1) Use of psychiatric drugs in the US has increased dramatically in recent decades, with 10% of the population prescribed antidepressants by 2005 and antipsychotics ranking as the top prescription drug in 2009.
2) However, clinical trials have found most psychiatric drugs to be only marginally more effective than placebo for depression and anxiety in adults. For children and adolescents, antidepressants actually show increased risks of suicidality compared to placebo in clinical trials.
3) Stimulants for ADHD show minimal benefits beyond reducing symptoms, with risks including decreased growth and potential for serious adverse cardiac and psychiatric effects. Long-term studies found medication no more effective than behavioral therapies.
This document summarizes trends shaping workers' compensation medication policies in 2014. It discusses the influence of various factors, including political influences from the Affordable Care Act and state elections; clinical influences like an aging population and the opioid epidemic; and product influences as new medications enter the market. It also outlines debates around issues like physician dispensing, compounded medications, medical marijuana, and opioid monitoring programs.
Journal presentation on essential tremorEjaj Ahmed
1) Essential tremor is a syndrome of isolated tremor of the upper limbs that has been present for at least 3 years, with or without tremor in other locations like the head or voice.
2) Propranolol and primidone are first-line pharmacological treatments that can reduce tremor severity by 55-60% through effects on the cortico-ponto-cerebellar-thalamic circuit implicated in essential tremor pathophysiology.
3) When medications are ineffective, neurostimulation techniques like deep brain stimulation targeting the thalamus or focused ultrasound thalamotomy can provide relief of tremors, though effectiveness may diminish over time and risks include ataxia, dys
Use of inotropic and vasoconstrictor medications in the pediatric heart failu...Texas Children's Hospital
This study analyzed data from over 54,000 pediatric patients with heart failure who received intravenous inotropic and/or vasoconstrictive medications. It found that the use of dobutamine and dopamine has decreased in recent years while other medications like milrinone have increased. Dobutamine and norepinephrine were associated with the highest odds ratios of inpatient mortality compared to patients who did not receive intravenous medications. The study concludes that dobutamine and dopamine have fallen out of favor for use in pediatric heart failure patients.
The document discusses drug induced diseases (DIDs), which are unintended harmful effects caused by medications. DIDs can affect many organ systems and cause conditions like skin disorders, lung disease, gastrointestinal issues, and neurological or kidney problems. Common causes of DIDs include nonsteroidal anti-inflammatory drugs, antibiotics, anticancer drugs, and anticonvulsants. DIDs are diagnosed based on symptoms occurring after drug intake. Treatment involves stopping the causative medication and managing symptoms. Preventing DIDs requires informing doctors of medical histories and only taking drugs as prescribed. DIDs remain an important health issue requiring more comprehensive research.
This document discusses issues in assessing and treating patients with co-occurring opiate dependence and chronic pain. It notes that while opiate treatment is commonly used for chronic pain, it can lead to physical dependence, tolerance, and potentially addiction. Assessing for problematic opioid use or addiction involves looking for behaviors like frequent dose increases, non-medical use, doctor shopping, or illicit drug use. Factors like a history of substance abuse or mental health conditions may increase risk. Proper evaluation and treatment should address both the pain condition and risk for opioid misuse or addiction.
This study compared treatment of provoked deep vein thrombosis (DVT) with rivaroxaban versus vitamin K antagonists (VKA). Patients receiving rivaroxaban required significantly fewer clinic visits than those on VKA (2.92 visits versus 14.58 visits). While on VKA, over a third of patients spent less than 60% of time within the therapeutic range and significant time above or below that range. The overall drug costs were similar between the two treatments, but rivaroxaban required less outpatient attendance. The study concludes that for provoked DVT, rivaroxaban results in safer anticoagulation and less clinic visits compared to VKA.
- The document discusses sociological theories of deviance and labeling, including Merton's strain theory, labelling theory proposed by Becker, and the concept of moral panic put forth by Stanley Cohen.
- It also presents a case study of the 1999 Columbine High School massacre, describing the background of the two shooters Eric Harris and Dylan Klebold, the planning and execution of the shootings, and the extensive media reaction in the aftermath.
NCompass Live - March 8, 2017
http://nlc.nebraska.gov/ncompasslive/
Each year when librarians report on their internship experiences we learn more about what worked well and what tips they might have learned along the way that will make for a better internship next time. The one thing that we hear every year is about the importance of planning and selecting an intern that is the right fit for the library and for the tasks that are planned for the internship. JoAnn McManus and Mary Jo Ryan, both with the Nebraska Library Commission, will address the planning involved in preparing for a new intern and share tips to providing your intern--and your library--with a great experience. Although the presentation focuses on ensuring that the newly announced library grant recipients of the 2017 Nebraska Library Internship Grant Program are armed with great information, other libraries will also pick up great tips for how to prepare and make the most out of internships at their libraries.
TRENDS AND PATTERNS OF GEOGRAPHIC VARIATIONS IN OPIOID PRESCRIBINGwith Wind
The document analyzes trends in opioid prescribing practices across US states from 2006 to 2017. It finds that while the total amount of opioids prescribed decreased over this period, the duration of prescriptions increased. Specifically:
- The total amount of opioids prescribed per person decreased 12.8% on average nationally, though there was significant variation between states.
- The mean duration of opioid prescriptions increased 37.6% nationally, with increases in every state.
- Prescriptions for durations of 30 days or longer, which are more likely to treat chronic pain, increased 37.7% nationally, with increases in 39 states.
- However, prescribing rates decreased for high dosages, short durations,
2016: Considerations on Polypharmacy and Adverse Drug Events-WatanabeSDGWEP
The document discusses issues related to polypharmacy and adverse drug events in older adults. It notes that polypharmacy is common in seniors, putting them at higher risk for adverse drug events, hospitalizations, and costs. The document also reviews tools that can help reduce inappropriate polypharmacy and prescribing, such as Beers criteria, STOPP criteria, and comprehensive medication reviews.
This document proposes developing a pharmacogenetic-guided warfarin dosing regimen for Puerto Rican patients starting anticoagulation therapy. It summarizes previous research showing genetics like CYP2C9 and VKORC1 genotypes influence warfarin dosing. The study aims to predict initial doses for 175 Puerto Rican veterans using a pharmacokinetic-pharmacogenetic model and develop a customized dosing algorithm incorporating genotypes and patient factors. Preliminary results show the model predicted doses for 121 patients with few outside the therapeutic range, and the customized algorithm had superior predictability compared to other models for Puerto Ricans.
After starting blood pressure medication, most let other lifestyle changes sl...Δρ. Γιώργος K. Κασάπης
Although physicians recommend that those who take blood pressure medications also keep up with lifestyle changes such as eating healthily and exercising, a large new study suggests that those who start on the drugs may not be adhering to the other advice. Looking at data from a Finnish cohort of nearly 9,000 patients over the age of 40 who started BP treatment, scientists found that these individuals were 82% more likely to become obese and 8% more likely to be physically inactive than those not on treatment.
Still, these people experienced a decline in their average alcohol consumption and were 26% more likely to quit smoking. Doctors ought to continue to emphasize the importance of lifestyle changes even as people start taking BP medication, the authors suggest.
This study examined the association between initial opioid prescribing patterns and the likelihood of long-term opioid use among patients who were opioid-naïve. The study used prescription drug monitoring program data from Oregon to identify over 500,000 patients who filled their first opioid prescription between 2012-2013. It found that receiving multiple prescriptions or higher total morphine milligram equivalents in the first 30 days was associated with greater odds of long-term opioid use (defined as 6 or more fills) in the following year. Patients who started on long-acting opioids also had higher risk than those starting on short-acting drugs. The associations remained after excluding patients likely using opioids for cancer or end-of-life care.
This document summarizes the key points from a conference on managing risk in the workplace by addressing substance abuse issues. The conference objectives are to identify signs of drug addiction, describe employer procedures for substance abuse, and explain potential liabilities. It discusses the opioid epidemic, prescription drug abuse trends, and provides statistics on prescription drug use. Guidelines are presented for screening employees, using urine drug testing, identifying aberrant behaviors, and establishing treatment plans when substance abuse is suspected.
This document provides a literature review on opioid use for chronic noncancer pain. It discusses how opioid prescriptions and related harms have increased substantially in recent decades. Several studies highlighted found higher opioid doses were associated with greater risks of overdose and other adverse outcomes. The document also reviews literature on risk evaluation strategies like urine drug testing and treatment agreements. It identifies a need for more research on nurse practitioner-specific guidelines and long-term opioid effectiveness for chronic pain.
This document contains a PowerPoint presentation with images and figures about Thailand's national antiretroviral treatment program from 2000-2007. It discusses the expansion of the program over time, including increasing enrollment numbers across provinces. It also analyzes patient characteristics and survival rates based on baseline CD4 count and enrollment year. The presentation contains copyright information and requires permission for reuse or distribution.
1) Use of psychiatric drugs in the US has increased dramatically in recent decades, with 10% of the population prescribed antidepressants by 2005 and antipsychotics ranking as the top prescription drug in 2009.
2) However, clinical trials have found most psychiatric drugs to be only marginally more effective than placebo for depression and anxiety in adults. For children and adolescents, antidepressants actually show increased risks of suicidality compared to placebo in clinical trials.
3) Stimulants for ADHD show minimal benefits beyond reducing symptoms, with risks including decreased growth and potential for serious adverse cardiac and psychiatric effects. Long-term studies found medication no more effective than behavioral therapies.
This document summarizes trends shaping workers' compensation medication policies in 2014. It discusses the influence of various factors, including political influences from the Affordable Care Act and state elections; clinical influences like an aging population and the opioid epidemic; and product influences as new medications enter the market. It also outlines debates around issues like physician dispensing, compounded medications, medical marijuana, and opioid monitoring programs.
Journal presentation on essential tremorEjaj Ahmed
1) Essential tremor is a syndrome of isolated tremor of the upper limbs that has been present for at least 3 years, with or without tremor in other locations like the head or voice.
2) Propranolol and primidone are first-line pharmacological treatments that can reduce tremor severity by 55-60% through effects on the cortico-ponto-cerebellar-thalamic circuit implicated in essential tremor pathophysiology.
3) When medications are ineffective, neurostimulation techniques like deep brain stimulation targeting the thalamus or focused ultrasound thalamotomy can provide relief of tremors, though effectiveness may diminish over time and risks include ataxia, dys
Use of inotropic and vasoconstrictor medications in the pediatric heart failu...Texas Children's Hospital
This study analyzed data from over 54,000 pediatric patients with heart failure who received intravenous inotropic and/or vasoconstrictive medications. It found that the use of dobutamine and dopamine has decreased in recent years while other medications like milrinone have increased. Dobutamine and norepinephrine were associated with the highest odds ratios of inpatient mortality compared to patients who did not receive intravenous medications. The study concludes that dobutamine and dopamine have fallen out of favor for use in pediatric heart failure patients.
The document discusses drug induced diseases (DIDs), which are unintended harmful effects caused by medications. DIDs can affect many organ systems and cause conditions like skin disorders, lung disease, gastrointestinal issues, and neurological or kidney problems. Common causes of DIDs include nonsteroidal anti-inflammatory drugs, antibiotics, anticancer drugs, and anticonvulsants. DIDs are diagnosed based on symptoms occurring after drug intake. Treatment involves stopping the causative medication and managing symptoms. Preventing DIDs requires informing doctors of medical histories and only taking drugs as prescribed. DIDs remain an important health issue requiring more comprehensive research.
This document discusses issues in assessing and treating patients with co-occurring opiate dependence and chronic pain. It notes that while opiate treatment is commonly used for chronic pain, it can lead to physical dependence, tolerance, and potentially addiction. Assessing for problematic opioid use or addiction involves looking for behaviors like frequent dose increases, non-medical use, doctor shopping, or illicit drug use. Factors like a history of substance abuse or mental health conditions may increase risk. Proper evaluation and treatment should address both the pain condition and risk for opioid misuse or addiction.
This study compared treatment of provoked deep vein thrombosis (DVT) with rivaroxaban versus vitamin K antagonists (VKA). Patients receiving rivaroxaban required significantly fewer clinic visits than those on VKA (2.92 visits versus 14.58 visits). While on VKA, over a third of patients spent less than 60% of time within the therapeutic range and significant time above or below that range. The overall drug costs were similar between the two treatments, but rivaroxaban required less outpatient attendance. The study concludes that for provoked DVT, rivaroxaban results in safer anticoagulation and less clinic visits compared to VKA.
- The document discusses sociological theories of deviance and labeling, including Merton's strain theory, labelling theory proposed by Becker, and the concept of moral panic put forth by Stanley Cohen.
- It also presents a case study of the 1999 Columbine High School massacre, describing the background of the two shooters Eric Harris and Dylan Klebold, the planning and execution of the shootings, and the extensive media reaction in the aftermath.
NCompass Live - March 8, 2017
http://nlc.nebraska.gov/ncompasslive/
Each year when librarians report on their internship experiences we learn more about what worked well and what tips they might have learned along the way that will make for a better internship next time. The one thing that we hear every year is about the importance of planning and selecting an intern that is the right fit for the library and for the tasks that are planned for the internship. JoAnn McManus and Mary Jo Ryan, both with the Nebraska Library Commission, will address the planning involved in preparing for a new intern and share tips to providing your intern--and your library--with a great experience. Although the presentation focuses on ensuring that the newly announced library grant recipients of the 2017 Nebraska Library Internship Grant Program are armed with great information, other libraries will also pick up great tips for how to prepare and make the most out of internships at their libraries.
Actualmente valores como la dignidad e integridad se van quedando atrás con el pasar del tiempo. Anteriormente se ubicaban en un puesto más importante, eran considerados como los requisitos que las personas deben poseer para el desarrollo de cualquier proyecto que sea considerado serio.
A pesar de que son cada vez más necesarios en la vida profesional y personal de las personas en la actualidad ha pasado a un segundo plano
The document discusses pipeline computing and its various types and applications. It defines pipeline computing as a technique to decompose a sequential process into parallel sub-processes that can execute concurrently. There are two main types - linear and non-linear pipelines. Linear pipelines use a single reservation table while non-linear pipelines use multiple tables. Common applications of pipeline computing include instruction pipelines in CPUs, graphics pipelines in GPUs, software pipelines using pipes, and HTTP pipelining. The document also discusses implementations of pipeline computing and its advantages like reduced cycle time and increased instruction throughput.
El resumen analiza un examen de lengua y literatura, estudios sociales y matemáticas para tercer grado. El examen contiene preguntas sobre un cuento, operaciones matemáticas, vocabulario, gramática, geografía de Nueva Segovia y árboles para reforestar.
This document discusses rainwater harvesting systems. It defines rainwater harvesting as collecting and storing rainwater from surfaces like rooftops or land. There are several types of rainwater harvesting systems, including rooftop catchments, ground catchments, and rock catchments. The typical components of a rainwater harvesting system are catchment areas, gutters, filters, storage tanks, and first flush diverters to improve water quality. Rainwater harvesting provides benefits like independent water supplies during droughts and reducing flood risks while providing potable water. On average, a 10m x 12m roof could collect over 67,000 liters of rainwater annually in a location with 800mm of annual rainfall.
Este documento describe 10 mitos comunes sobre la migración a Microsoft Office 365 en la nube. Los mitos incluyen que Office 365 solo incluye las herramientas de Office en línea, que mantener los datos localmente es más seguro que en la nube, y que la migración a la nube es demasiado compleja. El documento refuta cada mito explicando las ventajas y capacidades reales de Office 365, como que incluye más herramientas de productividad además de Office, que la seguridad es mejor en la nube, y que Microsoft ofrece asist
Peptic ulcer management in the era of nsaidEva Puspita
This document discusses the risks of nonsteroidal anti-inflammatory drugs (NSAIDs) in causing gastrointestinal complications and the role of proton pump inhibitors (PPIs) in managing these risks. It provides evidence that PPIs are effective in healing and preventing gastric ulcers in patients taking NSAIDs, including COX-2 selective NSAIDs. The document specifically highlights studies showing esomeprazole to be more effective than other PPIs at reducing acid secretion and ulcer formation in this high-risk patient population.
This document provides an overview of non-steroidal anti-inflammatory drugs (NSAIDs) and their mechanisms of action. It discusses how NSAIDs work by inhibiting the cyclooxygenase (COX) pathway and thereby reducing the production of prostaglandins, which are mediators of pain, fever, and inflammation. The summary describes the key effects of NSAIDs, including their analgesic, antipyretic and anti-inflammatory properties through suppression of prostaglandin synthesis. It also briefly mentions the risks of NSAID use, such as potential gastrointestinal toxicity.
This document contains an architectural design plan for a residential property consisting of 3 sentences:
The design plan includes drawings of the plot size, location and site plan, floor plans for the ground floor and first floor, exterior views of the front, north-east and east sides of the building, and details of features like the puja ghar, living room, kitchen, bedrooms, bathroom and balcony.
It provides information on the architects, owners, and floor area of 216 square meters for the property.
The document appears to be a presentation on the architectural design for a residential building that was presented by a group of 6 people.
Este documento describe la estrategia de búsqueda utilizada para encontrar artículos de revisión sobre la prevención de la obesidad y el sobrepeso en niños y adolescentes. La búsqueda inicial usó descriptores como "prevención", "obesidad", "sobrepeso", "niños" y "adolescentes", obteniendo más de 16,000 resultados. Luego, se aplicaron filtros como tipo de artículo, fecha, idioma, sexo y edad, reduciendo los resultados a solo 10 artículos relevantes.
This document discusses the selection of biological methods for assessing the quality of industrial effluents. It identifies existing bioassays for evaluating acute and chronic toxicity of wastewater. Biological methods can be divided into microbiological, limnological, and ecotoxicological tests. Common ecotoxicological tests identified include those using algae, microcrustaceans like Daphnia, fish, and bacteria to analyze effluent toxicity. The document compares different test methods and variables for routinely monitoring effluents and researching their impacts.
- NSAIDs are the most commonly prescribed drugs for chronic pain but can have serious side effects.
- While effective for pain relief and inflammation, all NSAIDs inhibit the COX enzyme and can increase risks of gastrointestinal bleeding, kidney damage, and cardiovascular events.
- Newer COX-2 inhibitors were found to have lower risk of gastrointestinal side effects but similar or higher risk of cardiovascular events compared to other NSAIDs.
- Due to their risks and side effects, NSAIDs should generally only be used at the lowest effective dose for the shortest necessary time period. Non-drug alternatives and treatments should also be considered.
Three species of vultures in South Asia, including the white-rumped vulture, have seen their populations decline by over 90% in recent decades due to the use of the veterinary drug diclofenac. Diclofenac is toxic to vultures and causes kidney failure when they eat the remains of livestock treated with the drug. Conservation efforts are underway to breed vultures in captivity and ban dangerous drugs, but diclofenac contamination of the vultures' food supply still threatens their survival. International organizations like IUCN are working with countries in the region to establish protected zones and continue conservation actions to save South Asia's critically endangered vultures from extinction.
Inflammation is the body's protective response to injury or infection that can lead to tissue damage. Inappropriate activation of the immune system can cause inflammation and lead to autoimmune diseases like rheumatoid arthritis (RA). In RA, white blood cells attack the synovium, stimulating T lymphocytes and macrophages to secrete pro-inflammatory cytokines that cause further inflammation and joint damage. Nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs) are used to treat RA by reducing inflammation and slowing disease progression. NSAIDs work by inhibiting cyclooxygenase enzymes and reducing prostaglandin production, while DMARDs target specific inflammatory cytokines involved in RA pathogenesis.
A study on prescription pattern and rational use of statins in tertiary care ...SriramNagarajan16
Objectives
Our objectives are to evaluate prescription pattern and rational use of statins in a tertiary care corporate hospital.
Methodology
It was a prospective observational study conducted for a period of 6 months and included various departments of 300
bedded multi specialty tertiary care corporate hospital. A total of 200 patients were included and the study criteria
was inpatients and induvial more than 18 years of either gender who are prescribed with HMG-CoA reductase
inhibitors.
Results
In the present study 200 patients belonged to the age group of above 18 years, out of which about 65% were male
and 35% were female. Atorvastatin (67%) was prescribed mostly and Rosuvastatin (29.5%) was also used.
Conclusion
It is finally concluded that Rational and prophylactic use of statins can reduce further complications of Diabetes
Mellitus (DM) and cardiac events.
Statins treatment is favourable in long term treatment of diseases, it is most effectively used in treatment of serious
disease conditions which has shown its immense therapeutic role in treatment
How are you feeling today and general health like that is the rest and general anaesthetic drugs and the rest and general issues are not good enough to drive through the rest of us and the rest is the rest and general issues and the rest is the best way of being with you all the way to work and I was in
Trends in Psychotropic Medication Costsfor Children and Adol.docxwillcoxjanay
Trends in Psychotropic Medication Costs
for Children and Adolescents, 1997-2000
Andrés Martin, MD, MPH; Douglas Leslie, PhD
Objective: To examine trends in psychotropic medi-
cation utilization and costs for children and adolescents
between January 1, 1997, and December 31, 2000.
Methods: Pharmacy claims were analyzed for mental
health users 17 years and younger (N = 83 039) from a
national database covering 1.74 million privately in-
sured youths. Utilization rates and costs for dispensed
medications were compared across psychotropic drug cat-
egories and individual agents over time.
Results: Overall use of psychotropic drugs increased from
59.5% of mental health outpatients in 1997 (a 1-year
prevalence of 28.7 per 1000) to 62.3% in 2000 (33.7 per
1000), a 4.7% increase. The largest changes in utiliza-
tion were seen for atypical antipsychotics (138.4%), atypi-
cal antidepressants (42.8%), and selective serotonin re-
uptake inhibitors (18.8%). The average prescription price
increased by 17.6% ($7.90 per prescription), a change
in turn attributed to a shift toward costlier medications
within the same category (55.1% of the increase, or $4.35)
and to pure inflation (44.9% of the increase, or $3.55;
P for trend �.001 for all comparisons). Almost half
(46.7%) of the $2.7 million gross sales differential was
accounted for by only 3 of the 39 drugs identified (am-
phetamine compound, risperidone, and sertraline), and
75% was accounted for by 7 drugs (the previous 3 and
bupropion, paroxetine, venlafaxine, and citalopram).
Conclusions: Psychotropic drug expenditure increases
during the late 1990s resulted from more youths being
prescribed drugs, a preference for newer and costlier medi-
cations, and the net effects of inflation. The impact of man-
aged care and pharmaceutical marketing effects on these
trends warrants further study.
Arch Pediatr Adolesc Med. 2003;157:997-1004
T
HE USE of psychotropic
medications in children has
become a highly visible is-
sue, receiving regular at-
tention from academics (for
a recent summary, see Jensen et al1), poli-
cymakers,2,3 and the lay press alike.4-6 In
contrast to the controversial and at times
charged reactions that the topic can en-
gender, reliable national estimates of the
extent of pediatric use of psychotropic
drugs have only recently started to be-
come available.7-9 Previous studies10,11 have
documented that most psychotropic medi-
cations are not prescribed by mental health
specialists but rather by general practi-
tioners, a pattern that is certainly appli-
cable to stimulants, the most widely used
psychotropic drug class for children: in
1995, pediatricians prescribed 50% of
stimulants, family practitioners 20%, and
psychiatrists only 13%.8
The financial implications of pediat-
ric pharmacotherapy have gone largely un-
examined, an important shortcoming given
that in the US expenditures for prescrip-
tion drugs have continued to be the fastest
growing component of health care across
a ...
This study analyzed opioid prescription trends among medical specialties in the U.S. from 2007-2012 using a national prescription database. The key findings were:
- Primary care specialties (family practice, internal medicine, general practice) accounted for nearly half of all dispensed opioid prescriptions in 2012.
- Specialties treating pain conditions like pain medicine, surgery, and physical medicine had the highest rates of opioid prescribing.
- Overall opioid prescribing rates increased from 2007-2010 but stabilized from 2010-2012 as most specialties reduced rates.
- The greatest increase in opioid prescribing was among physical medicine specialists, while the largest decreases were in emergency medicine and dentistry.
Adverse Drug Reactions Risk Factors, Epidemiology, and Management Strategiesijtsrd
Objectives The objective of this article is to review the impact of various factors on the occurrence of Adverse Drug Reactions ADRs . Summary ADRs can be caused by several factors, including patient related, drug related, and social factors. Age is a crucial factor in the occurrence of ADRs, with both very young and very old patients being more vulnerable than other age groups. Alcohol consumption also plays a significant role in ADRs. Other factors that affect ADRs include gender, race, pregnancy, breastfeeding, kidney problems, liver function, drug dose and frequency, and many others. The medical literature has extensively documented the impact of these factors on ADRs. Taking these factors into account during medical evaluation enables healthcare professionals to choose the most appropriate medication regimen for their patients. Conclusion Various factors affect the occurrence of ADRs, some of which can be changed such as smoking or alcohol consumption while others cannot be changed such as age or genetic factors . Understanding the impact of these factors on ADRs can help healthcare professionals to select the best medication for their patients and provide them with appropriate advice. Pharmacogenomics, a new and innovative science, emphasizes the genetic predisposition of ADRs, providing a new perspective in the drug selection decision making process. B. Divya Durga "Adverse Drug Reactions- Risk Factors, Epidemiology, and Management Strategies" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-7 | Issue-2 , April 2023, URL: https://www.ijtsrd.com.com/papers/ijtsrd56216.pdf Paper URL: https://www.ijtsrd.com.com/pharmacy/other/56216/adverse-drug-reactions-risk-factors-epidemiology-and-management-strategies/b-divya-durga
A Cross Sectional Study of Ethnic Differences in Occurrence and Severity of A...iosrphr_editor
Non-steroidal anti-inflammatory drugs are the most widely used "over the counter" medication all over the world despite their complications in different major organs. Present studies envisaged for knowing the occurrence and severity of adverse drug reactions from NSAIDs in different ethnic communities of Sikkim. A cross sectional study was undertaken in the medicine outpatients department of a secondary and tertiary care hospital. The patients belonging to Nepalese, Bhutias, Lepchas ethnic communities and others community (settlers from other parts of India) were included to analyzed the data based on the age and gender, ethnicity and ADRs, drugs and ADRs. Severity assessment was done using Hartwing and Siegel scale and causality assessment by Naranjo scale. Total 109 cases of ADRs, predominating in female were detected. Nepalese were the most affected and Gastrointestinal tract (GIT) being the most affected organ in them. Diclofenac showed maximum number of ADRs in all the communities. Maximum number of cases occurred on single day use (40.36%) of drugs. All the cases were belonging to the "possible category" and the maximum being the mild (72.48%) in nature. It is advisable to consider the ethnic/racial differences equally with other factors, to improve the safety and efficacy of a drug.
This study aimed to detect adverse drug reactions (ADRs) induced by cardiovascular drugs using trigger tools in outpatient departments in Nasik City, India. A total of 180 patient prescriptions were analyzed to identify triggers, which are clues that signal potential ADRs. 21 triggers were found in 11.66% of prescriptions. 14 ADRs were detected using the triggers, for a success rate of 71%. However, 6 triggers did not detect any ADRs, for a failure rate of 29%. The most common ADRs detected were hypotension, hypertension, vertigo and cough. This study demonstrates that trigger tools can effectively detect ADRs, but requires further improvement to reduce the failure rate.
Adverse drug reactions among critically ill patients at cairoAlexander Decker
The study aimed to assess the frequency and outcomes of adverse drug reactions among critically ill patients at Cairo University Hospital. The study found that 21% of the 150 critically ill patients studied experienced adverse drug reactions, ranging from mild to moderate or severe. Over half of the reactions were life-threatening. Due to the prevalence of adverse drug reactions in critically ill patients and their potential severity, the study recommends hospitals establish policies for managing adverse drug reactions and for healthcare providers to closely monitor patients and potential drug interactions when initiating new medications.
PHARMACOVIGILANCE TERMINOLOGIES ASKED IN INTERVIEWS-
For more information regarding PHARMACOVIGILANCE, CLINICAL RESEARCH, CLINICAL DATA MANAGEMENT & DRUG REGULATORY AFFAIRS kindly contact us on 9028839789
Patterns of Opioid Use and Risk of Opioid Overdose Death Among Medicaid PatientsPaul Coelho, MD
This study examined patterns of opioid use and risk of opioid overdose death among 150,821 noncancer pain patients in the Washington Medicaid program between 2006 and 2010. The results showed that compared to patients taking 1-19 mg per day of opioids, the risk of overdose death significantly increased at higher daily doses of 50 mg or more. Patients using both long-acting and short-acting Schedule II opioids had nearly 5 times the risk of overdose death compared to those using non-Schedule II opioids alone. Concurrent use of sedative-hypnotics, even at low opioid doses, was associated with a substantially greater risk of overdose death.
Patterns of opioid use and risk of opioid overdose.Paul Coelho, MD
This study examined patterns of opioid use and risk of opioid overdose death among 150,821 noncancer pain patients in the Washington Medicaid program between 2006 and 2010. The results showed that risk of overdose death significantly increased with higher average daily opioid doses, with a 4.9 times higher risk at doses of 200 mg or more per day compared to doses of 1-19 mg. Patients using both long-acting and short-acting Schedule II opioids had a 4.7 times higher risk than those using non-Schedule II opioids alone. Concurrent use of sedative-hypnotics was associated with a significantly increased risk of overdose death compared to nonuse, with benzodiazepines and skeletal muscle relaxants posing the
Regulatory terminologies used in PV (Pharmacovigilance)MubasheeraMg
This document defines various regulatory terminologies used in pharmacovigilance (PV). It defines key terms like pharmacovigilance, adverse drug reactions, clinical trials, causality assessment, and data mining. It also provides definitions for terms related to evaluating drug safety like absolute risk, incidence, benefits, harms, and effectiveness/risk analysis. Regulatory organizations involved in PV like CIOMS, ICH, and MedDRA are also defined.
Problems and challenges faced in consumer reporting of adverse drug reactions...Mohammed Alshakka
This document discusses consumer reporting of adverse drug reactions (ADRs) in developing countries like Yemen, Nepal, and Malaysia. It finds that Malaysia has a good system for consumer involvement, while Yemen lacks drug policies and regulation. Nepal's system is still developing and lacks consumer reporting. Consumer reporting can provide additional information to national pharmacovigilance programs and help reduce ADR-related illness, but is still not widely implemented in developing countries.
Impact of potential inappropriate nsai ds use in chronic painAbout Silvia Ussai
This study analyzed data from a pharmacovigilance surveillance system to assess patterns of NSAID and opioid use in patients with chronic pain. It found that 97% of patients used NSAIDs for over 21 consecutive days, which is considered potentially inappropriate. About one-fourth of long-term NSAID users also took medications for gastrointestinal issues. The study estimated that the annual cost per individual for long-term NSAID use combined with gastrointestinal medications was 61.23 euros. Only 11% of patients received opioids, and only 2% used them long-term over 90 days. The study found no evidence of escalating opioid dosages, a proxy for dependence risk.
Pharmacovigilance: The conscientious today for safe tomorrowpharmaindexing
This document discusses pharmacovigilance, which is the detection, assessment, understanding, and prevention of adverse drug reactions. It describes traditional pharmacovigilance methods like spontaneous reporting systems and their limitations. It also outlines new approaches to strengthen pharmacovigilance, including broadening reporter bases to include patients, using quantitative signal detection methods to analyze large reporting databases, and leveraging electronic health records and administrative databases for observational studies.
This document discusses adverse drug reactions (ADRs), including:
1) Defining ADRs and distinguishing them from adverse drug events. ADRs are unintended effects caused directly by a drug, while adverse events can have other causes.
2) Around 5-10% of hospitalized patients experience an ADR, contributing to increased costs and length of stay. ADRs can reduce quality of life and rarely cause death.
3) Pharmacovigilance aims to detect, understand, and prevent ADRs through monitoring, reporting, and research on drug safety. Pharmacists play a key role in pharmacovigilance.
Pharmacovigilance involves monitoring the safety of drugs at all stages, from development through post-marketing. It aims to detect, understand, and prevent adverse drug reactions through activities like adverse event reporting, drug monitoring, and studying medication errors and drug-related deaths. Pharmacovigilance is important for protecting public health as patterns of drug use change over time with globalization and advances in technology and medicine.
1) The document defines many terms used in pharmacovigilance, including adverse event, adverse reaction, causality assessment, signal, and serious adverse reaction.
2) An adverse event is any untoward medical occurrence during treatment but not necessarily caused by the treatment, while an adverse reaction is characterized by a suspected causal relationship to the treatment.
3) A signal refers to reported information about a potential causal relationship between an adverse event and drug that was previously unknown or incompletely documented.
West Virginia has high rates of opioid and benzodiazepine prescription and misuse according to the document. It ranks third highest for opioid prescriptions per capita and first for benzodiazepine prescriptions. In 2014 over 400,000 opioid prescriptions and 300,000 benzodiazepine prescriptions were filled for West Virginia Medicaid recipients. West Virginia Medicaid has policies like quantity limits and a lock-in program to curb prescription drug abuse and encourages providers and recipients to follow best practices for responsible prescribing and use.
This document contains summaries of several research papers on topics related to chronic pain, suicide risk, and bipolar disorder:
1) One study found that tapering opioid doses for chronic pain patients was associated with increased risks of overdose and mental health crisis compared to patients who did not taper. Higher tapering speeds were linked to even greater risks.
2) Another study observed chronic pain patients undergoing opioid tapering or transition to buprenorphine treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine use predicted dropout. Pain levels varied after treatment.
3) Research on combat veterans found that those exposed to combat had higher rates of PTSD, suicide attempts, strokes and chronic pain
Labeling Woefulness: The Social Construction of FibromyalgiaPaul Coelho, MD
This document discusses the social construction of fibromyalgia and how it has been established as a legitimate disease label despite a lack of clear biological or clinical evidence. It argues that fibromyalgia serves social and economic purposes for various groups, including patients, doctors, pharmaceutical companies, and the media, but poses risks by medicalizing psychosocial problems. The document proposes that widespread pain is a normal human experience for some that is best addressed by exploring psychosocial factors rather than believing the solution lies in neurobiology. Examining fibromyalgia as a social construct may be more helpful for patients than continuing to medicalize their experiences.
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrosp...Paul Coelho, MD
This study analyzed outcomes for 240 patients with chronic pain who were prescribed long-term opioid therapy above 90 mg morphine-equivalent daily doses. Patients were offered an outpatient opioid taper or transition to buprenorphine if taper was not tolerated. 44.6% successfully tapered, 18.8% transitioned to buprenorphine, and 36.6% dropped out of treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine/z-drug use predicted greater dropout. Pain intensity changes after treatment were mixed, with over half of tapered patients reporting increased pain and about half of transitioned patients reporting decreased pain.
This document appears to be a questionnaire assessing symptoms of widespread pain and calculating a WPI (Widespread Pain Index) score and SS (Symptom Severity) score. It asks the respondent to indicate areas of pain on a diagram and rate the severity of symptoms like fatigue, thinking difficulties, and unrefreshed sleep. It also inquires about additional symptoms like abdominal pain, depression, and headaches. The final section rates pain-related worry and fear on a scale. Additional questions determine if the respondent has a workers compensation or disability claim related to their pain complaint.
Fibromyalgia is a condition that causes chronic aches and pains all over the body, fatigue, and often a sleep disorder. The doctor diagnosed the patient with fibromyalgia based on a score of 13 or more on the fibromyalgia questionnaire from the American College of Rheumatology, which is consistent with the syndrome. By focusing on and managing the diagnosis of fibromyalgia, the patient's other pain symptoms can decrease.
This document contains two studies related to psychological treatments for chronic conditions:
1) A study of chronic fatigue syndrome patients found that poorer outcomes were predicted by membership in a self-help group, receiving sickness benefits, and symptoms of dysphoria. Severity and duration of symptoms did not predict response.
2) A randomized controlled trial of 125 fibromyalgia patients compared operant behavioral therapy, cognitive behavioral therapy, and attention placebo. Both behavioral therapies significantly reduced pain intensity while cognitive therapy improved cognitive and affective variables and operant therapy improved physical functioning and behaviors. The attention placebo resulted in no improvement or deterioration.
This document summarizes three studies on the risks and efficacy of opioids for chronic non-cancer pain (CNP). The first study finds that while opioids were associated with small improvements in pain and physical functioning compared to placebo, they also increased the risk of vomiting. Comparisons to other medications found similar benefits to pain and functioning. The second study finds no difference in pain-related function between opioid and non-opioid groups over 12 months, and higher rates of adverse effects and pain intensity in the opioid group. The third study finds limited effectiveness of opioids for CNP, as opioid users did not report improvements in outcomes after 2 years. Regarding risks, higher opioid doses are associated with increased overdose risk across several patient groups in
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
Mortality quadrupled among opioid-driven hospitalizations notably within lowe...Paul Coelho, MD
This study analyzed national hospitalization data from 1993-2014 to examine trends in mortality and characteristics of hospitalizations related to opioids compared to other drug and non-drug hospitalizations. The key findings were:
1) Mortality among opioid-related hospitalizations quadrupled from 0.43% before 2000 to 2.02% in 2014, increasing 0.12 percentage points per year relative to other drug hospitalizations.
2) While total opioid-related hospitalizations remained stable, diagnoses shifted from opioid dependence/abuse to opioid/heroin poisoning, which have higher mortality rates. Hospitalizations for poisoning grew by 0.01 per 1,000 people annually after 2000.
3) Patients hospitalized for opioid/
Prescriptions filled following an opioid-related hospitalization.Paul Coelho, MD
This study analyzed prescription drug fills within 30 days of discharge for 36,719 patients hospitalized for opioid misuse. Only 16.7% received medications approved for opioid dependence, while 40.3% filled antidepressant prescriptions and 22.4% filled opioid pain medication prescriptions. Concurrently, 13.9% filled benzodiazepine prescriptions and 7.4% filled both benzodiazepine and opioid prescriptions, indicating a need for improved education on risks. Overall, more effort is required to ensure patients receive recommended post-hospitalization treatment and support services.
This study examined the risk of psychiatric hospitalization in the offspring (second generation) of Finns who were evacuated to Sweden without parents during World War II (first generation), compared to offspring of Finns who were not evacuated. The study found that daughters of mothers who were evacuated during childhood had an elevated risk of psychiatric hospitalization, especially for mood disorders. However, there was no increased risk found for offspring of evacuated fathers or for male offspring of evacuated mothers. This suggests that early childhood adversity experienced by the first generation, such as war-related trauma, may be associated with mental health problems that persist into the second generation.
Correlation of opioid mortality with prescriptions and social determinants -a...Paul Coelho, MD
This study analyzed Medicare Part D data from 2013-2014 to examine the relationship between opioid prescription rates, socioeconomic factors, and opioid-related mortality rates at the county level in the United States. The results showed that higher county-level opioid prescription rates, especially those from emergency medicine, family medicine, internal medicine, and physician assistants, were associated with higher opioid-related mortality rates. Higher poverty levels and proportions of white populations in counties also correlated with increased mortality. Additionally, prescribers in the highest quartile of opioid prescription rates had a disproportionate impact on mortality compared to the remaining 75% of prescribers.
This report examines CMS's oversight of Medicare Part D beneficiaries who receive opioid prescriptions and providers who prescribe opioids to these beneficiaries. It finds that while CMS provides guidance to Part D plan sponsors on monitoring beneficiaries at high risk of opioid overuse, it lacks complete data on the full population of beneficiaries at risk. It also finds that CMS oversees prescribing through its contractor NBI MEDIC but does not specifically analyze opioid prescription data or require reporting on actions taken regarding inappropriate opioid prescribing. The report concludes that CMS needs more comprehensive oversight to reduce the risks of opioid misuse, overdose, and inappropriate prescribing among Medicare beneficiaries.
The place-of-antipsychotics-in-the-therapy-of-anxiety-disorders-and-obsessive...Paul Coelho, MD
This document summarizes a research article about the use of antipsychotic drugs in the treatment of anxiety disorders and obsessive-compulsive disorders. The review finds evidence that certain second-generation antipsychotics (SGAPs), like quetiapine, risperidone, and aripiprazole, can be effective for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD). Quetiapine in particular receives a recommendation as a first-line treatment for GAD. However, the review finds insufficient evidence for SGAPs in the treatment of social anxiety disorder and panic disorder. First-generation antipsychotics are not recommended for any anxiety disorders based on their side effect profiles
Structured opioid refill clinic epic smartphrases Paul Coelho, MD
#*** I explained to the patient the risks of combining opioids and benzodiazepines based on medical literature. We agreed to slowly taper the patient off benzodiazepines and trial safer alternatives for sleep and anxiety issues.
#*** I showed the patient their fibromyalgia screening questionnaire results, which were consistent with a fibromyalgia diagnosis. Fibromyalgia can amplify other painful conditions and is often the primary source of morbidity when present with other chronic pain diagnoses.
#*** We discussed the patient's high risk opioid regimen based on their dose exceeding CDC guidelines. While willing to work on a harm reduction plan, it will require a taper or switching to buprenorphine due to safety concerns.
Opioids for the Treatment of Chronic Pain: Mistakes Made, Lessons Learned, an...Paul Coelho, MD
This document summarizes the key issues regarding the use of opioids for chronic pain treatment:
1) An overreliance on opioids to treat chronic pain has contributed to the prescription opioid abuse epidemic in the US, as outpatient use allows for abuse and diversion of these addictive drugs.
2) While clinical trials show opioids effectively treat acute pain and are initially effective for chronic pain, real-world use reveals increased risks of abuse, addiction, and poor functional outcomes over the long-term.
3) The evidence supporting chronic opioid therapy was limited and observational in nature, yet convinced the medical community until larger population studies showed increased abuse rates contrary to initial assumptions.
The potential adverse influence of physicians’ words.Paul Coelho, MD
The physician's words can inadvertently amplify patients' symptoms and increase somatic distress if not carefully considered. Learning about potential side effects from medications, procedures, or test results can lead patients to experience and report those effects more frequently through psychological mechanisms like misattribution and increased attention to bodily sensations. Discussing concepts like nocebo and viscerosomatic amplification with patients can help provide reassuring explanations for symptoms and make them feel less intrusive. Physicians should thoughtfully consider their word choices and focus on benefits as well as side effects to minimize undue distress.
This document is an evidence report published by the Institute for Clinical and Economic Review (ICER) that evaluates the comparative clinical effectiveness and value of cognitive and mind-body therapies for chronic low back and neck pain. It was authored by Jeffrey Tice and others from ICER. The report assesses the clinical evidence on therapies such as cognitive behavioral therapy and mindfulness-based stress reduction and presents economic analyses of the long-term cost-effectiveness and potential budget impact of these therapies. It also incorporates input from clinical experts and stakeholders.
The conundrum of opioid tapering in long term opioid therapy for chronic pain...Paul Coelho, MD
The document discusses the challenges clinicians face when tapering patients off long-term opioid therapy for chronic pain. It explains that opioid dependence can cause worsening pain, psychiatric symptoms, and functioning during tapering due to neuroplastic changes. While tapering seems logical to address risks of high-dose opioids, it may paradoxically make a patient's issues worse due to protracted abstinence syndrome. The document provides guidance for managing these complex patients focused on both pain and opioid dependence.
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Test bank calculating drug dosages a patient safe approach to nursing and math 2nd edition by castillo werner mccullough
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A heightened child formula, with the trio of Nano Calcium, HMO, and DHA mixed in the golden ratio, combined with NANO technology to help nourish the body deeply and comprehensively, helps children increase height, boost brain power, and improve the immune system and overall well-being.
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Cancer treatment has advanced significantly over the years, offering patients various options tailored to their specific type of cancer and stage of disease. Understanding the different types of cancer treatments can help patients make informed decisions about their care. In this ppt, we have listed most common forms of cancer treatment available today.
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1. Use of Non-Steroidal Anti-Inflammatory Drugs That
Elevate Cardiovascular Risk: An Examination of Sales and
Essential Medicines Lists in Low-, Middle-, and High-
Income Countries
Patricia McGettigan1
, David Henry2,3,4
*
1 William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom, 2 Institute for Clinical Evaluative Sciences, Toronto,
Canada, 3 Department of Medicine, University of Toronto, Toronto, Canada, 4 School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
Abstract
Background: Certain non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., rofecoxib [Vioxx]) increase the risk of heart attack
and stroke and should be avoided in patients at high risk of cardiovascular events. Rates of cardiovascular disease are high
and rising in many low- and middle-income countries. We studied the extent to which evidence on cardiovascular risk with
NSAIDs has translated into guidance and sales in 15 countries.
Methods and Findings: Data on the relative risk (RR) of cardiovascular events with individual NSAIDs were derived from
meta-analyses of randomised trials and controlled observational studies. Listing of individual NSAIDs on Essential Medicines
Lists (EMLs) was obtained from the World Health Organization. NSAID sales or prescription data for 15 low-, middle-, and
high-income countries were obtained from Intercontinental Medical Statistics Health (IMS Health) or national prescription
pricing audit (in the case of England and Canada). Three drugs (rofecoxib, diclofenac, etoricoxib) ranked consistently highest
in terms of cardiovascular risk compared with nonuse. Naproxen was associated with a low risk. Diclofenac was listed on 74
national EMLs, naproxen on just 27. Rofecoxib use was not documented in any country. Diclofenac and etoricoxib
accounted for one-third of total NSAID usage across the 15 countries (median 33.2%, range 14.7–58.7%). This proportion did
not vary between low- and high-income countries. Diclofenac was by far the most commonly used NSAID, with a market
share close to that of the next three most popular drugs combined. Naproxen had an average market share of less than
10%.
Conclusions: Listing of NSAIDs on national EMLs should take account of cardiovascular risk, with preference given to low
risk drugs. Diclofenac has a risk very similar to rofecoxib, which was withdrawn from worldwide markets owing to
cardiovascular toxicity. Diclofenac should be removed from EMLs.
Please see later in the article for the Editors’ Summary.
Citation: McGettigan P, Henry D (2013) Use of Non-Steroidal Anti-Inflammatory Drugs That Elevate Cardiovascular Risk: An Examination of Sales and Essential
Medicines Lists in Low-, Middle-, and High-Income Countries. PLoS Med 10(2): e1001388. doi:10.1371/journal.pmed.1001388
Academic Editor: Fiona Mary Turnbull, The George Institute for Global Health, Australia
Received September 10, 2012; Accepted January 3, 2013; Published February 12, 2013
Copyright: ß 2013 McGettigan, Henry. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The William Harvey Research Institute and the Institute for Clinical Evaluative Sciences assisted with the purchase of data for this study. No external
funding was received. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript
Competing Interests: The authors have declared that no competing interests exist.
Abbreviations: EML, Essential Medicines List; NSAID, non-steroidal anti-inflammatory drug; RR, relative risk; WHO, World Health Organization.
* E-mail: david.henry@ices.on.ca
PLOS Medicine | www.plosmedicine.org 1 February 2013 | Volume 10 | Issue 2 | e1001388
2. Introduction
Non-steroidal anti-inflammatory drugs (NSAIDs) are among the
most widely used of therapeutic agents. Taken singly or in
combination with other classes of drug, they relieve symptoms
across multiple clinical indications, including short and long term
pain states and a range of musculoskeletal disorders.
Serious adverse effects of NSAIDs are well understood, being
related largely to their underlying mechanisms of action [1].
Extensive pharmaco-epidemiological studies and meta-analyses
have documented hazards, in particular serious gastrointestinal
[2,3] and cardiovascular complications [4–9]. These studies have
enabled some discrimination in risk between individual members
of this large class of drugs, providing guidance on selection
according to patient risk profiles [10]. Gastrointestinal damage can
be reduced by co-prescription of proton pump inhibitors [11]. In
contrast, there is no convincing evidence that low dose aspirin
mitigates the cardiovascular risk of NSAIDs [12,13]. Faced with
patients at high risk of cardiovascular events, prescribers have a
choice of advising against use of a NSAID or recommending a
drug with a lower risk. This dilemma is not limited to doctors
working in high-income countries. With the widespread use of
NSAIDs and a steep rise in cardiovascular disease, it is a particular
concern in low- and middle-income countries [14].
Precise summary information on cardiovascular risk with
NSAIDs has been available since 2006 and current evidence
suggests that there are significant differences between commonly
used members of the class [4–9,13]. There are strong reasons for
choosing low risk NSAIDs in those at high risk of cardiovascular
events. Our interest here is the extent to which this is reflected in
Essential Medicines Lists (EMLs) and in data on sales across
several countries.
Methods
Estimating Cardiovascular Risk with Individual Drugs
We ranked NSAIDs by cardiovascular risk (with non-use as
reference) using relative risk (RR) values derived from published
meta-analyses of randomised trials and controlled observational
studies that reported RR for three or more individual drugs [4–9].
Data on pairwise comparisons of individual agents, representing
the least confounded comparisons of RR, were obtained from the
most recent meta-analysis [9].
Essential Medicines Lists
Essential medicines are those satisfying the priority health care
needs of the population. They are selected with due regard
to public health relevance, evidence on efficacy and safety, and
comparative cost-effectiveness. We determined the NSAIDs
recommended by the World Health Organization (WHO) in its
Model List of Essential Medicines [15], and by individual
countries with published national EMLs [16]. National EMLs
are informed by the WHO Model List of Essential Medicines and
modified to reflect national health care priorities [17]. For the
countries with published EMLs, we compared the information on
cardiovascular risk with individual NSAIDs and their inclusion in
the country EML.
Measuring Sales of NSAIDs in Different Countries
Intercontinental Medical Statistics Health (IMS Health) tracks
over 80% of global pharmaceutical use by sampling individual
country sales through multiple supply routes to retail pharmacies
and hospitals (http://www.imshealth.com/portal/site/ims/).
These sales include both indirect sales from wholesalers and
direct sales from manufacturers. In some countries, hospital audits
are based on data sourced from hospital pharmacies. In each
country, the sampling data are projected to estimate sales for the
whole country. We purchased data from IMS Health on the mass
of individual NSAIDs sold in 2011 in 13 countries in the South
Asian, Southeast Asian, and Asian Pacific regions (Multinational
Integrated Data Analysis, MIDAS). The countries included in the
analyses were: Australia, Bangladesh, China, China (Hong Kong),
Indonesia, Malaysia, New Zealand, Pakistan, Philippines, Singa-
pore, Taiwan, Thailand, and Vietnam. The data reflected retail
pharmacy and hospital sales in all countries except Bangladesh
and Pakistan (retail pharmacy sales) and China (hospital sales).
Defined daily doses (DDD), established by the WHO Collaborat-
ing Centre for Drug Statistics Methodology (WHOCC), permit
comparisons of use between different drugs and across different
countries [18]. We calculated the numbers of DDD of individual
NSAIDs for each country using the values published by the
WHOCC [18].
Data on NSAID prescriptions dispensed in the community in
England during 2011 were obtained from public prescription cost
analysis reports [19]. For Canada, we purchased data on NSAID
prescriptions dispensed in the community during 2011 from IMS
Brogan (IMS Brogan Inc., Ottawa, Canada). We did not have
sufficient information to convert prescription data to DDD, but
assumed that the proportionality of market shares for individual
NSAIDs calculated from prescriptions would be equivalent to that
derived from sales data.
Results
Cardiovascular Risk with Individual NSAIDs
The meta-analyses were fairly constant in their findings
(Table 1). The NSAIDs that had consistently higher cardiovascular
risks (RRs) were rofecoxib, etoricoxib, and diclofenac. All were
found to have a higher RR than naproxen in pairwise analyses in
the most recent published meta-analysis [9]. Indometacin and
meloxicam had moderately elevated RR values that were
significantly greater than naproxen [9]. Etodolac was found to
have an elevated risk but in pairwise analysis, it did not have a
statistically significantly higher RR than naproxen [9]. Celecoxib
and ibuprofen were associated with elevated RR values when used
in clinical trials in high doses but not in the lower doses typically
used in the community. We judged naproxen to have the lowest
risk. Five of the six meta-analyses found it to be risk-neutral
(Table 1). We classified rofecoxib, etoricoxib, and diclofenac as
‘‘high risk’’ drugs for the purpose of analysis. This is conservative
in that other NSAIDs could also be considered high risk.
EML Inclusions
The WHO Model List of Essential Medicines includes three
drugs, paracetamol, acetyl salicylic acid (aspirin), and ibuprofen, in
the category ‘‘non-opioids and non-steroidal anti-inflammatory
medicines.’’ Of 100 countries with EMLs published on the WHO
website, most included fewer than six agents in this class. The
NSAIDs most commonly recommended were: aspirin (88 coun-
tries), ibuprofen (90 countries), diclofenac (74 countries), indome-
tacin (56 countries), and naproxen (27 countries) (Table S2).
Significantly, 51 of the countries that listed diclofenac did not list
naproxen. Selective cyclooxygenase-2 (cox-2) inhibitors were
included on the EMLs of 12 countries. Of 86 EMLs published
or updated since 2007, diclofenac was listed on 74, naproxen on
27.
An Examination of NSAID Sales in 15 Countries
PLOS Medicine | www.plosmedicine.org 2 February 2013 | Volume 10 | Issue 2 | e1001388
3. Patterns of NSAID Use
Figure 1 presents the market shares of the nine most widely sold
NSAIDs in 15 countries. The analyses are presented in Table 2. Full
data are provided in Table S1. Diclofenac was the most popular
NSAID, with a market share almost equal to that of the next three
most popular NSAIDs combined (ibuprofen, mefenamic acid,
naproxen). There was no documented use of rofecoxib. Etoricoxib
was commonly sold in Bangladesh, Malaysia, Hong Kong, and
Singapore. ‘‘High risk’’ NSAIDs (diclofenac and exoricoxib)
comprised about one-third of the market across the 15 countries
(median 33.2%, range 14.7–58.7%), and this proportion did not
differ between high- and low-income states (Table 2).
Discussion
NSAIDs with a high risk of cardiovascular complications are
widely used. Diclofenac and etoricoxib together account for
approximately one-third of all sales of NSAIDs in the 15 countries
included in our analysis. There was no difference between high-
and low-income countries. Diclofenac was by far the most popular
NSAID, despite having an RR identical to rofecoxib [9], which
was withdrawn from world markets 8 years ago owing to
cardiovascular toxicity [20]. The information on cardiovascular
risk associated with diclofenac has been available to regulators,
writers of guidelines and essential medicines lists, and prescribers
for at least 5 years [4–9]. Calls have been made for its withdrawal
[21]. High levels of sales as recently as 2011 suggest that none of
this information has resulted in effective action. There has been a
slow decline in prescription numbers in England, Australia, and
Canada since 2006 (Figure S1), but it remains popular in all three
countries, particularly in England where it is the single most-
prescribed NSAID (Table S1). While the popularity of diclofenac
in high-income countries is well known, to our knowledge this is
the first report that highlights the risks associated with its dominant
market position in low- and middle-income countries.
Etoricoxib is the other high risk NSAID that features in this
study. While there is limited information on its cardiovascular risk,
an updated meta-analysis published by us in 2011 found a
doubling of cardiovascular risk compared with non-use [9]. It
was significantly more harmful than ibuprofen and naproxen in
pairwise comparisons. In a large head-to-head randomised clinical
trial, it had an identical cardiovascular risk to diclofenac [22]. In
the current study, etoricoxib accounted for 28% of NSAID sales
in Singapore, and 14% in Bangladesh, Hong Kong, and Malaysia.
In England, it is prescribed as often as celecoxib (Table S1), but it
is not licensed in North America.
Based on meta-analyses of randomised and non-randomised
studies, the greatest amount of evidence supports naproxen as the
safest choice to minimize cardiovascular risk. However, it was
listed in only 27 out of 86 national EMLs published or updated
since 2007. In contrast, diclofenac was included on 74 of these
EMLs. On average, diclofenac was used three times as frequently
as naproxen. In other words, evidence on the relative cardiovas-
cular safety of this drug has failed to translate into appropriate
selection for EMLs or usage. The WHO Model List of Essential
Medicines provides limited guidance for selection of NSAIDs on
EMLs [15]. It includes aspirin and ibuprofen, but offers no advice
on their safety or cost-effectiveness relative to each other or to
other NSAIDs.
There are a number of limitations to this work. Most obviously, we
do not have information on the risk profiles of patients taking
NSAIDs. However, the large and consistent volumes of use of high
risk NSAIDs make it very likely that these drugs are being taken by
substantial numbers of individuals at high risk of serious cardiovas-
cular events. We relied on sales data for 13 countries and prescription
sales for England and Canada. Sales data provide the most com-
prehensive estimates capturing non-prescription and hospital use in
addition to community prescribing, although coverage of all sectors
was variable in our study. We could not analyse prevalence of use or
dosage, and while it is possible that duration of treatment varies
between individual drugs, we don’t think this is likely to distort
greatly the patterns we have observed in the overall sales data.
Importantly, the increase in cardiovascular risk has been reported
very early in the course of diclofenac treatment [9,21].
Table 1. Summary of relative risk estimates for cardiovascular events with individual NSAIDs (versus non-use).
NSAID Serious Cardiovascular Events; RR (95% CI) Versus Non-use of NSAIDs
Observational Studies (Outcomes) Randomised Studies (Outcomes)
Hernandez-Diaz
et al., 2006 [4]
(AMI)
Singh et al.,
2006 [5]
(AMI)
McGettigan and
Henry, 2006 [6]
(CV Events)
McGettigan and
Henry, 2011 [9]
(CV Events)
Trelle et al.,
2011 [7] (APTC
Composite Outcomes)
Kearney et al.,
2006 [8]
(CV Events)
Etoricoxib nr nr nr 2.05 (1.45–2.88) 1.53 (0.74–3.17) nr
Etodolac nr nr nr 1.55 (1.28–1.87) nr nr
Rofecoxib 1.27 (1.12–1.44) nr 1.35 (1.15–1.59) 1.45 (1.33–1.59) 1.44 (1.00–1.99) 1.42 (1.13–1.78)
(with celecoxib)a
Diclofenac 1.39 (1.18–1.64) 1.38 (1.22–1.57) 1.40 (1.16–1.70) 1.40 (1.27–1.55) 1.60 (0.85–2.99) 1.63 (1.12–2.37)
Indometacin nr nr 1.30 (1.07–1.60) 1.30 (1.19–1.41) nr nr
Meloxicam nr nr 1.25 (1.00–1.55) 1.20 (1.07–1.33) nr nr
Ibuprofen 1.01 (0.89–1.15) 1.11 (1.06–1.17) 1.07 (0.97–1.18) 1.18 (1.11–1.25) 2.26 (1.11–4.89) 1.51 (0.96–2.37)
Celecoxib 0.97 (0.86–1.08) nr 1.06 (0.91–1.23) 1.17 (1.08–1.27) 1.43 (0.94–2.16) 1.42 (1.13–1.78)
(with rofecoxib)a
Naproxen 0.98 (0.87–1.11) 0.99 (0.88–1.11) 0.97 (0.87–1.07) 1.09 (1.02–1.16) 1.22 (0.78–1.93) 0.92 (0.67–1.26)
Piroxicam nr nr 1.06 (0.70–1.59) 1.08 (0.91–1.30) nr nr
a
celecoxib and rofecoxib analysed together.
AMI, acute myocardial infarction; APTC, Anti-Platelet Trialists Collaboration; CV, cardiovascular; nr, not reported.
doi:10.1371/journal.pmed.1001388.t001
An Examination of NSAID Sales in 15 Countries
PLOS Medicine | www.plosmedicine.org 3 February 2013 | Volume 10 | Issue 2 | e1001388
4. The findings here have significant implications for public health.
For instance, in China the age- and sex-standardised death rate
from cardiovascular disease is estimated to be 312/100,000 for
males and 260/100,000 for females [23]. Diclofenac is the most
commonly used NSAID in hospitals in China. We assume com-
munity use follows a similar pattern. If it were taken by only 1% of
China’s population of approximately 1.3 billion annually, based
on the relative risk calculations from meta-analyses it could
cause 14,000 additional unintended deaths. These deaths are
preventable—lower risk NSAIDs, including naproxen and low-
dose ibuprofen, are widely available and are equally efficacious
[24,25]. Both are available as generic products.
Figure 1. Individual NSAID defined daily doses (DDD) expressed as a percentage of total NSAID DDD sales in each country in 2011.
Data reflect retail pharmacy and hospital sales in all countries except Bangladesh and Pakistan [retail pharmacy sales], China [hospital sales], and
England and Canada [prescription sales only].
doi:10.1371/journal.pmed.1001388.g001
Table 2. Analysis of use of selected NSAIDs in 15 countries.
NSAID Individual NSAID Use Expressed as Percent of Total NSAID Sales in All Countries in 2011
Median Maximum Minimum
Diclofenac 27.80% 43.40% 8.30%
Ibuprofen 11.00% 26.60% 3.30%
Naproxen 9.40% 28.20% 0.00%
Mefenamic Acid 9.10% 34.70% 0.00%
Celecoxib 7.20% 21.20% 0.20%
Meloxicam 3.60% 21.00% 0.30%
Piroxicam 3.10% 23.60% 0.00%
Etoricoxib 2.80% 27.60% 0.20%
Indometacin 3.67% 7.20% 0.00%
Ketoprofen 1.10% 9.50% 0.20%
High Risk NSAIDsa
33.20% 58.69% 14.65%
HMIC 31.10% 58.70% 15.80%
LMIC 37.30% 57.50% 14.70%
Percentage refers to proportion of total NSAID sales in all countries studied. HMIC (high-/high middle-income countries): Australia, China, China (Hong Kong), Malaysia,
New Zealand, Singapore, Taiwan, Thailand, UK/England, Canada; LMIC (low-/low middle-income countries): Bangladesh, Indonesia, Pakistan, Philippines, Vietnam.
a
Diclofenac, etoricoxib.
doi:10.1371/journal.pmed.1001388.t002
An Examination of NSAID Sales in 15 Countries
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5. There is increasing regulatory concern about diclofenac. The
European Medicines Agency has just commenced (as of October
2012) a new review of its cardiovascular safety [26]. In low- and
middle-income countries, national EMLs are authoritative influ-
ences on drug choice, being used as the basis for procurement of
safe, cost-effective medicines for public reimbursement and to
guide local medicines production [17]. NSAID recommendations
on national EMLs should be based on the optimum balance of
benefit and harm and give preference to low risk drugs, in parti-
cular to ibuprofen and naproxen. Diclofenac has no advantage in
terms of gastrointestinal safety [11] and it has a clear cardiovas-
cular disadvantage [9]. Given the availability of safer alternatives,
diclofenac should be de-listed from national EMLs. There are
strong arguments to revoke its marketing authorisations globally.
Supporting Information
Figure S1 NSAID prescriptions dispensed in the com-
munity in England, Australia, and Canada. Data sources:
England, National Health Service Prescription Cost Analysis
Reports; publicly available up to and including 2011 (http://www.
ic.nhs.uk/pubs/prescostanalysis2011 Accessed 12November 2012);
Australia, Australian Statistics on Medicines Reports, publicly
available up to and including 2009 (http://www.health.gov.au/
internet/main/publishing.nsf/Content/health-pbs-general-pubs-asm.
htm) (accessed 12 November 2012); Canada, data estimates of
prescription numbers dispensed annually, 2007–2011 inclusive, in the
community in Canada, purchased from Intercontinental Medical
Statistics (IMS), IMS Brogan, a unit of IMS Health, Toronto, Canada
(http://www.imshealth.com/portal/site/ims?CURRENT_LOCALE=
en_ca) (accessed 12 November 2012). Cox-2-selective, all
‘‘coxib’’ NSAIDs available each year in each country including
celecoxib, etoricoxib, lumiracoxib, rofecoxib, valdecoxib; non-
selective NSAIDs, all NSAIDs except Cox-2 selective (coxibs)
and meloxicam.
(TIF)
Table S1 Use of individual NSAIDs expressed as a
percentage of total NSAID use in each country in 2011.
Use is expressed as sales of defined daily doses (DDD, in
millions) for all countries except England and Canada
where it is expressed as millions of prescriptions
dispensed in the community.
(DOCX)
Table S2 NSAIDs listed on national Essential Medicines
Lists; World Health Organization (2012) Essential
Medicines Selection.
(XLSX)
Author Contributions
Conceived and designed the experiments: PMG DH. Analyzed the data:
PMG DH. Wrote the first draft of the manuscript: PMG. Contributed to
the writing of the manuscript: PMG DH. ICMJE criteria for authorship
read and met: PMG DH. Agree with manuscript results and conclusions:
PMG DH.
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6. Editors’ Summary
Background. Non-steroidal anti-inflammatory drugs
(NSAIDs) are among the most widely used drugs. Aspirin,
the first NSAID, was developed in 1897 but there are now
many different NSAIDs. Some can be bought over-the-
counter but others are available only with prescription.
NSAIDs can help relieve short- and long-term pain, reduce
inflammation (redness and swelling), and reduce high fevers.
Common conditions that are treated with NSAIDs include
headaches, toothache, back ache, and arthritis. NSAIDs work
by stopping a class of enzymes called cyclo-oxygenases
(COXs) from making prostaglandins, some of which cause
pain and inflammation. Like all drugs, NSAIDs have some
unwanted side effects. Because certain prostaglandins
protect the stomach lining from the stomach acid that helps
to digest food, NSAID use can cause indigestion and
stomach ulcers (gastrointestinal complications). In addition,
NSAIDs increase the risk of heart attacks and stroke to
varying degrees and therefore should be avoided by people
at high risk of cardiovascular diseases—conditions that affect
the heart and/or blood vessels.
Why Was This Study Done? Different NSAIDs are
associated with different levels of cardiovascular risk.
Selective COX-2 inhibitors (e.g., rofecoxib, celecoxib, etor-
icoxib) generally have fewer stomach-related side effects
than non-selective COX inhibitors (e.g., naproxen, ibuprofen,
diclofenac). However, some NSAIDs (rofecoxib, diclofenac,
etoricoxib) are more likely to cause cardiovascular events
than others (e.g., naproxen). When doctors prescribe NSAIDs,
they need to consider the patient’s risk profile. Particularly
for patients with higher risk of cardiovascular events, a
doctor should either advise against NSAID use or recom-
mend one that has a relatively low cardiovascular risk.
Information on the cardiovascular risk associated with
different NSAIDs has been available for several years, but
have doctors changed their prescribing of NSAIDs based on
the information? This question is of particular concern in
low- and middle-income countries where cardiovascular
disease is increasingly common. In this study, the researchers
investigate the extent to which evidence on the cardiovas-
cular risk associated with different NSAIDs has translated into
guidance and sales in 15 low-, middle-, and high-income
countries.
What Did the Researchers Do and Find? The researchers
derived data on the relative risk of cardiovascular events
associated with individual NSAIDs compared to non-use of
NSAIDs from published meta-analyses of randomized trials
and observational studies. They obtained information on the
NSAIDs recommended in 100 countries from national
Essential Medicines Lists (EMLs; essential medicines are
drugs that satisfy the priority health care needs of a
population). Finally, they obtained information on NSAID
sales for 13 countries in the South Asian, Southeast Asian,
and Asian Pacific regions and NSAID prescription data for
Canada and England. Rofecoxib, diclofenac, and etoricoxib
consistently increased cardiovascular risk compared with no
NSAIDs. All three had a higher relative risk of cardiovascular
events than naproxen in pairwise analyses. Naproxen was
associated with the lowest cardiovascular risk. No national
EMLs recommended rofecoxib, which was withdrawn from
world markets 8 years ago because of its cardiovascular risk.
Seventy-four national EMLs listed diclofenac, but only 27
EMLs listed naproxen. Diclofenac was the most commonly
used NSAID, with an average market share across the 15
countries of nearly 30%. By contrast, naproxen had an
average market share of less than 10%. Finally, across both
high- and low-/middle-income countries, diclofenac and
etoricoxib accounted for one-third of total NSAID usage.
What Do These Findings Mean? These findings show
that NSAIDs with higher risk of cardiovascular events are
widely used in low-/middle- as well as high-income
countries. Diclofenac is the most popular NSAID, despite its
higher relative risk of cardiovascular events, which is similar
to that of rofecoxib. Diclofenac is also widely listed on EMLs
even though information on its higher cardiovascular risk has
been available since 2006. In contrast, naproxen, one of the
safest in relative terms of the NSAIDs examined, was among
the least popular and was listed on a minority of EMLs. Some
aspects of the study’s design may affect the accuracy of
these findings. For example, the researchers did not look at
the risk profiles of the patients actually taking NSAIDs.
However, given the volume of use of high-risk NSAIDS, it is
likely that these drugs are taken by many individuals at high
risk of cardiovascular events. Overall, these findings have
important implications for public health and, given the wide
availability of safer alternatives, the researchers suggest that
diclofenac should be removed from national EMLs and that
its marketing authorizations should be revoked globally.
Additional Information. Please access these Web sites via
the online version of this summary at http://dx.doi.org/
10.1371/journal.pmed.1001388.
N This study is further discussed in a PLOS Medicine
Perspective by K. Srinath Reddy and Ambuj Roy
N The UK National Health Service Choices website provides
detailed information on NSAIDS
N MedlinePlus provides information about aspirin, ibuprofen,
naproxen, and diclofenac; it also provides links to other
information about pain relievers (in English and Spanish)
N The American Heart Association has information on
cardiovascular disease; ‘‘Can Patients With Cardiovascular
Disease Take Nonsteroidal Antiinflammatory Drugs?’’ is a
Cardiology Patient Page in the AHA journal Circulation
N The British Heart Foundation also provides information
about cardiovascular disease and has a factsheet on
NSAIDs and cardiovascular disease
N The World Health Organization has a fact sheet on
essential medicines; the WHO Model List of Essential
Medicines (in English and French), and national EMLs are
available
An Examination of NSAID Sales in 15 Countries
PLOS Medicine | www.plosmedicine.org 6 February 2013 | Volume 10 | Issue 2 | e1001388