2 Minute Medicine Rewind June 29 – July 5, 2015

A Decision Analysis of Percutaneous Left Atrial Appendage Occlusion Relative to Novel and Traditional Oral Anticoagulation for Stroke Prevention in Patients with New-Onset Atrial Fibrillation

There are no studies in the literature directly comparing the different treatment strategies for stroke prevention in atrial fibrillation (AF). Decision-analytic models may offer insight by providing a framework to balance the benefits and disadvantages of each treatment strategy. The authors developed a decision-analytic model to evaluate the cost-effectiveness of non-pharmacological strategies (left atrial appendage occlusion; LAAO), novel anticoagulants (dabigatran, rivaroxaban, apixaban) and traditional anticoagulants (warfarin) for stroke prevention in AF. The model was built using real-world population of patients with new-onset AF and looked at the gains in health (measured in quality adjusted life years; QALY) relative to the costs associated with various treatments. The authors found that patients on warfarin had the lowest discounted QALY (5.13 QALYs), followed by dabigatran (5.18 QALYs), rivaroxaban and LAAO (5.21 QALYs), and apixaban (5.25 QALYs). For the average patient on warfarin it cost $15 776 over their lifetime, $18 280 for rivaroxaban, $19 156 for apixaban, $20 794 for dabigatran, and $21 789 for LAAO. Apixaban dominated dabigatran (i.e. which means it was less expensive and had a greater associated QALY). The incremental cost-effectiveness ratio (ICER) for apixaban relative to warfarin was $28 167/QALY. This means that it cost $28 167 for each additional quality adjusted life year on apixaban compared to warfarin. In conclusion, the benefits of the new anticoagulants come at an increased cost, and apixaban is the most cost-effective therapy for stroke prevention in patients with new-onset AF.

Treatment of Young People With Antipsychotic Medications in the United States

During the past several years, clinical trials have supported the effectiveness of antipsychotics for numerous childhood and adolescent psychiatric conditions. The effectiveness of any antipsychotic medication needs to be counterbalanced with the known cardiovascular and metabolic side effects. The purpose of this retrospective descriptive analysis was to describe antipsychotic prescription patterns among patients by sex and age group (younger children, 1-6 years; older children 7-12 years; adolescents, 13-18 years; and young adults, 19-24 years) in the United States in the years 2006, 2008 and 2010 (also a subset from 2009). Data were retrieved from the IMS LifeLinkLRx Longitudinal Prescription database, which includes approximately 60% of all retail pharmacies in the US. The authors found the percentages of young people using antipsychotic medications in 2006 and 2010, respectively, were 0.14% and 0.11% for younger children, 0.85% and 0.80% for older children, 1.10% and 1.19% for adolescents, and 0.69% and 0.84% for young adults. In terms of comparisons between sexes, males in 2010 were more likely than females to use antipsychotics, especially during childhood and adolescence: 0.16% vs 0.06% for younger children, 1.20% vs 0.44% for older children, 1.42% vs 0.95% for adolescents, and 0.88% vs 0.81% for young adults. The most common diagnoses treated with antipsychotics were attention-deficit/hyperactivity disorder in younger children (52.5%), older children (60.1%), and adolescents (34.9%) and depression in young adults (34.5%). Overall the use of antipsychotics increased from 2006 to 2010 for adolescents and young adults but not for children aged 12 years or younger. This pattern of use is consistent with management of developmentally limited impulsive and aggressive behaviors rather than psychotic symptoms.

Recent Changes in the Prevalence of and Factors Associated With Frequency of Indoor Tanning Among US Adults

An objective of the Healthy People 2020 is to reduce indoor tanning to prevent the incidence of skin cancer. The purpose of this study was to examine the changes in prevalence and frequency of indoor tanning factors associated with frequency of indoor tanning among US adults. The authors collected data from the 2010 and 2013 National Health Interview Survey, which is a nationally representative sample of the US civilian, noninstitutinalized population 18 years or older (N = 59 145). They defined indoor tanning as using an indoor tanning device 1 or more times during the 12 months before each survey. The authors found significant reductions in indoor tanning from 2010 to 2013 among all adults (decline from 5.5% to 4.2%; p<0.001). This decline was also observed among male and female infrequent tanners (tanning 1-9 times/year) and female frequent tanners (tanning greater than 10 times/year). Compared with their respective reference groups, indoor tanning frequency among female tanners was 28% lower among the oldest group (p=0.006), 45% lower among college graduates (p<0.001), 33% lower among women in fair or poor health (p=0.02), and 23% lower among women meeting aerobic or strength physical activity criteria (p=0.01). These results are encouraging in terms of the reductions in tanning. These decreases may be partly attributable to the increased awareness of its harms and laws restricting access among minors, however despite these reductions the study found an estimated 7.8 million women and 1.9 million men who continue to engage in indoor tanning.

Risk factors for 30-day mortality in patients with pneumonia who receive appropriate initial antibiotics: an observational cohort study

Despite a proper initial antibiotic trial for any infectious disease, patients may still not improve, develop adverse outcomes or deteriorate. In this prospective, observational study at ten medical institutions, investigators analyzed the risk factors for 30-day mortality in hospitalized patients who received appropriate initial antibiotics and identified potential candidates who would benefit from adjunctive therapy. The authors found the 30-day mortality to be 11% (61 of 579 patients) in the group given the appropriate initial antibiotic and 17% (29 of 168) in the patients given the inappropriate initial antibiotic. Albumin concentration of less than 30 mg/L (adjusted OR 3.39, 95% CI 1.83–6.28), non-ambulatory status (3.34, 1.84–6.05), pH of less than 7.35 (3.13, 1.52–6.42), respiration rate of at least 30 breaths per min (2.33, 1.28–4.24), and blood urea nitrogen of at least 7.14 mmol/L (2.20, 1.13–4.30) were independent risk factors in patients given appropriate initial antibiotic treatment. The 30-day mortality was 1% (one of 126 patients), 1% (two of 168), 17% (23 of 137), 22% (20 of 89), and 44% (14 of 32) for patients with no, one, two, three, and four or five risk factors, respectively. The association between number of risk factors and increased 30-day mortality (patients with two or more risk factors were at a higher risk for death during the 30 days), despite appropriate initial antibiotic treatment, makes screening for these high-risk patients important as they may require adjunctive therapy to improve outcomes.

How to Monitor Patients Receiving Direct Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Practice Tool Endorsed by Thrombosis Canada, the Canadian Stroke Consortium, the Canadian Cardiovascular Pharmacists Network, and the CCS

Guidelines for the novel direct oral anticoagulants (DOACS)- apixaban, dabigatran, endoxaban and rivaroxaban- for stroke prevention in atrial fibrillation (AF) have focused primarily on patient selection and therapy initiation, with little guidance on patient follow-up and monitoring for these long-term therapies. The authors set out guidelines for how to monitor patients receiving these DOACs. They report that follow-up visits should focus on 3 objectives: ensuring proper DOAC use, maximizing adherence (because of their short half-life) and minimizing bleeding. In order to maximize optimal use of these medications, the authors created an ABCDE anticoagulant monitoring checklist that emphasizes: A (adherence; ensure regular usage by asking at every follow-up visit), B (bleeding; unnecessary concomitant use of aspirin or nonsteroidal anti-inflammatory drugs, other drug interactions, uncontrolled hypertension, syncope, falls, and incorrect DOAC dosing for age or renal function), C (creatinine clearance; decreasing renal function may necessitate dose reduction, therapy discontinuation, or use of an alternate anticoagulant), D (drug interactions), and E (examination; measuring office blood pressure and encourage home monitoring). Using this systematic and proactive clinical monitoring approach, guided by a checklist, will optimize the benefit–risk ratio in this new era of anticoagulant therapy.

Image: PD

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