Trending Topics in Health-System Pharmacy
How effective are muscle relaxants for low back pain?
Low back pain is a common reason for adult patients to visit their primary care physicians, who often prescribe analgesics and muscle relaxants to relieve the pain. To investigate the efficacy, acceptability, and safety of muscle relaxants for low back pain, researchers at Neuroscience Research Australia performed a systematic review and meta-analysis of randomized controlled trials. Data from 49 trials published in Medline, Embase, CINAHL, CENTRAL, ClinicalTrials.gov, clinicialtrialsregister.eu, and WHO ICTRP from inception to February 23, 2021, were used in the analysis. Over 6,505 participants with non-specific back pain were included in the study.
The results of the investigation, published in the BMJ on July 8, 2021, showed that considerable uncertainty exists about the clinical efficacy and safety of muscle relaxants. Very low- and low-certainty evidence shows that non-benzodiazepine antispasmodics might provide small but not clinically important reductions in pain intensity at or before two weeks and might increase the risk of an adverse event in acute low back pain. The authors conclude that large, high quality, placebo-controlled trials are urgently needed to resolve uncertainty.
New data could help guide choice of antihyperglycermic meds
Both sulfonylureas and SGLT2 inhibitors are often used as second-line antihyperglycemic agents after metformin treatment. But the question of how effective these medications are, and whether they are associated with all-cause mortality, spurred researchers from the VA St Louis Health Care System, Washington University in St. Louis, and St. Louis University to perform a comparative effectiveness study. The cohort study used data from the US Department of Veterans Affairs to compare the use of SGLT2 inhibitors versus sulfonylureas in individuals receiving metformin for treatment of type 2 diabetes.
A total of 23,870 individuals with new use of SGLT2 inhibitors and 104,423 individuals with new use of sulfonylureas were enrolled between October 1, 2016, and February 29, 2020, and followed up until January 31, 2021. The results of the study, published in JAMA Internal Medicine on June 28, 2021, indicated that compared with sulfonylureas, SGLT2 inhibitors were associated with reduced risk of all-cause mortality.
Compared with sulfonylureas, SGLT2 inhibitors were also associated with a reduced risk of death, regardless of cardiovascular disease status, in several categories of estimated glomerular filtration rate and in participants with no albuminuria, microalbuminuria, and macroalbuminuria. In per-protocol analyses, continued use of SGLT2 inhibitors was associated with a reduced risk of death compared with continued use of sulfonylureas. In addition, continued use of SGLT2 inhibitors with metformin was associated with a reduced risk of death compared with SGLT2 inhibitor treatment without metformin.
The authors suggest that these results provide data from a real-world setting that may help guide the choice of antihyperglycemic therapy for patients with type 2 diabetes.
Caffeine may not be associated with arrhythmias
The idea that caffeine consumption increases the risk of cardiac arrhythmias is common. However, evidence to substantiate this risk is lacking.
To assess the association between consumption of common caffeinated products and the risk of arrhythmias, researchers at the University of California, San Francisco conducted a prospective cohort study that analyzed longitudinal data from the UK Biobank between January 1, 2006, and December 31, 2018. After exclusion criteria were applied, data from 386,258 individuals were available for analysis. Measured outcomes included any cardiac arrhythmia, including atrial fibrillation or flutter, supraventricular tachycardia, ventricular tachycardia, premature atrial complexes, and premature ventricular complexes.
The study, published in JAMA Internal Medicine on July 19, 2021, showed that after adjustment for demographic characteristics, comorbid conditions, and lifestyle habits, each additional cup of habitual coffee consumed was associated with a 3% lower risk of incident arrhythmia.
In addition, 2 distinct interaction analyses, one using a caffeine metabolism–related polygenic score of 7 genetic polymorphisms and another restricted to CYP1A2 rs762551 alone, did not reveal any evidence of effect modification. A mendelian randomization study that used these same genetic variants revealed no significant association between underlying propensities to differing caffeine metabolism and the risk of incident arrhythmia.
The authors concluded that neither habitual coffee consumption nor genetically mediated differences in caffeine metabolism was associated with a heightened risk of cardiac arrhythmias.
New guidelines to help manage BP in CKD patients
The recently published Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline for the management of BP in patients with chronic kidney disease who are not receiving dialysis reflects new evidence on the risks and benefits of BP-lowering therapy among patients with CKD. A summary of the updated guideline, published on June 22, 2021 in the Annals of Internal Medicine, describes the 11 recommendations and 20 practice points. Among the recommendations are those for BP measurement, BP targets, choice of drug therapy, and diet and lifestyle,
Because the risks for cardiovascular disease and death are greater than the risk for kidney failure in most individuals living with CKD, the KDIGO work group recommends a focus on standardized BP measurement and a target systolic BP of less than 120 mm Hg.
The full recommendation is available on the KDIGO website (kdigo.org).
Is levothyroxine overused in the U.S.?
Levothyroxine is one of the most commonly prescribed drugs in the United States, with approximately 7% of the population having an active prescription. Although levothyroxine is intended to treat hypothyroidism (low thyroid hormone), a significant number of prescriptions seem to be provided to patients with subclinical hypothyroidism or normal thyroid function. To better understand the use of levothyroxine in the U.S. over time, researchers at the Mayo Clinic and Yale University analyzed national data for commercially insured and Medicare Advantage enrollees from 2008 to 2018.
A retrospective analysis of deidentified administrative claims data linked with laboratory results from OptumLabs Data Warehouse, which includes commercially insured and Medicare Advantage enrollees throughout the U.S., was used for the study. The cohort included adults with newly filled levothyroxine prescriptions between January 1, 2008, and December 31, 2018 who had a thyrotropin level measured within 3 months prior to levothyroxine initiation. Pregnant women and patients with a history of thyroid surgery, thyroid cancer, or central hypothyroidism were excluded.
Results of the study, published on June 21, 2021 in JAMA Internal Medicine, indicated that levothyroxine treatment was commonly initiated for mildly increased thyrotropin levels over the 10-year period. Among patients for whom full thyroid function test results were available, 60% of those for whom levothyroxine treatment was initiated had subclinical hypothyroidism and 30% had normal thyroid function, with no significant change in these patterns over time.
The authors point out that because the study included commercially insured patients, who may be more likely to use levothyroxine, these findings may not generalize to other populations. In addition, symptoms or other potential compelling reasons for levothyroxine initiation could not be assessed. However, they observe that frequent initiation of levothyroxine in these patients is at odds with evidence demonstrating no significant association of levothyroxine replacement with measures of health-related quality of life, thyroid-related symptoms, depressive symptoms, fatigue, or cognitive function. They conclude that these results suggest substantial overuse of levothyroxine during the entire duration of the study, indicating opportunities to improve patient care.