RESUMEN
Patients with nonalcoholic fatty liver disease (NAFLD) are at an increased risk of cardiovascular disease. Hydoxy-3-methyglutaryl-coenzyme reductase inhibitors, statins, reduce the risk of cardiovascular events.1 Studies have shown that statins are safe among patients with liver disease, including those with compensated cirrhosis,2 and their use is associated with lower mortality, hepatic decompensation, and possibly hepatocellular carcinoma.3,4 Despite these data, statins are under prescribed among patients with liver disease due to concerns about hepatotoxicity.5 This study aimed to assess prevalence and patient factors associated with indicated statin use in patients with NAFLD in a real-world cohort.
Asunto(s)
Inhibidores de Hidroximetilglutaril-CoA Reductasas , Neoplasias Hepáticas , Enfermedad del Hígado Graso no Alcohólico , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/epidemiología , Neoplasias Hepáticas/complicaciones , Neoplasias Hepáticas/epidemiología , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Enfermedad del Hígado Graso no Alcohólico/tratamiento farmacológico , Enfermedad del Hígado Graso no Alcohólico/epidemiología , PrevalenciaRESUMEN
BACKGROUND AND AIMS: Patients with decompensated cirrhosis are prescribed numerous medications. Data are limited as to whether patients are receiving medications they need and avoiding those they do not. We examined a large national claims database (2010-2015) to characterize the complete medication profile as well as the factors associated with appropriate and potentially inappropriate medication use in 12,621 patients with decompensated cirrhosis. APPROACH AND RESULTS: Clinical guidelines and existing literature were used to determine appropriate and potentially inappropriate medications in decompensated cirrhosis. The total medication days' supply was calculated from pharmacy data and divided by the follow-up period for each decompensation. Ascites was the most common (86.5%), followed by hepatic encephalopathy (HE; 37.8%), variceal bleeding (VB; 17.5%), hepatorenal syndrome (6.3%), and spontaneous bacterial peritonitis (SBP; 6.1%). For patients with ascites, 55.8% filled a diuretic. For patients with HE, 32.4% and 63.3% filled rifaximin and lactulose, respectively. After VB, 60.3% of patients filled a nonselective beta blocker, and after an episode of SBP, 48.0% of patients filled an antibiotic for prophylaxis. The minority (4.5%-17.3%) had enough medication to cover >50% follow-up days. Potentially inappropriate medication use was common: 53.2% filled an opiate, 46.0% proton pump inhibitors, 14.2% benzodiazepines, and 10.1% nonsteroidal anti-inflammatory drugs. Disease severity markers were associated with more appropriate mediation use but not consistently associated with less inappropriate medication use. CONCLUSIONS: Patients with decompensated cirrhosis are not filling indicated medications as often or as long as is recommended and are also filling medications that are potentially harmful. Future steps include integrating pharmacy records with medical records to obtain a complete medication list and counseling on medication use with patients at each visit.
Asunto(s)
Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/prevención & control , Cirrosis Hepática , Administración del Tratamiento Farmacológico , Lista de Medicamentos Potencialmente Inapropiados/estadística & datos numéricos , Pautas de la Práctica en Medicina , Ascitis/etiología , Ascitis/terapia , Estudios de Cohortes , Progresión de la Enfermedad , Duración de la Terapia , Femenino , Necesidades y Demandas de Servicios de Salud , Humanos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/tratamiento farmacológico , Cirrosis Hepática/epidemiología , Cirrosis Hepática/fisiopatología , Fallo Hepático/etiología , Fallo Hepático/terapia , Masculino , Administración del Tratamiento Farmacológico/normas , Administración del Tratamiento Farmacológico/estadística & datos numéricos , Persona de Mediana Edad , Gravedad del Paciente , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Mejoramiento de la Calidad , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: Type 1 hepatorenal syndrome (HRS) is a fatal complication of cirrhosis. Treatments trend toward HRS reversal, but few show clear mortality benefit. We sought to quantify the progress-or lack thereof-in improving outcomes of type 1 HRS over time. METHODS: We performed a systematic review and meta-analysis for randomized controlled trials (RCTs) comparing type 1 HRS outcomes including (a) overall survival (liver transplant-free survival if reported) and (b) HRS reversal. Each study arm was analyzed separately to look at changes in outcomes over time. RCTs published comparing medical treatments for type 1 HRS were searched using several databases through July 31, 2019. RESULTS: Fourteen RCTs (28 arms) involving 778 participants enrolled between 2002 and 2018 were included. Twelve RCTs measured HRS reversal. In conjunction with albumin (or plasma expander), the most common medications used were terlipressin (13 arms), antibiotics (7), norepinephrine (6), dopamine (4), and midodrine/octreotide (3). Pooled survival rate was 34.6% (95% CI 26.4-43.8), and pooled HRS reversal rate was 42.8% (95% CI 34.2-51.9). Regression analyzing the incremental effect of the year the RCT was initiated showed that more recent studies were not associated with improved survival (OR 1.02, 95% CI 0.94-1.11, p = 0.66) or HRS reversal rates (OR 1.03, 95% CI 0.96-1.11, p = 0.41). There was no survival improvement when RCTs with endpoints assessed ≤ or > 1 month were analyzed separately with respective OR of 1.07 (95% CI 0.95-1.20, p = 0.26) and 0.97 (95% CI 0.85-1.12, p = 0.70). CONCLUSION: Outcomes have not improved for patients with type 1 HRS since 2002. There is a need to improve prevention and treatment of type 1 HRS.
Asunto(s)
Síndrome Hepatorrenal/tratamiento farmacológico , Síndrome Hepatorrenal/mortalidad , Adulto , Albúminas/uso terapéutico , Antibacterianos/uso terapéutico , Dopamina/uso terapéutico , Quimioterapia Combinada , Femenino , Síndrome Hepatorrenal/etiología , Humanos , Masculino , Persona de Mediana Edad , Midodrina/uso terapéutico , Norepinefrina/uso terapéutico , Octreótido/uso terapéutico , Sustitutos del Plasma/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Análisis de Regresión , Tasa de Supervivencia , Terlipresina/uso terapéutico , Resultado del Tratamiento , Vasoconstrictores/uso terapéutico , Adulto JovenRESUMEN
Cirrhosis is a morbid condition associated with frequent hospitalizations and high mortality. Management of cirrhosis requires complex medication regimens to treat underlying liver disease, complications of cirrhosis and comorbid conditions. This review examines the complexities of medication management in cirrhosis, barriers to optimal medication use, and potential interventions to streamline medication regimens and avoid medication errors. A literature review was performed by searching PUBMED through December 2017 and article reference lists to identify articles relevant to medication management, complications, adherence, and interventions to improve medication use in cirrhosis. The structural barriers in cirrhosis include sheer medication complexity related to the number of medications and potential for cognitive impairment in this population, faulty medication reconciliation and limited adherence. Tested interventions have included patient self-education, provider driven patient education, intensive case management including medication blister packs and smartphone applications. Initiatives are needed to improve patient, caregiver and provider education on appropriate use of medications in patients with cirrhosis. A multidisciplinary team should be established to coordinate care with close monitoring, address patient and caregiver concerns, and to provide timely access to outpatient evaluation of urgent/complex issues. Future studies evaluating the clinical outcomes and cost effectiveness of interventions are needed.
Asunto(s)
Cirrosis Hepática/tratamiento farmacológico , Cumplimiento de la Medicación , Administración del Tratamiento Farmacológico , Manejo de Caso , Humanos , Educación del Paciente como AsuntoRESUMEN
INTRODUCTION: The elder abuse and neglect burden in Milwaukee County, Wisconsin, is substantial, with 3384 reports made from 2006 to 2009. Current prevalence estimates are determined from reported cases only and are likely underestimated. Provider awareness of victim and perpetrator characteristics is necessary to increase recognition and response. METHODS: A cross-sectional analysis of elder abuse and neglect cases reported to the Milwaukee County Department on Aging (MCDA) from 2006 to 2009 was performed to provide a profile of the county's elder abuse burden by victim, perpetrator, and reporter characteristics. Annual reporting trends were identified using Poisson regression analysis. RESULTS: Fifty-eight percent of MCDA reports of abuse were substantiated after investigation. Victims in Milwaukee County tended to be older than 75 (64%), female (64%), and white (62%). Reporting rates to the MCDA were significantly lower in 2009 than 2006. Perpetrators were often adult children (48%) or a spouse (14%). Forty percent of life-threatening cases of self-neglect were due to unfulfilled medical needs. Most reports were made by medical professionals (23%), relatives of the victim (21%), and community agencies (18%). Only 13% of elder abuse victims were placed in nursing homes and assisted living centers; many received services to assist independent living. DISCUSSION: Although this study is limited to reported cases only, it provides a valuable profile of pertinent elder abuse characteristics in Milwaukee County. CONCLUSION: Characteristics of vulnerable elders, potential abusers, and investigation outcomes are described to inform clinical practice about this important social issue.