背景:处方级联是多重用药的重要贡献者。关于哪些老年人经历处方级联的风险最高,人们知之甚少。我们探索了哪些老年退伍军人在加巴喷丁(包括加巴喷丁和普瑞巴林)-环利尿剂(LD)级联反应的风险最高,鉴于近年来加巴喷丁类药物处方的急剧增加。
方法:使用退伍军人事务和医疗保险索赔数据(2010-2019年),我们进行了处方序列对称性分析(PSSA),以评估老年退伍军人(≥66岁)加巴喷丁开始注射环利尿剂前后的利尿剂.为了识别级联,我们计算了调整后的序列比(ASR),评估LD相对于gabapentinoid起始的时间性。探索高危人群,我们使用了多变量逻辑回归,并将处方顺序建模为二元因变量。我们计算了调整后的赔率比(aOR),测量因素与一个处方订单相对于另一个处方订单的关联程度。
结果:在发起gabapentinoid的151,442名退伍军人中,1,981例患者在开始加巴喷丁类药物后6个月内开始LD,而1,599例患者在开始加巴喷丁类药物前6个月内开始LD.在gabapentinoid-LD组中,平均年龄是73岁,98%是男性,13%是黑人,5%是西班牙裔,80%是白人。各组患者在患者和健康利用因素之间相似(所有比较的标准化平均差<0.10)。ASR为1.23(95%CI:1.13,1.34),强烈暗示级联的存在。年龄≥85岁的人不太可能发生级联(与66-74岁相比;aOR0.74,95%CI:0.56-0.96),服用≥10种药物的患者更有可能发生级联反应(与0-4种药物相比;aOR为1.39,95%CI:1.07-1.82).
结论:在老年人中,那些年轻且服用许多药物的人可能患gabapentinoid-LD级联的风险更高,导致多重用药和潜在的药物相关危害恶化。我们没有确定这种级联的强预测因子,这表明,处方级联预防工作应该是广泛的,而不是集中在特定的亚组。
BACKGROUND: Prescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)-loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years.
METHODS: Using Veterans Affairs and Medicare claims data (2010-2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high-risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another.
RESULTS: Of 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid-LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade\'s presence. People age ≥85 years were less likely to have the cascade (compared to 66-74 years; aOR 0.74, 95% CI: 0.56-0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0-4 drugs; aOR 1.39, 95% CI: 1.07-1.82).
CONCLUSIONS: Among older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid-LD cascade, contributing to worsening polypharmacy and potential drug-related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups.