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Liver Function Status among us Adults having both Hyperlipidemia and Hyperglycemia: A Cross Sectional Study
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VA L U E I N H E A LT H 1 9 ( 2 0 1 6 ) A 1 - A 3 1 8
PCV15 Adherence to Dabigatran and the Risk of Stroke Cheetham TC, Bider-Canfield Z, Reynolds K Kaiser Permanente Southern California, Pasadena, CA, USA
Objectives: To determine if poor adherence to dabigatran is associated with an increased risk of stroke. Methods: A case-control study, nested in a population of dabigatran users, was conducted within an integrated health care delivery system. Eligible patients had a diagnosis of atrial fibrillation (AF) and a prescription for dabigatran between November 2010 and June 2015. Strokes, based on a primary hospital discharge diagnosis after starting dabigatran, were the case defining events. In addition, the stroke had to occur while the patient was a current or recent (within 30 days) user of dabigatran based on pharmacy dispensing records. Up to 4 controls were matched to each case using age, gender, duration of dabigatran use and CHADS2 score (< 3 or ≥ 3). Adherence was measured by medication possession ratio (MPR) for the year prior to the stroke date (1-yr MPR) in cases, or the equivalent event date in controls. MPR < 0.8 was defined as poor adherence. A conditional logistic regression model was used to evaluate the association between adherence and stroke events. Secondary models include peripheral vascular disease (PVD) as a confounder. Results: A total of 1833 AF patients were identified and 49 strokes occurred in this population. After applying exclusion criteria, 23 stroke cases remained eligible and these were matched to 84 controls. Matching produced populations with similar characteristics. Overall, the mean age was 73.1 years, 75.7% were males and the duration of dabigatran therapy was 630 days. For cases, 39.1% had poor adherence vs. 11.9% in controls. The odds ratios (OR) for stroke, associated with 1-yr MPR < 0.8 was 3.5 (95% CI; 1.1-11.5). The OR with PVD in the model was still elevated but no longer significant. Conclusions: In this small study, patients with poor adherence to dabigatran had a higher odds of stroke although the association was not independent of PVD status. PCV16 Trends in Er Visits Due to Hyperkalemia in the United States Aggarwal S, Topaloglu H NOVEL Health Strategies, Chevy Chase, MD, USA
Objectives: Hyperkalemia is a metabolic abnormality seen frequently in the Emergency Department. The most common condition leading to hyperkalemia is missed dialysis in a patient with end stage renal disease, but many other conditions can predispose an individual to hyperkalemia, such as acute renal failure, extensive burns, trauma, or severe rhabdomyolysis or severe acidosis. The objective of this study was to assess the resource burden on United States emergency room departments due to hyperkalemia. Methods: The number of emergency room (ED/ER) visits due to hyperkalemia, with International Classification of Diseases (ICD-9) code 276.7, were estimated using the Centers for Medicare & Medicaid Services (CMS) Agency for Healthcare Research and Quality (AHRQ) 2011 data for ED visits. A review of recent publications on hyperkalemia management was also conducted using the databases Pubmed, Embase, Biosis, Google Scholar and Cochrane. Results: The annual number of ED visits with Hyperkalemia as one of the diagnoses is estimated to be 814,181 (SE 23,526). The annual number of ED visits with Hyperkalemia as the first listed diagnosis is estimated to be 66,989 (SE 2284. Among the age groups 18-44, 45-64, 65-84, 85+ the majority of ED visits were in the 45-64 (36.04%) and 65-84 (39.44%) groups (hyperkalemia as the first listed diagnosis). Among the five payer types, Medicare, Medicaid, Private insurance, Uninsured and Other, the majority of patients belonged to Medicare (68.41%). The trend was similar for patients with Hyperkalemia as one of the diagnosis or first diagnosis. Conclusions: This analysis confirms previous findings that hyperkalemia is common in the emergency department. There is a need for quick, safe and effective treatments for hyperkalemia, which can be easily administered in emergency department setting. PCV17 Systematic Review of Burden of Hyperkalemia due to Angiotensin Enzyme Converting Inhibitors Aggarwal S1, Kumar S2, Topaloglu H1 1NOVEL Health Strategies, Chevy Chase, MD, USA, 2Institute for Global Policy Research, Washington, DC, USA
Objectives: Hyperkalemia can develop as a result of treatment with angiotensinconverting–enzyme (ACE) inhibitors or angiotensin-receptor blockers. This side effect is most common in patients with risk factors such as diabetes mellitus, heart failure, chronic kidney disease, or advanced age. The objective of this research was to conduct a systematic review on hyperkalemia caused due to angiotensin-converting–enzyme inhibitors. Methods: A systematic literature search for epidemiology and the burden of disease studies was undertaken for the databases Pubmed, Embase, Biosis, Google Scholar and Cochrane. Data was collected for the study type, methods, country and key findings. Extracted study data included hyperkalemia incidence, complications, mortality, available treatment options, as well as healthcare resource utilization and medical costs associated with hyperkalemia. Results: A total of 321 studies were identified based on the keywords. Of these, 23 studies met the inclusion criteria. Although the prevalence of hyperkalemia in the general population is unknown, it is present in 1-10% of hospitalized patients. Hyperkalemia is a common problem in patients with conditions that reduce potassium excretion, especially when treated with beta-adrenergic blockers that inhibit Na+,K+-ATPase activity or RAAS inhibitors (RAASIs) [angiotensin-converting-enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), mineralocorticoid receptor antagonists or renin inhibitors] that decrease aldosterone excretion. Hyperkalemia has been attributed to the use of ACE inhibitors in 10 to 38 percent of hospitalized patients with this complication. Hyperkalemia develops in approximately 10 percent of outpatients within a year after ACE inhibitors are prescribed. A study suggested that the mortality and morbidity from hyperkalemia as a result of combined treatment with ACE inhibitors and spironolactone may outweigh the potential long-term benefits in certain high-risk patients. Conclusions: Our review shows that there
is high burden of hyperkalemia in patients using ACE inhibitors. There is a need for quick, safe and effective treatments for hyperkalemia. PCV18 Liver Function Status among us Adults having both Hyperlipidemia and Hyperglycemia: A Cross Sectional Study Sakharkar P, Deb S Roosevelt University College of Pharmacy, Schaumburg, IL, USA
Objectives: Non-alcoholic fatty liver disease (NAFLD) is a multistage disorder that progresses from bland hepatic steatosis, non-alcoholic steatohepatitis, and fibrosis to irreversible cirrhosis. Hyperlipidemia and hyperglycemia, hallmarks of metabolic syndrome suggested being associated with liver dysfunction. The primary aim of this study was to examine the liver function status among adults having both hyperlipidemia and hyperglycemia in the United States. Methods: The National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2012 was used to examine the association between hyperlipidemia, hyperglycemia and liver enzymes amongst adults in the United States. Data were analyzed for descriptive statistics and for differences using the t test, Chi square test and ANOVA. A regression analysis was performed to identify relationships between demographic and above biomarkers. A p value of < 0.05 was considered statistically significant. Results: A total of 35,509 adults (≥ 20 yrs.) were included in this study. Sample mean age was 46.6 ± 0.22 yrs., majority were non-Hispanic white (46.7%) and female (51.3%). Seventy one percent adults had elevated LDL-C (> 130mg/dl), 19% had HDL-C (< 60mg/dl) and 11% had HbA1C > 7%. Adults with combination of hyperlipidemia and hyperglycemia were associated with 42% chance of having elevated ALT, 37% chance of elevated AST and 51% chance of elevated ALP levels. Adults with HbA1C > 7% had 16% chance of elevated ALT, 10% chance of elevated AST and 31% chance of elevated ALP levels (p< 0.001). Regression analysis showed significant relationship between age, gender, ethnicity, HbA1C, combination of hyperlipidemia and hyperglycemia, ALT, AST and ALP (p< 0.05). Conclusions: Chances of having elevated liver enzyme significantly increase when the individual has hyperlipidemia compared to hyperglycemia. Moreover, no potentiation was observed when individuals’ had both disease. We hypothesize that augmented levels of blood lipids and glucose indepndantly potentiates the liver dysfunction by initiating inflammatory mediators in the hepatocytes. PCV19 Trends in the Utilization of Warfarin and Non-Vitamin K Oral Anticoagulants in Elderly Patients with Atrial Fibrillation Alalwan A, Voils S, Hartzema A University of Florida, Gainesville, FL, USA
Background: Warfarin has been used for more than 60 years to decrease the risk of stroke and death in patients with atrial fibrillation (AF). In recent years, the FDA has approved four non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in AF: dabigatran, rivaroxaban, apixaban, and edoxaban. Objectives: To determine the annual prevalence of anticoagulant use in patients with AF and the longitudinal trends of oral anticoagulant (OACs) use and transition between OACs in AF patients. Methods: A cross-sectional retrospective longitudinal analysis was conducted using Truven Health MarketScan® Research Databases for Medicare beneficiaries from Jan 2008 to Dec 2013. We included patients 65 years and older with AF. The annual prevalence of individual OAC use was estimated from 2008 to 2013. Results: We Identified 2,389,243 individuals from 2008 to 2013. The average anticoagulated AF patients were about 43%. The prevalence of warfarin use decreased from 492 per 1000 patients with AF in 2008 to 326 per 1000 patients in 2013. This decrease in warfarin use was paralleled by an increased prevalence of NOAC use. The prevalence of dabigatran increased from 8 per 1000 patients with AF in 2010 to 64 per 1000 in 2013, and the prevalence of rivaroxaban increased from 0.8 per 1000 patients in 2011 to 65 per 1000 patients in 2013. Among the overall NOACs, apixaban showed the highest prevalence in the first year of approval, at 14 per 1000 patients. The average percentage of the patients who used more than one OAC since the introduction of NOACs was 5% of the OACs users. Conclusions: Prevalence of warfarin use has continued to decrease over time following the introduction of NOACs. The increase in NOACs prescribing suggests a perception among prescribers of improved safety and/or effectiveness of NOACs compared to warfarin. PCV20 Use of Real-World Data to Estimate Prevalence of CommerciallyInsured High Cardiovascular Risk Patients in the United States Hardin J1, Quek RG1, Roehl K2, Richhariya A3, Gandra SR1 Oaks, CA, USA, 2Amgen, Thousand Oaks, CA, USA, 3Seattle Genetics, Southeast Bothell, WA, USA 1Amgen, Inc., Thousand
Objectives: To estimate prevalence of US commercially-insured high cardiovascular risk patients. Methods: Using Truven MarketScan commercial claims (2006-2012) and National Health and Nutrition Examination Survey (NHANES) data (2005-2010), four mutually exclusive cohorts (stratified by age ≥ 20-< 65 and > 65-< 75 years) were created. Estimates of the prevalence of US commercially-insured patients were generated using the Medical Expenditure Panel Survey (2010). Using Marketscan and including patients (aged ≥ 20 and < 75) who were followed for ≥ one year, three hierarchical cohorts were created: 1-familial hypercholesterolemia (FH); 2-atherosclerotic cardiovascular disease (ASCVD) [not in 1 with myocardial infarction; unstable angina; ischemic stroke; stable angina; coronary revascularization; carotid stenosis; peripheral vascular disease; abdominal aortic aneurysm]; 3-type 2 diabetes mellitus (T2DM) [not in 1-2 with T2DM]. Using NHANES and including patients (aged ≥ 20 and < 75) the high risk primary prevention cohort (HRPP) included: [not in 1-3 with Framingham 10-year CHD risk score > 20%]. The ASCVD, T2DM, and HRPP cohorts included patients prescribed statin at and ≤ 12 months post diagnosis; FH cohort included patients prescribed high intensity statin and ezetimibe concurrently for ≥ 30 days at and < 12 month post diagnosis. Proportions
VA L U E I N H E A LT H 1 9 ( 2 0 1 6 ) A 1 - A 3 1 8
PCV15 Adherence to Dabigatran and the Risk of Stroke Cheetham TC, Bider-Canfield Z, Reynolds K Kaiser Permanente Southern California, Pasadena, CA, USA
Objectives: To determine if poor adherence to dabigatran is associated with an increased risk of stroke. Methods: A case-control study, nested in a population of dabigatran users, was conducted within an integrated health care delivery system. Eligible patients had a diagnosis of atrial fibrillation (AF) and a prescription for dabigatran between November 2010 and June 2015. Strokes, based on a primary hospital discharge diagnosis after starting dabigatran, were the case defining events. In addition, the stroke had to occur while the patient was a current or recent (within 30 days) user of dabigatran based on pharmacy dispensing records. Up to 4 controls were matched to each case using age, gender, duration of dabigatran use and CHADS2 score (< 3 or ≥ 3). Adherence was measured by medication possession ratio (MPR) for the year prior to the stroke date (1-yr MPR) in cases, or the equivalent event date in controls. MPR < 0.8 was defined as poor adherence. A conditional logistic regression model was used to evaluate the association between adherence and stroke events. Secondary models include peripheral vascular disease (PVD) as a confounder. Results: A total of 1833 AF patients were identified and 49 strokes occurred in this population. After applying exclusion criteria, 23 stroke cases remained eligible and these were matched to 84 controls. Matching produced populations with similar characteristics. Overall, the mean age was 73.1 years, 75.7% were males and the duration of dabigatran therapy was 630 days. For cases, 39.1% had poor adherence vs. 11.9% in controls. The odds ratios (OR) for stroke, associated with 1-yr MPR < 0.8 was 3.5 (95% CI; 1.1-11.5). The OR with PVD in the model was still elevated but no longer significant. Conclusions: In this small study, patients with poor adherence to dabigatran had a higher odds of stroke although the association was not independent of PVD status. PCV16 Trends in Er Visits Due to Hyperkalemia in the United States Aggarwal S, Topaloglu H NOVEL Health Strategies, Chevy Chase, MD, USA
Objectives: Hyperkalemia is a metabolic abnormality seen frequently in the Emergency Department. The most common condition leading to hyperkalemia is missed dialysis in a patient with end stage renal disease, but many other conditions can predispose an individual to hyperkalemia, such as acute renal failure, extensive burns, trauma, or severe rhabdomyolysis or severe acidosis. The objective of this study was to assess the resource burden on United States emergency room departments due to hyperkalemia. Methods: The number of emergency room (ED/ER) visits due to hyperkalemia, with International Classification of Diseases (ICD-9) code 276.7, were estimated using the Centers for Medicare & Medicaid Services (CMS) Agency for Healthcare Research and Quality (AHRQ) 2011 data for ED visits. A review of recent publications on hyperkalemia management was also conducted using the databases Pubmed, Embase, Biosis, Google Scholar and Cochrane. Results: The annual number of ED visits with Hyperkalemia as one of the diagnoses is estimated to be 814,181 (SE 23,526). The annual number of ED visits with Hyperkalemia as the first listed diagnosis is estimated to be 66,989 (SE 2284. Among the age groups 18-44, 45-64, 65-84, 85+ the majority of ED visits were in the 45-64 (36.04%) and 65-84 (39.44%) groups (hyperkalemia as the first listed diagnosis). Among the five payer types, Medicare, Medicaid, Private insurance, Uninsured and Other, the majority of patients belonged to Medicare (68.41%). The trend was similar for patients with Hyperkalemia as one of the diagnosis or first diagnosis. Conclusions: This analysis confirms previous findings that hyperkalemia is common in the emergency department. There is a need for quick, safe and effective treatments for hyperkalemia, which can be easily administered in emergency department setting. PCV17 Systematic Review of Burden of Hyperkalemia due to Angiotensin Enzyme Converting Inhibitors Aggarwal S1, Kumar S2, Topaloglu H1 1NOVEL Health Strategies, Chevy Chase, MD, USA, 2Institute for Global Policy Research, Washington, DC, USA
Objectives: Hyperkalemia can develop as a result of treatment with angiotensinconverting–enzyme (ACE) inhibitors or angiotensin-receptor blockers. This side effect is most common in patients with risk factors such as diabetes mellitus, heart failure, chronic kidney disease, or advanced age. The objective of this research was to conduct a systematic review on hyperkalemia caused due to angiotensin-converting–enzyme inhibitors. Methods: A systematic literature search for epidemiology and the burden of disease studies was undertaken for the databases Pubmed, Embase, Biosis, Google Scholar and Cochrane. Data was collected for the study type, methods, country and key findings. Extracted study data included hyperkalemia incidence, complications, mortality, available treatment options, as well as healthcare resource utilization and medical costs associated with hyperkalemia. Results: A total of 321 studies were identified based on the keywords. Of these, 23 studies met the inclusion criteria. Although the prevalence of hyperkalemia in the general population is unknown, it is present in 1-10% of hospitalized patients. Hyperkalemia is a common problem in patients with conditions that reduce potassium excretion, especially when treated with beta-adrenergic blockers that inhibit Na+,K+-ATPase activity or RAAS inhibitors (RAASIs) [angiotensin-converting-enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), mineralocorticoid receptor antagonists or renin inhibitors] that decrease aldosterone excretion. Hyperkalemia has been attributed to the use of ACE inhibitors in 10 to 38 percent of hospitalized patients with this complication. Hyperkalemia develops in approximately 10 percent of outpatients within a year after ACE inhibitors are prescribed. A study suggested that the mortality and morbidity from hyperkalemia as a result of combined treatment with ACE inhibitors and spironolactone may outweigh the potential long-term benefits in certain high-risk patients. Conclusions: Our review shows that there
is high burden of hyperkalemia in patients using ACE inhibitors. There is a need for quick, safe and effective treatments for hyperkalemia. PCV18 Liver Function Status among us Adults having both Hyperlipidemia and Hyperglycemia: A Cross Sectional Study Sakharkar P, Deb S Roosevelt University College of Pharmacy, Schaumburg, IL, USA
Objectives: Non-alcoholic fatty liver disease (NAFLD) is a multistage disorder that progresses from bland hepatic steatosis, non-alcoholic steatohepatitis, and fibrosis to irreversible cirrhosis. Hyperlipidemia and hyperglycemia, hallmarks of metabolic syndrome suggested being associated with liver dysfunction. The primary aim of this study was to examine the liver function status among adults having both hyperlipidemia and hyperglycemia in the United States. Methods: The National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2012 was used to examine the association between hyperlipidemia, hyperglycemia and liver enzymes amongst adults in the United States. Data were analyzed for descriptive statistics and for differences using the t test, Chi square test and ANOVA. A regression analysis was performed to identify relationships between demographic and above biomarkers. A p value of < 0.05 was considered statistically significant. Results: A total of 35,509 adults (≥ 20 yrs.) were included in this study. Sample mean age was 46.6 ± 0.22 yrs., majority were non-Hispanic white (46.7%) and female (51.3%). Seventy one percent adults had elevated LDL-C (> 130mg/dl), 19% had HDL-C (< 60mg/dl) and 11% had HbA1C > 7%. Adults with combination of hyperlipidemia and hyperglycemia were associated with 42% chance of having elevated ALT, 37% chance of elevated AST and 51% chance of elevated ALP levels. Adults with HbA1C > 7% had 16% chance of elevated ALT, 10% chance of elevated AST and 31% chance of elevated ALP levels (p< 0.001). Regression analysis showed significant relationship between age, gender, ethnicity, HbA1C, combination of hyperlipidemia and hyperglycemia, ALT, AST and ALP (p< 0.05). Conclusions: Chances of having elevated liver enzyme significantly increase when the individual has hyperlipidemia compared to hyperglycemia. Moreover, no potentiation was observed when individuals’ had both disease. We hypothesize that augmented levels of blood lipids and glucose indepndantly potentiates the liver dysfunction by initiating inflammatory mediators in the hepatocytes. PCV19 Trends in the Utilization of Warfarin and Non-Vitamin K Oral Anticoagulants in Elderly Patients with Atrial Fibrillation Alalwan A, Voils S, Hartzema A University of Florida, Gainesville, FL, USA
Background: Warfarin has been used for more than 60 years to decrease the risk of stroke and death in patients with atrial fibrillation (AF). In recent years, the FDA has approved four non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in AF: dabigatran, rivaroxaban, apixaban, and edoxaban. Objectives: To determine the annual prevalence of anticoagulant use in patients with AF and the longitudinal trends of oral anticoagulant (OACs) use and transition between OACs in AF patients. Methods: A cross-sectional retrospective longitudinal analysis was conducted using Truven Health MarketScan® Research Databases for Medicare beneficiaries from Jan 2008 to Dec 2013. We included patients 65 years and older with AF. The annual prevalence of individual OAC use was estimated from 2008 to 2013. Results: We Identified 2,389,243 individuals from 2008 to 2013. The average anticoagulated AF patients were about 43%. The prevalence of warfarin use decreased from 492 per 1000 patients with AF in 2008 to 326 per 1000 patients in 2013. This decrease in warfarin use was paralleled by an increased prevalence of NOAC use. The prevalence of dabigatran increased from 8 per 1000 patients with AF in 2010 to 64 per 1000 in 2013, and the prevalence of rivaroxaban increased from 0.8 per 1000 patients in 2011 to 65 per 1000 patients in 2013. Among the overall NOACs, apixaban showed the highest prevalence in the first year of approval, at 14 per 1000 patients. The average percentage of the patients who used more than one OAC since the introduction of NOACs was 5% of the OACs users. Conclusions: Prevalence of warfarin use has continued to decrease over time following the introduction of NOACs. The increase in NOACs prescribing suggests a perception among prescribers of improved safety and/or effectiveness of NOACs compared to warfarin. PCV20 Use of Real-World Data to Estimate Prevalence of CommerciallyInsured High Cardiovascular Risk Patients in the United States Hardin J1, Quek RG1, Roehl K2, Richhariya A3, Gandra SR1 Oaks, CA, USA, 2Amgen, Thousand Oaks, CA, USA, 3Seattle Genetics, Southeast Bothell, WA, USA 1Amgen, Inc., Thousand
Objectives: To estimate prevalence of US commercially-insured high cardiovascular risk patients. Methods: Using Truven MarketScan commercial claims (2006-2012) and National Health and Nutrition Examination Survey (NHANES) data (2005-2010), four mutually exclusive cohorts (stratified by age ≥ 20-< 65 and > 65-< 75 years) were created. Estimates of the prevalence of US commercially-insured patients were generated using the Medical Expenditure Panel Survey (2010). Using Marketscan and including patients (aged ≥ 20 and < 75) who were followed for ≥ one year, three hierarchical cohorts were created: 1-familial hypercholesterolemia (FH); 2-atherosclerotic cardiovascular disease (ASCVD) [not in 1 with myocardial infarction; unstable angina; ischemic stroke; stable angina; coronary revascularization; carotid stenosis; peripheral vascular disease; abdominal aortic aneurysm]; 3-type 2 diabetes mellitus (T2DM) [not in 1-2 with T2DM]. Using NHANES and including patients (aged ≥ 20 and < 75) the high risk primary prevention cohort (HRPP) included: [not in 1-3 with Framingham 10-year CHD risk score > 20%]. The ASCVD, T2DM, and HRPP cohorts included patients prescribed statin at and ≤ 12 months post diagnosis; FH cohort included patients prescribed high intensity statin and ezetimibe concurrently for ≥ 30 days at and < 12 month post diagnosis. Proportions