Ambulatory Fluoroquinolone Use in the United States, 2014 to 2019

Importance. Fluoroquinolones have been subject to increasing safety concerns and regulatory advisories. In the face of emerging risks, some evidence suggest they remain widely prescribed in ambulatory settings, and the impact of regulatory risk communications remains unclear. Objectives. i) To quantify and characterize ambulatory fluoroquinolone utilization in the United States between January 2014 and December 2019, and ii) to evaluate the effect of 2016 U.S. Food and Drug Administration (FDA) advisories on fluoroquinolone use. Design, participants and outcomes. We used IQVIA’s National Disease and Therapeutic Index (NDTI), a nationally representative audit of ambulatory care, to quantify quarterly and annual outpatient visits where a fluoroquinolone was used (treatment visits) among individuals age 20 years and older. We used descriptive statistics to report the utilization trends from January 2014 to December 2019, stratified by fluoroquinolone type, diagnoses and prescriber characteristics. We applied segmented-regression analysis to quantify the impact of 2016 FDA risk communications on fluoroquinolone use. Results. Between 2014 and 2019, fluoroquinolone treatment visits decreased by 27.8%, from 19.1 million visits in 2014 to 13.8 million visits in 2019. Decreases in use were concentrated among non-surgeons, who experienced a 37.3% decline in use over the six-year period; whereas, use among surgeons increased by 25.6% over the same period. The magnitude of fluoroquinolone use varied by clinical indication and provider age. For example, over 6 years, use declined by 45.9% for respiratory conditions, by 28.5% for urogenital conditions and by 20.4% for gastrointestinal conditions. Fluoroquinolone use declined by 73.9% among providers 44 years old. Between 2014 and 2019, most fluoroquinolone treatment visits were accounted for by ciprofloxacin (58.39 % of treatment visits), followed by levofloxacin (34.14 % of treatment visits). Nine calendar quarters prior to the 2016 regulatory advisories, there were approximately 4.8 million fluoroquinolone treatment visits per quarter. In 4th quarter of 2016, fluoroquinolone use significantly dropped by 641,035 visits (p-value = 0.000, 95% C= -937368, -344702). On segmented regression, the FDA advisories were associated with statistically significant changes in both the level and trend in fluoroquinolone use. Conclusions and Relevance. Large reductions in ambulatory fluoroquinolone use in the United States have coincided with increasing evidence and FDA risk communications regarding of their potential risks. Despite this, changes in fluoroquinolone use have varied based on patient and provider characteristics, suggesting heterogeneous effects of emerging risks on clinical practice

ACUTE MYOCARDIAL INFARCTION WITH VITAMIN B12 DEFICIENCY AND MILD HYPERHOMOCYSTEINEMIA: A CASE REPORT AND REVIEW

A 38-year old male was diagnosed with acute myocardial infarction (AMI) without a history of any significant clinical conditions. His subjective complaints and objective findings were clearly suggesting an acute ischemic attack along with vitamin B12 deficiency. While managing him for AMI, serology tests for vitamin B12 revealed low levels along with mild elevation of serum homocysteine level. He was managed with thrombolytic agent, β-adrenergic blocker, aspirin, antiplatelet agents, anticoagulants, statin, vitamin B complex and folic acid supplements. The clinical pharmacist intervened by suggesting discontinuation of Clopidogrel as two antiplatelet agents (Clopidogrel and Ticagrelor) were administered along with an anticoagulant, thereby increasing the risk of bleeding in the patient. Clopidogrel was stopped as Ticagrelor is a better antiplatelet agent when given in combination with low dose aspirin. Also, aspirin dose was reduced to enhance the efficacy of Ticagrelor and provide better secondary prevention for vascular diseases

Suspected hepatotoxicity and thrombocytopenia: Sodium valproate and carbamazepine

A young male was admitted in a tertiary care hospital with the complaints of excessive nausea, loose stools and fever with chills since few days. He was found to have thrombocytopenia, elevated liver enzymes, and suspected renal impairment. The patient was a known case of epilepsy, mood disorder and mental retardation. Since 6 months he was on sodium valproate, carbamazepine and trihexiphenidyl/risperidone fixed dose combination. Suspecting adverse drug reactions (thrombocytopenia, elevated liver enzymes), carbamazepine and sodium valproate were withdrawn. The patient was treated symptomatically with anti-pyretics and parentral fluids. On follow-up visit, the liver enzymes and platelet count were normal. The patient was maintained on levetiracetam and trihexiphenidyl/risperidone and the caretakers were counseled for the drugs therapy and monitoring parameters