Problemas de adherencia al inicio de tratamientos para la enfermedad cardiovascular y diabetes

[spa] INTRODUCCIÓN: La patología cardiovascular es prevalente y causa una elevada mortalidad, discapacidad y carga económica a nivel mundial. La falta de adherencia a los tratamientos para la enfermedad cardiovascular y la diabetes empeora el control de la enfermedad y los resultados clínicos. Los problemas de adherencia al inicio de los tratamientos, como la no iniciación y la dispensación única, ocurren porque el paciente no empieza los tratamientos farmacológicos prescritos por primera vez u obtiene únicamente la primera unidad o envase de medicación de una nueva prescripción. En España, estos dos comportamientos tienen una prevalencia que oscila entre el 7% y el 23% y los factores explicativos y su impacto ha sido escasamente estudiado. OBJETIVOS: 1) Estimar la prevalencia de las conductas de no iniciación tras tres y seis meses y de la dispensación única en tratamientos farmacológicos para la enfermedad cardiovascular y diabetes. 2) Identificar los factores explicativos de la no iniciación y de la dispensación única de tratamientos farmacológicos para la enfermedad cardiovascular y diabetes. 3) Evaluar el impacto de la no iniciación y la dispensación única del tratamiento farmacológico para la enfermedad cardiovascular y diabetes en la adecuación al seguimiento clínico del paciente. MÉTODOS: Se llevó a cabo un estudio de cohortes observacional basado en registros electrónicos médicos del Institut Català de Salut. La variable no iniciación fue creada con datos de prescripción y facturación y se definió como la no dispensación de un fármaco tras tres meses siguientes a la prescripción. Se incluyeron las nuevas prescripciones (sin prescripción de un fármaco del mismo grupo los 3 meses previos) realizadas en Atención Primaria de cuatro subgrupos farmacológicos para el tratamiento farmacológico para la enfermedad cardiovascular que se encontraban entre los 13 más prescritos y/o costosos en 2014 en Cataluña: Insulinas y análogos de acción prolongada para inyección o insulinas (ATC-4: A10AE), Inhibidores de la agregación plaquetaria, excluyendo la heparina o antiagregantes plaquetarios (ATC-4: B01AC), Inhibidores de la Enzima Convertidora de la Angiotensina en monofármacos o IECA (ATC-4: C09AA) e Inhibidores de la enzima 3-Hidroxi-3-metil-glutaril-CoA reductasa o estatinas (ATC-4: C10AA). Los datos faltantes fueron imputados mediante imputación simple multivariante. Objetivos 1 y 2: La unidad básica de análisis para este objetivo fue la prescripción. Se seleccionaron aquellas prescripciones que cumplían los criterios de inclusión y que se habían realizado entre el 1 de julio de 2013 y 30 de junio de 2014. Se calcularon las prevalencias de no iniciación tras tres y seis meses y de dispensación única y se identificaron sus factores explicativos mediante modelos de regresión logística multinivel para cada uno de los cuatro subgrupos farmacológicos. Objetivo 3: La unidad básica de análisis para este objetivo fue el paciente. Se seleccionaron aquellos pacientes que cumplían criterios de inclusión y que habían recibido una nueva prescripción entre el 1 de enero de 2012 y el 31 de diciembre de 2013. Se estimó la proporción de pacientes iniciadores y no iniciadores que recibieron un adecuado seguimiento clínico según Guías de Práctica Clínica utilizando como variables proxy el coste de las pruebas y las visitas de seguimiento y se realizaron modelos de regresión logística multinivel. Paralelamente, se hizo el mismo análisis para los pacientes que retiraron dos o más recetas y los pacientes que retiraron una única receta (dispensación única). RESULTADOS: Objetivo 1: La prevalencia de no iniciación del tratamiento farmacológico para la enfermedad cardiovascular e insulinas fue de entre el 5,7% y el 7, 8% tras tres meses, de entre el 5,0% y el 7,9% tras seis meses y de entre el 10,6% y 18,4% para la dispensación única. Objetivo 2: Los siguientes factores incrementaron la probabilidad de no iniciación y dispensación única: el país de origen extranjero; tener un diagnóstico de enfermedad cardiovascular establecida o urticaria y recibir la prescripción de un médico sustituto. Entre los factores que disminuyeron la probabilidad de no iniciación y dispensación única destacan: mayor edad, mayor índice de masa corporal, mayor nivel socioeconómico y tener un diagnóstico de hipertensión, dislipemia, diabetes, enfermedad cardiovascular reciente y de trastornos mentales. Objetivo 3: Los pacientes no iniciadores tenían menos probabilidades de tener un adecuado seguimiento clínico que los pacientes iniciadores (Odds Ratio entre 0,60 y 0,77, p<0,001). Los pacientes iniciadores que retiraron una única receta de la medicación tenían menos probabilidades de tener un adecuado seguimiento que los pacientes que retiraron dos o más recetas (Odds Ratio entre 0,64 y 0,70, p<0,001) excepto en el caso de los pacientes con IECA. CONCLUSIONES: La presente tesis demuestra que la no iniciación y dispensación única de tratamientos para la enfermedad cardiovascular y la diabetes son comportamientos prevalentes en España. Una mayor edad o índice de masa corporal, tener un diagnóstico de hipertensión, dislipemia, enfermedad cardiovascular previa, el país de origen y recibir la prescripción de un prescriptor substituto, entre otros, influyó tanto en la no iniciación como en la dispensación única. Estos dos comportamientos se relacionan con un peor seguimiento clínico del paciente del paciente

Effectiveness and safety of oral anticoagulants for non-valvular atrial fibrillation: a population-based cohort study in primary healthcare in Catalonia

Objectives: Our objective was to analyse effectiveness and safety of oral anticoagulants (OAC) for stroke prevention in non-valvular atrial fibrillation.Material and methods: Population-based cohort study including adults initiating oral anticoagulants, either direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA), during 2011–2020.Data source: SIDIAP, capturing information from the electronic health records of Primary Health Care in Catalonia, Spain.Study outcomes: stroke, cerebral and gastrointestinal (GI) haemorrhage, assessed by patients’ subgroups according to different clinical characteristics.Results: We included 90,773 patients. Male sex, older than 75, previous event, peripheral artery disease, deep vein thrombosis, or receiving antiplatelets, antidiabetics or proton pump inhibitors (PPI) was associated with higher stroke risk. For DOAC-treated, treatment switch increased stroke risk, while being adherent had a protective effect. Men, antidiabetic treatment or a previous event increased the risk of cerebral bleeding. Receiving direct oral anticoagulants had a protective effect in comparison to vitamin K antagonists. For DOAC-treated, treatment switch increased, and adherence decreased the bleeding risk. Men, people with chronic kidney disease or a previous event posed an increased risk of gastrointestinal bleeding, whereas receiving PPI had a protective effect. For DOAC-treated, switch was associated with a higher bleeding risk.Conclusion: Being men, a previous event and DOAC-switch posed a higher risk for all study outcomes. direct oral anticoagulants had a protective effect against cerebral bleeding in comparison to vitamin K antagonists. Adherence to direct oral anticoagulants resulted in lower risk of stroke and cerebral bleeding. We found no differences in the risk of stroke and gastrointestinal bleeding when we compared direct oral anticoagulants vs. vitamin K antagonists

Prevenció de l'alcoholisme

Treballs d'Educació Farmacètica als ciutadans. Unitat Docent d'Estades en Pràctiques Tutelades. Facultat de Farmàcia , curs: 2014, Tutores: Maria Rubio Valera i Mª Angels Via Sosa. Coordinadora: Marian March Pujol,L’alcohol és una substància que forma part del dia a dia en la nostra cultura, tant als àpats com al lleure (1,2). És una de les substàncies d’abús més consumida per tots els segments de la població sent generalitzada a Espanya fins i tot en la població escolar (3) a partir dels 13 anys (4). A Europa suposa el tercer factor de risc de mort per darrere del tabac i de la hipertensió arterial (5). Amb aquest treball es pretén informar als adolescents sobre l’alcoholisme, que coneguin la malaltia, la distingeixin del consum de risc i puguin identificar ambdues, a més de conèixer les seves problemàtiques i mesures de prevenció. La sessió d’educació de la ciutadania esta dirigida a un públic jove de 15-17 anys el qual ja s’ha iniciat o podria iniciar-se en un futur al consum d’aquesta substància. El consum de risc i perjudicial i l’alcoholisme suposen una problemàtica de salut molt important que té conseqüències no només en l’individu sinó que també en tota la societat. El farmacèutic pot aportar, en el àmbit de la salut pública, educació sanitària per conscienciar a la població a més d’eines d’ajuda per prevenir aquesta problemàtica

Sex and gender differences in the use of oral anticoagulants for non-valvular atrial fibrillation: A population-based cohort study in primary health care in Catalonia

Objectives: To describe the sex and gender differences in the treatment initiation and in the socio-demographic and clinical characteristics of all patients initiating and oral anticoagulant (OAC), and the sex and gender differences in prescribed doses and adherence and persistence to the treatment of those receiving direct oral anticoagulants (DOAC). Material and methods: Cohort study including patients with non-valvular atrial fibrillation (NVAF) who initiated OAC in 2011-2020. Data proceed from SIDIAP, Information System for Research in Primary Care, in Catalonia, Spain. Results: 123,250 people initiated OAC, 46.9% women and 53.1% men. Women were older and the clinical characteristics differed between genders. Women had higher risk of stroke than men at baseline, were more frequently underdosed with DOAC and discontinued the DOAC less frequently than men. Conclusion: We described the dose adequacy of patients receiving DOAC, finding a high frequency of underdosing, and significantly higher in women in comparison with men. Adherence was generally high, only with higher levels in women for rivaroxaban. Persistence during the first year of treatment was also high in general, being significantly more persistent women than men in the case of dabigatran and edoxaban. Dose inadequacy, lack of adherence and of persistence can result in less effective and safe treatments. It is necessary to conduct studies analysing sex and gender differences in health and disease

Type 2 diabetes mellitus and COVID-19: a narrative review

Type-2 diabetes mellitus (T2DM) is a chronic metabolic disorder. The incidence and prevalence of patients with T2DM are increasing worldwide, even reaching epidemic values in most high- and middle-income countries. T2DM could be a risk factor of developing complications in other diseases. Indeed, some studies suggest a bidirectional interaction between T2DM and COVID-19. A growing body of evidence shows that COVID-19 prognosis in individuals with T2DM is worse compared with those without. Moreover, various studies have reported the emergence of newly diagnosed patients with T2DM after SARS-CoV-2 infection. The most common treatments for T2DM may influence SARS-CoV-2 and their implication in infection is briefly discussed in this review. A better understanding of the link between TD2M and COVID-19 could proactively identify risk factors and, as a result, develop strategies to improve the prognosis for these patients

Effectiveness and safety of oral anticoagulants for non-valvular atrial fibrillation: a population-based cohort study in primary healthcare in Catalonia

Oral anticoagulants; Atrial fibrillation; Primary healthcareAnticoagulants orals; Fibril·lació auricular; Atenció primària de salutAnticoagulantes orales; Fibrilación auricular; Atención primaria de saludObjectives: Our objective was to analyse effectiveness and safety of oral anticoagulants (OAC) for stroke prevention in non-valvular atrial fibrillation. Material and methods: Population-based cohort study including adults initiating oral anticoagulants, either direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA), during 2011–2020. Data source: SIDIAP, capturing information from the electronic health records of Primary Health Care in Catalonia, Spain. Study outcomes: stroke, cerebral and gastrointestinal (GI) haemorrhage, assessed by patients’ subgroups according to different clinical characteristics. Results: We included 90,773 patients. Male sex, older than 75, previous event, peripheral artery disease, deep vein thrombosis, or receiving antiplatelets, antidiabetics or proton pump inhibitors (PPI) was associated with higher stroke risk. For DOAC-treated, treatment switch increased stroke risk, while being adherent had a protective effect. Men, antidiabetic treatment or a previous event increased the risk of cerebral bleeding. Receiving direct oral anticoagulants had a protective effect in comparison to vitamin K antagonists. For DOAC-treated, treatment switch increased, and adherence decreased the bleeding risk. Men, people with chronic kidney disease or a previous event posed an increased risk of gastrointestinal bleeding, whereas receiving PPI had a protective effect. For DOAC-treated, switch was associated with a higher bleeding risk. Conclusion: Being men, a previous event and DOAC-switch posed a higher risk for all study outcomes. direct oral anticoagulants had a protective effect against cerebral bleeding in comparison to vitamin K antagonists. Adherence to direct oral anticoagulants resulted in lower risk of stroke and cerebral bleeding. We found no differences in the risk of stroke and gastrointestinal bleeding when we compared direct oral anticoagulants vs. vitamin K antagonists

Sex and gender differences in the use of oral anticoagulants for non-valvular atrial fibrillation: a population-based cohort study in primary health care in Catalonia

Oral anticoagulants; Atrial fibrillation; Gender differencesAnticoagulants orals; Fibril·lació auricular; Diferències de gènereAnticoagulantes orales; Fibrilación auricular; Diferencias de géneroObjectives: To describe the sex and gender differences in the treatment initiation and in the socio-demographic and clinical characteristics of all patients initiating an oral anticoagulant (OAC), and the sex and gender differences in prescribed doses and adherence and persistence to the treatment of those receiving direct oral anticoagulants (DOAC). Material and methods: Cohort study including patients with non-valvular atrial fibrillation (NVAF) who initiated OAC in 2011–2020. Data proceed from SIDIAP, Information System for Research in Primary Care, in Catalonia, Spain. Results: 123,250 people initiated OAC, 46.9% women and 53.1% men. Women were older and the clinical characteristics differed between genders. Women had higher risk of stroke than men at baseline, were more frequently underdosed with DOAC and discontinued the DOAC less frequently than men. Conclusion: We described the dose adequacy of patients receiving DOAC, finding a high frequency of underdosing, and significantly higher in women in comparison with men. Adherence was generally high, only with higher levels in women for rivaroxaban. Persistence during the first year of treatment was also high in general, being significantly more persistent women than men in the case of dabigatran and edoxaban. Dose inadequacy, lack of adherence and of persistence can result in less effective and safe treatments. It is necessary to conduct studies analysing sex and gender differences in health and disease

Outcomes of COVID-19 Infection in People Previously Vaccinated Against Influenza: Population-Based Cohort Study Using Primary Health Care Electronic Records

COVID-19; SARS-CoV-2; Electronic health records; Influenza vaccines; Primary health careCOVID-19; SARS-CoV-2; Registres sanitaris electrònics; Vacunes contra la grip; Atenció primària de salutCOVID-19; SARS-CoV-2; Registros de salud electrónicos; Vacunas contra la gripe; Atención primaria de saludBackground: A possible link between influenza immunization and susceptibility to the complications of COVID-19 infection has been previously suggested owing to a boost in the immunity against SARS-CoV-2. Objective: This study aimed to investigate whether individuals with COVID-19 could have benefited from vaccination against influenza. We hypothesized that the immunity resulting from the previous influenza vaccination would boost part of the immunity against SARS-CoV-2. Methods: We performed a population-based cohort study including all patients with COVID-19 with registered entries in the primary health care (PHC) electronic records during the first wave of the COVID-19 pandemic (March 1 to June 30, 2020) in Catalonia, Spain. We compared individuals who took an influenza vaccine before being infected with COVID-19, with those who had not taken one. Data were obtained from Information System for Research in Primary Care, capturing PHC information of 5.8 million people from Catalonia. The main outcomes assessed during follow-up were a diagnosis of pneumonia, hospital admission, and mortality. Results: We included 309,039 individuals with COVID-19 and compared them on the basis of their influenza immunization status, with 114,181 (36.9%) having been vaccinated at least once and 194,858 (63.1%) having never been vaccinated. In total, 21,721 (19%) vaccinated individuals and 11,000 (5.7%) unvaccinated individuals had at least one of their outcomes assessed. Those vaccinated against influenza at any time (odds ratio [OR] 1.14, 95% CI 1.10-1.19), recently (OR 1.13, 95% CI 1.10-1.18), or recurrently (OR 1.10, 95% CI 1.05-1.15) before being infected with COVID-19 had a higher risk of presenting at least one of the outcomes than did unvaccinated individuals. When we excluded people living in long-term care facilities, the results were similar. Conclusions: We could not establish a protective role of the immunity conferred by the influenza vaccine on the outcomes of COVID-19 infection, as the risk of COVID-19 complications was higher in vaccinated than in unvaccinated individuals. Our results correspond to the first wave of the COVID-19 pandemic, where more complications and mortalities due to COVID-19 had occurred. Despite that, our study adds more evidence for the analysis of a possible link between the quality of immunity and COVID-19 outcomes, particularly in the PHC setting

Initiation and Single Dispensing in Cardiovascular and Insulin Medications: Prevalence and Explanatory Factors

: Background: Adherence problems have negative effects on health, but there is little information on the magnitude of non-initiation and single dispensing. Objective: The aim of this study was to estimate the prevalence of non-initiation and single dispensation and identify associated predictive factors for the main treatments prescribed in Primary Care (PC) for cardiovascular disease (CVD) and diabetes. Methods: Cohort study with real-world data. Patients who received a first prescription (2013-2014) for insulins, platelet aggregation inhibitors, angiotensin-converting enzyme inhibitors (ACEI) or statins in Catalan PC were included. The prevalence of non-initiation and single dispensation was calculated. Factors that explained these behaviours were explored. Results: At three months, between 5.7% (ACEI) and 9.1% (antiplatelets) of patients did not initiate their treatment and between 10.6% (statins) and 18.4% (ACEI) filled a single prescription. Body mass index, previous CVD, place of origin and having a substitute prescriber, among others, influenced the risk of non-initiation and single dispensation. Conclusions: The prevalence of non-initiation and single dispensation of CVD medications and insulin prescribed in PC in is high. Patient and health-system factors, such as place of origin and type of prescriber, should be taken into consideration when prescribing new medications for CVD and diabetes

Antidiabetic treatment and COVID-19 Outcomes: A population-based cohort study in primary health care in Catalonia during the first wave of the pandemic

Aims: To analyse if antidiabetic treatment was associated with better COVID-19 outcomes in type 2 diabetic patients, measured by hospital admission and mortality rates as severe outcomes. Methods: Cohort study including COVID-19 patients registered in the Primary Care electronic records, in March-June 2020, comparing exposed to metformin in monotherapy with exposed to any other antidiabetic. Data source: SIDIAP (Information System for Research in Primary Care), which captures clinical information of 5,8 million people from Catalonia, Spain. Results: We included 31,006 diabetic patients infected with COVID-19, 43.7% previously exposed to metformin, 45.5% of them in monotherapy. 16.4% were admitted to hospital and 15.1% died. Users of insulin in monotherapy (OR 1.29, 95% CI 1.11-1.50), combined with metformin (OR 1.38, 1.13-1.69) or IDPP4 alone (OR 1.29, 1.03-1.63) had higher risk of severe outcomes than those in metformin monotherapy. Users of any insulin (OR 1.61, 1.32-1.97) or combined with metformin (OR 1.69, 1.30-2.20) had a higher risk of mortality. Conclusions: Patients receiving metformin monotherapy in our study showed a lower risk of hospitalization and death in comparison to those treated with other frequent antidiabetic agents. We cannot distinguish if better outcomes are related with the antidiabetic therapy or with other factors, such as metabolic control or interventions applied during the hospital admission