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Drug News Abstracts - March 2024

Concerns Raised about Cardiovascular Safety of Therapeutic Cannabis Use

Recreational use of cannabis has been linked with cardiovascular adverse effects. In response to the rise in use of medical cannabis to treat chronic pain, Danish researchers designed a study, published in the European Heart Journal, to investigate whether these associations with new-onset arrhythmias would hold true for medical cannabis use.

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Zinc Supplementation Decreases Hand-Foot Skin Reaction in Patients Treated With Regorafenib

Hand-foot skin reaction (HFSR), characterized by abnormalities of the skin on the palms of the hands and soles of the feet, occurs in approximately 35% of cancer patients treated with vascular endothelial growth factor receptor—tyrosine kinase inhibitors (VEGFR-TKIs). But despite its prevalence, effective interventions for HFSR are lacking.

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Resmetirom Helps Resolve Nonalcoholic Steatohepatitis and Improves Liver Fibrosis

Nonalcoholic steatohepatitis (NASH) is a progressive liver disease, with a global prevalence of 4% to 6%. NASH is characterized by 5% or greater hepatic steatosis with hepatocellular damage and inflammation. Once it progresses to clinically meaningful fibrosis, the risk of adverse outcomes increases, especially among patients with type 2 diabetes. MAESTRO-NASH is an ongoing phase 3 trial evaluating the safety and efficacy of resmetirom, an oral, liver-directed thyroid hormone receptor beta (THRβ)-selective agonist, in adults with biopsy-confirmed NASH and fibrosis. In NASH, THRβ formation in the liver is impaired, which leads to a reduction in mitochondrial function and beta oxidation of fatty acids in association with increasing fibrosis. The double-blind, placebo-controlled trial is being conducted at 245 sites in 15 countries with a planned duration of 54 months. A report in the New England Journal of Medicine describes results of the primary biopsy end points at week 52.

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Drug News Abstracts Archive

Drug News Abstracts - September 2022
Evening Dosing of Antihypertensive Not Superior to Morning DosingA randomized UK trial in more than 21,000 patients with hypertension has challenged the long-standing belief that evening doses of antihypertensive medications lead to better outcomes. Results of the trial TIME (Treatment In Morning vs. Evening), a large, prospective, randomized trial that tested whether evening doses of antihypertensives improved major CV outcomes compared with morning dosing, were presented at the European Society of Cardiology Congress in Barcelona.READ MORE...Adults taking antihypertensive medications in the UK who had a valid e-mail address were recruited and followed for more than 5 years. After signing up on the trial website, participants were randomized, 10,503 to evening dosing and 10,601 to morning dosing. Average age of patients was 65; 58% were men and 98% were white. Information on outcomes was obtained from e-mail contact with participants and through record linkages to national databases. Further data was gathered from family doctors and hospitals in the UK and was adjudicated by a blinded committee.The composite endpoint for the study was hospitalization for nonfatal MI, nonfatal stroke, or vascular death. This occurred at similar frequencies regardless of the time of medication administration: 362 participants (3.4%) in the evening dosing group and 390 participants (3.7%) in the morning dosing group experienced these outcomes, for an unadjusted hazard ratio (HR) of 0.95. Other outcomes also showed that neither time of antihypertensive dosing was superior to the other. These outcomes include:Nonfatal stroke: HR, 0.93Nonfatal MI: HR, 0.92CV death: HR, 1.1All-cause mortality: HR, 1.04During the presentation, researchers concluded that patients can take their regular antihypertensive medications at a time of day that is convenient and works for them. (Practical Cardiology. (2022). TIME study: No added benefit from nighttime dosing of blood pressure medications. Retrieved August 2022 from https://www.practicalcardiology.com/view/time-study-no-added-benefit-from-nighttime-dosing-of-blood-pressure-medications; European Society of Cardiology. (2022). Evening dosing of blood pressure medication not better than morning dosing. Press release. Retrieved August 2022 from https://www.escardio.org/The-ESC/Press-Office/Press-releases/Evening-dosing-of-blood-pressure-medication-not-better-than-morning-dosing) Released: September 2022Nursing Drug Handbook© 2022 Wolters KluwerCDC Report Details Safety of COVID-19 Booster Doses for Children Ages 5 to 11A report from the Centers for Disease Control and Prevention (CDC) published in MMWR detailed the findings of safety monitoring of COVID-19 vaccine booster doses administered to children ages 5 to 11. On May 17, 2022, the FDA authorized a booster dose of the Pfizer-BioNTech COVID-19 vaccine under Emergency Use Authorization for children ages 5 to 11 years, to be given 5 months after receipt of the second primary series dose. Approximately 650,000 booster doses were administered to individuals in this age group in the first 10 weeks of rollout (May 17 to July 31).READ MORE...Safety data were obtained from v-safe, a voluntary smartphone-based safety surveillance system established to monitor adverse events after COVID-19 vaccination, and from VAERS (Vaccine Adverse Event Reporting System), a national passive vaccine safety surveillance system comanaged by the CDC and FDA. Through v-safe, health surveys are sent daily to registrants during the first week after vaccine administration, with questions about potential local injection-site reactions and systemic reactions as well as health inputs. If parents indicate on the survey that they sought medical care for their child after vaccination, the CDC’s v-safe call center contacts them and encourages completion of a VAERS report. VAERS was developed to monitor adverse events after vaccination; it accepts reports from health care providers, vaccine manufacturers, and members of the public. Serious events that are included in the report include hospitalization, life-threatening illness, permanent disability, congenital anomalies/birth defects, or death.During those first 10 weeks, approximately 657,302 U.S. children received a third (booster) dose of the Pfizer-BioNTech vaccine; 3,249 reports were made to v-safe for children in this age group. Both local injection-site reactions (n = 2,224) and systemic reactions (n = 1,483) were reported; the prevalence of both was similar to that seen after the second dose of the vaccine:Local reactions: 68.5% booster, 68.0% second doseSystemic reactions: 45.6% booster, 45.8% second doseThe most frequently reported adverse events were injection-site pain (n = 2,166), fatigue (n = 938), and headache (n = 647); most were mild and were most frequently reported the day after vaccination. In the week after receiving the booster, 225 enrolled children were unable to attend school, and 392 were unable to complete daily activities. The inability to attend school was reported less frequently than after the second dose (6.9% vs. 10.0%), but inability to complete daily activities was reported more frequently (12.1% vs. 7.5%).VAERS received 581 reports of adverse events after receipt of the booster by children ages 5 to 11; 578 (99.5%) of these reports were considered nonserious. The most commonly reported events (71.1%) were vaccine administration errors (such as preparation errors, incorrect dose, and inappropriate age). Local and systemic reactions were common among the VAERS reports, but no reports of myocarditis or death were received. Only three serious reports were made to VAERS: new-onset diabetes 10 days after vaccination, facial swelling 3 days after vaccination, and pain, fatigue, and malaise 5 days after vaccination.These findings may change somewhat over time, as safety monitoring continues, more school-age children receive boosters, and as vaccine providers gain additional experience with pediatric doses of COVID-19 vaccines. Continued education of vaccine providers might reduce the errors reported to VAERS. (Hause, A. M., et al. (2022). Safety monitoring of Pfizer-BioNTech COVID-19 vaccine booster doses among children aged 5-11 years – United States, May 17 – July 31, 2022. MMWR, 71(33): 1047–1051. Retrieved August 2022 from https://www.cdc.gov/mmwr/volumes/71/wr/mm7133a3.htm) Released: September 2022Nursing Drug Handbook© 2022 Wolters KluwerOlokizumab Effectiveness Expands Treatment Options for Rheumatoid ArthritisA new drug for rheumatoid arthritis (RA) has been shown to be at least as effective as the current gold standard treatment. Currently, if a patient’s disease progresses on initial therapy with the folic acid antagonist methotrexate, combination therapy with the tumor necrosis inhibitor adalimumab plus methotrexate is administered. Olokizumab is a monoclonal antibody that targets IL-6, which is known to play a role in the inflammatory process and in the progression of joint damage in RA.READ MORE...CREDO2 (Clinical Rheumatoid Arthritis Development of Olokizumab) was a Phase III, double-blind, randomized, placebo- and active-controlled, international trial conducted from May 2016 through November 2019 at 209 sites worldwide. Results of the multicenter study, published in the New England Journal of Medicine, compared treatment with olokizumab plus methotrexate to placebo and to the gold standard, adalimumab plus methotrexate, testing for superiority to placebo and for noninferiority to adalimumab.The study randomly assigned patients with RA and inadequate response to initial methotrexate treatment to receive olokizumab 64 mg every 2 weeks (n = 464), olokizumab 64 mg every 4 weeks (n = 479), adalimumab 40 mg every 2 weeks (n = 462), or placebo (n = 243). All patients continued receiving methotrexate. Patients were followed to determine if they met the criteria for an American College of Rheumatology 20 (ACR20) response by week 12. Such a response entails at least 20% fewer tender or swollen joints and an improvement of at least 20% in 3 of 5 treatment domains:Patient’s global assessment of disease activityPatient’s assessment of painProvider’s global assessment of disease activityPatient function according to score on Health Assessment Question-Disability IndexC-reactive protein level.Results demonstrated that, in patients with RA who were receiving maintenance methotrexate, olokizumab was superior to placebo and noninferior to adalimumab in producing ACR20 response at week 12. The proportion of patients who reached ACR20 response at 12 weeks was 44.4% with placebo, 70.3% with olokizumab every 2 weeks, 71.4% with olokizumab every 4 weeks, and 66.9% with adalimumab. Both dosages of olokizumab were considered noninferior to adalimumab on this measure.The percentage of patients with a Disease Activity Score 28 of less than 3.2 (a measure of acute inflammation) at week 12 was 12.8% of those receiving placebo, 45.3% of those receiving olokizumab every 2 weeks, 45.7% of those receiving olokizumab every 4 weeks, and 38.3% of those receiving adalimumab. The percentage of patients who achieved remission, as assessed by Clinical Disease Activity Index score of 2.8 or less at week 24, was 41.4% with placebo, 11.2% with olokizumab every 2 weeks, 12.1% with olokizumab every 4 weeks, and 13.0% with adalimumab. Adverse events occurred in approximately 70% of patients and were most commonly infections that were mild to moderate in severity.These results offer another option for treatment for patients with RA, up to 25% of whom don’t respond well to current treatment options. Larger and longer trials are needed to further elucidate the safety and efficacy of olokizumab in RA. (Smolen, J. S., et al. (2022). Olokizumab versus placebo or adalimumab in rheumatoid arthritis. New Engl J Med, 387: 715–726. Retrieved August 2022 from https://www.nejm.org/doi/full/10.1056/NEJMoa2201302) Released: September 2022Nursing Drug Handbook© 2022 Wolters KluwerUpdated Recommendations for Statin Use for Primary Prevention of Cardiovascular DiseaseUpdated recommendations for use of statins as primary prevention of atherosclerotic cardiovascular disease (CVD) in adults have been published by the U.S. Preventive Services Task Force (USPSTF) in JAMA. These recommendations were based on review of evidence on the benefits and harms of statins for reducing CVD-related morbidity or mortality and all-cause mortality in adults age 40 and older without a previous history of CVD and no signs or symptoms of CVD who were considered at risk.READ MORE...In pooled analysis, statins were associated with a decreased risk of all-cause mortality (18 trials), relative risk (RR), 0.92; of fatal or nonfatal stroke (15 trials), RR, 0.78; of fatal or nonfatal MI (12 trials), RR, 0.67; and with a decreased risk of composite CV outcomes (15 trials), RR, 0.72. No significant harm was associated with statin use in these studies, suggesting a significant overall benefit to their use as primary prevention.Based on this analysis, USPSTF makes the following clinical recommendations:Clinicians should prescribe statins as preventive for CVD in adults ages 40 to 75 who have at least one risk factor for CVD and a 10-year CVD event risk of 10% or greater; the analysis showed with moderate certainty that use of statins in this population had at least a moderate net benefit.Clinicians can selectively offer statins to those ages 40 to 75 with at least one CVD risk factor and a 10-year CVD event risk between 7.5% and 10%, taking the patient’s values and preference into account, as well as the presence of factors not included in the original risk assessment; the analysis showed with moderate certainty that use of statins in this population had a smaller net benefit.Evidence is insufficient to determine how beneficial it would be to prescribe statins as primary prevention for CVD events and mortality in adults age 76 or older with no history of CVD. Such use would be at the discretion of the clinician, taking other factors into consideration.The analysis also demonstrates directions for research, including improving the accuracy of CVD risk prediction in all racial, ethnic, and socioeconomic groups, gaining a clearer picture of the benefits and harms of statins as primary prevention in older adults, and determining the efficacy and safety of long-term statin use in younger adults, as well as examining the effects of early versus delayed initiation of statin therapy for primary prevention of CVD disease. (US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force recommendation statement. (2022). JAMA, 328(8): 746-753. Retrieved August 2022 from https://jamanetwork.com/journals/jama/fullarticle/2795521) Released: September 2022Nursing Drug Handbook© 2022 Wolters Kluwer
Drug News Abstracts - August 2022
Need for Access to Contraception Still Unmet for Many WomenThe Family Planning 2020 Initiative set a goal of increasing the number of women using modern contraceptives by 120 million in priority countries. A new report in The Lancet estimates that this number increased by 69 million in these countries, which would fall 51 million short of that goal. In the study, part of the systematic analysis for the Global Burden of Disease Study 2019, higher rates of contraceptive coverage were linked with the availability of a diverse range of contraceptive choices. This study elucidates the major increases in contraceptive use and the reductions in unmet need that have occurred since 1980.READ MORE...Researchers examined 1,162 population-based surveys of contraceptive use by women of reproductive age (ages 15 to 49) who self-reported current use of contraceptives for family planning. Using regression analysis, they determined estimates of the contraceptive prevalence rate (CPR) and modern CPR (mCPR), whether the demand for contraception was satisfied, and the contraceptive method mix, and examined them in both partnered and unpartnered women in five age groups.Between 1970 and 2019, increases were observed in use of all contraceptives (CPR), increasing by 18.7 percentage points, and that of mCPR, by 20.1 percentage points. The demand satisfied increased by 24.3 percentage points. In 2019, the average CPR was 51.9%, average of mCPR was 47.7%, and demand satisfied was 79.1%, although there were considerable differences geographically.Women ages 15 to 24 accounted for 16.0% of total need but 26.5% of global unmet need. The lowest rate of demand satisfied was found in women ages 15 to 19 (64.8%), followed by those ages 20 to 24 (71.9%); 43.2 million women ages 15 to 24 had unmet needs for contraception in 2019. These lower rates of satisfied demand in young women are cause for concern because of the effects both on the women themselves and society in general. Use of contraception is associated with reductions in maternal and neonatal mortality due to the avoidance of unintended and adolescent pregnancies, and access to contraceptives supports pursuit of education and economic opportunities. To address these disparities, family planning programs must determine the accessibility and acceptance of existing methods in use by other women among this younger age group.The methods women used to meet their contraception needs differed by marital status, age, and region. Compared with partnered women of all ages, unpartnered women more commonly used oral contraceptive pills and condoms; long-acting reversible methods (such as, IUDs, contraceptive implants, or injections) tended to be used most by women ages 20 to 49, and older women were more likely to use female sterilization.The absence of contraceptives tailored to the needs of younger women might be one explanation for the unmet need in that population; for example, if female sterilization is the method most often available, it’s unlikely to appeal to young women who haven’t had children yet. (Haakenstad, A., et al. (2022). Measuring contraceptive method mix, prevalence, and demand satisfied by age and marital status in 204 countries and territories, 1970–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet, 400(10348), 295–327. Retrieved July 2022 from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00936-9/fulltext#seccestitle210)Released: August 2022Nursing Drug Handbook© 2022 Wolters KluwerMacrolide Antibiotics May Be Associated with Hearing Loss in ChildrenMacrolides are one of the most used medications in children, with the most frequently prescribed being azithromycin, clarithromycin, and erythromycin. A retrospective case-control study published in JAMA Otolaryngology–Head and Neck Surgery attempted to determine whether that outpatient macrolide treatment was associated with pediatric sensorineural hearing loss. Past research has linked sensorineural hearing loss in adults to prior use of high-dose or IV macrolide treatment, but it hasn’t been studied in children.READ MORE...Using data from TRICARE, the health insurance system for U.S. uniformed service members and their families, the study analyzed 875 matched pairs of children, adolescents, and young adults with and without sensorineural hearing loss from records of outpatient encounters from October 2009 to September 2014. They were matched by age, sex, and time elapsed since the date of antibiotic prescription. Mean age was 5.7 years; patients were 62% male, and 66% non-Hispanic white. Multivariate logistic regression was used to compare the risk of prior macrolide exposure with penicillin exposure, adjusted for other risk factors and potential confounders.They found that compared with peers without hearing loss, pediatric patients with sensorineural hearing loss were more likely to have received a prescription for a macrolide antibiotic compared to one for penicillin (adjusted odds ratio [aOR], 1.31). The odds were significantly higher when more than 180 days had elapsed between antibiotic exposure and the patient’s testing and diagnosis of hearing loss (aOR, 1.79).Currently, 56% of pediatric sensorineural hearing loss is considered idiopathic; this study suggests that macrolides warrant further study as potential risk factors. The results could also guide practice by encouraging early recognition of sudden hearing loss after macrolide use, given the success rate of prompt hyperbaric oxygen treatment for these patients. (Lopilato, J. (2022). Kids’ hearing loss associated with common antibiotics. MedPage Today. Retrieved July 2022 from https://www.medpagetoday.com/pediatrics/generalpediatrics/99855; Dabekaussen, K. F., et al. (2022). Association of outpatient oral macrolide use with sensorineural hearing loss in children, adolescents, and young adults. JAMA Otolaryngol—Head Neck Cancer. Retrieved July 2022 from https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2794472?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF)Released: August 2022Nursing Drug Handbook© 2022 Wolters KluwerOntamalimab Showed Sustained Treatment Response in Crohn DiseaseIn a substantial number of patients with Crohn disease, nonresponse or loss of response to the approved treatments results in an unmet need for novel treatments with a good safety profile and more durable efficacy. OPERA-II, a multicenter, open-label phase 2 extension study, examined the long-term safety and efficacy of one of these treatments, ontamalimab, a fully human IgG monoclonal antibody against mucosal addressin cell adhesion molecule-1.READ MORE...All patients in the study had completed 12 weeks of treatment in OPERA, a phase 2, double-blind, placebo-controlled trial that examined three dosage strengths of ontamalimab (22.5 mg, 75 mg, or 225 mg) and compared clinical response and remission in 265 patients with Crohn disease, or had had a clinical response to a 225-mg dose of ontamalimab in another study, TOSCA, a 12-week, open-label study in which ontamalimab was given to 39 patients with active Crohn disease who had previously received immunosuppressants. In OPERA, clinical response and remission were observed in greater proportions of patients in the treatment group than with placebo, although these differences hadn’t reached statistical significance, and in TOSCA, 80% of treated patients had a clinical response and 77% were in clinical remission at week 12.Conducted from July 2011 through July 2016 in 81 centers in 15 countries worldwide, OPERA-II examined safety (adverse events and serious adverse events) and efficacy (clinical remission and response rates at weeks 24 and 72, the rate of relapse and time to relapse, the proportions of patients with changes in dosage, and proportion who discontinued by week 16) outcomes in patients with moderate to severe Crohn with a history of failed immunosuppressant therapy. Participants received ontamalimab at 75 mg every 4 weeks for 72 weeks, and then were followed up every 4 weeks for 24 weeks. Dosage could be decreased to 22.5 mg for intolerance or adverse events or increased to 225 mg in patients with inadequate response.Overall, 149 of 268 patients completed the study; 74 patients discontinued during the study period and another 45 during follow-up. The most common event leading to discontinuation was disease flare, in 19.8% of patients; 2 patients died, no patients required dosage reductions, and 157 had dosage escalations. Median time to dosage escalation was 28 weeks. Of the 68 patients who required dosage escalation by week 8, 13 subsequently discontinued the study by week 16. During the treatment period, 249 patients reported a total of 1,550 adverse events, of which 385 were considered treatment related. During the follow-up period, 133 patients experienced a total of 461 adverse events, of which 42 were treatment related.Rates of clinical remission of Crohn disease, defined as a score on the Harvey Bradshaw index (HBI) less than or equal to 5, was 48.1% at baseline, 47.8% at the end of week 24 of follow-up, and 37.3% at week 72. Of the 128 patients who were not in remission at baseline, 84 achieved remission during the study, with a median time to remission of 16.9 weeks. Similar results were seen in response, as measured by decreases in HBI greater than or equal to 3 points; at baseline the response rate was 63.1%, at week 24 it was 54.5%, and by week 72 was 42.5%. Of the 99 patients who hadn’t demonstrated clinical response at baseline, 68 did so during the study, with a median time to response of 13.9 weeks. In those who received the higher, 225-mg dose, the proportion of those in remission remained relatively stable from week 12 (31.8%) to week 72 (32.2%). Relapse was defined as an increase greater than or equal to 3 points in HBI score from the lowest HBI score measured, with a total HBI score greater than or equal to 8. Of the 226 patients who had experienced clinical response at any time during the study, 119 (52.7%) experienced relapse, with the median time to relapse of 67.4 weeks. (D’Haens, G. R., et al. (2022). Long-term safety and efficacy of the anti-mucosal addressin cell adhesion molecule-1 monoclonal antibody ontamalimab (SHP647) for the treatment of Crohn’s disease: The OPERA II study. Inflamm Bowel Dis, 28(7), 1034–1044. Retrieved July 2022 from https://academic.oup.com/ibdjournal/article/28/7/1034/6357026#363711481)Released: August 2022Nursing Drug Handbook© 2022 Wolters Kluwer
Drug News Abstracts - July 2022
Lidocaine Infusions Relieve Pain in Chronic MigrainePatients with a particularly refractory form of chronic migraine who received a multiday continuous lidocaine infusion as part of aggressive inpatient treatment reported significant improvement in pain immediately following the infusion, and almost half of those who responded reported sustained relief at 1 month. This retrospective cohort study, published in Regional Anesthesia and Pain Medicine, analyzed medical records of patients with chronic migraine (at least 15 headache days/month for at least 3 months, in which at least 8 days meet criteria for migraine) refractory to outpatient treatment. These patients are treated in hospital with infusions of NSAIDs, corticosteroids, and neuroleptics, hoping to break the cycle of pain.READ MORE...Researchers examined the medical records of 609 hospital admissions from April 2017 to April 2020 at the Jefferson Inpatient Headache Unit in Philadelphia. This comprised 537 unique patients; 72 admissions were repeat admissions. Mean number of days between hospitalization for repeat admissions was 215.2 days. The mean age of the patients was 46, and 81% were female; all met criteria for refractory chronic migraine. The patients received continuous lidocaine infusions, starting at 1 mg/min and titrated to a maximum of 4 mg/min based on daily plasma levels, pain response, and tolerability. The infusions were planned for 5 to 7 days, although length differed based on clinical factors; for example, hospitalization and the infusion could be extended if the patient reported that the pain was slowly but steadily improving. The patients were otherwise be discharged from the hospital if they reported being pain-free for from 12 to 24 hours, or had a pain level that the patient felt allowed improved function, or if they experienced minimal response to treatment by hospital day 5. Mean duration of treatment was 5.2 days.Patients recorded pain intensity using a self-report Numerical Rating Scale, from 0 (pain-free) to 10 (worst pain imaginable); researchers measured change in that self-reported headache pain from baseline to discharge. At baseline and at postdischarge office visits (25 to 65 days after discharge), patients were also asked the number of headache days they had experienced during the previous 28 days, as well as current worst daily pain and average daily pain.A decline in median pain ratings was seen with lidocaine infusion: from 7.0 at baseline to 1.0 at discharge. Nearly 88% of patients showed a reduction in pain ratings by at least 2 points during the hospitalization period. These patients were labeled acute responders; of the 535 acute responders with available postdischarge data, 43.2% showed sustained improvements. Average pain remained below baseline at the postdischarge visit, with a median score of 5.5, and the patients reported fewer headache days in the previous month compared to baseline: 22.5 days vs. 26.8 days.The high acute responder rate is an encouraging finding, providing evidence of rapid relief for these patients. The waning of the effect seen over follow-up reflects the challenges presented by refractory chronic migraine. These results should offer support for design and implementation of randomized, controlled studies of lidocaine infusions to allow increased use of this treatment. Clinicians meanwhile can use these study results in their communications with patients, describing the likelihood of relief and the expected duration of that relief. (Shukla, D. (2022). Chronic migraine: Common anesthetic relieves pain in new study. Medical News Today. Retrieved June 2022 from https://www.medicalnewstoday.com/articles/chronic-migraine-common-anesthetic-relieves-pain-in-new-study; Schwenk, E. S., et al. (2022). Lidocaine infusions for refractory chronic migraine: A retrospective analysis. Region Anesth Pain Med, 47(7), 408–413. Retrieved June 2022 from https://rapm.bmj.com/content/47/7/408)Released: July 2022Nursing Drug Handbook© 2022 Wolters KluwerMaternal Vaccination for COVID-19 Offers Some Protection for Their InfantsVaccination against SARS-CoV2 during pregnancy is known to result in detectable maternal antibodies to the virus in cord blood, human milk, and serum specimens from infants, but it’s unknown how this fact correlates with protection against COVID-19 in infants under age 6 months, who are at high risk for complications of COVID-19 but aren’t eligible for vaccination. A case-control study published in the New England Journal of Medicine assessed the effectiveness of full maternal vaccination (that is, two doses of an mRNA SARS-CoV2 vaccine) against hospitalization for COVID-19 in infants younger than age 6 months. Between July 2021 and March 2022, the study enrolled infants hospitalized for COVID-19 (case infants; n = 537) and matched them with hospitalized infants who didn’t have COVID-19 (control infants; n = 521) at 30 hospitals across 22 U.S. states. Median age of infants was 2 months; 19% of case infants and 24% of control infants had at least one underlying health condition. All case infants were identified with COVID-19 as the primary reason for their admission or with a clinical syndrome consistent with acute COVID-19 who then tested positive on a SARS-CoV2 PCR test; control infants were hospitalized for other reasons and tested negative on a PCR test. Researchers attempted to enroll a control infant for every case infant, with a date of hospital admission that was within 4 weeks of the admission date of the case infants.READ MORE...The overall effectiveness of maternal vaccination against COVID-associated hospitalization in their infants age 6 months and younger was 52%; its effectiveness against intensive care unit admission was 70%. Among case infants, 113 (21%) required intensive care treatment for COVID-19, including 64 (12%) who required mechanical ventilation or vasoactive infusions. Two infants died and two required ECMO treatment; none of these four infants was born to fully vaccinated mothers.The study examined appropriate timing of maternal vaccination to facilitate the greatest transfer of maternal antibodies. In this study, effectiveness at preventing hospitalization was 69% when vaccinated after 20 weeks of pregnancy and 38% when the last vaccination was given during the first 20 weeks of pregnancy. The researchers were also able to examine results during the period of the circulation of the delta and omicron variants of the virus. Of the 537 case infants, 181 were admitted during the delta circulation period and 356 during the omicron circulation period. The effectiveness of the maternal vaccination against COVID-19 hospitalization was 80% during the delta period and 38% during the omicron period.These data support the safety of COVID-19 vaccination during pregnancy. The CDC recommends vaccination, including boosters, for pregnant people. Despite the known benefits and safety of the mRNA vaccine, vaccination rates during pregnancy still lag: only 71% of pregnant people in the United States were fully vaccinated, with an even lower rate among non-Hispanic Black people (58%). (Halasa, N. B., et al. (2022). Maternal vaccination and risk of hospitalization for Covid-19 among infants. New Engl J Med, 387, 109–119. Retrieved June 2022 from https://www.nejm.org/doi/full/10.1056/NEJMoa2204399?query=featured_coronavirus; Rasmussen, S. A., & Jamieson, D. J. (2022). Covid-19 vaccination during pregnancy—Two for the price of one. New Engl J Med, 387, 178–179. Retrieved June 2022 from https://www.nejm.org/doi/full/10.1056/NEJMe2206730?query=recirc_curatedRelated_article)Released: July 2022Nursing Drug Handbook© 2022 Wolters KluwerNewer P2Y12 Inhibitors Improve Mortality in Patients with MI Complicated by Cardiac Arrest or Cardiogenic ShockManagement of acute myocardial infarction (MI) complicated by cardiac arrest or cardiogenic shock is challenging, and current treatment is less successful in these patients. A review and meta-analysis published in Mayo Clinic Proceedings offers evidence that “newer” P2Y12 receptor inhibitors should be preferred when treating this high-risk population.READ MORE...Current treatment of acute MI complicated by cardiac arrest or cardiogenic shock includes percutaneous coronary intervention followed by use of dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor. Clopidogrel, the first P2Y12 inhibitor on the market, has been the standard of care; this study examined results of trials that compared outcomes with other P2Y12 inhibitors ticagrelor and prasugrel vs. clopidogrel.Because the large sample sizes seen in other studies of MI are not possible for these conditions, the review identified only eight studies, seven of them cohort studies. The studies comprised 1100 patients; 695 patients (63.2%) received clopidogrel and 405 patients (36.8%) received the newer P2Y12 inhibitors ticagrelor or prasugrel. They compared outcomes: early mortality, either in-hospital or 30-day all-cause mortality; 1-year, all-cause mortality; and the incidence of major bleeding and stent thrombosis.The “newer” P2Y12 cohort (prasugrel and ticagrelor) had lower rates of early mortality (odds ratio [OR], 0.60) and of 1-year mortality (OR, 0.51). The analysis did not find a significant difference in major bleeding (OR, 1.21) or in stent thrombosis (OR, 2.01) with use of ticagrelor or prasugrel, although there were numerically more bleeding events with the “newer” drugs.The study is limited by the retrospective, observational character of most of the studies involved; there is the risk that selection bias comes into play, as clinicians determine that certain patients would benefit from the more potent newer P2Y12 receptor inhibitors. In addition, it would be valuable to design a study that examined these complications separately, recognizing that cardiac arrest and cardiogenic shock have different effects on, for example, perfusion of other organs. (Patlolla, S. H., et al. (2022). Newer P2Y12 inhibitors vs clopidogrel in acute myocardial infarction with cardiac arrest or cardiogenic shock: A systematic review and meta-analysis. Mayo Clin Proceed, 97(6), 1074–1085. Retrieved June 2022 from https://www.mayoclinicproceedings.org/article/S0025-6196(22)00120-3/fulltext; Effron, M. B. (2022). Importance of more potent antiplatelet therapy in myocardial infarction with cardiac arrest or cardiogenic shock. Mayo Clin Proceed, 97(6), 1041–1043. Retrieved June 2022 from https://www.mayoclinicproceedings.org/article/S0025-6196(22)00255-5/fulltext)Released: July 2022Nursing Drug Handbook© 2022 Wolters Kluwer
Drug News Abstracts - June 2022
Mepolizumab a Good Choice in Chronic Rhinosinusitis with Comorbid AsthmaResults of the phase III SYNAPSE study demonstrated the effectiveness of mepolizumab in reducing nasal polyp size and nasal obstruction in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). Mepolizumab is an MAb that prevents interleukin-5 from binding to its receptors on eosinophils, thus selectively inhibiting eosinophilic inflammation. The burden of disease in CRSwNP is greatest among those with comorbid asthma or aspirin-exacerbated respiratory disease (AERD) and in patients with eosinophilic infiltration. The researchers conducted a subgroup analysis targeting those patients that suggests that mepolizumab should be the treatment choice in CRSwNP in patients with comorbid asthma or AERD.READ MORE...SYNAPSE was a randomized, double-blind, 52-week study in patients with severe bilateral CRSwNP eligible for surgery despite intranasal corticosteroid treatment. Enrolled patients received subcutaneous mepolizumab 100 mg or placebo every 4 weeks plus standard of care (daily mometasone furoate nasal spray, saline nasal irrigations, and short courses of steroids or antibiotics, as needed) for 52 weeks. The patients had recurrent bilateral nasal polyps. The study reported the proportion of patients with greater than or equal to 1-point increase in total endoscopic nasal polyp score at week 52 and greater than or equal to 3-point improvement in nasal obstruction visual analog (VAS) score by weeks 49 to 52. Endoscopic nasal polyp score ranges from 0 (no polyps) to 4 (large polyps causing complete obstruction of inferior meatus) for each nostril, for a highest possible total score of 8. The nasal obstruction VAS score ranges from 0 to 10. This subgroup analysis included 407 patients; 289 had comorbid asthma, 108 had comorbid AERD, 371 had blood eosinophil cell (BEC) counts greater than or equal to 150 cells/f mm3, and 278 had BEC counts greater than or equal to 300 cells/f mm3.In the intent-to-treat population, more patients who received mepolizumab had greater than or equal to 1-point improvement from baseline in endoscopic nasal polyp score—50.5% of patients vs. 28.4% in the placebo group. The proportions of patients with greater than or equal to 1-point improvement in endoscopic nasal polyp score was higher across the various subgroups with mepolizumab vs. placebo:· Comorbid asthma: 52.9% vs. 29.5%· Comorbid AERD: 51.1% vs. 20.6%· BEC count greater than or equal to 150 cells/f mm3: 49.5% vs. 28.1%· BEC count greater than or equal to 300 cells/f mm3: 50.4% vs. 28.1%The proportion of patients who had a greater than or equal to 3-point improvement in nasal obstruction VAS score also differed greatly across these subgroups:· Comorbid asthma: 60.0% vs. 34.9%· Comorbid AERD: 64.4% vs. 30.2%· BEC count greater than or equal to 150 cells/f mm3: 59.1% vs. 34.1%· BEC count greater than or equal to 300 cells/f mm3: 59.0% vs. 32.4%Among the other findings is that patients receiving mepolizumab had a lower risk of surgery than those receiving placebo. This reduction was greater in patients without asthma than those with asthma but was similar irrespective of the presence of AERD. This benefit may be an important consideration for patients who express concern over the risks associated with surgery. (Bachert, C., et al. (2022). Mepolizumab for chronic rhinosinusitis with nasal polyps: Treatment efficacy by comorbidity and blood eosinophil count. J Allergy Clin Immunol, 149(5), 1711-1721.E6.Retrieved June 2022 from https://www.jacionline.org/article/S0091-6749(22)00001-X/fulltext#fx1)Released: June 2022Nursing Drug Handbook© 2022 Wolters KluwerOral Antivirals for COVID-19The best tool health care providers have to combat spread of COVID-19 disease is the vaccine program targeting the virus. However, research into treatments to mitigate the effects of the virus after infection are ongoing. In December 2021 two oral antiviral treatments were made available under an Emergency Use Authorization (EUA): ritonavir-boosted nirmatrelvir and molnupiravir.READ MORE...The Centers for Disease Control and Prevention has issued a health advisory with updates on the availability of and use of these treatments for mild to moderate COVID-19. When theseagents were first made available, ensuring adequate supplies to keep up with demand was challenging due to the rapid increase in omicron variant cases of COVID-19. These treatments are growing in importance as that highly transmissible variant continues as the predominant strain, with new subvariants emerging, and as mitigation strategies such as masking and social distancing are being phased out. The FDA has ensured that oral antivirals are widely available and can be accessed with a provider prescription at pharmacies and at Test-to-Treat locations.Both ritonavir-boosted nirmatrelvir and molnupiravir work best early in the course of illness before SARS-CoV2 can have a chance to replicate and do damage. They are authorized for use within 5 days of symptom onset in nonhospitalized patients who have tested positive for SARS-CoV2 and are at high risk. High-risk patients include those over age 65 or those older than age 12 with an underlying condition that increases the risk of severe outcomes of COVID-19, such as cancer, heart disease, diabetes, and obesity. The preferred therapies are the oral antiviral ritonavir-boosted nirmatrelvir and the infusion remdesivir. The alternatives, molnupiravir and the monoclonal antibody bebtelovimab (available under EUA since February 2022) are to be used only when the preferred treatments are unavailable, not feasible, or not appropriate. Ritonavir-boosted nirmatrelvir produced an 89% reduction in the risk of hospitalization and death; molnupiravir is less efficacious, producing a 30% reduction in risk. There are numerous considerations that come into play when deciding on which oral antiviral to use. Ritonavir-boosted nirmatrelvir should be avoided by those with severe kidney or liver disease; in addition, because ritonavir acts to boost levels of nirmatrelvir by slowing down hepatic metabolism of the other drug through inhibition of CYP3A4, its use should be avoided with other drugs highly dependent on CYP3A enzymes for clearance. Its use should also be avoided with use of CYP3A inducers, which can result in low levels of ritonavir and therefore loss of virologic response. Molnupiravir use should be avoided in those who are, or are attempting to become, pregnant and in those under age 18; men with sexual contact with women of childbearing age should use a reliable method of contraception during molnupiravir treatment and for 3 months afterward.In the battle against the pandemic, health care providers and their patients should be doing everything they can to avoid COVID-19 disease and disease progression in patients with risk factors: vaccinations, testing, isolation when positive, and these antiviral treatments. Providers should educate their patients at high risk not to overlook mild cases and to remember that accurate testing remains key to COVID-19 prevention. (Petty, L. A., & Malani, P. N. (2022). Oral antiviral medications for COVID-19. JAMA Patient Page. Retrieved June 2022 from https://jamanetwork.com/journals/jama/fullarticle/2791780#:~:text=Two%20new%20oral%20antiviral,US%20under%20emergency%20use%20authorization;Katella, K. (2022).13 things to know about Paxlovid, the latest COVID-19 pill. Yale Medicine. Retrieved June 2022 from https://www.yalemedicine.org/news/13-things-to-know-paxlovid-covid-19; U.S. Food & Drug Administration. (2021, December 22). Coronavirus (COVID-19) update: FDA authorizes first oral antiviral for treatment of COVID-19. [Press Release]. Retrieved June 2022 from https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-oral-antiviral-treatment-covid-19;Centers for Disease Control and Prevention. (2022, April 25). Updated information on availability and use of treatments for outpatients with mild to moderate COVID-19 who are at increased risk for severe outcomes of COVID-19. [Press release]. Retrieved June 2022 from https://emergency.cdc.gov/han/2022/han00463.asp;National Institutes of Health. COVID-19 Treatment Guidelines. (2022). Ritonavir-boosted nirmatrelvir (Paxlovid). Retrieved June 2022 from https://www.covid19treatmentguidelines.nih.gov/therapies/antiviral-therapy/ritonavir-boosted-nirmatrelvir--paxlovid-/)Released: June 2022Nursing Drug Handbook© 2022 Wolters KluwerPolypharmacy and Disability in Older AdultsA new Japanese study published in Geriatrics and Gerontology International evaluated the relationship between high-risk prescribing practices and the risk for disability in people age 65 and older. These practices include polypharmacy (the use of five or more prescription drugs) and the use of drugs with sedative or anticholinergic properties, including antipsychotics, benzodiazepines, and antiparkinsonian drugs. These prescribing practices have been previously shown to be associated with physical frailty among older adults.READ MORE...The researchers for the University of Tsukuba conducted a population-based, case-control study, the study cohort nested within a cohort of older adults in a Japanese city. Using combined medical claims and long-term care (LTC) needs certification database, researchers identified 2,123 individuals who received a first LTC needs certification and matched them to 40,295 controls (accounting for 89% of the over-65 population) based on age, sex, residence, and the observation period. In Japan, people age 65 and older with a functional disability are eligible for LTC services; an LTC needs certification is needed to access these services, so the researchers were able to use it as a proxy for disability.The study demonstrated a dose-response relationship between both polypharmacy and the use of drugs with sedative or anticholinergic properties with the risk for LTC needs certification. Adjusted odds ratios (OR) of this outcome were as follows:· Polypharmacy (5 to 9 prescription drugs): OR, 1.32· Hyperpolypharmacy (greater than or equal to 10 prescription drugs): OR, 1.87· Cumulative doses of drugs with sedative or anticholinergic properties, in terms of defined daily dose:o defined daily dose 1–364: OR, 1.07o defined daily dose 365–729: OR, 1.25o defined daily dose greater than 730: OR, 1.33Further study should examine whether adjusting prescribing patterns in these patients could reduce the risk of LTC needs certification in older adults and reduce the LTC burden for the public. (University of Tsukuba. (2022, May 18). Potential pitfalls of high-risk prescribing practices in older adults. AlphaGalileo. Retrieved June 2022 from https://www.alphagalileo.org/en-gb/Item-Display/ItemId/221191?returnurl=https://www.alphagalileo.org/en-gb/Item-Display/ItemId/221191;Kuroda, N., et al. (2022). Associations of polypharmacy and drugs with sedative or anticholinergic properties with the risk of long-term care needs certification among older adults in Japan: A population-based, nested case–control study. Geriatr Gerontol Int. Advanced online publication. Retrieved June 2022 from https://onlinelibrary.wiley.com/doi/full/10.1111/ggi.14393)Released: June 2022Nursing Drug Handbook© 2022 Wolters KluwerRisdiplam Effective Long-Term for Spinal Muscular AtrophyGenentech presented long-term data from the FIREFISH study, including one-year data for the open-label extension, at the European Paediatric Neurology Society Conference, held April 28 through May 2, 2022. FIREFISH is a phase II/III, 2-part, multicenter trial that examined the long-term efficacy and safety of risdiplam in infants with symptomatic Type 1 spinal muscular atrophy (SMA). SMA is a group of severe, progressive neuromuscular diseases that is the leading cause of infant mortality. It’s caused by a mutation of the SMN1 gene that leads to a deficiency of the SMN protein, resulting in cellular imbalance in motor neurons that in turn causes the motor neuron endplates to not properly connect to muscle and leads to death of the motor neurons. Without treatment, depending on the type of SMA, the patients can lose physical strength; and the ability to walk, eat, or breathe can be significantly diminished or lost. Untreated infants with type 1 SMA typically don’t survive past age 2. Risdiplam is a survival motor neuron 2 splicing modifier that allows production of full-length SMN protein and thereby can affect the progression of SAM.READ MORE...The original study evaluated efficacy and safety in infants ages 1 to 7 months at the time of trial enrollment. Part 1 of the trial was a dose-finding study; in part 2, the patients received liquid risdiplam orally or via feeding tube once daily. After 24 months, the trial entered a 3-year open-extension phase. At 36 months after trial enrollment, 91% (n = 58) of children treated with risdiplam were alive. The marker chosen to demonstrate efficacy was the percentage of children able to sit without support for 5 seconds, as assessed by the Bayley Scale of Infant Development at month 12. Without treatment, infants with type 1 SMA are never able to sit without support. At this 36-month follow-up, among the 48 children who could be assessed, 32 maintained that ability and 4 gained it between months 24 and 36, and no child who had gained the ability to sit without support for 5 seconds lost that ability. Further, 20 children maintained and 15 gained the ability to sit without support for at least 30 seconds. The children had other successes in the improvement or maintenance of skills measured on the Hammersmith Infant Neurological Examination between 24 and 36 months on treatment:· Ability to hold head up: 36 maintained, 3 gained, 0 lost this ability· Pivot while sitting: 15 maintained, 11 gained, 0 lost this ability· Stand with support: 6 maintained, 5 gained, 1 lost this ability· Walk while holding on: 1 maintained, 2 gained, 0 lost this abilityThe study showed overall continued reduction in serious adverse events and hospitalization over time. The rate of serious adverse events decreased by approximately 50% after each 12-month treatment period and a 78% reduction between the first and third year of treatment. The rate of hospitalization decreased from 1.24 per patient per year over 12 months to 0.70 hospitalizations per patient per year over 36 months. (Genentech. (2022, April 28). New three-year data for Genentech’s Evrysdi (risdiplam) show long-term improvements in survival and motor milestones in babies with type 1 spinal muscular atrophy (SMA). [Press Release]. Retrieved June 2022 from https://www.gene.com/media/press-releases/14950/2022-04-28/new-three-year-data-for-genentechs-evrys)Released: June 2022Nursing Drug Handbook© 2022 Wolters Kluwer
Drug News Abstracts - May 2022
Differences in Response to Antidepressants in Combination with Mood Stabilizers and Antipsychotics for Unipolar and Bipolar DepressionA study published in the Journal of Clinical Psychopharmacology is the first to explore clinical response rates to antidepressants in combination augmentation strategies with either antipsychotics or mood stabilizers and to illuminate the differences between response to similar pharmacotherapies in patients with unipolar and bipolar depression. Antidepressant prescriptions in bipolar disorder have surged in the past two decades, from 17.9% to 40.9% of patients, mostly based on the success of newer antidepressants in treating unipolar depression. They remain the leading treatment prescribed for bipolar disorder, despite inconsistent evidence for efficacy and the occurrence of adverse events, such as treatment-emergent affective switch (TEAS).READ MORE...The study relied on data from a research database for patients followed at the McGill University Health Center’s Mood Disorders Clinic for 2 or more years (mean, 7.5 years). It included 206 patients; 76 met the criteria for treatment-resistant depression (TRD), failing two or more trials with different antidepressants in either monotherapy or combination therapy for 3 or more weeks. The remaining 130 patients met criteria for bipolar disorder, all of whom had failed to respond to one or more trials with a mood stabilizer plus an antipsychotic. Clinical outcomes were determined by comparing changes on these behavioral scales between start of a treatment regimen and after 3 months of an unchanged regimen; scales were the 17-item Hamilton Depression Rating Scale (HAMD-17), Quick Inventory of Depressive Symptomatology (QIDS-C16), and Clinical Global Impression–Severity of Illness (CGI-S). Response was defined as 50% or greater reduction from the pretreatment HAMD-17 score, and remission was defined as a score of less than 7 on the HAMD-17 at the end point.At baseline, the TRD group had, on average, moderate to severe depression (HAMD-17: 23.86), with scores on QIDS-C16 of 15.0 and on CGI-S of 5.2. The bipolar group had, on average, mild to moderate depression (HAMD-17, 18.3), with scores on QIDS-C16 of 12.3 and on CGI-S of 4.5. Clinical improvements in depression severity were seen with the different treatment strategies:· Antidepressants plus antipsychotics produced significantly greater improvement on HAMD-17 for the TRD group (score, 9.2) vs. bipolar group (score, 5.1), but no significant differences on other scales: 5.6 vs. 4.5 on QIDS-C16 and 1.7 vs. 1.4 on CGI-S.· Antidepressants plus mood stabilizers showed marginally greater improvement on HAMD-17 for the TRD group (score, 8.8) vs. the bipolar group (score, 6.3); the combination of antidepressants, antipsychotics, plus mood stabilizers also showed marginally significant differences between the TRD group (score, 9.3) and the bipolar group (score, 6.9) on the HAMD-17. But other clinical scales failed to reveal significant differences in outcomes.Response and remission rates did not differ significantly between the two types of depression, nor did they differ based on any type of combination treatment. Response rates were 26% in the TRD group and 19% in the bipolar group for all treatment strategies; remission occurred in 5% of the TRD group and in 7% of the bipolar group. These low rates of remission reflect the refractory nature of depression in these patients.These data, seen in a natural clinical setting, highlight the importance of augmentation strategies in depression. The study also showed that the reduction of depressive symptoms was greater in the TRD group compared with the bipolar group when pharmacologic combinations included an antidepressant and that adding an antidepressant to the treatment regimen for bipolar depression increased the risk of TEAS, cycle acceleration, and mood destabilization in these patients. Taken together, these results raise questions about the use of antidepressants in bipolar disorder. (Moderie, C., et al. (2022). Distinct effects of antidepressants in association with mood stabilizers and/or antipsychotics in unipolar and bipolar depression. J Clin Psychopharmacol, 42(2), 118–124. Retrieved May 2022 from https://journals.lww.com/psychopharmacology/Fulltext/2022/03000/Distinct_Effects_of_Antidepressants_in_Association.2.aspx)Released: May 2022Nursing Drug Handbook© 2022 Wolters KluwerAtogepant and Sumatriptan Safe to Administer Together for MigraineAcute treatment for migraine attacks includes triptans; the most commonly used triptan is sumatriptan. Preventive therapies are also beneficial; they may be used in those with severe or frequent migraine attacks and in those with a poor response to acute treatments. Atogepant, a calcitonin gene-related peptide (CGRP) receptor antagonist, has been approved as a preventive treatment for migraine; it can be expected, therefore, that it could possibly be given in combination with sumatriptan.READ MORE...An open-label, randomized, 3-way crossover study evaluated the possibility of how administering the two drugs together affected pharmacokinetic parameters, and compared how the body absorbed, distributed, and eliminated the two drugs when given together compared to each drug given alone. The trial enrolled 30 healthy adults, of whom 27 completed the study; 29 received a single oral 100-mg dose of sumatriptan, 28 received a single oral 60-mg atogepant dose, and 27 received the drugs administered together. Blood samples were drawn to determine plasma drug concentrations on days 1, 8, and 15, and safety and tolerability were monitored by physical exams, vital signs, clinical lab tests, and ECGs.Most of the pharmacokinetic parameters were only minimally changed when atogepant was given with sumatriptan, compared to either drug given alone. The peak plasma concentration (Cmax) of atogepant was reduced by 22% when administered with sumatriptan. Coadministration delayed the median atogepant Tmax (time to maximum plasma drug concentration) by 1.5 hours. This lower Cmax and delayed Tmax could be attributed to the effect of sumatriptan on gastric emptying. However, these changes are expected to have minimal clinical relevance because use with sumatriptan was not shown to not affect the overall systemic exposure to atogepant.These results allay concerns about the safety and tolerability of using these two antimigraine medications together, leading to more options for treating severe or frequent migraines. Further studies are needed to confirm these findings. (Boinpally, R., et al. (2021). Atogepant and sumatriptan: No clinically relevant drug-drug interactions in a randomized, open-label, crossover trial. Pain Management; 12(4), 499–508. Retrieved May 2022 from https://www.futuremedicine.com/doi/10.2217/pmt-2021-0073)Released: May 2022Nursing Drug Handbook© 2022 Wolters KluwerRisk of Anaphylaxis after Second Dose of COVID Vaccine is Low in Those Who Had Such a Reaction to First DoseOne barrier to successful vaccination is the occurrence of rare adverse reactions to the vaccines, including severe allergic reactions, which occur in 7.9 per 1 million vaccinations. As the rollout for the SARS-CoV2 mRNA vaccines was underway, allergic reactions rapidly led to recommendations that people with an immediate allergic reaction to the first dose shouldn’t receive additional doses. But this places those people at risk of contracting the disease.READ MORE...A review article published in JAMA Internal Medicine examined 22 studies and asked the question: What is the risk of an immediate severe allergic reaction (anaphylaxis) to a second dose of a SARS-CoV2 mRNA vaccine among individuals who had an immediate allergic reaction of any severity to their first dose? The researchers examined studies conducted from the onset of COVID-19 vaccination through October 4, 2021; immediate allergic reaction was defined as one that occurred within 4 hours of the first dose. The individuals received the second vaccine under the supervision of an allergist.The meta-analysis identified 1,366 individuals who had immediate allergic reactions to their first vaccination, among them, 78 persons who had suffered an anaphylactic reaction to the first dose. Of the 1,366 individuals, pooled analysis showed that 6 experienced severe immediate allergic reaction (absolute risk, 0.16%) and 232 developed mild immediate symptoms (absolute risk, 13.65%) to the second dose of the vaccine. Of the 78 persons who had suffered anaphylaxis after the first dose, 4 had a second severe allergic immediate reaction (absolute risk, 4.94%) and 15 had mild immediate symptoms (absolute risk, 9.54%). None of the 6 persons who experienced severe allergic reactions to the second dose died; 5 recovered after receiving IM epinephrine and the sixth recovered without treatment. Subgroup analysis, examining studies that permitted altered dosing, premedication before vaccination, or skin testing, didn’t result in alterations to these findings.These findings contradict the common assumption that a history of allergic reactions guarantees another to subsequent vaccine exposure. In such individuals, consultation with an allergist before the second vaccination is recommended. (Chu, D. K., et al. (2022). Risk of second allergic reaction to SARS-CoV-2 vaccines: A systematic review and meta-analysis. JAMA Intern Med, 182(4), 376–385. Retrieved May 2022 from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2788991)Released: May 2022Nursing Drug Handbook© 2022 Wolters KluwerFDA Considering Changes to Improve Safe Disposal of Unused Prescription Opioid AnalgesicsThe FDA is seeking public comments until June 21, 2022, to a potential change to the Opioid Analgesic Risk Evaluation and Mitigation Strategy that would require that opioid analgesics used in outpatient settings be dispensed with prepaid mail-back envelopes and that pharmacists provide patient education on safe disposal of unused opioids. They seek comments from interested parties: patients, patient advocates, health care professionals, academics, researchers, pharmaceutical industry, and other government entities.READ MORE...The FDA’s efforts to address the opioid crisis include a focus on encouraging appropriate disposal of unused opioids. Current recommendations for disposal of unused drugs include permanent collection sites, such as kiosks in pharmacies or at community take-back events. If such opportunities aren’t available, the FDA recommends flushing those opioids on the Flush List (safe to be disposed in that way) or mixing with an unpalatable substance and disposing in the household trash. All these methods have their drawbacks, from environmental concerns to worries about safety to concerns about cost and inconvenience. Data show that educating patients about disposal options increases the disposal rate of unused medications; it’s hoped that providing an easy, cost-free option along with education will further increase that rate.Patients commonly report having unused opioid analgesics after surgical procedures; studies show a range of 67% to 92% of patients, depending on the surgery, report excess opioid analgesics. Opioids used for chronic pain can also result in excess pills requiring disposal, due to changes in dose or medication, discontinuation of opioid treatment, or death of the patient. These unused opioids then end up sitting in their house, creating opportunities for nonmedical use, accidental exposure, overdose, and new cases of opioid addiction. Despite the risks associated with having unused opioid analgesics in the home, most studies found that fewer than 50% of patients report disposing of them. Patient education on the need to dispose of them has been shown to increase disposal rates; in one study that examined the effect of providing patient education, a take-home disposal method, or both, use of either intervention increased the disposal rate by about 12% and the combined intervention increased the disposal rate by 19.5%. It is reasonable to assume that mail-back envelopes are one such method that could increase this disposal rate.The FDA is anticipating that this REMS-mandated disposal program could complement programs already in place. Recognizing that dispensing mail-back envelopes with every opioid prescription would be inefficient, the FDA proposes the use of algorithms that could enable pharmacists to target those prescriptions most likely to result in unused medications (that is, when filling new prescriptions for acute pain treatment or when changing the dose, medication, or formulation in a recurring prescription). (U.S. Food & Drug Administration. News Release. (2022). FDA considers new approach to improve safe disposal of prescription opioid analgesics, decrease unnecessary exposure to unused medication. Retrieved May 2022 from https://www.fda.gov/news-events/press-announcements/fda-considers-new-approach-improve-safe-disposal-prescription-opioid-analgesics-decrease-unnecessary; Federal Register. (2022). Providing mail-back envelopes and education on safe disposal with opioid analgesics dispensed in an outpatient setting; establishment of a public docket; request for comments. Retrieved May 2022 from https://www.federalregister.gov/documents/2022/04/21/2022-08372/providing-mail-back-envelopes-and-education-on-safe-disposal-with-opioid-analgesics-dispensed-in-an)Released: May 2022Nursing Drug Handbook© 2022 Wolters Kluwer
Drug News Abstracts - April 2022
Follow-Up Analysis Shows that Adding Isatuximab to Treatment for Resistant Multiple Myeloma Provides Continued SurvivalThe addition of the anti-CD38 monoclonal antibody isatuximab to pomalidomide-dexamethasone treatment resulted in a greater than 6-month difference in median overall survival compared to treatment without isatuximab in relapsed and refractory multiple myeloma. This finding was reported in a prespecified second interim analysis of a key secondary endpoint in the ICARIA-MM study; results of that study supported the March 2020 approval of isatuximab for multiple myeloma.READ MORE...ICARIA-MM was a randomized, multicenter, open-label phase 3 study that enrolled adults with relapsed or refractory multiple myeloma who had received at least two previous lines of therapy. This therapy could include lenalidomide and a protease inhibitor, but no prior pomalidomide treatment was permitted. Patients were recruited from hospitals in 24 countries worldwide; 307 patients were randomly assigned to receive isatuximab plus pomalidomide-dexamethasone (n = 154) or to pomalidomide-dexamethasone alone (n = 153).Median overall survival was 24.6 months in the isatuximab plus pomalidomide-dexamethasone group and 17.7 months in the pomalidomide-dexamethasone group (hazard ratio [HR], 0.76). Serious treatment-emergent adverse effects were observed in 111 patients (73%) who received isatuximab plus pomalidomide-dexamethasone, and in 90 patients (60%) who received pomalidomide-dexamethasone. At cutoff of follow-up, 18% of the patients in the isatuximab plus pomalidomide-dexamethasone group and 8% of patients in the pomalidomide-dexamethasone group remained on the study treatment; death had occurred in 60% of patients. Updated progression-free survival analysis showed a median duration of progression-free survival of 11.1 months with isatuximab plus pomalidomide-dexamethasone and of 5.9 months with pomalidomide-dexamethasone (HR, 0.60).This improved survival supports the assertion that this treatment should be considered as standard of care for patients with multiple myeloma refractory to usual treatments (lenalidomide and protease inhibitors). (Richardson, P. G., Perrot, A., et al. Isatuximab plus pomalidomide and low-dose dexamethasone versus pomalidomide and low-dose dexamethasone in patients with relapsed and refractory multiple myeloma (ICARIA-MM): Follow-up analysis of a randomised phase 3 study. (2022). Lancet Oncol, 23(3), 416-427. Retrieved March 2022 from https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(22)00019-5/fulltext; Stenger, M. (2022). Interim analysis of overall survival in ICARIA-MM: Addition of isatuximab to pomalidomide/dexamethasone in relapsed or refractory multiple myeloma. The ASCOT Post. Retrieved March 2022 from https://ascopost.com/news/march-2022/interim-analysis-of-overall-survival-in-icaria-mm-addition-of-isatuximab-to-pomalidomidedexamethasone-in-relapsed-or-refractory-multiple-myeloma/#:~:text=The%20investigators%20concluded%2C%20%E2%80%9CAddition%20of,refractory%20or%20relapsed%20multiple%20myeloma)Released: April 2022Nursing Drug Handbook© 2022 Wolters KluwerRelying on Informal Sources of Information Increases Vaccine Hesitancy in Medicare BeneficiariesCirculation of misleading information on the COVID-19 vaccines on social media is considered one of the important causes for vaccine hesitancy. A study published in the Journal of the American Geriatric Society examined this hypothesis, and further sought to learn if reliance on multiple sources of information about COVID-19 was associated with less vaccine hesitancy among a sample of Medicare beneficiaries.READ MORE...The Medicare Current Beneficiary Survey (MCBS) contains data collected from a nationally representative sample of Medicare beneficiaries. The MCBS COVID-19 Fall 2020 Rapid Response Supplement, administered between October and November 2020, included a study cohort of 7,278 beneficiaries, a weighted sample representing 43,829,153 community-dwelling Medicare beneficiaries. Respondents answered questions about their sources of COVID-19 information and about their presumptive vaccine uptake (the questions were posed before vaccines were available). The survey aimed to determine COVID-19 vaccine hesitancy, scored as 1 if they answered, “probably not, definitely not, not sure” and 0 if they answered, “definitely, probably,” to the question “Would you get a COVID-19 vaccine if available?” Then they analyzed these findings according to key independent variables: the reliance on formal vs. informal sources of COVID-19 information, and the total number of information sources the respondent relies on, both formal and informal. Informal sources include social media, the Internet, or friends and family. Formal sources include traditional news outlets, government guidance, and information from medical professionals.The survey demonstrated that 16% of respondents (n = 1,231) reported getting their information about COVID-19 from informal information sources. Vaccine hesitancy was found in 44% of those relying on informal information sources vs. 38% of those who reported relying on formal information sources. Relying on informal sources was associated with a 29% higher odds of vaccine hesitancy (OR, 1.29). Relying on more, varied sources of information on COVID-19 was associated with lower odds of vaccine hesitancy, with a decrease of 0.91 in odds ratio for each additional source used.These results can provide insights to guide future efforts that aim to build up positive attitudes toward the vaccine and to increase vaccine uptake. In addition, they add support to the importance of taking precautionary measures to address false anti-vaccination claims. The study has limitations, as the survey didn’t include Medicare beneficiaries living in long-term care facilities and, importantly, was conducted before the vaccines were available. But later events have strengthened the evidence for its hypothesis proving true. (Kim, J., Kim, Y., et al. (2022). Source of information on COVID-19 vaccine and vaccine hesitancy among U.S. Medicare beneficiaries. J Am Geriatr Soc, 70(3), 677–680. Retrieved March 2022 from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17619)Released: April 2022Nursing Drug Handbook© 2022 Wolters KluwerWHO-Recommended Essential Medicines Not Always Available in Age-Appropriate Formulations for Young ChildrenThe World Health Organization (WHO) compiles and disseminates the WHO Essential Medicines List for children (EMLc) to guide the selection of medicines for use in children ages 0 to 12. Essential medications are defined as those necessary to prevent, treat, or manage the most prevalent diseases in a population. The EMLc is an important tool; for most low- and middle-income countries, the list serves as a template for national drug formularies. But a study published in Archives of Diseases in Childhood documents that most essential enteral medications listed in both the 2011 and 2019 EMLc couldn’t be considered age-appropriate for children under age 6.READ MORE...The study sought to determine the appropriateness of all enteral formulations on the EMLc by assessing two important characteristics: swallowability and dose adaptability. Researchers defined age-appropriate formulations as ones which “a child of a specified age or age-group would have the natural ability to use (either directly or indirectly) without the product having to be altered from its original presentation before administration.” Two pharmacists evaluated each of the recommended medications for each of the five age-groups under age 12 and ranked them as 1 (not age-appropriate), 2 (possibly age-appropriate), or 3 (age-appropriate) for those two characteristics.When assessing swallowing ability, they used certain criteria to gain consistency in their evaluations:Liquids, oral powders/granules, dispersible tablets: appropriate from birth, with dose volumes under 10 mL being acceptable under age 5Crushed tablets, sprinkle capsules: appropriate from age 6 months, or the age at which a child can swallow solidsChewable tablets, dispersible tablets: appropriate from age 2, or the age at which a child can safely chew and swallow tabletsConventional tablets and capsules: not appropriate for those under age 5; children this age are incapable of swallowing the medication safelyEffervescent tablets: not appropriate for those under age 5, because of the need for large volumes, typically in excess of 100 to 200 mL.To examine dose adaptability, the evaluators compared the recommended doses in mg/kg body weight or mg/m2 BSA for each essential medicine, as given in the WHO formulary, to the mean body weight or BSA for each age-group. They determined whether the volume of a liquid or size/amount of a solid form was appropriate to deliver the recommended dose to a given age-group.The evaluation found that, in the 2011 edition of the EMLc, 77% of formulations were appropriate for older children (older than age 6). But for younger children, those percentages dropped: 34% were age-appropriate for preschoolers (ages 3 to 5), 30% were age-appropriate for toddlers (ages 1 to 2), 22% were age-appropriate for infants (ages 28 days to 11 months), and 15% were age-appropriate for neonates (ages 0 to 27 days). Overall, these proportions held true for EMLc 2019. The researchers further found that 55% of the active pharmaceutical ingredients were available in a variety of formulations that resulted in the drug being appropriate for all age-groups and that at least 47% had, at the minimum, one formulation (usually an oral liquid) that was considered appropriate for all age groups. But in practice, especially in low-income countries, the whole range of formulations aren’t readily commercially available. For example, only 33% of drugs on the 2011 EMLc were available in Nigeria in formulations suitable for younger children, significantly lower than the 52% to 57% availability seen in countries like the United States, the United Kingdom, and France.Going forward, all formulations included in the EMLc should be assessed for age-appropriateness, and that assessment should be a guide to development of new products or alternative administration strategies. Ensuring that age-appropriate formulations are actually available can help support decisions and strategies intended to provide access to essential medicines. (Orubu, E. S., Duncan, J., et al. (2022). WHO essential medicines for children 2011-2019: Age-appropriateness of enteral formulations. Arch Dis Child, 107, 317–322. Retrieved March 2022 from https://adc.bmj.com/content/107/4/317)Released: April 2022Nursing Drug Handbook© 2022 Wolters KluwerCardioselective Beta Blockers a Better Choice for Patients with COPD Who Experience Heart AttackBeta blockers are known to reduce death and adverse cardiac events in patients after a myocardial infarction (MI). But clinicians hesitate to prescribe beta blockers in patients with respiratory disease who experience an MI, fearing that the beta blockers might precipitate bronchospasm and reduced pulmonary function in these patients. A retrospective Taiwanese study investigated use of beta blockers, and specifically of cardioselective beta blockers, in patients with chronic obstructive pulmonary disease (COPD) being treated in hospital after their first-ever MI.READ MORE...The study identified 65,699 patients with COPD in the Taiwan National Health Insurance Research Database who were prescribed beta blockers after their first MI from January 2001 to December 2013. After excluding patients who had been treated with both cardioselective and nonselective beta blockers, those younger than age 20, those who died during their hospitalization for that initial MI, and those who had been followed up for less than 90 days, the study enrolled 14,789 patients. The researchers examined patient records for all-cause mortality and for the secondary outcomes of hospitalization for heart failure, incidence of major cardiac or cerebrovascular events (MACCE), including death, revascularization, repeated MI, or ischemic stroke, and of major adverse pulmonary events (MAPE), such as exacerbations of COPD and hospitalizations due to pneumonia. The patients were categorized into two groups: 7,247 patients were prescribed cardioselective beta blockers during that hospitalization and 7,542 patients were prescribed nonselective beta blockers. There were no significant differences in most baseline characteristics between the two groups, and no significant differences in hospital treatment for the initial MI, including similar admission rates and ICU stays, the need for inotropic agents and intubation, and interventions for coronary artery disease.The patients who were prescribed cardioselective beta blockers had a lower risk of all-cause mortality than those who were prescribed nonselective beta blockers—8.9 vs. 9.6 events per 100 person-years (HR, 0.93), and of MACCE—13.2 vs. 13.9 events per 100 person-years (HR, 0.96), as well as of hospitalization for heart failure—3.3 vs. 3.8 events per 100 person-years (HR, 0.89). The incidence of MAPE was significantly lower in the cardioselective group compared to the nonselective group: 10 vs. 10.8 events per 100 person-years (HR, 0.94).Similar results were found in subgroup analysis between those prescribed the cardioselective beta blocker bisoprolol (n = 5,644; 74% of patients receiving cardioselective beta blockers) and those prescribed the nonselective beta blocker carvedilol (n = 4,881; 64.7% of patients receiving nonselective beta blockers). All-cause mortality was significantly lower with bisoprolol than with carvedilol at the end of follow-up—9.3 vs. 10.3 events per 100 person-years (HR, 0.90), as was hospitalization for heart failure—3.5 vs. 4.4 events per 100 person-years (HR, 0.84), and MAPE—10.5 vs. 11.5 events per 100 person-years (HR, 0.94). Incidence of MACCE was not significantly different between the two drugs: 14 vs. 14.7 events per 100 person-years (HR, 0.96).These results strongly suggest that patients with COPD who experience an MI can be prescribed beta blockers, but they should be cardioselective beta blockers, as they are safer and more effective than nonselective beta blockers in this population. The study has limitations, as it’s a retrospective study only; a randomized, controlled trial is still needed to confirm these beneficial effects. (Chung, C-M., Lin, M-S., et al. (2022). Cardioselective versus nonselective ß-blockers after myocardial infarction in adults with chronic obstructive pulmonary disease. Mayo Clinic Proceed, 97(3), 531-546. Retrieved March 2022 from https://www.mayoclinicproceedings.org/article/S0025-6196(21)00622-4/fulltext#secsectitle0010)Released: April 2022Nursing Drug Handbook© 2022 Wolters Kluwer
Drug News Abstracts - March 2022
Combination of Inhaled Corticosteroids and Long-Acting Beta Agonists Improves Lung Function in Children Born PrematurelyCombination therapy with an inhaled corticosteroid (ICS) and a long-acting beta agonist (LABA) significantly improved lung spirometry results in children with significant lung function deficits compared with either steroids alone or placebo. These are results of a study conducted in Wales, at the Children’s Hospital for Wales in Cardiff, which tested the combination in school-aged children who had been born prematurely (before 34 weeks’ gestation). These children are known to be at increased risk of decreases in future lung function, especially when they are diagnosed with bronchopulmonary dysplasia (BPD) in infancy.READ MORE...The randomized controlled trial enrolled 53 children ages 7 to 14, who were born at <34 weeks’ gestation, with low lung function (pretreatment %FEV1 [percent forced expiratory volume in 1 second] ≤85%) and examined whether 12 weeks of treatment would improve incentive spirometry results and exercise capacity. Approximately 40% of participants in the study had BPD; other signs of respiratory morbidity were similar in all groups. They were randomized to the ICS fluticasone 50 mcg plus placebo (n = 20), fluticasone 50 mcg plus the LABA salmeterol 25 mcg (n = 19), and placebo (n = 14), all given as 2 puffs per day for 12 weeks.Both ICS and ICS/LABA combination treatment produced improvements in %FEV1, both significantly greater than placebo. The increase in %FEV1 with ICS was 7.7% higher than placebo; with the ICS/LABA combination, the increase was twice as great: 14.1% higher than placebo. The %FEV1 increased from 75.1% to 81.1% (mean difference, 6.0%) in the ICS group and from 77.9% to 86.2% (mean difference, 8.3%) in the ICS/LABA group. Active treatment decreased the fractional exhaled nitric oxide (FENO) and increased postexercise bronchodilator response but didn’t improve exercise capacity. The FENO dropped from 29.8 ppb (parts per billion) to 15.7 ppb in the ICS group and from 25.2 ppb to 15.9 ppb in the ICS/LABA group. FENO didn’t decrease after placebo.The combination ICS/LABA may produce its greater effects by targeting both the structural changes in the respiratory system of children born preterm and inflammatory processes, as suggested by the improvement in FENO. The lack of improvement in exercise capacity in this trial may have resulted from the test not being sensitive enough to note small differences, especially in a population that might have been habitually inactive. (Goulden, N., et al. (2022). Inhaled corticosteroids alone and in combination with long-acting β2 receptor agonists to treat reduced lung function in preterm-born children: A randomized clinical trial. JAMA Pediatr,176(2), 133–141. Retrieved March 2022 from https://jamanetwork.com/journals/jamapediatrics/fullarticle/2786783)Released: March 2022Nursing Drug Handbook© 2022 Wolters KluwerThird Dose Boosts COVID-19 Vaccine Efficacy in Patients with CLLIn an Israeli study, in patients with CLL (chronic lymphocytic leukemia) who had failed to achieve an antibody response to two doses of an mRNA vaccine against SARS-CoV2, close to a quarter of the patients in the study became seropositive after a third dose.Patients were enrolled from July 2020 to August 2021; eligible patients had a diagnosis of CLL or small lymphocytic lymphoma (SLL), were age 18 or older, had no know history of SARS-CoV2 infection, and had failed to respond to a second dose of a vaccine against SARS-CoV2. The 172 patients were classified into three groups: the treatment-naive (n = 40, 23.3%), those who were on active treatment for CLL/SLL (n = 100, 58.1%), and those not currently receiving treatment who had been treated previously (n = 32, 18.6%). Among those who had received treatment in the past, 24 (75%) were in remission, 18 of them in complete remission, and 8 (25%) were experiencing relapse. Patients on active treatment included 59 who were receiving a Bruton tyrosine kinase inhibitor (ibrutinib or acalabrutinib) and 39 receiving venetoclax either with or without an anti-CD20 antibody (rituximab or obinutuzumab).READ MORE...Serologic response after the third vaccine dose correlated with the degree of immunosuppression accompanying CLL in each patient. Antibody response was seen in 41/172 patients (23.8%), with a median antibody level of 2 AU/mL. Treatment-naïve patients and those who were no longer receiving treatment for their illness had higher response rates and higher antibody levels: 16/40 (40%) of treatment-naive patients had antibody response, with median antibody level of 8 AU/mL, and 13/32 of patients no longer on treatment, with median antibody level of 6 AU/mL. In actively treated patients, response rates were lower (n = 12/100, 12%), with a median antibody level of 0 AU/mL.Among patients who had previously received treatment, serologic response rates of those in complete remission was 38.9%, in partial remission was 50%, and those experiencing relapse was 37.5%. Among those on active treatment, those receiving BTK inhibitors had a response rate of 15.3% and those receiving venetoclax with or without anti-CD20 antibodies had a response rate of 7.7%. Only 1 of 28 patients (3.6%) treated with anti-CD20 antibodies within 12 months of the third dose responded, compared to 15/63 (22.7%) of those treated with anti-CD20 antibodies at least 12 months before. Each month that elapsed from the end of anti-CD20 antibody treatment increased odds for serologic response to the vaccine by 1.03 times.The study authors suggested that an additional booster be considered for all patients with CLL who had been vaccinated with mRNA vaccines. Since results were lowest in those on active therapy, they suggest that it may be appropriate to delay the start of treatment to allow for vaccination before treatment produces immunosuppression. (Herishanu, Y., et al. (2022). Efficacy of a third BNT162b2 mRNA COVID-19 vaccine dose in patients with CLL who failed standard 2-dose vaccination. Blood, 139(5): 678–685. Retrieved March 2022 from https://ashpublications.org/blood/article/139/5/678/482889/Efficacy-of-a-third-BNT162b2-mRNA-COVID-19-vaccine?searchresult=1)Released: March 2022Nursing Drug Handbook© 2022 Wolters KluwerStatin Intolerance May Be OverestimatedFindings of a recent meta-analysis indicate that intolerance to statin therapy is much less common than previous data suggested, showing that fewer than 1 in 10 patients are unable to tolerate the cholesterol-lowering treatment. Nonadherence to statin therapy due to the fear of statin intolerance results in suboptimal treatment for dyslipidemia and a high risk of cardiovascular events.READ MORE...The meta-analysis of 176 studies (involving more than 4 million patients) published in the European Heart Journal found that 9.1% of patients had statin intolerance. The analysis included 112 randomized clinical trials and 64 cohort studies of statin-treated patients followed for a mean of 19 months. It estimated the overall prevalence of statin intolerance and also aimed to determine prevalence according to differing international diagnostic criteria and in different disease settings. In addition, the researchers identified possible risk factors for statin intolerance.In published studies, the mean prevalence of statin intolerance in randomized clinical trials was 4.9%, and in cohort studies was 17%. The higher prevalence in cohort studies, which is as high as 30%, is most likely an overestimate and could be attributable to “nocebo” effects. On the other hand, it’s possible that exclusion criteria in randomized controlled trials may result in underestimates, as older patients and those with comorbidities associated with statin intolerance are excluded. When examining prevalence of intolerance based on varied diagnostic criteria, it was 7% in studies that used the National Lipid Association (NLA) criteria, which defines intolerance as an adverse effect that limits quality of life and leads to a decision to decrease or stop the statin. Prevalence under International Lipid Expert Panel criteria, which were similar to those of NLA, was 6.7%. Under the stricter definition provided by the European Atherosclerosis Society, which focused specifically on statin-associated muscle symptoms (SAMS) and CK elevations, prevalence was 5.9%.Increased risk of statin intolerance was associated with demographic characteristics and with clinical indices. Women had a 47% higher relative risk (RR) of statin intolerance compared to men, and the RR was 31.2% higher in those over age 65 than in younger patients. Positive associations were also seen in patients with obesity (RR, 30.6%), diabetes (RR, 26.6%), and hypothyroidism (RR, 37.6%). The positive associations in Black and Asian patients and in those with chronic liver and kidney disease were smaller, but still clinically significant.Nonadherence with statin therapy is most commonly ascribed to muscle pain, but it’s important for clinicians to determine whether that muscle pain is actually related to statin use. The criteria necessary for a diagnosis of SAMS are that the symptoms (pain, weakness, or cramps, often with CK changes or severe myopathy) must appear within 12 weeks after treatment initiation or dose increase. Clinicians should explore whether muscle pain at later stages results from interactions with a new medication or as a result of a comorbid condition that’s not controlled. (O’Riordan, M. (2022). Statin intolerance overestimated – Only ‘small number’ get side effects: Meta-analysis. TCTmd.com. Retrieved March 2022 from https://www.tctmd.com/news/statin-intolerance-overestimated-only-small-number-get-side-effects-meta-analysisBytyҫi, I., et al. (2022). Prevalence of statin intolerance: A meta-analysis. Eur Heart J, 1–16. Retrieved March 2022 from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehac015/6529098?login=false)Released: March 2022Nursing Drug Handbook© 2022 Wolters Kluwer
Drug News Abstracts - February 2022
Efficacy of Outpatient Treatment with Ciclesonide in COVID-19Systemic corticosteroids have been used to treat severe COVID-19 infection, resulting in lower 28-day mortality rates in these patients. But the role of inhaled steroids in mild to moderate COVID-19 infection is less clear. Inhaled ciclesonide is a promising candidate: it’s been shown to have anti-inflammatory properties in lung and bronchial structures through inhibition of the PAK1 enzyme in cells, a known pathogenic pathway for COVID-19.READ MORE...A phase 3, multicenter, double-blind, randomized clinical trial conducted in 400 nonhospitalized patients with mild to moderate COVID-19 infection from June to November 2020 compared inhaled ciclesonide to placebo. Patients were randomly assigned to receive ciclesonide (n = 197) by metered-dose inhaler, 160 mcg/actuation, 2 actuations b.i.d., for a total daily dose of 640 mcg, or placebo (N = 203) for 30 days. The primary endpoint was time to alleviation of COVID-19-related symptoms, including cough, dyspnea, fever, shaking chills, muscle pains, headache, sore throat, and lack of sense of taste or smell). The study also followed the patients to determine if they had subsequent emergency department (ED) visits or hospital admissions for reasons attributable to COVID-19. Patients were eligible for the study if they were older than age 12, were positive for SARS-Cov2 but not at risk for hospitalization, with an oxygen saturation of at least 93% on room air and at least one of the common symptoms of COVID-19 infection. They were told to notify researchers if they experienced an ED visit or hospitalization during the study; they were instructed to seek ED evaluation if their oxygen saturation level fell below 92%. All patients took the study medication for 30 days, even if symptoms resolved earlier.The median time to alleviation of all COVID-related symptoms was 19.0 days in both the ciclesonide and placebo arms. There was also no difference in resolution of symptoms by day 30 (odds ratio, 1.28). The most common symptoms on day 30 were cough (11.7% vs. 12.3%), muscle pain (9.6% vs. 8.9%), and dyspnea (10.2% vs. 7.9%). But though there were no differences in resolution of symptoms, those treated with inhaled ciclesonide had fewer subsequent ED visits or hospital admissions for reasons related to COVID-19 by day 30 compared to those receiving placebo (1.0% vs. 5.4%; odds ratio, 0.18).An important consideration is that it’s not uncommon for patients with COVID-19 infection to continue to experience lingering symptoms for some time; as a result, testing for this endpoint may have masked a significant portion of the population who were able to safely return to usual life and who were no longer at risk for viral transmission. The secondary outcome of fewer ED visits or hospitalizations may be more relevant, offering evidence that inhaled ciclesonide or other steroids are a low-cost intervention that can prevent such events. (Clemency, B. M., et al. (2021). Efficacy of inhaled ciclesonide for outpatient treatment of adolescents and adults with symptomatic COVID-19: A randomized clinical trial. JAMA Intern Med, 182(1), 42–49. Retrieved February 2022 from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2786012)Released: February 2022Nursing Drug Handbook© 2022 Wolters KluwerWhich Vaccine for COVID-19 Booster?Although the vaccines against SARS-CoV2 that have been available in the United States since early 2021 provide high levels of protection against severe illness and death resulting from COVID-19 infection, the increasing number of breakthrough infections in fully vaccinated persons from the delta variant starting in late spring 2021, followed by the even more transmissible omicron variant, raised concerns about waning immunity. The phase 1-2, open-label MixNMatch study, conducted at 10 sites in the United States, was designed to assist in the development of booster strategies during the ongoing pandemic. It assessed both homologous boosters (the same as the primary vaccine) and heterologous boosters (different from the primary vaccine) in persons who had completed a COVID-19 vaccination regimen at least 12 weeks earlier and had no reported history of SARS-CoV2 infection.READ MORE...MixNMatch enrolled 458 people, who received a booster from one of three vaccines: 154 received the Moderna mRNA vaccine, 100 mcg; 150 received the Johnson & Johnson/Janssen vaccine, 5 × 1010 virus particles; and 150 received the Pfizer/BioNtech vaccine, 30 mcg. Both homologous and heterologous booster vaccines had an acceptable safety profile and immunogenicity. As with the primary series of vaccines, mild adverse effects—myalgia, headache, malaise, injection-site pain—were common. Reactogenicity was similar to that seen in previous evaluations of the vaccines and didn’t differ between homologous and heterologous boosters. In addition, all boosters were immunogenic in participants, regardless of which primary vaccine regimen they had received.The factor increases after booster in both binding and neutralizing antibody titers were similar or greater after heterologous boosters than after homologous boosters. Homologous boosters increased neutralizing antibody titers by a factor of 4 to 20; in heterologous boosters, they increased by a factor of 5 to 55. Increases were greatest in participants who received an mRNA booster after a primary J&J/Janssen vaccination (34 with Pfizer/BioNTech, 55 with Moderna). Interestingly, binding antibody titers peaked at day 15 for those who received an mRNA vaccine as a booster and were similar or declining on day 29; for those who received the J&J/Janssen vaccine as a booster, titers on day 29 were similar to those measured on day 15.Spike-specific T-cell responses increased in all combinations but the homologous J&J/Janssen-boosted subgroup. CD8+ T-cell levels were more durable in participants whose primary vaccine was J&J/Janssen, and heterologous booster with that vaccine substantially increased spike-specific CD8+ T-cells in those who had previously received the mRNA vaccines. These vaccine-elicited spike-specific T-cell responses may contribute to the antibody response and the prevention of severe disease in cases of breakthrough infections.These data strongly suggest that both homologous and heterologous booster vaccine doses will increase protective efficacy against symptomatic SARS-CoV2 infection. The data show that an immune response will be generated for each of these vaccines used as a booster regardless of the primary vaccination regimen. (Atmar, R. L., et al. (2022). Homologous and heterologous covid-19 booster vaccinations. New Engl J Med. Retrieved February 2022 from https://www.nejm.org/doi/full/10.1056/NEJMoa2116414?query=TOC)Released: February 2022Nursing Drug Handbook© 2022 Wolters KluwerOral Penicillin Recommended for Treatment of High-Risk Rheumatic Heart DiseaseMore than 39 million people worldwide have rheumatic heart disease, a condition in which heart valves are permanently damaged as a result of a bout of rheumatic fever, which can occur if strep throat or scarlet fever is inadequately treated. Most cases of rheumatic heart disease, especially in lower income nations, aren’t diagnosed until after severe valvular heart disease or other CV complications have already developed.READ MORE...The recommended treatment for rheumatic heart disease is a long-term (that is, 10 years or longer) regimen of penicillin G benzathine, given by IM injection every 3 to 4 weeks. For many years, death after these injections were ascribed to anaphylaxis, but evidence is growing that points to a different cause: cardiac compromise. Such a shift in perspective has important ramifications for the management of this disease, and an American Heart Association Presidential Advisory statement addresses this, recommending oral penicillin as a safer option for some patients with rheumatic heart disease at high risk for a vasovagal response and resultant cardiac compromise.The advisory panel divided patients into low-risk and elevated-risk groups, based on symptoms and the severity of the underlying valvular heart disease. The risks of cardiac compromise are highest among patients with severe valvular disease, as they have low CV reserves and may not compensate well to pain on injection. Patients with severe mitral stenosis, who depend on increased preload to maintain cardiac output, are at highest risk.The advisory panel suggests that those with a low risk of cardiac compromise and no history of penicillin allergy or anaphylaxis can safely continue to receive the injectable penicillin G benzathine, and they advocate a multifaceted strategy for vasovagal reaction risk reduction in those patients. Noting that pain or fear of the penicillin injection, along with physiologic and other stresses, such as dehydration, drives the vasovagal response, the advisory panel recommends the following protocols:Reduce injection pain and anxiety by applying pressure and ice to the injection site and administering acetaminophen or NSAIDs.Ensure that patients are well-hydrated and have eaten a small amount of food in the hour before injection.To reduce the risk of postural hypotension and fainting, administer the injection with the patient supine.Ensure that those administering the injection can recognize and quickly treat any cardiac symptoms.For those in the elevated-risk group, the advisory panel states that treatment with oral penicillin should be strongly considered. They note that making a change from injectable to oral penicillin prophylaxis carries its own challenges, particularly requiring a commitment from governments to ensure its availability and from health care providers to educate patients. (American Heart Association. (2022). Oral penicillin, not injectable, advised for people with high-risk rheumatic heart disease. Retrieved February 2022 from https://newsroom.heart.org/news/oral-penicillin-not-injectable-advised-for-people-with-high-risk-rheumatic-heart-disease?preview=326b; Sanyahumbi, A., et al. (2022). Penicillin reactions in patients with severe rheumatic heart disease: A Presidential Advisory from the American Heart Association. J Am Heart Assoc. Retrieved February 2022 from https://www.ahajournals.org/doi/10.1161/JAHA.121.024517)Released: February 2022Nursing Drug Handbook© 2022 Wolters KluwerInhaled Treprostinil Continues to Prevent Progression Events in Pulmonary Hypertension on Post Hoc AnalysisInterstitial lung disease complicated by pulmonary hypertension (PH-ILD) results in worse outcomes than other forms of ILD: worsened functional status, increased requirements for supplemental oxygen, increased health care resource use, and increased mortality. INCREASE, a 16-week, phase 3, multicenter, double-blind, placebo-controlled study, showed a benefit from inhaled treprostinil, a stable prostacyclin analogue with potent vasodilation on pulmonary vasculature, in patients with PH-ILD. The study’s primary endpoint—change in 6-minute walking distance from baseline, a measure of exercise tolerance—showed improvement of 31 meters in the active treatment group. In addition, treatment with inhaled treprostinil resulted in a delayed time to first disease progression compared to placebo, and fewer clinical worsening events.READ MORE...Post hoc analysis sought to determine the efficacy of continuing inhaled treprostinil use after disease progression. It therefore evaluated the effects of continued treatment on the frequency of multiple disease progression events. On analysis, 147 disease progression events occurred in the inhaled treprostinil group (in 89 of 163 patients; 55%) compared with 215 events in the placebo group (in 109 of 163 patients; 67%). The incidence of each type of disease progression event was also lower in the inhaled treprostinil group vs. placebo:15% decline in 6-minute walking distance (45 vs. 64 events)exacerbation of lung disease (48 vs. 72 events)10% decline in forced vital capacity (19 vs. 33 events)cardiopulmonary hospitalization (23 vs. 33 events)death (10 vs. 12 events).Fewer patients receiving inhaled treprostinil experienced multiple progression events compared with those receiving the placebo (35 patients, 22% vs. 58 patients, 36%).This comprehensive analysis of all disease progression events in the INCREASE study provides a more complete view of the benefits of inhaled treprostinil in patients with PH-ILD and supports the continuation of this therapy in those patients who do experience a clinical worsening event. (Nathan, S. D., et al. (2021). Efficacy of inhaled treprostinil on multiple disease progression events in patients with pulmonary hypertension due to parenchymal lung disease in the INCREASE trial. Am J Respir Crit Care Med, 205(2), 198–207. Retrieved February 2022 from https://www.atsjournals.org/doi/full/10.1164/rccm.202107-1766OC; Behr, J. (2022). Inhaled treprostinil in pulmonary hypertension in the context of interstitial lung disease: A success, finally. Am J Respir Crit Care Med, 205(2), 144–145. Retrieved February 2022 from https://www.atsjournals.org/doi/full/10.1164/rccm.202110-2444ED)Released: February 2022Nursing Drug Handbook© 2022 Wolters Kluwer
Drug News Abstracts - January 2022
Apixaban a Better Choice for Atrial Fibrillation in Older AdultsA retrospective cohort study offered compelling evidence that the direct oral anticoagulant (DOAC) apixaban carries a smaller risk of bleeding complications than rivaroxaban. DOACs have replaced warfarin as the treatment of choice for stroke prevention in atrial fibrillation, but they haven’t been tested head-to-head in randomized clinical trials. Choice of which DOAC to use has come down to clinician preference; this study aimed to determine differences between the two DOACs, rivaroxaban and apixaban.READ MORE...The observational study looked at claims data on 581,451 Medicare beneficiaries (mean age, 77 years; 50.2% women) with atrial fibrillation who initiated treatment with a DOAC between January 2013 and November 2018. Apixaban was given to 353,879 patients (61%); 227,572 patients (39%) received rivaroxaban. About 23.1% of patients (n = 134,393) received a reduced dose of either drug. The claims data was examined for evidence of the primary outcome, a composite of major ischemic events (stroke and systemic embolism) and major hemorrhagic events (intracerebral hemorrhage, other intracranial bleeding, and fatal extracranial bleeding).The effectiveness of the two drugs was similar, but new users of rivaroxaban had a greater risk of a range of adverse outcomes compared with those started on apixaban. Through median follow-up of about 6 months, the rate of the primary outcome was higher with rivaroxaban (16.1 per 1,000 person-years) vs. apixaban (13.4 per 1,000 person-years). Breaking down the composite shows that rivaroxaban was associated both with more major ischemic events than apixaban (8.6 vs. 7.6 per 1,000 person-years; hazard ratio [HR], 1.12) and with more major hemorrhagic events (7.5 vs. 5.9 per 1,000 person-years; HR, 1.26). Other key outcomes also favored apixaban: fatal extracranial bleeding (1.4 per 1,000 person-years with rivaroxaban vs. 1.0 per 1,000 person-years with apixaban; HR, 1.41), nonfatal extracranial bleeding (39.7 per 1,000 person-years with rivaroxaban vs. 18.5 per 1,000 person-years with apixaban; HR, 2.07), fatal ischemic or hemorrhagic events (4.5 vs. 3.3 per 1,000 person-years; HR, 1.34), and total mortality (44.2 vs. 41.0 per 1,000 person-years; HR, 1.06). The risk of the primary outcome was higher with rivaroxaban whether the patients received a reduced dose (27.4 vs. 2.1 per 1,000 person-years; HR, 1.28) or a standard dose (13.2 vs. 11.4 per 1,000 person-years; HR, 1.13).This new analysis, because of its size, allowed investigators to examine differences in events that occurred less frequently, to combine ischemic and hemorrhagic events to get a risk-benefit picture, and to include analysis of different dosage strengths. These results demonstrate that although the two drugs are comparable in efficacy, apixaban is superior in safety. (Neale, T. (2021). Apixaban appears safer, more effective than rivaroxaban in Medicare study. TCTMD. Retrieved January 2022 from https://www.tctmd.com/news/apixaban-appears-safer-more-effective-rivaroxaban-medicare-study; Ray, W. A., et al. (2021). Association of rivaroxaban vs apixaban with major ischemic or hemorrhagic events in patients with atrial fibrillation. JAMA, 326(23), 2395–2404. Retrieved January 2022 from https://jamanetwork.com/journals/jama/article-abstract/2787319)Released: January 2022 Nursing Drug Handbook © 2022 Wolters KluwerEtrolizumab for Ulcerative ColitisAnti-integrin therapy is used to treat ulcerative colitis because it blocks the effect of the cell-surface glycoprotein integrin on the surface of leukocytes and endothelial cell adhesion molecules, thereby inhibiting leukocytes from interacting with the intestinal mucosa. The Lancet Gastroenterology and Hepatology published results of studies that evaluated etrolizumab, a gut-targeted anti-β7 integrin monoclonal antibody, as induction and maintenance therapy for ulcerative colitis. The HIBISCUS studies compared the efficacy and safety of etrolizumab to the tumor necrosis factor (TNF) blocker adalimumab and placebo for induction of remission in patients with moderate to severe ulcerative colitis. Another study, LAUREL, compared etrolizumab to placebo as maintenance therapy.READ MORE...HIBISCUS I and II followed up on findings of a phase 2 study that indicated that etrolizumab significantly improved induction of clinical remission compared to placebo. The HIBISCUS studies, identically designed, multicenter, phase 3, randomized, double-blind, placebo-controlled and active-controlled studies, enrolled patients with moderate to severe ulcerative colitis, with a Mayo Clinic total score of 6 to 12 and endoscopic subscore of 2 or greater, rectal bleeding subscore of 1 or greater, and a stool frequency subscore of 1 or greater, who hadn’t previously been treated with TNF blockers. Patients were randomly assigned to subcutaneous etrolizumab 105 mg once every 4 weeks (n = 144 in HIBISCUS I and 143 in HIBISCUS II), to subcutaneous adalimumab 160 mg on day 1, 80 mg at week 2, and 40 mg at weeks 4, 6, and 8 (n = 142 in HIBISCUS I and 143 in HIBISCUS II), or to placebo (n = 72 in HIBISCUS I and 72 in HIBISCUS II).The studies tested for induction of remission at week 10, defined as a Mayo Clinic total score of 2 or lower, with individual subscores of 1 or lower, including a rectal bleeding subscore of 0. Posted analysis of both studies were examined for several clinical and endoscopic endpoints. Etrolizumab was found to be significantly superior to placebo for induction of remission in HIBISCUS I, but not in HIBISCUS II. In HIBISCUS I, 28 patients (19.4%) in the etrolizumab group and 5 patients (6.9%) in the placebo group were in remission by week 10. On pooled analysis, treatment with etrolizumab was not superior to the TNF blocker adalimumab for induction of remission, endoscopic improvement, clinical response, histologic remission, or endoscopic remission.LAUREL, a randomized, placebo-controlled, double-blind, phase 3 study, examined etrolizumab and compared it to placebo for maintenance of remission. The study enrolled adults with an established diagnosis of moderate to severe ulcerative colitis for at least 3 months, corroborated by clinical and endoscopic evidence. After an open-label induction phase, where 359 patients received subcutaneous etrolizumab 105 mg once every 4 weeks, if the participant had a clinical response at week 10, they were enrolled in the maintenance phase. The study found that 214 patients had such response, and were randomly assigned to receive subcutaneous etrolizumab 105 mg once every 4 weeks (n = 108) or placebo (n = 106) until week 62. At week 62, 32 patients (29.6%) in the etrolizumab group and 21 patients (20.6%) in the placebo group were in remission, a difference that is not clinically significant. (Rubin, D. T., et al. (2021). Etrolizumab versus adalimumab or placebo as induction therapy for moderately to severely active ulcerative colitis (HIBISCUS): Two phase 3 randomised, controlled trials. Lancet Gastroenterol Hepatol, 7(1), 17–27. Retrieved January 2022 from https://www.thelancet.com/journals/langas/article/PIIS2468-1253(21)00338-1/fulltext;Vermeire, S, et al. (2021). Etrolizumab for maintenance therapy in patients with moderately to severely active ulcerative colitis (LAUREL): A randomized, placebo-controlled, double-blind, phase 3 study. Lancet Gastroenterol Hepatol, 7(1), 28–37. Retrieved January 2022 from https://www.thelancet.com/journals/langas/article/PIIS2468-1253(21)00295-8/fulltext)Released: January 2022 Nursing Drug Handbook © 2022 Wolters KluwerAccelerating Development of Gene Therapies for Rare DiseasesGene therapy represents hope for individuals with rare genetic disorders. But the very rarity of these disorders means that pharmaceutical companies cannot recover the costs incurred in the development of these therapies. The National Institutes for Health (NIH) have announced the launch of a consortium that aims to reduce some of those associated costs and to encourage companies to pursue gene therapies for rare disorders.READ MORE...The Bespoke Gene Therapy Consortium, or BGTC, will focus on adeno-associated virus (AAV) vectors, one of the safest platforms for gene delivery. BGTC aims to make AAV vector technology more accessible, pursuing an understanding of the life cycle of AAV, thereby facilitating optimization of vector generation and delivery. In addition, the consortium aims to streamline regulatory requirements: Because AAV vectors have been used before in clinical trials, it’s hoped that their use will shorten the path from animal models to human clinical trials. Working with the FDA, the consortium will explore methods of streamlining the FDA approval process for safe, effective gene therapies.The consortium includes the NIH in general as well as various components, including the National Institute for Neurological Disorders and Stroke and National Human Genome Research Institute, the FDA, and 15 partners. These partners include 10 pharma companies, including Biogen, Janssen, and Spark Therapeutics, and 5 nonprofits, including The Alliance for Regenerative Medicine, National Organization for Rare Disorders, CureDuchenne, American Society of Gene and Cell Therapy, and the National Institute for Innovation in Manufacturing Biopharmaceutics. The members of the consortium will contribute about $76 million for 5 years to support the BGTC-funded projects, with about half coming from NIH institutes and centers. BGTC will fund research to support 4 to 6 clinical trials, focusing on different rare diseases. It’s hoped that this approach will have substantial positive impacts on the larger gene therapy field. (Philippidis, A. (2021). National Institutes of Health, U.S. Food and Drug Administration, 15 partners to accelerate development of rare disease gene therapies. Human Gene Therapy, 32 (No. 23-24). Retrieved January 2022 from https://www.liebertpub.com/doi/full/10.1089/hum.2021.29188.bfs; Foundation for NIH. (n.d.). Accelerating Medicines Partnership® Bespoke Gene Therapy Consortium (AMP® BGTC). Retrieved January 2022 from https://fnih.org/our-programs/AMP/BGTC)Released: January 2022 Nursing Drug Handbook © 2022 Wolters Kluwer
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