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Muscle Relaxant Use Among Hemodialysis Patients: Prevalence, Clinical Indications, and Adverse Outcomes.
Am J Kidney Dis. 2019 04; 73(4):525-532.AJ

Abstract

RATIONALE & OBJECTIVE

Muscle relaxants are often used to treat musculoskeletal pain or cramping, which are commonly experienced by hemodialysis patients. However, the extent to which muscle relaxants are prescribed in this population and the risks associated with their use have not been characterized.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

140,899 Medicare-covered adults receiving hemodialysis in 2011, identified in the US Renal Data System.

EXPOSURE

Time-varying muscle relaxant exposure.

OUTCOMES

Primary outcomes were time to first emergency department visit or hospitalization for altered mental status, fall, or fracture. Secondary outcomes were death and composites of death with each of the primary outcomes.

ANALYTICAL APPROACH

Multivariable Cox regression analysis.

RESULTS

10% of patients received muscle relaxants in 2011. 11%, 6%, 3%, and 13% had an episode of altered mental status, fall, fracture, and death, respectively. Muscle relaxant use was associated with higher risk for altered mental status (HR, 1.39; 95% CI, 1.29-1.51) and fall (HR, 1.18; 95% CI, 1.05-1.33) compared to no use. Muscle relaxant use was not statistically significantly associated with higher risk for fracture (HR, 1.17; 95% CI, 0.98-1.39). Muscle relaxant use was associated with lower hazard of death (HR, 0.85; 95% CI, 0.76-0.94). However, hazards were higher for altered mental status or death (HR, 1.17; 95% CI, 1.10-1.25), fall or death (HR, 1.14; 95% CI, 1.06-1.22), and fracture or death (HR, 1.10; 95% CI, 1.01-1.20).

LIMITATIONS

A causal association between muscle relaxant use and outcomes cannot be inferred, and residual confounding cannot be excluded. Exposure and outcomes were ascertained using administrative claims.

CONCLUSIONS

Muscle relaxant use was common in hemodialysis patients and associated with altered mental status and falls. We could not rule out a clinically meaningful association between muscle relaxant use and fracture. The lower risk for death with muscle relaxants may have been the result of residual confounding. Future research to define the appropriate use of muscle relaxants in this population is warranted.

Authors+Show Affiliations

Department of Medicine, University of California, San Francisco, CA; Division of Nephrology, San Francisco VA Medical Center, San Francisco, CA.Department of Medicine, University of California, San Francisco, CA; Division of Nephrology, San Francisco VA Medical Center, San Francisco, CA; Department of Epidemiology & Biostatistics, University of California, San Francisco, CA.Department of Epidemiology & Biostatistics, University of California, San Francisco, CA.Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA.Department of Epidemiology & Biostatistics, University of California, San Francisco, CA.Department of Medicine, University of California, San Francisco, CA; Division of Nephrology, San Francisco VA Medical Center, San Francisco, CA. Electronic address: julie.ishida@ucsf.edu.

Pub Type(s)

Journal Article
Multicenter Study
Observational Study
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

30639233

Citation

Mina, Diana, et al. "Muscle Relaxant Use Among Hemodialysis Patients: Prevalence, Clinical Indications, and Adverse Outcomes." American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation, vol. 73, no. 4, 2019, pp. 525-532.
Mina D, Johansen KL, McCulloch CE, et al. Muscle Relaxant Use Among Hemodialysis Patients: Prevalence, Clinical Indications, and Adverse Outcomes. Am J Kidney Dis. 2019;73(4):525-532.
Mina, D., Johansen, K. L., McCulloch, C. E., Steinman, M. A., Grimes, B. A., & Ishida, J. H. (2019). Muscle Relaxant Use Among Hemodialysis Patients: Prevalence, Clinical Indications, and Adverse Outcomes. American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation, 73(4), 525-532. https://doi.org/10.1053/j.ajkd.2018.11.008
Mina D, et al. Muscle Relaxant Use Among Hemodialysis Patients: Prevalence, Clinical Indications, and Adverse Outcomes. Am J Kidney Dis. 2019;73(4):525-532. PubMed PMID: 30639233.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Muscle Relaxant Use Among Hemodialysis Patients: Prevalence, Clinical Indications, and Adverse Outcomes. AU - Mina,Diana, AU - Johansen,Kirsten L, AU - McCulloch,Charles E, AU - Steinman,Michael A, AU - Grimes,Barbara A, AU - Ishida,Julie H, Y1 - 2019/01/11/ PY - 2018/04/27/received PY - 2018/11/25/accepted PY - 2019/1/15/pubmed PY - 2020/2/1/medline PY - 2019/1/15/entrez KW - Muscle relaxant KW - US Renal Data System (USRDS) KW - altered mental status KW - back pain KW - cramps KW - cyclobenzaprine KW - drug safety KW - fall KW - fracture KW - hemodialysis KW - muscle spasticity KW - musculoskeletal pain KW - prescribing patterns SP - 525 EP - 532 JF - American journal of kidney diseases : the official journal of the National Kidney Foundation JO - Am J Kidney Dis VL - 73 IS - 4 N2 - RATIONALE & OBJECTIVE: Muscle relaxants are often used to treat musculoskeletal pain or cramping, which are commonly experienced by hemodialysis patients. However, the extent to which muscle relaxants are prescribed in this population and the risks associated with their use have not been characterized. STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: 140,899 Medicare-covered adults receiving hemodialysis in 2011, identified in the US Renal Data System. EXPOSURE: Time-varying muscle relaxant exposure. OUTCOMES: Primary outcomes were time to first emergency department visit or hospitalization for altered mental status, fall, or fracture. Secondary outcomes were death and composites of death with each of the primary outcomes. ANALYTICAL APPROACH: Multivariable Cox regression analysis. RESULTS: 10% of patients received muscle relaxants in 2011. 11%, 6%, 3%, and 13% had an episode of altered mental status, fall, fracture, and death, respectively. Muscle relaxant use was associated with higher risk for altered mental status (HR, 1.39; 95% CI, 1.29-1.51) and fall (HR, 1.18; 95% CI, 1.05-1.33) compared to no use. Muscle relaxant use was not statistically significantly associated with higher risk for fracture (HR, 1.17; 95% CI, 0.98-1.39). Muscle relaxant use was associated with lower hazard of death (HR, 0.85; 95% CI, 0.76-0.94). However, hazards were higher for altered mental status or death (HR, 1.17; 95% CI, 1.10-1.25), fall or death (HR, 1.14; 95% CI, 1.06-1.22), and fracture or death (HR, 1.10; 95% CI, 1.01-1.20). LIMITATIONS: A causal association between muscle relaxant use and outcomes cannot be inferred, and residual confounding cannot be excluded. Exposure and outcomes were ascertained using administrative claims. CONCLUSIONS: Muscle relaxant use was common in hemodialysis patients and associated with altered mental status and falls. We could not rule out a clinically meaningful association between muscle relaxant use and fracture. The lower risk for death with muscle relaxants may have been the result of residual confounding. Future research to define the appropriate use of muscle relaxants in this population is warranted. SN - 1523-6838 UR - https://www.unboundmedicine.com/medline/citation/30639233/Muscle_Relaxant_Use_Among_Hemodialysis_Patients:_Prevalence_Clinical_Indications_and_Adverse_Outcomes_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0272-6386(18)31125-9 DB - PRIME DP - Unbound Medicine ER -