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Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain.
J Am Geriatr Soc. 2021 10; 69(10):2842-2850.JA

Abstract

BACKGROUND/OBJECTIVES

Gabapentinoids are commonly prescribed to relieve pain. The development of edema, an established adverse effect of gabapentinoids, may lead to a potentially harmful prescribing cascade whereby individuals are subsequently prescribed diuretics and exposed to diuretic-induced adverse events. The frequency of this prescribing cascade is unknown. Our objective was to measure the association between new dispensing of a gabapentinoid and the subsequent dispensing of a diuretic in older adults with new low back pain.

DESIGN

Population-based cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

A total of 260,344 community-dwelling adults aged 66 years or older, newly diagnosed with low back pain between April 1, 2011, and March 31, 2019.

MEASUREMENTS

Exposure status was assigned using dispensed medications in the 1 week after low back pain diagnosis. Older adults newly dispensed a gabapentinoid (N = 7867) were compared with older adults who were not newly dispensed a gabapentinoid (N = 252,477). Hazard ratios (HRs) with 95% confidence intervals (CIs) for dispensing of a diuretic within 90 days of follow-up among older adults prescribed gabapentin relative to those who were not.

RESULTS

Older adults newly dispensed a gabapentinoid had a higher risk of being subsequently dispensed a diuretic within 90 days compared with older adults who were not prescribed a gabapentinoid (2.0% vs. 1.3%). After covariate adjustment, new gabapentinoid users had a higher rate of being dispensed a diuretic compared with those not prescribed a gabapentinoid (HR: 1.44, 95% CI: 1.23, 1.70). The rate of diuretic prescription among new gabapentinoid users increased with increasing gabapentinoid dosages.

CONCLUSIONS

We have demonstrated the presence of a potentially inappropriate and harmful prescribing cascade. Given the widespread use of gabapentinoids, the population-based scale of this problem may be substantial. Increased awareness of this prescribing cascade is required to reduce the unnecessary use of diuretics and the exposure of patients to additional adverse drug events.

Authors+Show Affiliations

Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. ICES, Toronto, Ontario, Canada.Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. ICES, Toronto, Ontario, Canada.Department of Medicine, University of Toronto, Toronto, Ontario, Canada.Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. ICES, Toronto, Ontario, Canada. Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.ICES, Toronto, Ontario, Canada.Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada. Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada.ICES, Toronto, Ontario, Canada. Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.Harvard Medical School and Harvard Chan School of Public Health, Boston, Massachusetts, USA.Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, Massachusetts, USA.Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. ICES, Toronto, Ontario, Canada. Department of Medicine, University of Toronto, Toronto, Ontario, Canada. Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. ICES, Toronto, Ontario, Canada.Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. ICES, Toronto, Ontario, Canada. Department of Medicine, University of Toronto, Toronto, Ontario, Canada. Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

34118076

Citation

Read, Stephanie H., et al. "Evidence of a Gabapentinoid and Diuretic Prescribing Cascade Among Older Adults With Lower Back Pain." Journal of the American Geriatrics Society, vol. 69, no. 10, 2021, pp. 2842-2850.
Read SH, Giannakeas V, Pop P, et al. Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain. J Am Geriatr Soc. 2021;69(10):2842-2850.
Read, S. H., Giannakeas, V., Pop, P., Bronskill, S. E., Herrmann, N., Chen, S., Luke, M. J., Wu, W., McCarthy, L. M., Austin, P. C., Normand, S. L., Gurwitz, J. H., Stall, N. M., Savage, R. D., & Rochon, P. (2021). Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain. Journal of the American Geriatrics Society, 69(10), 2842-2850. https://doi.org/10.1111/jgs.17312
Read SH, et al. Evidence of a Gabapentinoid and Diuretic Prescribing Cascade Among Older Adults With Lower Back Pain. J Am Geriatr Soc. 2021;69(10):2842-2850. PubMed PMID: 34118076.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain. AU - Read,Stephanie H, AU - Giannakeas,Vasily, AU - Pop,Paula, AU - Bronskill,Susan E, AU - Herrmann,Nathan, AU - Chen,Simon, AU - Luke,Miles J, AU - Wu,Wei, AU - McCarthy,Lisa M, AU - Austin,Peter C, AU - Normand,Sharon-Lise, AU - Gurwitz,Jerry H, AU - Stall,Nathan M, AU - Savage,Rachel D, AU - Rochon,Paula, Y1 - 2021/06/12/ PY - 2021/04/28/revised PY - 2021/03/02/received PY - 2021/05/06/accepted PY - 2021/6/13/pubmed PY - 2021/11/25/medline PY - 2021/6/12/entrez KW - dose-dependence KW - drug safety KW - gabapentinoids KW - prescribing SP - 2842 EP - 2850 JF - Journal of the American Geriatrics Society JO - J Am Geriatr Soc VL - 69 IS - 10 N2 - BACKGROUND/OBJECTIVES: Gabapentinoids are commonly prescribed to relieve pain. The development of edema, an established adverse effect of gabapentinoids, may lead to a potentially harmful prescribing cascade whereby individuals are subsequently prescribed diuretics and exposed to diuretic-induced adverse events. The frequency of this prescribing cascade is unknown. Our objective was to measure the association between new dispensing of a gabapentinoid and the subsequent dispensing of a diuretic in older adults with new low back pain. DESIGN: Population-based cohort study. SETTING: Ontario, Canada. PARTICIPANTS: A total of 260,344 community-dwelling adults aged 66 years or older, newly diagnosed with low back pain between April 1, 2011, and March 31, 2019. MEASUREMENTS: Exposure status was assigned using dispensed medications in the 1 week after low back pain diagnosis. Older adults newly dispensed a gabapentinoid (N = 7867) were compared with older adults who were not newly dispensed a gabapentinoid (N = 252,477). Hazard ratios (HRs) with 95% confidence intervals (CIs) for dispensing of a diuretic within 90 days of follow-up among older adults prescribed gabapentin relative to those who were not. RESULTS: Older adults newly dispensed a gabapentinoid had a higher risk of being subsequently dispensed a diuretic within 90 days compared with older adults who were not prescribed a gabapentinoid (2.0% vs. 1.3%). After covariate adjustment, new gabapentinoid users had a higher rate of being dispensed a diuretic compared with those not prescribed a gabapentinoid (HR: 1.44, 95% CI: 1.23, 1.70). The rate of diuretic prescription among new gabapentinoid users increased with increasing gabapentinoid dosages. CONCLUSIONS: We have demonstrated the presence of a potentially inappropriate and harmful prescribing cascade. Given the widespread use of gabapentinoids, the population-based scale of this problem may be substantial. Increased awareness of this prescribing cascade is required to reduce the unnecessary use of diuretics and the exposure of patients to additional adverse drug events. SN - 1532-5415 UR - https://www.unboundmedicine.com/medline/citation/34118076/Evidence_of_a_gabapentinoid_and_diuretic_prescribing_cascade_among_older_adults_with_lower_back_pain_ L2 - https://doi.org/10.1111/jgs.17312 DB - PRIME DP - Unbound Medicine ER -