Gabapentin and Pregabalin Use and Association with Adverse Outcomes among Hemodialysis Patients

Background Gabapentin and pregabalin are used to manage neuropathic pain, pruritus, and restless legs syndrome in patients on hemodialysis. These patients may be especially predisposed to complications related to these agents, which are renally cleared, but data regarding the risk thereof are lacking.Methods From the US Renal Data System, we identified 140,899 Medicare-covered adults receiving hemodialysis with Part D coverage in 2011. Using Cox regression models in which we adjusted for demographics, comorbidities, duration of exposure, number of medications, and use of potentially confounding concomitant medications, we investigated the association between gabapentin and pregabalin, modeled as separate time-varying exposures, and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture. We evaluated risk according to daily dose categories: gabapentin (>0–100, >100–200, >200–300, and >300 mg) and pregabalin (>0–100 and >100 mg).Results In 2011, 19% and 4% of patients received gabapentin and pregabalin, respectively. Sixty-eight percent of gabapentin or pregabalin users had a diagnosis of neuropathic pain, pruritus, or restless legs syndrome. Gabapentin was associated with 50%, 55%, and 38% higher hazards of altered mental status, fall, and fracture, respectively, in the highest dose category, but even lower dosing was associated with a higher hazard of altered mental status (31%–41%) and fall (26%–30%). Pregabalin was associated with up to 51% and 68% higher hazards of altered mental status and fall, respectively.Conclusions Gabapentin and pregabalin should be used judiciously in patients on hemodialysis, and research to identify the most optimal dosing is warranted.

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Management of Restless Legs Syndrome in Pregnancy and Lactation

Journal of Primary Care & Community Health ◽

10.1177/2150132720905950 ◽

2020 ◽

Vol 11 ◽

pp. 215013272090595

Author(s):

Marjan Jahani Kondori ◽

Bhanu Prakash Kolla ◽

Katherine M. Moore ◽

Meghna P. Mansukhani

Keyword(s):

Restless Legs Syndrome ◽

Iron Supplementation ◽

Intravenous Iron ◽

Adverse Outcomes ◽

Efficacy And Safety ◽

Restless Legs ◽

Pregnancy And Lactation ◽

Iron Replacement ◽

In Pregnancy ◽

Pathophysiologic Mechanisms

Restless legs syndrome (RLS) affects about 20% of all pregnant women. RLS symptoms are usually moderate to severe in intensity during pregnancy and can result in insomnia, depression, and other adverse outcomes. Although iron deficiency has been implicated as a potential etiological factor, other mechanisms can also play a role. Nonpharmacologic methods are the primary recommended form of treatment for RLS in pregnancy and lactation. Iron supplementation may be considered when the serum ferritin is low; however, several patients are unable to tolerate iron or have severe symptoms despite oral iron replacement. Here, we describe a case of severe RLS in pregnancy and illustrate the dilemmas in diagnosis and management. We review the literature on the prevalence, diagnosis, course, possible underlying pathophysiologic mechanisms and complications of RLS in pregnancy. We describe current best evidence on the efficacy, and safety of nonpharmacologic therapies, oral and intravenous iron supplementation, as well as other medication treatments for RLS in pregnancy and lactation. We highlight gaps in the literature and provide a practical guide for the clinical management of RLS in pregnancy and during breastfeeding.

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Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.09910917 ◽

2018 ◽

Vol 13 (5) ◽

pp. 746-753 ◽

Cited By ~ 33

Author(s):

Julie H. Ishida ◽

Charles E. McCulloch ◽

Michael A. Steinman ◽

Barbara A. Grimes ◽

Kirsten L. Johansen

Keyword(s):

Confidence Interval ◽

Mental Status ◽

Oral Morphine ◽

Altered Mental Status ◽

Hazard Ratio ◽

Adverse Outcomes ◽

Dependent Manner ◽

Opioid Use ◽

Opioid Dose ◽

Dose Increment

Background and objectivesPatients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited.Design, setting, participants, & measurementsUsing the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (>60 mg, ≤60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment).ResultsThe median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture.ConclusionsOpioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.

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Pregabalin in restless legs syndrome with and without neuropathic pain

Acta Neurologica Scandinavica ◽

10.1111/j.1600-0404.2007.00796.x ◽

2007 ◽

Vol 115 (5) ◽

pp. 347-350 ◽

Cited By ~ 46

Author(s):

M. Sommer ◽

C. G. Bachmann ◽

K. M. Liebetanz ◽

J. Schindehütte ◽

T. Tings ◽

...

Keyword(s):

Neuropathic Pain ◽

Restless Legs Syndrome ◽

Restless Legs

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Survival in Restless Legs Syndrome: An 11-Year Surveillance, Community-Based Population Study

Neuroepidemiology ◽

10.1159/000508855 ◽

2020 ◽

Vol 54 (5) ◽

pp. 375-382

Author(s):

Esther Cubo ◽

Carla Collazo Riobo ◽

Cesar Gallego-Nieto ◽

Miren Elizari-Roncal ◽

Teresa Barroso-Pérez ◽

...

Keyword(s):

Regression Analysis ◽

General Population ◽

Restless Legs Syndrome ◽

Cox Regression ◽

Cox Regression Analysis ◽

Restless Legs ◽

Risk Of Mortality ◽

Increased Risk ◽

Standardized Mortality Ratios

Background: A growing body of evidence relates restless legs syndrome (RLS) to an increased risk of mortality attributable to both cerebrovascular and cardiovascular events. The aim was to investigate survival in patients with RLS. Methods: This was an observational, retrospective longitudinal study of a cohort of patients followed up for 11 years. RLS was diagnosed by a physician using the International RLS Study Group criteria. Mortality was analyzed using age-standardized mortality ratios (SMR: observed/expected deaths) and Cox regression analysis. Results: Vital status was studied in a cohort of 232 patients: 181 women (78%), 96 with RLS (41.4%) with a mean age at baseline of 49.8 ± 15.0 years and a mean RLS duration of 14.1 ± 1.9 years, and 136 non-RLS (58.6%) with a mean age of 51.3 ± 14.9 years. This RLS cohort was followed up for a period of 10.4 ± 2.0 years. As of September 2019, 17 (7.3%) patients died (6 with RLS, 6.3%), and the most frequent cause was oncological (66.7%). A total of 944 person-years of observations were available for survival analysis. RLS was not associated with increased mortality in adjusted Cox regression analysis (HR = 1.12, 95% CI: 0.40–3.15), and survival was similar to that expected for the general population (SMR = 0.61, 95% CI: 0.27–1.36). Conclusions: RLS seems not to be associated with increased mortality compared to the general population. Still, studies with prospective data collection with large samples are needed to study the long-term mortality risk factors in RLS cohorts.

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Risk Factors for In-hospital Mortality from Coronavirus Disease 2019 Infection Among Black Patients—An Urban Center Experience

Clinical Infectious Diseases ◽

10.1093/cid/ciaa1468 ◽

2020 ◽

Author(s):

Ashish Bhargava ◽

Mamta Sharma ◽

Kathleen Riederer ◽

Elisa Akagi Fukushima ◽

Susanna M Szpunar ◽

...

Keyword(s):

Risk Factors ◽

Hospital Mortality ◽

Mental Status ◽

Multivariable Analysis ◽

Case Fatality ◽

Altered Mental Status ◽

Adverse Outcomes ◽

Urban Hospital ◽

Duration Of Symptoms ◽

Black Patients

Abstract Background Racial disparities are central in the national conversation about coronavirus disease 2019 (COVID-19) , with Black/African Americans being disproportionately affected. We assessed risk factors for death from COVID-19 among Black inpatients at an urban hospital in Detroit, Michigan. Methods This was a retrospective, single-center cohort study. We reviewed the electronic medical records of patients positive for severe acute respiratory syndrome coronavirus 2 (the COVID-19 virus) on qualitative polymerase chain reaction assay who were admitted between 8 March 2020 and 6 May 2020. The primary outcome was in-hospital mortality. Results The case fatality rate was 29.1% (122/419). The mean duration of symptoms prior to hospitalization was 5.3 (3.9) days. The incidence of altered mental status on presentation was higher among patients who died than those who survived, 43% vs 20.0%, respectively (P < .0001). From multivariable analysis, the odds of death increased with age (≥60 years), admission from a nursing facility, Charlson score, altered mental status, higher C-reactive protein on admission, need for mechanical ventilation, presence of shock, and acute respiratory distress syndrome. Conclusions These demographic, clinical, and laboratory factors may help healthcare providers identify Black patients at highest risk for severe COVID-19–associated outcomes. Early and aggressive interventions among this at-risk population may help mitigate adverse outcomes.

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