Dr. Christine Leong

Could changes in pharmacotherapy peripregnancy contribute to the shift in means of suicide?

by Leong C

Published by CMAJ

December 4, 2017

URL: http://www.cmaj.ca.uml.idm.oclc.org/content/189/48/E1497.long

Antidepressants for depression in patients with dementia: a review of the literature

by Leong C

Published by Consultant Pharmacist

April 1, 2014

OBJECTIVE:

To evaluate the literature investigating the efficacy and safety of antidepressants for treating depression in individuals with dementia.
DATA SOURCES:

A literature search was conducted using MEDLINE, PUBMED, EMBASE, and Cochrane databases from inception to May 2013 for studies in English that evaluated the treatment of depression in patients with dementia. All relevant randomized controlled trials (RCTs) and meta-analyses were identified using the search terms "dementia" or "Alzheimer's disease," and "depression" or "major depressive disorder." Reference lists from retrieved articles and practice guidelines were also searched for relevant literature.
STUDY SELECTION AND DATA EXTRACTION:

Only randomized, placebo-controlled trials and meta-analyses that compared an antidepressant with placebo for the treatment of depression in patients with dementia were included.
DATA SYNTHESIS:

In this systematic review, 10 RCTs and 3 meta-analyses were identified that examined the efficacy and safety of antidepressants compared with placebo in treating depression in patients with dementia. The majority of the RCTs consisted of a small sample size, and the antidepressants studied were not routinely used in practice.
CONCLUSIONS:

The evidence for antidepressants in the treatment of depression in patients with dementia is inconclusive. The accumulation of evidence suggests nonpharmacologic approaches and watchful waiting be attempted for the first 8 to 12 weeks in a patient who presents with both mild-to-moderate depression and dementia. In cases of severe depression, or depression not managed through nonpharmacologic means, a trial of an antidepressant may be initiated. However, further well-designed trials are needed to support these recommendations.

URL: https://www-ncbi-nlm-nih-gov.uml.idm.oclc.org/pubmed/24704894

Community Pharmacy Practice Barriers in Preventing Drug Misuse, Divergence and Overdose: A Focus Group Study

by Leong C, Sareen J, Enns MW, Bolton J, Alessi-Severini S

Published by Healthcare Quarterly

January 1, 2015

Community pharmacists frequently encounter patients suspected to be at risk of medication misuse, divergence and overdose; yet, little research exists in describing how pharmacists effectively identify and intervene during these encounters. This study aimed to understand the barriers and facilitators in community pharmacy practice using a focus group design to help inform policymakers in the development of effective and feasible strategies for limiting the means of medication misuse. Findings revealed three themes: (1) patient-level barriers (deciphering signs of misuse); (2) pharmacist-level barriers (type of practice experience); and (3) system-level barriers (prescriber, third-party payer). Insight into pharmacy practice provided a foundation for future study to explore strategies for improving care for at-risk patients.

URL: http://www.longwoods.com.uml.idm.oclc.org/content/24434

Antiepileptic use for epilepsy and nonepilepsy disorders: A population-based study (1998-2013)

by Leong C, Mamdani MM, Gomes T, Juurlink DN, Macdonald EM, Yogendran M

Published by Neurology

March 8, 2016

OBJECTIVE:

To examine the trends in antiepileptic drug (AED) use among individuals living in Manitoba with and without a history of epilepsy.
METHODS:

Using data obtained from administrative health databases in Manitoba, we assessed the quarterly prevalence of AED use between 1998 and 2013 among individuals with and without a history of epilepsy using cross-sectional time series analysis.
RESULTS:

Over the study period, the number of individuals prescribed AEDs increased more than 3-fold, from 8,883 to 27,246. The prevalence of AED use among patients with epilepsy increased by 3%, from 789.6 per 1,000 in 1998/1999 to 813.9 per 1,000 in 2012/2013 (p < 0.001 after 2006). In contrast, we observed a 210% increase in AED use among patients without epilepsy from 6.8 to 21.1 per 1,000 over the same period (p < 0.001). We observed a 55-fold rise in gabapentin use among patients without a seizure disorder (from 0.2 to 11.1 per 1,000; p < 0.001), while gabapentin use among those with epilepsy increased only 2-fold, from 21.6 to 41.3 per 1,000 (p < 0.001). CONCLUSIONS: There has been a marked increase in the prevalence of AED users over the last 15 years, with a large shift towards the use of newer antiepileptic agents (primarily gabapentin) among those without epilepsy. Further research on the effect of these trends on health and economic outcomes will be of interest for clinicians and policymakers.

URL: http://n.neurology.org/content/86/10/939.long

New antidepressant use in older adults: a Canadian population-based study (1997-2013)

by Leong C, Enns MW, Sareen J, Alessi-Severini S, Bolton J, Prior HJ, Chateau D

Published by Aging Ment Health

July 1, 2017

OBJECTIVE:

There has been much attention on appropriate prescribing in older adults in recent years. Recent guidelines favor the use of newer antidepressants over older agents based on their safety profile in this population. This study aimed to examine whether there has been a decline in older antidepressants and an increase in newer antidepressants used by older adults.
METHOD:

A retrospective cross-sectional study using administrative databases examined the annual incidence of antidepressant use (per 1000) of community-dwelling adults ≥60 years old between 1997/1998 and 2012/2013 in Manitoba, Canada.
RESULTS:

The population of Manitoba ≥60 years increased by 25.6% from 188,296 to 236,569 from 1997/1998 to 2012/2013. New antidepressant use peaked to 45.9 per 1000 in 1999/2000, and then decreased steadily to 30.5 per 1000 in 2012/2013 (p < 0.0001). Incident amitriptyline use was high but declined from 15.5 to 7.4 per 1000 (p < 0.001). An increase in incident trazodone, mirtazapine, and venlafaxine use was observed (p < 0.001). CONCLUSIONS: There has been an overall decrease in the annual incidence of antidepressant users in older adults over the last 16 years, with a marked decline in new amitriptyline use and an increase in the incidence of newer agents.

URL: http://www.tandfonline.com.uml.idm.oclc.org/doi/full/10.1080/13607863.2016.1154014

Community Pharmacists' Perspectives on Dispensing Medications With the Potential for Misuse, Diversion, and Intentional Overdose: Results of a Province-Wide Survey of Community Pharmacists in Canada

by Leong C, Alessi-Severini S, Sareen J, Enns MW, Bolton J

Published by Subst Use Misuse

November 9, 2016

BACKGROUND:

Community pharmacists frequently encounter patients at risk of medication misuse, diversion, and intentional overdose. However, few studies have examined the perspective of the pharmacist on the identification and management of these patients.
OBJECTIVE:

To understand the perspective of community pharmacists on the dispensing of select medications commonly associated with misuse, diversion, and overdose.
METHODS:

An online survey was disseminated by electronic mail to community pharmacists listed in the College of Pharmacists of Manitoba directory. The survey was open from July to September 2014. Descriptive statistics were used to describe demographic information of the pharmacist and practice setting, and pharmacists' perceptions on the dispensing of select medications.
RESULTS:

A total of 82 community pharmacists completed the survey. Most pharmacists considered a one-month supply appropriate for a psychotropic agent; but a 7-10 day-supply was considered appropriate for an opioid for acute pain. Factors that aid pharmacist decisions on providing select medications to patients include familiarity with the patient, ease of access to medical history information, and ease of access to the prescribing physician. Only 10.3%, 16.2%, and 32.4% felt they have received adequate training on the management of patients at risk for suicide, drug diversion, and medication misuse, respectively.
CONCLUSION:

Findings from this study demonstrated a need for improved systems for managing patients at risk for medication misuse, diversion, and overdose. Strategies that warrant further attention for limiting the means of medication misuse include increased access to electronic medical records and providing additional continuing education support for community pharmacists.

URL: http://www.tandfonline.com.uml.idm.oclc.org/doi/full/10.1080/10826084.2016.1197261

Cerebrovascular, Cardiovascular, and Mortality Events in New Users of Selective Serotonin Reuptake Inhibitors and Serotonin Norepinephrine Reuptake Inhibitors: A Propensity Score-Matched Population-Based Study

by Leong C, Alessi-Severini S, Enns MW, Nie Y, Sareen J, Bolton J, Prior HJ, Chateau D.

Published by Journal of Clinical Psychopharmacology

June 1, 2017

BACKGROUND:

Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are widely prescribed for mood and anxiety disorders. However, it is not clear whether SNRIs are more strongly associated with cardiovascular and cerebrovascular events than SSRIs.
METHODS:

This was a propensity score-matched, population-based, cohort study of Manitobans who started an SSRI or SNRI between April 1, 1998, and March 31, 2014. The primary outcome was a composite of acute myocardial infarction (AMI), stroke, or cardiovascular-related hospitalization within 1 year of drug initiation. Each component of the primary outcome and death were analyzed separately in secondary analyses.
RESULTS:

A total of 225,504 and 54,635 patients initiated treatment on an SSRI and SNRI, respectively. After propensity score matching, a higher risk was observed for the primary outcome among SNRI users (weighted hazards ratio [HR], 1.13; 95% confidence interval [CI], 1.06-1.21). Secondary analyses showed that the risk of nonfatal stroke was higher among SNRI users (weighted HR, 1.20; 95% CI, 1.08-1.33). The risk of death was higher among SNRI users without mood and/or anxiety disorders (weighted HR, 1.17; 95% CI; 1.03-1.32). No differences were observed in the risk of AMI or fatal stroke between SSRI and SNRI use.
CONCLUSIONS:

New SNRI use was associated with a higher risk of nonfatal stroke relative to SSRI use. Further investigation is warranted regarding the higher risk of death observed in our subgroup analysis among incident SNRI users without mood and/or anxiety disorders.

URL: http://ovidsp.tx.ovid.com.uml.idm.oclc.org/sp-3.27.2b/ovidweb.cgi?QS2=434f4e1a73d37e8c5a069e886e3737f23a4c9dde0bb2d9ba74fb45b9d333e3018584d2dee12f1b7f85aa3e09353955c4137197e67e97cd058f793861da887e0b1938946dd6b479388dafab7a97058e3a29ae6519c11057f71953d3a1b2b6e7a71c6c83b5809c22e1f680a657d8f547493c78d77f0d9fbd0fb95eb642cce4c80f1b0b88ff10399d6996c37e0ddbd46d57fdf62bf967e158c72273c9802103e815577555d0c1580dd4a43ac87a295e5d164025ac864de3d0b167216f003a282dd0feeff2a0a5597eff50da7189ab1752d4b4ce5c8adc2a8e331f155613438ef5c326235e7ac6f651b5

Psychotropic Drug Use before, during, and after Pregnancy: A Population-Based Study in a Canadian Cohort (2001-2013)

by Leong C, Raymond C, Château D, Dahl M, Alessi-Severini S, Falk J, Bugden S, Katz A

Published by Canadian Journal of Psychiatry

August 1, 2017

OBJECTIVE:

To describe the extent of increase in use and the rate of continuation versus discontinuation of psychotropic agents before, during, and after pregnancy.
METHODS:

Rates of psychotropic use (antidepressants, anxiolytic/sedative-hypnotics, antiepileptics, antipsychotics, lithium, stimulants) among women with a hospital-recorded pregnancy outcome were assessed using databases at the Manitoba Centre for Health Policy. Rate of use was defined as ≥1 prescription over the total number of pregnancies in the 3-12 months before pregnancy, 0-3 months before pregnancy, during pregnancy, or 3 months after pregnancy. Continued use was defined as ≥2 prescriptions with gap ≤14 days. Poisson regression was used to analyze trends.
RESULTS:

Over the study period, a psychotropic drug was used before, during, or after pregnancy in 41,923 of 224,762 pregnancies. From 2001 to 2013, psychotropic use increased 1.5-fold from 11.1% to 16.2% ( p < 0.0001) in the 3-12 months before pregnancy, 1.6-fold from 6.4% to 10.5% ( p < 0.0001) in the 3 months before pregnancy, 1.8-fold from 3.3% to 6.0% ( p < 0.0001) during pregnancy, and 1.5-fold from 6.2% to 9.5% ( p < 0.0001) in the 3 months postpartum. Among the 13,579 women who received at least 1 psychotropic agent in the 3 months prior to pregnancy, 38.5% stopped the agent prior to pregnancy and only 10.3% continued use throughout pregnancy. Continued use throughout pregnancy was higher (56.9%) among the 6693 women who received at least 2 prescriptions for a psychotropic agent and were at least 80% adherent in the 3 months prior to pregnancy. CONCLUSION: The use of psychotropic agents increased over 12 years. The safety of continuing versus discontinuing these agents during pregnancy remains uncertain, but we observed a decrease in psychotropic drug use during the pregnancy period.

URL: http://journals.sagepub.com.uml.idm.oclc.org/doi/abs/10.1177/0706743717711168?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

Opioid use during pregnancy: a population-based cohort study

by Falk J, Dahl M, Raymond CB, Chateau D, Katz A, Leong C, Bugden S

Published by CMAJ Open

June 26, 2017

BACKGROUND:

Opioid use has increased dramatically in North America. The safety of opioids in pregnancy is uncertain, but they are associated with several fetal abnormalities and contribute to rising rates of neonatal abstinence syndrome. We examined opioid use before and during pregnancy in a complete population-based cohort.
METHODS:

We examined opioid use in a cohort of all pregnant women in Manitoba, Canada, from 2001 to 2013. Opioid use was defined by prescriptions for opioids, converted to oral morphine equivalents (MEQ), during the 3 months before pregnancy and for each trimester. Given that the exposure per person may vary (because not all women complete all time periods), we determined a weighted number of pregnancies in each period.
RESULTS:

During the study period, 174 848 completed pregnancies were eligible for analysis (173 680 live births and 1168 stillbirths and intrauterine deaths), which represented a weighted value of 175 174 pregnancies. Among these pregnancies, 6.7% of the women filled opioid prescriptions in the 3 months before pregnancy. Use declined to 4.2% during the first trimester and further declined to 3.0% and 2.9% in the second and third trimesters, respectively. Over the study period, there was a modest increase in opioid use overall (from 7.3% to 7.7%). MEQ did not decline during pregnancy, and the mean MEQ increased significantly over the study period (from 284 mg to 1218 mg). Prescriptions for codeine were filled by 96.9% of the users, accounting for 66.2% of MEQ.
INTERPRETATION:

Although many of the women using opioids before pregnancy discontinued or reduced use of these drugs during pregnancy, the volume of opioids consumed by those who continued opioid use did not decline during pregnancy. The increasing dosage and increased use of higher-potency opioids by pregnant women highlights the need for continued evaluation of and education about the benefits and risks of this practice.

URL: https://www-ncbi-nlm-nih-gov.uml.idm.oclc.org/pmc/articles/PMC5498419/

Validity of the days supply field in pharmacy administrative claims data for the identification of blister packaging of medications

by Leong C, Sareen J, Leslie WD3 Enns MW, Bolton J, Alessi-Severini S, Katz LY, Logsetty S, Snider C, Berry J, Prior HJ, Chateau D

Published by Pharmacoepidemiol Drug Saf

December 1, 2017

PURPOSE:

Pharmacy claims data is often used in pharmacoepidemiology studies, but no studies to date have examined whether it was possible to identify the use of blister packs in these databases. We aimed to determine whether medications dispensed in days divisible by 7 are more likely to be blister packed than medications dispensed in other quantities.
METHODS:

Community pharmacies in Manitoba were invited to participate in a mail-out survey to identify the use of blister packaging for up to 25 patients who had a solid oral medication dispensed from April 1, 2012 to March 31, 2014. Eligible medications were identified using the population-based province-wide retail pharmacy network. Algorithms for identifying the use of blister packaging were determined by comparing the proportion of fills that confirmed blister pack use between different days supply quantities.
RESULTS:

Twenty-seven out of 32 pharmacies that agreed to participate completed the survey. The total number of prescriptions in the analysis was 2045 of which 131 (6.4%) were dispensed in blister packaging. Overall, prescriptions dispensed in days divisible by 7 yielded a 72.5% sensitivity, 86.6% specificity, 30.3% PPV, and 97.9% NPV compared with prescriptions dispensed in other quantities. A 28-day to 30-day comparison yielded an 87.9% sensitivity, 96.1% specificity, 64.6% PPV, and 99.0% NPV.
CONCLUSION:

While the NPV was high, the PPV for identifying blister packaging using the days supply field in pharmacy claims data was modest given the low prevalence in blister pack use. The best predictor occurred when 28 days was compared with 30 days. KEY POINTS Blister packs are arranged in 4 × 7 compartments and are often used to improve adherence, but no studies have examined whether it was possible to identify the use of blister packs using the days supply field in pharmacy claims data. Findings show that a 28-day supply yielded a high sensitivity and specificity for identifying the use of blister packaging compared with a 30-day supply, but there is potential for misclassification. Future studies directed at examining subgroups that are more likely to use blister packs and replication of findings using other data sources in other jurisdictions are encouraged.

URL: http://onlinelibrary-wiley-com.uml.idm.oclc.org/doi/10.1002/pds.4288/abstract