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BackgroundTHEMIS (NCT01991795) showed that in patients with type 2 diabetes (T2D) and stable coronary artery disease (CAD) but with no prior myocardial infarction (MI) or stroke, ticagrelor plus acetylsalicylic acid (ASA) decreased the incidence of ischaemic cardiovascular events compared with placebo plus ASA. To complement these findings, we assessed disease burden and healthcare resource utilization (HRU) in US patients with CAD and T2D, but without a prior MI or stroke.MethodsThis observational study used 2013-2014 data from the Diabetes Collaborative Registry linked to Medicare administrative claims. Two cohorts of patients with T2D were studied: patients at high cardiovascular risk (THEMIS-like cohort; N = 56 040) and patients at high cardiovascular risk or taking P2Y12 inhibitors (CAD-T2D cohort; N = 69 790). Outcomes included the composite of all-cause death, MI and stroke; the individual events from the composite endpoint; HRU; and costs.ResultsMedian age was 73.0 years, and median follow-up was 1.3 years in both cohorts. Event rates of the composite outcome were 16.34 (95% confidence interval: 16.31-16.37) and 17.64 (17.61-17.67) per 100 person-years for the THEMIS-like and CAD-T2D cohorts, respectively. The incidence rate of bleeding events was 0.13 events per 100 person-years in both cohorts. Healthcare costs per patient-year were USD 8741 and USD 9150 in the THEMIS-like and CAD-T2D cohorts, respectively.ConclusionsPatients in the THEMIS-like cohort and the broader CAD-T2D population had similarly substantial cardiovascular event rates and healthcare costs, indicating that patients with CAD and T2D similar to the THEMIS population are at an increased cardiovascular risk.

Background: Elevated serum uric acid (sUA) is associated with heart failure (HF). Hypothesis: Urate‐lowering therapy (ULT) in HF is associated with lower risk of HF hospitalization (hHF) and mortality. Methods: Data on patients with HF and gout or hyperuricemia in the Clinical Practice Research Datalink database linked to the Hospital Episode Statistics and the Office for National Statistics in the United Kingdom were analyzed. Risks of hHF and all‐cause mortality or cardiovascular‐related mortality by ULT exposure (ULT initiated within ≤6 months of gout or hyperuricemia diagnosis) were analyzed in a propensity score‐matched cohort using adjusted Cox proportional hazards regression models. Results: Of 2174 propensity score‐matched pairs, patients were predominantly male, aged >70 years, with mean ± standard deviation sUA 9.3 ± 1.8 (ULT‐exposed) and 9.4 ± 1.9 mg/dL (ULT‐unexposed). At 5 years, ULT‐exposed patients had a 43% lower risk of hHF or all‐cause mortality (adjusted hazard ratio [HR]: 0.57; 95% confidence interval [CI]: 0.51–0.65) and a 19% lower risk of hHF or cardiovascular‐related mortality (adjusted HR: 0.81; 95% CI: 0.71–0.92) versus no ULT exposure. Conclusion: ULT was associated with reduced risk of adverse clinical outcomes in patients with HF and gout or hyperuricemia over 5 years. Practitioner points: Raised serum uric acid is strongly associated with heart failure (HF); however, it is unknown whether urate‐lowering therapy (ULT) could help patients with HF.We assessed the relationship between ULT and HF outcomes using UK patient data, and found that the risk of the composite of hospital admission for HF or death was lower with ULT than with no ULT.These results support further investigation into the potential benefit of ULT in HF. [ABSTRACT FROM AUTHOR]

Objective To investigate sociodemographic and gender factors associated with suicide and suicide attempts among new users of antidepressants aged 75 and above. Design Register-based cohort study. Setting National population-based cohort of Swedish residents aged =75 years. Participants 185 225 patients who initiated antidepressant medication between 1 January 2007 and 31 December 2013 were followed until 31 December 2014. Main outcome measures Suicide and suicide attempts. Fine and Gray regression models were used to analyse the sociodemographic factors (age, country of birth, marital status, education level, last occupation, income and social allowance) associated with suicidal behaviours in the entire cohort and by gender. Results During follow-up, 295 suicides and 654 suicide attempts occurred. Adjusted sub-hazard ratios (aSHRs) for suicide were lower among older age groups (aSHR 0.73, 95% CI 0.53 to 0.99 for those 85-89 years; and aSHR 0.53, 95% CI 0.33 to 0.86 for those =90 years). A similar pattern was observed for suicide attempts. Suicide attempts were more common among those born in foreign countries (aSHR 1.58, 95% CI 1.16 to 2.15 for those born in another Nordic country; and aSHR 1.43, 95% CI 1.06 to 1.93 for those born in non-Nordic countries). In the gender-stratified analyses, being single or divorced, and born in another Nordic country was associated with a higher risk of suicide among men. Educational and occupational history and being born in a non-Nordic country influenced risk of suicidal behaviours in women. Conclusion Suicidal behaviours occurred more commonly among new users who were 'younger' old adults and those with foreign background, suggesting that those groups might require greater support when initiating antidepressant therapy. Our findings suggest the need for gender-specific, multifaceted approaches to the prevention of suicidal behaviours in late life. [ABSTRACT FROM AUTHOR]

Objectives To analyse the association between refill adherence to lipid-lowering medications, and the risk of cardiovascular disease (CVD) and mortality in patients with type 2 diabetes mellitus. Design Cohort study. Setting National population-based cohort of Swedish patients with type 2 diabetes mellitus. Participants 86 568 patients aged ≥18 years, registered with type 2 diabetes mellitus in the Swedish National Diabetes Register, who filled at least one prescription for lipid-lowering medication use during 2007-2010, 87% for primary prevention. Exposure and outcome measures Refill adherence of implementation was assessed using the medication possession ratio (MPR), representing the proportion of days with medications on hand during an 18-month exposure period. MPR was categorised by five levels (≤20%, 21%-40%, 41%-60%, 61%-80% and >80%). Patients without medications on hand for ≥180 days were defined as non-persistent. Risk of CVD (myocardial infarction, ischaemic heart disease, stroke and unstable angina) and mortality by level of MPR and persistence was analysed after the exposure period using Cox proportional hazards regression and Kaplan-Meier, adjusted for demographics, socioeconomic status, concurrent medications and clinical characteristics. Results The hazard ratios for CVD ranged 1.33-2.36 in primary prevention patients and 1.19-1.58 in secondary prevention patients, for those with MPR ≤80% (p<0.0001). The mortality risk was similar regardless of MPR level. The CVD risk was 74% higher in primary prevention patients and 33% higher in secondary prevention patients, for those who were non-persistent (p<0.0001). The mortality risk was 6% higher in primary prevention patients and 18% higher in secondary prevention patients, for nonpersistent patients (p<0.0001). Conclusions Higher refill adherence to lipid-lowering medications was associated with lower risk of CVD in primary and secondary prevention patients with type 2 diabetes mellitus. [ABSTRACT FROM AUTHOR]

Background Several countries have introduced generic substitution, but few studies have assessed its effect on refill adherence. This study aimed to analyse whether generic substitution influences refill adherence to statin treatment. Methods Between 1 July 2006 and 30 June 2007, new users of simvastatin (n = 108,806) and atorvastatin (n = 7,464) were identified in the Swedish Prescribed Drug Register. The present study included atorvastatin users as an unexposed control group because atorvastatin was patent-protected and thus not substitutable. We assessed refill adherence using continuous measure of medication acquisition (CMA). To control for potential confounders, we used analysis of covariance (ANCOVA). Differences in CMA associated with generic substitution and generic substitution at first-time statin purchase were analysed. Results Nine of ten simvastatin users were exposed to generic substitution during the study period, and their adherence rate was higher than that of patients without substitution [84.6% (95% CI 83.5-85.6) versus 59.9% (95% CI 58.4-61.4), p < 0.001]. CMA rose with increasing age (60-69 years 16.7%, p < 0.0001 and 70-79 years 17.8%, p < 0.0001, compared to 18-39 years) and secondary prevention (12.8%, p < 0.0001). CMA was lower among patients who were exposed to generic substitution upon initial purchase, compared to those who were exposed to a generic substitution subsequently [80.4% (95% CI 79.4-90.9) versus 89.8% (88.7-90.9), p < 0.001]. This difference decreased when those with only one statin purchase were excluded. Conclusions Statin refill adherence was higher among patients who exposed to generic substitution compared to those who were not. Increasing age and previous cardiovascular disease affected refill adherence. [ABSTRACT FROM AUTHOR]

Objectives: To estimate the cost of illness (COI) of individuals with self-reported adverse drug events (ADEs) from a societal perspective and to compare these estimates with the COI for individuals without ADE. Furthermore, to estimate the direct costs resulting from two ADE categories, adverse drug reactions (ADRs) and subtherapeutic effects of medication therapy (STE). Design: Cross-sectional study. Setting: The adult Swedish general population. Participants: The survey was distributed to a random sample of 14 000 Swedish residents aged 18 years and older, of which 7099 responded, 1377 reported at least one ADE and 943 reported an ADR or STE. Main outcome measures: Societal COI, including direct and indirect costs, for individuals with at least one self-reported ADE, and the direct costs for prescription drugs and healthcare use resulting from self-reported ADRs and STEs were estimated during 30 days using a bottom-up approach. Results: The economic burden for individuals with ADEs were (95% CI) 442.7 to 599.8 international dollars (Int$), of which direct costs were Int$ 279.6 to 420.0 (67.1%) and indirect costs were Int$ 143.0 to 199.8 (32.9%). The average COI was higher among those reporting ADEs compared with other respondents (COI: Int$ 442.7 to 599.8 versus Int$ 185.8 to 231.2). The COI of respondents reporting at least one ADR or STE was Int$ 468.9 to 652.9. Direct costs resulting from ADRs or STEs were Int$ 15.0 to 48.4. The reported resource use occurred both in hospitals and outside in primary care. Conclusions: Self-reported ADRs and STEs cause resource use both in hospitals and in primary care. Moreover, ADEs seem to be associated with high overall COI from a societal perspective when comparing respondents with and without ADEs. There is a need to further examine this relationship and to study the indirect costs resulting from ADEs. [ABSTRACT FROM AUTHOR]

Objectives: To describe the use and evaluate the effectiveness of different lipid lowering therapies in unselected patients with type 1 and type 2 diabetes in clinical practice. Design: Observational population-based study using the personal identification number to link information from the National Diabetes Register, the Prescribed Drug Register and the Patient register in Sweden. All patients in the NDR aged 18-75 years with diabetes more than one year were eligible, but only patients starting any lipid lowering treatment with at least three prescriptions 1 July 2006-30 June 2007 were included (n = 37182). The mean blood lipid levels in 2008 and reductions in LDL cholesterol were examined. Results: Blood lipid levels were similar in patients treated with simvastatin, atorvastatin and rosuvastatin, showing similar lipid lowering effect as currently used. Users of pravastatin, fluvastatin, ezetimib and fibrate more seldom reach treatment goals. Moderate daily doses of the statins were used, with 76% of simvastatin users taking 20 mg or less, 48% of atorvastatin users taking 10 mg, 55% of pravastatin users taking 20 mg, and 76% of rosuvastatin users taking 5 or 10 mg. Conclusions: This observational study shows that the LDL-C levels in patients taking simvastatin, atorvastatin or rosuvastatin are very similar as currently used, as well as their LDL-C lowering abilities. There is potential to intensify lipid lowering treatment to reduce the remaining high residual risk and achieve better fulfilment of treatment goals, since the commonly used doses are only low to moderate. [ABSTRACT FROM AUTHOR]

Purpose: To compare antidepressant utilization patterns and mortality in relation to antidepressant use in men and women aged 20-34 years., Methods: We used data from the Swedish Prescribed Drug Register to identify adults aged 20-34 years who purchased at least one antidepressant in 2006. Information on death and migration was obtained from the Total Population Register by record linkage. One-year prevalence and proportion of new users, amount of purchased antidepressants, concurrent use of other antidepressants, mood stabilizers and antipsychotics and mortality were assessed., Results: The one-year prevalence of antidepressant use was 5.6% among all Swedes aged 20-34 years (n = 94,239) and was higher among women than men (7.2 vs. 4.0%, p < 0.001). Selective serotonin reuptake inhibitors were the most dominant class of antidepressants at baseline and were more common among women than men (78.7 vs. 71.7%, p < 0.001). Of the new users, 22.3% filled only one prescription during the study period, men more often than women (24.1 vs. 21.4%, p < 0.001). The mortality rate was higher in men than in women (24 vs. 14 per 10,000, p = 0.009). Concurrent use of mood stabilizers (48 vs. 16 per 10,000, p < 0.001) and antipsychotics (50 vs. 14 per 10,000, p < 0.001) was associated with increased mortality in men and women., Conclusions: Almost twice as many Swedish women than men aged 20-34 years purchased antidepressants in 2006. Differences in utilization patterns between sexes were rather small. Discontinuation rates were high, indicating that health care providers need to acquire an increased awareness on attitudes to treatment. In both sexes, mortality rates were elevated among those concurrently using mood stabilizers and antipsychotics, which needs further investigation.