Etiology
Some antimicrobials increased admissions and ED visits for hypoglycemia in older users of glipizide or glyburide Clinical impact ratings:
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Parekh TM, Raji M, Lin YL, et al. Hypoglycemia after antimicrobial drug prescription for older patients using sulfonylureas. JAMA Intern Med. 2014;174:1605-12.
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Question
Conclusion
In older patients who use glipizide or glyburide, does concurrent use of antimicrobials that interact with sulfonylureas increase risk for hypoglycemia?
In older patients receiving glipizide or glyburide, concurrent use of some antimicrobials increased risk for hypoglycemia-related hospitalization or emergency department visits.
Methods
Sources of funding: Agency for Health Care Research and Quality and National Institutes of Health.
Design: Retrospective, population-based cohort study, with linkage of several files in the Texas Medicare beneficiaries databases. Setting: Texas, USA. Patients: Medicare Parts A and B beneficiaries ≥ 66 years of age who had overlapping prescriptions for any of 16 antimicrobial agents and glipizide (31 184 patients with 68 186 episodes) or glyburide (30 411 patients with 65 349 episodes). Exclusion criteria included enrollment in an HMO in the year before or 14 days after the antimicrobial filling date or additional prescription for an antimicrobial agent in the 2 weeks after the initial prescription. Risk factors: Exposure to antimicrobial drugs suspected to interact with sulfonylureas (ciprofloxacin, clarithromycin, fluconazole, levofloxacin, metronidazole, moxifloxacin, sulfamethoxazole–trimethoprim). Comparator noninteracting antimicrobial drugs had no evidence of interaction with metabolizing enzymes and had not been linked to hypoglycemia (amoxicillin, azithromycin, cefdinir, cefuroxime, cephalexin, clindamycin, doxycycline, nitrofurantoin, and penicillin V). Outcomes: Hospitalization or emergency department visit for hypoglycemia at 14 days after antimicrobial exposure.
Main results Results for glipizide and glyburide were combined. Ciprofloxacin, clarithromycin, levofloxacin, metronidazole, and sulfamethoxazole–trimethoprim, but not fluconazole or moxifloxacin, were associated with increased risk for hospitalization or emergency department visits for hypoglycemia (Table).
Association between interacting antimicrobial drugs and hospitalization or emergency department visits for hypoglycemia in older glipizide or glyburide users at 14 d* Interacting antimicrobial drugs Clarithromycin
For correspondence: Dr. J.S. Goodwin, University of Texas Medical Branch, Galveston, TX, USA. E-mail [email protected].
Commentary Global prevalence of type 2 diabetes mellitus in elderly persons is increasing. Recent guidelines emphasize the avoidance of hypoglycemic episodes in older persons, even in the absence of symptoms (1), and recommend higher hemoglobin A1c targets than for younger adults (2). Randomized controlled trials often exclude frail elderly patients, who may have polypharmacy and comorbid conditions, and data are usually derived from cohort studies (3). Parekh and colleagues examined the interaction between antimicrobial drugs, sulfonylureas, and risk for hypoglycemia in patients ≥ 66 years of age using Texas Medicare claims data. Bias by indication is likely: The “interacting” antibiotics are used for different indications than the “noninteracting” antibiotics. Because clinical data on infection are lacking, we cannot ascertain the link between hypoglycemia and infection. No adjustment was made for drugs other than antibiotics. Although statistically significant (due to the large numbers), the odds ratios are not large. The results are intriguing enough to warrant a prospective cohort study looking at risk factors for hypoglycemia (including antibiotics and other drugs) in older persons treated with sulfonylureas. Should we change our practice based on the results of this study? Most of the “interacting” antibiotics are given for specific indications (if used correctly), and it is difficult to foresee alternative treatments. A heightened awareness to hypoglycemia in older patients treated with these antibiotics is warranted. We should carefully appraise the balance between potency, side effects, drug interactions, and risk for hypoglycemia when prescribing antidiabetes drugs for older patients (1). Noa Eliakim-Raz, MD Leonard Leibovici, MD Rabin Medical Center, Beilinson Campus Petach-Tikvah, Israel
Adjusted odds ratio (95% CI)† 3.96 (2.42 to 6.49)
Levofloxacin
2.60 (2.18 to 3.10)
Sulfamethoxazole–trimethoprim
2.56 (2.12 to 3.10)
Metronidazole
2.11 (1.28 to 3.47)
Ciprofloxacin
1.62 (1.33 to 1.97)
Moxifloxacin
1.13 (0.65 to 1.98)
Fluconazole
0.92 (0.52 to 1.61)
*CI defined in Glossary. Compared with noninteracting microbial drugs. †Adjusted for age, sex, race/ethnicity, Medicaid eligibility, comorbid conditions, past hypoglycemia emergency department visits, acute hospitalizations in the past year, nursing home residence, and indication for antimicrobial drug use.
References 1. Du YF, Ou HY, Beverly EA, Chiu CJ. Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options. Clin Interv Aging. 2014;9:1963-80. 2. Sinclair AJ, Paolisso G, Castro M, et al; European Diabetes Working Party for Older People. European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus. Executive summary. Diabetes Metab. 2011;37:S27-38. 3. Shorr RI, Ray WA, Daugherty JR, Griffin MR. Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas. Arch Intern Med. 1997;157:1681-6.
17 February 2015 Annals of Internal Medicine ACP Journal Club Downloaded From: http://annals.org/ by a Penn State University Hershey User on 05/27/2015
JC13
姝 2015 American College of Physicians
Some antimicrobials increased admissions and ED visits for hypoglycemia in older users of glipizide or glyburide Clinical impact ratings:
多多多多多多夞
多多多多多多夞
多多多多多多夞
Parekh TM, Raji M, Lin YL, et al. Hypoglycemia after antimicrobial drug prescription for older patients using sulfonylureas. JAMA Intern Med. 2014;174:1605-12.
多多多多多多夞
多多多多多多夞
多多多多多多夞
Question
Conclusion
In older patients who use glipizide or glyburide, does concurrent use of antimicrobials that interact with sulfonylureas increase risk for hypoglycemia?
In older patients receiving glipizide or glyburide, concurrent use of some antimicrobials increased risk for hypoglycemia-related hospitalization or emergency department visits.
Methods
Sources of funding: Agency for Health Care Research and Quality and National Institutes of Health.
Design: Retrospective, population-based cohort study, with linkage of several files in the Texas Medicare beneficiaries databases. Setting: Texas, USA. Patients: Medicare Parts A and B beneficiaries ≥ 66 years of age who had overlapping prescriptions for any of 16 antimicrobial agents and glipizide (31 184 patients with 68 186 episodes) or glyburide (30 411 patients with 65 349 episodes). Exclusion criteria included enrollment in an HMO in the year before or 14 days after the antimicrobial filling date or additional prescription for an antimicrobial agent in the 2 weeks after the initial prescription. Risk factors: Exposure to antimicrobial drugs suspected to interact with sulfonylureas (ciprofloxacin, clarithromycin, fluconazole, levofloxacin, metronidazole, moxifloxacin, sulfamethoxazole–trimethoprim). Comparator noninteracting antimicrobial drugs had no evidence of interaction with metabolizing enzymes and had not been linked to hypoglycemia (amoxicillin, azithromycin, cefdinir, cefuroxime, cephalexin, clindamycin, doxycycline, nitrofurantoin, and penicillin V). Outcomes: Hospitalization or emergency department visit for hypoglycemia at 14 days after antimicrobial exposure.
Main results Results for glipizide and glyburide were combined. Ciprofloxacin, clarithromycin, levofloxacin, metronidazole, and sulfamethoxazole–trimethoprim, but not fluconazole or moxifloxacin, were associated with increased risk for hospitalization or emergency department visits for hypoglycemia (Table).
Association between interacting antimicrobial drugs and hospitalization or emergency department visits for hypoglycemia in older glipizide or glyburide users at 14 d* Interacting antimicrobial drugs Clarithromycin
For correspondence: Dr. J.S. Goodwin, University of Texas Medical Branch, Galveston, TX, USA. E-mail [email protected].
Commentary Global prevalence of type 2 diabetes mellitus in elderly persons is increasing. Recent guidelines emphasize the avoidance of hypoglycemic episodes in older persons, even in the absence of symptoms (1), and recommend higher hemoglobin A1c targets than for younger adults (2). Randomized controlled trials often exclude frail elderly patients, who may have polypharmacy and comorbid conditions, and data are usually derived from cohort studies (3). Parekh and colleagues examined the interaction between antimicrobial drugs, sulfonylureas, and risk for hypoglycemia in patients ≥ 66 years of age using Texas Medicare claims data. Bias by indication is likely: The “interacting” antibiotics are used for different indications than the “noninteracting” antibiotics. Because clinical data on infection are lacking, we cannot ascertain the link between hypoglycemia and infection. No adjustment was made for drugs other than antibiotics. Although statistically significant (due to the large numbers), the odds ratios are not large. The results are intriguing enough to warrant a prospective cohort study looking at risk factors for hypoglycemia (including antibiotics and other drugs) in older persons treated with sulfonylureas. Should we change our practice based on the results of this study? Most of the “interacting” antibiotics are given for specific indications (if used correctly), and it is difficult to foresee alternative treatments. A heightened awareness to hypoglycemia in older patients treated with these antibiotics is warranted. We should carefully appraise the balance between potency, side effects, drug interactions, and risk for hypoglycemia when prescribing antidiabetes drugs for older patients (1). Noa Eliakim-Raz, MD Leonard Leibovici, MD Rabin Medical Center, Beilinson Campus Petach-Tikvah, Israel
Adjusted odds ratio (95% CI)† 3.96 (2.42 to 6.49)
Levofloxacin
2.60 (2.18 to 3.10)
Sulfamethoxazole–trimethoprim
2.56 (2.12 to 3.10)
Metronidazole
2.11 (1.28 to 3.47)
Ciprofloxacin
1.62 (1.33 to 1.97)
Moxifloxacin
1.13 (0.65 to 1.98)
Fluconazole
0.92 (0.52 to 1.61)
*CI defined in Glossary. Compared with noninteracting microbial drugs. †Adjusted for age, sex, race/ethnicity, Medicaid eligibility, comorbid conditions, past hypoglycemia emergency department visits, acute hospitalizations in the past year, nursing home residence, and indication for antimicrobial drug use.
References 1. Du YF, Ou HY, Beverly EA, Chiu CJ. Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options. Clin Interv Aging. 2014;9:1963-80. 2. Sinclair AJ, Paolisso G, Castro M, et al; European Diabetes Working Party for Older People. European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus. Executive summary. Diabetes Metab. 2011;37:S27-38. 3. Shorr RI, Ray WA, Daugherty JR, Griffin MR. Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas. Arch Intern Med. 1997;157:1681-6.
17 February 2015 Annals of Internal Medicine ACP Journal Club Downloaded From: http://annals.org/ by a Penn State University Hershey User on 05/27/2015
JC13
姝 2015 American College of Physicians
