Inpatient Insights
Is β-blocker use at discharge associated with an increased risk in patients with COPD following acute myocardial infarction?
Although β-blockers are associated with decreased mortality in patients with CVD, some patients with COPD who received metoprolol in the BLOCK-COPD trial experienced increased risk of exacerbations requiring hospitalization, raising questions about the overall risk and benefit in patients with COPD following acute myocardial infarction (MI).
To investigate this question, LaFon and colleagues conducted a prospective, longitudinal cohort study with 6 months of follow-up for enrolled patients aged 35 years or older with COPD who underwent cardiac catheterization for acute MI at 18 BLOCK-COPD network hospitals in the United States from June 2020 through May 2022.
The primary outcome was time to the composite outcome of death or all-cause hospitalization or revascularization. Of 502 patients with COPD and acute MI who were prescribed a β-blocker at discharge, there was no increased risk of the primary end point of all-cause mortality, revascularization, hospitalization, cardiovascular events, COPD-related or respiratory events, or treatment for COPD exacerbations. The study was published in JAMA Network Open on May 21, 2024.
The authors suggest that their results add valuable context to the findings of the BLOCK-COPD trial, which observed increased risk of hospitalization for exacerbations among individuals with COPD with high exacerbation risk who received metoprolol. Although potential harm in selected patients cannot be ruled out, they suggest that their findings support the continued use of β-blockers among patients with COPD who have experienced acute MI. ■
Antihypertensive medication may increase fracture risk in older nursing home residents
Limited information is available on the association between initiation of antihypertensive medication and risk of fractures in older, long-term nursing home residents.
In a study published in the June 2024 JAMA issue, Dave and colleagues conducted a retrospective cohort study using target trial emulation for data derived from almost 30,000 older long-term care Veterans Health Administration nursing home residents from January 1, 2006, to October 31, 2019. Episodes of antihypertensive medication initiation were identified, and eligible initiation episodes were matched with comparable controls who did not initiate therapy.
The primary outcome was nontraumatic fracture of the humerus, hip, pelvis, radius, or ulna within 30 days of antihypertensive medication initiation. Results were computed among subgroups of residents with dementia, across systolic and diastolic BP thresholds of 140 mm Hg and 80 mm Hg, respectively, and with use of prior antihypertensive therapies. In the propensity score–matched cohort, the incidence rate of fractures per 100 person-years in residents initiating antihypertensive medication was 5.4 compared with 2.2 in the control arm. Antihypertensive medication initiation was also associated with higher risk of severe falls requiring hospitalizations or emergency department visits and syncope. Fracture risk was higher among subgroups of residents with dementia, systolic BP of 140 mm Hg or higher, diastolic BP of 80 mm Hg or higher, and no recent antihypertensive medication use.
The authors suggest that given the widespread use of antihypertension medication in older adults, any observed association with fracture risk has significant implications for clinical medicine and public health. They emphasize the need for caution and additional monitoring when initiating antihypertensive medication in this vulnerable population. ■
SGLT2 inhibitors show promise for use in solid organ transplant recipients
SGLT2 inhibitors are commonly used for the treatment of diabetes and for their cardiovascular and kidney benefits in patients with or without diabetes. However, use in solid organ transplant recipients is controversial because transplant recipients were excluded from the major clinical trials assessing SGLT2 inhibitors. A study published in Pharmacotherapy on May 21, 2024, assessed the available literature for data on the efficacy and safety of SGLT2 inhibitor use in solid organ transplant recipients and identified knowledge gaps based on the data present.
Studies were excluded if they were meta-analyses, review articles, commentaries, single case reports, or in vitro studies, or did not involve the use of SGLT2 inhibitors in solid organ transplant recipients with a diabetic, cardiovascular, or kidney outcome being assessed. Analysis of 20 studies showed that the use of SGLT2 inhibitors in solid organ transplant recipients seems to have a similar A1C-lowering effect in solid organ transplant recipients when compared to the general population. Additionally, the use of SGLT2 inhibitors in transplant recipients does not seem to increase the rate of adverse event rates compared with the general patient population.
The authors suggest that based on currently available data, an SGLT2 inhibitor could be considered for use for diabetes in solid organ transplant recipients at 1 year after transplant. Earlier use could be considered; however, extra caution surrounding patient-specific factors, including recent UTI history, surgical needs, kidney function, and current immunosuppression would need to be considered prior to initiation. They note that although SGLT2 inhibitors seem to be a safe option short term, no studies have assessed the cardiovascular and renal protective effects of SGLT2 inhibitors in solid organ transplant recipients, and future studies should assess the use of SGLT2 inhibitors for longer periods of time and focus on assessing the potential cardiovascular and kidney benefits in solid organ transplant recipients. Additionally, the impact of transplant-specific characteristics including renal function post-transplant, tacrolimus levels, and overall immunosuppression on SGLT2 inhibitor outcomes post-initiation should be researched. ■
Use of one-time I.V. antibiotics in the emergency department adds cost but not benefit
Although research shows that one-time doses of I.V. antibiotics do not improve resolution of infection, providers continue to use them, especially in the emergency department (ED). In a recent study published in JAPhA on May 3, 2024, researchers at Veteran Health Indiana evaluated the difference in average total cost of an ED stay between patients who received a one-time dose of I.V. antibiotics in the ED before discharge on oral antibiotics and patients who were only discharged on oral antibiotics. Secondary objectives were to evaluate the differences in durations of stay between the two groups, as well as the differences in adverse drug effects and need for health care contact after discharge.
Chart reviews identified patients who received and did not receive a one-time dose of I.V. antibiotics in the ED between April 30, 2020, and April 30, 2022, and a micro-costing approach was used to determine ED-associated costs per patient. A total of 102 patients were analyzed in each group.
Patients who received a one-time dose of intravenous antibiotics in the ED before being discharged on oral antibiotics had an average length of stay of 4.55 hours, compared to an average length of stay of 2.82 hours for patients who did not receive a one-time dose of I.V. antibiotics before being discharged on oral antibiotics. One-time dosing of I.V. antibiotics in the ED incurred an additional cost of approximately $556 per patient, totaling over $56,000 in our study cohort.
The authors concluded that the use of one-time intravenous antibiotics in the ED did not confer any additional benefits to patients but resulted in significantly reduced throughput in the ED and increased health care costs. ■