Chronic pain, defined as pain lasting longer than 3 to 6 months in duration, affects about 100 million Americans.¹ The use of opioids in the management of chronic nonmalignant pain is common in primary care. The U.S., with only 5% of the global population, nevertheless is the world’s leading opioid consumer.² For example, it is estimated that the U.S. consumes 56% of the global supply of morphine, 99% of hydrocodone, and 83% of oxycodone; this consumption is a growing problem in the use of chronic opioid therapy in managing chronic nonmalignant pain.^2,3 The high rates of use of opioids continues, despite a lack of solid evidence on the long-term effectiveness of opioids for managing chronic nonmalignant pain and on the associated risks of opioid addiction, abuse, and misuse.^3,4 Among veterans, the prevalence of opioid abuse and misuse has been reported to be about 30%, a nearly 7-fold occurrence compared with that in the general population.^5,6

Due to the pervasiveness of opioid abuse and misuse among veterans, a project was initiated to develop, implement, and evaluate an Opioid Monitoring Clinic (OMC) as a clinical referral system within the primary care service of the VA Southern Nevada Healthcare System (VASNHS) in North Las Vegas. A health care provider (HCP) needs assessment was conducted at the facility, resulting in recommendations to improve adherence to evidence-based clinical practice guidelines in opioid management and regular monitoring of veterans on chronic opioid therapy for the identification of opioid abuse and misuse. Based on the results, an advanced practice registered nurse (APRN) in consultation with the chief of primary care at VASNHS and teamlet support (a registered nurse, licensed practical nurse, and medical support assistant) started the OMC. The OMC was developed consistent with the 2010 VA/DoD clinical practice guidelines for managing opioid therapy for chronic pain.⁷

After 6 months of OMC operation, the project also was evaluated for efficacy. First, a retrospective chart review of participants was conducted to identify the use of opioid pain agreements, prescription drug monitoring programs (PDMP) for controlled substance use review, and urine drug screens (UDSs). The chart review also included the average daily morphine equivalent dose (MED) for patients and OMC retention rates. Second, an online survey of primary care providers (PCPs) assessed their adherence to evidence-based guidelines in opioid management and satisfaction of the OMC services.

Background

In 1997, the average sales and distribution of opioids in the U.S. was 96 mg MED per individual, which increased to 710 mg per individual in 2010.^8,9 The MED is a standardized daily dose measure for all opioids.¹⁰ At VASNHS North Las Vegas, there were 5,881 patients on opioid therapy in 2013 with about 13% of patients on opioid therapy using about 100 mg MED/d. The potential for abuse and misuse was great. Almost 30% of patients on chronic opioid therapy for chronic nonmalignant pain abuse their opioid prescriptions.^5,7 Subsequently, opioid analgesics were responsible for nearly 60% of overdose deaths in 2010.¹¹

In 2010, there were about 12 million people in the U.S. who abused or misused prescription opioids, using them for nonmedical reasons; annually, the prevalence rate of Americans who abuse and misuse opioids is about 2 million people.¹² The 5-year prevalence rate of opioid abuse among veterans is at least 3%.⁶ This results in health care expenditures with an average excess medical cost of $20,546 per year for patients who misuse opioids compared with those who do not.¹³ The economic burden among veterans is even higher. Baser and colleagues reported that the annual economic cost for veterans who abused their opioid prescriptions was nearly $29,000.⁶

Unfortunately, injudicious opioid prescribing by HCPs is often cited as a contributor to the growing problem of opioid abuse and misuse in the U.S.¹⁴ Health care provider education on the proper and judicious use of opioids and adherence to clinical practice guidelines in the management of chronic pain is a crucial factor in reducing the complications of chron

Method

This project evaluated the APRN-led OMC with both quantitative and qualitative data from patients and PCPs. The OMC was implemented at VASNHS North Las Vegas, which serves almost 60,000 veterans. Patients referred to the OMC who were eligible for admission were veterans aged ≥ 18 years, who had chronic nonmalignant pain for at least 3 months, were receiving chronic opioid therapy, and were considered high risk for abuse or misuse of opioids. Patients were considered high risk if they had documented aberrant behaviors, such as multiple early refill requests, history of lost medications, drug screens not showing prescribed opioid(s), positive drug screens for controlled substance not prescribed, nonadherence with plan of care, or a history of substance abuse, including alcohol, cocaine, heroin, and marijuana. Veterans found to be suicidal or homicidal were excluded from the OMC and instead were referred to appropriate specialty care for further evaluation. A total of 61 veteran participants were successfully recruited.

Primary care physicians, physician assistants, and APRNs working at VASNHS on a full-time and part-time basis were eligible for participation as PCPs in this project. Thirty of 42 eligible PCPs participated and responded to the secure online provider survey (71% response rate).

Risks and benefits were discussed, and a written informed consent was obtained for each participant. There were no apparent risks or adverse effects encountered during project implementation and evaluation. Prior to data collection, permission for the study was obtained from the VA facility. An institutional review board application through the University of Nevada, Las Vegas’ Office of Research Integrity-Human Subjects was also submitted and approved through an expedited review.

Results

Table 1 details patient data, including demographics on the veteran participants. The av

Review of PDMPs revealed that 20% of the participants received controlled substances from other HCPs. Consequently, all OMC patients completed and had reinforced OPAs that served 2 purposes. First, the content in the agreement provided patient education regarding the potential hazards of opioid use. Second, the content provided specific expectations from the patient if opioid therapy is continued, including opioid risk reduction strategies (ie, random UDSs and pill counts, PDMP for controlled substance utilization review), and the consequences of lack of adherence to opioid management.

The majority of patients remained as patients and continued to be monitored after 6 months at the OMC (Table 2). However, only 64% were retained in the OMC, in large part because 36% had their opioids discontinued due to discovery of active illicit substance use, opioi

The mean MED/d among OMC participants was 54 mg/d before admission, which decreased gradually to 22 mg/d after 6 months of OMC care; this represented a 59% MED reduction (Table 3). Using the exact single-tailed Wilcoxon signed rank

Primary Care Providers

Based on the survey of PCPs, 40% of respondents referred at least 1 patient to the OMC. The majority (90%) acknowledged following the VA/DoD guidelines for opioid management, with 80% using an OPA more than usual since the implementation of the OMC, and 54% routinely accessing a PDMP for controlled substance utilization review. Moreover, 93% of PCPs routinely ordered a UDS when indicated.

For 3 months prior to opening the OMC in 2013, 1,606 UDSs were ordered at VASNHS. The UDS number steadily increased, and 6 months after opening the OMC, UDSs increased to 2,293 from months 4 to 6, representing a 30% increase. This was an expected outcome from the OMC—more PCPs now were following the VA/DoD clinical practice guidelines regarding the monitoring of patients on chronic opioid therapy.

A survey assessed the level of satisfaction among PCPs who had referred their patients to the OMC. Although only 11 PCPs responded to this question, a large majority found the OMC to have a positive effect on primary care services; many noted receiving fewer complaints regarding pain medications and fewer walk-ins. The majority recognized the advantage of the OMC in facilitating more PCP time for managing other medical problems beyond opioid use, which tends to be challenging and time consuming. Overall, 100% were satisfied with the OMC service.

Finally, 82% of PCPs reported that the OMC referral process did not need improvement. Two PCPs (18%) left positive feedback, reporting that the OMC was “simple, easy and accessible” and that the referral process “so far, it is great.” Another PCP noted, “I want patients who are suicidal but still need pain control with narcotics to be addressed.”

Discussion

The OMC has shown great promise in identifying abuse and misuse of opioids through evidence-based guidelines and risk-mitigation strategies. In the past, VA clinics specifically focused on opioid renewal have been implemented. In 2002, the Philadelphia VAMC opened an opioid renewal clinic (ORC) to assist PCPs in the management of patients with chronic pain on chronic opioid therapy.¹⁵ The Philadelphia VAMC ORC was operated collaboratively by PCPs and Pharmacy Service. They reported that 51% of their patients initially had documented aberrant behaviors, and 45% of these patients resolved their aberrant behaviors through intensive opioid monitoring using random UDSs.¹⁴ Thirteen percent of their patients were found to have an opioid addiction disorder and eventually were referred to addiction treatment; and 4% were weaned off opioids due to consistently negative UDSs.¹⁴

In the same manner, the OMC has effectively identified patients who abused and misused their opioids and consequently referred these patients for pain interventional management or to the VASNHS alcohol and drug treatment program as appropriate, which falls under the VASNHS Mental Health Care line, a service that is vital for veterans who are suicidal and homicidal. The importance of mental health care cannot be understated, as many patients with chronic pain also experience mental health challenges.

The Malcom Randall VAMC in Gainesville, Florida, structured a nurse-led, multidisciplinary ORC in 2003.¹⁶ A retrospective review of their program showed that 33% of patients had a positive UDS for marijuana, cocaine, or alcohol. The ORC had increased patient involvement in substance abuse treatment, resulting in some patients taking lower opioid dosages than before.

The New York Harbor VAMC reduced opioid cost by effectively switching veterans on expensive long-acting opioids, such as oxycodone and fentanyl, to less expensive alternatives, such a long-acting morphine.¹⁷ A secondary purpose of the New York initiative was to reduce the potential for inappropriate use of expensive long-acting opioids. Accordingly, the initiative reduced the number of expensive long-acting and potentially inappropriate opioids from 165 to 69 prescriptions in less than 6 months (November 2007 through March 2008). Similarly, after 6 months of operation, the OMC significantly reduced opioid prescription from 54 mg to 22 MED/d. This reduction represents a significant pharmacy cost savings. The combination of the discontinuation of opioids for patients found to be abusing and misusing opioids coupled with the decrease in pill burden resulting from changes from short-acting to long-acting opioids also resulted in significant savings for VA facilities.

The impact of the OMC on PCP adherence to opioid management guidelines as well as PCP satisfaction with the OMC services was significant. Similarly, Wiedemer and colleagues found significant PCP satisfaction with the ORC.¹⁵ The ability to spend more time with patients on other medical problems while allowing the OMC to focus on opioid and pain management was found to be beneficial. Buy-in among PCPs coupled with their concerns for chronic opioid therapy for high-risk patients facilitated the success of the OMC. The commitment of the VASNHS leadership to the OMC and their support for the APRN in leading this initiative were important facilitators in the success of the OMC.

Limitations

Long-term evaluation of the OMC with a larger sample is needed to fully evaluate its impact on decreasing opioid misuse and abuse. This project was limited by a small sample size, although the results are promising. Pharmacy costs, emergency department visits, as well as patient satisfaction, physical and emotional function, and pain levels are outcomes that need to be considered over the long term. Incorporating mental health counseling, cognitive behavior therapy, self-management programs, and group educational sessions have the potential to be important OMC services. The continued success and cost-effectiveness of the OMC can be a potentially significant model for this type of service that can be applied to clinics outside the VA system.

Implications

Possible implications to practice settings that are considering an OMC or ORC include the chance that patients will want to be discharged from such a clinic and return to the PCP for opioid management. Collaborative relationships and communication between PCPs and OMC providers are important to facilitate adherence and consistency with pain care. Collaboration and effective communication can be facilitated by electronic recording and reporting. For example, the VA Computerized Patient Record System can alert PCPs to patient discharges from the OMC along with OMC provider recommendations for patient care. Another challenge for the OMC would be a lack of referrals for patients who are at high risk for opioid abuse or misuse. These challenges can be mitigated by providing in-services, educational flyers, and advertisement promotions regarding OMC services. With the high prevalence of opioid abuse and misuse as well as the subsequent exorbitant health-related costs and deaths associated with opioids, OMCs and ORCs are viable options for improving opioid management in the treatment of patients with nonmalignant chronic pain.

Conclusion

The OMC effectively reduced the MED of patients referred to the clinic by 59%. The significant reduction in the opioid dose of patients referred to the OMC resulted from the implementation of evidence-based strategies that were used to identify abuse of prescription opioids, the use of illicit substances that can cause opioid-related complications, and the discovery of doctor shopping, coupled with gradual dose reductions for patients when appropriate. Provider satisfaction and increased use of evidence-based guidelines in opioid management and risk mitigation strategies, such as OPAs, PDMP databases, and UDS were evident. These results suggest that an OMC can be an effective program to help identify abuse and misuse of prescription opioids among high-risk patients and can improve patient safety and provider satisfaction.

Acknowledgments
This material is the result of work supported with resources and the use of facilities at the VA Southern Nevada Healthcare System.

Chronic pain, defined as pain lasting longer than 3 to 6 months in duration, affects about 100 million Americans.¹ The use of opioids in the management of chronic nonmalignant pain is common in primary care. The U.S., with only 5% of the global population, nevertheless is the world’s leading opioid consumer.² For example, it is estimated that the U.S. consumes 56% of the global supply of morphine, 99% of hydrocodone, and 83% of oxycodone; this consumption is a growing problem in the use of chronic opioid therapy in managing chronic nonmalignant pain.^2,3 The high rates of use of opioids continues, despite a lack of solid evidence on the long-term effectiveness of opioids for managing chronic nonmalignant pain and on the associated risks of opioid addiction, abuse, and misuse.^3,4 Among veterans, the prevalence of opioid abuse and misuse has been reported to be about 30%, a nearly 7-fold occurrence compared with that in the general population.^5,6

Due to the pervasiveness of opioid abuse and misuse among veterans, a project was initiated to develop, implement, and evaluate an Opioid Monitoring Clinic (OMC) as a clinical referral system within the primary care service of the VA Southern Nevada Healthcare System (VASNHS) in North Las Vegas. A health care provider (HCP) needs assessment was conducted at the facility, resulting in recommendations to improve adherence to evidence-based clinical practice guidelines in opioid management and regular monitoring of veterans on chronic opioid therapy for the identification of opioid abuse and misuse. Based on the results, an advanced practice registered nurse (APRN) in consultation with the chief of primary care at VASNHS and teamlet support (a registered nurse, licensed practical nurse, and medical support assistant) started the OMC. The OMC was developed consistent with the 2010 VA/DoD clinical practice guidelines for managing opioid therapy for chronic pain.⁷

After 6 months of OMC operation, the project also was evaluated for efficacy. First, a retrospective chart review of participants was conducted to identify the use of opioid pain agreements, prescription drug monitoring programs (PDMP) for controlled substance use review, and urine drug screens (UDSs). The chart review also included the average daily morphine equivalent dose (MED) for patients and OMC retention rates. Second, an online survey of primary care providers (PCPs) assessed their adherence to evidence-based guidelines in opioid management and satisfaction of the OMC services.

Background

In 1997, the average sales and distribution of opioids in the U.S. was 96 mg MED per individual, which increased to 710 mg per individual in 2010.^8,9 The MED is a standardized daily dose measure for all opioids.¹⁰ At VASNHS North Las Vegas, there were 5,881 patients on opioid therapy in 2013 with about 13% of patients on opioid therapy using about 100 mg MED/d. The potential for abuse and misuse was great. Almost 30% of patients on chronic opioid therapy for chronic nonmalignant pain abuse their opioid prescriptions.^5,7 Subsequently, opioid analgesics were responsible for nearly 60% of overdose deaths in 2010.¹¹

In 2010, there were about 12 million people in the U.S. who abused or misused prescription opioids, using them for nonmedical reasons; annually, the prevalence rate of Americans who abuse and misuse opioids is about 2 million people.¹² The 5-year prevalence rate of opioid abuse among veterans is at least 3%.⁶ This results in health care expenditures with an average excess medical cost of $20,546 per year for patients who misuse opioids compared with those who do not.¹³ The economic burden among veterans is even higher. Baser and colleagues reported that the annual economic cost for veterans who abused their opioid prescriptions was nearly $29,000.⁶

Unfortunately, injudicious opioid prescribing by HCPs is often cited as a contributor to the growing problem of opioid abuse and misuse in the U.S.¹⁴ Health care provider education on the proper and judicious use of opioids and adherence to clinical practice guidelines in the management of chronic pain is a crucial factor in reducing the complications of chron

Method

This project evaluated the APRN-led OMC with both quantitative and qualitative data from patients and PCPs. The OMC was implemented at VASNHS North Las Vegas, which serves almost 60,000 veterans. Patients referred to the OMC who were eligible for admission were veterans aged ≥ 18 years, who had chronic nonmalignant pain for at least 3 months, were receiving chronic opioid therapy, and were considered high risk for abuse or misuse of opioids. Patients were considered high risk if they had documented aberrant behaviors, such as multiple early refill requests, history of lost medications, drug screens not showing prescribed opioid(s), positive drug screens for controlled substance not prescribed, nonadherence with plan of care, or a history of substance abuse, including alcohol, cocaine, heroin, and marijuana. Veterans found to be suicidal or homicidal were excluded from the OMC and instead were referred to appropriate specialty care for further evaluation. A total of 61 veteran participants were successfully recruited.

Primary care physicians, physician assistants, and APRNs working at VASNHS on a full-time and part-time basis were eligible for participation as PCPs in this project. Thirty of 42 eligible PCPs participated and responded to the secure online provider survey (71% response rate).

Risks and benefits were discussed, and a written informed consent was obtained for each participant. There were no apparent risks or adverse effects encountered during project implementation and evaluation. Prior to data collection, permission for the study was obtained from the VA facility. An institutional review board application through the University of Nevada, Las Vegas’ Office of Research Integrity-Human Subjects was also submitted and approved through an expedited review.

Results

Table 1 details patient data, including demographics on the veteran participants. The av

Review of PDMPs revealed that 20% of the participants received controlled substances from other HCPs. Consequently, all OMC patients completed and had reinforced OPAs that served 2 purposes. First, the content in the agreement provided patient education regarding the potential hazards of opioid use. Second, the content provided specific expectations from the patient if opioid therapy is continued, including opioid risk reduction strategies (ie, random UDSs and pill counts, PDMP for controlled substance utilization review), and the consequences of lack of adherence to opioid management.

The majority of patients remained as patients and continued to be monitored after 6 months at the OMC (Table 2). However, only 64% were retained in the OMC, in large part because 36% had their opioids discontinued due to discovery of active illicit substance use, opioi

The mean MED/d among OMC participants was 54 mg/d before admission, which decreased gradually to 22 mg/d after 6 months of OMC care; this represented a 59% MED reduction (Table 3). Using the exact single-tailed Wilcoxon signed rank

Primary Care Providers

Based on the survey of PCPs, 40% of respondents referred at least 1 patient to the OMC. The majority (90%) acknowledged following the VA/DoD guidelines for opioid management, with 80% using an OPA more than usual since the implementation of the OMC, and 54% routinely accessing a PDMP for controlled substance utilization review. Moreover, 93% of PCPs routinely ordered a UDS when indicated.

For 3 months prior to opening the OMC in 2013, 1,606 UDSs were ordered at VASNHS. The UDS number steadily increased, and 6 months after opening the OMC, UDSs increased to 2,293 from months 4 to 6, representing a 30% increase. This was an expected outcome from the OMC—more PCPs now were following the VA/DoD clinical practice guidelines regarding the monitoring of patients on chronic opioid therapy.

A survey assessed the level of satisfaction among PCPs who had referred their patients to the OMC. Although only 11 PCPs responded to this question, a large majority found the OMC to have a positive effect on primary care services; many noted receiving fewer complaints regarding pain medications and fewer walk-ins. The majority recognized the advantage of the OMC in facilitating more PCP time for managing other medical problems beyond opioid use, which tends to be challenging and time consuming. Overall, 100% were satisfied with the OMC service.

Finally, 82% of PCPs reported that the OMC referral process did not need improvement. Two PCPs (18%) left positive feedback, reporting that the OMC was “simple, easy and accessible” and that the referral process “so far, it is great.” Another PCP noted, “I want patients who are suicidal but still need pain control with narcotics to be addressed.”

Discussion

The OMC has shown great promise in identifying abuse and misuse of opioids through evidence-based guidelines and risk-mitigation strategies. In the past, VA clinics specifically focused on opioid renewal have been implemented. In 2002, the Philadelphia VAMC opened an opioid renewal clinic (ORC) to assist PCPs in the management of patients with chronic pain on chronic opioid therapy.¹⁵ The Philadelphia VAMC ORC was operated collaboratively by PCPs and Pharmacy Service. They reported that 51% of their patients initially had documented aberrant behaviors, and 45% of these patients resolved their aberrant behaviors through intensive opioid monitoring using random UDSs.¹⁴ Thirteen percent of their patients were found to have an opioid addiction disorder and eventually were referred to addiction treatment; and 4% were weaned off opioids due to consistently negative UDSs.¹⁴

In the same manner, the OMC has effectively identified patients who abused and misused their opioids and consequently referred these patients for pain interventional management or to the VASNHS alcohol and drug treatment program as appropriate, which falls under the VASNHS Mental Health Care line, a service that is vital for veterans who are suicidal and homicidal. The importance of mental health care cannot be understated, as many patients with chronic pain also experience mental health challenges.

The Malcom Randall VAMC in Gainesville, Florida, structured a nurse-led, multidisciplinary ORC in 2003.¹⁶ A retrospective review of their program showed that 33% of patients had a positive UDS for marijuana, cocaine, or alcohol. The ORC had increased patient involvement in substance abuse treatment, resulting in some patients taking lower opioid dosages than before.

The New York Harbor VAMC reduced opioid cost by effectively switching veterans on expensive long-acting opioids, such as oxycodone and fentanyl, to less expensive alternatives, such a long-acting morphine.¹⁷ A secondary purpose of the New York initiative was to reduce the potential for inappropriate use of expensive long-acting opioids. Accordingly, the initiative reduced the number of expensive long-acting and potentially inappropriate opioids from 165 to 69 prescriptions in less than 6 months (November 2007 through March 2008). Similarly, after 6 months of operation, the OMC significantly reduced opioid prescription from 54 mg to 22 MED/d. This reduction represents a significant pharmacy cost savings. The combination of the discontinuation of opioids for patients found to be abusing and misusing opioids coupled with the decrease in pill burden resulting from changes from short-acting to long-acting opioids also resulted in significant savings for VA facilities.

The impact of the OMC on PCP adherence to opioid management guidelines as well as PCP satisfaction with the OMC services was significant. Similarly, Wiedemer and colleagues found significant PCP satisfaction with the ORC.¹⁵ The ability to spend more time with patients on other medical problems while allowing the OMC to focus on opioid and pain management was found to be beneficial. Buy-in among PCPs coupled with their concerns for chronic opioid therapy for high-risk patients facilitated the success of the OMC. The commitment of the VASNHS leadership to the OMC and their support for the APRN in leading this initiative were important facilitators in the success of the OMC.

Limitations

Long-term evaluation of the OMC with a larger sample is needed to fully evaluate its impact on decreasing opioid misuse and abuse. This project was limited by a small sample size, although the results are promising. Pharmacy costs, emergency department visits, as well as patient satisfaction, physical and emotional function, and pain levels are outcomes that need to be considered over the long term. Incorporating mental health counseling, cognitive behavior therapy, self-management programs, and group educational sessions have the potential to be important OMC services. The continued success and cost-effectiveness of the OMC can be a potentially significant model for this type of service that can be applied to clinics outside the VA system.

Implications

Possible implications to practice settings that are considering an OMC or ORC include the chance that patients will want to be discharged from such a clinic and return to the PCP for opioid management. Collaborative relationships and communication between PCPs and OMC providers are important to facilitate adherence and consistency with pain care. Collaboration and effective communication can be facilitated by electronic recording and reporting. For example, the VA Computerized Patient Record System can alert PCPs to patient discharges from the OMC along with OMC provider recommendations for patient care. Another challenge for the OMC would be a lack of referrals for patients who are at high risk for opioid abuse or misuse. These challenges can be mitigated by providing in-services, educational flyers, and advertisement promotions regarding OMC services. With the high prevalence of opioid abuse and misuse as well as the subsequent exorbitant health-related costs and deaths associated with opioids, OMCs and ORCs are viable options for improving opioid management in the treatment of patients with nonmalignant chronic pain.

Conclusion

The OMC effectively reduced the MED of patients referred to the clinic by 59%. The significant reduction in the opioid dose of patients referred to the OMC resulted from the implementation of evidence-based strategies that were used to identify abuse of prescription opioids, the use of illicit substances that can cause opioid-related complications, and the discovery of doctor shopping, coupled with gradual dose reductions for patients when appropriate. Provider satisfaction and increased use of evidence-based guidelines in opioid management and risk mitigation strategies, such as OPAs, PDMP databases, and UDS were evident. These results suggest that an OMC can be an effective program to help identify abuse and misuse of prescription opioids among high-risk patients and can improve patient safety and provider satisfaction.

Acknowledgments
This material is the result of work supported with resources and the use of facilities at the VA Southern Nevada Healthcare System.

Chronic pain, defined as pain lasting longer than 3 to 6 months in duration, affects about 100 million Americans.¹ The use of opioids in the management of chronic nonmalignant pain is common in primary care. The U.S., with only 5% of the global population, nevertheless is the world’s leading opioid consumer.² For example, it is estimated that the U.S. consumes 56% of the global supply of morphine, 99% of hydrocodone, and 83% of oxycodone; this consumption is a growing problem in the use of chronic opioid therapy in managing chronic nonmalignant pain.^2,3 The high rates of use of opioids continues, despite a lack of solid evidence on the long-term effectiveness of opioids for managing chronic nonmalignant pain and on the associated risks of opioid addiction, abuse, and misuse.^3,4 Among veterans, the prevalence of opioid abuse and misuse has been reported to be about 30%, a nearly 7-fold occurrence compared with that in the general population.^5,6

Due to the pervasiveness of opioid abuse and misuse among veterans, a project was initiated to develop, implement, and evaluate an Opioid Monitoring Clinic (OMC) as a clinical referral system within the primary care service of the VA Southern Nevada Healthcare System (VASNHS) in North Las Vegas. A health care provider (HCP) needs assessment was conducted at the facility, resulting in recommendations to improve adherence to evidence-based clinical practice guidelines in opioid management and regular monitoring of veterans on chronic opioid therapy for the identification of opioid abuse and misuse. Based on the results, an advanced practice registered nurse (APRN) in consultation with the chief of primary care at VASNHS and teamlet support (a registered nurse, licensed practical nurse, and medical support assistant) started the OMC. The OMC was developed consistent with the 2010 VA/DoD clinical practice guidelines for managing opioid therapy for chronic pain.⁷

After 6 months of OMC operation, the project also was evaluated for efficacy. First, a retrospective chart review of participants was conducted to identify the use of opioid pain agreements, prescription drug monitoring programs (PDMP) for controlled substance use review, and urine drug screens (UDSs). The chart review also included the average daily morphine equivalent dose (MED) for patients and OMC retention rates. Second, an online survey of primary care providers (PCPs) assessed their adherence to evidence-based guidelines in opioid management and satisfaction of the OMC services.

Background

In 1997, the average sales and distribution of opioids in the U.S. was 96 mg MED per individual, which increased to 710 mg per individual in 2010.^8,9 The MED is a standardized daily dose measure for all opioids.¹⁰ At VASNHS North Las Vegas, there were 5,881 patients on opioid therapy in 2013 with about 13% of patients on opioid therapy using about 100 mg MED/d. The potential for abuse and misuse was great. Almost 30% of patients on chronic opioid therapy for chronic nonmalignant pain abuse their opioid prescriptions.^5,7 Subsequently, opioid analgesics were responsible for nearly 60% of overdose deaths in 2010.¹¹

In 2010, there were about 12 million people in the U.S. who abused or misused prescription opioids, using them for nonmedical reasons; annually, the prevalence rate of Americans who abuse and misuse opioids is about 2 million people.¹² The 5-year prevalence rate of opioid abuse among veterans is at least 3%.⁶ This results in health care expenditures with an average excess medical cost of $20,546 per year for patients who misuse opioids compared with those who do not.¹³ The economic burden among veterans is even higher. Baser and colleagues reported that the annual economic cost for veterans who abused their opioid prescriptions was nearly $29,000.⁶

Unfortunately, injudicious opioid prescribing by HCPs is often cited as a contributor to the growing problem of opioid abuse and misuse in the U.S.¹⁴ Health care provider education on the proper and judicious use of opioids and adherence to clinical practice guidelines in the management of chronic pain is a crucial factor in reducing the complications of chron

Method

This project evaluated the APRN-led OMC with both quantitative and qualitative data from patients and PCPs. The OMC was implemented at VASNHS North Las Vegas, which serves almost 60,000 veterans. Patients referred to the OMC who were eligible for admission were veterans aged ≥ 18 years, who had chronic nonmalignant pain for at least 3 months, were receiving chronic opioid therapy, and were considered high risk for abuse or misuse of opioids. Patients were considered high risk if they had documented aberrant behaviors, such as multiple early refill requests, history of lost medications, drug screens not showing prescribed opioid(s), positive drug screens for controlled substance not prescribed, nonadherence with plan of care, or a history of substance abuse, including alcohol, cocaine, heroin, and marijuana. Veterans found to be suicidal or homicidal were excluded from the OMC and instead were referred to appropriate specialty care for further evaluation. A total of 61 veteran participants were successfully recruited.

Primary care physicians, physician assistants, and APRNs working at VASNHS on a full-time and part-time basis were eligible for participation as PCPs in this project. Thirty of 42 eligible PCPs participated and responded to the secure online provider survey (71% response rate).

Risks and benefits were discussed, and a written informed consent was obtained for each participant. There were no apparent risks or adverse effects encountered during project implementation and evaluation. Prior to data collection, permission for the study was obtained from the VA facility. An institutional review board application through the University of Nevada, Las Vegas’ Office of Research Integrity-Human Subjects was also submitted and approved through an expedited review.

Results

Table 1 details patient data, including demographics on the veteran participants. The av

Review of PDMPs revealed that 20% of the participants received controlled substances from other HCPs. Consequently, all OMC patients completed and had reinforced OPAs that served 2 purposes. First, the content in the agreement provided patient education regarding the potential hazards of opioid use. Second, the content provided specific expectations from the patient if opioid therapy is continued, including opioid risk reduction strategies (ie, random UDSs and pill counts, PDMP for controlled substance utilization review), and the consequences of lack of adherence to opioid management.

The majority of patients remained as patients and continued to be monitored after 6 months at the OMC (Table 2). However, only 64% were retained in the OMC, in large part because 36% had their opioids discontinued due to discovery of active illicit substance use, opioi

The mean MED/d among OMC participants was 54 mg/d before admission, which decreased gradually to 22 mg/d after 6 months of OMC care; this represented a 59% MED reduction (Table 3). Using the exact single-tailed Wilcoxon signed rank

Primary Care Providers

Based on the survey of PCPs, 40% of respondents referred at least 1 patient to the OMC. The majority (90%) acknowledged following the VA/DoD guidelines for opioid management, with 80% using an OPA more than usual since the implementation of the OMC, and 54% routinely accessing a PDMP for controlled substance utilization review. Moreover, 93% of PCPs routinely ordered a UDS when indicated.

For 3 months prior to opening the OMC in 2013, 1,606 UDSs were ordered at VASNHS. The UDS number steadily increased, and 6 months after opening the OMC, UDSs increased to 2,293 from months 4 to 6, representing a 30% increase. This was an expected outcome from the OMC—more PCPs now were following the VA/DoD clinical practice guidelines regarding the monitoring of patients on chronic opioid therapy.

A survey assessed the level of satisfaction among PCPs who had referred their patients to the OMC. Although only 11 PCPs responded to this question, a large majority found the OMC to have a positive effect on primary care services; many noted receiving fewer complaints regarding pain medications and fewer walk-ins. The majority recognized the advantage of the OMC in facilitating more PCP time for managing other medical problems beyond opioid use, which tends to be challenging and time consuming. Overall, 100% were satisfied with the OMC service.

Finally, 82% of PCPs reported that the OMC referral process did not need improvement. Two PCPs (18%) left positive feedback, reporting that the OMC was “simple, easy and accessible” and that the referral process “so far, it is great.” Another PCP noted, “I want patients who are suicidal but still need pain control with narcotics to be addressed.”

Discussion

The OMC has shown great promise in identifying abuse and misuse of opioids through evidence-based guidelines and risk-mitigation strategies. In the past, VA clinics specifically focused on opioid renewal have been implemented. In 2002, the Philadelphia VAMC opened an opioid renewal clinic (ORC) to assist PCPs in the management of patients with chronic pain on chronic opioid therapy.¹⁵ The Philadelphia VAMC ORC was operated collaboratively by PCPs and Pharmacy Service. They reported that 51% of their patients initially had documented aberrant behaviors, and 45% of these patients resolved their aberrant behaviors through intensive opioid monitoring using random UDSs.¹⁴ Thirteen percent of their patients were found to have an opioid addiction disorder and eventually were referred to addiction treatment; and 4% were weaned off opioids due to consistently negative UDSs.¹⁴

In the same manner, the OMC has effectively identified patients who abused and misused their opioids and consequently referred these patients for pain interventional management or to the VASNHS alcohol and drug treatment program as appropriate, which falls under the VASNHS Mental Health Care line, a service that is vital for veterans who are suicidal and homicidal. The importance of mental health care cannot be understated, as many patients with chronic pain also experience mental health challenges.

The Malcom Randall VAMC in Gainesville, Florida, structured a nurse-led, multidisciplinary ORC in 2003.¹⁶ A retrospective review of their program showed that 33% of patients had a positive UDS for marijuana, cocaine, or alcohol. The ORC had increased patient involvement in substance abuse treatment, resulting in some patients taking lower opioid dosages than before.

The New York Harbor VAMC reduced opioid cost by effectively switching veterans on expensive long-acting opioids, such as oxycodone and fentanyl, to less expensive alternatives, such a long-acting morphine.¹⁷ A secondary purpose of the New York initiative was to reduce the potential for inappropriate use of expensive long-acting opioids. Accordingly, the initiative reduced the number of expensive long-acting and potentially inappropriate opioids from 165 to 69 prescriptions in less than 6 months (November 2007 through March 2008). Similarly, after 6 months of operation, the OMC significantly reduced opioid prescription from 54 mg to 22 MED/d. This reduction represents a significant pharmacy cost savings. The combination of the discontinuation of opioids for patients found to be abusing and misusing opioids coupled with the decrease in pill burden resulting from changes from short-acting to long-acting opioids also resulted in significant savings for VA facilities.

The impact of the OMC on PCP adherence to opioid management guidelines as well as PCP satisfaction with the OMC services was significant. Similarly, Wiedemer and colleagues found significant PCP satisfaction with the ORC.¹⁵ The ability to spend more time with patients on other medical problems while allowing the OMC to focus on opioid and pain management was found to be beneficial. Buy-in among PCPs coupled with their concerns for chronic opioid therapy for high-risk patients facilitated the success of the OMC. The commitment of the VASNHS leadership to the OMC and their support for the APRN in leading this initiative were important facilitators in the success of the OMC.

Limitations

Long-term evaluation of the OMC with a larger sample is needed to fully evaluate its impact on decreasing opioid misuse and abuse. This project was limited by a small sample size, although the results are promising. Pharmacy costs, emergency department visits, as well as patient satisfaction, physical and emotional function, and pain levels are outcomes that need to be considered over the long term. Incorporating mental health counseling, cognitive behavior therapy, self-management programs, and group educational sessions have the potential to be important OMC services. The continued success and cost-effectiveness of the OMC can be a potentially significant model for this type of service that can be applied to clinics outside the VA system.

Implications

Possible implications to practice settings that are considering an OMC or ORC include the chance that patients will want to be discharged from such a clinic and return to the PCP for opioid management. Collaborative relationships and communication between PCPs and OMC providers are important to facilitate adherence and consistency with pain care. Collaboration and effective communication can be facilitated by electronic recording and reporting. For example, the VA Computerized Patient Record System can alert PCPs to patient discharges from the OMC along with OMC provider recommendations for patient care. Another challenge for the OMC would be a lack of referrals for patients who are at high risk for opioid abuse or misuse. These challenges can be mitigated by providing in-services, educational flyers, and advertisement promotions regarding OMC services. With the high prevalence of opioid abuse and misuse as well as the subsequent exorbitant health-related costs and deaths associated with opioids, OMCs and ORCs are viable options for improving opioid management in the treatment of patients with nonmalignant chronic pain.

Conclusion

The OMC effectively reduced the MED of patients referred to the clinic by 59%. The significant reduction in the opioid dose of patients referred to the OMC resulted from the implementation of evidence-based strategies that were used to identify abuse of prescription opioids, the use of illicit substances that can cause opioid-related complications, and the discovery of doctor shopping, coupled with gradual dose reductions for patients when appropriate. Provider satisfaction and increased use of evidence-based guidelines in opioid management and risk mitigation strategies, such as OPAs, PDMP databases, and UDS were evident. These results suggest that an OMC can be an effective program to help identify abuse and misuse of prescription opioids among high-risk patients and can improve patient safety and provider satisfaction.

Acknowledgments
This material is the result of work supported with resources and the use of facilities at the VA Southern Nevada Healthcare System.

Single-agent therapy with decitabine elicited favorable responses in patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) who had cytogenetic abnormalities associated with an unfavorable risk profile, a study showed.

Even though the responses were not long lasting, the overall survival rates were similar to those of AML patients who had an intermediate-risk cytogenetic profile and who had received the same treatment regimen.

Adult AML patients with karyotypes associated with unfavorable risk and older patients with AML (aged 60 or older) generally have poor outcomes, with a median survival in the range of 1 year. Those with AML and TP53 mutations tend to be older (median age, 61-67 years), and nearly all patients have karyotypes associated with unfavorable risk. These patients have particularly dismal outcomes, with median survival in the range of 4-6 months, if they receive cytotoxic chemotherapy.

In their study, John S Welch, MD, of Washington University, St Louis, and his colleagues evaluated somatic mutations and their relationships to clinical responses in 84 adult patients with AML or MDS who received treatment with decitabine as monotherapy.

Decitabine was administered at a dose of 20 mg/m² of body surface area per day for 10 consecutive days in monthly cycles. An extension cohort that included 32 additional patients also were treated with decitabine but in different protocols.

Of the entire cohort of 116 patients, 15 patients (13%) achieved a complete remission, and 38 patients had bone marrow blast clearance with less than 5% blasts (complete remission with incomplete count recovery or morphologic complete remission). The overall response rate was 46%. In addition, 9 patients (8%), achieved a partial response, stable disease was observed in 23 patients (20%), and progressive disease was seen in 19 patients (16%).

Clinical responses were strongly correlated with karyotypes associated with unfavorable risk and the presence of TP53 mutations. Bone marrow blast clearance (complete remission, complete remission with incomplete count recovery, or morphologic complete remission) occurred in 29 of 43 patients with karyotypes associated with unfavorable risk (67%), compared with 24 of 71 patients with karyotypes associated with intermediate or favorable risk (34%). The same pattern was observed in all patients with TP53 mutations (100%) versus 32 of 78 patients with wildtype TP53 mutations (41%).

“Additional studies will be required to determine whether these differences in survival are truly due to improved responses associated with decitabine or whether conventional chemotherapy with an anthracycline and cytarabine actually decreases the rate of survival among patients with unfavorable-risk cytogenetic profiles,” wrote Dr. Welch and his colleagues.

The study was supported by the Specialized Program of Research Excellence in AML of the National Cancer Institute and the Genomics of AML Program Project. Dr. Welch had no disclosures, and several of his coauthors reported relationships with industry.

Single-agent therapy with decitabine elicited favorable responses in patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) who had cytogenetic abnormalities associated with an unfavorable risk profile, a study showed.

Even though the responses were not long lasting, the overall survival rates were similar to those of AML patients who had an intermediate-risk cytogenetic profile and who had received the same treatment regimen.

Adult AML patients with karyotypes associated with unfavorable risk and older patients with AML (aged 60 or older) generally have poor outcomes, with a median survival in the range of 1 year. Those with AML and TP53 mutations tend to be older (median age, 61-67 years), and nearly all patients have karyotypes associated with unfavorable risk. These patients have particularly dismal outcomes, with median survival in the range of 4-6 months, if they receive cytotoxic chemotherapy.

In their study, John S Welch, MD, of Washington University, St Louis, and his colleagues evaluated somatic mutations and their relationships to clinical responses in 84 adult patients with AML or MDS who received treatment with decitabine as monotherapy.

Decitabine was administered at a dose of 20 mg/m² of body surface area per day for 10 consecutive days in monthly cycles. An extension cohort that included 32 additional patients also were treated with decitabine but in different protocols.

Of the entire cohort of 116 patients, 15 patients (13%) achieved a complete remission, and 38 patients had bone marrow blast clearance with less than 5% blasts (complete remission with incomplete count recovery or morphologic complete remission). The overall response rate was 46%. In addition, 9 patients (8%), achieved a partial response, stable disease was observed in 23 patients (20%), and progressive disease was seen in 19 patients (16%).

Clinical responses were strongly correlated with karyotypes associated with unfavorable risk and the presence of TP53 mutations. Bone marrow blast clearance (complete remission, complete remission with incomplete count recovery, or morphologic complete remission) occurred in 29 of 43 patients with karyotypes associated with unfavorable risk (67%), compared with 24 of 71 patients with karyotypes associated with intermediate or favorable risk (34%). The same pattern was observed in all patients with TP53 mutations (100%) versus 32 of 78 patients with wildtype TP53 mutations (41%).

“Additional studies will be required to determine whether these differences in survival are truly due to improved responses associated with decitabine or whether conventional chemotherapy with an anthracycline and cytarabine actually decreases the rate of survival among patients with unfavorable-risk cytogenetic profiles,” wrote Dr. Welch and his colleagues.

The study was supported by the Specialized Program of Research Excellence in AML of the National Cancer Institute and the Genomics of AML Program Project. Dr. Welch had no disclosures, and several of his coauthors reported relationships with industry.

Single-agent therapy with decitabine elicited favorable responses in patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) who had cytogenetic abnormalities associated with an unfavorable risk profile, a study showed.

Even though the responses were not long lasting, the overall survival rates were similar to those of AML patients who had an intermediate-risk cytogenetic profile and who had received the same treatment regimen.

Adult AML patients with karyotypes associated with unfavorable risk and older patients with AML (aged 60 or older) generally have poor outcomes, with a median survival in the range of 1 year. Those with AML and TP53 mutations tend to be older (median age, 61-67 years), and nearly all patients have karyotypes associated with unfavorable risk. These patients have particularly dismal outcomes, with median survival in the range of 4-6 months, if they receive cytotoxic chemotherapy.

In their study, John S Welch, MD, of Washington University, St Louis, and his colleagues evaluated somatic mutations and their relationships to clinical responses in 84 adult patients with AML or MDS who received treatment with decitabine as monotherapy.

Decitabine was administered at a dose of 20 mg/m² of body surface area per day for 10 consecutive days in monthly cycles. An extension cohort that included 32 additional patients also were treated with decitabine but in different protocols.

Of the entire cohort of 116 patients, 15 patients (13%) achieved a complete remission, and 38 patients had bone marrow blast clearance with less than 5% blasts (complete remission with incomplete count recovery or morphologic complete remission). The overall response rate was 46%. In addition, 9 patients (8%), achieved a partial response, stable disease was observed in 23 patients (20%), and progressive disease was seen in 19 patients (16%).

Clinical responses were strongly correlated with karyotypes associated with unfavorable risk and the presence of TP53 mutations. Bone marrow blast clearance (complete remission, complete remission with incomplete count recovery, or morphologic complete remission) occurred in 29 of 43 patients with karyotypes associated with unfavorable risk (67%), compared with 24 of 71 patients with karyotypes associated with intermediate or favorable risk (34%). The same pattern was observed in all patients with TP53 mutations (100%) versus 32 of 78 patients with wildtype TP53 mutations (41%).

“Additional studies will be required to determine whether these differences in survival are truly due to improved responses associated with decitabine or whether conventional chemotherapy with an anthracycline and cytarabine actually decreases the rate of survival among patients with unfavorable-risk cytogenetic profiles,” wrote Dr. Welch and his colleagues.

The study was supported by the Specialized Program of Research Excellence in AML of the National Cancer Institute and the Genomics of AML Program Project. Dr. Welch had no disclosures, and several of his coauthors reported relationships with industry.

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Solanezumab, a monoclonal antibody that targets amyloid plaques, did not slow cognitive decline in patients with mild Alzheimer’s disease.

Although the drug did reduce soluble amyloid beta by 40%, compared with placebo, that change did not translate into a clinically meaningful cognitive benefit, Eric Siemers, MD, said in a press briefing called by Eli Lilly & Co., which manufactures solanezumab. The company did not release specific cognitive data from the highly anticipated Expedition 3 trial, except to say that changes on the ADAS-Cog14 (Alzheimer’s Disease Assessment Scale–cognitive subscale-14), the main cognitive endpoint, had a nonsignificant P value of 0.095 [Corection: Changed from 0.95 in original posting]. Functional data were also withheld.

Courtesy NIH

[email protected]

On Twitter @alz_gal

Solanezumab, a monoclonal antibody that targets amyloid plaques, did not slow cognitive decline in patients with mild Alzheimer’s disease.

Although the drug did reduce soluble amyloid beta by 40%, compared with placebo, that change did not translate into a clinically meaningful cognitive benefit, Eric Siemers, MD, said in a press briefing called by Eli Lilly & Co., which manufactures solanezumab. The company did not release specific cognitive data from the highly anticipated Expedition 3 trial, except to say that changes on the ADAS-Cog14 (Alzheimer’s Disease Assessment Scale–cognitive subscale-14), the main cognitive endpoint, had a nonsignificant P value of 0.095 [Corection: Changed from 0.95 in original posting]. Functional data were also withheld.

Courtesy NIH

[email protected]

On Twitter @alz_gal

Solanezumab, a monoclonal antibody that targets amyloid plaques, did not slow cognitive decline in patients with mild Alzheimer’s disease.

Although the drug did reduce soluble amyloid beta by 40%, compared with placebo, that change did not translate into a clinically meaningful cognitive benefit, Eric Siemers, MD, said in a press briefing called by Eli Lilly & Co., which manufactures solanezumab. The company did not release specific cognitive data from the highly anticipated Expedition 3 trial, except to say that changes on the ADAS-Cog14 (Alzheimer’s Disease Assessment Scale–cognitive subscale-14), the main cognitive endpoint, had a nonsignificant P value of 0.095 [Corection: Changed from 0.95 in original posting]. Functional data were also withheld.

Courtesy NIH

[email protected]

On Twitter @alz_gal

Childhood Adversity Is Linked to Blood Pressure Dysfunction

A difficult childhood may be associated with a risk of poor blood pressure regulation, researchers reported. In some studies, blood pressure variability has been associated with an elevated risk of cardiovascular disease and complications from hypertension.  

Researchers at the Augusta University Medical College of Georgia investigated the effect of adverse childhood experiences (eg, childhood abuse or neglect, dysfunctional homes, or low socioeconomic status) during the transition from childhood to adulthood. Earlier research has linked adverse childhood experiences to faster increase of blood pressure in adulthood.

The investigators conducted periodic around-the-clock blood pressure monitoring to capture daytime and nighttime readings in 373 participants between the ages of 7 and 38 during a 23-year period. Participants who reported childhood adversity were 17% more likely to have blood pressure that was higher than the clinical definition of hypertension during the daytime.

"Adverse environments in early life have been consistently associated with the increased risk of hypertension in later life," said Shaoyong Su, PhD, lead author and Associate Professor of Pediatrics at Augusta University Medical College of Georgia. "We found that children who experienced childhood abuse or neglect, dysfunctional homes, and low socioeconomic status were far more likely to have higher blood pressure at night, as well as blood pressure variability over 24 hours, in addition to more rapid onset of hypertension at an earlier age."

Twenty-four-hour ambulatory blood pressure is considered a better predictor of organ damage and cardiovascular events because it can assess not only nighttime blood pressure levels, but also the blood pressure variability in real life. Blood pressure was monitored as many as 15 times during the study.

Researchers said that there was no difference in blood pressure regulation at various ages, thus suggesting that the patterns of adverse events in childhood are similar through young adulthood.

Most physicians focus on average blood pressure readings, but the new findings suggest that they should also ask younger patients about childhood adversity and watch for high blood pressure variability, noted Dr. Su. "This is not something most clinicians currently address, but it is a simple step that could identify many individuals at risk of adult hypertension and help them achieve control at an earlier age. This could avoid problems as they age," he added.

Blood pressure variability has been linked to various problems in adults, including decreased brain function in older adults, increased risk of stroke, and poorer post-stroke recovery. Likewise, early-onset hypertension and prehypertension have been linked to adverse preclinical cardiovascular disease, including left ventricular hypertrophy and evidence of increased arterial stiffness.

The current study was funded by the NIH and the National Heart Lung and Blood Institute.

Poor Sleep May Increase Risk for Irregular Heart Rhythms

Disruptions in sleep may increase the risk of atrial fibrillation, according to preliminary research. Obstructive sleep apnea, sleep interrupted by pauses in breathing, is a known risk factor for atrial fibrillation, which can lead to stroke, heart failure, and other heart-related complications. But whether there is a relationship between disrupted sleep and atrial fibrillation in the absence of sleep apnea is unclear.

Researchers at the University of California, San Francisco examined three sources of data, each using a different approach, to isolate and confirm the effects of poor sleep on atrial fibrillation. Their analyses of these studies showed that disrupted sleep, including insomnia, may be independently associated with atrial fibrillation. People who reported frequent nighttime awakening had an approximately 26% higher risk of developing atrial fibrillation, compared with those who did not wake up many times. In addition, people diagnosed with insomnia had a 29% higher risk of developing atrial fibrillation, compared with those without insomnia.

"The idea that these three studies gave us consistent results was exciting," said lead study author Matt Christensen, a fourth-year medical student at the University of Michigan in Ann Arbor. Past research has shown a link between poor sleep among people with atrial fibrillation. This study, however, focused on people whose pre-existing sleep disruptions were associated with developing atrial fibrillation later in life.

The data sources included the Health eHeart Study, an Internet-based cross-sectional study of more than 4,600 people; the Cardiovascular Health Study, an 11-year longitudinal study of more than 5,700 people, of whom almost 1,600 (28%) developed atrial fibrillation; and the California Healthcare Cost and Utilization Project, a hospital-based database spanning five years and covering almost 14 million patients.

In all three studies, researchers adjusted for the effects of obstructive sleep apnea and atrial fibrillation risk factors that might also be related to sleep. Some of those factors were age, sex, race, diabetes, high blood pressure, heart failure, and smoking.

In a separate analysis, the same researchers reviewed a subset of participants in the Cardiovascular Health Study to understand the effect of sleep disruptions during different sleep phases on the risk of atrial fibrillation in patients without obstructive sleep apnea. The analysis showed that having less REM sleep than other sleep phases during the night is linked to a higher likelihood of developing atrial fibrillation.

"By examining the actual characteristics of sleep, such as how much REM sleep you get, it points us toward a more plausible mechanism. There could be something particular about how sleep impacts the autonomic nervous system," said Mr. Christensen.  

Another possible explanation for the link between sleep disruptions and atrial fibrillation is that frequent waking puts extra stress on the heart's chambers, said Mr. Christensen. Participants in this analysis were also enrolled in the Sleep Heart Health Study. They had a formal sleep study to objectively measure sleep quality. That element strengthened the study's conclusions because it did not rely on self-reported data, said Mr. Christensen.

In this analysis, 1,131 people (average age, 77) participated in a study with almost 10 years of follow-up. Researchers measured how long participants slept, how well they slept, how long it took to fall asleep, and the patterns of sleep (ie, how much time was spent in REM sleep vs non-REM sleep). Then they analyzed the sleep disruptions' effects to control the effects of age, sex, race, smoking, diabetes, high blood pressure, and other risk factors.

The exact link between sleep and the development of atrial fibrillation is still a mystery, but we are getting closer to a clear picture, said the study authors. "Ultimately, even without a clear understanding of the responsible mechanisms, we believe these findings suggest that strategies to enhance sleep quality, such as incorporating known techniques to improve sleep hygiene, may help prevent this important arrhythmia," said senior author Gregory Marcus, MD, MAS, a cardiologist at the University of California, San Francisco.

Poor sleep is a known contributor to other heart disease risk factors such as high blood pressure, obesity, and stroke. Getting enough physical activity, avoiding too much caffeine, and having an evening routine are good starting tips for sound sleep, said the researchers.  

This study was funded in part by the Sarnoff Cardiovascular Research Foundation, the NIH, and the Agency for Healthcare Research and Quality.

Popular Heartburn Medication May Increase Ischemic Stroke Risk

Proton pump inhibitors (PPIs), which are used to reduce stomach acid and treat heartburn, may increase the risk of ischemic stroke, according to preliminary research. "PPIs have been associated with unhealthy vascular function, including heart attacks, kidney disease and dementia," said Thomas Sehested, MD, lead author and a researcher at the Danish Heart Foundation in Copenhagen. "We wanted to see if PPIs also posed a risk for ischemic stroke, especially given their increasing use in the general population."

Researchers analyzed the records of 244,679 Danish patients (average age, 57) who had an endoscopy. During nearly six years of follow up, 9,489 patients had an ischemic stroke for the first time in their lives. Researchers determined whether the stroke occurred while patients were using one of the following four PPIs: omeprazole, pantoprazole, lansoprazole, and esomeprazole.  

For ischemic stroke, researchers found that overall stroke risk increased by 21% when patients were taking a PPI. At the lowest doses of the PPIs, the researchers found slight or no increased stroke risk. At the highest dose of these four PPIs, stroke risk increased by amounts ranging from 30% percent for lansoprazole to 94% for pantoprazole. There was no increased risk of stroke associated with another group of acid-reducing medications known as H2 blockers, which includes famotidine and ranitidine.

In comparison with nonusers, users of PPI were older and had more health conditions, including atrial fibrillation, at baseline (3.4% vs 3.8%). The study accounted for age, gender, and medical factors, including high blood pressure, atrial fibrillation, heart failure, and the use of certain pain relievers that have been linked to heart attack and stroke.

The authors believe that their findings, along with those of previous studies, should encourage more cautious use of PPIs. Most PPIs in the United States are now available over the counter, noted Dr. Sehested. "At one time, PPIs were thought to be safe, without major side effects. This study further questions the cardiovascular safety of these drugs."

Although their study did not find a link between H2 blockers and stroke, the authors could not say that this group of drugs would be better for patients than PPIs. Doctors prescribing PPIs should carefully consider whether their use is warranted and for how long, said Dr. Sehested. "We know from prior studies that a lot of individuals are using PPIs for a much longer time than indicated, which is especially true for elderly patients."

Study limitations include an observational design, which cannot establish cause and effect, and the fact that nearly all the participants were white. Authors believe that a randomized controlled trial of PPIs and cardiovascular disease is warranted. This study was funded by the Danish Heart Foundation.

Catheter Ablations Reduce Risks of Recurrent Stroke

Patients with atrial fibrillation and a prior history of stroke who undergo catheter ablation to treat the abnormal heart rhythm lower their long-term risk of a recurrent stroke by 50%, according to research from the Intermountain Medical Center Heart Institute.

When medications are not successful in treating the arrhythmia, catheter ablations are used to create scar tissue in the upper left atrium of the heart that prevents rapid, chaotic electric currents, often from the pulmonary veins, from causing the abnormal rhythm.

"One of the most devastating complications of atrial fibrillation is a stroke, and its prevention is the treatment cornerstone of the abnormal heart rhythm," said Jared Bunch, MD, lead author of the study and Director of Electrophysiology at the Intermountain Medical Center Heart Institute in Salt Lake City. "Patients that have a prior history of stroke have a much greater risk of recurrent strokes. Our new research shows [that] the more successful we are in treating the abnormal rhythm through the process required with catheter ablation, the better chance we have of lowering a patient's long-term risk of stroke."

The Intermountain study compared a group of 140 patients, who had a prior history of stroke and underwent their first catheter ablation, with two other patient groups, both of which also had a prior history of stroke, including 416 patients with atrial fibrillation who did not receive a catheter ablation, and 416 patients with stroke who did not have atrial fibrillation. The patients were followed for five years and observed for recurrent outcomes of stroke, heart failure, and death.

The five-year risk of patients having another stroke was decreased in the patients who had a catheter ablation to treat atrial fibrillation, compared with the group that had no catheter ablation to treat their abnormal heart rhythm. The stroke rates of patients with atrial fibrillation who underwent an ablation procedure were similar to those of patients with no history of atrial fibrillation.

"One of the most important findings of this study was that stroke rates in patients that underwent an ablation were similar to [those of] patients with no history of atrial fibrillation. This suggests that our management approach can alter some of the negative effects and natural history of atrial fibrillation. As physicians, we spend a lot of our time and energy trying to prevent stroke. This study helps us understand better how our management approaches can alter stroke risk," said Dr. Bunch. "Our research shows that more aggressive treatment of atrial fibrillation by using catheter ablations will reduce the chances [that] a person will have a life-threatening stroke."

Migraine Increases Cardiovascular Risk in Women With Symptoms of Ischemic Heart Disease

Among women being evaluated for ischemic heart disease, those who reported a history of migraine headaches have an increased risk of future cardiovascular (CV) event. This finding is primarily driven by the more than twofold increased risk of stroke.

Data regarding the association between migraine headaches and CV events in women have been inconsistent. Cecil A. Rambarat, MD, a resident at the University of Florida in Gainesville, and colleagues conducted a study to determine the long-term risk of CV events among women with and without migraine headaches who were evaluated for suspected ischemic heart disease in the Women's Ischemia Syndrome Evaluation (WISE) Study.  

Women reporting a history of migraine headache were identified from the WISE cohort. Extended follow-up data were available, for a median follow-up of six years. Cox proportional adjusted hazard ratios (HR) were constructed for time to first adverse CV event (ie, CV death, nonfatal myocardial infarction [MI], heart failure hospitalization, or nonfatal stroke) among women with and without migraine headaches. In addition, HRs were determined for each event separately, as well as for all-cause death, angina hospitalization, death or MI, and CV death or MI.  

Data on self-reported migraine headaches were available for 917 women. A total of 224 (24.4%) women reported a history of migraine headaches. Compared with those who did not report a history of migraines, women with a history of migraine headaches had an increased adjusted risk of CV events (HR, 1.83) at a median follow-up of six years. This result was mainly due to an increase in the risk of stroke (HR, 2.33).    

The variables for which Dr. Rambarat and colleagues adjusted the data included age, race, BMI, history of diabetes, hypertension, dyslipidemia, smoking, family history of coronary artery disease, WISE coronary artery disease severity score, and aspirin use.

Childhood Adversity Is Linked to Blood Pressure Dysfunction

A difficult childhood may be associated with a risk of poor blood pressure regulation, researchers reported. In some studies, blood pressure variability has been associated with an elevated risk of cardiovascular disease and complications from hypertension.  

Researchers at the Augusta University Medical College of Georgia investigated the effect of adverse childhood experiences (eg, childhood abuse or neglect, dysfunctional homes, or low socioeconomic status) during the transition from childhood to adulthood. Earlier research has linked adverse childhood experiences to faster increase of blood pressure in adulthood.

The investigators conducted periodic around-the-clock blood pressure monitoring to capture daytime and nighttime readings in 373 participants between the ages of 7 and 38 during a 23-year period. Participants who reported childhood adversity were 17% more likely to have blood pressure that was higher than the clinical definition of hypertension during the daytime.

"Adverse environments in early life have been consistently associated with the increased risk of hypertension in later life," said Shaoyong Su, PhD, lead author and Associate Professor of Pediatrics at Augusta University Medical College of Georgia. "We found that children who experienced childhood abuse or neglect, dysfunctional homes, and low socioeconomic status were far more likely to have higher blood pressure at night, as well as blood pressure variability over 24 hours, in addition to more rapid onset of hypertension at an earlier age."

Twenty-four-hour ambulatory blood pressure is considered a better predictor of organ damage and cardiovascular events because it can assess not only nighttime blood pressure levels, but also the blood pressure variability in real life. Blood pressure was monitored as many as 15 times during the study.

Researchers said that there was no difference in blood pressure regulation at various ages, thus suggesting that the patterns of adverse events in childhood are similar through young adulthood.

Most physicians focus on average blood pressure readings, but the new findings suggest that they should also ask younger patients about childhood adversity and watch for high blood pressure variability, noted Dr. Su. "This is not something most clinicians currently address, but it is a simple step that could identify many individuals at risk of adult hypertension and help them achieve control at an earlier age. This could avoid problems as they age," he added.

Blood pressure variability has been linked to various problems in adults, including decreased brain function in older adults, increased risk of stroke, and poorer post-stroke recovery. Likewise, early-onset hypertension and prehypertension have been linked to adverse preclinical cardiovascular disease, including left ventricular hypertrophy and evidence of increased arterial stiffness.

The current study was funded by the NIH and the National Heart Lung and Blood Institute.

Poor Sleep May Increase Risk for Irregular Heart Rhythms

Disruptions in sleep may increase the risk of atrial fibrillation, according to preliminary research. Obstructive sleep apnea, sleep interrupted by pauses in breathing, is a known risk factor for atrial fibrillation, which can lead to stroke, heart failure, and other heart-related complications. But whether there is a relationship between disrupted sleep and atrial fibrillation in the absence of sleep apnea is unclear.

Researchers at the University of California, San Francisco examined three sources of data, each using a different approach, to isolate and confirm the effects of poor sleep on atrial fibrillation. Their analyses of these studies showed that disrupted sleep, including insomnia, may be independently associated with atrial fibrillation. People who reported frequent nighttime awakening had an approximately 26% higher risk of developing atrial fibrillation, compared with those who did not wake up many times. In addition, people diagnosed with insomnia had a 29% higher risk of developing atrial fibrillation, compared with those without insomnia.

"The idea that these three studies gave us consistent results was exciting," said lead study author Matt Christensen, a fourth-year medical student at the University of Michigan in Ann Arbor. Past research has shown a link between poor sleep among people with atrial fibrillation. This study, however, focused on people whose pre-existing sleep disruptions were associated with developing atrial fibrillation later in life.

The data sources included the Health eHeart Study, an Internet-based cross-sectional study of more than 4,600 people; the Cardiovascular Health Study, an 11-year longitudinal study of more than 5,700 people, of whom almost 1,600 (28%) developed atrial fibrillation; and the California Healthcare Cost and Utilization Project, a hospital-based database spanning five years and covering almost 14 million patients.

In all three studies, researchers adjusted for the effects of obstructive sleep apnea and atrial fibrillation risk factors that might also be related to sleep. Some of those factors were age, sex, race, diabetes, high blood pressure, heart failure, and smoking.

In a separate analysis, the same researchers reviewed a subset of participants in the Cardiovascular Health Study to understand the effect of sleep disruptions during different sleep phases on the risk of atrial fibrillation in patients without obstructive sleep apnea. The analysis showed that having less REM sleep than other sleep phases during the night is linked to a higher likelihood of developing atrial fibrillation.

"By examining the actual characteristics of sleep, such as how much REM sleep you get, it points us toward a more plausible mechanism. There could be something particular about how sleep impacts the autonomic nervous system," said Mr. Christensen.  

Another possible explanation for the link between sleep disruptions and atrial fibrillation is that frequent waking puts extra stress on the heart's chambers, said Mr. Christensen. Participants in this analysis were also enrolled in the Sleep Heart Health Study. They had a formal sleep study to objectively measure sleep quality. That element strengthened the study's conclusions because it did not rely on self-reported data, said Mr. Christensen.

In this analysis, 1,131 people (average age, 77) participated in a study with almost 10 years of follow-up. Researchers measured how long participants slept, how well they slept, how long it took to fall asleep, and the patterns of sleep (ie, how much time was spent in REM sleep vs non-REM sleep). Then they analyzed the sleep disruptions' effects to control the effects of age, sex, race, smoking, diabetes, high blood pressure, and other risk factors.

The exact link between sleep and the development of atrial fibrillation is still a mystery, but we are getting closer to a clear picture, said the study authors. "Ultimately, even without a clear understanding of the responsible mechanisms, we believe these findings suggest that strategies to enhance sleep quality, such as incorporating known techniques to improve sleep hygiene, may help prevent this important arrhythmia," said senior author Gregory Marcus, MD, MAS, a cardiologist at the University of California, San Francisco.

Poor sleep is a known contributor to other heart disease risk factors such as high blood pressure, obesity, and stroke. Getting enough physical activity, avoiding too much caffeine, and having an evening routine are good starting tips for sound sleep, said the researchers.  

This study was funded in part by the Sarnoff Cardiovascular Research Foundation, the NIH, and the Agency for Healthcare Research and Quality.

Popular Heartburn Medication May Increase Ischemic Stroke Risk

Proton pump inhibitors (PPIs), which are used to reduce stomach acid and treat heartburn, may increase the risk of ischemic stroke, according to preliminary research. "PPIs have been associated with unhealthy vascular function, including heart attacks, kidney disease and dementia," said Thomas Sehested, MD, lead author and a researcher at the Danish Heart Foundation in Copenhagen. "We wanted to see if PPIs also posed a risk for ischemic stroke, especially given their increasing use in the general population."

Researchers analyzed the records of 244,679 Danish patients (average age, 57) who had an endoscopy. During nearly six years of follow up, 9,489 patients had an ischemic stroke for the first time in their lives. Researchers determined whether the stroke occurred while patients were using one of the following four PPIs: omeprazole, pantoprazole, lansoprazole, and esomeprazole.  

For ischemic stroke, researchers found that overall stroke risk increased by 21% when patients were taking a PPI. At the lowest doses of the PPIs, the researchers found slight or no increased stroke risk. At the highest dose of these four PPIs, stroke risk increased by amounts ranging from 30% percent for lansoprazole to 94% for pantoprazole. There was no increased risk of stroke associated with another group of acid-reducing medications known as H2 blockers, which includes famotidine and ranitidine.

In comparison with nonusers, users of PPI were older and had more health conditions, including atrial fibrillation, at baseline (3.4% vs 3.8%). The study accounted for age, gender, and medical factors, including high blood pressure, atrial fibrillation, heart failure, and the use of certain pain relievers that have been linked to heart attack and stroke.

The authors believe that their findings, along with those of previous studies, should encourage more cautious use of PPIs. Most PPIs in the United States are now available over the counter, noted Dr. Sehested. "At one time, PPIs were thought to be safe, without major side effects. This study further questions the cardiovascular safety of these drugs."

Although their study did not find a link between H2 blockers and stroke, the authors could not say that this group of drugs would be better for patients than PPIs. Doctors prescribing PPIs should carefully consider whether their use is warranted and for how long, said Dr. Sehested. "We know from prior studies that a lot of individuals are using PPIs for a much longer time than indicated, which is especially true for elderly patients."

Study limitations include an observational design, which cannot establish cause and effect, and the fact that nearly all the participants were white. Authors believe that a randomized controlled trial of PPIs and cardiovascular disease is warranted. This study was funded by the Danish Heart Foundation.

Catheter Ablations Reduce Risks of Recurrent Stroke

Patients with atrial fibrillation and a prior history of stroke who undergo catheter ablation to treat the abnormal heart rhythm lower their long-term risk of a recurrent stroke by 50%, according to research from the Intermountain Medical Center Heart Institute.

When medications are not successful in treating the arrhythmia, catheter ablations are used to create scar tissue in the upper left atrium of the heart that prevents rapid, chaotic electric currents, often from the pulmonary veins, from causing the abnormal rhythm.

"One of the most devastating complications of atrial fibrillation is a stroke, and its prevention is the treatment cornerstone of the abnormal heart rhythm," said Jared Bunch, MD, lead author of the study and Director of Electrophysiology at the Intermountain Medical Center Heart Institute in Salt Lake City. "Patients that have a prior history of stroke have a much greater risk of recurrent strokes. Our new research shows [that] the more successful we are in treating the abnormal rhythm through the process required with catheter ablation, the better chance we have of lowering a patient's long-term risk of stroke."

The Intermountain study compared a group of 140 patients, who had a prior history of stroke and underwent their first catheter ablation, with two other patient groups, both of which also had a prior history of stroke, including 416 patients with atrial fibrillation who did not receive a catheter ablation, and 416 patients with stroke who did not have atrial fibrillation. The patients were followed for five years and observed for recurrent outcomes of stroke, heart failure, and death.

The five-year risk of patients having another stroke was decreased in the patients who had a catheter ablation to treat atrial fibrillation, compared with the group that had no catheter ablation to treat their abnormal heart rhythm. The stroke rates of patients with atrial fibrillation who underwent an ablation procedure were similar to those of patients with no history of atrial fibrillation.

"One of the most important findings of this study was that stroke rates in patients that underwent an ablation were similar to [those of] patients with no history of atrial fibrillation. This suggests that our management approach can alter some of the negative effects and natural history of atrial fibrillation. As physicians, we spend a lot of our time and energy trying to prevent stroke. This study helps us understand better how our management approaches can alter stroke risk," said Dr. Bunch. "Our research shows that more aggressive treatment of atrial fibrillation by using catheter ablations will reduce the chances [that] a person will have a life-threatening stroke."

Migraine Increases Cardiovascular Risk in Women With Symptoms of Ischemic Heart Disease

Among women being evaluated for ischemic heart disease, those who reported a history of migraine headaches have an increased risk of future cardiovascular (CV) event. This finding is primarily driven by the more than twofold increased risk of stroke.

Data regarding the association between migraine headaches and CV events in women have been inconsistent. Cecil A. Rambarat, MD, a resident at the University of Florida in Gainesville, and colleagues conducted a study to determine the long-term risk of CV events among women with and without migraine headaches who were evaluated for suspected ischemic heart disease in the Women's Ischemia Syndrome Evaluation (WISE) Study.  

Women reporting a history of migraine headache were identified from the WISE cohort. Extended follow-up data were available, for a median follow-up of six years. Cox proportional adjusted hazard ratios (HR) were constructed for time to first adverse CV event (ie, CV death, nonfatal myocardial infarction [MI], heart failure hospitalization, or nonfatal stroke) among women with and without migraine headaches. In addition, HRs were determined for each event separately, as well as for all-cause death, angina hospitalization, death or MI, and CV death or MI.  

Data on self-reported migraine headaches were available for 917 women. A total of 224 (24.4%) women reported a history of migraine headaches. Compared with those who did not report a history of migraines, women with a history of migraine headaches had an increased adjusted risk of CV events (HR, 1.83) at a median follow-up of six years. This result was mainly due to an increase in the risk of stroke (HR, 2.33).    

The variables for which Dr. Rambarat and colleagues adjusted the data included age, race, BMI, history of diabetes, hypertension, dyslipidemia, smoking, family history of coronary artery disease, WISE coronary artery disease severity score, and aspirin use.

Childhood Adversity Is Linked to Blood Pressure Dysfunction

A difficult childhood may be associated with a risk of poor blood pressure regulation, researchers reported. In some studies, blood pressure variability has been associated with an elevated risk of cardiovascular disease and complications from hypertension.  

Researchers at the Augusta University Medical College of Georgia investigated the effect of adverse childhood experiences (eg, childhood abuse or neglect, dysfunctional homes, or low socioeconomic status) during the transition from childhood to adulthood. Earlier research has linked adverse childhood experiences to faster increase of blood pressure in adulthood.

The investigators conducted periodic around-the-clock blood pressure monitoring to capture daytime and nighttime readings in 373 participants between the ages of 7 and 38 during a 23-year period. Participants who reported childhood adversity were 17% more likely to have blood pressure that was higher than the clinical definition of hypertension during the daytime.

"Adverse environments in early life have been consistently associated with the increased risk of hypertension in later life," said Shaoyong Su, PhD, lead author and Associate Professor of Pediatrics at Augusta University Medical College of Georgia. "We found that children who experienced childhood abuse or neglect, dysfunctional homes, and low socioeconomic status were far more likely to have higher blood pressure at night, as well as blood pressure variability over 24 hours, in addition to more rapid onset of hypertension at an earlier age."

Twenty-four-hour ambulatory blood pressure is considered a better predictor of organ damage and cardiovascular events because it can assess not only nighttime blood pressure levels, but also the blood pressure variability in real life. Blood pressure was monitored as many as 15 times during the study.

Researchers said that there was no difference in blood pressure regulation at various ages, thus suggesting that the patterns of adverse events in childhood are similar through young adulthood.

Most physicians focus on average blood pressure readings, but the new findings suggest that they should also ask younger patients about childhood adversity and watch for high blood pressure variability, noted Dr. Su. "This is not something most clinicians currently address, but it is a simple step that could identify many individuals at risk of adult hypertension and help them achieve control at an earlier age. This could avoid problems as they age," he added.

Blood pressure variability has been linked to various problems in adults, including decreased brain function in older adults, increased risk of stroke, and poorer post-stroke recovery. Likewise, early-onset hypertension and prehypertension have been linked to adverse preclinical cardiovascular disease, including left ventricular hypertrophy and evidence of increased arterial stiffness.

The current study was funded by the NIH and the National Heart Lung and Blood Institute.

Poor Sleep May Increase Risk for Irregular Heart Rhythms

Disruptions in sleep may increase the risk of atrial fibrillation, according to preliminary research. Obstructive sleep apnea, sleep interrupted by pauses in breathing, is a known risk factor for atrial fibrillation, which can lead to stroke, heart failure, and other heart-related complications. But whether there is a relationship between disrupted sleep and atrial fibrillation in the absence of sleep apnea is unclear.

Researchers at the University of California, San Francisco examined three sources of data, each using a different approach, to isolate and confirm the effects of poor sleep on atrial fibrillation. Their analyses of these studies showed that disrupted sleep, including insomnia, may be independently associated with atrial fibrillation. People who reported frequent nighttime awakening had an approximately 26% higher risk of developing atrial fibrillation, compared with those who did not wake up many times. In addition, people diagnosed with insomnia had a 29% higher risk of developing atrial fibrillation, compared with those without insomnia.

"The idea that these three studies gave us consistent results was exciting," said lead study author Matt Christensen, a fourth-year medical student at the University of Michigan in Ann Arbor. Past research has shown a link between poor sleep among people with atrial fibrillation. This study, however, focused on people whose pre-existing sleep disruptions were associated with developing atrial fibrillation later in life.

The data sources included the Health eHeart Study, an Internet-based cross-sectional study of more than 4,600 people; the Cardiovascular Health Study, an 11-year longitudinal study of more than 5,700 people, of whom almost 1,600 (28%) developed atrial fibrillation; and the California Healthcare Cost and Utilization Project, a hospital-based database spanning five years and covering almost 14 million patients.

In all three studies, researchers adjusted for the effects of obstructive sleep apnea and atrial fibrillation risk factors that might also be related to sleep. Some of those factors were age, sex, race, diabetes, high blood pressure, heart failure, and smoking.

In a separate analysis, the same researchers reviewed a subset of participants in the Cardiovascular Health Study to understand the effect of sleep disruptions during different sleep phases on the risk of atrial fibrillation in patients without obstructive sleep apnea. The analysis showed that having less REM sleep than other sleep phases during the night is linked to a higher likelihood of developing atrial fibrillation.

"By examining the actual characteristics of sleep, such as how much REM sleep you get, it points us toward a more plausible mechanism. There could be something particular about how sleep impacts the autonomic nervous system," said Mr. Christensen.  

Another possible explanation for the link between sleep disruptions and atrial fibrillation is that frequent waking puts extra stress on the heart's chambers, said Mr. Christensen. Participants in this analysis were also enrolled in the Sleep Heart Health Study. They had a formal sleep study to objectively measure sleep quality. That element strengthened the study's conclusions because it did not rely on self-reported data, said Mr. Christensen.

In this analysis, 1,131 people (average age, 77) participated in a study with almost 10 years of follow-up. Researchers measured how long participants slept, how well they slept, how long it took to fall asleep, and the patterns of sleep (ie, how much time was spent in REM sleep vs non-REM sleep). Then they analyzed the sleep disruptions' effects to control the effects of age, sex, race, smoking, diabetes, high blood pressure, and other risk factors.

The exact link between sleep and the development of atrial fibrillation is still a mystery, but we are getting closer to a clear picture, said the study authors. "Ultimately, even without a clear understanding of the responsible mechanisms, we believe these findings suggest that strategies to enhance sleep quality, such as incorporating known techniques to improve sleep hygiene, may help prevent this important arrhythmia," said senior author Gregory Marcus, MD, MAS, a cardiologist at the University of California, San Francisco.

Poor sleep is a known contributor to other heart disease risk factors such as high blood pressure, obesity, and stroke. Getting enough physical activity, avoiding too much caffeine, and having an evening routine are good starting tips for sound sleep, said the researchers.  

This study was funded in part by the Sarnoff Cardiovascular Research Foundation, the NIH, and the Agency for Healthcare Research and Quality.

Popular Heartburn Medication May Increase Ischemic Stroke Risk

Proton pump inhibitors (PPIs), which are used to reduce stomach acid and treat heartburn, may increase the risk of ischemic stroke, according to preliminary research. "PPIs have been associated with unhealthy vascular function, including heart attacks, kidney disease and dementia," said Thomas Sehested, MD, lead author and a researcher at the Danish Heart Foundation in Copenhagen. "We wanted to see if PPIs also posed a risk for ischemic stroke, especially given their increasing use in the general population."

Researchers analyzed the records of 244,679 Danish patients (average age, 57) who had an endoscopy. During nearly six years of follow up, 9,489 patients had an ischemic stroke for the first time in their lives. Researchers determined whether the stroke occurred while patients were using one of the following four PPIs: omeprazole, pantoprazole, lansoprazole, and esomeprazole.  

For ischemic stroke, researchers found that overall stroke risk increased by 21% when patients were taking a PPI. At the lowest doses of the PPIs, the researchers found slight or no increased stroke risk. At the highest dose of these four PPIs, stroke risk increased by amounts ranging from 30% percent for lansoprazole to 94% for pantoprazole. There was no increased risk of stroke associated with another group of acid-reducing medications known as H2 blockers, which includes famotidine and ranitidine.

In comparison with nonusers, users of PPI were older and had more health conditions, including atrial fibrillation, at baseline (3.4% vs 3.8%). The study accounted for age, gender, and medical factors, including high blood pressure, atrial fibrillation, heart failure, and the use of certain pain relievers that have been linked to heart attack and stroke.

The authors believe that their findings, along with those of previous studies, should encourage more cautious use of PPIs. Most PPIs in the United States are now available over the counter, noted Dr. Sehested. "At one time, PPIs were thought to be safe, without major side effects. This study further questions the cardiovascular safety of these drugs."

Although their study did not find a link between H2 blockers and stroke, the authors could not say that this group of drugs would be better for patients than PPIs. Doctors prescribing PPIs should carefully consider whether their use is warranted and for how long, said Dr. Sehested. "We know from prior studies that a lot of individuals are using PPIs for a much longer time than indicated, which is especially true for elderly patients."

Study limitations include an observational design, which cannot establish cause and effect, and the fact that nearly all the participants were white. Authors believe that a randomized controlled trial of PPIs and cardiovascular disease is warranted. This study was funded by the Danish Heart Foundation.

Catheter Ablations Reduce Risks of Recurrent Stroke

Patients with atrial fibrillation and a prior history of stroke who undergo catheter ablation to treat the abnormal heart rhythm lower their long-term risk of a recurrent stroke by 50%, according to research from the Intermountain Medical Center Heart Institute.

When medications are not successful in treating the arrhythmia, catheter ablations are used to create scar tissue in the upper left atrium of the heart that prevents rapid, chaotic electric currents, often from the pulmonary veins, from causing the abnormal rhythm.

"One of the most devastating complications of atrial fibrillation is a stroke, and its prevention is the treatment cornerstone of the abnormal heart rhythm," said Jared Bunch, MD, lead author of the study and Director of Electrophysiology at the Intermountain Medical Center Heart Institute in Salt Lake City. "Patients that have a prior history of stroke have a much greater risk of recurrent strokes. Our new research shows [that] the more successful we are in treating the abnormal rhythm through the process required with catheter ablation, the better chance we have of lowering a patient's long-term risk of stroke."

The Intermountain study compared a group of 140 patients, who had a prior history of stroke and underwent their first catheter ablation, with two other patient groups, both of which also had a prior history of stroke, including 416 patients with atrial fibrillation who did not receive a catheter ablation, and 416 patients with stroke who did not have atrial fibrillation. The patients were followed for five years and observed for recurrent outcomes of stroke, heart failure, and death.

The five-year risk of patients having another stroke was decreased in the patients who had a catheter ablation to treat atrial fibrillation, compared with the group that had no catheter ablation to treat their abnormal heart rhythm. The stroke rates of patients with atrial fibrillation who underwent an ablation procedure were similar to those of patients with no history of atrial fibrillation.

"One of the most important findings of this study was that stroke rates in patients that underwent an ablation were similar to [those of] patients with no history of atrial fibrillation. This suggests that our management approach can alter some of the negative effects and natural history of atrial fibrillation. As physicians, we spend a lot of our time and energy trying to prevent stroke. This study helps us understand better how our management approaches can alter stroke risk," said Dr. Bunch. "Our research shows that more aggressive treatment of atrial fibrillation by using catheter ablations will reduce the chances [that] a person will have a life-threatening stroke."

Migraine Increases Cardiovascular Risk in Women With Symptoms of Ischemic Heart Disease

Among women being evaluated for ischemic heart disease, those who reported a history of migraine headaches have an increased risk of future cardiovascular (CV) event. This finding is primarily driven by the more than twofold increased risk of stroke.

Data regarding the association between migraine headaches and CV events in women have been inconsistent. Cecil A. Rambarat, MD, a resident at the University of Florida in Gainesville, and colleagues conducted a study to determine the long-term risk of CV events among women with and without migraine headaches who were evaluated for suspected ischemic heart disease in the Women's Ischemia Syndrome Evaluation (WISE) Study.  

Women reporting a history of migraine headache were identified from the WISE cohort. Extended follow-up data were available, for a median follow-up of six years. Cox proportional adjusted hazard ratios (HR) were constructed for time to first adverse CV event (ie, CV death, nonfatal myocardial infarction [MI], heart failure hospitalization, or nonfatal stroke) among women with and without migraine headaches. In addition, HRs were determined for each event separately, as well as for all-cause death, angina hospitalization, death or MI, and CV death or MI.  

Data on self-reported migraine headaches were available for 917 women. A total of 224 (24.4%) women reported a history of migraine headaches. Compared with those who did not report a history of migraines, women with a history of migraine headaches had an increased adjusted risk of CV events (HR, 1.83) at a median follow-up of six years. This result was mainly due to an increase in the risk of stroke (HR, 2.33).    

The variables for which Dr. Rambarat and colleagues adjusted the data included age, race, BMI, history of diabetes, hypertension, dyslipidemia, smoking, family history of coronary artery disease, WISE coronary artery disease severity score, and aspirin use.

NEW ORLEANS – The use of proton pump inhibitors (PPIs) was associated with significantly increased risk of having a first ischemic stroke in a large nationwide Danish cohort study, Thomas S. Sehested, MD, reported at the American Heart Association scientific sessions.

The relationship was dose dependent. At the lowest available dose of each of the four PPIs studied there was no significantly increased risk. At the intermediate doses of three of the four PPIs studied, the increased risk of ischemic stroke became statistically significant. And the highest dose of each drug was associated with the greatest ischemic stroke risk.

Bruce Jancin/Frontline Medical News

[email protected]

NEW ORLEANS – The use of proton pump inhibitors (PPIs) was associated with significantly increased risk of having a first ischemic stroke in a large nationwide Danish cohort study, Thomas S. Sehested, MD, reported at the American Heart Association scientific sessions.

The relationship was dose dependent. At the lowest available dose of each of the four PPIs studied there was no significantly increased risk. At the intermediate doses of three of the four PPIs studied, the increased risk of ischemic stroke became statistically significant. And the highest dose of each drug was associated with the greatest ischemic stroke risk.

Bruce Jancin/Frontline Medical News

[email protected]

NEW ORLEANS – The use of proton pump inhibitors (PPIs) was associated with significantly increased risk of having a first ischemic stroke in a large nationwide Danish cohort study, Thomas S. Sehested, MD, reported at the American Heart Association scientific sessions.

The relationship was dose dependent. At the lowest available dose of each of the four PPIs studied there was no significantly increased risk. At the intermediate doses of three of the four PPIs studied, the increased risk of ischemic stroke became statistically significant. And the highest dose of each drug was associated with the greatest ischemic stroke risk.

Bruce Jancin/Frontline Medical News

[email protected]

Nearly 2 decades ago, I was a pediatric infectious diseases fellow fielding a call from a community pediatrician seeking advice on patient management. The patient in question was a 15-year-old male with fever, rash, and cervical adenopathy – a good clinical story for Epstein-Barr virus infection. A heterophile antibody test was negative, however, as were EBV titers.

We talked for a couple of minutes about the vagaries of EBV testing, as well as other organisms that could cause a mononucleosis-like illness. “Cytomegalovirus is a possibility, along with toxoplasmosis,” I told him. “I’d also test for HIV.”

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville, Ky., and Kosair Children’s Hospital, also in Louisville. Email her at [email protected].

Nearly 2 decades ago, I was a pediatric infectious diseases fellow fielding a call from a community pediatrician seeking advice on patient management. The patient in question was a 15-year-old male with fever, rash, and cervical adenopathy – a good clinical story for Epstein-Barr virus infection. A heterophile antibody test was negative, however, as were EBV titers.

We talked for a couple of minutes about the vagaries of EBV testing, as well as other organisms that could cause a mononucleosis-like illness. “Cytomegalovirus is a possibility, along with toxoplasmosis,” I told him. “I’d also test for HIV.”

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville, Ky., and Kosair Children’s Hospital, also in Louisville. Email her at [email protected].

Nearly 2 decades ago, I was a pediatric infectious diseases fellow fielding a call from a community pediatrician seeking advice on patient management. The patient in question was a 15-year-old male with fever, rash, and cervical adenopathy – a good clinical story for Epstein-Barr virus infection. A heterophile antibody test was negative, however, as were EBV titers.

We talked for a couple of minutes about the vagaries of EBV testing, as well as other organisms that could cause a mononucleosis-like illness. “Cytomegalovirus is a possibility, along with toxoplasmosis,” I told him. “I’d also test for HIV.”

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville, Ky., and Kosair Children’s Hospital, also in Louisville. Email her at [email protected].

Dallas dermatologist Alan Menter, MD, doesn’t boast bullying-prevention superpowers, but what he does have is close enough: An eagerness to get the word out to anyone – parent or principal, psychologist or pediatrician – who can help prevent a child with psoriasis from being bullied.

Over his long career, Dr. Menter has made many calls to adults in positions of influence over children. “I’ve talked to pediatricians, and I’ve even called up schools and talked to principals to try get the bullying situation reduced to an extent where the kids can live happy, normal lives without kids taunting them.”

Dr. Menter, chief of dermatology at Baylor University in Dallas, has plenty of company. Other dermatologists are paying close attention to their youngest patients with psoriasis as researchers work to get a better handle on the bullying problem.

[email protected]

Dallas dermatologist Alan Menter, MD, doesn’t boast bullying-prevention superpowers, but what he does have is close enough: An eagerness to get the word out to anyone – parent or principal, psychologist or pediatrician – who can help prevent a child with psoriasis from being bullied.

Over his long career, Dr. Menter has made many calls to adults in positions of influence over children. “I’ve talked to pediatricians, and I’ve even called up schools and talked to principals to try get the bullying situation reduced to an extent where the kids can live happy, normal lives without kids taunting them.”

Dr. Menter, chief of dermatology at Baylor University in Dallas, has plenty of company. Other dermatologists are paying close attention to their youngest patients with psoriasis as researchers work to get a better handle on the bullying problem.

[email protected]

Dallas dermatologist Alan Menter, MD, doesn’t boast bullying-prevention superpowers, but what he does have is close enough: An eagerness to get the word out to anyone – parent or principal, psychologist or pediatrician – who can help prevent a child with psoriasis from being bullied.

Over his long career, Dr. Menter has made many calls to adults in positions of influence over children. “I’ve talked to pediatricians, and I’ve even called up schools and talked to principals to try get the bullying situation reduced to an extent where the kids can live happy, normal lives without kids taunting them.”

Dr. Menter, chief of dermatology at Baylor University in Dallas, has plenty of company. Other dermatologists are paying close attention to their youngest patients with psoriasis as researchers work to get a better handle on the bullying problem.

[email protected]

Patients with double-hit lymphomas (DHLs) and double-expressor lymphomas (DELs) have inferior outcomes after undergoing autologous stem cell transplantation (ASCT), according to a new study published in the Journal of Clinical Oncology.

The worst outcomes were observed in patients with concurrent DELs and DHLs, and this “supports the concept that the double-hit/double-expressor biology appears to render DLBCL resistant to and less likely to be cured by chemotherapy,” write Alex Herrera, MD, an oncologist at the City of Hope, Duarte, Calif., and his colleagues.

But that said, a significant proportion of patients with relapsed/refractory DEL did experience durable remissions following ASCT, particularly those with isolated DEL without DHL.

This suggests that “the presence of DEL alone should not be considered a contraindication to ASCT,” the authors wrote (J Clin Oncol. 2016 Oct. 24. doi: 10.1200/JCO.2016.68.2740).

DHLs and DELs are subtypes of diffuse large B-cell lymphoma (DLBCL), and while they are associated with poor outcomes after standard chemoimmunotherapy, data remain limited as to outcomes of patients with relapsed or refractory disease who undergo ASCT.

The retrospective multicenter study included 117 patients with chemotherapy-sensitive relapsed/refractory DLBCL who underwent ASCT and had archival tumor material available. DEL with MYC/BCL2 coexpression was observed in 52 patients (44%) while 15 patients expressed MYC-R (13%), of whom 12 (10%) had DHL.

The median follow-up time was 45 months for survivors, and the 4-year progression-free survival (PFS) and overall survival (OS) were 54% for the entire cohort.

The 4-year PFS and OS in patients with DHL was worse as compared to those without DHL; 28% vs. 57% (P = .013), and 25% vs. 66% (P less than .001), respectively.

Those with DHL had poorer PFS (28%) and OS (25%), compared with patients with DEL but not DHL (PFS, 53% and OS, 61%) as well as patients with neither DEL nor DHL (PFS, 60% and OS, 70%; three-way P value for PFS, P = .013; OS, P = .002).

Patients with concurrent DEL and DHL had the poorest outcome, with a 4-year PFS of 0%.

After researchers adjusted for clinical characteristics, the only factors that remained significantly associated with PFS were DEL (hazard ratio, 1.8; P = .035) and DHL (HR, 2.9; P = .009). Factors that were significantly associated with OS were DHL (HR, 3.4; P = .004) and remission status at ASCT (HR for partial response, 2.4; P = .007).

Overall, patients with DHL were less likely to achieve a complete response following salvage therapy, and those with DEL and patients with DHL had a shorter time to relapse after induction therapy.

“Although some patients with relapsed/refractory DHL had long-term remission after ASCT (isolated DHL without DEL), the low survival rate in this group argues that alternative transplantation strategies, including allogeneic hematopoietic stem cell transplantation or peri-ASCT relapse prevention strategies should be studied,” they concluded.

Patients with double-hit lymphomas (DHLs) and double-expressor lymphomas (DELs) have inferior outcomes after undergoing autologous stem cell transplantation (ASCT), according to a new study published in the Journal of Clinical Oncology.

The worst outcomes were observed in patients with concurrent DELs and DHLs, and this “supports the concept that the double-hit/double-expressor biology appears to render DLBCL resistant to and less likely to be cured by chemotherapy,” write Alex Herrera, MD, an oncologist at the City of Hope, Duarte, Calif., and his colleagues.

But that said, a significant proportion of patients with relapsed/refractory DEL did experience durable remissions following ASCT, particularly those with isolated DEL without DHL.

This suggests that “the presence of DEL alone should not be considered a contraindication to ASCT,” the authors wrote (J Clin Oncol. 2016 Oct. 24. doi: 10.1200/JCO.2016.68.2740).

DHLs and DELs are subtypes of diffuse large B-cell lymphoma (DLBCL), and while they are associated with poor outcomes after standard chemoimmunotherapy, data remain limited as to outcomes of patients with relapsed or refractory disease who undergo ASCT.

The retrospective multicenter study included 117 patients with chemotherapy-sensitive relapsed/refractory DLBCL who underwent ASCT and had archival tumor material available. DEL with MYC/BCL2 coexpression was observed in 52 patients (44%) while 15 patients expressed MYC-R (13%), of whom 12 (10%) had DHL.

The median follow-up time was 45 months for survivors, and the 4-year progression-free survival (PFS) and overall survival (OS) were 54% for the entire cohort.

The 4-year PFS and OS in patients with DHL was worse as compared to those without DHL; 28% vs. 57% (P = .013), and 25% vs. 66% (P less than .001), respectively.

Those with DHL had poorer PFS (28%) and OS (25%), compared with patients with DEL but not DHL (PFS, 53% and OS, 61%) as well as patients with neither DEL nor DHL (PFS, 60% and OS, 70%; three-way P value for PFS, P = .013; OS, P = .002).

Patients with concurrent DEL and DHL had the poorest outcome, with a 4-year PFS of 0%.

After researchers adjusted for clinical characteristics, the only factors that remained significantly associated with PFS were DEL (hazard ratio, 1.8; P = .035) and DHL (HR, 2.9; P = .009). Factors that were significantly associated with OS were DHL (HR, 3.4; P = .004) and remission status at ASCT (HR for partial response, 2.4; P = .007).

Overall, patients with DHL were less likely to achieve a complete response following salvage therapy, and those with DEL and patients with DHL had a shorter time to relapse after induction therapy.

“Although some patients with relapsed/refractory DHL had long-term remission after ASCT (isolated DHL without DEL), the low survival rate in this group argues that alternative transplantation strategies, including allogeneic hematopoietic stem cell transplantation or peri-ASCT relapse prevention strategies should be studied,” they concluded.

Patients with double-hit lymphomas (DHLs) and double-expressor lymphomas (DELs) have inferior outcomes after undergoing autologous stem cell transplantation (ASCT), according to a new study published in the Journal of Clinical Oncology.

The worst outcomes were observed in patients with concurrent DELs and DHLs, and this “supports the concept that the double-hit/double-expressor biology appears to render DLBCL resistant to and less likely to be cured by chemotherapy,” write Alex Herrera, MD, an oncologist at the City of Hope, Duarte, Calif., and his colleagues.

But that said, a significant proportion of patients with relapsed/refractory DEL did experience durable remissions following ASCT, particularly those with isolated DEL without DHL.

This suggests that “the presence of DEL alone should not be considered a contraindication to ASCT,” the authors wrote (J Clin Oncol. 2016 Oct. 24. doi: 10.1200/JCO.2016.68.2740).

DHLs and DELs are subtypes of diffuse large B-cell lymphoma (DLBCL), and while they are associated with poor outcomes after standard chemoimmunotherapy, data remain limited as to outcomes of patients with relapsed or refractory disease who undergo ASCT.

The retrospective multicenter study included 117 patients with chemotherapy-sensitive relapsed/refractory DLBCL who underwent ASCT and had archival tumor material available. DEL with MYC/BCL2 coexpression was observed in 52 patients (44%) while 15 patients expressed MYC-R (13%), of whom 12 (10%) had DHL.

The median follow-up time was 45 months for survivors, and the 4-year progression-free survival (PFS) and overall survival (OS) were 54% for the entire cohort.

The 4-year PFS and OS in patients with DHL was worse as compared to those without DHL; 28% vs. 57% (P = .013), and 25% vs. 66% (P less than .001), respectively.

Those with DHL had poorer PFS (28%) and OS (25%), compared with patients with DEL but not DHL (PFS, 53% and OS, 61%) as well as patients with neither DEL nor DHL (PFS, 60% and OS, 70%; three-way P value for PFS, P = .013; OS, P = .002).

Patients with concurrent DEL and DHL had the poorest outcome, with a 4-year PFS of 0%.

After researchers adjusted for clinical characteristics, the only factors that remained significantly associated with PFS were DEL (hazard ratio, 1.8; P = .035) and DHL (HR, 2.9; P = .009). Factors that were significantly associated with OS were DHL (HR, 3.4; P = .004) and remission status at ASCT (HR for partial response, 2.4; P = .007).

Overall, patients with DHL were less likely to achieve a complete response following salvage therapy, and those with DEL and patients with DHL had a shorter time to relapse after induction therapy.

“Although some patients with relapsed/refractory DHL had long-term remission after ASCT (isolated DHL without DEL), the low survival rate in this group argues that alternative transplantation strategies, including allogeneic hematopoietic stem cell transplantation or peri-ASCT relapse prevention strategies should be studied,” they concluded.

SAN DIEGO – Long-term cystic fibrosis survivors are prone to a singular form of diabetes, according to Katie Larson Ode, MD.

Medical advances have dramatically boosted life expectancy for people with cystic fibrosis, allowing some to survive into middle age. “As more of our patients live longer, [cystic fibrosis–related diabetes (CFRD)] will become a much more common problem for endocrinologists, educators, nurses, and nutritionists to address,” said Dr. Ode, a pediatrician at the University of Iowa in Iowa City. “Proper management of cystic fibrosis-related diabetes is lifesaving for our CF patients.”

In the 1950s, few children with CF lived past elementary school age. Now, researchers estimate that the median life span for babies born and diagnosed in 2010 could reach more than 50 years (Ann Intern Med. 2014 Aug 19;161[4]:233-41), according to the Cystic Fibrosis Foundation.

But as they age, CF patients’ risk for CFRD also increases.

A 2009 study led by Dr. Moran (Diabetes Care 2009 Sep;32[9]: 1626-31) tracked 872 CF patients from three periods in the 1990s and 2000s and found CFRD in 2% of children, 19% of adolescents, and 40%-50% of adults. “For a typical CF patient, the chances of developing CFRD by age 40 are roughly 80%,” said Andrew Norris, MD, PhD, of the departments of pediatrics and biochemistry at the University of Iowa.

What’s next? The University of Iowa’s Dr. Larson said he is hopeful about advances in medical care. “Currently, patients must follow an extremely complex regimen of airway clearance, inhaled antibiotics, and oral medications, typically with recurrent hospitalization with increasing age and eventual death from lung disease or lung transplant,” she said. “However, in the past few years, we have had a dramatic change for a percentage of our patients with the development of small molecules that can actually fix the chloride-channel defect itself.”

The treatment seems to arrest and even improve lung disease in eligible patients, she said. “So the future seems very bright for CF.”

The Cystic Fibrosis Foundation has developed a 3-year Envision program to train adult and pediatric endocrinologists in the care of CFRD and endocrine issues.

Dr. Moran had no relevant disclosures. Dr. Norris has consulted for Vertex Pharmaceuticals, which makes cystic fibrosis therapeutics, in the past year. Dr. Larson Ode reports that her research is funded by the National Institutes of Health and the Cystic Fibrosis Foundation.

SAN DIEGO – Long-term cystic fibrosis survivors are prone to a singular form of diabetes, according to Katie Larson Ode, MD.

Medical advances have dramatically boosted life expectancy for people with cystic fibrosis, allowing some to survive into middle age. “As more of our patients live longer, [cystic fibrosis–related diabetes (CFRD)] will become a much more common problem for endocrinologists, educators, nurses, and nutritionists to address,” said Dr. Ode, a pediatrician at the University of Iowa in Iowa City. “Proper management of cystic fibrosis-related diabetes is lifesaving for our CF patients.”

In the 1950s, few children with CF lived past elementary school age. Now, researchers estimate that the median life span for babies born and diagnosed in 2010 could reach more than 50 years (Ann Intern Med. 2014 Aug 19;161[4]:233-41), according to the Cystic Fibrosis Foundation.

But as they age, CF patients’ risk for CFRD also increases.

A 2009 study led by Dr. Moran (Diabetes Care 2009 Sep;32[9]: 1626-31) tracked 872 CF patients from three periods in the 1990s and 2000s and found CFRD in 2% of children, 19% of adolescents, and 40%-50% of adults. “For a typical CF patient, the chances of developing CFRD by age 40 are roughly 80%,” said Andrew Norris, MD, PhD, of the departments of pediatrics and biochemistry at the University of Iowa.

What’s next? The University of Iowa’s Dr. Larson said he is hopeful about advances in medical care. “Currently, patients must follow an extremely complex regimen of airway clearance, inhaled antibiotics, and oral medications, typically with recurrent hospitalization with increasing age and eventual death from lung disease or lung transplant,” she said. “However, in the past few years, we have had a dramatic change for a percentage of our patients with the development of small molecules that can actually fix the chloride-channel defect itself.”

The treatment seems to arrest and even improve lung disease in eligible patients, she said. “So the future seems very bright for CF.”

The Cystic Fibrosis Foundation has developed a 3-year Envision program to train adult and pediatric endocrinologists in the care of CFRD and endocrine issues.

Dr. Moran had no relevant disclosures. Dr. Norris has consulted for Vertex Pharmaceuticals, which makes cystic fibrosis therapeutics, in the past year. Dr. Larson Ode reports that her research is funded by the National Institutes of Health and the Cystic Fibrosis Foundation.

SAN DIEGO – Long-term cystic fibrosis survivors are prone to a singular form of diabetes, according to Katie Larson Ode, MD.

Medical advances have dramatically boosted life expectancy for people with cystic fibrosis, allowing some to survive into middle age. “As more of our patients live longer, [cystic fibrosis–related diabetes (CFRD)] will become a much more common problem for endocrinologists, educators, nurses, and nutritionists to address,” said Dr. Ode, a pediatrician at the University of Iowa in Iowa City. “Proper management of cystic fibrosis-related diabetes is lifesaving for our CF patients.”

In the 1950s, few children with CF lived past elementary school age. Now, researchers estimate that the median life span for babies born and diagnosed in 2010 could reach more than 50 years (Ann Intern Med. 2014 Aug 19;161[4]:233-41), according to the Cystic Fibrosis Foundation.

But as they age, CF patients’ risk for CFRD also increases.

A 2009 study led by Dr. Moran (Diabetes Care 2009 Sep;32[9]: 1626-31) tracked 872 CF patients from three periods in the 1990s and 2000s and found CFRD in 2% of children, 19% of adolescents, and 40%-50% of adults. “For a typical CF patient, the chances of developing CFRD by age 40 are roughly 80%,” said Andrew Norris, MD, PhD, of the departments of pediatrics and biochemistry at the University of Iowa.

What’s next? The University of Iowa’s Dr. Larson said he is hopeful about advances in medical care. “Currently, patients must follow an extremely complex regimen of airway clearance, inhaled antibiotics, and oral medications, typically with recurrent hospitalization with increasing age and eventual death from lung disease or lung transplant,” she said. “However, in the past few years, we have had a dramatic change for a percentage of our patients with the development of small molecules that can actually fix the chloride-channel defect itself.”

The treatment seems to arrest and even improve lung disease in eligible patients, she said. “So the future seems very bright for CF.”

The Cystic Fibrosis Foundation has developed a 3-year Envision program to train adult and pediatric endocrinologists in the care of CFRD and endocrine issues.

Dr. Moran had no relevant disclosures. Dr. Norris has consulted for Vertex Pharmaceuticals, which makes cystic fibrosis therapeutics, in the past year. Dr. Larson Ode reports that her research is funded by the National Institutes of Health and the Cystic Fibrosis Foundation.