HEART FAILURE

EHR alert may increase life-saving prescriptions

According to a study published in the Journal of the American College of Cardiology, tools embedded in the electronic health record (EHR) may increase the prescription of life-saving therapies for patients with heart failure with reduced ejection fraction (HFrEF).¹

Mineralocorticoid receptor antagonists (MRAs) were specifically included because MRAs are underprescribed for patients with HFrEF.

Researchers conducted a three-arm, pragmatic, cluster-randomized trial comparing the effectiveness of an alert during individual patient encounters versus a message about multiple patients between encounters versus usual care on MRA prescribing. Patients were cluster-randomized by a cardiologist (60 per arm). Inclusion criteria were adult patients with HFrEF, no active MRA prescription, no contraindication to MRA, and an outpatient cardiologist in a large health system.

In total, 2,211 patients were included: 755 for the alert, 812 for the message, and 644 for usual care (control). The average age was 72.2 years, the average EF was 33%. Patients were predominantly male and White.

New MRA prescribing was noted for 29.6% in the alert arm, 15.6% in the message arm, and 11.6% in the control arm. In addition, researchers found the alert more than doubled MRA prescribing compared with the control and improved MRA prescribing compared with the message.

Reference: 1. Mukhopadhyay A, Reynolds HR, Phillips LM, et al Cluster-randomized trial comparing ambulatory decision support tools to improve heart failure care. J Am Coll Cardiol. 2023;81(14):1303-1316. doi:10.1016/j.jacc.2023.02.005.

NEURODEGENERATION

New guidelines to recognize N₂O-induced degeneration

Authors of a paper published in Practical Neurology have reportedly developed the first guidelines to recognize, investigate, and treat nitrous oxide-induced subacute combined degeneration of the cord (N₂O-SACD).

The authors claim that the recreational use of nitrous oxide (N₂O) has increased rapidly in recent years and is now the second most commonly used recreational drug among young people in the United Kingdom.

N₂O-SACD is a pattern of myeloneuropathy usually associated with severe vitamin B₁₂ deficiency, the authors write. It can cause serious and permanent disability but, if recognized early, may be effectively treated. The initial presenting complaint is often distal paresthesia involving the lower and/or upper limbs. If the patient ignores this or if N₂O-SACD is not diagnosed at presentation, patients may then develop gait ataxia (worse in low lighting), falls, or inability to walk independently.

Reference: 1. Paris A, Lake L, Joseph A, et al Nitrous oxide-induced subacute combined degeneration of the cord: diagnosis and treatment. Pract Neurol. [e-pub Feb. 22, 2023]

LOWER BACK PAIN

Effectiveness of nonopioid pharmacotherapy

According to a paper published in the Journal of Orthopedic Research, nonsteroidal anti-inflammatory drugs (NSAIDs) can be efficiently and effectively employed in the management of patients with acute low back pain (LBP).

However, the authors stress that clinicians also consider other strategies, such as the association with paracetamol or the use of myorelaxants.

The authors conducted a systematic review of randomized controlled trials investigating the efficacy of myorelaxants, NSAIDs, and paracetamol for acute LBP. They specifically included studies that investigated the lumbar spine and involved patients with acute LBP with symptom duration of less than 12 weeks. The authors did not consider studies investigating use of opioids in acute LBP. Data from 18 studies and 3,478 patients were available.

Overall, myorelaxants and NSAIDs were effective in reducing pain and disability in acute LBP at approximately 1 week, the combination of NSAIDs and paracetamol was associated with a greater improvement than monotherapy with NSAIDs, paracetamol alone did not promote any significant improvement in clinical outcomes, and placebo was not effective in reducing pain. The authors concluded that myorelaxants, NSAIDs, and NSAIDs with paracetamol could reduce pain and disability in patients with acute LBP.

Reference: 1. Baroncini A, Maffulli N, Al-Zyoud H, Bell A, Sevic A, Migliorini F. Nonopioid pharmacological management of acute low back pain: a level I of evidence systematic review. J Orthop Res. [e-pub Feb. 22, 2023]

OPIOIDS

Opioids most common substance contributing to pediatric death

Opioids were found to be the most common substances contributing to fatal pediatric poisonings, highlighting the importance of tailored prevention measures, according to a paper published in Pediatrics.¹

Researchers analyzed deaths attributed to poisonings among children younger than 5 years from 2005 to 2018. These data were collected from 40 states participating in the National Fatality Review-Case Reporting System. Demographic, supervisor, death investigation, and substance-related variables using descriptive statistics were specifically analyzed.

Results included 731 poisoning-related fatalities. About 42% occurred among infants less than 1 year old. Over half (65.1%) of fatalities occurred in the child's home. In about 16% of cases, a child protective services case was open at the time of the child's death. About one-third (32.2%) of instances of death were supervised by an individual other than the biological parent.

Opioids were the most common substance contributing to death (43.7% of cases). In 2005, opioids were 24.1% of the substances contributing to death, and 52.2% in 2018.

Over-the-counter pain, cold, and allergy medications were the next largest group contributing to pediatric death (14.8%).

Reference: 1. Gaw CE, Curry AE, Osterhoudt KC, Wood JN, Corwin DJ.Characteristics of fatal poisonings among infants and young children in the United States. Pediatrics. 2023;151(4):e2022059016.

NEPHROPATHY

FDA approves drug for reduction of proteinuria

The FDA has granted accelerated approval to sparsentan (FILSPARI), an endothelin and angiotensin II receptor antagonist, for the reduction of proteinuria in adults with primary immunoglobulin A nephropathy (IgAN) at risk for rapid disease progression.¹ The FDA is still evaluating whether the drug slows kidney function decline in patients with IgAN. Continued approval is contingent upon verification and description of clinical benefit in a confirmatory clinical trial.²

Sparsentan has a boxed warning indicating it is only available through a specific risk evaluation and mitigation strategies program due to hepatotoxicity and embryo-fetal toxicity.

Clinicians should measure serum aminotransferases and total bilirubin levels before initiating treatment, and alanine aminotransferase and aspartate aminotransferase monthly for 12 months, then every 3 months during treatment. If aminotransferase elevations are more than 3x Upper Limit of Normal, treatment should be interrupted and the patient should be closely monitored.

Sparsentan is contraindicated in pregnancy and for any patient who is on angiotensin receptor blockers, endothelin receptor antagonists, or aliskiren.

Other warnings and precautions issued in the prescribing information include hypotension, acute kidney injury, hyperkalemia, and fluid retention. The most common adverse events reported with the use of sparsentan are peripheral edema, hypotension (including orthostatic hypotension), dizziness, hyperkalemia, and anemia.

References: 1. Travere Therapeutics announces FDA accelerated approval of FILSPARI(TM) (Sparsentan), the first and only non-immunosuppressive therapy for the reduction of proteinuria in IGA nephropathy. Travere Therapeutics, Inc. 2023. https://ir.travere.com/news-releases/news-release-details/travere-therapeutics-a. Accessed March 9, 2023.

2. FILSPARI Prescribing Information. 2023.