Department of Medicine, University of California, San Francisco, CA; Division of Nephrology, San Francisco VA Medical Center, San Francisco, CA.
Department of Medicine, University of California, San Francisco, CA; Division of Nephrology, San Francisco VA Medical Center, San Francisco, CA; Department of Epidemiology & Biostatistics, University of California, San Francisco, CA.
Am J Kidney Dis. 2019 Apr;73(4):525-532. doi: 10.1053/j.ajkd.2018.11.008. Epub 2019 Jan 11.
RATIONALE & OBJECTIVE: Muscle relaxants are often used to treat musculoskeletal pain or cramping, which are commonly experienced by hemodialysis patients. However, the extent to which muscle relaxants are prescribed in this population and the risks associated with their use have not been characterized.
Observational cohort study.
SETTING & PARTICIPANTS: 140,899 Medicare-covered adults receiving hemodialysis in 2011, identified in the US Renal Data System.
Time-varying muscle relaxant exposure.
Primary outcomes were time to first emergency department visit or hospitalization for altered mental status, fall, or fracture. Secondary outcomes were death and composites of death with each of the primary outcomes.
Multivariable Cox regression analysis.
10% of patients received muscle relaxants in 2011. 11%, 6%, 3%, and 13% had an episode of altered mental status, fall, fracture, and death, respectively. Muscle relaxant use was associated with higher risk for altered mental status (HR, 1.39; 95% CI, 1.29-1.51) and fall (HR, 1.18; 95% CI, 1.05-1.33) compared to no use. Muscle relaxant use was not statistically significantly associated with higher risk for fracture (HR, 1.17; 95% CI, 0.98-1.39). Muscle relaxant use was associated with lower hazard of death (HR, 0.85; 95% CI, 0.76-0.94). However, hazards were higher for altered mental status or death (HR, 1.17; 95% CI, 1.10-1.25), fall or death (HR, 1.14; 95% CI, 1.06-1.22), and fracture or death (HR, 1.10; 95% CI, 1.01-1.20).
A causal association between muscle relaxant use and outcomes cannot be inferred, and residual confounding cannot be excluded. Exposure and outcomes were ascertained using administrative claims.
Muscle relaxant use was common in hemodialysis patients and associated with altered mental status and falls. We could not rule out a clinically meaningful association between muscle relaxant use and fracture. The lower risk for death with muscle relaxants may have been the result of residual confounding. Future research to define the appropriate use of muscle relaxants in this population is warranted.
肌肉松弛剂常用于治疗血液透析患者常经历的肌肉骨骼疼痛或痉挛。然而，该人群中肌肉松弛剂的使用程度以及与使用相关的风险尚未确定。
观察性队列研究。
2011 年在美国肾脏数据系统中确定的 140899 名接受血液透析的医疗保险覆盖的成年人。
随时间变化的肌肉松弛剂暴露。
2011 年，10%的患者使用了肌肉松弛剂。分别有 11%、6%、3%和 13%的患者出现了精神状态改变、跌倒、骨折和死亡。与未使用肌肉松弛剂相比，使用肌肉松弛剂与精神状态改变（HR，1.39；95%CI，1.29-1.51）和跌倒（HR，1.18；95%CI，1.05-1.33）的风险更高相关。肌肉松弛剂的使用与骨折风险的升高无统计学显著相关性（HR，1.17；95%CI，0.98-1.39）。肌肉松弛剂的使用与死亡风险降低相关（HR，0.85；95%CI，0.76-0.94）。然而，精神状态改变或死亡（HR，1.17；95%CI，1.10-1.25）、跌倒或死亡（HR，1.14；95%CI，1.06-1.22）、骨折或死亡（HR，1.10；95%CI，1.01-1.20）的风险更高。
不能推断肌肉松弛剂使用与结局之间存在因果关系，也不能排除残留混杂因素。暴露和结局是通过行政索赔确定的。
肌肉松弛剂在血液透析患者中很常见，与精神状态改变和跌倒有关。我们不能排除肌肉松弛剂使用与骨折之间存在临床有意义的关联。肌肉松弛剂降低死亡风险可能是残留混杂因素的结果。需要进一步研究以确定该人群中肌肉松弛剂的适当使用。
