Department of Neurology, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA.
Department of Public Health Sciences, Social and Scientific Systems, Silver Spring, Maryland, USA.
Am J Nephrol. 2020;51(6):424-432. doi: 10.1159/000507725. Epub 2020 May 19.
The opioid epidemic is a public health emergency and appropriate medication prescription for pain remains challenging. Physicians have increasingly prescribed gabapentinoids for pain despite limited evidence supporting their use. We determined the prevalence of concomitant gabapentinoid and opioid prescriptions and evaluated their associations with outcomes among dialysis patients.
We used the United States Renal Data System to identify patients treated with dialysis with Part A, B, and D coverage for all of 2010. Patients were grouped into 4 categories of drugs exposure status in 2010: (1) no prescriptions of either an opioid or gabapentinoid, (2) ≥1 prescription of an opioid and no prescriptions of gabapentinoids, (3) no prescriptions of an opioid and ≥1 prescription of gabapenbtinoids, (4) ≥1 prescription of both an opioid and gabapentinoid. Outcomes included 2-year all-cause death, dialysis discontinuation, and hospitalizations assessed in 2011 and 2012.
The study population included 153,758 dialysis patients. Concomitant prescription of an opioid and gabapentin (15%) was more common than concomitant prescription of an opioid and pregabalin (4%). In adjusted analyses, concomitant prescription of an opioid and gabapentin compared to no prescription of either was associated with increased risk of death (hazard ratio [HR] 1.16, 95% CI 1.12-1.19), dialysis discontinuation (HR 1.14, 95% CI 1.03-1.27), and hospitalization (HR 1.33, 95% CI 1.31-1.36). Concomitant prescription of an opioid and pregabalin compared to no prescription of either was associated with increased mortality (HR 1.22, 95% CI 1.16-1.28) and hospitalization (HR 1.37, 95% CI 1.33-1.41), but not dialysis discontinuation (HR 1.13, 95% CI 0.95-1.35). Prescription of opioids and gabepentinoids compared to only being prescribed opioids was associated with higher risk of hospitalizations, but not mortality, or dialysis discontinuation.
Concomitant prescription of opioids and gabapentinoids among US dialysis patients is common, and both drugs have independent effects on outcomes. Future research should prospectively investigate the potential harms of such drugs and identify safer alternatives for treatment of pain in end-stage renal disease patients.
阿片类药物泛滥是公共卫生紧急事件，而疼痛的适当药物处方仍然具有挑战性。尽管没有证据支持其使用，但医生还是越来越多地开加巴喷丁类药物治疗疼痛。我们确定了同时开加巴喷丁类药物和阿片类药物处方的流行情况，并评估了它们与透析患者结局的关系。
我们使用美国肾脏数据系统（United States Renal Data System）确定了 2010 年所有接受 A、B 和 D 部分治疗的透析患者。患者根据 2010 年的药物暴露状态分为 4 组：（1）未同时开具阿片类药物或加巴喷丁类药物处方；（2）同时开具阿片类药物处方，但未开具加巴喷丁类药物处方；（3）未同时开具阿片类药物和加巴喷丁类药物处方，但开具了加巴喷丁类药物处方；（4）同时开具阿片类药物和加巴喷丁类药物处方。结局包括 2011 年和 2012 年评估的 2 年全因死亡、透析终止和住院。
研究人群包括 153758 名透析患者。同时开具阿片类药物和加巴喷丁（15%）处方比同时开具阿片类药物和普瑞巴林（4%）处方更为常见。在调整分析中，与未同时开具阿片类药物和加巴喷丁类药物相比，同时开具阿片类药物和加巴喷丁类药物与死亡风险增加相关（风险比 [HR] 1.16，95%CI 1.12-1.19）、透析终止（HR 1.14，95%CI 1.03-1.27）和住院（HR 1.33，95%CI 1.31-1.36）。与未同时开具阿片类药物和加巴喷丁类药物相比，同时开具阿片类药物和普瑞巴林与死亡率增加相关（HR 1.22，95%CI 1.16-1.28）和住院（HR 1.37，95%CI 1.33-1.41），但与透析终止无关（HR 1.13，95%CI 0.95-1.35）。与仅开具阿片类药物相比，同时开具阿片类药物和加巴喷丁类药物与住院风险增加相关，但与死亡率或透析终止无关。
美国透析患者同时开具阿片类药物和加巴喷丁类药物的情况很常见，这两种药物对结局都有独立的影响。未来的研究应该前瞻性地调查这些药物的潜在危害，并确定更安全的替代药物，以治疗终末期肾病患者的疼痛。
