ARBs and ACE inhibitor use remained unchanged

The emergence of Covid-19 was associated with small but statistically significant increases in prescriptions for psychotropic, anticonvulsant, and opioid medications among residents of nursing homes in Ontario, Canada, researchers reported.

In a pharmacology study involving 630 nursing homes, increases were recorded in the use of antipsychotics, benzodiazepines, antidepressants, anticonvulsants, and opioids in the early months of the Covid-19 pandemic, while no significant changes were found in the prescribing of antibiotics, angiotensin receptor blockers (ARBs), or angiotensin-converting enzyme (ACE) inhibitors.

The findings, published Aug. 2 in JAMA Network Open, suggest that the Covid-19 pandemic may have negatively impacted a decade-long effort to reduce the inappropriate use of antipsychotics, benzodiazepines, and opioids within nursing homes, wrote researcher Michael Campitelli, MPH, of the Institute for Clinical Evaluative Sciences, Toronto, and colleagues.

They noted that while absolute increases in psychotropic prescriptions were small during the first wave of the pandemic, this research finding and those of another recently published cross sectional nursing home study conducted in Ontario add support to concerns of inappropriate prescribing.

“Although a rise in short-term use of psychotropics may be appropriate because of a greater prevalence of accepted indications and diminished access to non-pharmacological options, studies in other populations show high rates of persistence in the use of these medications after initiation,” they wrote, adding that “[p]eriodic medication reviews for residents should target psychotropics prescribed during the pandemic to minimize inappropriate persistence in their use.”

Early in the Covid-19 pandemic, there were reports—later proven to be unfounded—that ARBs and ACE inhibitors might be associated with worse Covid-19 outcomes or increased susceptibility to SARS-CoV-2.

“The finding of no significant change in the dispensation of ARBs and ACE inhibitors after the pandemic among Ontario nursing home residents, despite these initial reports, is important given that the abrupt withdrawal of these medications can be harmful,” the researchers wrote.

Campitelli and colleagues conducted an interrupted time-series analysis in their attempt to expose how Covid-19 and related disturbances in care may have affected the dispensation of medications commonly prescribed to nursing home residents.

The study included data from all nursing homes (n=630) in Ontario, and residents were divided into consecutive weekly cohorts during different observation periods, beginning March 5-11, 2017, and ending September 20-26, 2020.

Across study years, the annual cohort size ranged from 75,850 to 76,549 residents (mean [SD] age, 83.4 [10.8] years; roughly 70% female).

Significant increased slope change observed in the weekly proportion of residents dispensed included:

  • Antipsychotics (parameter estimate [β]=0.051; standard error [SE]=0.010; P<0 .001).
  • Benzodiazepines (β=0.026; SE=0.003; P<0.001), antidepressants (β=0.046; SE=0.013; P<0.001), trazodone hydrochloride (β=0.033; SE=0.010; P<0.001).
  • Anticonvulsants (β=0.014; SE=0.006; P=0.03).
  • Opioids (β=0.038; SE=0.007; P<0.001).

The absolute difference in observed versus estimated use in the last week of the pandemic period ranged from 0.48% (for anticonvulsants) to 1.52% (for antipsychotics).

In commentary published with the study, Nathan Stall, MD, who conducted the previously published cross-sectional Ontario nursing home study, along with colleagues from the University of Toronto, wrote that beyond the data on drug prescribing, the study by Campitelli et al, “provide[s] us with an important opportunity to reflect on the consequences of isolating nursing home residents with frailty and cognitive decline and restricting them from visits from loved ones and essential caregivers for their own safety.”

“The pressure of the Covid-19 pandemic has revealed critical vulnerabilities in the long-term care system, including the longstanding devaluation of essential family caregivers,” they wrote. “In the wake of this pandemic, long-term care systems must have inviolable safeguards in place that allow residents and their families greater autonomy over decisions that consider the balance of quantity and quality of life.”

Study limitations cited by the researchers included the inability to directly correlate the medication changes with Covid-19 infection rates or deaths in the included nursing homes, which the researchers consider an important area of future study.

Campitelli and colleagues added that other important areas for future research include “the drivers and appropriateness of these medication changes, potential variation in prescribing behaviors across homes and clinical subpopulations, and any consequences for residents’ health and quality of life outcomes.”

  1. The emergence of Covid-19 was associated with small but statistically significant increases in prescriptions for psychotropic, anticonvulsant, and opioid medications among residents of nursing homes in Ontario, Canada.

  2. The Covid-19 pandemic may have negatively impacted a decade-long effort to reduce the inappropriate use of antipsychotics, benzodiazepines, and opioids within nursing homes, researchers concluded.

Salynn Boyles, Contributing Writer, BreakingMED™

This research was funded by the Canadian Institutes of Health Research (CIHR) and the Institute for Clinical Evaluative Sciences (ICES), and by the OHDP, a Province of Ontario initiative to support Ontario’s ongoing response to COVID-19 and its related effects.

Campinelli reported no disclosures.

Stall reported having published, having held grant funding, and currently holding grant funding with authors of the study, ie, Michael A. Campitelli, Susan Bronskill, Mina Tadrous, Andrea Gruneir, David B. Hogan, and Colleen J. Maxwell; and that co-author Susan Bronskill is on his thesis committee and being supported by the Department of Medicine’s Eliot Phillipson Clinician-Scientist Training Program and the Clinician Investigator Program at the University of Toronto and the Vanier Canada Graduate Scholarship.

Cat ID: 125

Topic ID: 79,125,282,403,494,931,730,933,125,190,926,192,927,928,921,925,934