RESUMEN
Background: Long-term use of inhaled corticosteroids (ICSs) is associated with several potential adverse effects. While patients unlikely to benefit should stop ICS use, abrupt discontinuation may result in an increased risk of chronic obstructive pulmonary disease (COPD) exacerbation. Stepwise tapering may reduce this risk but data are limited, and there is no consensus on the likelihood of COPD exacerbations following ICS discontinuation. The North Texas Veterans Affairs Health Care System conducted a single center, retrospective cohort study to evaluate the rate of COPD exacerbations following the discontinuation of ICS therapy using different schedules of discontinuation. Methods: Data were collected from the electronic health records of patients aged ≥ 40 years with a diagnosis of COPD who were on a stable dose of an ICS for ≥ 1 year that was subsequently discontinued with a last documented fill date between January 10, 2021 and September 1, 2021. Eligible patients were followed for COPD exacerbations that resulted in hospitalization until November 1, 2022. Descriptive statistics were used to evaluate characteristics of patients who experienced an exacerbation. Results: Seventy-five patients were included: 5 (7%) experienced an exacerbation following ICS discontinuation. Age, sex, race, and ethnicity were similar for those patients who did vs did not have an exacerbation. Unexpectedly, the mean baseline eosinophil count for patients with an exacerbation was 92 cells/µL compared with 227.4 cells/µL for those without an exacerbation. Nine patients had their ICS tapered gradually, and none of them experienced an exacerbation. Conclusions: Study findings suggest that there is a relatively low risk of COPD exacerbation following ICS discontinuation, regardless of whether a taper was performed. This result may indicate that it is reasonable to abruptly discontinue ICS in eligible patients.
RESUMEN
BACKGROUND: Studies have shown an association between metformin use and vitamin B12 deficiency. Since 2017, the American Diabetes Association (ADA) Standards of Medical Care in Diabetes Guideline has included a recommendation for periodic vitamin B12 measurements in metformin-treated patients, especially those with anemia or peripheral neuropathy. OBJECTIVE: To determine the overall incidence and impact of the ADA Guideline on vitamin B12 monitoring in a veteran population on long-term metformin therapy. METHODS: Retrospective chart review was performed for patients on metformin who started therapy prior to 2005 at the VA North Texas Health Care System (VANTXHCS). The primary outcome was the proportion of patients with at least 1 vitamin B12 level drawn during 2016 versus 2018. Metformin dose and duration, vitamin B12 supplementation, and incident neuropathy prescriptions or diagnosis were also analyzed. RESULTS: Of 394 patients included for the primary outcome, 136 (34.5%) had at least 1 vitamin B12 level in 2016 versus 198 (50.3%) patients in 2018 (odds ratio: 1.94, P < .001). Of the 394 patients, 157 were diagnosed with neuropathy or prescribed a medication for neuropathy without a vitamin B12 level in the previous year or with a low level that was not supplemented. CONCLUSION: Vitamin B12 monitoring significantly increased between 2016 and 2018, aligning with the release of the 2017 ADA guidelines. However, a large proportion of patients were identified who were diagnosed with or treated for neuropathy without adequate vitamin B12 monitoring.