Tocilizumab (Actemra) has undergone a label revision with respect to changes in neutrophil count, platelet count, lipid values, and liver enzymes.11 It is recommended that laboratory monitoring be performed due to potential consequences of treatment-related changes in these tests. It has most commonly been seen in polyarticular (PJIA) and systemic juvenile idiopathic arthritis (SJIA).
In The Literature
Berry et al published data on the relationship between the use of nonbenzodiazepine sedative hypnotics and hip fractures in nursing home residents.12 They conducted a case-crossover study looking at the nonbenzodiazepine agents zolpidem tartrate, zaleplon, and eszopiclone (Ambien/CR, Edluar, Intermezzo, Zolpimist; Sonata; and Lunesta, respectively), and their propensity for increasing the hip fracture risk in a nationwide sample of long-stay nursing home residents. Patients were stratified by individual and facility-level characteristics. Participants (n=15,528) aged 50 and older and that had suffered a hip fracture documented through Medicare Part A and D medical claims were evaluated. Days before and after the fracture were evaluated for nonbenzodiazepine hypnotic drug use. The mean age of study participants was 81 years, of which 78% were female.
Eleven percent of study participants (n=1,715) were dispensed a nonbenzodiazepine hypnotic prior to the hip fracture. The risk for hip fracture was elevated among these patients with an odds ratio (OR) of 1.66. In new users of nonbenzodiazepine hypnotics, the association with hip fracture was greater (OR 2.20). Additionally, the association with hip fracture was also slightly greater in residents with normal or mild cognition impairment (OR 1.86) compared to participants with moderate to severe impairment (OR 1.43). Participants with moderate functional status impairment had an OR of 1.71, and were at greater risk for having a hip fracture compared to more functionally debilitated patients (OR 1.16). Those who were more independent had less of a risk of hip fracture compared to those who required some assistance with moving (OR 2.02). These results are consistent with those of prior studies showing an increased risk of falls and fracture with nonbenzodiazepine hypnotics in older patients. This study confirmed a 66% increase in hip fracture risk within 30 days of using one of these agents.
Many patients are prescribed nonbenzodiazepine sleep medications that have mechanisms of action and metabolism similar to benzodiazepines. Patients have difficulty sleeping from pain, psychiatric/mood, or other reasons. Giving an older patient a long-term (or short-term) prescription for zolpidem without working up the issue can often lead to more harm than good, noted Berry et al, especially in more cognitively impaired, less mobile individuals and those taking many different medications.
