1.3 million American adults with diabetes ration their insulin due to cost; younger adults and the uninsured are most likely to ration

1. 1.3 million American adults with diabetes ration their insulin due to cost; younger adults and the uninsured are most likely to ration
Inflation Reduction Act will improve insulin access for seniors, but privately insured and uninsured Americans still face significant burden
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2477
URL goes live when the embargo lifts
An analysis of national health data in the United States has found that insulin rationing is common among those living with diabetes, especially among older adults and the uninsured. Limiting Medicare copays to $35 a month under the Inflation Reduction Act may improve insulin access for seniors, but privately insured and uninsured Americans will still face significant burdens access. The brief research report is published in Annals of Internal Medicine.

Insulin is a critical and life-saving treatment for Americans with diabetes, but cost- and insurance-related insulin rationing and nonadherence is likely common.

Researchers from Harvard Medical School and Hunter College studied data from the 2021 National Health Interview Survey (NHIS) to determine the prevalence and correlates of insulin rationing. They assessed the responses of 982 adults who used insulin to serve as a representative sample of more than 6 million American adults with diabetes. The authors found that 16.5%, or up to 1.3 million, of insulin users rationed insulin. Among all users, delaying the purchase of insulin was the most common form of rationing. Among those with type 1 diabetes, taking less insulin than needed was most common. Insulin rationing was also more common among younger adults (20.4%) than seniors over 65 years of age (11.2%). The authors also report that rates of insulin rationing were highest among uninsured persons and persons with private insurance but lowest among persons insured through Medicaid. They add that participants who rationed insulin reported feeling overwhelmed by the demands of living with diabetes. According to the authors, their findings may be related to the already high and increasing cost of insulin in the United States.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Adam Gaffney, MD, MPH, please email Darcey Rakestraw at darcey@2050strategies.com.
----------------------------
2. Increased anxiety and depression symptoms appeared in early days of the pandemic
After the first 2 months, mental disorders symptoms varied significantly across populations
Abstract: https://www.acpjournals.org/doi/10.7326/M22-1507
URL goes live when the embargo lifts
A review of 43 studies conducted during the COVID-19 pandemic suggests that increased number of reported infections and stringent government response to COVID-19 were associated with increased anxiety and depression symptoms in the early days of the pandemic. However, after the first 2 months, changes in symptoms varied significantly across populations. The findings are published in Annals of Internal Medicine.

Mental health experts have previously warned about the possibility of increased ill mental health due to the COVID-19 pandemic. It is important to quantify impacts on mental health to inform future public health efforts that balance minimizing both the spread of infection and possible mental health harms.

Researchers from the University of Bern, Bern, Switzerland, reviewed 43 studies comprising 331,628 participants to assess the trajectory of mental health symptoms during the first year of the pandemic and examine dose-response relations with characteristics of the pandemic and its containment. The studies measured self-reported mental health parameters including changes in symptoms of psychological distress, sleep disturbances, and mental well-being. The authors found that symptoms of depression and anxiety in the general population worsened slightly in the first 2 months of the pandemic, but mental health impacts varied significantly by population after that period. They noted that increase symptoms of depression and anxiety were associated with more stringent governmental responses and higher number of reported infections, but caution that these findings apply to the general population at the beginning of the pandemic and do not include important developments, such as later waves or variants of COVID-19. The authors suggest that while the pandemic continues and to prepare for future pandemics, governments need to ensure that adequate mental health service provision and appropriate interventions exist for those who need them.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Georgia Salanti, PhD, please contact Thomy Tonia at thomai.tonia@ispm.unibe.ch.
----------------------------
3. Benefit of opioids prescribed in the emergency department remains unclear
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2162
URLs go live when the embargo lifts
A systematic review of 42 academic research articles has found that the risk-benefit balance of using opioids to treat musculoskeletal pain in the emergency department (ED) setting remains unclear. The review is published in Annals of Internal Medicine.

Opioid analgesics are commonly administered in EDs to manage pain and may be prescribed upon discharge for short-term pain management, with a goal of rapid pain control and avoidance of hospitalizaiton. However, many patients who later experience opioid dependence, overdose, and death first interact with these medications in ED settings. There is debate about the appropriate use of opioids to treat pain outside of ED settings, but guidelines do not address the differences in expected benefits and harms of opioids versus nonopioid analgesics.

Researchers from the University of Sydney reviewed 42 articles studying the application of opioids in ED settings to evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in this setting. They found that opioids may provide statistically but not clinically greater pain relief compared with placebo and paracetamol but are no more effective than some nonopioid options, particularly NSAIDs, across a range of musculoskeletal condition categories. They also report that opioids were associated with more adverse outcomes than placebo, paracetamol, and NSAIDs, but certainty was low. The authors advise that their analysis of adverse events suggests that clinicians should be cautious about replacing opioids with anesthetics, such as ketamine. They also add that future research in this area should consider including measures of other outcomes of interest to ED clinicians and policymakers, such as rate of hospitalization, and potential harms, such as long-term opioid use after initiation in the ED.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author, Caitlin M.P. Jones, please contact Christine Lin at christine.lin@sydney.edu.au.
----------------------------
4. Study of claims data compares apixaban vs rivaroxaban for patients with atrial fibrillation and valvular heart disease
Apixaban associated with a lower rate of ischemic stroke or systemic embolism and a lower rate of bleeding
Abstract: https://www.acpjournals.org/doi/10.7326/M22-0318
URLs go live when the embargo lifts

A large population-based study of patients with atrial fibrillation (AF) and valvular heart disease (VHD) found that use of apixaban was associated with a lower rate of ischemic stroke or systemic embolism and a lower rate of intracranial or gastrointestinal (GI) bleeding compared with rivaroxaban. The authors say clinicians should consider these findings when selecting anticoagulants in this patient population. The study is published in Annals of Internal Medicine.

VHD is common among patients with AF. The presence of VHD increases the risk for death, major adverse cardiovascular events, and major bleeding. Despite the common use of apixaban and rivaroxaban in this population, direct comparisons are lacking.

Researchers from the Perelman School of Medicine, University of Pennsylvania studied data from a large commercial health insurance database from January 2013 to December 2020 to emulate a target trial of effectiveness and safety of apixaban and rivaroxaban in patients with AF and VHD. Of the 33,907 patients included in the study, 23,712 took apixaban for the first time and 10,195 were treated with rivaroxaban. In the propensity score–matched sample of patients with AF and VHD, the incidence rate of ischemic stroke or systemic embolism per 1,000 person-years of follow-up was 5.2 among apixaban users and 9.1 among rivaroxaban users. The incidence rate of GI or intracranial bleeding per 1,000 person-years of follow-up was 14.3 among apixaban users and 28.1 among rivaroxaban users. There was no statistically significant difference in all-cause mortality between the two groups. Since there are no direct, randomized comparisons of apixaban and rivaroxaban in patients with both AF and VHD, these findings have important clinical implications for patients.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author, Ghadeer K. Dawwas, MSc, MBA, PhD, please email Frank Otto at Frank.Otto@pennmedicine.upenn.edu.