Riluzole prescribing, uptake and treatment discontinuation in people with amyotrophic lateral sclerosis in Scotland
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LETTER TO THE EDITORS
Riluzole prescribing, uptake and treatment discontinuation in people with amyotrophic lateral sclerosis in Scotland Kiran Jayaprakash1,3 · Stella A. Glasmacher1,3 · Bernard Pang3 · Emily Beswick1,2,3 · Arpan R. Mehta1,2,3,4 · Rachel Dakin1,2,3 · Judith Newton1,2,3 · Siddharthan Chandran1,2,3,4,5 · Suvankar Pal1,2,3,4 · the CARE-MND Consortium Received: 30 April 2020 / Revised: 11 May 2020 / Accepted: 13 May 2020 © The Author(s) 2020
Dear Sirs, Riluzole is the only globally licensed drug treatment for amyotrophic lateral sclerosis (ALS), a rapidly progressive neurodegenerative condition. Trials and population studies have reported a survival gain of approximately 2–4 months with treatment [1, 2], and a low frequency of adverse effects [3]. The National Institute for Health and Care Excellence (NICE) recommends that clinicians offer riluzole to all people with ALS (pwALS) in the absence of contraindications [4]. However, in practice, prescribing and uptake are likely to be influenced by a number of clinical factors. Current evidence on rate of treatment discontinuation is limited by selection bias, stemming mainly from trials and small observational studies. We investigated factors influencing riluzole prescription, uptake and discontinuation using data from a large national disease register with 99% case ascertainment. Participants were drawn from the Clinical Audit Research and Evaluation of MND (CARE-MND) platform, a prospectively maintained population-based register comprising longitudinal clinical, and research data for all pwALS in
Scotland [5]. We extracted clinical characteristics of people with definite, probable or possible ALS [6]. Summary statistics are reported as median with interquartile range (IQR). Data were analysed using multivariable multinomial logistic regression and are reported as odds ratio (OR) with 95% confidence intervals (CIs). Missing data were handled using multiple imputation (m = 5). Data on the presence/absence of cognitive impairment were used to inform imputation of missing Edinburgh Cognitive and Behavioural Screen (ECAS) scores. Analyses were performed in R (3.6.2.). 768 pwALS were identified between January 2015 and April 2020. 468 pwALS (60.9%) were male, median age at diagnosis was 68 years (IQR 60–75) and median time from onset to diagnosis was 11 months (IQR 7–19). Site of onset was limb (338, 63.3%), bulbar (150, 28.1%), mixed (38, 7.1%) and pure respiratory (8, 1.5%). The median ALSFRSR score was 38 (IQR 31–42) and the median ECAS score was 109/136 (IQR 91–115, n = 253). Of all pwALS, 632 (86.5%) were offered riluzole and 283 (38.7%) did not commence treatment, which was due to patient preference in 223 (78.8%) cases (Fig. 1). Older age was significantly associated with pwALS not being offered riluzole, and with not starting riluzole. Sex, diagnostic delay,
Kiran Jayaprakash and Stella Glasmacher are joint first authors. 6
Department of Neurology, NHS Tayside, Dundee, UK
7
Centre for Clinical Brain Sciences, University of Edinburgh, C
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