 |
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Medication Use and the 5-Year Incidence of Early Age-Related Maculopathy
The Beaver Dam Eye Study
Arch Ophthalmol. 2001;119:1354-1359.
ABSTRACT
| |
Objective To evaluate incident early age-related maculopathy (ARM) after a 5-year
interval with respect to medication use.
Design Population-based incidence study.
Setting Participants were adults aged 43 to 86 years living in Beaver Dam, Wis,
when first examined in 1988-1990 (n = 4926); they were reexamined in 1993-1995
(n = 3684).
Methods All participants were examined and interviewed and stereoscopic color
fundus photographs were taken. All procedures were done by standard protocol
at both examinations. Incidence of ARM was based on grading using the Wisconsin
ARM Grading System. All prescribed and over-the-counter medications in current
use were brought to the examination site and the names were recorded at that
time.
Results There were 678 drug preparations (active ingredients) being used at
the baseline examination. No relations were found between most antihypertensive
drugs, most central nervous system medications, aspirin and other nonsteroidal
anti-inflammatory agents, estrogens, lipid-lowering agents, and incident early
ARM over the 5-year period. Age- and sex-adjusted logistic regression analyses
suggested possible associations (P<.10) between
the use of phenothiazine antidopaminergics (odds ratio [OR], 2.83; 95% confidence
interval [CI], 0.97-8.23; P = .06), desiccated thyroid
hormones (OR, 2.32; 95% CI, 0.89-6.07; P = .09),
and calcium channel blockers (OR, 1.70; 95% CI, 0.93-3.12; P = .08) with incident ARM. When additional information on past use
was included in the regression model, the association remained for calcium
channel blockers, but not for phenothiazines and desiccated thyroid hormones.
A lower incidence of early ARM occurred in those who took antidepressants
(OR, 0.34; 95% CI, 0.12-0.94; P = .04) at the baseline
examination.
Conclusion Although many different medications were being used at the baseline
examination in the Beaver Dam Eye Study cohort, there were no striking associations
with the 5-year incidence of early ARM.
INTRODUCTION
AGE-RELATED maculopathy (ARM) is an important cause of visual loss in
persons 65 years or older.1-2
Its pathogenesis is not well understood.3-4
Aside from family history, and to a lesser extent cigarette smoking, there
are few strong or consistent associations with ARM.5
One particular class of exposure has not been widely studied with respect
to ARM, namely, use of medications. Anecdotal cases of associations between
the use of steroids and neovascular ARM have been reported.6
A study by el Baba et al7 described 15 patients
with ARM complicated by massive subretinal and/or vitreous hemorrhages, of
whom 8 were taking oral anticoagulants, salicylates, or salicylate-like medications.
However, no relation between aspirin use and the presence8
or incidence of ARM9 was found in 2 other studies.
In the Age-Related Eye Disease Study, use of hydrochlorothiazide diuretic
was associated with the presence of large retinal drusen but not with geographic
atrophy or exudative macular degeneration.10
In Oulu, Finland,8 and in Melton Mowbray, England,11 there were no associations found between use of antihypertensive
medications or sedatives and the presence of early or late ARM.
Although exposures to medications (eg, chloroquine, diiodohydroxyquin,
thioridazine, chlorpromazine, and trifluoperazine) that are known to directly
affect the retinal pigment epithelium (RPE) might also be expected to exacerbate
the incidence and progression of ARM,12 to
our knowledge, there have been no population-based data examining these associations.
The purpose of this report is to describe the relation between a wide range
of commonly used medications and the incidence of early ARM and its component
lesions in the Beaver Dam Eye Study.
PARTICIPANTS AND METHODS
POPULATION
Identification and description of the population appear in previous
reports.13-17
Briefly, a private census of the population of Beaver Dam, Wis (99% white),
was performed from September 15, 1987, to May 4, 1988, to identify all residents
in the city or township of Beaver Dam who were 43 to 84 years of age. Of the
5924 eligible individuals, 4926 participated in the baseline examination between
March 1, 1988, and September 14, 1990. Nonparticipants consisted of 226 persons
(3.8%) who had died before the examination, 18 (0.3%) who could not be located,
337 (5.7%) who permitted an interview only (of these, 61 had moved), and 417
(7.0%) who refused to participate (of these, 39 had moved). Comparisons between
participants and nonparticipants at the time of the baseline examination appear
elsewhere.14
Prior to the start of the 5-year follow-up examination on March 1, 1993,
385 (7.8%) of the participants had died. Of the 4541 surviving participants
in the baseline examination, 3684 (81.1%) participated in the follow-up examination
between March 1, 1993, and June 14, 1995.15
Four (0.1%) participants could not be located, 259 (5.7%) permitted an interview
only (of these, 48 had moved out of the area), 423 (9.3%) refused to participate
(of these, 44 had moved out of the area), and 171 (3.8%) died during the examination
period. Both the mean and median times between the baseline and 5-year follow-up
examinations were 4.8 years and the SD was 0.4 years.
Comparisons between participants and nonparticipants at follow-up are
presented elsewhere.15 Persons who were alive
and did not participate in the follow-up eye examination (n = 686) were older
at baseline than those who did (62.7 vs 60.4 years; P<.001).
After adjusting for age, those who were alive during the study period and
did not participate were more likely to have fewer years of education, lower
income, poorer visual acuity, a history of cardiovascular disease, a history
of never drinking alcohol, smoked more (pack-years), higher serum cholesterol
levels, and higher systolic and diastolic blood pressures, and to be retired
at baseline than persons who participated.
PROCEDURES
Similar procedures were used at both baseline and follow-up examinations
and are described in detail elsewhere.14-21
Informed consent was obtained from each participant at the beginning of the
examination. Medication use was assessed using a standardized questionnaire
administered by the examiners at each examination.16
Participants were asked to bring to the examination all medications (prescription
and over-the-counter) that they were regularly taking. The examiner asked
whether there were other medications that were being taken but were not brought.
If there were, the participant was asked to call the study examiner with the
medication's name. In addition, at the baseline examination they were asked
if they had used specific classes of drugs in the past. Information on duration
of use was not obtained. Participants were asked to list the pharmacy or pharmacies
where they usuallyobtained their medications. Participants, their physicians,
and their pharmacies were called, when necessary, to verify medication and
reason for use.
The name of the drug entered into the drug database is structured as
a code table in which the code is assigned a record number reflecting that
of the American Hospital Formulary Service for each active ingredient.22 In addition, subclassification information was included
(eg, type of diuretic: thiazide, potassium sparing, loop).
Stereoscopic 30° color fundus photographs centered on the disc (Diabetic
Retinopathy Study [DRS] standard field 1)23
and macula (DRS standard field 2), and a nonstereoscopic color fundus photograph
temporal to but including the fovea of each eye were taken. For purposes of
this study, the 3583 people with at least 1 eye free of confounding lesions
(eg, chorioretinal scars due to trauma, total retinal detachment) at both
examinations (right eye, n = 3497; left eye, n = 3519; both eyes, n = 3435)
are included in the analyses.
DEFINITIONS
Grading for ARM was performed in a masked fashion using a standardized
protocol, the Wisconsin ARM Grading System.18-20
Grading procedures, lesion descriptions, and detailed definitions for the
presence and severity of specific lesions appear elsewhere.19-21
The incidence of early ARM was defined by the presence of either soft
indistinct drusen or the presence of any type of drusen associated with RPE
depigmentation or increased retinal pigment at follow-up when none of these
lesions was present at baseline. Current age was defined as the age at the
time of the baseline examination. For cigarette smoking, a participant was
classified as having never smoked if he/she had smoked fewer than 100 cigarettes
in his/her lifetime, as being an ex-smoker if he/she had smoked at least 100
cigarettes in his/her lifetime but had stopped smoking before the baseline
examination, or as a current smoker if he/she had not stopped.
STATISTICAL METHODS
The SAS statistical software package was used for all statistical analyses.24 The 5-year incidence of specific lesions of early
ARM (soft indistinct drusen, increased retinal pigment, and RPE depigmentation)
and early ARM were used as end points for all analyses. We did not examine
associations of medication use at baseline with incident exudative macular
degeneration (0.5%), geographic atrophy (0.3%), or late ARM (0.9%) because
of the low incidence of these conditions in the population.21
The relations between current use of medications at baseline, categorized
by indication for use and for some specific medications, and the incidence
of specific maculopathy lesions were examined using logistic regression models
controlling for age and sex. When associations of P<.10
were found, further models were created to include past use when available
(ever used vs never used). Final models including age, sex, and other risk
factors for ARM lesions, including smoking status at baseline (never, past,
current), history of beer consumption at baseline (no, yes), and history of
heavy alcohol drinking status at baseline (never, past, current) were created.25
RESULTS
Persons who were alive and did not participate in the follow-up examination
were less likely to be taking thyroid medications at the baseline examination
(7.9 vs 10.0%; P = .05). There were no statistically
significant differences in the age-adjusted frequency of use of oral steroids,
gout medications, quinine, cholesterol- and blood pressure–lowering
medications, diuretics, or aspirin at baseline between participants and nonparticipants.
Nonparticipants in the 5-year follow-up had a slightly higher average number
of medications taken at baseline compared with participants (3.6 vs 3.4; P = .08). After adjusting for age and sex, participants
with early ARM at baseline were more likely to participate in the 5-year follow-up
than those in whom ARM was absent (Cochran-Mantel-Haenszel test for general
association, P = .003).
There were 678 drug preparations (678 unique active ingredients) currently
used at the baseline examination, most (n = 610) were currently used by fewer
than 50 persons who were at risk for incidence of early ARM. Three hundred
fifty-seven of the 678 drug preparations were included in the present analyses.
We limit the data presented to medication categories for which there has been
recent interest in possible relations with ARM or for when there was some
reason to suggest a possible association (P<.10).
In some cases we present results for categories of drugs that may contain
preparations with different active ingredients (eg, antihistamines), and in
other cases we present the data for a specific active ingredient (eg, aspirin).
After adjusting for age and sex, we found one association (antidepressants)
with incident early ARM of P<.05 (Table 1, Table 2,
and Table 3). There were no associations
between antihypertensive medications as a group or specific types of antihypertensive
medications except for calcium channel blockers (age- and sex-adjusted odds
ratio [OR], 1.70; 95% confidence interval [CI], 0.93-3.12; P = .08) (Table 1) and
early ARM. For the 3 specific calcium channel blockers, diltiazem (n = 17),
nifedipine (n = 30), and verapamil (n = 42), used at baseline, only nifedipine
was associated with the incidence of early ARM (OR, 2.29; 95% CI, 0.89-5.87; P = .08) and this was largely due to the incidence of soft
indistinct drusen (OR, 2.50; 95% CI, 0.97-6.41; P
= .06). This association of current use of nifedipine and incident early ARM
remained after controlling for smoking (OR, 2.30; 95% CI, 0.90-5.91; P = .08) or beer drinking (OR, 2.30; 95% CI, 0.93-6.14; P = .07) history status at baseline and when past users
were included with current users of calcium channel blockers (OR, 1.84; 95%
CI, 1.02-3.34; P = .04). We found no association
of calcium channel blocker use and early ARM in those with no history of hypertension
(data not shown).
|
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Table 1. Age- and Sex-Adjusted Odds Ratios for Antihypertensive Drug
Exposures at Baseline and 5-Year Incidence of Age-Related Maculopathy in the
Beaver Dam Eye Study*
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Table 2. Age- and Sex-Adjusted Odds Ratios for Central Nervous System
Drug Exposures at Baseline and the 5-Year Incidence of Early Age-Related Maculopathy
in the Beaver Dam Eye Study*
|
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Table 3. Age- and Sex-Adjusted Odds Ratios for Other Drug Exposures
at Baseline and 5-Year Incidence of Age-Related Maculopathy in the Beaver
Dam Eye Study*
|
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The use of antidepressants at baseline was associated with a 66% reduction
in the incidence of early ARM (OR, 0.34; 95% CI, 0.12-0.94) (Table 2). In the 68 persons using tricyclic tertiary amine compounds
(eg, amitriptyline, clomipramine, doxepin, imipramine, triamipramine) the
age-and sex-adjusted OR was 0.25 for the development of incident early ARM
(95% CI, 0.06-1.03; P = .06) compared with those
not using these types of antidepressants. This association remained after
controlling for smoking, beer drinking history, and hypertension status at
baseline (data not shown). The incidence of soft drusen (OR, 0.31; 95% CI,
0.08-1.29; P = .11) and RPE abnormalities (OR, 0.62;
95% CI, 0.19-2.05; P = .44) was lower in users of
tertiary amine tricyclic compounds; however, the associations were not statistically
significant. Although the incidence of early ARM was lower for those using
amitriptylines, the most frequently used of the antidepressants, compared
with persons not using this drug, the association was not statistically significant
(Table 2). There were too few
persons using secondary amines (n = 11), tetracyclics (n = 3), or serotonin
reuptake inhibitors (n = 4) at baseline to examine whether they were associated
with incident early ARM. When past use was included with current users of
tertiary amine tricyclic compounds, an association with lower incidence of
early ARM (OR, 0.35; 95% CI, 0.13-0.98; P = .05)
was found.
Association between the use of antipsychotic agents and incident early
ARM are shown by class/active agent in Table 2. Persons taking phenothiazines at baseline had a higher
5-year incidence of early ARM (OR, 2.83; 95% CI, 0.97-8.23; P = .06). Use of phenothiazines was not statistically significantly
associated with incident increased retinal pigment (OR, 2.72; 95% CI, 0.74-9.93; P = .13) or soft drusen (OR, 1.54; 95% CI, 0.44-5.43; P = .50). When past use of antipsychotics was combined
with current use (OR, 1.44; 95% CI, 0.77-2.68; P
= .26) or when past use of phenothiazines was combined with current use (OR,
1.49; 95% CI, 0.60-3.69; P = .39), there was no association
with incident early ARM. Other antipsychotic drugs (eg, phenylbutylpiperadines,
thioxanthenes, and dibenzepins) were too infrequently used in the population
to examine their relation with early incident ARM. Barbiturate and nonbarbiturate
sedatives and antianxiety drugs were not associated with incident early ARM
(Table 2).
An association was found between desiccated thyroid hormone use and
incident early ARM (Table 3).
This was largely due to the incidence of soft indistinct drusen (OR, 2.74;
95% CI, 1.06-7.08; P = .04). There was no association
of synthetic thyroid hormone use at baseline and incident early ARM. Aspirin,
other nonsteroidal anti-inflammatory agents, acetaminophens, oral and nasal
steroids, estrogens and progesterones, gout medications, lipid-lowering agents,
cardiac glycosides, chloroquine and quinine, and antihistamines used at baseline
were not associated with incident early ARM (Table 2 and Table 3).
COMMENT
Data from the Beaver Dam Eye Study cohort offered an opportunity to
examine the associations of medication use with the incidence of early ARM
and its specific lesions. The cohort was large, the currently used medications
were brought to the examination site, and trained examiners recorded the names
of the medications. The ARM lesions were determined using standardized photographic
and grading protocols at both the baseline and follow-up examinations.
There were few significant associations between incident early ARM and
medications used in the population. The borderline association of antipsychotic
drugs with incident early ARM (incident large drusen and pigmentary abnormalities)
was not unexpected, as antidopaminergic phenothiazines (eg, chlorpromazine,
prochlorperazine, and perphenazine) have long been known to be associated
with pigmentary abnormalities of the RPE.12
However, the finding of a protective effect of antidepressants with incident
early ARM was unexpected. The antidepressants most frequently used were tricyclic
tertiary amines (eg, amitriptyline, desipramine, and imipramine). The biologic
reason why these drugs, which have complex pharmacologic actions on neurologic
pathways, have a protective effect for ARM in this study is not known. This
may represent a chance or spurious finding.
Any conclusions or explanations regarding associations, or lack of them,
described herein must be made with caution for a number of reasons. First,
because this was not a study primarily aimed at identifying effects of commonly
used drugs, we have virtually no information about dosage, duration of use,
or longest exposure. The lack of such information might be expected to decrease
the ability to estimate the strength of an association as persons taking low
doses of a drug for short periods would be similarly classified as persons
taking high doses for long periods. Also, age may be an important consideration
when evaluating drug and drug dosage effects (ie, an age of "vulnerability"
may exist). Second, the concomitant low frequency of medication use and of
early ARM incidence limits our ability to detect (or reject) meaningful relations.
For example, to achieve a power of 0.80 to detect an OR of a given drug of
equal to 2.0 or greater with an  = .05, with an overall incidence of
early ARM of 8.2% and a total sample size of 2832 (as in the Beaver Dam cohort),
we estimated that 175 persons had to be currently taking the drug of interest.
Although there may be some potentially meaningful relations among these that
are not statistically significant, the associations are likely to be small
if "real." However, as suggested by Rothman,26
it may be that some of these relations are important and warrant further study.
Third, some findings (eg, those between calcium channel blockers, desiccated
thyroid hormones, and antidepressants), which may be of potential biological
significance, may be entirely due to chance.
In summary, we find no striking associations between medication use
and incident early ARM. A few of these associations may be interesting to
look at in examining other cohorts. Also, studies in larger cohorts with information
on dosage and duration of medication use as well as late ARM will be necessary
to find weaker associations with ARM lesions.
AUTHOR INFORMATION
Accepted for publication March 8, 2001.
This research is supported by National Institutes of Health grant EY06594
(Drs R. Klein and B. E. K. Klein) and, in part, by Research to Prevent Blindness,
Inc, New York, NY (Dr R. Klein, Senior Scientific Investigator Award).
We acknowledge the work of Lee Vermeulen, who helped in the development
of the drug database; Rick Chappell, PhD, who provided statistical advice;
and the guidance and input of the Beaver Dam Scientific Advisory Board (Mary
Frances Cotch, PhD, Mae Gordon, PhD, Lee Jampol, MD, Dan Seigel, PhD, and
Robert Wallace, MD).
Corresponding author: Ronald Klein, MD, MPH, Department of Ophthalmology
and Visual Sciences, University of Wisconsin–Madison, 610 N Walnut St,
460 WARF, Madison, WI 53705-2397.
Ronald Klein, MD;
Barbara E. K. Klein, MD;
Susan C. Jensen, MS;
Karen J. Cruickshanks, PhD;
Kris E. Lee, MS;
Lorraine G. Danforth, BS;
Sandra C. Tomany, MS
From the Departments of Ophthalmology and Visual Sciences (Drs R. Klein,
B. E. K. Klein, and Cruickshanks and Mss Jensen, Lee, Danforth, and Tomany)
and Preventive Medicine (Dr Cruickshanks), University of Wisconsin Medical
School, Madison.
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