pharmaceuticals
Article
Risk of Hospitalization for Adverse Drug Events in Women and
Men: A Post Hoc Analysis of an Active Pharmacovigilance
Study in Italian Emergency Departments
Giada Crescioli 1,2 , Ennio Boscia 1 , Alessandra Bettiol 3 , Silvia Pagani 4 , Giulia Spada 4 , Giuditta Violetta Vighi 4 ,
Roberto Bonaiuti 1,5 , Mauro Venegoni 6 , Giuseppe Danilo Vighi 4 , Alfredo Vannacci 1,2,5,† ,
Niccolò Lombardi 1,2, *,† and on behalf of the MEREAFaPS Study Group ‡
1
2
3
4
5
Citation: Crescioli, G.; Boscia, E.;
Bettiol, A.; Pagani, S.; Spada, G.;
Vighi, G.V.; Bonaiuti, R.; Venegoni, M.;
6
*
†
‡
Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and
Toxicology, University of Florence, 50139 Florence, Italy; giada.crescioli@unifi.it (G.C.);
ennio.boscia@stud.unifi.it (E.B.); roberto.bonaiuti@unifi.it (R.B.); alfredo.vannacci@unifi.it (A.V.)
Tuscan Regional Center of Pharmacovigilance, 50122 Florence, Italy
Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
alessandra.bettiol@unifi.it
Internal Medicine, Medical Department, Vimercate Hospital, ASST di Vimercate, 20871 Vimercate, Italy;
silvia.pagani@asst-brianza.it (S.P.); giulia.spada@asst-brianza.it (G.S.);
giudittavioletta.vighi@asst-brianza.it (G.V.V.); giuseppedanilo.vighi@asst-vimercate.it (G.D.V.)
Joint Laboratory of Technological Solutions for Clinical Pharmacology, Pharmacovigilance and
Bioinformatics, University of Florence, 50139 Florence, Italy
Pharmacology Unit, Department of Diagnostics and Public Health, University of Verona, 37100 Verona, Italy;
mauro.venegoni@gmail.com
Correspondence: niccolo.lombardi@unifi.it; Tel.: +39-055-27-58-206
These authors contributed equally to this manuscript.
Membership of the MEREAFaPS Study Group is provided in the Acknowledgments.
Vighi, G.D.; Vannacci, A.; et al. Risk
of Hospitalization for Adverse Drug
Events in Women and Men: A Post
Hoc Analysis of an Active
Pharmacovigilance Study in Italian
Emergency Departments.
Pharmaceuticals 2021, 14, 678. https://
doi.org/10.3390/ph14070678
Academic Editor: Olivia Manfrini
Received: 12 June 2021
Accepted: 13 July 2021
Published: 15 July 2021
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Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
Abstract: This post hoc analysis of an Italian active pharmacovigilance study describes pharmacological differences of ADEs leading to emergency department (ED) visits and hospitalization in women
and men. During the study period (January 2007–December 2018), 61,855 reports of ADEs leading
to ED visits were collected. Overall, 30.6% of ADEs resulted in hospitalization (30% in women and
31% in men). Multivariate logistic regression showed that, among women, drug classes significantly
associated with an increased risk of hospitalization were heparins (ROR 1.41, CI 1.13–176), antidepressants (ROR 1.12, CI 1.03–1.23) and antidiabetics (ROR 1.13, CI 1.02–1.24). Among men, only vitamin
K antagonists (ROR 1.28, CI 1.09–1.50), opioids (ROR 1.30, CI 1.06–1.60) and digitalis glycosides (ROR
1.32, CI 1.09–1.59) were associated with a higher risk of hospitalization. Overall, older age, multiple
suspected drugs and the presence of comorbidities were significantly associated with a higher risk of
hospitalization. A significantly reduced risk of hospitalization was observed in both women and men
experiencing an adverse event following immunization (ROR 0.36, CI 0.27–0.48 and 0.83, 0.42–0.74,
respectively) compared to drugs. Results obtained from this real-world analysis highlight important
aspects of drug safety between sexes.
Keywords: pharmacovigilance; clinical pharmacology; male; female; emergency department
1. Introduction
Women and men are characterized by significant differences in terms of adverse drug
event (ADE) occurrence derived from a heterogeneous set of factors in which both intrinsic
and extrinsic elements concur [1,2]. Among these: (a) differences between men and women
in body–water, muscle/fat mass ratio, organ blood flow and function; (b) physiological aspects such as menopause, pregnancy and menstruation; (c) prevalence of diseases
and, consequently, in prescription patterns; (d) the possible impact of genetics and hor-
4.0/).
Pharmaceuticals 2021, 14, 678. https://doi.org/10.3390/ph14070678
https://www.mdpi.com/journal/pharmaceuticals
Pharmaceuticals 2021, 14, 678
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monal variations in response to drugs [3–6]. All these factors describe the complexity of
gender pharmacology.
As for randomized clinical trials, exclusion of women and limitation in drug safety
evaluation are well-known issues [7,8]. Moreover, characterization of ADEs leading to
emergency department (ED) admission in men and women is still lacking. Estimates of
ADE risk between the two sexes from observational real-world data, especially from active
pharmacovigilance studies, may represent the best strategy to fill this gap [9].
The MEREAFaPS Study was the first national active pharmacovigilance study performed in Italy. The study was based on electronic ED medical records with detailed
information on patient populations, which allowed for consideration of risk predictors
and modifying factors of ADEs and ADE-related hospitalization, such as polypharmacy
and comorbidity, as well as sociodemographic characteristics [9]. This post hoc analysis of
data retrieved from the MEREAFaPS Study database aimed to analyze pharmacological
characteristics of ADEs leading to ED visits in women and men and to estimate differences
in risk of hospitalization by different suspected drug classes.
2. Results
2.1. Case Characteristics
Between 1 January 2007 and 31 December 2018, 61,855 reports of ADEs leading to ED
visit were collected: 35,010 (56.6%) ADE reports for women and 26,845 (43.4%) for men.
Table 1 shows the characteristics of cases. Overall, the majority of patients were
Caucasian adults aged 20–79 years, with a median age of 62.4 years for women and
63.8 years for men. In both men and women, the majority of reports were related to drugs,
and ≥5 suspected drugs (polypharmacy) were reported in 23.2% of ADE reports for women
and 25.4% of ADE reports for men.
Table 1. Case characteristics.
ED Visits for ADEs
Women
N = 35,010 (%)
Men
N = 26,845 (%)
1510 (4.3)
1607 (4.6)
15,238 (43.5)
8456 (24.2)
7880 (22.5)
319 (0.9)
62.4 (39.6–78.9)
1701 (6.3)
1194 (4.5)
10,801 (40.2)
7610 (28.4)
5295 (19.7)
244 (0.9)
63.8 (40.8–77.9)
467 (1.3)
291 (0.8)
30,729 (87.8)
102 (0.3)
3421 (9.8)
425 (1.6)
259 (1.0)
23,503 (87.6)
54 (0.2)
2604 (9.7)
0.005
34,425 (98.3)
585 (1.7)
26,259 (97.8)
586 (2.2)
<0.001
14,948 (42.7)
5937 (17.0)
5988 (17.1)
8137 (23.2)
11,054 (41.2)
4575 (17.0)
4409 (16.4)
6807 (25.4)
<0.001
p-Value
Patient Age, Years
≤5
6–19
20–64
65–79
≥80
Not Available
Median (IQR), Years
<0.001
0.108
Patients’ Ethnicity
Asian
Black or African American
Caucasian
Other
Not available
Type of Drug
Drug
Vaccine
No. of Suspected Drugs Involved in the ADE
1
2
3–4
≥5
Pharmaceuticals 2021, 14, 678
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Table 1. Cont.
ED Visits for ADEs
Women
N = 35,010 (%)
Men
N = 26,845 (%)
Most Frequently Reported Suspected ATC Drug Classes
N = 44,119
N = 34,242
Antithrombotic Agents (B01)
7322 (16.6)
8732 (15.5)
<0.001
Antibacterials (J01)
Anti-inflammatory and Antirheumatic Products (M01)
Psycholeptics (N05)
Analgesics (N02)
Diabetes agents (A10)
7203 (16.3)
3805 (8.6)
3717 (8.4)
3559 (8.1)
3051 (6.9)
5186 (15.2)
2812 (8.2)
2052 (6.0)
1915 (5.6)
2991 (8.7)
<0.001
0.039
<0.001
<0.001
<0.001
30,478 (87.1)
4532 (12.9)
23,187 (86.4)
3658 (13.6)
0.013
18,221 (52.1)
16,789 (48.0)
13,691 (51.0)
13,154 (49.0)
0.010
0
1
2
3–4
≥5
18,221 (52.1)
4100 (11.7)
2980 (8.5)
4414 (12.6)
5295 (15.1)
13,691 (51.0)
2977 (11.1)
2220 (8.3)
3343 (12.5)
4614 (17.2)
<0.001
Most Frequently Reported Concomitant ATC Drug Classes
N = 61,184
N = 50,843
Renin–Angiotensin System Inhibitors (C09)
5943 (9.7)
5175 (10.2)
0.009
Drugs for Acid Related Disorders (A02)
5063 (8.3)
4090 (8.0)
0.162
Diuretics (C03)
4899 (8.0)
3987 (7.8)
0.311
Antithrombotic Agents (B01)
4851 (7.9)
4273 (8.4)
0.004
Beta Blocking Agents (C07)
4521 (7.4)
4040 (8.0)
<0.001
22,261 (63.6)
12,749 (36.4)
16,684 (62.2)
10,161 (37.9)
<0.001
22,261 (63.6)
6111 (17.5)
2819 (8.1)
3819 (10.9)
16,684 (62.2)
4641 (17.3)
2243 (8.4)
3277 (12.2)
<0.001
3892 (14.2)
1391 (5.0)
1321 (4.8)
1060 (3.8)
1023 (3.7)
1020 (3.7)
828 (3.0)
808 (2.9)
3261 (14.3)
1306 (5.7)
1207 (5.3)
577 (2.4)
1413 (6.1)
372 (1.6)
776 (3.4)
943 (4.09)
<0.001
34,558 (98.7)
452 (1.3)
26,569 (99.0)
276 (1.0)
0.003
p-Value
Presence of a Suspected Drug with Parenteral Administration
No
Yes
Concomitant Drugs
No
Yes
No. of Concomitant Drugs *
Presence of Comorbidities
No
Yes
No. of Comorbidities
0
1
2
≥3
Most Frequently Reported Comorbidities
Hypertension
Diabetes
Atrial Fibrillation
Allergic Disease
Heart Disease
Depression
Dyslipidaemia
Renal Failure
Presence of CAM
No
Yes
Pharmaceuticals 2021, 14, 678
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Table 1. Cont.
ED Visits for ADEs
Women
N = 35,010 (%)
Men
N = 26,845 (%)
p-Value
1024 (2.9)
281 (0.8)
240 (0.7)
433 (1.2)
550 (2.1)
258 (1.0)
147 (0.6)
399 (1.5)
<0.001
0.036
0.031
0.008
24,418 (69.8)
10,592 (30.3)
18,519 (69.0)
8326 (31.0)
0.042
Type of Event
Abuse/Misuse
Interactions
Overdose
Therapeutic Errors
Hospitalization
No
Yes
ADE: adverse drug event; ATC: anatomical therapeutic chemical; CAM: complementary and alternative medicines; ED: emergency
department; IQR: interquartile range. * Number of concomitant drugs: “0” means that patient was not taking concomitant drugs, but only 1
or more suspected drugs; “1” means that patient was taking only 1 concomitant drug with at least 1 suspected drug; “2” or “≥3” means
that patient was taking 2 or more than 3 concomitant drugs with at least 1 suspected drug.
A statistically significant difference between the two sexes was observed for all the
most frequently reported suspected ATC drug classes. For both sexes, the most frequently reported ATC classes of suspected drugs were antithrombotic agents (16.6% in
women and 15.5% in men), followed by antibacterials (16.3% vs. 15.2%), anti-inflammatory
and antirheumatic products (8.6% vs. 8.2%), psycholeptics (8.4% vs. 6.0%), analgesics
(8.1% vs. 5.6%) and antidiabetics (6.9% vs. 8.7%).
The presence of concomitant drugs was reported in 48% of cases for women and 49%
of cases for men. For both sexes, the most frequently reported ATC classes of concomitant
drugs were renin–angiotensin system inhibitors (9.7% vs. 10.2%), followed by drugs for
acid related disorders (8.3% vs. 8.0%), diuretics (8.0% vs. 7.8%), antithrombotic agents
(7.9% vs. 8.4%) and beta blocking agents (7.4% vs. 8.0%).
Comorbidities were reported in 36.4% of cases for women and 37.9% of cases for men,
with 10.9% of women and 12.2% of men affected by three or more concomitant diseases.
For both sexes, the most reported comorbidity was hypertension, followed by diabetes and
atrial fibrillation.
A statistically significant difference between the two sexes was observed for ADEs
caused by abuse/misuse, drug–drug or herb–drug interactions, overdose and therapeutic errors.
Overall, 18,918 (30.5%) ADEs caused patient hospitalization (30% in women and 31%
in men, p-value = 0.042).
2.2. Hospitalization among Both Sexes
A statistically significant increased risk of hospitalization was observed for both
women and men exposed to antihemorrhagics, antianaemic and perfusion preparations
(ROR 1.32, 95% CI 1.14–1.52 and 1.33, 1.13–1.56, respectively); sedative or hypnotic agents
(ROR 1.11, 1.01–1.21 and 1.15, 1.02–1.31), particularly benzodiazepines; antipsychotics
(ROR 1.57, 1.38–1.79 and 1.44, 1.22–1.68); antiepileptics (ROR 1.23, 1.10–1.39 and 1.21,
1.05–1.38); diuretics (ROR 1.25, 1.15–1.36 and 1.16, 1.06–1.26) and, for diabetes agents,
insulin (ROR 1.32, 1.12–1.55 and 1.19, 1.01–1.41) (Table 2).
A significantly reduced risk of hospitalization was observed for both women and men
exposed to renin–angiotensin system inhibitors (ROR 0.89, 0.83–0.95 and 0.91, 0.84–0.98,
respectively), particularly angiotensin II receptor blockers (plain and combinations) and
ibuprofen (ROR 0.52, 0.36–0.76 and 0.56, 0.34–0.90) (Table 2).
Pharmaceuticals 2021, 14, 678
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Table 2. Suspected drug classes and risk of hospitalization.
ED Visits for ADEs
ED Visits for ADEs
Adjusted ROR
Resulting in Hospitalization
(95% CI)
Women
N = 35,010 (%)
Men
N = 26,845 (%)
Women
N = 10,592 (row %)
Men
N = 8326 (row %)
Women
Men
1363 (3.9)
824 (2.4)
77 (0.2)
341 (1.0)
56 (0.2)
3294 (9.4)
2679 (7.7)
1044 (3.9)
652 (2.4)
57 (0.2)
240 (0.9)
46 (0.2)
2927 (10.9)
2435 (9.1)
672 (57.0)
414 (55.1)
31 (58.5)
181 (61.2)
25 (61.0)
1490 (54.9)
1206 (54.8)
507 (43.0)
337 (44.9)
22 (41.5)
115 (38.9)
16 (39.0)
1226 (45.1)
995 (45.2)
1.13 (1.00–1.26)
1.12 (0.97–1.29)
0.78 (0.49–1.24)
1.41 (1.13–1.76)
0.96 (0.56–1.64)
0.92 (0.85–1.00)
0.94 (0.86–1.02)
1.14 (1.00–1.30)
1.28 (1.09–1.50)
0.79 (0.46–1.36)
1.16 (0.89–1.50)
0.60 (0.32–1.12)
0.81 (0.74–0.88)
0.79 (0.72–0.87)
Blood and Blood Forming Organs B
Anticoagulants (B01AA, B01AB, B01AE, B01AF, B01AX)
Vitamin K Antagonists (B01AA)
Factor Xa Inhibitors (B01AF)
Unfractionated and Low-Molecular-Weight Heparins (B01AB)
Direct Thrombin Inhibitors (B01AE)
Antiplatelets (B01AC)
Acetylsalicylic Acid (B01AC06)
Platelet P2Y12 Receptor Antagonists (B01AC04, B01AC05, B01AC22, B01AC24,
B01AC25)
Antihemorrhagics, Antianaemic and Perfusion Preparations (B02, B03, B05)
689 (2.0)
705 (2.6)
317 (51.5)
299 (48.5)
0.91 (0.78–1.07)
0.81 (0.69–0.95)
828 (2.4)
680 (2.5)
438 (54.3)
369 (45.7)
1.32 (1.14–1.52)
1.33 (1.13–1.56)
Analgesics (N02)
Opioid Analgesics (N02A)
Nonopioid Analgesics (N02B)
Antimigraine Preparations (N02C)
1346 (3.8)
737 (2.1)
615 (1.8)
43 (0.1)
775 (2.9)
405 (1.5)
387 (1.4)
10 (0.04)
490 (61.3)
323 (60.7)
174 (60.8)
12 (85.7)
309 (38.7)
209 (39.3)
112 (39.2)
2 (14.3)
0.85 (0.75–0.96)
0.94 (0.81–1.10)
0.74 (0.61–0.89)
0.77 (0.39–1.54)
1.07 (0.91–1.24)
1.30 (1.06–1.60)
0.85 (0.67–1.07)
0.43 (0.09–2.08)
Sedative or Hypnotic Agents (N05B, N05C)
Benzodiazepines (N05BA, N05CD)
Nonbenzodiazepine or Nonbarbiturate Sedatives (N05CF)
Antidepressants (N06A)
Selective Serotonin Reuptake Inhibitors (N06AB)
Nonselective Serotonin Reuptake Inhibitors (N06AA)
Other Antidepressants (N06AF, N06AG, N06AX)
Antipsychotics (N05A)
Antiepileptics (N03)
Anti-Parkinson Drugs (N04)
Other Nervous System Agents (N01, N07)
2422 (6.9)
2251 (6.4)
200 (0.6)
2385 (6.8)
1489 (4.3)
141 (0.4)
917 (2.6)
1051 (3.0)
1353 (3.9)
395 (1.1)
164 (0.5)
1111 (4.1)
1008 (3.8)
99 (0.4)
1116 (4.2)
669 (2.5)
73 (0.3)
444 (1.7)
673 (2.5)
960 (3.6)
340 (1.3)
131 (0.5)
1110 (67.9)
1034 (68.6)
92 (63.5)
1101 (68.0)
705 (69.7)
57 (62.6)
425 (66.6)
569 (61.7)
637 (58.2)
192 (54.7)
65 (53.3)
525 (32.1)
473 (31.4)
53 (36.6)
519 (32.0)
306 (30.3)
34 (37.4)
213 (33.4)
353 (38.3)
457 (41.8)
159 (45.3)
57 (46.7)
1.11 (1.01–1.21)
1.12 (1.02–1.22)
1.04 (0.78–1.38)
1.12 (1.03–1.23)
1.19 (1.07–1.33)
1.01 (0.71–1.42)
1.05 (0.91–1.20)
1.57 (1.38–1.79)
1.23 (1.10–1.39)
1.06 (0.86–1.30)
0.90 (0.66–1.25)
1.15 (1.02–1.31)
1.15 (1.01–1.32)
1.33 (0.89–1.99)
1.08 (0.95–1.23)
1.07 (0.91–1.26)
1.27 (0.79–2.04)
1.07 (0.88–1.30)
1.44 (1.22–1.68)
1.21 (1.05–1.38)
0.99 (0.80–1.24)
1.25 (0.87–1.78)
740 (2.1)
260 (0.7)
190 (0.5)
121 (0.4)
122 (0.4)
40 (0.1)
591 (2.2)
221 (0.8)
179 (0.7)
89 (0.3)
81 (0.3)
37 (0.1)
227 (52.8)
61 (45.5)
76 (55.1)
45 (52.3)
41 (63.1)
15 (50.0)
203 (47.2)
73 (54.5)
62 (44.9)
41 (47.7)
24 (36.9)
15 (50.0)
0.79 (0.67–0.94)
0.62 (0.46–0.83)
1.08 (0.79–1.46)
1.00 (0.68–1.48)
0.90 (0.61–1.34)
0.88 (0.45–1.71)
0.92 (0.77–1.10)
1.05 (0.78–1.41)
0.76 (0.56–1.05)
1.30 (0.84–2.01)
0.83 (0.50–1.36)
1.03 (0.53–2.00)
Nervous System N
Anti-Infectives for Systemic Use J
Antibacterials (J01)
Penicillins (J01C)
Quinolones (J01M)
Cephalosporins (J01D)
Macrolides (J01F)
Sulfamethoxazole and Trimethoprim (J01E)
Pharmaceuticals 2021, 14, 678
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Table 2. Cont.
ED Visits for ADEs
Other Antibacterials (J01A, J01B, J01G, J01R, J01X)
Vaccines (J07)
Antivirals and Antiretrovirals (J05)
Other Anti-Infective Agents (J02, J04, J06)
ED Visits for ADEs
Adjusted ROR
Resulting in Hospitalization
(95% CI)
Women
N = 35,010 (%)
Men
N = 26,845 (%)
Women
N = 10,592 (row %)
Men
N = 8326 (row %)
Women
Men
60 (0.2)
34 (0.1)
91 (0.3)
49 (0.1)
29 (0.1)
45 (0.2)
154 (0.6)
44 (0.2)
14 (51.9)
3 (50.0)
29 (32.6)
20 (58.8)
13 (48.2)
3 (50.0)
60 (67.4)
14 (41.2)
0.54 (0.29–0.99)
0.37 (0.11–1.23)
0.77 (0.49–1.22)
0.98 (0.55–1.77)
1.40 (0.66–2.96)
0.33 (0.10–1.10)
0.95 (0.68–1.33)
0.69 (0.36–1.33)
5793 (16.6)
3255 (9.3)
2620 (7.5)
4004 (11.4)
156 (0.5)
3225 (9.2)
4482 (12.8)
2213 (6.3)
935 (2.7)
3029 (8.7)
813 (2.3)
435 (1.2)
1991 (5.7)
4998 (18.6)
3120 (11.6)
1990 (7.4)
3203 (11.9)
120 (0.5)
2745 (10.2)
4004 (14.9)
1929 (7.2)
989 (3.7)
3361 (12.5)
463 (1.7)
490 (1.8)
2082 (7.8)
2531 (53.7)
1477 (51.4)
1092 (56.4)
2100 (56.3)
64 (54.2)
1743 (55.2)
2000 (52.6)
1033 (53.9)
438 (48.0)
1311 (46.3)
425 (62.8)
208 (49.9)
1008 (49.4)
2181 (46.3)
1399(48.6)
843 (43.6)
1633 (43.7)
54 (45.8)
1413 (44.8)
1805 (47.4)
884 (46.1)
475 (52.0)
1519 (53.7)
252 (37.2)
209 (50.1)
1033 (50.6)
0.89 (0.83–0.95)
0.99 (0.92–1.08)
0.84 (0.77–0.91)
1.25 (1.15–1.36)
0.83 (0.60–1.15)
1.29 (1.18–1.41)
0.92 (0.85–0.99)
0.99 (0.90–1.09)
1.01 (0.89–1.16)
0.84 (0.77–0.91)
1.10 (0.95–1.27)
1.03 (0.85–1.26)
1.13 (1.02–1.25)
0.91 (0.84–0.98)
0.99 (0.91–1.08)
0.88 (0.80–0.98)
1.16 (1.06–1.26)
0.87 (0.60–1.26)
1.16 (1.05–1.27)
0.94 (0.87–1.03)
0.97 (0.88–1.08)
1.09 (0.96–1.25)
0.92 (0.85–1.01)
1.32 (1.09–1.59)
0.84 (0.70–1.02)
1.14 (1.03–1.25)
1991 (5.7)
662 (1.9)
1475 (4.2)
4899 (14.0)
329 (0.9)
301 (0.9)
260 (0.7)
11 (0.03)
1864 (6.9)
641 (2.4)
1360 (5.1)
3975 (14.8)
152 (0.6)
263 (1.0)
158 (0.6)
7 (0.03)
961 (52.6)
345 (52.3)
692 (53.2)
2319 (55.3)
142 (65.1)
114 (51.4)
141 (63.2)
2 (50.0)
867 (47.4)
315 (47.7)
610 (46.9)
1872 (44.7)
76 (34.9)
108 (48.7)
82 (36.8)
2 (50.0)
1.13 (1.02–1.24)
1.32 (1.12–1.55)
1.04 (0.93–1.16)
1.06 (0.98–1.14)
1.01 (0.81–1.27)
0.81 (0.63–1.03)
1.27 (0.99–1.63)
0.50 (0.10–2.35)
1.06 (0.96–1.18)
1.19 (1.01–1.41)
0.96 (0.86–1.08)
1.04 (0.96–1.13)
1.24 (0.89–1.72)
0.92 (0.72–1.19)
1.21 (0.88–1.67)
0.77 (0.14–4.19)
928 (2.7)
576 (2.2)
472 (61.9)
291 (38.1)
1.19 (1.04–1.37)
1.18 (0.99–1.40)
Cardiovascular System C
Renin–Angiotensin System Inhibitors (C09)
ACE Inhibitors (Plain and Combinations) (C09A, C09B)
Angiotensin II Receptor Blockers (Plain and Combinations) (C09C, C09D)
Diuretics (C03)
Low-Ceiling Diuretics (C03A, C03B)
High-Ceiling Diuretics (C03C)
Beta Blocking Agents (C07)
Calcium Channel Blockers (C08)
Antiarrhythmics (C01B)
Lipid Modifying Agents (C10)
Digitalis Glycosides (C01AA)
Antiadrenergic Agents C02CA
Other Cardiovascular Agents (C01, C02, C04, C05, Excluding C01AA and C02CA)
Alimentary Tract and Metabolism A
Diabetes agents (A10)
Insulins (A10A)
Oral diabetes agents (A10B)
Antiulcer and antacid agents (A02B, A02A)
Antiemetics and antinauseants (A03F, A04)
Antidiarrheals (A07)
Drugs for constipation (A06)
Stomatological preparations (A01)
Other gastrointestinal agents (A03, A05, A08, A09, A11, A12, A13, A14, A15, A16,
excluding A03F)
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Table 2. Cont.
ED Visits for ADEs
ED Visits for ADEs
Adjusted ROR
Resulting in Hospitalization
(95% CI)
Women
N = 35,010 (%)
Men
N = 26,845 (%)
Women
N = 10,592 (row %)
Men
N = 8326 (row %)
Women
Men
Nonsteroidal Anti-Inflammatory Drugs (M01A)
Ketoprofen (M01AE03, M01AE53)
Ibuprofen (M01AE01, M01AE51)
Diclofenac (M01AB05, M01AB55)
Nimesulide (M01AX17)
Ketorolac (M01AB15)
Naproxen (M01AE02, M01AE52, M01AE56)
Etoricoxib (M01AH05)
608 (1.7)
103 (0.3)
172 (0.5)
88 (0.3)
56 (0.2)
55 (0.2)
21 (0.06)
57 (0.2)
322 (1.2)
52 (0.2)
111 (0.4)
50 (0.2)
24 (0.09)
35 (0.1)
8 (0.03)
16 (0.06)
170 (63.4)
26 (65.0)
37 (62.7)
36 (65.5)
16 (55.2)
13 (54.2)
6 (75.0)
23 (76.7)
98 (36.6)
14 (35.0)
22 (37.3)
19 (34.6)
13 (44.8)
11 (45.8)
2 (25.0)
7 (23.3)
0.66 (0.55–0.79)
0.69 (0.44–1.09)
0.52 (0.36–0.76)
1.12 (0.72–1.74)
0.81 (0.45–1.47)
0.47 (0.25–0.89)
0.65 (0.25–1.73)
0.83 (0.48–1.42)
0.83 (0.65–1.07)
0.82 (0.44–1.54)
0.56 (0.34–0.90)
1.04 (0.58–1.86)
2.19 (0.96–5.02)
0.72 (0.34–1.48)
0.61 (0.12–3.12)
1.11 (0.41–3.04)
Others (M01AA, M01AC, M01AG, M01AX)
Muscle Relaxants (M03)
Antigout Preparations (M04)
Topical Products (M02)
Bisphosphonates (M05)
83 (0.2)
112 (0.3)
1138 (3.3)
26 (0.07)
356 (1.0)
32 (0.1)
79 (0.3)
1388 (5.2)
20 (0.07)
59 (0.2)
22 (61.1)
33 (55.9)
616 (47.1)
8 (80.0)
145 (82.4)
14 (38.9)
26 (44.1)
692 (52.9)
2 (20.0)
31 (17.6)
0.62 (0.37–1.02)
0.69 (0.46–1.05)
1.20 (1.06–1.37)
0.88 (0.37–2.08)
0.83 (0.66–1.03)
1.49 (0.72–3.08)
0.72 (0.44–1.17)
1.08 (0.96–1.22)
0.22 (0.05–0.98)
1.25 (0.74–2.10)
260 (0.7)
22 (0.06)
220 (0.6)
144 (0.5)
23 (0.09)
143 (0.5)
95 (64.2)
10 (41.7)
93 (57.1)
53 (35.8)
14 (58.3)
70 (42.9)
0.79 (0.61–1.03)
1.32 (0.56–3.12)
1.05 (0.80–1.39)
0.77 (0.55–1.10)
2.09 (0.90–4.87)
0.98 (0.70–1.37)
192 (0.6)
891 (2.5)
258 (0.7)
179 (0.7)
960 (3.6)
149 (0.6)
50 (49.5)
395 (46.0)
83 (63.4)
51 (50.5)
464 (54.0)
48 (36.6)
0.65 (0.47–0.91)
1.05 (0.91–1.21)
0.75 (0.57–0.98)
0.70 (0.50–0.98)
1.18 (1.03–1.36)
0.82 (0.57–1.17)
1143 (3.3)
2285 (6.5)
33 (0.09)
654 (2.4)
675 (2.5)
29 (0.1)
441 (58.8)
937 (74.8)
10 (40.0)
309 (41.2)
315 (25.2)
15 (60.0)
0.87 (0.77–0.99)
0.93 (0.85–1.02)
0.56 (0.26–1.20)
1.28 (1.09–1.51)
1.02 (0.87–1.20)
1.26 (0.60–2.63)
Musculoskeletal system M
Antineoplastic and Immunomodulating Agents L
Antineoplastic Agents (L01)
Immune Modulators (L03)
Endocrine Therapy (L02)
Respiratory System R
Nasal, Throat, Cough and Cold Preparations (R01, R02, R05)
Bronchodilators (R03)
Antihistamines for Systemic Use (R06)
Hormonal Preparations H
Corticosteroids for Systemic Use (H02)
Thyroid Therapy (H03)
Other Hormonal Agents (H01, H04, H05)
Genitourinary System and Sex Hormones G
Systemic and Vaginal Contraceptives (G01)
14 (0.04)
6 (0.02)
6 (75.0)
2 (25.0)
1.29 (0.43–3.89)
0.91 (0.16–5.23)
Drugs Used in Benign Prostatic Hypertrophy (G04)
Other Gynaecological Agents and Sex Hormones (G02, G03)
60 (0.2)
161 (0.5)
1953 (7.3)
41 (0.2)
27 (2.9)
44 (72.1)
910 (97.1)
17 (27.9)
0.93 (0.55–1.57)
0.79 (0.55–1.14)
0.98 (0.88–1.08)
0.75 (0.40–1.42)
Analyses were adjusted for age, ethnicity, presence of two or more suspected drugs, presence of concomitant drugs and presence comorbidities. ADE: adverse drug event; CI: confidence interval; ED: emergency
department; ROR: odds ratio.
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2.3. Hospitalization Risks among Women
A significantly increased risk of hospitalization was observed only for women when
exposed to unfractionated and low-molecular-weight heparins (ROR 1.41, 1.13–1.76), antidepressants (ROR 1.12, 1.03–1.23) and diabetes agents (ROR 1.13, 1.02–1.24) (Table 2).
A statistically significant reduced risk of hospitalization was observed only for women
when exposed to analgesics (ROR 0.85, 0.75–0.96), particularly nonopioid analgesics; antibacterials (ROR 0.79, 0.67–0.94), particularly penicillins; beta blocking agents (ROR 0.92,
0.85–0.99); nonsteroidal anti-inflammatory drugs (ROR 0.66, 0.55–0.79), particularly ketorolac; and corticosteroids for systemic use (ROR 0.87, 0.77–0.99) (Table 2).
2.4. Hospitalization Risks among Men
A statistically significant increased risk of hospitalization was observed only for men
when exposed to vitamin K antagonists (ROR 1.28, 1.09–1.50), opioid analgesics (ROR 1.30,
1.06–1.60), and digitalis glycosides (ROR 1.32, 1.09–1.59) (Table 2).
A significantly reduced risk of hospitalization was observed only for men when
exposed to antiplatelets (ROR 0.81, 0.74–0.88), particularly acetylsalicylic acid and platelet
P2Y12 receptor antagonists (Table 2).
2.5. Predictors of Hospitalization
A statistically significant increased risk of hospitalization was observed for both
elderly women and men (ROR 1.35, 95% CI 1.27–1.42 and 1.23, 1.16–1.31, respectively)
compared to adults, in patients treated with more than one suspected drug (two suspected
drugs ROR 1.98, 1.81–2.17 and 1.66, 1.50–1.84; three to four suspected drugs ROR 4.14,
3.66–4.69 and 2.92, 2.53–3.38; five or more drugs ROR 6.58, 5.66–7.66 and 4.15, 3.48–4.96),
and in patients who presented concomitant conditions (ROR 1.51, 1.44–1.59 and 1.57,
1.48–1.66) (Table 3).
Table 3. Predictors of hospitalization among women and men expressed as reporting odds ratios.
Women
Men
Crude ROR
(95% CI)
Adjusted ROR
(95% CI)
Crude ROR
(95% CI)
Adjusted ROR
(95% CI)
1
0.62 (0.56–0.69)
2.00 (1.90–2.10)
1
0.85 (0.77–0.95)
1.35 (1.27–1.42)
1
0.41 (0.37–0.46)
1.79 (1.69–1.88)
1
0.56 (0.50–0.64)
1.23 (1.16–1.31)
1
0.79 (0.61–1.03)
0.57 (0.46–0.72)
0.78 (0.50–1.22)
1
1.24 (0.95–1.63)
0.89 (0.70–1.13)
1.09 (0.69–1.73)
1
0.96 (0.74–1.25)
0.61 (0.48–0.76)
0.63 (0.33–1.19)
1
1.43 (1.08–1.88)
0.93 (0.73–1.19)
0.86 (0.44–1.67)
1
0.30 (0.20–0.34)
1
0.36 (0.27–0.48)
1
0.27 (0.21–0.35)
1
0.83 (0.42–0.74)
1
1.56 (1.45–1.67)
2.52 (2.36–2.69)
4.24 (4.00–4.51)
1
1.98 (1.81–2.17)
4.14 (3.66–4.69)
6.58 (5.66–7.66)
1
1.45 (1.33–1.57)
2.39 (2.21–2.58)
3.91 (3.65–4.17)
1
1.66 (1.50–1.84)
2.92 (2.53–3.38)
4.15 (3.48–4.96)
1
1.98 (1.89–2.07)
1
1.51 (1.44–1.59)
1
2.09 (1.98–2.20)
1
1.57 (1.48–1.66)
Age Classes
Adults (20–64 Years)
Children and Adolescents (0–19 Years)
Elderly (≥65 Years)
Ethnicity
Caucasians
Black or African American
Asian
Other
AEFI
No
Yes
Number of Suspected Drugs
1
2
3–4
≥5
Concomitant Conditions
No
Yes
Analyses were adjusted for age classes, ethnicity, type of drug, number of suspected drugs, number of concomitant drugs and presence of
comorbidities. AEFI: adverse events following immunization; CI: confidence interval; ROR: reporting odds ratios.
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A significantly increased risk of hospitalization was observed only for men of Black or
African American ethnicity (ROR 1.43, 1.08–1.88) compared to Caucasians (Table 3).
A significantly reduced risk of hospitalization was observed for both male and female
children and adolescents (ROR 0.85, 0.77–0.95 and 0.56, 0.50–0.64, respectively) compared
to adults, and for patients who experienced an adverse event following immunization
(ROR 0.36, 0.27–0.48 and 0.83, 0.42–0.74) (Table 3).
2.6. Adverse Events
Table 4 shows the description of ADEs according to the most commonly reported
suspected drug classes (see Table 1). A statistically significant difference between women
and men was observed for the following ADEs: (1) haemorrhages, alteration of the international normalized ratio and unintentional or intentional overdose in patients exposed to
anticoagulants and antiplatelets; (2) dermatologic reactions, gastrointestinal disturbances,
neurological effects and anaphylaxis due to antibacterials; (3) dermatologic reactions,
gastrointestinal disturbances, localized or peripheral edema and abuse or self-harm due
to nonsteroidal anti-inflammatory drugs; (4) hypoglycaemia and gastrointestinal disturbances due to insulin and oral antidiabetic agents; (5) neurological effects, gastrointestinal
disturbances, dermatologic reactions, localized or peripheral edema and unspecified hypersensitivity due to opioid and nonopioid analgesics. Details of each ADE manifestation
are also reported (italics).
Table 4. Adverse events manifestation by most commonly reported suspected drug classes.
ED Visits for ADEs Resulting in Hospitalization
Women
No. of Preferred Terms
N = 47,937 (%)
Men
No. of Preferred Terms
N = 36,231 (%)
4431 (43.65)
1476 (14.52)
858 (8.46)
394 (3.88)
554 (5.46)
54 (0.53)
78 (0.77)
183 (1.8)
822 (8.10)
514 (5.06)
167 (1.65)
5719 (51.45)
2083 (18.83)
1009 (9.13)
805 (7.28)
601 (5.44)
59 (0.54)
151 (1.37)
195 (1.76)
661 (5.97)
574 (5.19)
145 (1.31)
Dermatologic Reactions
Urticaria
Localized or General Pruritus
Erythema
Rash
Localized or Peripheral Edema
Gastrointestinal Disturbances
Nausea or Vomiting
Abdominal Pain
Diarrhoea
Unspecified Hypersensitivity
Neurological Effects
Respiratory Reactions
Dyspnoea
Throat Tightness
6413 (47.74)
1893 (14.10)
1661 (12.38)
1197 (8.91)
249 (1.85)
1049 (7.82)
1532 (11.43)
700 (5.22)
397 (2.96)
351 (2.62)
636 (4.74)
778 (5.67)
728 (5.43)
405 (3.02)
127 (0.95)
4441 (47.73)
1315 (14.14)
1038 (11.16)
853 (9.17)
238 (2.55)
746 (8.03)
913 (9.83)
380 (4.09)
247 (2.66)
237 (2.55)
414 (4.46)
468 (5.03)
486 (5.22)
279 (3.0)
64 (0.69)
Anaphylaxis
117 (0.87)
118 (1.27)
p-Value
Anticoagulants and Antiplatelets (B01A)
Haemorrhage
Epistaxis
Gastrointestinal
Genitourinary
Central Nervous System
Dermatologic
Pulmonary
Ophthalmic
Altered International Normalized Ratio
Anaemia
Unintentional or Intentional Overdose
<0.001
<0.001
0.658
0.045
Antibacterials (J01)
<0.001
0.571
<0.001
0.311
0.013
0.514
0.004
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Table 4. Cont.
ED Visits for ADEs Resulting in Hospitalization
Women
No. of Preferred Terms
N = 47,937 (%)
Men
No. of Preferred Terms
N = 36,231 (%)
2220 (32.11)
768 (11.11)
572 (8.28)
376 (5.44)
378 (5.47)
1256 (18.18)
497 (7.2)
351 (5.08)
83 (1.2)
91 (1.32)
58 (0.84)
949 (13.73)
235 (3.4)
243 (3.51)
100 (1.45)
1571 (30.01)
579 (11.06)
385 (7.35)
278 (5.31)
244 (4.66)
862 (16.51)
316 (6.04)
149 (2.85)
98 (1.87)
65 (1.24)
65 (1.24)
844 (16.14)
198 (3.79)
216 (4.13)
52 (0.99)
3721 (57.44)
1226 (18.93)
504 (7.78)
179 (2.76)
196 (3.03)
116 (2.56)
127 (1.96)
2049 (56.63)
607 (16.7)
270 (7.43)
103 (3.04)
119 (3.28)
101 (2.78)
74 (2.04)
2124 (28.29)
167 (2.22)
411 (5.47)
258 (3.44)
204 (2.71)
115 (1.53)
246 (3.28)
107 (1.43)
2076 (27.65)
1370 (18.25)
508 (6.77)
65 (0.86)
1011 (13.47)
343 (4.57)
286 (3.81)
214 (2.85)
168 (2.24)
380 (5.07)
173 (2.31)
152 (2.03)
106 (1.41)
866 (23.21)
85 (2.28)
147 (3.94)
97 (2.6)
99 (2.65)
84 (2.25)
117 (3.14)
32 (0.86)
725 (19.43)
409 (10.96)
199 (5.33)
34 (0.91)
686 (18.39)
249 (6.68)
193 (5.17)
125 (3.35)
119 (3.19)
248 (6.64)
89 (2.38)
97 (2.60)
91 (2.44)
p-Value
Nonsteroidal Anti-Inflammatory Drugs (M01A)
Dermatologic Reactions
Urticaria
Localized or General Pruritus
Erythema
Rash
Gastrointestinal Disturbances
Abdominal Pain
Nausea or Vomiting
Melena
Gastritis
Hematemesis
Localized or Peripheral Edema
Unspecified Hypersensitivity
Respiratory Reactions
Abuse or Self-Harm
0.012
0.014
<0.001
0.262
0.081
0.026
Sedative or Hypnotic Agents (N05B, N05C)
Neurological Effects
Drowsiness
Altered Mental Status or Bradyphrenia
Loss of Consciousness
Bradykinesia
Muscular Weakness
Presyncope or Syncope
0.292
Opioid and Nonopioid Analgesics (N02A, N02B)
Neurological Effects
Muscular Weakness
Dizziness
Presyncope or Syncope
Drowsiness
Hyperhidrosis
Altered Mental Status
Headache
Gastrointestinal Disturbances
Nausea or Vomiting
Abdominal Pain
Constipation
Dermatologic Reactions
Urticaria
Localized or General Pruritus
Erythema
Rash
Localized or Peripheral Edema
Abuse or Self-Harm
Respiratory Distress
Unspecified Hypersensitivity
<0.001
<0.001
<0.001
0.001
0.787
0.051
<0.001
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Table 4. Cont.
ED Visits for ADEs Resulting in Hospitalization
Women
No. of Preferred Terms
N = 47,937 (%)
Men
No. of Preferred Terms
N = 36,231 (%)
Hypoglycaemia (from Mild to Severe)
Hypoglycaemia-Related Symptoms
Shock, Loss of Consciousness or Seizures
Altered Mental Status
Presyncope or Syncope
Acidosis
Neurological Effects
Drowsiness
1476 (42.73)
620 (26.41)
260 (7.52)
139 (4.03)
72 (2.09)
89 (2.58)
432 (12.51)
114 (3.3)
1530 (46.8)
575 (17.62)
276 (8.45)
129 (3.96)
80 (2.45)
46 (1.41)
413 (12.63)
117 (3.58)
Hyperhidrosis
Muscular Weakness
Aphasia, Dizziness or Tremor
Therapeutic Errors
Gastrointestinal Disturbances
88 (2.55)
61 (1.77)
63 (1.82)
152 (4.4)
151 (4.37)
85 (2.60)
41 (1.25)
71 (2.17)
164 (5.02)
98 (3.01)
p-Value
Insulin and Oral Antidiabetic Agents (A10)
0.001
0.699
0.876
0.233
0.003
ADE: adverse drug event; ED: emergency department.
2.7. Suspected Drugs
Supplementary Table S1 shows the most commonly reported suspected drugs by
patients’ age. Overall, the most commonly reported drug was warfarin, followed by
amoxicillin/clavulanate, acetylsalicylic acid, ketoprofen and ibuprofen. In patients aged
≤19 years old, the most commonly reported drug was amoxicillin/clavulanate, followed
by ibuprofen; amoxicillin, alone; hexavalent vaccine and paracetamol. Among elderly
patients (age ≥ 65 years), the most commonly reported drug was warfarin, followed by
acetylsalicylic acid, amoxicillin/clavulanate, long-acting insulin glargine and furosemide.
3. Discussion
The primary aim of our study was to give an overview of differences in ADE-related
hospitalization by the most frequently reported suspected drug classes in women and men
in Italy. This post hoc analysis showed a higher frequency of ED admission in women,
although for this group the frequency of hospitalization resulted lower than in men. This
evidence are comparable to those already available in literature, both at the Italian [10,11]
and international level [12,13].
Our data reported that men were exposed to polypharmacy (≥5 suspected drugs along
with ≥5 concomitant drugs) more frequently than women at the time of ED admission, also
presenting more than three comorbidities compared to women. This could be a possible
explanation of the higher rate of hospitalization observed among men in our sample. In
fact, at a global level, the proportion of serious and fatal reports also associated with
hospitalization is higher for males [14].
It is noteworthy that vaccination safety was confirmed by the evidence that the majority of ADE reports were not associated to vaccines, nor was increased risk of hospitalization
due to AEFI occurrence was observed among sexes. Although vaccines represent one
of the most frequent cause of ADE in specific subgroups, such as children, their safety
was confirmed by several observational studies and by health care authorities: adverse
events following immunization are mostly nonserious and rarely cause ED visits and
hospitalization [15].
According to the study by McHugh and colleagues [16], abuse/misuse and overdoses
were more frequently reported among women. A possible explanation of these realworld evidences may be related to the higher prevalence of use of analgesics (i.e., opioids)
and sedatives and hypnotics (i.e., benzodiazepines) among women in Italy [17], which
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could also be confirmed by the higher number of ADE reports related to these suspected
drug classes for women in our sample. Furthermore, it is well-known that opioids and
benzodiazepines have a high tolerance and dependence potential [18].
On the other hand, interactions (particularly drug–drug and drug–disease interactions)
and therapeutic errors were more frequently reported among men. It is well-known that
men, particularly the elderly or those exposed to polypharmacy as in our sample, take
less care of themselves and, therefore, could be exposed to a greater risk of therapeutic
errors, especially in absence of a caregiver, whose lacking is known to be more common
among men [19]. Moreover, women more often act as caregivers, and the effect of having a
caregiver appears less important for women compared to men [20].
Considering predictors of hospitalization, except for vaccines discussed above, our
study confirms a higher risk of hospitalization for both sexes in old age (≥65 years) and
in subjects exposed to more than one suspected drug [21]. Moreover, even if genetic
differences in drug response related to ethnicity are well established [22,23], social and
economic status may have influenced the likelihood of seeing African American ethnicity
associated with an increased risk of hospitalization for men. In fact, as reported by an
Italian investigation, low education level, lack of employment and negative self-perceived
economic resources were conditions associated with the risk of hospitalization, a longer
hospital stay and greater recourse to urgent hospitalization [24].
As a final consideration, the majority of ADE manifestations observed in both sexes
were represented by dose-dependent and preventable events (Type A reactions), which
are usually associated with pharmacodynamic and pharmacokinetic properties of each
suspected drug class, and by hypersensitivity events (Type B reactions), whose frequency
is higher for antibacterials for systemic use [25].
3.1. Drug Classes and Hospitalization Risk among Both Women and Men
3.1.1. Increased Hospitalization
Scientific literature provides several studies concerning antipsychotic safety in women
and men [26]. In much research, some side effects, such as weight gain, passivity, hypotension and hyperprolactinemia, are reported to be particularly problematic for women [27].
Nevertheless, in our sample, both women and men are at risk of hospitalization if exposed
to antipsychotics. In fact, men and women may experience different ADEs: metabolic
abnormalities, hypertension and cardiovascular risk are more frequently reported in men,
while women are at a higher risk for gaining weight, developing diabetes and needing
laxatives [28].
According to Landmark and Johannessen, there are no suggestion of sex-related influences on antiepileptics pharmacokinetics. In particular, sex does not influence antiepileptics
efficacy and safety to a clinically relevant degree. Nevertheless, the use of enzyme inducers or inhibitors, such as carbamazepine or valproate, may be considered with caution,
regardless of the patient’s sex [29].
In contrast with our results, the German Pharmacovigilance Project found higher rates
of hospitalization due to electrolyte disturbances and arrhythmias in women than in men
treated with diuretics. According to the authors, even if dose adjustments are not required
for patient’s sex, diuretics elimination in women is reduced, leading to a higher frequency
of hyponatraemia and hypokalaemia [30]. Results highlighted by our analysis may derive
from a country-specific prescription patterns of diuretics, particularly high-ceiling ones. In
fact, in the last report of the Italian Medicine Agency, no relevant differences were observed
in diuretics prevalence of use in the general population [17]. Moreover, the clinical impact
of concomitant diseases on hospitalization risk should also be considered.
To date, few studies focused on sex differences in the treatment of diabetes mellitus
(Type 2) [31]. In line with our results, examination of the antidiabetic ADE pairs by drug
class showed high rates of GLP-1RA-, insulin-, and SGLT2i-related reporting in both
women and men. Explanations for possible different ADEs reporting by gender in diabetic
subjects should be further explored [32,33].
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3.1.2. Decreased Hospitalization
Results regarding the risk of hospitalization related to the use of renin–angiotensin
system inhibitors and angiotensin II receptor blockers obtained in our sample are strengthened by the evidence of no sex-related differences in the pharmacokinetics of these drugs.
Even if the premenopausal cardio-protective effects of estrogen may result in part from
renin–angiotensin–aldosterone system inhibition, the efficacy and safety of medications
acting on this system seems not to be imbalanced between the two sexes [30].
Compared with other nonsteroidal anti-inflammatory agents, ibuprofen shows a
favourable safety profile. The majority of ADEs may be described as gastrointestinal and
cardiovascular, but their incidence is relatively rare in both women and men [34]. Moreover,
the menstrual cycle did not affect the pharmacokinetics of S-ibuprofen or R-ibuprofen, and
only the concomitant administration of oral contraceptives may lead to a higher clearance.
Nevertheless, the clinical impact of such interaction seems of little relevance [35].
3.2. Drug Classes and Hospitalization Risk among Women
3.2.1. Increased Hospitalization
Our results regarding unfractionated and low-molecular-weight heparins are confirmed by Blanco-Molina et al., who showed an increased rate of major bleeding events in
women, irrespective of the active principle used. The authors attributed the higher rate of
bleeding in women to their older age, lower body weight or to the higher dosage, which
may contribute to reach higher plasma concentration of heparins and increase the risk of
ADEs [30,36].
Despite depression’s prevalence in women, the vast majority of research focused on
depression has been dedicated to studying males. Different gastric environment, slower
gastric emptying and longer colonic transit observed in women can increase antidepressants absorption. In addition, a higher percentage of adipose tissue in women can prolong
the half-life of lipophilic drugs. Differences in metabolism or clearance may contribute to
higher plasma concentrations in women, and estrogen is a substrate for some of the same cytochrome P450 isozymes as well as antidepressants, possibly shifting their metabolism [30].
Thus, women show a decreased tolerability of such antidepressants, which could lead to
dizziness, nausea, abnormal vision, constipation and somnolence [37].
While insulins increased hospitalization risk both in women and men, in our sample,
oral antidiabetics related-ADEs were more frequently reported only in women. This is in
line with previous evidences that some antidiabetics (i.e., thiazolidinediones) double the
risk of fractures among diabetic women but not among men [30]. However, in the study by
Rodenburg et al., hypoglycaemic coma due to insulin and antidiabetic agents were more
frequent in men [38], whereas Hendriksen and colleagues found that hypoglycaemia was
significantly lower in women than in men [13].
3.2.2. Decreased Hospitalization
Concerning nonopioid analgesics, mainly represented by paracetamol in our sample,
we observed a reduced risk of hospitalization in women compared to men. This is in
contrast with the review by Tamargo et al., which reported that paracetamol overdose and
consequent acute liver failure are more common in women. In fact, men show lower plasma
levels and higher clearance due to increased activity of the glucuronidation pathway [30].
Several studies from United States and Europe showed that antibiotics prescription is
higher in women, although well-known risk factors for bacterial infections (i.e., alcohol
drinking, smoking and obesity) are more prevalent in men [39,40]. Despite this, our analysis
showed a lower risk of hospitalization due to antibiotic-related ADEs in this group. It can
be assumed that women prescribed with antibiotics are more likely to receive appropriate
prescriptions and to follow their therapy correctly [41].
Estrogen and progesterone inhibit the cardiac expression of β1-adrenoceptors and
reduce β-adrenergic-mediated stimulation. This cardio-protective effect may lead to sexspecific differences in beta blockers pharmacodynamics [40]. This evidence may explain
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our results concerning beta blockers safety profile in women. In fact, in women, more
ADEs were observed for CYP 2D6-dependent beta blockers (i.e., metoprolol, carvedilol,
nebivolol and propranolol), suggesting a possible increasing in hospitalization risk in case
of drug–drug or drug–herb interactions [42].
Women receive diuretics more often than men, suggesting possible sex-related differences in the treatment of hypertension [40]. In contrast with our analysis, Rodenburg
et al. found that women were more frequently admitted to the hospital with an ADE
related to high-ceiling and low-ceiling diuretics and cardiotonic glycosides than men [43].
However, no information was reported in this study respect to hospitalization. Therefore,
we cannot exclude that, although women are more exposed to diuretics and are admitted
more frequently to ED, ADE seriousness in women may not require hospitalization.
3.3. Drug Classes and Hospitalization Risk among Men
3.3.1. Increased Hospitalization
As a result of their mechanism of action, anticoagulants cause different types of
haemorrhages. Rodenburg et al. showed that the risk of a hospital admission differs
between women and men for different types of bleeding. As in our study, men were
more at risk for ED visits, in particular caused by unspecified and recurrent and persistent
haematuria, haemoptysis and subdural haemorrhage [13]. Warfarin efficacy in reducing
the risk of thromboembolism in women and men did not differ and did not pose women
at a greater risk of major haemorrhagic complications. Women had more minor bleeding
complications than men did, and they require less mg per week than men to maintain
a therapeutic International Normalized Ratio, with older women requiring the lowest
doses [40]. Another study confirms that the risk of hospitalizations for bleeding in any
specific form due to anticoagulants or salicylates use was significantly higher in men. In
particular, hospitalizations for haematuria and haemoptysis were much more frequent
in men than in women. Risk for ADE-related hospitalization varied per type of reaction.
Where men seemed to have a higher risk of hospitalization for haematuria, haemoptysis,
cerebral bleeding and bone fractures [44], women were at higher risk for anaemia [38]. Of
note, these studies considered anticoagulants and antiplatelets as a unique drug class, even
if their pharmacological properties are not comparable.
Regarding opioids, women experience more ADEs (i.e., nausea and vomiting, respiratory depression) despite smaller dose requirements for pain control [38,40]. In our sample,
a higher risk of hospitalization was not observed in women but was in men, according to
the study by Hendriksen et al., which showed a small difference in the number of hospital
admission in favour of men [13].
From our analysis, risk of hospitalization due to cardiotonic glycosides was significantly increased in men. According to the evidences published in literature, women
have higher serum digoxin concentrations due to reduced distribution volume and lower
clearance that increases only during pregnancy [40]. When directly compared, cardiotonic
glycosides are responsible for a twofold higher risk for ED visits in women than men [43]
and accounted for a risk for women to be hospitalized with an ADE that was twice as
high as for men [43]. Our study did not underline an increased risk for hospitalization
in women but, in line with the above cited articles, highlighted a worse safety profile for
cardiotonic glycosides in men.
3.3.2. Decreased Hospitalization
As for antiplatelets, the majority of studies available in literature on this topic calculated pooled risk for anticoagulants and antiplatelets as combined drug classes. Following
this approach, ED visits for bleeding due to anticoagulants or salicylates use were significantly higher in men [38]. However, when antiplatelets, alone, were considered, more
frequent and severe bleedings were observed in women [40]. Again, our study did not
underline an increased risk for hospitalization in women but confirmed a better safety
profile for antiplatelets in men.
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3.4. Limitations and Strengths
Main limitations and strengths of the MEREAFaPS Study have already been described [9,45]. For this specific post hoc analysis, limitations are mainly represented by the
lack of information on drug use and regarding drug–drug combinations and interactions.
Points of strength include minimization of reporting bias by investigating only ADE-related
ED visits and hospitalization and the availability of individual patient information, which
enabled us to adjust for several demographic and clinical variables. Finally, to the best
of our knowledge, this is the first analysis of its kind investigating drug safety in women
and men in the setting of the ED without a direct comparison between the two groups.
This methodological approach avoids obtaining estimates biased by all the well-known
biological differences between sexes.
4. Materials and Methods
This is a post hoc analysis performed on pharmacovigilance reports of suspected AE
collected between 1 January 2007 and 31 December 2018 in the EDs participating to the
MEREAFaPS Study [9,45–47].
As described in previous publications [48,49], all ADEs leading to ED visits were
collected from the ED clinical charts and hospitalization data were collected from the
hospitals discharge database. Patients who developed an ADE while in the ED were
excluded. Trained monitors recorded: (1) patients’ demographic characteristics; (2) patients’
clinical status on ED visits; (3) suspected and concomitant drugs; (4) ADEs description.
Suspected and concomitant drugs were classified according to the Anatomical Therapeutic Chemical (ATC) classification system. ADE description according to diagnosis and
symptoms was coded using the Medical Dictionary for Regulatory Activities (MedDRA)
and organized by System Organ Class (SOC) and Preferred Term (PT) [48]. As already
described in previous publications, “suspected” drugs were defined as those mainly associated with the reported ADE, while “concomitant” drugs as those described in the report
form at the time of ADE manifestation, which were used by the patient concomitantly with
the suspected drugs, but which were not considered directly associated with the ADE.
Number of concomitant drugs “0” means that patient was not taking concomitant drugs,
but only 1 or more suspected drugs; “1” means that patient was taking only 1 concomitant
drug with at least 1 suspected drug; “2” or “≥3” means that patient was taking 2 or more
than 3 concomitant drugs with at least 1 suspected drug.
Descriptive statistics were used to summarize data. Categorical data were reported as
frequencies and percentages and compared using the chi-square test, whereas continuous
data were reported as median values with the related interquartile ranges (IQR) and compared using the Mann–Whitney test. Univariate logistic regression was used to estimate
the reporting odds ratios (RORs) of hospitalization with 95% confidence intervals (CIs).
In order to reduce bias due to biological differences between women and men, comparisons were made within each sex group rather than between the two sexes. For example,
estimating the hospitalization risk associated to anticoagulants, women exposed to these
suspected drugs were compared to not exposed ones. The same contingency was built
for men. Multivariate logistic regression was performed and adjusted for: age, ethnicity,
number of suspected drugs, presence of concomitant drugs and presence of concomitant
conditions. All results were considered to be statistically significant at p-value < 0.05. Data
management and statistical analysis were carried out using STATA 16.1.
The coordinating centre of Tuscany Region (Italy) approved MEREAFaPS Study
(Notification number 1225—21 December 2009), and the local institutional ethics committee
approved the MEREAFaPS Study (Study number 3055/2010, Protocol number 45288—
6 August 2014) according to the legal requirements concerning observational studies. Due
to the retrospective nature of the present study and data anonymization, patient consent to
participate was not required.
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5. Conclusions
Results obtained from this real-world analysis highlight important aspects of drug
safety between sexes. Healthcare professionals, particularly physicians operating in ED and
clinical pharmacologists, should always consider differences in drug safety among women
and men, considering a personalized approach for each group in terms of prescription
appropriateness and ADE management and prevention.
Supplementary Materials: The following are available online at https://www.mdpi.com/article/10
.3390/ph14070678/s1, Table S1: Most commonly reported suspected drugs by patient’s age.
Author Contributions: Conceptualization, N.L. and G.C.; methodology, A.B.; formal analysis, A.B.
and R.B.; data curation, G.S., G.V.V. and E.B.; writing—original draft preparation, G.C. and S.P.;
writing—review and editing, G.C., S.P. and N.L.; supervision, A.V., G.D.V. and M.V. All authors have
read and agreed to the published version of the manuscript.
Funding: This study was funded by a research grant from the AIFA (the Italian Medicines Agency),
Rome, Italy, Tuscan County resolution DGRT 790/2016 All. C. The funder of the study had no role in
the collection, analysis or interpretation of data, nor in the writing of the report, nor in the decision to
submit the article for publication.
Institutional Review Board Statement: The coordinating centre of Tuscany Region (Italy) approved
MEREAFaPS Study (Notification number 1225—21 December 2009), and the local institutional
ethics committee approved the MEREAFaPS Study (Study number 3055/2010, Protocol number
45288—6 August 2014) according to the legal requirements concerning observational studies.
Informed Consent Statement: Due to the retrospective nature of the present study and data
anonymization, patient consent to participate was not required.
Data Availability Statement: Data that support the findings of this study are available upon reasonable request from the corresponding author, N.L.
Acknowledgments: Members of the MEREAFaPS Study group who provided patient data for this
study: Maria Luisa Aiezza (Naples), Alessandra Bettiol (Florence), Daria Bettoni (Brescia), Corrado Blandizzi (Pisa), Roberto Bonaiuti (Florence), Valentina Borsi (Florence), Annalisa Capuano
(Naples), Errica Cecchi (Prato), Irma Convertino (Pisa), Giada Crescioli (Florence), Martina Del
Lungo (Florence), Cristina Di Mauro (Naples), Gabriella Farina (Milan), Sara Ferraro (Pisa), Annamaria Fucile (Naples), Elena Galfrascoli (Milan), Elisabetta Geninatti (Turin), Linda Giovannetti
(Florence), Luca Leonardi (Pisa), Rosa Liccardo (Naples), Niccolò Lombardi (Florence), Anna Marra
(Ferrara), Eleonora Marrazzo (Turin), Giovanna Monina (Gallarate), Alessandro Mugelli (Florence),
Silvia Pagani (Vimercate), Maria Parrilli (Florence), Concetta Rafaniello (Naples), Francesco Rossi
(Naples), Marco Rossi (Siena), Stefania Rostan (Naples), Marco Ruocco (Vimercate), Marita Sironi
(Vimercate), Giulia Spada (Vimercate), Liberata Sportiello (Naples), Marco Tuccori (Pisa), Alfredo
Vannacci (Florence), Mauro Venegoni (Vimercate), Giuditta Violetta Vighi (Vimercate), Giuseppe
Danilo Vighi (Vimercate).
Conflicts of Interest: The authors declare no conflict of interest.
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