The exposure cohort included new users of any HCTZ-containing products (referred to as HCTZ henceforth), and the comparator cohort included new users of ACEI monotherapy or non–HCTZ ACEI combination products (referred to as ACEI henceforth). We included patients with continuous enrollment in plans with both medical and drug coverage for at least 183 days prior to the index date (defined below). We examined the risk of NMSC among patients exposed to HCTZ-containing products compared with patients who received angiotensin-converting enzyme inhibitors (ACEIs) in a large, demographically and geographically diverse US population. In the United States, HCTZ-amiloride combinations make up less than 1% of the HCTZ market share. One-third of HCTZ-containing products in the Danish studies included amiloride, which also has photosensitizing properties and could have contributed to the observed increased risk. The Danish population, of which 93% are Caucasians, may have different NMSC susceptibility genes, racial composition, and sun exposure behaviors than the US population. It is likely that the ensuing sunburns due to phototoxic reactions result in photodamage, as observed with high-dose oral psoralen and SCC ( 15).Īlthough the positive associations observed in the Danish studies were supported by biological plausibility, some aspects of these studies limited the generalizability of their findings to the US population. Instead, it is believed that these reactions are a type of cell-mediated hypersensitivity response ( 14).
Photoallergic reactions do not result in cell damage.
MT PILGRIM M B ASSOCIATION SKIN
Phototoxic reactions occur following the activation of drug or its metabolite by light in viable skin cells, resulting in generation of reactive oxygen intermediates, which leads to nuclear cytoplasm or cell membrane alteration and ultimately cell damage ( 12, 13). The ensuing pathogenesis of phototoxic and photoallergic reactions is different. Several in vitro studies suggested that HCTZ and other sulfonamide-containing drugs may trigger drug-induced phototoxic reactions ( 8–11). Occurring at a higher frequency, phototoxic reactions are usually dose-dependent and require greater drug exposure ( 7). Although photoallergic reactions are less common than phototoxic reactions, they are not dependent on the dose of the medication or intensity of sun exposure and usually occur hours after the initial exposure as a delayed hypersensitivity reaction ( 7).
Drug-induced photosensitivity can occur as photoallergic or phototoxic reactions ( 7). The biological plausibility for an association between HCTZ and NMSC is likely related to its photosensitizing properties ( 6). An earlier observational study ( 5), conducted in 1 Danish county, also found an elevated risk of SCC associated with ever use of HCTZ. Both studies also observed a dose-response effect. Recently, the US Food and Drug Administration and European Union Pharmacovigilance Risk Assessment Committee were alerted to 2 Danish population-based case-control studies ( 3, 4) that found an elevated risk of nonmelanoma skin cancer (NMSC), which includes basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), associated with HCTZ-containing products. Single-ingredient and 25 mg strength HCTZ-containing products contributed to the largest proportion of use at 43% (9 million) and 55% (11.5 million) of the total patients, respectively ( 2). In 2017, an estimated 20.9 million patients received a dispensed prescription for HCTZ-containing products in the United States ( 2). If he has the proper training, the assistant minister may also provide counseling services to church members.Hydrochlorothiazide (HCTZ) is indicated for the treatment of hypertension and edema resulting from various etiologies ( 1). In an outreach role, the associate pastor makes new church members feel welcome and supervises teams of outreach personnel as they visit with prospective members.
The assistant minister may have the responsibility of contacting church members outside the church setting, including visiting church members while they are in the hospital and providing follow-up care for those who are grieving. The assistant minister serves as a second preacher for the church, offering services when the head minister is out of town on business or on vacation and filling in as a pastor for other churches in the denominational association. Depending on the church, he may have regular tasks assigned to him, or the assistant minister may serve in whatever position he is needed to fill within the church. The primary function of an assistant, or associate, minister is to help the head pastor lead the church. Associate Ministers What Are the Duties of an Assistant Minister?
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