Hypersensitivity reactions to biologics (part I): allergy as an important differential diagnosis in complex immune-derived adverse events

Purpose

Biotechnological substances (BSs) are strongly relied upon to prevent rejection of transplanted organs, and to treat oncological, allergological, and other inflammatory diseases. Allergic reactions to partly foreign biologics can occur due to their potential immunogenicity. The severity of an immune response to a biological drug may range from no clinical significance to a severe, life-threatening anaphylactic reaction.

Methods

Detailed searches were performed on Pubmed, Web of Science, and Google Scholar to include all available publications. In addition, the Food and Drug Administration, the European Medicines Agency, and British Columbia Cancer Agency Drug Manual databases were screened for hypersensitivity reaction (HSR), infusion reaction, injection site reaction, urticaria, and anaphylaxis for individual BSs.

Results

Treatment with BSs can cause various types of HSR. These are mentioned in the literature with definitions such as allergic reactions, anaphylactoid reactions, anaphylaxis, HSR, infusion reactions, injection site reactions, cytokine release syndrome, and urticaria. Due to the overlap in signs and symptoms in the reported descriptions, it is not always possible to differentiate these reactions properly according to their pathomechanism. Similarly, many data reported as anaphylaxis actually describe severe anaphylactic reactions (grades III or IV).

Conclusion

There is an urgent need for a simpler symptom- or system-based classification and scoring system to create an awareness for HSRs to BSs. A better understanding of the pathophysiology of HSRs and increased clinical experience in the treatment of side effects will provide timely control of unexpected reactions. As a result, immunotherapy with BSs will become safer in the future.

Clinical Characterization and Diagnostic Approaches for Patients Reporting Hypersensitivity Reactions to Quinolones

BACKGROUND

Quinolones are the second most frequent cause of hypersensitivity reactions (HSRs) to antibiotics. A marked increase in the number of patients with HSRs to quinolones has been detected.

OBJECTIVE

To describe the clinical characteristics of patients with HSRs to quinolones and present methods for their diagnosis.

METHODS

Patients attending the allergy unit due to reactions suggestive of HSRs to quinolones were prospectively evaluated between 2005 and 2018. Diagnosis was achieved using clinical history, skin tests (STs), basophil activation tests (BATs), and drug provocation tests (DPTs) if ST and BAT results were negative.

RESULTS

We included 128 subjects confirmed as having HSRs to quinolones and 42 found to be tolerant. Anaphylaxis was the most frequent entity in immediate HSRs and was most commonly induced by moxifloxacin. Patients were evaluated a median of 150 days (interquartile range, 60-365 days) after the reaction. Of patients who underwent ST and BAT, 40.7% and 70%, respectively, were positive. DPT with a quinolone was performed in 48 cases, giving results depending on the culprit drug: when moxifloxacin was involved, 62.5% of patients gave a positive DPT result to ciprofloxacin, whereas none reacted to levofloxacin. The risk of HSR was 96 times higher in subjects who reported moxifloxacin-induced anaphylaxis and 18 times higher in those reporting immediate reactions compared with clinical entities induced by quinolones other than moxifloxacin and nonimmediate reactions.

CONCLUSIONS

The diagnosis of HSR to quinolones is complex. The use of clinical history is essential as a first step. BAT shows higher sensitivity than STs. DPTs can be useful for finding safe alternative quinolones.

Efficacy and Safety of Azilsartan Medoxomil and Telmisartan in Hypertensive Patients: A Randomized, Assessor-Blinded Study

BACKGROUND

Few studies have compared the safety and efficacy of azilsartan medoxomil (AZL-M) and telmisartan in hypertensive patients, especially using ambulatory blood pressure monitoring (ABPM).

OBJECTIVE

The objective of this study was to compare the efficacy and safety profile of AZL-M and telmisartan in hypertensive patients using ABPM and clinic blood pressure (BP) monitoring.

MATERIALS AND METHODS

This prospective, randomized, open-label, blinded endpoint, parallel-arm study included 700 patients, aged 18-70 years, with clinic and 24-h mean ambulatory systolic BP (SBP) of 150-180 mmHg and 130-170 mmHg, respectively. They were randomized equally into two groups: Group A received AZL-M 40 mg and Group T received telmisartan 40 mg; the dose was force titrated to 80 mg after 2 weeks if the response rate was not achieved. BP (clinical and ambulatory) was measured after 12 weeks and compared with baseline measurements.

RESULTS

AZL-M significantly reduced the 24-h mean ambulatory SBP (Group A: 112.74 ± 7.58 mmHg; Group T: 113.96 ± 8.52 mmHg; P < 0.0001) and diastolic BP (Group A: 71.39 ± 5.89 mmHg; Group T: 67.29 ± 6.79 mmHg; P < 0.0001) compared with telmisartan at week 12. The clinic SBP significantly decreased in Group A at weeks 4 (-30.69± -0.33 mmHg) and 12 (-39.69± -1.09 mmHg) (for both, P = 0.0001). Dose titration was done in 99 and 128 patients from Group A and Group T, respectively (P = 0.012). Headache was the most common adverse drug reaction (Group A: 21; Group T: 27) and fatigue the least.

CONCLUSION

This study found that AZL-M has greater antihypertensive efficacy than telmisartan, with comparable side effects. In addition, ABPM was shown to be a feasible method for such studies.

Adverse drug reactions associated with chemotherapeutic agents used in breast cancer: Analysis of patients' online forums

BACKGROUND

Breast cancer is the most common type of cancer in women worldwide. The benefits of chemotherapy vary depending on the treatment regimen used and the characteristic of the tumour. However, adverse drug reactions associated with chemotherapeutic agents can cause dose delays or reductions; thereby, affecting the treatment outcomes.

OBJECTIVE

To explore adverse drug reactions of chemotherapeutic agents used to treat breast cancer from the patients' perspective.

METHODS

A total of 110 threads from nine online discussion forums were evaluated. They were exported into NVivo for Mac where content analysis was applied. Threads were read carefully to observe emerging patterns which were then coded into sub-themes and grouped into main themes.

RESULTS

The participants' characteristics on online discussion forums were often missing. Four hundred and eleven participants experienced 473 adverse drug reactions that were mainly associated with the nervous and immune systems. The forums' analysis yielded three main themes: patient-patient advice, self-medication and lifestyle changes.

CONCLUSION

Online discussion forums proposed valued source of data on adverse drug reactions associated with chemotherapeutic agents and overall patients' experience with cancer. The adverse drug reactions experienced by patients changed their priorities and the way they dealt with the disease. Therefore, healthcare professionals must consider the patients' experience and attitudes towards cancer when designing a treatment plan. This can be established by increasing communication between healthcare professionals and patients.

Evaluation of adverse drug reaction profile of antiepileptic drugs in persons with epilepsy: A cross-sectional study

INTRODUCTION

Newer antiepileptic drugs (AEDs) are preferred over conventional AEDs with the perception of better safety profile and efficacy though there is a lack of confirmatory evidence. The present study assessed the adverse drug reactions' (ADRs) profile of AEDs prescribed in persons with epilepsy (PWE) as per the System Organ Class (SOC) and compared them on the basis of demographics and treatment pattern.

MATERIAL AND METHODS

This prospective, cross-sectional, and observational study was conducted in PWE attending Neurology Outpatient-Department from February 2016 to April 2019 who were presented with any ADR. World Health Organization-Uppsala Monitoring Centre (WHO-UMC) scale was used for the causality assessment of suspected ADRs.

RESULTS

Among the 1011 PWE on AEDs, male:female ratio was 622:389, adult:pediatric ratio 736:275, and conventional:newer AEDs ratio 624:387. Among monotherapy PWE (47.1%), commonly used AEDs were levetiracetam (34.4%), valproic acid (22.9%), carbamazepine (18.3%), phenytoin (11.9%), and other AEDs (12.5%). A total of 1990 ADRs (1.96 ADRs per PWE) were reported as per SOC; among them, newer vs. conventional AEDs did not reveal any significant difference; however, monotherapy vs. polytherapy showed differences in nervous system disorders (p = 0.01) and skin and subcutaneous tissue disorders (p = 0.005). Causality assessment revealed 0.3% certain, 27.3% probable, 61.3% possible, and 11.1% unlikely association of ADRs with AEDs. Depending on the ADRs, there was either withdrawal of AED (0.9%), reduction in dose (48.4%), or continuation in the same dose as before (50.7%).

CONCLUSION

The ADR analysis showed that newer AEDs were associated with a similar trend of ADRs as that of conventional AEDs. Thus, the choice among newer and conventional AEDs should preferably focus on the experience of better efficacy in addition to safety data.

Effect of educational intervention on awareness of pharmacovigilance among medical undergraduates in a tertiary care teaching hospital

AIM

(1) To assess the knowledge and attitude of undergraduates about adverse drug reaction (ADR) reporting at a tertiary care teaching hospital. (2) To assess the effect of educational intervention among medical undergraduates on knowledge and attitude about pharmacovigilance (PV).

MATERIALS AND METHODS

Cross-sectional, questionnaire-based survey conducted at a tertiary care teaching hospital. Respondents were 192 undergraduate students (2^nd year). The study instrument was a self-developed, prevalidated semi-structured questionnaire. Participants were given 1 h to complete the questionnaire. After this, a 2 h lecture about PV was taken. Participants were asked to fill the same questionnaire after the educational intervention. Pre- and post-test questionnaire were compared.

RESULTS

There was an overall improvement in all three aspects, i.e., awareness, knowledge, and attitude. Most of the students had knowledge of the meaning of PV and reporting of ADR by doctors. However, there was a significant improvement in the knowledge regarding reporting of ADR by dentist, nurses, and pharmacist. Similarly, students were aware of the fact that ADR with allopathic medicines should be reported, but postintervention, there was improvement in percentage regarding reporting of ADR in the case of herbal and traditional medicine, blood products, and biological and medical device. There was a significant improvement in percentage regarding awareness about process of reporting ADR after exposure to lecture.

CONCLUSION

There is a need of increasing awareness among the medical students to improve the reporting of ADRs. Adequate consideration needs to be given to the subject of ADRs in the clinical pharmacology and therapeutics curricula in undergraduate medical education.

Multiple widespread fixed drug eruption caused by rabeprazole

Fixed drug eruption is one of the most common forms of cutaneous adverse drug reactions. Analgesics and antibiotics are the most common drugs causing fixed drug eruption. Here, we report a case of multiple widespread fixed drug eruption caused by rabeprazole.

Risk factors associated with the severity of adverse drug reactions by Xiyanping injection: A propensity score-matched analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Xiyanping injection (XYP), extraction of Andrographis paniculate (Andrographis paniculata (Burm. f.) Nees, chuan xin lian), is a Chinese patent medicine approved to treat bronchitis in China. In 2017, safety incidents associated with treatment of XYP began to emerge throughout China. However, the risk factors of severity of adverse reactions by XYP remain uncertain.

AIM OF THE STUDY

To determine risk factors for the severity of XYP-associated adverse drug reactions (ADRs).

MATERIALS AND METHODS

We analyzed a total of 26,317 cases of ADRs linked to the use of XYP injection in the China National Adverse Drug Reaction Monitoring Information System from 2004 to 2017. Data were analyzed with respect to age, gender, ethnicity, previous ADRs, family history of ADRs, dosage specification, medication frequency specification, body weight, route of administration, herb-drug interactions (ribavirin, cefatriaxone, penicillin sodium, ambroxol hydrochloride, clindamycin, cefoxitin sodium, azithromycin, ceftazidime, amoxicillin sodium and clavulanate potassium, levofloxacin, cefazolin sodium pentahydrate, acyclovir) by univariate analysis and multivariate analysis. Propensity score matching was used to compare severity of (general or serious) ADRs.

RESULTS

We included 24,911 cases of general ADRs and 1406 cases of serious ADRs. Univariate analysis identified age (p ​< ​0.001), body weight (p ​< ​0.001), route of administration (p ​= ​0.008), co-administration of XYP with ribavirin (p ​= ​0.031) as risk factors of severity of ADRs. Multivariate analysis identified XYP ​+ ​ribavirin combination (p ​= ​0.048) and age (p ​< ​0.001) as the independent risk factors. Upon propensity score matching, the variables were relatively balanced amongst the two groups of patients with general or severe ADRs, and the level of severity in patients who received treatment of XYP ​+ ​ribavirin increased (p ​= ​0.020).

CONCLUSIONS

Age and co-administration of ribavirin may be potential risk factors for the severity of XYP-associated ADRs. This reminds us to pay more attention to the safety of elderly medication. Minimizing the herb-drug-interaction effects of XYP and ribavirin is a viable treatment target for healthcare professionals in managing serious ADRs amongst patients receiving XYP injection.

Adverse drug reactions associated with amitriptyline - protocol for a systematic multiple-indication review and meta-analysis

BACKGROUND

Unwanted anticholinergic effects are both underestimated and frequently overlooked. Failure to identify adverse drug reactions (ADRs) can lead to prescribing cascades and the unnecessary use of over-the-counter products. The objective of this systematic review and meta-analysis is to explore and quantify the frequency and severity of ADRs associated with amitriptyline vs. placebo in randomized controlled trials (RCTs) involving adults with any indication, as well as healthy individuals.

METHODS

A systematic search in six electronic databases, forward/backward searches, manual searches, and searches for Food and Drug Administration (FDA) and European Medicines Agency (EMA) approval studies, will be performed. Placebo-controlled RCTs evaluating amitriptyline in any dosage, regardless of indication and without restrictions on the time and language of publication, will be included, as will healthy individuals. Studies of topical amitriptyline, combination therapies, or including < 100 participants, will be excluded. Two investigators will screen the studies independently, assess methodological quality, and extract data on design, population, intervention, and outcomes ((non-)anticholinergic ADRs, e.g., symptoms, test results, and adverse drug events (ADEs) such as falls). The primary outcome will be the frequency of anticholinergic ADRs as a binary outcome (absolute number of patients with/without anticholinergic ADRs) in amitriptyline vs. placebo groups. Anticholinergic ADRs will be defined by an experienced clinical pharmacologist, based on literature and data from Martindale: The Complete Drug Reference. Secondary outcomes will be frequency and severity of (non-)anticholinergic ADRs and ADEs. The information will be synthesized in meta-analyses and narratives. We intend to assess heterogeneity using meta-regression (for indication, outcome, and time points) and I2 statistics. Binary outcomes will be expressed as odds ratios, and continuous outcomes as standardized mean differences. Effect measures will be provided using 95% confidence intervals. We plan sensitivity analyses to assess methodological quality, outcome reporting etc., and subgroup analyses on age, dosage, and duration of treatment.

DISCUSSION

We will quantify the frequency of anticholinergic and other ADRs/ADEs in adults taking amitriptyline for any indication by comparing rates for amitriptyline vs. placebo, hence, preventing bias from disease symptoms and nocebo effects. As no standardized instrument exists to measure it, our overall estimate of anticholinergic ADRs may have limitations.

SYSTEMATIC REVIEW REGISTRATION

Submitted to PROSPERO; assignment is in progress.

"ADR PvPI" Android mobile app: Report adverse drug reaction at any time anywhere in India

BACKGROUND:

To improve the public health and promote instant adverse drug reaction (ADR) reporting, a need to develop an ADR Pharmacovigilance Programme of India (PvPI) mobile app was identified by the National Coordination CentrePvPI (NCCPvPI) to serve the Pan India ADR reporting. The objective of this study was to develop an indigenous Googlebased Android mobile application known as “ADR PvPI” and to analyze the ADRrelated data reported through this mobile application on pilot basis.

MATERIALS AND METHODS:

The ADR PvPI mobile application was indigenously developed by NCCPvPI officials within 6 months. The study of spontaneous ADR reporting was carried out between September 2017 and September 2018. This article provides an overview of the salient features of ADR PvPI mobile application, guides on how to fillin ADRs, reporting trends of ADR, types of ADR as per System Organ Class and pharmacological classes of drugs.

RESULTS:

Till date, >5500 users have downloaded the app with an average rating of 4.26. In that tenure, 262 reports have been received through ADR PvPI mobile app. During the year 2017, 3.55% of reports were received through ADR PvPI mobile app and the percentage of reports received by 2018 was 96.45%.

CONCLUSION:

The frequency of ADR reporting has significantly increased over the past 1 year and should be promoted further through awareness and training programs.

Adverse drug reactions

An adverse drug reaction (ADR) is defined as a response to a medicinal product which is noxious and unintended. ADRs are an important cause of morbidity and mortality and increase health costs. The pharmacovigilance systems allow the identification and prevention of the risks associated with use of a drug, especially of recently marketed drugs; they detect signals from data of the global ADR register and also support decisions taken by regulatory agencies in different countries. Only a few drugs are withdrawn from the market, mainly due to hepatotoxicity. Spontaneous notification of ADR is the cheapest, simplest and most used method to recognize new safety drug problems, under-reporting being its main limitation. The future of pharmacovigilance and ADRs will include a higher involvement of patients, doctors, health authorities and pharmaceutical companies, and the use of new technologies.

Safety analysis of Lexiva tablets 700 (fosamprenavir calcium hydrate) in post-marketing surveillance in Japan

Objective: Fosamprenavir, a protease inhibitor (PI) to treat human immunodeficiency virus (HIV)-infected patients, has been approved in more than 40 countries and mainly used with nucleoside reverse transcriptase inhibitors. In Japan, Lexiva tablet (fosamprenavir calcium hydrate) has been marketed since January 2005 and used in clinical practice. The safety and effectiveness of fosamprenavir in HIV-infected Japanese patients were evaluated in an observational surveillance study (OTH112334).Methods: A post-marketing surveillance study (PMS) of fosamprenavir usage in HIV-infected Japanese subjects evaluating drug safety was conducted under Good Post-marketing Study Practice from January 2005 to December 2014.Results: Of 364 patients receiving fosamprenavir, 51% received emtricitabine/tenofovir disoproxil fumarate. Adverse events whose causal relationship could not be completely ruled out (adverse drug reactions; ADRs) were reported in 43.7%; the most common were diarrhoea (10.4%), hyperlipidaemia (8.5%) and hypertriglyceridaemia (6.9%). Serious ADRs were reported in 26 patients (32 events), including 1 death attributed to hepatic failure. Most ADRs occurred within 180 days after fosamprenavir was started. ADRs were more frequent in patients with the Centers for Disease Control and Prevention category B (AIDS or lipid disorders) or in those taking fosamprenavir combined with abacavir and lamivudine. Although spontaneous bleeding has been reported in hemophiliac patients taking other PIs, in this survey, only one muscle haemorrhage case was reported in 24 hemophiliac patients.Conclusions: The results of this PMS analysis in Japan support its known safety profile and identified no new safety risks for people living with HIV/AIDS in Japan currently on, or beginning treatment with, fosamprenavir.

A stratification method based on clustering for the minimization of data masking effect in signal detection

Background

Data masking is an inborn defect of measures of disproportionality in adverse drug reactions (ADRs) signal detection. Many previous studies can be roughly classified into three categories: data removal, regression and stratification. However, frequency differences of adverse drug events (ADEs) reports, which would be an important factor of masking, were not considered in these methods. The aim of this study is to explore a novel stratification method for minimizing the impact of frequency differences on real signals masking.

Methods

Reports in the Chinese Spontaneous Reporting Database (CSRD) between 2010 and 2011 were selected. The overall dataset was stratified into some clusters by the frequency of drugs, ADRs, and drug-event combinations (DECs) in sequence. K-means clustering was used to conduct stratification according to data distribution characteristics. The Information Component (IC) was adopted for signal detection in each cluster respectively. By extracting ADRs from drug product labeling, a reference database was introduced for performance evaluation based on Recall, Precision and F-measure. In addition, some DECs from the Adverse Drug Reactions Information Bulletin (ADRIB) issued by CFDA were collected for further reliability evaluation.

Results

With stratification, the study dataset was divided into 21 clusters, among which the frequency of DRUGs, ADRs or DECs followed the similar order of magnitude respectively. Recall increased by 34.95% from 29.93 to 40.39%, Precision reduced by 10.52% from 54.56 to 48.82%, while F-measure increased by 14.39% from 38.65 to 44.21%. According to ADRIB after 2011, 5 DECs related to Potassium Magnesium Aspartate, 61 DECs related to Levofloxacin Hydrochloride and 26 DECs related to Cefazolin were highlighted.

Conclusions

The proposed method is effectively and reliably for the minimization of data masking effect in signal detection. Considering the decrease of Precision, it is suggested to be a supplement rather than an alternative to non-stratification method.

Serious adverse drug reactions at two children's hospitals in South Africa

BACKGROUND

The high HIV prevalence in South Africa may potentially be shaping the local adverse drug reaction (ADR) burden. We aimed to describe the prevalence and characteristics of serious ADRs at admission, and during admission, to two South African children's hospitals.

METHODS

We reviewed the folders of children admitted over sequential 30-day periods in 2015 to the medical wards and intensive care units of each hospital. We identified potential ADRs using a trigger tool developed for this study. A multidisciplinary team assessed ADR causality, type, seriousness, and preventability through consensus discussion. We used multivariate logistic regression to explore associations with serious ADRs.

RESULTS

Among 1050 patients (median age 11 months, 56% male, 2.8% HIV-infected) with 1106 admissions we found 40 serious ADRs (3.8 per 100 drug-exposed admissions), including 9/40 (23%) preventable serious ADRs, and 8/40 (20%) fatal or near-fatal serious ADRs. Antibacterials, corticosteroids, psycholeptics, immunosuppressants, and antivirals were the most commonly implicated drug classes. Preterm neonates and children in middle childhood (6 to 11 years) were at increased risk of serious ADRs compared to infants (under 1 year) and term neonates: adjusted odds ratio (aOR) 5.97 (95% confidence interval 1.30 to 27.3) and aOR 3.63 (1.24 to 10.6) respectively. Other risk factors for serious ADRs were HIV infection (aOR 3.87 (1.14 to 13.2) versus HIV-negative) and increasing drug count (aOR 1.08 (1.04 to 1.12) per additional drug).

CONCLUSIONS

Serious ADR prevalence in our survey was similar to the prevalence found elsewhere. In our setting, serious ADRs were associated with HIV-infection and the antiviral drug class was one of the most commonly implicated. Similar to other sub-Saharan African studies, a large proportion of serious ADRs were fatal or near-fatal. Many serious ADRs were preventable.

Clinical Profiles of Nalfurafine Hydrochloride for the Treatment of Pruritus Patients

Nalfurafine hydrochloride is a selective kappa-opioid agonist that has antipruritic effects. Here we describe the clinical trials for treatment of uremic pruritus in dialysis patients and on hepatic pruritus in patients with chronic liver disease. Among cytochrome P-450 (CYP) isoforms in humans, CYP3A4 is the major isoform involved in metabolic decyclopropylmethylation of nalfurafine hydrochloride. Nalfurafine hydrochloride was found to be a substrate for P-glycoprotein (P-gp), but had no inhibitory effects on P-gp-mediated transport. The efficacy of oral nalfurafine hydrochloride at 2.5 and 5 μg for refractory pruritus in hemodialysis patients was observed within the first 7 days of treatment, and the effects persisted for the 52-week treatment period. Nalfurafine hydrochloride is also effective in the treatment of conventional refractory pruritus in peritoneal dialysis patients. Moreover, nalfurafine hydrochloride at 2.5 and 5 μg is effective for the treatment of refractory pruritus in chronic liver disease patients within the first 7 days of drug administration. In all the clinical trials, most adverse drug reactions (ADRs) were mild and resolved quickly and there was no clinical safety problem. Following 52 weeks of treatment, hemodialysis patients did not develop physical or psychological dependence, indicating no addiction risks. In summary, nalfurafine hydrochloride administered orally at doses of 2.5 and 5 μg was safe and effective for treatment of refractory pruritus in patients undergoing hemodialysis or peritoneal dialysis and in chronic liver disease patients.

Evaluation of Drug-Induced Liver Injury Developed During Hospitalization Using Electronic Health Record (EHR)-Based Algorithm

Purpose

The incidence of drug-induced liver injury (DILI) has been increasing; however, few algorithms are available to identify DILI in electronic health records (EHRs). We aimed to identify and evaluate DILI with an appropriate screening algorithm.

Methods

We collected data from 3 university hospitals between June 2015 and May 2016 using our newly developed algorithm for identifying DILI. Among patients with alanine transferase (ALT) ≤ 120 IU/L and total bilirubin (TB) ≤ 2.4 mg/dL in blood test results within 48 hours of admission, those who either had 1) ALT > 120 IU/L and TB > 2.4 mg/dL or 2) ALT > 200 IU/L at least once during hospitalization were identified. After excluding patients with liver disease-related diagnosis at discharge, medical records were retrospectively reviewed to evaluate epidemiological characteristics of DILI.

Results

The total number of inpatients was 256,598, of whom 1,100 (0.43%) were selected by the algorithm as suspected DILI. Subsequently, 365 cases (0.14% of total inpatients, 95% confidence interval, 0.13–0.16) were identified as DILI, yielding a positive predictive value of 33.1%. Antibiotics (n = 214, 47.2%) were the major class of causative drug followed by chemotherapeutic agents (n = 87, 19.2%). The most common causative drug was piperacillin-tazobactam (n = 38, 8.4%); the incidence of DILI by individual agent was highest for methotrexate (19.4 cases/1,000 patients administered the drug). Common reasons for excluding suspected DILI cases were ischemic hepatitis and postoperative liver dysfunction.

Conclusions

Using our EHR-based algorithm, we identified that approximately 0.14% of patients developed DILI during hospitalization. Further studies are needed to modify criteria for more accurate identification of DILI.

Gastropathy in patients with Wilson disease

Background: Gastrointestinal symptoms are common in patients with Wilson disease (WD) and may be related to the disease itself or to adverse drug reactions (ADRs).Aim: To investigate gastroscopy findings in patients with WD and to analyze the risk of gastropathy in the context of different manifestations and treatments of WD as well as Helicobacter pylori infection status.Methods: This cross-sectional study included patients diagnosed or monitored for WD between 2007 and 2017. All enrolled patients were examined with gastroscopy and checked for infection with a urease test. Based on predominant manifestations, WD was classified as pre-symptomatic, hepatic (only liver symptoms) or neurological. Patients were divided into three treatment groups: untreated, treated with d-penicillamine (DPA) or zinc sulfate therapy.Results: Of 115 patients, 58 were male and the median age was 30 years. Gastropathy was observed in 65.2% of all patients. Factors that increased the risk of gastropathy were zinc sulfate (odds ratio [OR] = 3.01; 95% confidence interval [CI]: 1.12-8.09, p = .03), H. pylori infection (OR = 2.96; 95%CI: 1.34-6.56, p = .01) and neurological manifestations (OR = 2.55; 95%CI: 1.16-5.60, p = .02). In total, 9.6% of patients had gastric or duodenal ulcers and 29.6% had esophageal varices but no difference was seen by treatment status. In multivariate analysis, zinc sulfate remained associated with higher risk of gastropathy compared with no treatment (OR = 4.57; 95%CI: 1.21-17.19; p = .03) and DPA (OR = 6.28; 95%CI: 1.43-27.56; p = .01).Conclusions: Our results show that gastropathy in WD may be influenced by the treatment used.KeypointsIn a retrospective study of 115 patients with Wilson's disease, gastric injury was frequent.Patients receiving zinc sulfate had increased gastropathy risk compared with those receiving no treatment or d-penicillamine.

Drug Hypersensitivity Reactions

Drug hypersensitivity reactions (DHRs) may be classified based on timing (immediate vs delayed), mechanisms, and pattern of clinical manifestations. Management may include selection of alternative, non-cross reactive agents, drug allergy testing, graded challenge and/or desensitization. Immediate skin testing only identifies risk for immediate-type allergic DHR and has a negative predictive value for only a limited number of drugs (eg, penicillin). Desensitization induces a temporary state of tolerance that is maintained only so long as the drug is continued. This article discusses special considerations about antibiotics, angiotensin-converting enzyme inhibitors, anesthetic agents, aspirin and nonsteroidal antiinflammatory drugs, radiocontrast media, and chemotherapeutic agents.

Interaction of Oatp1b2 expression and nonalcoholic steatohepatitis on pravastatin plasma clearance

The downregulation of hepatic uptake transporters, including those of the OATP family, are a well known consequence of nonalcoholic steatohepatitis (NASH). Prior studies have shown that the combination of NASH and Oatp1b2 knockout synergistically reduces the clearance of pravastatin (PRAV) in the methionine and choline deficient (MCD) mouse model of NASH, and the current study therefore aimed to determine the impact of NASH and genetic heterozygosity of Oatp1b2 on PRAV clearance, modeling the overlap between the 24% of the human population who are heterozygous for non-functioning OATP1B1, and the ~15% with NASH, potentially placing these people at higher risk of statin-induced myopathy. Therefore, male C57BL/6 wild-type (WT), Oatp1b2+/- (HET), and Oatp1b2-/- (KO) mice were fed either a control (methionine and choline sufficient) or methionine and choline-deficient (MCD) diet to induce NASH. After six weeks of feeding, pravastatin was administered via the carotid artery. Blood and bile samples were collected throughout 90 min after PRAV administration. The concentration of PRAV in plasma, bile, liver, kidney, and muscle was determined by liquid chromatography-tandem mass spectrometry. MCD diet did not alter the plasma AUC values of PRAV in either WT or HET mice. However, the MCD diet increased plasma AUC by 4.4-fold in KO mice. MCD diet and nonfunctional Oatp1b2 synergistically increased not only plasma AUC but also the extrahepatic tissue concentration of pravastatin, whereas the partially decreased function of Oatp1b2 and NASH together were insufficient in significantly altering PRAV pharmacokinetics. These data suggest that a single copy of fully functional OATP1B1 in NASH patients may be sufficient to avoid the increase of pravastatin toxicity.

Machine learning-based identification and rule-based normalization of adverse drug reactions in drug labels

Background

Use of medication can cause adverse drug reactions (ADRs), unwanted or unexpected events, which are a major safety concern. Drug labels, or prescribing information or package inserts, describe ADRs. Therefore, systematically identifying ADR information from drug labels is critical in multiple aspects; however, this task is challenging due to the nature of the natural language of drug labels.

Results

In this paper, we present a machine learning- and rule-based system for the identification of ADR entity mentions in the text of drug labels and their normalization through the Medical Dictionary for Regulatory Activities (MedDRA) dictionary. The machine learning approach is based on a recently proposed deep learning architecture, which integrates bi-directional Long Short-Term Memory (Bi-LSTM), Convolutional Neural Network (CNN), and Conditional Random Fields (CRF) for entity recognition. The rule-based approach, used for normalizing the identified ADR mentions to MedDRA terms, is based on an extension of our in-house text-mining system, SciMiner. We evaluated our system on the Text Analysis Conference (TAC) Adverse Drug Reaction 2017 challenge test data set, consisting of 200 manually curated US FDA drug labels. Our ML-based system achieved 77.0% F1 score on the task of ADR mention recognition and 82.6% micro-averaged F1 score on the task of ADR normalization, while rule-based system achieved 67.4 and 77.6% F1 scores, respectively.

Conclusion

Our study demonstrates that a system composed of a deep learning architecture for entity recognition and a rule-based model for entity normalization is a promising approach for ADR extraction from drug labels.

Drug-drug interactions in patients undergoing chemoradiotherapy and the impact of an expert team intervention

Background Several studies have examined the drug-drug interaction patterns in different patient populations and treatment settings; however, there is a need, particularly in the field of oncology and radiotherapy, for evaluating methods targeted towards preventing potential drug-drug interactions. One of the measures proposed is identifying potential interactions using computer programs and their evaluation by pharmacologists or clinical pharmacists, thereby providing clinically relevant information to the treating physician regarding the required prescription changes. Objective To determine the prevalence of potential drug-drug interactions in patients receiving chemoradiotherapy and assess the usefulness of expert team recommendations in minimizing interactions. Setting Patients admitted to the radiotherapy and oncology ward of a tertiary care teaching hospital in Karnataka, India. Method We conducted a prospective, cross-sectional study of prescriptions written for patients receiving chemoradiotherapy. Prescriptions containing two or more drugs, at least one of the drugs being an anticancer drug, were analyzed. They were screened for potential drug-drug interactions using the Lexicomp® drug interaction software. The interactions were classified as X, drug combination to be avoided; D, modification of therapy to be considered; and C, therapy to be monitored, as per the Lexicomp criteria. Main outcome measure The number of drug-drug interactions detected that were accepted by the treating radio-oncologist as requiring prescription change before and after the prescription review by an expert team. Results Two hundred twenty-three prescriptions were screened for the presence of drug-drug interactions; 106 prescriptions (47.53%) containing 620 drugs and 211 drug-drug interactions were identified. Of the 211 interactions identified, 6.64% (14/211), 18.48% (39/211), and 74.88% (158/211) drug-drug interactions belonged to category X, D, and C, respectively. Twenty-seven (50.94%) of the 53 category X and D interactions identified were accepted the oncologist as requiring a change in the prescription; an additional 13 (24.53%) interactions were identified as significant by the expert team, and 11 (84.62%) of these were accepted by the oncologist. Conclusion A system of alerting the treating physician to a potential drug-drug interaction leads to avoidance of prescription of the interacting drug combination, and the assistance by an expert team adds significantly to avoidance of clinically relevant drug interactions.

Tardive Reactivation of Progressive Multiple Sclerosis During Treatment with Biotin

Multiple sclerosis (MS) is a common autoimmune disease of the central nervous system, causing neurological disability in young adults. A growing understanding of its immunopathogenesis has led to an expanding array of therapies. Notable new advances in disease-modifying therapies for relapsing forms of multiple sclerosis that are based on anti-inflammatory activity have recently been developed. Management of progressive MS is still challenging. Data published in 2014 suggested that daily high doses of biotin, a vitamin involved in myelin synthesis, might have a beneficial impact on disability and progression in progressive MS. However, some patients worsened while on biotin without any clear explanation for this effect. We report the case of a 41-year-old patient suffering from primary progressive (PP) MS who presented after 16 months of treatment with high doses of biotin (QIZENDAY) with worsening of his Expanding Disability Status Scale (EDSS) score and the appearance of a symptomatic new T2 pseudo-tumoural lesion on brain magnetic resonance imaging (MRI), suggestive of tardive inflammatory reactivation possibly due to the biotin. The newer and more effective therapies for MS are, however, associated with risks that necessitate an active management strategy and continuous vigilance. Physicians should be aware of iatrogenic neurological complications and the possible paradoxical effects of biotin. Future treatment approaches to progressive MS must include identification of a biomarker of disease activity. The study of neurofilaments in the cerebrospinal fluid (CSF) and the serum could be of interest when determining the optimal treatment strategy.

The Efficiency of Multi-Faceted Educational Intervention on Knowledge, Perceived Behavior, and Practice Skills towards Pharmacovigilance among Undergraduate Pharmacy Students of India

BACKGROUND

The primary reason for poor adverse drug reaction (ADR) signal detection worldwide is the under-reporting of ADRs by healthcare professionals. Multidisciplinary teams, including pharmacists, may play an essential role in targeting this issue.

AIM

The purpose of the study was to evaluate the impact of a multi-faceted educational intervention (MEI) on the knowledge, perception, and practice skills of pharmacovigilance among undergraduate pharmacy students.

METHODS

A longitudinal, prospective study using a single group before-and-after intervention design was conducted among 100 undergraduate pharmacy students at Togari Veeramallappa Memorial College of Pharmacy, Ballari, India (TVMCP), affiliated to Vijayanagara Institute of Medical Sciences (VIMS), Ballari, India. The questionnaire was structured using previous studies and standardized. It had three groups of questions. Group 1 questions evaluated the knowledge (K1-K8), group 2 tested perceptions (A1-A6), and group 3 tested the practice skills of pharmacovigilance (P1-P5) of the participant. The participants were graded in 3 categories as poor, unsatisfactory, and satisfactory, depending upon the mean score. Matched pairs student t-test and The Wilcoxon Signed rank statistical test was used to assess the impact of the MEI on the participants' knowledge, perception, and practice skills score, along with recording different factors preventing them from being actively involved in the pharmacovigilance program.

RESULTS

The educational intervention improved the pharmacovigilance knowledge, perception, and practice skills scores of our pharmacy students.

CONCLUSION

Our study showed that knowledge, perception, and practice skills scores increased after MEI highlighting the need for regular educational campaigns to healthcare professions.