A risk-benefit assessment of the newer oral antifungal agents used to treat onychomycosis

The newer antifungal agents itraconazole, terbinafine and fluconazole have become available to treat onychomycosis over the last 10 years. During this time period these agents have superseded griseofulvin as the agent of choice for onychomycosis. Unlike griseofulvin, the new agents have a broad spectrum of action that includes dermatophytes, Candida species and nondermatophyte moulds. Each of the 3 oral antifungal agents, terbinafine, itraconazole and fluconazole, is effective against dermatophytes with relatively fewer data being available for the treatment of Candida species and nondermatophyte moulds. Itraconazole is effective against Candida onychomycosis. Terbinafine may be more effective against C. parapsilosis compared with C. albicans; furthermore with Candida species a higher dose of terbinafine or a longer duration of therapy may be required compared with the regimen for dermatophytes. The least amount of experience in treating onychomycosis is with fluconazole. Griseofulvin is not effective against Candida species or the nondermatophyte moulds. The main use of griseo-fulvin currently is to treat tinea capitis. Ketoconazole may be used by some to treat tinea versicolor with the dosage regimens being short and requiring the use of only a few doses. The preferred regimens for the 3 oral antimycotic agents are as follows: itraconazole - pulse therapy with the drug being administered for 1 week with 3 weeks off treatment between successive pulses; terbinafine - continuous once daily therapy; and fluconazole - once weekly treatment. The regimen for the treatment of dermatophyte onychomycosis is: itraconazole - 200mg twice daily for I week per month x 3 pulses; terbinafine - 250 mg/day for 12 weeks; or, fluconazole - 150 mg/wk until the abnormal-appearing nail plate has grown out, typically over a period of 9 to 18 months. For the 3 oral antifungal agents the more common adverse reactions pertain to the following systems, gastrointestinal (for example, nausea, gastrointestinal distress, diarrhoea, abdominal pain), cutaneous eruption, and CNS (for example, headache and malaise). Each of the new antifungal agents is more cost-effective than griseofulvin for the treatment of onychomycosis and is associated with high compliance, in part because of the shorter duration of therapy. The newer antifungal agents are generally well tolerated with drug interactions that are usually predictable.

Open-label study to evaluate the healing rate and safety of the Profore Extra Four-Layer Bandage System in patients with venous leg ulceration

BACKGROUND

Venous ulcers are increasing in prevalence, especially since these are observed more frequently in the elderly, and the number of individuals in this age group is becoming a larger portion of the population.

OBJECTIVE

To determine the healing rate and safety of the Profore Extra Four-Layer Bandage System in the management of venous leg ulcers.

METHODS

In an open-label study, patients aged 18 years or older with venous leg ulcers were treated with a high compression four-layer bandage system in which a hydrocellular dressing was placed in contact with the wound. The combination is designated the "Profore Extra Four-Layer Bandage System." Follow-up visits took place weekly unless there was heavy exudation from the ulcer or if there was marked edema of the leg at the start of the study requiring reapplication of the bandage system.

RESULTS

Fifteen patients were entered into the study (men 8, women 7, mean age 66 years, mean duration of ulcers 1.3 years). Thirteen of the 15 patients completed the study, with two withdrawals. In one patient who withdrew, the ulcer became infected and required treatment with antibiotics. The other termination from the study occurred for reasons unrelated to treatment. The ulcer in this patient healed in 7 weeks. Ten of the 13 patients (77%) who completed the study, and 10 (67%) of 15, who had enrolled experienced complete (100%) healing. Healing of > 80% of the ulcers occurred in 11 of 13 patients (85%) who completed the study and in 12 (80%) of 15 enrolled patients. No patient experienced a study-related adverse event. One patient developed contact dermatitis and was later found to have stasis dermatitis. It is unclear whether the initial event was contact or stasis dermatitis.

CONCLUSION

In this open-label study, a high compression system, using the Profore Extra Four-Layer Bandage with a hydrocellular dressing in contact with the wound, was found to be effective and safe for the treatment of venous leg ulcers.

Anticonvulsant hypersensitivity syndrome: incidence, prevention and management

Although the anticonvulsant hypersensitivity syndrome was first described in 1950, confusion still abounds regarding the syndrome. The triad of fever, rash and internal organ involvement occurring 1 to 8 weeks after exposure to an anticonvulsant heralds this rare (1 in 1,000 to 10,000 exposures) but serious reaction. Aromatic anticonvulsants [phenytoin, phenobarbital (phenobarbitone) and carbamazepine] are the most frequently involved drugs; however, there have also been several cases of anticonvulsant hypersensitivity syndrome associated with lamotrigine. Fever, in conjunction with malaise and pharyngitis, is often the first sign. This is followed by a rash which can range from a simple exanthem to toxic epidermal necrolysis. Internal organ involvement usually involves the liver, although other organs such as the kidney, CNS or lungs may be involved. Hypothyroidism may be a complication in these patients approximately 2 months after occurrence of symptoms. The aromatic anticonvulsants are metabolised to hydroxylated aromatic compounds, such as arene oxides. If detoxification of this toxic metabolite is insufficient, the toxic metabolite may bind to cellular macromolecules causing cell necrosis or a secondary immunological response. Cross-reactivity among the aromatic anticonvulsants may be as high as 75%. In addition, there is a familial tendency to hypersensitivity to anticonvulsants. Discontinuation of the anticonvulsant is essential in patients who develop symptoms compatible with anticonvulsant hypersensitivity syndrome. A minimum battery of laboratory tests, such as liver transaminases, complete blood count and urinalysis and serum creatinine, should be performed. Corticosteroids are usually administered if symptoms are severe. Patients with anticonvulsant hypersensitivity syndrome should avoid all aromatic anticonvulsants; benzodiazepines, valproic acid (sodium valproate) or one of the newer anticonvulsants can be used for seizure control. However, valproic acid should be used very cautiously in the presence of hepatitis. There is no evidence that lamotrigine cross-reacts with aromatic anticonvulsants. In addition, family counselling is a vital component of patient management.

The effectiveness of antidepressants in elderly depressed outpatients: a prospective case series study

BACKGROUND

This study examined the effectiveness of antidepressants in a group of elderly depressed outpatients by assessing depression prevalence and recording adverse events over time.

METHOD

A prospective practice-based observational study (1991-1994) included consecutive outpatients at least 65 years of age with a DSM-III-R diagnosis of major affective disorder and who were prescribed antidepressant medications. Depressive symptoms were examined over time (stage 1 = 0 to 2 months; stage 2 = 2 to 6 months; stage 3 = 6 months to 2 years) with the Montgomery-Asberg Depression Rating Scale (MADRS). The cutoff scores of MADRS <18 and MADRS > or =18 were used in survival statistics. Adverse events were recorded systematically.

RESULTS

A total of 213 patients were seen over 2677 visits (mean +/- SD age = 75.5+/-6.1 years). MADRS scores for 85.8% of patients declined to below 18 within the first 2 months of antidepressant treatment. MADRS scores were above 18 for 37.3% of patients after 6 months and for 37.1% after 2 years. The mean time to decline in MADRS scores to below 18 in stage 1 was 36.1 days, and there was a significant difference between the antidepressant classes (log rank = 8.3, df = 3, p = .04), with tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)/reversible inhibitors of monoamine oxidase A (RIMAs) having shorter times to response. The mean time to reach scores above cutoff during stage 2 was 144.3 days (log rank = 5.7, df = 3, p = .13) and during stage 3, 538.6 days (log rank = 9.8, df = 3, p = .02). Patients receiving TCAs and MAOIs/RIMAs had longer durations of MADRS scores below cutoff during stage 3 than those taking atypical antidepressants and selective serotonin reuptake inhibitors. All antidepressant classes reported similar adverse event profiles.

CONCLUSION

This study systematically examined antidepressant effectiveness in a prospective design. TCAs and MAOIs/RIMAs were shown to be superior in effectiveness during 2 of the 3 treatment stages.

Ethanol-induced apoptosis in vitro

OBJECTIVES

The aim is to study the apoptotic process in a human hepatocyte model for ethanol (EtOH)-induced apoptosis.

DESIGN AND METHODS

Normal human primary hepatocytes (HPH) and Hep G2 cells were exposed to increasing EtOH. 6000 cells/ sample were analyzed by transmission electron microscopy.

RESULTS

Apoptotic cells were observed (mmol/L EtOH): 40: 6 +/-0.5%, 60:13 +/- 2% (p < 0.05), 80: 26 +/- 1% (p < 0.001) (vs. control). Two consecutive doses of 80 mmol/L for 24 h each additionally increased apoptosis 55 +/- 3% (p < 0.0001 vs. control and p < 0.001 vs. single dose). In response to this exposure, there is a stronger apoptotic activity in HPH when compared to Hep G2 (p < 0.05).

CONCLUSIONS

In vitro, EtOH-induced apoptosis is regulated by dose level and the frequency of exposure.

Inducers of cytochrome P450 2E1 enhance methotrexate-induced hepatocytoxicity

OBJECTIVES

To study the effect of cytochrome P450 2E1-inducers on methotrexate (MTX)-induced cytotoxicity in human hepatocytes, and investigate the role of silymarin in preventing this toxicity.

DESIGN AND METHODS

Cells were exposed to MTX in the presence of either ethanol (EtOH) or acetaminophen (APAP), or either combined with silymarin (S). Apoptosis and necrosis were measured by analyzing 6000 cells/sample using transmission electron microscopy, while cytokine release and apoptosis were quantitated by ELISA. Cytokine expression was measured by RT-PCR. Gluthatione (GSH) content was determined in cytosolic (c) and mitochondrial (m) fractions.

RESULTS

MTX+EtOH and MTX+APAP increased MTX cytotoxicity 2.9-fold and 1.9-fold, respectively. S abolished this toxicity. MTX + EtOH increased the release of IL 6, IL 8 and TNF alpha by 1.0, 1.2, and 1.1 times, respectively. Cytokine expression was upregulated versus control for IL 6 (22%), IL 8 (38%), and TNF alpha (29%). Addition of 0.5 mmol/L S downregulated TNF alpha expression and reduced cytokine release. TNF alpha increased cytotoxicity by 22%, while anti-TNFalpha antibody eradicated it. MTX+EtOH depleted 45% mGSH (0 < 0.001) while S replenished it to 87% (p < 0.001), when both were compared to control levels.

CONCLUSIONS

Cytochrome P450 2E1-inducers contribute to increase oxidative stress in MTX-exposed cells by increasing TNF alpha and depleting both cGSH and mGSH. This enhances MTX-cytotoxicity and promotes apoptosis.

Predictors of sustained response to alpha interferon therapy in chronic hepatitis C

OBJECTIVES

To utilize cytokine levels to predict sustained response (SR) to alpha interferon (IFN alpha) therapy in chronic hepatitis C patients, and to determine the relationship between serum tumor necrosis factor alpha (TNF alpha), interleukin (IL) IL 6, IL 8, IL 12, transforming growth factor beta (TGF beta 1) and the degree of liver damage as reflected by traditional markers.

DESIGN AND METHODS

Serum cytokine levels were assessed using ELISA in 18 patients included in a controlled clinical trial of IFN alpha.

RESULTS

Of the 18 patients, 27% were sustained responders (SR), 27% were response and relapse responders (RR), and 46% were non-responders (NR). Multivariate analysis showed that a low serum TNF alpha level and high serum IL 8 levels were independent factors associated with SR to IFN alpha therapy. Serum TNF alpha level highly correlated with viral load and genotype predictive values (p < 0.001). Therapy lowered the IL 6 and IL 12 profile. TGF beta 1 levels in serum are positively correlated with fibrinogenesis.

CONCLUSIONS

IFN alpha therapy modulates immune response to hepatitis C virus, contributing to sustained response.

Drug interactions with itraconazole, fluconazole, and terbinafine and their management

A drug interaction develops when the effect of a drug is increased or decreased or when a new effect is produced by the prior, concurrent, or subsequent administration of the other. Before prescribing a drug, it is important to obtain a thorough drug history of the prescription and nonprescription medications taken by the patient. The nonprescription medications may include items such as nutritional supplements and herbal medications. The risk of side effects is an inevitable consequence of drug use. The frequency of adverse reactions is increased in those patients receiving multiple medications. Drug interactions reported in animal or in vitro studies may not necessarily develop in humans. When drug interactions are observed with a particular agent, it cannot be automatically assumed that all closely related drugs will necessarily produce the same interaction. However, caution is advised until sufficient experience accrues. The prescriber should not overestimate or underestimate the potential for a given drug interaction on the basis of personal experience alone. Drug interactions will not necessarily occur in every patient who is given a particular combination of drugs known to produce an interaction. For a clinically significant drug interaction to be manifest, several other factors may be relevant other than just using the two drugs. In many instances drug interactions can be predicted and therefore avoided if the pharmacodynamic effects, the pharmacokinetic properties, and the mechanisms of action of the 2 drugs in question are known. In the case of contraindicated drugs, it may be possible to use an alternative agent.

Age- and gender-related use of low-dose drug therapy: the need to manufacture low-dose therapy and evaluate the minimum effective dose

OBJECTIVES

Low-dose drug therapy is promoted as a way to maximize benefit and minimize adverse drug effects when prescribing for older adults. This population-based study evaluates the age and sex-related use of two common therapies: thiazide diuretics, where evidence supports the use of low-dose therapy, and beta-blockers, where trials have not evaluated the minimum effective dose.

DESIGN

Using linked administrative databases we identified all of the 120,613 persons dispensed a thiazide diuretic therapy and 12,908 myocardial infarction survivors dispensed beta-blocker therapy in Canada's largest province. We used logistic regression models to study the association of age and sex with dispensing of low-dose thiazide diuretic and beta-blocker therapy at doses lower than evaluated in trials.

RESULTS

Of 120,613 older people dispensed a thiazide diuretic, 32,372 (26.8%) were dispensed a low dose. Patients 85 years of age or older, relative to the youngest group, were 30% more likely to be dispensed low-dose therapy (OR=1.31; 95% CI, 1.27 to 1.36; P < .001). Women were 8% more likely than men to be dispensed a low-dose thiazide diuretic (OR=1.08; 95% CI, 1.05 to 1.11; P < .001). Of 10,991 myocardial infarction survivors dispensed atenolol, metoprolol, propranolol, or timolol, 9458 (86.1%) were dispensed a lower-than-evaluated dose. Patients 85 years of age or older, relative to those in the youngest group, were more than twice as likely to be dispensed a lower-than-evaluated beta-blocker therapy dose (OR=2.28; 95% CI, 1.74 to 3.04; P < .001). No difference was noted in the use of beta-blocker therapy dose by sex (OR=1.0; 95% CI, .89 to 1.15; P = .95).

CONCLUSIONS

Low-dose thiazide diuretic therapy prescribed widely to older people, particularly those of advanced age and women. The vast majority of myocardial infarction survivors were dispensed beta-blocker therapy at lower-than-evaluated doses. These findings highlight the need to manufacture low-dose thiazide diuretic therapy and to evaluate the minimum effective dose of beta-blocker therapy.

The new oral antifungal agents for onychomycosis of the toenails

OBJECTIVE

To review the use of the new oral antifungal agents, itraconazole, terbinafine and fluconazole for the treatment of onychomycosis of the toenails.

BACKGROUND

Until about 10 years ago the two oral agents available to treat onychomycosis were griseofulvin and ketoconazole. Since then the new oral antifungal agents have superseded the traditional oral agents for the management of toenail onychomycosis.

METHODS

Literature review.

RESULTS AND CONCLUSION

Itraconazole, terbinafine and fluconazole have been used approximately 100 million times to treat superficial mycoses. These agents are more effective than the traditional antimycotics for the treatment of pedal onychomycosis; furthermore, the new agents have a broader spectrum of action than griseofulvin. In general, itraconazole, terbinafine and fluconazole have a favorable adverse-effects profile with drug interactions that are usually predictable and manageable. The new oral antifungal agents have a high benefit-to-risk ratio when used to treat toenail onychomycosis.

Utilization of health care resources by obese Canadians

BACKGROUND

The prevalence of obesity in Canada has been increasing in recent years. Using data from the National Population Health Survey (NPHS), the authors determined the prevalence of obesity among Canadians, the associated comorbidities and the patterns of resource utilization by obese people.

METHODS

The NPHS, a cross-sectional survey conducted in 1994, was administered to 17,626 Canadians 12 years of age or older who were not long-term residents of hospitals or long-term care facilities and were not residing on First Nations reserves or Canadian Armed Forces bases, or in the Yukon and Northwest Territories. For the authors' analysis, the study population consisted of 12,318 Canadians aged 20-64 years who were not pregnant and for whom the body mass index (BMI) had been calculated. The prevalence of comorbidities, health status index scores, self-esteem, self-rated health, restriction of activity, health care resource utilization (physician visits, disability days, admissions to hospital and medication use) were determined for obese people (BMI of 27 or greater) and nonobese people.

RESULTS

The NPHS data revealed that 35.2% of men and 25.8% of women in Canada were obese in 1994. Obese respondents were more likely than nonobese respondents to suffer from stress (adjusted odds ratio [OR] 1.20, 95% confidence interval [CI] 1.11-1.31), activity restrictions (adjusted OR 1.39, 95% CI 1.26-1.54) and a number of chronic comorbidities. Obese respondents were also more likely to consult with physicians (adjusted OR 1.32, 95% CI 1.22-1.43), be prescribed a number of medications and to require excess disability days (adjusted OR 1.22, 95% CI 1.08-1.36).

INTERPRETATION

Obesity represents a substantial burden on the health of Canadians and on Canada's health care resources.

Needs survey of Canadian rosacea patients

BACKGROUND

In 1995, a Rosacea Awareness Program (RAP) was initiated in Canada to make available educational resources for physicians and rosacea patients. Material is in French or English, and is accessible though physician offices and by toll-free telephone. Information was communicated to the public via noncommercial, editorial media. The RAP created a database of rosacea patients in Canada.

OBJECTIVE

We investigated if individuals in the database had a confirmed diagnosis of rosacea, how they perceived their treatment by the medical system, and identified their needs.

METHODS

A two-page questionnaire was mailed to 7874 individuals registered with the RAP. Thirty percent of these individuals responded. Where comparisons were made a chi-squared statistic was used.

RESULTS

Over 70% learned of the RAP via public media. It took patients an average of 5 years to have a diagnosis made after the first symptoms appeared. In the majority of patients (53%) the diagnosis was ultimately made by a specialist. Fifty-eight individuals said they had not discussed their condition with their doctor. Patients were likely to continue on medication that was prescribed (60%) and topical metronidazole was the most common medication used, mostly the gel formulation. Most patients used these twice daily. Patients were very satisfied with treatments and almost 90% had reduced symptoms. Despite receiving explanations and written material, patients expressed a strong interest in more information being available on skin care, make-up, and psychological aspects of rosacea.

CONCLUSIONS

The RAP provides a needed educational service and is a useful database. Patients are very knowledgeable about their disease, but despite this and excellent therapeutic responses, the patients demand more information.

Ethanol-modulated cytokine production and expression in skin cells exposed to methotrexate

Evidence suggests a link between alcohol consumption, psoriasis and the response of psoriatic patients to methotrexate (MTX) therapy. Ethanol (EtOH) may play a role in the pathogenesis of psoriasis by upregulating the expression and inducing the local secretion of proinflammatory cytokines, e.g. interleukins IL-1alpha, IL-6, chemokine IL-8 and tumor necrosis factor alpha (TNF-alpha). We investigated whether EtOH or MTX or their combination influence the secretion of these cytokines using normal human primary skin cells (NHPSC) and epidermoid cell line A431. The objectives of this study were: (1) to quantify the differences in cellular changes induced by MTX, (2) to measure the effect of EtOH on MTX toxicity and (3) to determine the relationship between MTX and EtOH exposure and production of proinflammatory cytokines. NHPSC and A431 were incubated with 0-10 mM MTX or alpha-MEM (control) in the presence or absence of 40 mM EtOH. A formazan 3-(4,5-dimethylthiazole-2-yl)-2, 5-diphenyl-tetrazolium bromide (MTT) assay was used as a marker for cell viability (control was 100%). Significance was calculated by ANOVA. Cytokine release into media was quantitated by ELISA. After 24 h of MTX exposure, the release of IL-1alpha was unchanged. IL-6 increased 1.7 times in both cultures, and IL-8 increased 1.7 times in NHPSC and 2.1 times in A431. TNF-alpha release increased twice in A431 but not in NHPSC. Human recombinant IL-1alpha and IL-6 for 24 h had no effect, while TNF-alpha reduced cytoviability by 30% in NHPSC and 22% in A431. Anti-TNF-alpha reversed the effect produced by TNF-alpha in NHPSC and reduced it in A431 (11.8%, p < 0.05). We concluded that in vitro in normal human primary keratinocytes, toxicity and inflammatory responses are enhanced by EtOH.

Antiepileptic drug hypersensitivity syndrome

The antiepileptic drug hypersensitivity syndrome (AHS) is an adverse drug reaction associated with the aromatic antiepileptic drugs (AEDs) phenytoin (PHT), carbamazepine (CBZ), phenobarbital (PB), and primidone. The syndrome is defined by the triad of fever, skin rash, and internal organ involvement. It can also be caused by other drugs, such as sulfonamides, dapsone, minocycline, terbinafine, azathioprine, and allopurinol. Diagnosis of AHS may be difficult because of the variety of clinical and laboratory abnormalities and manifestations and because the syndrome may mimic infectious, neoplastic, or collagen vascular disorders. The incidence is approximately 1 in 3,000 exposures. AHS starts with fever, rash, and lymphadenopathy, within the first 2-8 weeks after initiation of therapy. Internal manifestations include, among others, agranulocytosis, hepatitis, nephritis, and myostitis. AHS is associated with a relative excess of reactive oxidative metabolites of the AED. Insufficient detoxification may lead to cell death or contribute to the formation of antigen that triggers an immune reaction. Crossreactivity among PHT, CBZ, and PB is as high as 70-80%.

Lamotrigine-induced severe cutaneous adverse reactions

PURPOSE

We systematically reviewed and analyzed published and unpublished cases of Stevens-Johnson syndrome (SJS), or toxic epidermal necrolysis (TEN) associated with lamotrigine (LTG) therapy to identify characteristics of these reactions.

METHODS

We performed a MEDLINE search (January 1985 to April 1998) and citation tracking for published reports. In addition, reports were requested from the Uppsala Monitoring Centre of the World Health Organization (WHO). Published and WHO cases of LTG-associated SJS or TEN were included if the causal relationship was assessed as either possible, probable, or definite.

RESULTS

We identified a total of 57 cases (43 cases of SJS, 14 cases of TEN), of which 13 (23%) were published. Cases in the SJS group were significantly younger than in the TEN group (21 years vs. 31 years). The median time to onset (17 days for SJS and TEN) and the median dosage at onset (50 mg vs. 87.5 mg) for SJS and TEN did not differ significantly. Concomitant use of valproate (VPA) was reported in 74% of the SJS cases and 64% of the TEN cases. In three cases, TEN was the cutaneous manifestation of the antiepileptic drug hypersensitivity syndrome (AHS).

CONCLUSIONS

The main features of severe cutaneous drug reactions, such as dosage, onset, and concomitant VPA use, do not differ in patients with LTG-induced SJS or TEN. SJS or TEN may also be the cutaneous manifestations of LTG-induced AHS. Further epidemiologic studies are needed to identify the incidence of severe LTG-induced cutaneous adverse reactions and the relative risk compared with other AEDs.

Quantifying the costs of serious adverse drug reactions to antiepileptic drugs

PURPOSE

We assessed from an institutional perspective the direct costs of severe adverse cutaneous or hypersensitivity reactions due to antiepileptic drug (AED) therapy that led to hospitalization or prolonged hospital stay.

METHODS

Patients admitted for or developing severe AED-induced cutaneous or hypersensitivity reactions while in hospital from January 1990 through June 1996 were identified by ICD-9 codes E936, E937, E693, E695.1, E995.1, and E995.2. Identified cases were analyzed retrospectively by chart review and were included in the analysis if a causal relationship was determined to be possible, probable, or definite. Clinical outcomes were abstracted and related direct costs of the adverse drug reactions (ADRs) calculated.

RESULTS

A total of 384 cases were identified by ICD-9 codes, of which 13 cases (mean age +/- SD 52.9+/-21.0 years) were included for further analysis. Eight patients (62%) were admitted because of an ADR (median length of stay 9.5 days; range 4-43), five (38%) experienced an ADR during hospitalization (median duration of ADR episodes 8.5 days; range: 7-21 days). The median direct medical costs of the ADRs were Canadian (CDN) $3,128 (range 1,149-21,293) per patient.

CONCLUSIONS

The management of serious cutaneous and hypersensitivity ADRs due to AEDs is associated with considerable direct medical costs. These figures should be considered along with drug acquisition costs and treatment of clinical successes and failures in the overall assessment of the economic impact of pharmacotherapy. Prospective collection of direct costs associated with ADRs in clinical trials would be of value.

Gender differences in adverse drug reactions

The objective of this study is to identify gender-related differences in the types of symptoms and drugs reported to cause an adverse drug reaction. Patient data from the Sunnybrook Health Science Centre ADR Clinic for the period from April 1986 to May 1996 were reviewed. Of the 2,367 patients assessed, 74.1% were female. The mean age of the patients was 43 +/- 17 years. Drug classes most frequently reported to elicit an adverse event were general antiinfectives (60.4%), nervous system agents (21.5%), and musculoskeletal agents (3.7%). Skin-related reactions accounted for 49.0% of all reported adverse drug reactions. More than one agent was reported to be responsible for the adverse drug reaction(s) in 50% of the female patients, versus 33.1% of all male patients. Of the female patients, 47.6% were referred for skin or oral challenge testing, versus 41.6% of the male patients. Of the female patients, 6.2% tested positive to the agent compared with 6.1% of all male patients. These results support previous findings that female gender is a risk factor for the development of adverse drug reactions. Further work is required to elucidate the mechanisms explaining the differences observed between male and female patients.

Lamotrigine-associated anticonvulsant hypersensitivity syndrome

We systematically reviewed and analyzed published and unpublished cases of lamotrigine-associated adverse drug reactions consistent with the features of the anticonvulsant hypersensitivity syndrome (AHS) to identify characteristics of the syndrome. We identified 26 cases (mean age, 28+/-18 years; range, 3.5 to 74 years; 54% female), of which nine were published. The characteristics of the syndrome associated with lamotrigine are comparable to AHS induced by older aromatic anticonvulsants.

Role of cytokines in ethanol-induced cytotoxicity in vitro in Hep G2 cells

BACKGROUND & AIMS

As shown previously by us, ethanol (EtOH) causes time- and concentration-dependent reduction in cytoviability. Tauroursodeoxycholic acid (TUDCA) and ursodeoxycholic acid (UDCA) were shown to reduce cytotoxicity. Long-term EtOH exposure leads to immunoregulatory and detoxification impairment. This study aimed to determine the relationship between cytokine (interleukin [IL]-1 alpha and IL-6 and tumor necrosis factor [TNF]-alpha) production and expression, glutathione (GSH) status, and EtOH-induced cytotoxicity on Hep G2 cells.

METHODS

Cells were incubated with 80 mmol/L EtOH or alpha-minimal essential medium (control) in the presence or absence of 50 mumol/L TUDCA or UDCA. Cytokine release was quantitated by enzyme-linked immunosorbent assay. Cytokine expression was measured by reverse-transcription polymerase chain reaction. GSH content was determined in both the cytosolic and mitochondrial fractions.

RESULTS

After 24 hours of EtOH exposure, the release of IL-1 alpha doubled, that of IL-6 increased 10 times, and that of TNF-alpha increased 3.5 times. Cytokine expression was up-regulated compared with control for IL-1 alpha (42%), IL-6 (26%), and TNF-alpha (52%). Addition of 50 mumol/L TUDCA or UDCA reduced cytokine release and expression. TNF-alpha increased cytotoxicity by 18%. Anti-TNF-alpha antibody almost abolished it. EtOH depleted mGSH levels by 55% (P < 0.001). TUDCA replenished them by 88%.

CONCLUSIONS

EtOH up-regulated expression of cytokines in Hep G2 cells is down-regulated by bile acids. Increased amounts of TNF-alpha and depletion in both cytosolic and mitochondrial GSH contribute to EtOH cytotoxicity. Bile acids prevent toxicity.