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Fioredda F, Skokowa J, Tamary H, Spanoudakis M, Farruggia P, Almeida A, Guardo D, Höglund P, Newburger PE, Palmblad J, Touw IP, Zeidler C, Warren AJ, Dale DC, Welte K, Dufour C, Papadaki HA. The European Guidelines on Diagnosis and Management of Neutropenia in Adults and Children: A Consensus Between the European Hematology Association and the EuNet-INNOCHRON COST Action. Hemasphere 2023; 7:e872. [PMID: 37008163 PMCID: PMC10065839 DOI: 10.1097/hs9.0000000000000872] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/09/2023] [Indexed: 04/03/2023] Open
Abstract
Neutropenia, as an isolated blood cell deficiency, is a feature of a wide spectrum of acquired or congenital, benign or premalignant disorders with a predisposition to develop myelodysplastic neoplasms/acute myeloid leukemia that may arise at any age. In recent years, advances in diagnostic methodologies, particularly in the field of genomics, have revealed novel genes and mechanisms responsible for etiology and disease evolution and opened new perspectives for tailored treatment. Despite the research and diagnostic advances in the field, real world evidence, arising from international neutropenia patient registries and scientific networks, has shown that the diagnosis and management of neutropenic patients is mostly based on the physicians' experience and local practices. Therefore, experts participating in the European Network for the Innovative Diagnosis and Treatment of Chronic Neutropenias have collaborated under the auspices of the European Hematology Association to produce recommendations for the diagnosis and management of patients across the whole spectrum of chronic neutropenias. In the present article, we describe evidence- and consensus-based guidelines for the definition and classification, diagnosis, and follow-up of patients with chronic neutropenias including special entities such as pregnancy and the neonatal period. We particularly emphasize the importance of combining the clinical findings with classical and novel laboratory testing, and advanced germline and/or somatic mutational analyses, for the characterization, risk stratification, and monitoring of the entire spectrum of neutropenia patients. We believe that the wide clinical use of these practical recommendations will be particularly beneficial for patients, families, and treating physicians.
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Affiliation(s)
| | - Julia Skokowa
- Department of Oncology, Hematology, Immunology, Rheumatology, and Clinical Immunology, University Hospital Tübingen, Germany
| | - Hannah Tamary
- The Rina Zaizov Hematology/Oncology Division, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Israel
| | - Michail Spanoudakis
- Department of Hematology, Warrington and Halton Teaching Hospitals NHS foundation Trust, Warrington, United Kingdom
| | - Piero Farruggia
- Pediatric Onco-Hematology, ARNAS Civico Di Cristina Benfratelli Hospital, Palermo, Italy
| | - Antonio Almeida
- Department of Hematology, Hospital da Luz Lisboa, Portugal
- Faculdade de Medicina, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Daniela Guardo
- Unit of Hematology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Petter Höglund
- Clinical Immunology and Transfusion Medicine Clinic, Karolinska University Hospital, Stockholm, Sweden
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jan Palmblad
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Ivo P. Touw
- Department of Hematology and Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Cornelia Zeidler
- Department of Oncology, Hematology, Immunology and Bone Marrow Transplantation, Hannover Medical School, Hannover, Germany
| | - Alan J. Warren
- Department of Hematology, University of Cambridge, United Kingdom
- Cambridge Institute for Medical Research, University of Cambridge, United Kingdom
- Wellcome Trust–Medical Research Council Stem Cell Institute, University of Cambridge, United Kingdom
| | | | - Karl Welte
- University Children’s Hospital Tübingen, Germany
| | - Carlo Dufour
- Unit of Hematology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Helen A. Papadaki
- Hemopoiesis Research Laboratory, School of Medicine, University of Crete, Heraklion, Greece
- Department of Hematology, University Hospital of Heraklion, Crete, Greece
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2
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Glocker C, Grohmann R, Burkhardt G, Seifert J, Bleich S, Held T, Toto S, Stübner S, Schüle C. Antipsychotic drug-induced neutropenia: results from the AMSP drug surveillance program between 1993 and 2016. J Neural Transm (Vienna) 2023; 130:153-163. [PMID: 36653686 PMCID: PMC9902410 DOI: 10.1007/s00702-023-02589-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/09/2023] [Indexed: 01/20/2023]
Abstract
Neutropenia and agranulocytosis (N&A) are relatively rare, but potentially fatal adverse drug reactions (ADR). This study presents cases of N&A related to one or more antipsychotic drugs (APDs) in psychiatric inpatients. Data on APD utilization and reports of N&A caused by APDs were analyzed by using data from an observational pharmacovigilance program in German-speaking countries-Arzneimittelsicherheit in der Psychiatrie (AMSP)-from 1993 to 2016. 333,175 psychiatric inpatients were treated with APDs for schizophrenia and other indications during the observation period. A total of 124 cases of APD-induced N&A were documented, 48 of which fulfilled the criteria for agranulocytosis, corresponding to a rate of 0.37, respectively, 0.14 in 1000 inpatients treated with APDs. Neutropenia was more often detected in women, whereas there was no difference regarding sex in cases of agranulocytosis. Clozapine had the highest relative risk for inducing N&A and was imputed alone as a probable cause of N&A in 60 cases (1.57‰ of all patients exposed). Perazine showed the second highest relative risk with 8 cases and an incidence 0.52‰, followed by quetiapine (15 cases resp. 0.23‰ of all patients exposed) and olanzapine (7 cases; 0.13‰ of all patients exposed). N&A most often occurred during the first 3 months of treatment. Overall N&A are severe and potentially fatal complications that can occur during treatment with APDs. The results from this study largely agree with the currently available literature, highlighting the positive effects of alertness and established appropriate monitoring.
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Affiliation(s)
- Catherine Glocker
- Department of Psychiatry und Psychotherapy, LMU Klinikum, Nußbaumstraße 7, 80336, Munich, Germany.
| | - R. Grohmann
- Department of Psychiatry und Psychotherapy, LMU Klinikum, Nußbaumstraße 7, 80336 Munich, Germany
| | - G. Burkhardt
- Department of Psychiatry und Psychotherapy, LMU Klinikum, Nußbaumstraße 7, 80336 Munich, Germany
| | - J. Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - S. Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - T. Held
- Department of Hematology and Cell Therapy, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - S. Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - S. Stübner
- Department of Forensic Psychiatry, Bezirksklinikum Ansbach, Feuchtwanger Str. 38, 91522 Ansbach, Germany
| | - C. Schüle
- Department of Psychiatry und Psychotherapy, LMU Klinikum, Nußbaumstraße 7, 80336 Munich, Germany
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3
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Diez-Feijóo R, Rodríguez-Sevilla JJ, Fernández-Rodríguez C, Flores S, Raya C, Ferrer A, Colomo L, Salar A. Case Report: High Doses of Intravenous Immunoglobulins as a Successful Treatment for Late Onset Immune Agranulocytosis After Rituximab Plus Bendamustine. Front Immunol 2022; 12:798251. [PMID: 35082788 PMCID: PMC8784545 DOI: 10.3389/fimmu.2021.798251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/10/2021] [Indexed: 01/09/2023] Open
Abstract
Late onset neutropenia (LON) related to rituximab or rituximab plus chemotherapy is defined as an unexplained absolute neutrophil count of ≤1.5 × 109/L starting at least four weeks after the last rituximab administration. LON is infrequent and its pathophysiology remains unknown. There are no guidelines or consensus strategies for the optimal management of patients developing LON. The majority of the patients recover promptly with no specific treatment and only some cases need to be managed with granulocytic colony stimulating factor (G-CSF), usually with a rapid response. Here, we describe a 69-year-old patient with Waldenström's macroglobulinemia who presented a septic event in the context of severe LON after rituximab plus bendamustine. The diagnosed of agranulocytosis was established by bone marrow examination. Interestingly, anti-neutrophil antibodies bound to the patient's granulocytes were found suggesting an autoimmune mechanism. The patient did not respond to G-CSF but achieved a rapid response after high doses of intravenous immunoglobulins with full white blood cell recovery.
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Affiliation(s)
- Ramon Diez-Feijóo
- Department of Hematology, Hospital del Mar, Barcelona, Spain.,Applied Clinical Research in Hematological Malignancies, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Juan Jose Rodríguez-Sevilla
- Department of Hematology, Hospital del Mar, Barcelona, Spain.,Applied Clinical Research in Hematological Malignancies, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | | | - Solange Flores
- Department of Hematology, Hospital del Mar, Barcelona, Spain.,Applied Clinical Research in Hematological Malignancies, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Carmen Raya
- Banc de Sang i Teixits, Hospital del Mar, Barcelona, Spain
| | - Ana Ferrer
- Department of Pathology, Hospital del Mar, Barcelona, Spain
| | - Luis Colomo
- Department of Pathology, Hospital del Mar, Barcelona, Spain
| | - Antonio Salar
- Department of Hematology, Hospital del Mar, Barcelona, Spain.,Applied Clinical Research in Hematological Malignancies, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
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4
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Solomou EE, Salamaliki C, Lagadinou M. How to Make the Right Diagnosis in Neutropenia. Clin Hematol Int 2021; 3:41-46. [PMID: 34595466 PMCID: PMC8432397 DOI: 10.2991/chi.k.210216.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/11/2021] [Indexed: 11/05/2022] Open
Abstract
Isolated neutropenia without anemia or thrombocytopenia is a common clinical problem. The etiology of neutropenia may vary from transient bone marrow suppression, caused by self-limited viral illnesses, to previously undiagnosed congenital syndromes or serious systemic diseases. Consequently, determining the underlying cause of neutropenia and what treatment is required can be challenging. Acquired neutropenia is common and most of the times an etiologic factor can be found. Congenital neutropenia (CN) is rare, and we still have a lot to learn from mutational analysis as to the exact role of gene abnormalities in the pathogenesis of these complex diseases. This mini-review discusses a proposed approach to neutropenia in the adult patient.
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Affiliation(s)
- Elena E Solomou
- Department of Internal Medicine, University of Patras Medical School, Rion 26500, Greece
| | - Christina Salamaliki
- Department of Internal Medicine, University of Patras Medical School, Rion 26500, Greece
| | - Maria Lagadinou
- Department of Internal Medicine, University of Patras Medical School, Rion 26500, Greece
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5
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Pattanaik S, Jain A, Ahluwalia J. Evolving Role of Pharmacogenetic Biomarkers to Predict Drug-Induced Hematological Disorders. Ther Drug Monit 2021; 43:201-220. [PMID: 33235023 DOI: 10.1097/ftd.0000000000000842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/21/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Drug-induced hematological disorders constitute up to 30% of all blood dyscrasias seen in the clinic. Hematologic toxicity from drugs may range from life-threatening marrow aplasia, agranulocytosis, hemolysis, thrombosis to mild leukopenia, and thrombocytopenia. Pathophysiologic mechanisms underlying these disorders vary from an extension of the pharmacological effect of the drug to idiosyncratic and immune-mediated reactions. Predicting these reactions is often difficult, and this makes clinical decision-making challenging. Evidence supporting the role of pharmacogenomics in the management of these disorders in clinical practice is rapidly evolving. Despite the Clinical Pharmacology Implementation Consortium and Pharmacogenomics Knowledge Base recommendations, few tests have been incorporated into routine practice. This review aims to provide a comprehensive summary of the various drugs which are implicated for the hematological adverse events, their underlying mechanisms, and the current evidence and practical recommendations to incorporate pharmacogenomic testing in clinical care for predicting these disorders.
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Affiliation(s)
| | - Arihant Jain
- Internal Medicine, Hematology and Bone Marrow Transplantation, and
| | - Jasmina Ahluwalia
- Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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6
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Tong H, Phan NVT, Nguyen TT, Nguyen DV, Vo NS, Le L. Review on Databases and Bioinformatic Approaches on Pharmacogenomics of Adverse Drug Reactions. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2021; 14:61-75. [PMID: 33469342 PMCID: PMC7812041 DOI: 10.2147/pgpm.s290781] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/26/2020] [Indexed: 12/27/2022]
Abstract
Pharmacogenomics has been used effectively in studying adverse drug reactions by determining the person-specific genetic factors associated with individual response to a drug. Current approaches have revealed the significant importance of sequencing technologies and sequence analysis strategies for interpreting the contribution of genetic variation in developing adverse reactions. Advance in next generation sequencing and platform brings new opportunities in validating the genetic candidates in certain reactions, and could be used to develop the preemptive tests to predict the outcome of the variation in a personal response to a drug. With the highly accumulated available data recently, the in silico approach with data analysis and modeling plays as other important alternatives which significantly support the final decisions in the transformation from research to clinical applications such as diagnosis and treatments for various types of adverse responses.
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Affiliation(s)
- Hang Tong
- School of Biotechnology, International University, Ho Chi Minh City, Vietnam.,Vietnam National University, Ho Chi Minh City, Vietnam
| | - Nga V T Phan
- School of Biotechnology, International University, Ho Chi Minh City, Vietnam.,Vietnam National University, Ho Chi Minh City, Vietnam
| | - Thanh T Nguyen
- Department of Translational Biomedical Informatics, Vingroup Big Data Institute, Hanoi, Vietnam
| | - Dinh V Nguyen
- Department of Respiratory, Allergy and Clinical Immunology, Vinmec International Hospital, Hanoi, Vietnam.,College of Health Sciences, VinUniversity, Hanoi, Vietnam
| | - Nam S Vo
- Department of Translational Biomedical Informatics, Vingroup Big Data Institute, Hanoi, Vietnam
| | - Ly Le
- School of Biotechnology, International University, Ho Chi Minh City, Vietnam.,Vietnam National University, Ho Chi Minh City, Vietnam.,Department of Translational Biomedical Informatics, Vingroup Big Data Institute, Hanoi, Vietnam
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7
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Kılıç Ö, İşeri Nepesov M, Ulukapı HB, Özdemir ZC, Bör Ö, Dinleyici EÇ. Paediatric Agranulocytosis Associated with Metamizole Treatment. Paediatr Drugs 2021; 23:105-110. [PMID: 33247375 DOI: 10.1007/s40272-020-00431-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Metamizole, which has antipyretic and pain-relieving properties, is generally used to treat fever in children who do not respond to paracetamol treatment. The most remarkable side effect of metamizole is that it causes myelotoxicity independently of dose. In this study, we aimed to present the clinical features of paediatric patients who developed agranulocytosis after the use of metamizole and draw attention to this side effect. METHODS The patients who were admitted to Eskişehir Osmangazi University Faculty of Medicine Hospital, Pediatric Infectious Diseases and Pediatric Hematology Service, between January 1, 2015, and December 31, 2018, with a diagnosis of secondary agranulocytosis to metamizole use were examined retrospectively. RESULTS In all, 12 patients were included in the study; oral metamizole was used in these patients for fever reduction. The mean absolute neutrophil count was 225/mm3 ± 226 (0-600/mm3) at admission, and the neutrophil value of 11 patients was < 500/mm3. The mean length of hospitalisation of the patients was 9.92 ± 8 (3-28) days. Eight patients received intravenous antibiotic therapy and four patients received at least one of the following treatments: intravenous immunoglobulin, granulocyte colony-stimulating factor and methylprednisolone. Bone marrow aspiration examination showed neutrophil/band maturation delaying in the myeloid series with normocellular bone marrow in three patients. Hypocellularity in the bone marrow and decrease in myeloid precursors were observed in three patients. There were no fatal cases. CONCLUSION The development of agranulocytosis after the use of metamizole causes long-term hospitalisation and may require the use of medications in treatment management. Considering the availability of alternative options to treat fever and pain, and given the side-effect profile of metamizole, it should not be the preferred, first-line antipyretic treatment in children.
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Affiliation(s)
- Ömer Kılıç
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey.
| | - Merve İşeri Nepesov
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Hasan Bora Ulukapı
- Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Zeynep Canan Özdemir
- Division of Pediatric Hematology-Oncology, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Özcan Bör
- Division of Pediatric Hematology-Oncology, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Ener Çağrı Dinleyici
- Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
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8
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Cismaru AL, Rudin D, Ibañez L, Liakoni E, Bonadies N, Kreutz R, Carvajal A, Lucena MI, Martin J, Sancho Ponce E, Molokhia M, Eriksson N, Krähenbühl S, Largiadèr CR, Haschke M, Hallberg P, Wadelius M, Amstutz U. Genome-Wide Association Study of Metamizole-Induced Agranulocytosis in European Populations. Genes (Basel) 2020; 11:genes11111275. [PMID: 33138277 PMCID: PMC7716224 DOI: 10.3390/genes11111275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
Agranulocytosis is a rare yet severe idiosyncratic adverse drug reaction to metamizole, an analgesic widely used in countries such as Switzerland and Germany. Notably, an underlying mechanism has not yet been fully elucidated and no predictive factors are known to identify at-risk patients. With the aim to identify genetic susceptibility variants to metamizole-induced agranulocytosis (MIA) and neutropenia (MIN), we conducted a retrospective multi-center collaboration including cases and controls from three European populations. Association analyses were performed using genome-wide genotyping data from a Swiss cohort (45 cases, 191 controls) followed by replication in two independent European cohorts (41 cases, 273 controls) and a joint discovery meta-analysis. No genome-wide significant associations (p < 1 × 10−7) were observed in the Swiss cohort or in the joint meta-analysis, and no candidate genes suggesting an immune-mediated mechanism were identified. In the joint meta-analysis of MIA cases across all cohorts, two candidate loci on chromosome 9 were identified, rs55898176 (OR = 4.01, 95%CI: 2.41–6.68, p = 1.01 × 10−7) and rs4427239 (OR = 5.47, 95%CI: 2.81–10.65, p = 5.75 × 10−7), of which the latter is located in the SVEP1 gene previously implicated in hematopoiesis. This first genome-wide association study for MIA identified suggestive associations with biological plausibility that may be used as a stepping-stone for post-GWAS analyses to gain further insight into the mechanism underlying MIA.
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Affiliation(s)
- Anca Liliana Cismaru
- Department of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.L.C.); (C.R.L.)
- Graduate School for Cellular and Biomedical Sciences, University of Bern, 3012 Bern, Switzerland
| | - Deborah Rudin
- Department of Clinical Pharmacology & Toxicology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (D.R.); (S.K.)
- Department of Biomedicine, University of Basel, 4051 Basel, Switzerland
| | - Luisa Ibañez
- Clinical Pharmacology Service, Hospital Universitari Vall d’Hebron, Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Fundació Institut Català de Farmacología, 08035 Barcelona, Spain;
| | - Evangelia Liakoni
- Department of Clinical Pharmacology & Toxicology, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.L.); (M.H.)
- Institute of Pharmacology, University of Bern, 3012 Bern, Switzerland
| | - Nicolas Bonadies
- Department of Hematology and Central Hematology Laboratory, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Reinhold Kreutz
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, 10117 Berlin, Germany;
| | - Alfonso Carvajal
- Centro de Estudios sobre la Seguridad de los Medicamentos, Universidad de Valladolid, 47005 Valladolid, Spain;
| | - Maria Isabel Lucena
- Servicio Farmacologia Clinica, Instituto de Investigación Biomedica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain;
| | - Javier Martin
- Instituto de Parasitología y Biomedicina Lopez-Neyra, Consejo Superior de Investigaciones Cientiíficas, 18016 Granada, Spain;
| | - Esther Sancho Ponce
- Servei d’Hematologia i Banc de Sang, Hospital General de Catalunya, 08190 Sant Cugat del Vallès, Spain;
| | - Mariam Molokhia
- Department of Population Health Sciences, King’s College London, London WC2R 2LS, UK;
| | - Niclas Eriksson
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden;
| | | | - Stephan Krähenbühl
- Department of Clinical Pharmacology & Toxicology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (D.R.); (S.K.)
| | - Carlo R. Largiadèr
- Department of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.L.C.); (C.R.L.)
| | - Manuel Haschke
- Department of Clinical Pharmacology & Toxicology, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.L.); (M.H.)
- Institute of Pharmacology, University of Bern, 3012 Bern, Switzerland
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, 751 85 Uppsala, Sweden; (P.H.); (M.W.)
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, 751 85 Uppsala, Sweden; (P.H.); (M.W.)
| | - Ursula Amstutz
- Department of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.L.C.); (C.R.L.)
- Correspondence:
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9
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Idiosyncratic Drug-Induced Neutropenia and Agranulocytosis in Elderly Patients. J Clin Med 2020; 9:jcm9061808. [PMID: 32531979 PMCID: PMC7356965 DOI: 10.3390/jcm9061808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023] Open
Abstract
Agranulocytosis is a rare, but serious and life-threatening hematologic disorder in elderly patients. Idiosyncratic drug-induced agranulocytosis (IDIA) has been classically defined by a neutrophil count below 0.5 × 109/L. The annual incidence of IDIA in Europe is about 1.6–9.2 cases per million inhabitants. Increasing age and female sex have been considered as risk factors for the development of this condition. Besides, it is well known that older people take on average more drugs than younger people. This condition is most often associated with the intake of antibacterial agents, antiplatelets, antithyroids, antipsychotics, antiepileptics and nonsteroidal anti-inflammatory drugs (NSAIDs). Initially, agranulocytosis may present without symptoms, but may quickly progress to a severe infection and sepsis. The causative drug should be immediately stopped. In febrile patients, blood cultures and where indicated, site-specific cultures should be obtained and early treatment with empirical broad-spectrum antibiotics started. Even with adequate treatment, the mortality rate is higher in elderly patients reaching up to 20%. Hematopoietic growth factors have proven to be useful as they shorten the duration of neutropenia. However, data on neutropenia and agranulocytosis in the elderly meeting the criteria of evidence-based medicine are still poor in the literature. This review analyzes the results of our experience as well as other published studies of the universal literature.
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10
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Palmblad J, Siersma V, Lind B, Bjerrum OW, Hasselbalch H, Andersen CL. Age-related prevalence and clinical significance of neutropenia - isolated or combined with other cytopenias: Real world data from 373 820 primary care individuals. Am J Hematol 2020; 95:521-528. [PMID: 32052479 DOI: 10.1002/ajh.25756] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/03/2020] [Accepted: 02/10/2020] [Indexed: 12/25/2022]
Abstract
Neutropenia (NP), that is, an absolute blood neutrophil count (ANC) <1.5 g/L, accompanies various diseases. However, the clinical significance of NP, detected in routine complete blood cell counts (CBC) in primary care, is poorly characterized. Here, from a primary care resource with ANCs from >370 000 individuals, we identified and followed neutropenic subjects for the next 4 years for novel ICD-10 based diagnoses of viral infections and hematological malignancies (ie, previously identified major outcomes in NP individuals) in Danish nationwide health registers. Risk estimates were assessed for children/adolescents (1-18 years) and adults (19-90 years) in relation to NP severity, and for isolated NP, bi- or pancytopenias. We found that NP was observed in 4.9% of children and in 1.9% of adults. The lower the ANC, the likelier was a diagnosis of viral infections or hematological malignancies established during the ensuing 4 years. Among neutropenic children, unspecified viral infections predominated, followed by mononucleosis (with other cytopenias in only 7% and 25% of the cases, respectively). All NP children with acute leukemia presented with bi- or pancytopenia from start of follow-up. In NP adults, hepatitis, followed by HIV, were the most common infections, and acute myelogenous leukemia (AML) and myelodysplastic syndromes (MDSs) the predominating hematological malignancies. Adult NP patients, subsequently diagnosed with hepatitis, HIV or AML, MDS, were bi- or pancytopenic in 42%, 47%, 90% and 91% of cases, respectively. Thus, presence of NP in even one CBC may be the first sign of a latent viral or hematological disorder requiring careful follow-up.
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Affiliation(s)
- Jan Palmblad
- Department of Hematology and MedicineThe Karolinska Institute at Karolinska University Hospital Huddinge Stockholm Sweden
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public HealthUniversity of Copenhagen Copenhagen Denmark
| | - Bent Lind
- Department of Clinical BiochemistryCopenhagen University Hospital Hvidovre Copenhagen Denmark
| | - Ole Weis Bjerrum
- Department of HematologyCopenhagen University Hospital Rigshospitalet Denmark
| | - Hans Hasselbalch
- Department of HematologyRoskilde University Hospital Herlev Denmark
| | - Christen Lykkegaard Andersen
- The Research Unit for General Practice and Section of General Practice, Department of Public HealthUniversity of Copenhagen Copenhagen Denmark
- Department of HematologyCopenhagen University Hospital Rigshospitalet Denmark
- Department of HematologyRoskilde University Hospital Herlev Denmark
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11
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Duwez M, Szymanski G, Carre M, Mallaret M, Lepelley M. [Idiosyncratic drug-induced agranulocytosis: 7 year-analysis in a French university hospital]. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 78:230-241. [PMID: 32248952 DOI: 10.1016/j.pharma.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Idiosyncratic drug-induced agranulocytosis is a rare but potentially serious haematological disorder. The pathophysiological mechanisms are complex and poorly understood. We aimed at investigating agranulocytosis drug related causes from the myelograms with "myeloid maturation arrest" performed in our university hospital over the last seven years. METHODS A retrospective analysis of myelograms collected for agranulocytosis was performed from 1st January 2010 to 31th December 2016. We used the method of Bégaud et al. for drug causality assessment. RESULTS Among the 104 myelograms analysed, 41 agranulocytosis were drug-induced, whose 28 were idiosyncratic. Among these 28 cases, 26 different drugs were involved. Agranulocytosis was a known adverse reaction in the summary of the product characteristics for 24 drugs, mainly associated with undetermined frequency (n=7). Mean onset latency was 38.1 days after starting the drug (calculated for n=23 cases) and granulocyte growth factors were used in 50% of cases without shortening the mean delay of blood count recovery. Bone marrow presented hypereosinophilia in 29% of cases. Pharmacovigilance reporting rate was 48%. CONCLUSION A "maturation arrest" in the myelogram is not pathognomonic for idiosyncratic drug-induced agranulocytosis. This rare event require multidisciplinary care involving haematologists, biologists and pharmacovigilance experts. Agranulocytosis reporting rate was high compared with usual adverse drug reaction reporting rate (5 to 10%), probably related to the potential severity of this event.
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Affiliation(s)
- M Duwez
- Département de pharmacie, CHU de Grenoble-Alpes, 38000 Grenoble, France.
| | - G Szymanski
- Laboratoire d'hématologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Carre
- Clinique universitaire d'hématologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Mallaret
- Centre régional de pharmacovigilance, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Lepelley
- Centre régional de pharmacovigilance, CHU de Grenoble-Alpes, 38000 Grenoble, France
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12
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Hisamatsu Y, Morinaga R, Watanabe E, Ohtani S, Shirao K. Febrile Neutropenia in a Patient with Non-Small Cell Lung Cancer Treated with the Immune-Checkpoint Inhibitor Nivolumab. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e920809. [PMID: 32018275 PMCID: PMC7020738 DOI: 10.12659/ajcr.920809] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patient: Male, 57-year-old Final Diagnosis: Febrile neutropenia Symptoms: Fever Medication: Nivolumab Clinical Procedure: Chemotherapy Specialty: Oncology
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Affiliation(s)
- Yasushi Hisamatsu
- Department of Thoracic Medical Oncology, Oita Prefectural Hospital, Oita City, Oita, Japan
| | - Ryotaro Morinaga
- Department of Thoracic Medical Oncology, Oita Prefectural Hospital, Oita City, Oita, Japan
| | - Erina Watanabe
- Department of Respiratory Medicine, Oita Prefectural Hospital, Oita City, Oita, Japan
| | - Satoshi Ohtani
- Department of Respiratory Medicine, Oita Prefectural Hospital, Oita City, Oita, Japan
| | - Kuniaki Shirao
- Department of Medical Oncology and Hematology, Oita University Faculty of Medicine, Yufu, Oita, Japan
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13
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Partial response in hairy cell leukemia with vemurafenib despite early discontinuation due to agranulocytosis. Anticancer Drugs 2020; 31:196-198. [DOI: 10.1097/cad.0000000000000821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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14
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Amoxicillin/Clavulanic Acid-Induced Agranulocytosis: A Case Report and Review of the Literature. Case Rep Hematol 2019; 2019:5718716. [PMID: 31781425 PMCID: PMC6855031 DOI: 10.1155/2019/5718716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/22/2019] [Accepted: 10/01/2019] [Indexed: 11/18/2022] Open
Abstract
Amoxicillin/clavulanic acid is one of the widely prescribed antibiotics in the outpatient setting giving excellent antimicrobial coverage and relatively safe profile in terms of adverse reactions. Gastrointestinal and cutaneous reactions are among the commonly reported. Our goal is to describe a case of agranulocytosis induced by amoxicillin/clavulanic acid in a previously healthy patient and review prior reports with similar presentation.
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15
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Böhm R, Proksch E, Schwarz T, Cascorbi I. Drug Hypersensitivity. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:501-512. [PMID: 30135011 DOI: 10.3238/arztebl.2018.0501] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/01/2017] [Accepted: 06/07/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Adverse drug reactions (ADRs) can be divided into pharmacological ADRs (type A) and hypersensitivity reactions (type B). Type B reactions can be further subdivided into immediate (<1 h, urticaria, anaphylaxis) and delayed reactions (>1 h, variable manifestation like exanthema, hepatitis, cytopenias). Prevention of hypersensitivity is often still a challenge. METHODS Selective literature search in Medline and Google Scholar as well as research in ADR databases like OpenVigil or SIDER. RESULTS Laboratory tests ([specific] IgE, lymphocyte transformation test), histological examination, dermatological tests (prick tests, epicutaneous testing) and-under certain circumstances-provocation tests can be used for diagnostics. There are only a few pharmacogenetic biomarkers to predict hypersensitivity reactions. Currently, testing for defined HLA genes is mandatory before prescription of abacavir and before the use of carbamazepine in Han Chinese or Thai patients. Immediate discontinuation of the trigger is essential in all allergic hypersensitivity reactions. Immediate reactions are treated with antihistamines, glucocorticoids and occasionally with epinephrine. Delayed reactions are usually treated with glucocorticoids. CONCLUSION Careful, structured diagnostics in case of suspected hypersensitivity together with adequate documentation (allergy passport) is necessary in order to avoid incidents in patients receiving subsequent treatment. Consistent use of existing resources (diagnostics and documentation) can help to avoid hypersensitivity reactions or to rapidly recognize and treat them, respectively.
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Affiliation(s)
- Ruwen Böhm
- Institute of Clinical and Experimental Pharmacology at the University Medical Center Schleswig-Holstein, Kiel; Department of Dermatology, Allergology and Venerology, University Medical Center Schleswig-Holstein, Kiel
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16
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Agafonova N, Shchegolkov E, Burgart Y, Saloutin V, Trefilova A, Triandafilova G, Solodnikov S, Maslova V, Krasnykh O, Borisevich S, Khursan S. Synthesis and Biological Evaluation of Polyfluoroalkylated Antipyrines and their Isomeric O-Methylpyrazoles. Med Chem 2019; 15:521-536. [DOI: 10.2174/1573406414666181106145435] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 10/19/2018] [Accepted: 10/30/2018] [Indexed: 11/22/2022]
Abstract
Background:
Formally belonging to the non-steroidal anti-inflammatory drug class
pyrazolones have long been used in medical practices.
Objective:
Our goal is to synthesize N-methylated 1-aryl-3-polyfluoroalkylpyrazolones as fluorinated
analogs of antipyrine, their isomeric O-methylated derivatives resembling celecoxib structure
and evaluate biological activities of obtained compounds.
Methods:
In vitro (permeability) and in vivo (anti-inflammatory and analgesic activities, acute toxicity,
hyperalgesia, antipyretic activity, “open field” test) experiments. To suggest the mechanism
of biological activity, molecular docking of the synthesized compounds was carried out into the
tyrosine site of COX-1/2.
Conclusion:
The trifluoromethyl antipyrine represents a valuable starting point in design of the
lead series for discovery new antipyretic analgesics with anti-inflammatory properties.
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Affiliation(s)
- Natalya Agafonova
- Postovsky Institute of Organic Synthesis of the Ural Branch of the Russian Academy of Sciences, S. Kovalevskoy Str., 22, Ekaterinburg 620990, Russian Federation
| | - Evgeny Shchegolkov
- Postovsky Institute of Organic Synthesis of the Ural Branch of the Russian Academy of Sciences, S. Kovalevskoy Str., 22, Ekaterinburg 620990, Russian Federation
| | - Yanina Burgart
- Postovsky Institute of Organic Synthesis of the Ural Branch of the Russian Academy of Sciences, S. Kovalevskoy Str., 22, Ekaterinburg 620990, Russian Federation
| | - Victor Saloutin
- Postovsky Institute of Organic Synthesis of the Ural Branch of the Russian Academy of Sciences, S. Kovalevskoy Str., 22, Ekaterinburg 620990, Russian Federation
| | - Alexandra Trefilova
- Perm National Research Polytechnic University, Komsomolsky Av., 29, Perm 614990, Russian Federation
| | - Galina Triandafilova
- Perm National Research Polytechnic University, Komsomolsky Av., 29, Perm 614990, Russian Federation
| | - Sergey Solodnikov
- Perm National Research Polytechnic University, Komsomolsky Av., 29, Perm 614990, Russian Federation
| | - Vera Maslova
- Perm National Research Polytechnic University, Komsomolsky Av., 29, Perm 614990, Russian Federation
| | - Olga Krasnykh
- Perm National Research Polytechnic University, Komsomolsky Av., 29, Perm 614990, Russian Federation
| | - Sophia Borisevich
- Ufa Institute of Chemistry of the Russian Academy of Sciences, Octyabrya Av., 71, Ufa 450078, Russian Federation
| | - Sergey Khursan
- Ufa Institute of Chemistry of the Russian Academy of Sciences, Octyabrya Av., 71, Ufa 450078, Russian Federation
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Ameri AH, Curtis BR, Sykes DB. Immune neutropenia mediated by micafungin. Am J Hematol 2019; 94:830-832. [PMID: 30945326 DOI: 10.1002/ajh.25483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/30/2019] [Accepted: 04/01/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Amir H. Ameri
- Division of HematologyMassachusetts General Hospital Cancer Center Boston Massachusetts
| | - Brian R. Curtis
- Platelet and Neutrophil Immunology LaboratoryBlood Research Institute, BloodCenter of Wisconsin Milwaukee Wisconsin
| | - David B. Sykes
- Division of HematologyMassachusetts General Hospital Cancer Center Boston Massachusetts
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18
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Revuelta-Herrero JL, García-Sánchez R, Anguita-Velasco J, de Lorenzo-Pinto A, Ortega-Navarro C, Sanjurjo-Sáez M. Drug safety surveillance within a strategy for the management of non-chemotherapy drug-induced neutropenia. Int J Clin Pharm 2019; 41:1143-1147. [PMID: 31256332 DOI: 10.1007/s11096-019-00873-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 06/22/2019] [Indexed: 01/23/2023]
Abstract
Background Severe non-chemotherapy drug-induced neutropenia is a rare idiosyncratic drug reaction that is considered potentially fatal. Objective To report, in terms of drug safety surveillance, the results of an institutional strategy for NCDIN. Method An observational and prospective study including all adult patients who received filgrastim for the treatment of NCDIN from June 2015 to December 2017 was carried out by hematologists and clinical pharmacists. Results 13 patients with severe NCDIN were included in the study. The median age was 51 (range 24-80) years old and 46.2% were male. Seven patients had one or more negative prognostic factors (age > 65 years, renal impairment, autoimmune diseases and/or a neutrophil count at diagnosis < 0.1 × 109 cells/L). A single drug was identified as causative in 3 patients, while in 10 cases, 2-3 drugs were considered as potentially causative. The most frequent drugs were metamizole, piperacillin/tazobactam, dexketoprofen and linezolid, among others. Seven patients developed NCDIN during their hospital stay while 6 were admitted to the emergency department. Patients were using a median of 11 drugs (IQR 8-15) at the time of diagnosis. No deaths were recorded. Conclusion Metamizole and piperacillin/tazobactam are the most common drugs linked to non-chemotherapy drug-induced neutropenia in our cohort.
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Affiliation(s)
- José Luis Revuelta-Herrero
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain.
| | - Raquel García-Sánchez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Javier Anguita-Velasco
- Haematology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, Madrid, 28007, Spain
| | - Ana de Lorenzo-Pinto
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Cristina Ortega-Navarro
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain
| | - María Sanjurjo-Sáez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain
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A Case of Dapsone-Induced Severe Agranulocytosis Causing Life-Threatening Skin Sepsis in a Sri Lankan Child with Borderline Leprosy: A Success Story! Case Rep Med 2019; 2019:2314379. [PMID: 31198424 PMCID: PMC6526580 DOI: 10.1155/2019/2314379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/21/2019] [Indexed: 11/18/2022] Open
Abstract
Leprosy is a common skin disease in Sri Lanka which is being increasingly diagnosed due to the existing successful public health programme. Dapsone is a drug which holds unique pharmacological properties where it serves as both anti-inflammatory and antimicrobial agents. Of its main adverse effects, agranulocytosis is a serious consequence which is reported mainly in adults and elderly. We report a 7-year-old child who sustained life-threatening skin and subcutaneous tissue sepsis because of dapsone-induced agranulocytosis. Besides, this case highlights the importance of meticulous monitoring of cell counts due to the risk of neutropenia and the natural history of cell recovery following occurrence of neutropenia. Though high mortality rate has been described in most of the similar cases reported, the child we describe made a complete recovery following severe neutropenic sepsis.
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20
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Lozier JN, Noel P. Immunohematological Disorders. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00062-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Warny M, Helby J, Nordestgaard BG, Birgens H, Bojesen SE. Lymphopenia and risk of infection and infection-related death in 98,344 individuals from a prospective Danish population-based study. PLoS Med 2018; 15:e1002685. [PMID: 30383787 PMCID: PMC6211632 DOI: 10.1371/journal.pmed.1002685] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/02/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Neutropenia increases the risk of infection, but it is unknown if this also applies to lymphopenia. We therefore tested the hypotheses that lymphopenia is associated with increased risk of infection and infection-related death in the general population. METHODS AND FINDINGS Of the invited 220,424 individuals, 99,191 attended examination. We analyzed 98,344 individuals from the Copenhagen General Population Study (Denmark), examined from November 25, 2003, to July 9, 2013, and with available blood lymphocyte count at date of examination. During a median of 6 years of follow-up, they developed 8,401 infections and experienced 1,045 infection-related deaths. Due to the completeness of the Danish civil and health registries, none of the 98,344 individuals were lost to follow-up, and those emigrating (n = 385) or dying (n = 5,636) had their follow-up truncated at the day of emigration or death. At date of examination, mean age was 58 years, and 44,181 (44.9%) were men. Individuals with lymphopenia (lymphocyte count < 1.1 × 109/l, n = 2,352) compared to those with lymphocytes in the reference range (1.1-3.7 × 109/l, n = 93,538) had multivariable-adjusted hazard ratios of 1.41 (95% CI 1.28-1.56) for any infection, 1.31 (1.14-1.52) for pneumonia, 1.44 (1.15-1.79) for skin infection, 1.26 (1.02-1.56) for urinary tract infection, 1.51 (1.21-1.89) for sepsis, 1.38 (1.01-1.88) for diarrheal disease, 2.15 (1.16-3.98) for endocarditis, and 2.26 (1.21-4.24) for other infections. The corresponding hazard ratio for infection-related death was 1.70 (95% CI 1.37-2.10). Analyses were adjusted for age, sex, smoking status, cumulative smoking, alcohol intake, body mass index, plasma C-reactive protein, blood neutrophil count, recent infection, Charlson comorbidity index, autoimmune diseases, medication use, and immunodeficiency/hematologic disease. The findings were robust in all stratified analyses and also when including only events later than 2 years after first examination. However, due to the observational design, the study cannot address questions of causality, and our analyses might theoretically have been affected by residual confounding and reverse causation. In principle, fluctuating lymphocyte counts over time might also have influenced analyses, but lymphocyte counts in 5,181 individuals measured 10 years after first examination showed a regression dilution ratio of 0.68. CONCLUSIONS Lymphopenia was associated with increased risk of hospitalization with infection and increased risk of infection-related death in the general population. Notably, causality cannot be deduced from our data.
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Affiliation(s)
- Marie Warny
- Department of Hematology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Jens Helby
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Børge Grønne Nordestgaard
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Henrik Birgens
- Department of Hematology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Stig Egil Bojesen
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- * E-mail:
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Hongo T, Nozaki S, Tsuchiya M, Inaba M, Takahashi K, Fujiwara T. Contrast medium-induced transient severe leukopenia. Acute Med Surg 2018; 5:185-188. [PMID: 29657733 PMCID: PMC5891103 DOI: 10.1002/ams2.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 09/21/2017] [Indexed: 11/07/2022] Open
Abstract
Case Contrast medium-induced transient leukopenia is very rare. Here, we report a case of a 73-year-old man diagnosed with contrast media-induced transient leukopenia. The patient underwent abdominal contrast-enhanced computed tomography, where he was given non-ionic iodinated contrast medium i.v. His medical history included an allergic reaction to a different contrast medium. One hour later, the patient was admitted to the emergency department complaining of chest discomfort. He had leukopenia and a fever (temperature of 38.9°C). Complete blood count showed a white blood cell count of 930/μL and an absolute neutrophilic count of 232/μL. Outcome The patient was given i.v. antibiotics and 5 mg chlorpheniramine maleic acid, 20 mg famotidine, and 125 mg methylprednisolone. The patient's white blood cell count recovered the next day, and he was discharged after 2 days of hospitalization. Conclusion We diagnosed the patient with contrast media-induced transient leukopenia, which is a rare phenomenon.
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Affiliation(s)
- Takashi Hongo
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
| | - Satoshi Nozaki
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
| | - Midori Tsuchiya
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
| | - Mototaka Inaba
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
| | - Kenji Takahashi
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
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Abstract
Drug-induced neutropenia and agranulocytosis are rare adverse events but can be fatal. Neutropenia can be induced by a myriad of drugs from almost every pharmacologic class. Octreotide is a somatostatin analog that has been used to treat variceal bleeding, acromegaly, and severe diarrhea associated with metastatic tumors, and to reduce symptoms in the setting of malignant bowel obstruction and pseudoobstruction. The most common adverse effects associated with octreotide include pain at the injection site and gastrointestinal effects such as loose stools, cramping, and nausea; neutropenia is not currently listed as an adverse effect of the drug. We describe the case of an 87-year-old man who developed neutropenia immediately after administration of three doses of subcutaneous octreotide. He presented to the hospital with a history of constipation and straining for 3 days. He was admitted, and laxatives, suppositories, and enemas were administered over the next 3 days to induce a bowel movement; however, they were ineffective. Bowel obstruction secondary to a mass was confirmed by computed tomography; the mass was eventually diagnosed as colon cancer. Octreotide 100 µg subcutaneously every 8 hours was started for the obstruction on the evening of hospital day 4. After the patient had received 3 doses of octreotide, his white blood cell count (WBC) had decreased from 4.1 × 103 /mm3 (neutrophils 75.4%, absolute neutrophil count [ANC] 3.1 × 103 /mm3 ) on admission to 1.6 × 103 /mm3 (neutrophils 62%, ANC 0.99 × 103 /mm3 ) on day 5. Given the temporal relationship of octreotide and neutropenia as well as the lack of a reasonable alternative cause, it was suspected that octreotide was the most likely culprit of the patient's neutropenia. Octreotide was subsequently discontinued, and his WBC increased to 4.9 × 103 /mm3 (neutrophils 66.3%, ANC 3.2 × 103 /mm3 ) the next day. The remainder of the patient's hospitalization was not significant for any further hematologic abnormalities. His WBC and ANC (WBC 6.7 × 103 /mm3 , neutrophils 83.2%, ANC 5.6 × 103 /mm3 ) remained stable 30 days after the incident. Use of the Naranjo Adverse Drug Reaction Probability Scale indicated a probable relationship (score of 5) between the patient's development of neutropenia and octreotide therapy. To our knowledge, this report highlights the first case of octreotide-associated neutropenia. Although the frequency of drug-induced neutropenia remains rare outside of cytotoxic chemotherapy, the importance of recognizing this adverse effect cannot be understated given the mortality risks for neutropenic patients.
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Affiliation(s)
- Stacy S Tse
- Geriatric Research Education and Clinical Centers, James J. Peters VA Medical Center, Bronx, New York
| | - Troy Kish
- Department of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York
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Agranulocytosis Associated with Topiramate: A Case Report and Review of Published Cases. Case Rep Hematol 2018; 2018:5846398. [PMID: 29545956 PMCID: PMC5818961 DOI: 10.1155/2018/5846398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 12/12/2017] [Indexed: 11/18/2022] Open
Abstract
A 41-year-old female presented to the hospital with sore throat and shortness of breath. She was hypoxic with an oxygen saturation of 87% in room air. Physical examination revealed swollen uvula with exudates. She had been started on topiramate for treatment of migraine few months ago. The dose of topiramate was increased to 100 mg twice daily 2 weeks ago. Complete blood count revealed an absolute neutrophil count (ANC) of 8 c/mm3. She was intubated and started on broad-spectrum antibiotics. She was transferred to our hospital on the fifth day of hospitalization. On arrival, her absolute neutrophil count was 10 c/mm3. Her agranulocytosis was attributed to topiramate after ruling out other possible causes. ANC improved after topiramate was stopped. ANC increased to 1000 after 5 days of stopping topiramate. We also reviewed published cases of topiramate-associated agranulocytosis. Agranulocytosis is a rare side effect of topiramate, and only 3 case reports have been published so far. In all cases, agranulocytosis developed after months of topiramate therapy and when dose was increased to 200 mg daily suggesting a dose-dependent effect. Next steps would be further research on the pathogenesis of agranulocytosis associated with topiramate and creation of registry for data synthesis.
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Fasullo S, Davì S, Cosenza G, Di Franco F, La Manna N, Giubilato A, Vetrano G, Maringhini G. Acute agranulocytosis after oral administration of dabigatran: a rare case report and a short review of literature. J Thromb Thrombolysis 2018; 45:588-592. [DOI: 10.1007/s11239-018-1624-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Curtis BR. Non-chemotherapy drug-induced neutropenia: key points to manage the challenges. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:187-193. [PMID: 29222255 PMCID: PMC6142577 DOI: 10.1182/asheducation-2017.1.187] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Non-chemotherapy idiosyncratic drug-induced neutropenia (IDIN) is a relatively rare but potentially fatal disorder that occurs in susceptible individuals, with an incidence of 2.4 to 15.4 cases per million population. Affected patients typically experience severe neutropenia within several weeks to several months after first exposure to a drug, and mortality is ∼5%. The drugs most frequently associated with IDIN include metamizole, clozapine, sulfasalazine, thiamazole, carbimazole, amoxicillin, cotrimoxazole, ticlopidine, and valganciclovir. The idiosyncratic nature of IDIN, the lack of mouse models and diagnostic testing, and its low overall incidence make rigorous studies to elucidate possible mechanisms exceptionally difficult. An immune mechanism for IDIN involving neutrophil destruction by hapten (drug)-specific antibodies and drug-induced autoantibodies is frequently suggested, but strong supporting evidence is lacking. Although laboratory testing for neutrophil drug-dependent antibodies is rarely performed because of the complexity and low sensitivity of tests currently in use, these assays could possibly be enhanced by using reactive drug metabolites in place of the parent drug. Patients typically experience acute, severe neutropenia, or agranulocytosis (<0.5 × 109 neutrophils/L) and symptoms of fever, chills, sore throat, and muscle and joint pain. Diagnosis can be difficult, but timely recognition is critical because if left untreated, there is an increase in mortality. Expanded studies of the production and mechanistic role of reactive drug metabolites, genetic associations, and improved animal models of IDIN are essential to further our understanding of this important disorder.
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Affiliation(s)
- Brian R Curtis
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
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28
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Hyperoxidation of ether-linked phospholipids accelerates neutrophil extracellular trap formation. Sci Rep 2017; 7:16026. [PMID: 29167447 PMCID: PMC5700140 DOI: 10.1038/s41598-017-15668-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 10/30/2017] [Indexed: 02/06/2023] Open
Abstract
Because neutrophil extracellular trap (NET) formation is involved in the pathology of a wide variety of diseases, NET-regulating compounds are expected to be useful for the therapies of these diseases. In this study, we identified sulfasalazine (SSZ) as a potent enhancer of NET formation both in vitro and in vivo. Although SSZ did not increase the amount of ROS generated, it accelerated the generation of ether-linked oxidized phospholipids, such as PE (18;1e/15-HETE) and PC (16;0e/13-HODE). Trolox, but not 2-ME, effectively suppressed lipid oxidation and NET formation that were induced by SSZ. SSZ is known as a potent inducer of ferroptosis in cancer cells by inhibiting xCT, a component of the cystine transporter. However, we found that SSZ accelerated NET formation in an xCT-independent manner. Structure-activity relationship studies revealed that the sulfapyridine moiety of SSZ plays a central role in enhancing NET formation. Furthermore, we found that two additional sulfonamide and sulfone derivatives possess NET-inducing activity by accelerating lipid oxidation. These results indicate that the hyperoxidation of ether-linked phospholipids is a key mechanism for accelerating NET formation.
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29
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Thurmond RL, Venable J, Savall B, La D, Snook S, Dunford PJ, Edwards JP. Clinical Development of Histamine H 4 Receptor Antagonists. Handb Exp Pharmacol 2017; 241:301-320. [PMID: 28233185 DOI: 10.1007/164_2016_130] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The discovery of the histamine H4 receptor (H4R) provided a new avenue for the exploration of the physiological role of histamine, as well as providing a new drug target for the development of novel antihistamines. The first step in this process was the identification of selective antagonists to help unravel the pharmacology of the H4R relative to other histamine receptors. The discovery of the selective H4R antagonist JNJ 7777120 was vital for showing a role for the H4R in inflammation and pruritus. While this compound has been very successful as a tool for understanding the function of the receptor, it has drawbacks, including a short in vivo half-life and hypoadrenocorticism toxicity in rats and dogs, that prevented advancing it into clinical studies. Further research let to the discovery of JNJ 39758979, which, similar to JNJ 7777120, was a potent and selective H4R antagonist and showed anti-inflammatory and anti-pruritic activity preclinically. JNJ 39758979 advanced into human clinical studies and showed efficacy in reducing experimental pruritus and in patients with atopic dermatitis. However, development of this compound was terminated due to the occurrence of drug-induced agranulocytosis. This was overcome by developing another H4R antagonist with a different chemical structure, toreforant, that does not appear to have this side effect. Toreforant has been tested in clinical studies in patients with rheumatoid arthritis, asthma, or psoriasis. In conclusions there have been many H4R antagonists reported in the literature, but only a few have been studied in humans underscoring the difficulty in finding ligands with all of the properties necessary for testing in the clinic. Nevertheless, the clinical data to date suggests that H4R antagonists can be beneficial in treating atopic dermatitis and pruritus.
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Affiliation(s)
| | | | - Brad Savall
- Janssen Research & Development, LLC, San Diego, CA, 92121, USA
| | - David La
- Janssen Research & Development, LLC, San Diego, CA, 92121, USA
| | - Sandra Snook
- Janssen Research & Development, LLC, San Diego, CA, 92121, USA
| | - Paul J Dunford
- Janssen Research & Development, LLC, San Diego, CA, 92121, USA
| | - James P Edwards
- Janssen Research & Development, LLC, San Diego, CA, 92121, USA
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30
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Wadelius M, Eriksson N, Kreutz R, Bondon-Guitton E, Ibañez L, Carvajal A, Lucena MI, Sancho Ponce E, Molokhia M, Martin J, Axelsson T, Kohnke H, Yue QY, Magnusson PKE, Bengtsson M, Hallberg P. Sulfasalazine-Induced Agranulocytosis Is Associated With the Human Leukocyte Antigen Locus. Clin Pharmacol Ther 2017; 103:843-853. [PMID: 28762467 PMCID: PMC5947520 DOI: 10.1002/cpt.805] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 12/12/2022]
Abstract
Agranulocytosis is a serious, although rare, adverse reaction to sulfasalazine, which is used to treat inflammatory joint and bowel disease. We performed a genome-wide association study comprising 9,380,034 polymorphisms and 180 HLA alleles in 36 cases of sulfasalazine-induced agranulocytosis and 5,170 population controls. Sulfasalazine-induced agranulocytosis was significantly associated with the HLA region on chromosome 6. The top hit (rs9266634) was located close to HLA-B, odds ratio (OR) 5.36 (95% confidence interval (CI) (2.97, 9.69) P = 2.55 × 10-8 ). We HLA-sequenced a second cohort consisting of 40 cases and 142 treated controls, and confirmed significant associations with HLA-B*08:01, OR = 2.25 (95% CI (1.02, 4.97) P = 0.0439), in particular the HLA-B*08:01 haplotype HLA-DQB1*02:01-DRB1*03:01-B*08:01-C*07:01, OR = 3.79 (95% CI (1.63, 8.80) P = 0.0019), and with HLA-A*31:01, OR = 4.81 (95% CI (1.52, 15.26) P = 0.0077). The number needed to test for HLA-B*08:01 and HLA-A*31:01 to avoid one case was estimated to be 1,500. We suggest that intensified monitoring or alternative treatment should be considered for known carriers of HLA-B*08:01 or HLA-A*31:01.
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Affiliation(s)
- Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Niclas Eriksson
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - Emmanuelle Bondon-Guitton
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire, Faculté de Médecine de l'Université de Toulouse, Toulouse, France
| | - Luisa Ibañez
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Fundació Institut Català de Farmacologia, Barcelona, Spain
| | - Alfonso Carvajal
- Centro de Estudios sobre la Seguridad de los Medicamentos, Universidad de Valladolid, Valladolid, Spain
| | - M Isabel Lucena
- S Farmacologia Clinica, Instituto de Investigación Biomedica de Málaga (IBIMA), H Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Madrid, Spain
| | - Esther Sancho Ponce
- Servei d'Hematologia i Banc de Sang, Hospital General de Catalunya, Sant Cugat del Vallès, Spain
| | - Mariam Molokhia
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London Department of Primary Care and Public Health Sciences, London, UK
| | - Javier Martin
- Instituto de Parasitologia y Biomedicina Lopez-Neyra, CSIC, Granada, Spain
| | - Tomas Axelsson
- Department of Medical Sciences, Molecular Medicine and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Hugo Kohnke
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | | | - Patrik K E Magnusson
- Swedish Twin Registry, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mats Bengtsson
- Department of Immunology, Genetics and Pathology, Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
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Abstract
INTRODUCTION To date, non-chemotherapy drug-induced severe neutropenia (neutrophil count of ≤0.5 x 109/L) also called idiosyncratic drug-induced agranulocytosis is little discussed in the literature. In the present paper, we report and discuss the clinical data and management of this rare disorder. Areas covered: To do this, we carried out a review of the literature using PubMed database of the US National Library of Medicine. We also used data from the American Society of Hematology educational books, textbooks of Hematology and Internal medicine, and information gleaned from international meetings. Expert opinion: Idiosyncratic agranulocytosis remains a potentially serious adverse event due to the frequency of severe sepsis with severe deep tissue infections (e.g., pneumonia), septicemia, and septic shock in approximately two-thirds of all hospitalized patients. In this context, several prognostic factors have been identified that may be helpful when identifying 'susceptible' patients. Old age (>65 years), septicemia or shock, renal failure, and a neutrophil count ≤0.1 × 109/L have been consensually accepted as poor prognostic factors. In our experience, modern management with pre-established procedures, intravenous broad-spectrum antibiotics and hematopoietic growth factors (particularly G-CSF) is likely to improve the prognosis. Thus with appropriate management, the mortality rate is currently between 5 to 10%.
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Affiliation(s)
- Emmanuel Andrès
- a Departments of Internal Medicine, Medical Clinic B , University Hospital of Strasbourg , Strasbourg , France.,b Referral Center of immune cytopenias , University Hospital of Strasbourg , Strasbourg , France
| | - Rachel Mourot-Cottet
- a Departments of Internal Medicine, Medical Clinic B , University Hospital of Strasbourg , Strasbourg , France.,b Referral Center of immune cytopenias , University Hospital of Strasbourg , Strasbourg , France
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Chen J, Zhong B, Wang Y. Agranulocytosis Induced by Sinomenine Hydrochloride. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:959-962. [PMID: 28874654 PMCID: PMC5597034 DOI: 10.12659/ajcr.904519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Patient: Female, 44 Final Diagnosis: Agranulocytosis Symptoms: Fever • pharyngalgia Medication: Sinomenine Clinical Procedure: Stop taking medicine and treat it Specialty: Rheumatology
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Affiliation(s)
- Juerong Chen
- Department of Rheumatology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Bing Zhong
- Department of Rheumatology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Yong Wang
- Department of Rheumatology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
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Koh S, Koh H, Kubo Y, Kuroda M, Nishimoto M, Yoshimura T, Nakashima Y, Nakane T, Nakamae H, Ohsawa M, Hino M. An Elderly Woman with Anti-neutrophil Antibody-positive Agranulocytosis Who Responded to High-dose Intravenous Methylprednisolone. Intern Med 2017; 56:2199-2203. [PMID: 28781303 PMCID: PMC5596284 DOI: 10.2169/internalmedicine.8268-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Although anti-neutrophil antibodies (ANAs) often exist and immunoreaction may be involved in agranulocytosis, few reports have so far described ANA-positive cases of agranulocytosis with an unknown etiology. We herein describe the case of a 69-year-old woman who presented with ANA-positive agranulocytosis. In this case, both the withdrawal of the drugs that had possibly caused neutropenia and the use of granulocyte-colony stimulating factor (G-CSF) were ineffective treatment measures. Approximately 2 weeks after the discontinuation of the suspected drugs, we initiated corticosteroid pulse therapy; the neutrophil count recovered by day 19 of steroid therapy. High-dose methylprednisolone therapy should thus be considered for patients demonstrating ANA-positive agranulocytosis with an unknown etiology that is refractory to G-CSF treatment.
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Affiliation(s)
- Shiro Koh
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Hideo Koh
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Yuki Kubo
- Department of Diagnostic Pathology, Graduate School of Medicine, Osaka City University, Japan
| | - Maiko Kuroda
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | | | - Takuro Yoshimura
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | | | - Takahiko Nakane
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Masahiko Ohsawa
- Department of Diagnostic Pathology, Graduate School of Medicine, Osaka City University, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka City University, Japan
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Verriere B, Gastaud L, Chamorey E, Peyrade F, Deletie E, Bouredji K, Quinsat D, Schiappa R, Thyss A, Re D. Description of late onset neutropenia in indolent lymphoma patients treated with bendamustine plus rituximab. Hematol Oncol 2017; 36:144-149. [PMID: 28685846 DOI: 10.1002/hon.2458] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/26/2017] [Accepted: 06/05/2017] [Indexed: 11/11/2022]
Abstract
Bendamustine (B) associated with rituximab (R) is widely described in literature for the management of patients with chronic lymphoid leukaemia (CLL) and indolent non-Hodgkin lymphoma. Safety data regarding late hematotoxicity such as late onset neutropenia (LON) are scarce. The aim of our study was to assess the incidence and to identify risk factors for LON in patients with indolent non-Hodgkin lymphoma and CLL treated with B and R (B-R). One hundred forty five patients were treated with B-R as first or second line. Patients with neutropenia prior induction treatment, treated beyond second line and relapsing within 3 months after the end of induction treatment, were excluded. Patients receiving at least 1 cycle of B-R and having LON during follow-up period were included and considered as eligible for toxicity assessment. A complete blood count was performed 4 weeks after the last cycle of induction treatment and thereafter every 3 months for 1 year. Thirty six patients were identified in our cohort (incidence of 25%), mostly affected by CLL (n = 11) and follicular lymphoma (FL) (n = 15). During follow-up, 84 events of LON were recorded, 61% and 39% were of grades 1/2 and 3/4, respectively. No episode of febrile neutropenia was documented. Amongst 13 of the 15 patients with FL undergoing R maintenance, 8 had treatment discontinuation because of LON. Median time for LON (grade > 2) and time to recovery (grade < 3) were of 11.2 and 17.3 weeks, respectively. One year after B-R induction, LON persisted in 4 patients. The risk of LON was increased both in patients with FL or CLL and performance status >1. The LON in B-R treated patients is clinically relevant. Close clinical and biological follow-up and treatment prophylaxis (eg, valaciclovir and cotrimoxazole) especially for FL patients undergoing maintenance with R monotherapy seems relevant.
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Affiliation(s)
- B Verriere
- Pharmacy department, Antibes Hospital, Antibes, France
| | - L Gastaud
- Oncology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - E Chamorey
- Biostatistics and epidemiology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - F Peyrade
- Oncology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - E Deletie
- Pharmacy department, Antibes Hospital, Antibes, France
| | - K Bouredji
- Oncology and hemato oncology department, Antibes Hospital, Antibes, France
| | - D Quinsat
- Internal Medicine department, Antibes Hospital, Antibes, France
| | - R Schiappa
- Biostatistics and epidemiology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - A Thyss
- Oncology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - D Re
- Oncology department, Anticancer Center Antoine Lacassagne, Nice, France.,Oncology and hemato oncology department, Antibes Hospital, Antibes, France
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Peng RR, Wu J, Zhao W, Qi T, Shi M, Guan Z, Lu H, Long F, Gao Z, Zhang S, Zhou P. Neutropenia induced by high-dose intravenous benzylpenicillin in treating neurosyphilis: Does it really matter? PLoS Negl Trop Dis 2017; 11:e0005456. [PMID: 28288165 PMCID: PMC5363990 DOI: 10.1371/journal.pntd.0005456] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 03/23/2017] [Accepted: 03/03/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Prompt therapy with high-dose intravenous benzylpenicillin for a prolonged period is critical for neurosyphilis patients to avoid irreversible sequelae. However, life-threatening neutropenia has been reported as a complication of prolonged therapy with high doses of benzylpenicillin when treating other diseases. This study aimed to investigate the incidence, presentation, management and prognosis of benzylpenicillin-induced neutropenia in treating neurosyphilis based on a large sample of syphilis patients in Shanghai. METHODOLOGY/PRINCIPAL FINDINGS Between 1st January 2013 and 31st December 2015, 1367 patients with neurosyphilis were treated with benzylpenicillin, 578 of whom were eligible for recruitment to this study. Among patients without medical co-morbidities, the total incidence of benzylpenicillin-induced neutropenia and severe neutropenia was 2.42% (95% CI: 1.38-4.13%) and 0.35% (95% CI: 0.06-1.39%), respectively. The treatment duration before onset of neutropenia ranged from 10 to 14 days, with a total cumulative dose of between 240 and 324 megaunits of benzylpenicillin. Neutropenia was accompanied by symptoms of chills and fever (5 patients), fatigue (2 patients), cough (1 patient), sore throat (1 patient), diarrhea (1 patient) and erythematous rash (1 patient). The severity of neutropenia was not associated with age, gender or type of neurosyphilis (p>0.05). Neutropenia, even when severe, was often tolerated and normalized within one week. A more serious neutropenia did not occur when reinstituting benzylpenicillin in patients with mild or moderate neutropenia nor when ceftriaxone was used three months after patients had previously experienced severe neutropenia. CONCLUSIONS/SIGNIFICANCE Benzylpenicillin-induced neutropenia was uncommon in our cohort of patients. Continuation of therapy was possible with intensive surveillance for those with mild or moderate neutropenia. For severe neutropenia, it is not essential to aggressively use hematopoietic growth factors or broad-spectrum antibiotics for patients in good physical condition after withdrawing anti-neurosyphilis regimen. We did not see an exacerbation of neutropenia in patients with the readministration of benzylpenicillin.
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Affiliation(s)
- Rui-Rui Peng
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Juan Wu
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Wei Zhao
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Tengfei Qi
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Mei Shi
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Zhifang Guan
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Haikong Lu
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Fuquan Long
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Zixiao Gao
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Sufang Zhang
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
| | - Pingyu Zhou
- Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, People's Republic of China
- * E-mail:
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36
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Shapiro RM, Zeller MP, Warkentin TE. Sepsis and persisting neutropenia in a drug addict. Am J Hematol 2017; 92:312-316. [PMID: 28052478 DOI: 10.1002/ajh.24639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/02/2016] [Accepted: 12/31/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Roman M. Shapiro
- Department of MedicineLondon Health Science CentreLondon Ontario Canada
| | - Michelle P. Zeller
- Department of Pathology and Molecular MedicineMichael G. DeGroote School of Medicine, McMaster UniversityHamilton Ontario Canada
- Department of MedicineMichael G. DeGroote School of Medicine, McMaster UniversityHamilton Ontario Canada
| | - Theodore E. Warkentin
- Department of Pathology and Molecular MedicineMichael G. DeGroote School of Medicine, McMaster UniversityHamilton Ontario Canada
- Department of MedicineMichael G. DeGroote School of Medicine, McMaster UniversityHamilton Ontario Canada
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Böhm R, Cascorbi I. Pharmacogenetics and Predictive Testing of Drug Hypersensitivity Reactions. Front Pharmacol 2016; 7:396. [PMID: 27818635 PMCID: PMC5073094 DOI: 10.3389/fphar.2016.00396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/07/2016] [Indexed: 12/15/2022] Open
Abstract
Adverse drug reactions adverse drug reaction (ADR) occur in approximately 17% of patients. Avoiding ADR is thus mandatory from both an ethical and an economic point of view. Whereas, pharmacogenetics changes of the pharmacokinetics may contribute to the explanation of some type A reactions, strong relationships of genetic markers has also been shown for drug hypersensitivity belonging to type B reactions. We present the classifications of ADR, discuss genetic influences and focus on delayed-onset hypersensitivity reactions, i.e., drug-induced liver injury, drug-induced agranulocytosis, and severe cutaneous ADR. A guidance how to read and interpret the contingency table is provided as well as an algorithm whether and how a test for a pharmacogenetic biomarker should be conducted.
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Affiliation(s)
- Ruwen Böhm
- Institute of Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein Kiel, Germany
| | - Ingolf Cascorbi
- Institute of Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein Kiel, Germany
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38
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Medrano-Casique N, Tong HY, Borobia AM, Carcas AJ, Frías J, Ramírez E. Nonchemotherapy drug-induced agranulocytosis in children detected by a prospective pharmacovigilance program. Pediatr Hematol Oncol 2016; 33:441-456. [PMID: 27922762 DOI: 10.1080/08880018.2016.1234523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES A prospective evaluation of nonchemotherapy drug-induced agranulocytosis (DIA) cases, which are infrequent in the pediatric population. We characterize agranulocytosis cases and assess lab test differences between drug- and nondrug-induced agranulocytosis. METHODS Through our Prospective Pharmacovigilance Program from Laboratory Signals at Hospital we detected pediatric agranulocytosis cases from July 2007 to December 2010. This program estimates the incidence, drug causality, clinical features, outcomes of DIA pediatric cases, and assesses laboratory differences with respect to non-DIA. RESULTS We detected 662 agranulocytosis in 308 pediatric patients, of which 14 were caused by nonchemotherapy drugs. The incidence rate of DIA for 10,000 pediatric patients was 3.92 (Poisson 95% confidence interval 1.09-8.77); 78.6% of DIA cases occurred in patients younger than 3 years. The final outcome was recovery without sequela in all cases. The pharmacologic group most frequently implicated was antimicrobial drugs (11 drugs), 7 of which were beta-lactams. The drugs most frequently suspected were cefotaxime and vancomycin (3 cases each). We found 3 drugs (cloperastine, codeine, and enoxaparin) not previously described to induce DIA. Automatic linear modeling (n = 56, R2 = 45.2%) showed a significant inverse association with platelets (R2 = 17.5%), hemoglobin, and alanine transaminase, and a direct association with red cell distribution (R2 = 16.2%). A generalized linear model (Type III, n = 1188; DIA, n = 86; likelihood ratio chi-squared = 156.16) retained eosinophils (p <.001), platelets (p <.001), total serum proteins (p <.001), and hemoglobin (p =.039). CONCLUSIONS We found a higher incidence of DIA in children than previously described. Our findings also suggest an immune-mediated destruction or myeloid toxicity, possibly facilitated by an increase in drug exposure.
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Affiliation(s)
- Nicolás Medrano-Casique
- a Department of Clinical Pharmacology , La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid , Madrid , Spain
| | - Hoi Y Tong
- a Department of Clinical Pharmacology , La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid , Madrid , Spain
| | - Alberto M Borobia
- a Department of Clinical Pharmacology , La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid , Madrid , Spain
| | - Antonio J Carcas
- a Department of Clinical Pharmacology , La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid , Madrid , Spain
| | - Jesús Frías
- a Department of Clinical Pharmacology , La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid , Madrid , Spain
| | - Elena Ramírez
- a Department of Clinical Pharmacology , La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid , Madrid , Spain
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Amoateng P, Adjei S, Osei-Safo D, Ahedor B, Mahmood SA, N'guessan BB, Asiedu-Gyekye IJ, Nyarko AK. Long-term continuous administration of a hydro-ethanolic extract of Synedrella nodiflora (L) Gaertn in male Sprague-Dawley rats: biochemical, haematological and histopathological changes. Ghana Med J 2016; 50:163-171. [PMID: 27752191 DOI: pmid/27752191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Conflicting reports about the toxicity of Synedrella nodiflora (L) Gaertn (family Asteraceae), a plant traditionally used in Ghana for the management of epilepsy, abound in literature. The present study evaluates the effect of a 90-day continuous oral administration of a hydro-ethanolic whole plant extract of Synedrella nodiflora (SNE) in male Sprague-Dawley rats. METHODS The toxicological evaluation of the extract (100, 300 and 1000 mgkg-1) was focused on haematological, serum biochemical parameters and histopathological changes of some isolated organs. RESULTS The extract produced no mortality in the rats treated during the study period. Only SNE 100 mgkg-1 produced significant decrease in white blood cell and neutrophil counts and an increase in albumin, globulin, total bilirubin, total protein and potassium levels. The higher doses (SNE 300 and 1000 mgkg-1) had no significant effect on all the haematological and biochemical parameters measured. Histopathological assessment of the liver, kidney and heart revealed no abnormalities in rats treated with the extracts. Only the SNE 1000 mgkg-1 produced distortions of the branching arrangements of the myocardial fibres and a congested vessel which indicates a healed infarction. CONCLUSIONS The findings suggest hydro-ethanolic extract of Synedrella nodiflora (L) Gaertn generally has a low toxicity profile following a 90-day continuous oral administration in male Sprague-Dawley rats under the present laboratory conditions. However patients with renal or cardiac problems should use the plant with caution. FUNDING Jointly supported by the International Foundation for Science, Stockholm, Sweden, through a grant (# F/5191-1) to Dr. Patrick Amoateng and the Office of Research, Innovation and Development (ORID), University of Ghana, Accra, Ghana, grant awarded to Dr. Patrick Amoateng (reference number: URF/6/ILG-002/2012-2013).
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Affiliation(s)
- Patrick Amoateng
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, University of Ghana, P.O Box LG 43, Legon, Accra, Ghana
| | - Samuel Adjei
- Department of Animal Experimentation, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, P. O. Box LG581, Legon, Accra, Ghana
| | - Dorcas Osei-Safo
- Department of Chemistry, University of Ghana, P. O. Box LG56, Legon, Accra, Ghana
| | - Believe Ahedor
- Department of Animal Experimentation, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, P. O. Box LG581, Legon, Accra, Ghana
| | - Seidu A Mahmood
- Pathology Unit, Department of Medical Laboratory Science, School of Biomedical & Allied Health Sciences, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Benoit B N'guessan
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, University of Ghana, P.O Box LG 43, Legon, Accra, Ghana
| | - Isaac J Asiedu-Gyekye
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, University of Ghana, P.O Box LG 43, Legon, Accra, Ghana
| | - Alexander K Nyarko
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, University of Ghana, P.O Box LG 43, Legon, Accra, Ghana
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Shen T, Gu D, Zhu Y, Shi J, Xu D, Cao X. The VCS parameters: Potential hematological indicators for predicting antituberculosis drug-induced neutropenia. Clin Chim Acta 2016; 459:147-149. [PMID: 27262821 DOI: 10.1016/j.cca.2016.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/30/2016] [Accepted: 05/31/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The morphological changes in activated neutrophils associated with antituberculosis drugs can be measured by volume, conductivity, and scatter (VCS) technology on the Coulter LH750 hematology analyzer. We conducted the current study to further validate the clinical usefulness of the neutrophil VCS parameters in predicting drug-induced neutropenia. METHODS Peripheral blood samples were collected from 52 patients with drug-induced neutropenia, 309 patients without any abnormal CBC, and 237 healthy controls. The mean neutrophil volume (MNV) with its distribution width (NDW) and the mean neutrophil scatter (MNS) were studied. RESULTS We observed a significant increase in the MNV and NDW as well as a significant decrease in the MNS in neutropenia patients approximately one week prior to development of neutropenia compared to healthy controls as well as to case controls. In addition, the delta MNV and delta MNS were respectively correlated well with delta absolute neutrophil counts when neutropenia occurred. The ROC curve analyses showed that the MNV、NDW and MNS had larger areas under curves compared to conventional parameters. With a cutoff of 150.15 for the MNV, a sensitivity of 84.4% and specificity of 75.7% were achieved prior to neutropenia. CONCLUSION The neutrophil VCS parameters may be clinically useful as potential hematological indicators for predicting antituberculosis drug-induced neutropenia.
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Affiliation(s)
- Tian Shen
- Department of Laboratory, The Sixth People's Hospital of Nantong, Nantong, Jiangsu 226011, China
| | - Delin Gu
- Department of Laboratory, The Sixth People's Hospital of Nantong, Nantong, Jiangsu 226011, China
| | - Yihua Zhu
- Department of Laboratory, The Second Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, China
| | - Junwei Shi
- Department of Tuberculosis, The Sixth People's Hospital of Nantong, Nantong, Jiangsu 226011, China
| | | | - Xingjian Cao
- Department of Laboratory, The Second Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, China.
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Hashmi HRT, Jabbour R, Schreiber Z, Khaja M. Benazepril-Induced Agranulocytosis: A Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:425-8. [PMID: 27335175 PMCID: PMC4920103 DOI: 10.12659/ajcr.898028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patient: Male, 61 Final Diagnosis: Benazepril induced agranulocytosis Symptoms: Sepsis Medication: — Clinical Procedure: None Specialty: Critical Care Medicine
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Affiliation(s)
| | - Rami Jabbour
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Zwi Schreiber
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Misbahuddin Khaja
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
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42
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Andersen CL, Tesfa D, Siersma VD, Sandholdt H, Hasselbalch H, Bjerrum OW, Felding P, Lind B, Olivarius NDF, Palmblad J. Prevalence and clinical significance of neutropenia discovered in routine complete blood cell counts: a longitudinal study. J Intern Med 2016; 279:566-75. [PMID: 26791682 DOI: 10.1111/joim.12467] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neutropenia, defined as an absolute blood neutrophil count (ANC) <1.5 G L(-1) , may accompany a variety of diseases. However, the clinical significance of neutropenia detected in a routine complete blood cell count is poorly understood. METHODS Using a primary care resource, comprising more than 370 000 individuals, we assessed the association with a number of previously recognized conditions as well as all-cause mortality in the 4 years following the identification of neutropenia. By matching laboratory data with Danish nationwide health registers, risk estimates were assessed. RESULTS Neutropenia was observed in approximately 1% of all individuals and was associated dose dependently with viral infections, haematological malignancies (but not autoimmune disorders or solid cancers) and mortality. Neutropenia was particularly associated with HIV, acute leukaemias and myelodysplastic syndromes. Odds ratios [95% confidence interval (CI)] for viral infections were 2.32 (1.84-2.91), 2.80 (2.20-3.57) and 4.77 (3.22-7.07) for subnormal (≥1.5-1.8 G L(-1) ), mild (≥1.0-1.5 G L(-1) ) and moderate-severe (≥0.0-1.0 G L(-1) ) neutropenic individuals, respectively (all P < 0.001). Likewise, odds ratios (95% CI) for haematological malignancies were 3.23 (2.35-4.45), 8.69 (6.58-11.47) and 46.03 (33.98-62.35 ), for the same neutropenia levels, respectively (all P < 0.001). Thus, the lower the ANC, the greater the likelihood of these diseases. The relative risk estimates observed for severe neutropenia corresponded to absolute risks of haematological malignancies and mortality from any cause of 40% and >50%, respectively. CONCLUSIONS Neutropenia is an ominous sign necessitating careful follow-up. The risk estimates presented here support focusing attention to viral diseases and haematological malignancies when neutropenia is observed.
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Affiliation(s)
- C L Andersen
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Hematology, Roskilde University Hospital, Roskilde, Denmark
| | - D Tesfa
- Departments of Hematology and Medicine, The Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - V D Siersma
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - H Sandholdt
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - H Hasselbalch
- Department of Hematology, Roskilde University Hospital, Roskilde, Denmark
| | - O W Bjerrum
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - P Felding
- The Elective Laboratory of the Capital Region, Copenhagen, Denmark
| | - B Lind
- The Elective Laboratory of the Capital Region, Copenhagen, Denmark
| | - Niels de F Olivarius
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - J Palmblad
- Departments of Hematology and Medicine, The Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
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van der Weide K, Loovers H, Pondman K, Bogers J, van der Straaten T, Langemeijer E, Cohen D, Commandeur J, van der Weide J. Genetic risk factors for clozapine-induced neutropenia and agranulocytosis in a Dutch psychiatric population. THE PHARMACOGENOMICS JOURNAL 2016; 17:471-478. [PMID: 27168101 DOI: 10.1038/tpj.2016.32] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/03/2016] [Accepted: 04/15/2016] [Indexed: 12/21/2022]
Abstract
Prescription of clozapine is complicated by the occurrence of clozapine-induced reduction of neutrophils. The aim of this study was to identify genetic risk factors in a population of 310 Dutch patients treated with clozapine, including 38 patients developing neutropenia and 31 patients developing agranulocytosis. NQO2 1541AA (NRH quinone oxidoreductase 2; protects cells against oxidative metabolites) was present at a higher frequency in agranulocytosis patients compared with control (23% versus 7%, P=0.03), as was ABCB1 (ABC-transporter-B1; drug efflux transporter) 3435TT (32% versus 20%, P=0.05). In patients developing neutropenia, ABCB1 3435TT and homozygosity for GSTT1null (glutathione-S-transferase; conjugates reactive clozapine metabolites into glutathione) were more frequent compared with control (34% versus 20%, P=0.05 and 31% versus 14%, P=0.03), whereas GSTM1null was less frequent in these patients (31% versus 52%, P=0.03). To investigate whether combinations of the identified genetic risk factors have a higher predictive value, should be confirmed in a larger case-control study.
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Affiliation(s)
- K van der Weide
- Department of Clinical Chemistry, St Jansdal Hospital, Harderwijk, The Netherlands
| | - H Loovers
- Department of Clinical Chemistry, St Jansdal Hospital, Harderwijk, The Netherlands.,Psychiatric Hospital GGz Centraal, Dependance Meerkanten, Ermelo, The Netherlands
| | - K Pondman
- Department of Clinical Chemistry, St Jansdal Hospital, Harderwijk, The Netherlands
| | - J Bogers
- Mental Health Services Rivierduinen, Oegstgeest, The Netherlands
| | - T van der Straaten
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Langemeijer
- Division of Medicinal Chemistry, Leiden/Amsterdam Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - D Cohen
- Mental Health Services North-Holland North, Heerhugowaard, The Netherlands
| | - J Commandeur
- AIMMS-Division of Molecular Toxicology, Department of Chemistry and Pharmaceutical Sciences, VU Amsterdam, Amsterdam, The Netherlands
| | - J van der Weide
- Department of Clinical Chemistry, St Jansdal Hospital, Harderwijk, The Netherlands.,Psychiatric Hospital GGz Centraal, Dependance Meerkanten, Ermelo, The Netherlands
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Abstract
BACKGROUND Anti-neutrophil antibodies are a well-recognized cause of neutropenia, producing a potential increase in risk of infection: in the majority of patients antibodies react against antigens located on the IgG Fc receptor type 3b (FcRIIIb), but other target antigens have been identified. DATA SOURCES In this review the most important papers of auto and alloimmune neutropenias of infancy and childhood were analyzed. PubMed, Google Scholar and Thompson ISI Web of Knowledge were searched for identifying relevant papers. RESULTS Primary autoimmune neutropenia of infancy is mostly a benign condition with self-limited course, whereas isolated alloimmune neonatal neutropenia or secondary autoimmune neutropenia may be occasionally complicated by severe infections. CONCLUSION Granulocyte colony stimulating factor is an effective therapy for patients affected by all types of autoimmune and alloimmune neutropenia, even though most of them do not need any therapy.
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45
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Palmblad J, Nilsson CC, Höglund P, Papadaki HA. How we diagnose and treat neutropenia in adults. Expert Rev Hematol 2016; 9:479-87. [PMID: 26778239 DOI: 10.1586/17474086.2016.1142867] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Neutropenias (NPs), being acute and often transient, or chronic, range from life-threatening conditions with very low absolute neutrophil blood counts (ANC) to disorders characterized by only mild NP and of no obvious significance for health. Many are caused by genetic variations/mutations, e.g. the benign familial NP and the chronic severe NPs (e.g. Kostmann disease). Some of the latter are associated with various bodily malformations. Many of the mild-to-moderate NPs are signs of underlying disorders that need specialized treatments (e.g. HIV, hepatitis, autoimmune disorders, the large granular lymphocyte syndrome). We provide here means for the evaluation of a previously unknown NP, suggest a triage and treatments.
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Affiliation(s)
- Jan Palmblad
- a Departments of Medicine and Hematology , The Karolinska Institutet, Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Christer C Nilsson
- a Departments of Medicine and Hematology , The Karolinska Institutet, Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Petter Höglund
- b Center for Hematology and Regenerative Medicine (HERM), Departments of Hematology and Clinical Immunology and Transfusion Medicine , Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Helen A Papadaki
- c Department of Hematology , University of Crete Medical School , Heraklion , Greece
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46
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Thompson RA, Isin EM, Ogese MO, Mettetal JT, Williams DP. Reactive Metabolites: Current and Emerging Risk and Hazard Assessments. Chem Res Toxicol 2016; 29:505-33. [DOI: 10.1021/acs.chemrestox.5b00410] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Richard A. Thompson
- DMPK, Respiratory, Inflammation & Autoimmunity iMed, AstraZeneca R&D, 431 83 Mölndal, Sweden
| | - Emre M. Isin
- DMPK, Cardiovascular & Metabolic Diseases iMed, AstraZeneca R&D, 431 83 Mölndal, Sweden
| | - Monday O. Ogese
- Translational Safety, Drug Safety and Metabolism, AstraZeneca R&D, Darwin Building 310, Cambridge Science Park, Milton Rd, Cambridge CB4 0FZ, United Kingdom
| | - Jerome T. Mettetal
- Translational Safety, Drug Safety and Metabolism, AstraZeneca R&D, 35 Gatehouse Dr, Waltham, Massachusetts 02451, United States
| | - Dominic P. Williams
- Translational Safety, Drug Safety and Metabolism, AstraZeneca R&D, Darwin Building 310, Cambridge Science Park, Milton Rd, Cambridge CB4 0FZ, United Kingdom
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Bartels M, Murphy K, Rieter E, Bruin M. Understanding chronic neutropenia: life is short. Br J Haematol 2015; 172:157-69. [PMID: 26456767 DOI: 10.1111/bjh.13798] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The pathophysiological mechanisms underlying chronic neutropenia are extensive, varying from haematopoietic stem cell disorders resulting in defective neutrophil production, to accelerated apoptosis of neutrophil progenitors or circulating mature neutrophils. While the knowledge concerning genetic defects associated with congenital neutropenia or bone marrow failure is increasing rapidly, the functional role and consequences of these genetic alterations is often not well understood. In addition, there is a large group of diseases, including primary immunodeficiencies and metabolic diseases, in which chronic neutropenia is one of the symptoms, while there is no clear bone marrow pathology or haematopoietic stem cell dysfunction. Altogether, these disease entities illustrate the complexity of normal neutrophil development, the functional role of the (bone marrow) microenvironment and the increased propensity to undergo apoptosis, which is typical for neutrophils. The large variety of disorders associated with chronic neutropenia makes classification almost impossible and possibly not desirable, based on the clinical phenotypes. However, a better understanding of the regulation of normal myeloid differentiation and neutrophil development is of great importance in the diagnostic evaluation of unexplained chronic neutropenia. In this review we propose insights in the pathophysiology of chronic neutropenia in the context of the functional role of key players during normal neutrophil development, neutrophil release and neutrophil survival.
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Affiliation(s)
- Marije Bartels
- Department of Paediatric Haematology and Stem Cell Transplantation, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Kate Murphy
- Department of Paediatric Haematology and Stem Cell Transplantation, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ester Rieter
- Department of Paediatric Haematology and Stem Cell Transplantation, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Marrie Bruin
- Department of Paediatric Haematology and Stem Cell Transplantation, University Medical Centre Utrecht, Utrecht, the Netherlands
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A granulocytosis associated with rufinamide: A case report. Brain Dev 2015; 37:825-8. [PMID: 25619447 DOI: 10.1016/j.braindev.2014.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/29/2014] [Accepted: 12/30/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND Rufinamide, a triazole derivative, is a novel antiepileptic drug (AED) chemically unrelated to other current AEDs. Previous studies on pediatric epilepsy treatment with rufinamide have demonstrated a frequency of leukopenia as an adverse event of 0.5%, and there has been no report of the development of agranulocytosis. Here, we report a patient with Lennox-Gastaut syndrome (LGS) who developed agranulocytosis associated with fever and skin rash with rufinamide. To the best of our knowledge, this is the first reported case of agranulocytosis induced by rufinamide. PATIENT A 10-year-old boy with a history of herpes encephalitis at the age of 1 year developed LGS, and was administered rufinamide as add-on therapy to valproate, lamotrigine, and clonazepam because of difficulties in controlling tonic seizures. Eighteen days after initiation of rufinamide, agranulocytosis developed associated with high fever and skin rash, all of which resolved after withdrawal of rufinamide. Bone marrow aspiration demonstrated normocellular marrow with selective decrease of mature myeloid series, and suggested that agranulocytosis was not related to malignancy or serious infection. CONCLUSION This case suggests that rufinamide may induce the potentially serious adverse effect of agranulocytosis. Patients should be monitored for clinical signs of agranulocytosis and consideration should be given to routine blood count determination for early detection of this.
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Metamizole (dipyrone)-associated agranulocytosis. An analysis of German spontaneous reports 1990-2012. Eur J Clin Pharmacol 2015; 71:1129-38. [PMID: 26169297 DOI: 10.1007/s00228-015-1895-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/24/2015] [Indexed: 12/16/2022]
Abstract
PURPOSE In 1986, the risk of agranulocytosis prompted German authorities to restrict the indications for metamizole use. After an initial decline, prescriptions increased from <20 million defined daily doses in 1990 to >140 million in 2012. Concurrently, spontaneous reports of agranulocytosis increased from about 10 in 1990 to >50 in 2012. In this study, reports were analyzed to identify targets for risk minimization measures. METHODS Reports of suspected metamizole-induced agranulocytosis (neutrophils < 0.5 × 10(9) cells/l) between 1990 and 2012 were identified in the German spontaneous reporting database. Cases for which original reporting documents were available were eligible for analysis. Patient characteristics, indication, clinical course, and outcome were assessed. RESULTS One hundred sixty-one reports were analyzed. The mean age of the patients was 56.8 years (11-93) and 64.6 % were female. Off-label use was identified in about 25 % of cases. Neutrophils fell below 100/μl in 63 and intercurrent infections developed in 109 cases. Thirty-eight patients (23.6 %) died. In two thirds of the cases, agranulocytosis occurred within 6 weeks of permanent or intermittent metamizole treatment, in 30.5 % within 7 days, including 18 cases of immediate onset after the first or second administration. CONCLUSION The reported cases show severe clinical courses and are, to some extent, a result of off-label use. Due to the absence of individual risk factors and presence of variable onset patterns, risk minimization measures should focus on restricting use to defined clinical situations and providing concise risk information for patients and healthcare professionals.
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Medrano-Casique N, Tong HY, Borobia AM, Carcas AJ, Frías J, Ramírez E. Non-Chemotherapy-Induced Agranulocytosis Detected by a Prospective Pharmacovigilance Program in a Tertiary Hospital. Basic Clin Pharmacol Toxicol 2015; 117:399-408. [DOI: 10.1111/bcpt.12418] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 05/11/2015] [Indexed: 01/30/2023]
Affiliation(s)
- Nicolás Medrano-Casique
- Department of Clinical Pharmacology; La Paz University Hospital; IdiPAZ; School of Medicine; Autonomous University of Madrid; Madrid Spain
| | - Hoi Y. Tong
- Department of Clinical Pharmacology; La Paz University Hospital; IdiPAZ; School of Medicine; Autonomous University of Madrid; Madrid Spain
| | - Alberto M. Borobia
- Department of Clinical Pharmacology; La Paz University Hospital; IdiPAZ; School of Medicine; Autonomous University of Madrid; Madrid Spain
| | - Antonio J. Carcas
- Department of Clinical Pharmacology; La Paz University Hospital; IdiPAZ; School of Medicine; Autonomous University of Madrid; Madrid Spain
| | - Jesús Frías
- Department of Clinical Pharmacology; La Paz University Hospital; IdiPAZ; School of Medicine; Autonomous University of Madrid; Madrid Spain
| | - Elena Ramírez
- Department of Clinical Pharmacology; La Paz University Hospital; IdiPAZ; School of Medicine; Autonomous University of Madrid; Madrid Spain
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