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Ng HS, Zhu F, Zhao Y, Yao S, Lu X, Ekuma O, Evans C, Fisk JD, Marrie RA, Tremlett H. Adverse Events Associated With Disease-Modifying Drugs for Multiple Sclerosis: A Multiregional Population-Based Study. Neurology 2024; 102:e208006. [PMID: 38181306 PMCID: PMC11097763 DOI: 10.1212/wnl.0000000000208006] [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: 03/01/2023] [Accepted: 09/27/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES It is not possible to fully establish the safety of a disease-modifying drug (DMD) for multiple sclerosis (MS) from randomized controlled trials as only very common adverse events occurring over the short-term can be captured, and the quality of reporting has been variable. We examined the relationship between the DMDs for MS and potential adverse events in a multiregion population-based study. METHODS We identified people with MS using linked administrative health data from 4 Canadian provinces. MS cases were followed from the most recent of first MS or related demyelinating disease event on January 1, 1996, until the earliest of emigration, death, or December 31, 2017. DMD exposure primarily comprised β-interferon, glatiramer acetate, natalizumab, fingolimod, dimethyl fumarate, teriflunomide, and alemtuzumab. We examined associations between DMD exposure and infection-related hospitalizations and physician visits using recurrent events proportional means models and between DMD exposure and 15 broad categories of incident adverse events using stratified multivariate Cox proportional hazard models. RESULTS We identified 35,894 people with MS. While virtually all DMDs were associated with a 42%-61% lower risk of infection-related hospitalizations, there was a modest increase in infection-related physician visits by 10%-33% for select DMDs. For incident adverse events, most elevated risks involved a second-generation DMD, with alemtuzumab's hazard of thyroid disorders being 19.42 (95% CI 9.29-36.51), hypertension 4.96 (95% CI 1.78-13.84), and cardiovascular disease 3.72 (95% CI 2.12-6.53). Natalizumab's highest risk was for cardiovascular disease (adjusted hazard ratio [aHR] 1.61; 95% CI 1.24-2.10). For the oral DMDs, fingolimod was associated with higher hazards of cerebrovascular (aHR 2.04; 95% CI 1.27-3.30) and ischemic heart diseases (aHR 1.64; 95% CI 1.10-2.44) and hypertension (aHR 1.73; 95% CI 1.30-2.31); teriflunomide with higher hazards of thyroid disorders (aHR 2.30; 95% CI 1.11-4.74), chronic liver disease (aHR 1.94; 95% CI 1.19-3.18), hypertension (aHR 1.76; 95% CI 1.32-2.37), and hyperlipidemia (aHR 1.61; 95% CI 1.07-2.44); and from complementary analyses (in 1 province), dimethyl fumarate with acute liver injury (aHR 6.55; 95% CI 1.96-21.87). DISCUSSION Our study provides an extensive safety profile of several different DMDs used to treat MS in the real-world setting. Our findings not only complement those observed in short-term clinical trials but also provide new insights that help inform the risk-benefit profile of the DMDs used to treat MS in clinical practice. The results of this study highlight the continued need for long-term, independent safety studies of the DMDs used to treat MS. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with MS, while DMD exposure reduces the risk of infection-related hospitalizations, there are increased risks of infection-related physician visits and incident adverse events for select DMDs.
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Affiliation(s)
- Huah Shin Ng
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Feng Zhu
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Yinshan Zhao
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Shenzhen Yao
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Xinya Lu
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Okechukwu Ekuma
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Charity Evans
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - John D Fisk
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ruth Ann Marrie
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Helen Tremlett
- From the Division of Neurology (H.S.N., F.Z., Y.Z., H.T.), Department of Medicine and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Flinders Health and Medical Research Institute (H.S.N.), College of Medicine and Public Health, Flinders University, Adelaide, Australia; SA Pharmacy (H.S.N.), Northern and Southern Adelaide Local Health Networks, Australia; College of Pharmacy and Nutrition (S.Y., C.E.), University of Saskatchewan; Saskatchewan Health Quality Council (S.Y., X.L.), Saskatoon; Department of Community Health Sciences (O.E.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Nova Scotia Health and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine (J.D.F.), Dalhousie University, Halifax; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
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Yang Y, Cai F, Zhou N, Liu S, Wang P, Zhang S, Zhang Y, Zhang A, Jia Z, Huang S. Dimethyl fumarate prevents ferroptosis to attenuate acute kidney injury by acting on NRF2. Clin Transl Med 2021; 11:e382. [PMID: 33931960 PMCID: PMC8087913 DOI: 10.1002/ctm2.382] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/11/2021] [Accepted: 03/24/2021] [Indexed: 12/29/2022] Open
Affiliation(s)
- Yunwen Yang
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.,Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Fangfang Cai
- The State Key Laboratory of Pharmaceutical Biotechnology, College of Life Sciences, Nanjing University, Nanjing, China
| | - Ning Zhou
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.,Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Suwen Liu
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.,Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Peipei Wang
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.,Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Shengnan Zhang
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.,Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Yue Zhang
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.,Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Aihua Zhang
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.,Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Zhanjun Jia
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.,Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Songming Huang
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.,Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
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