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Somisetty S, Santina A, Sarraf D, Mieler WF. The Impact of Systemic Medications on Retinal Function. Asia Pac J Ophthalmol (Phila) 2023; 12:115-157. [PMID: 36971705 DOI: 10.1097/apo.0000000000000605] [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: 12/05/2022] [Accepted: 02/02/2023] [Indexed: 03/29/2023] Open
Abstract
This study will provide a thorough review of systemic (and select intravitreal) medications, along with illicit drugs that are capable of causing various patterns of retinal toxicity. The diagnosis is established by taking a thorough medication and drug history, and then by pattern recognition of the clinical retinal changes and multimodal imaging features. Examples of all of these types of toxicity will be thoroughly reviewed, including agents that cause retinal pigment epithelial disruption (hydroxychloroquine, thioridazine, pentosan polysulfate sodium, dideoxyinosine), retinal vascular occlusion (quinine, oral contraceptives), cystoid macular edema/retinal edema (nicotinic acid, sulfa-containing medications, taxels, glitazones), crystalline deposition (tamoxifen, canthaxanthin, methoxyflurane), uveitis, miscellaneous, and subjective visual symptoms (digoxin, sildenafil). The impact of newer chemotherapeutics and immunotherapeutics (tyrosine kinase inhibitor, mitogen-activated protein kinase kinase, checkpoint, anaplastic lymphoma kinase, extracellular signal-regulated kinase inhibitors, and others), will also be thoroughly reviewed. The mechanism of action will be explored in detail when known. When applicable, preventive measures will be discussed, and treatment will be reviewed. Illicit drugs (cannabinoids, cocaine, heroin, methamphetamine, alkyl nitrite), will also be reviewed in terms of the potential impact on retinal function.
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Affiliation(s)
- Swathi Somisetty
- Jules Stein Eye Institute, University of California, Los Angeles, CA
| | - Ahmad Santina
- Jules Stein Eye Institute, University of California, Los Angeles, CA
| | - David Sarraf
- Jules Stein Eye Institute, University of California, Los Angeles, CA
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Cid-Bertomeu P, Huerva V. Use of interferon alpha 2b to manage conjunctival primary acquired melanosis and conjunctival melanoma. Surv Ophthalmol 2022; 67:1391-1404. [PMID: 35278438 DOI: 10.1016/j.survophthal.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/03/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
Primary acquired melanosis (PAM) is acquired conjunctival pigmentation that can give rise to conjunctival melanoma (CM), a malignant tumor of the bulbar and palpebral conjunctiva or the caruncle. Surgical excision is the treatment of choice for this neoplasm. Topical chemotherapy is also used for patients with PAM with atypia or CM, hand in patients with recurrent or extensive disease, this may be an important option. Of the several chemotherapeutic drugs used, topical interferon alpha 2b (IFN-α2b) has become popular because of its low toxicity. Clinical evidence from case reports and case series supports the efficacy of IFN-α2b as the preferred adjuvant treatment for PAM and CM. In addition, topical IFN-α2b has been successfully applied to melanocytic tumors refractory to other treatments, such as cryotherapy and topical mitomycin C. In patients with locally advanced CM, the combination of IFN-α2b and systemic immunotherapy may serve as an alternative to exenteration. Given the low frequency of CM, long-term multicenter studies are needed to demonstrate the efficacy of IFN-α2b for preventing local recurrence and distant metastasis.
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Affiliation(s)
- Pau Cid-Bertomeu
- Department of Ophthalmology, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Valentín Huerva
- Department of Ophthalmology, University Hospital Arnau de Vilanova, Lleida, Spain.; School of Medicine, University of Lleida, Lleida, Spain.; Biomedical Research Institute of Lleida, University of Lleida, Lleida, Spain..
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Lan S, Cui Z, Yin Q, Liu Z, Liang L, He H, Liu H, Guo Z, Yu Y, Wu D. Prospective study of clinical characteristics of melanoma patients with retinopathy caused by a high-dose interferon α-2b. Melanoma Res 2021; 31:550-554. [PMID: 34524220 PMCID: PMC8568323 DOI: 10.1097/cmr.0000000000000769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 07/08/2021] [Indexed: 11/25/2022]
Abstract
Retinopathy is a rare side effect of interferon α-2b treatment. The goal of this study was to prospectively investigate the clinical characteristics of Chinese patients with melanomas who developed retinopathy following high doses of interferon α-2b (HD-IFN) therapy. The study included 56 melanoma stage I-III patients that were treated with HD-IFN. Fourty-three patients developed HD-IFN-induced retinopathies. Forty-three melanoma patients (76%) developed retinopathy after being treated with HD-IFN. Among these patients, 49% had cotton-wool spots, 19% had retinal hemorrhage, and 30% had retinal hemorrhage. The median time of occurrence of retinopathy was 4 weeks after treatment, and the median time of duration was 4 weeks. No patient showed other symptoms except one who had blurred vision. A comparison of clinical characteristics (age, gender, primary site, stage, and ulceration) and laboratory examinations (white blood cell and platelet counts, hemoglobin, serum lactate dehydrogenase, alanine transaminase, aspartate aminotransferase, triiodothyronine, thyroxine, thyroid-stimulating hormone, and lipid) between the HD-IFN-induced retinopathy patients and nonretinopathy patients did not show any significant differences (P > 0.05). Although all patients that developed retinopathy had diabetes or hypertension, an equal percentage of patients were without retinopathy had diabetes or hypertension. HD-IFN therapy in patients with melanomas may induce mild retinopathy. Our results; however, do not necessarily suggest to discontinue the HD-IFN treatment because retinopathy is a reversible disorder.
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Sargazi S, Sheervalilou R, Rokni M, Shirvaliloo M, Shahraki O, Rezaei N. The role of autophagy in controlling SARS-CoV-2 infection: An overview on virophagy-mediated molecular drug targets. Cell Biol Int 2021; 45:1599-1612. [PMID: 33818861 PMCID: PMC8251464 DOI: 10.1002/cbin.11609] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/22/2021] [Accepted: 04/01/2021] [Indexed: 12/16/2022]
Abstract
Autophagy-dependent cell death is a prominent mechanism that majorly contributes to homeostasis by maintaining the turnover of organelles under stressful conditions. Several viruses, including coronaviruses (CoVs), take advantage of cellular autophagy to facilitate their own replication. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a beta-coronavirus (β-CoVs) that mediates its replication through a dependent or independent ATG5 pathway using specific double-membrane vesicles that can be considered as similar to autophagosomes. With due attention to several mutations in NSP6, a nonstructural protein with a positive regulatory effect on autophagosome formation, a potential correlation between SARS-CoV-2 pathogenesis mechanisms and autophagy can be expected. Certain medications, albeit limited in number, have been indicated to negatively regulate autophagy flux, potentially in a way similar to the inhibitory effect of β-CoVs on the process of autophagy. However, there is no conclusive evidence to support their direct antagonizing effect on CoVs. Off-target accumulation of a major fraction of FDA-approved autophagy modulating drugs may result in adverse effects. Therefore, medications that have modulatory effects on autophagy could be considered as potential lead compounds for the development of new treatments against this virus. This review discusses the role of autophagy/virophagy in controlling SARS-CoV-2, focusing on the potential therapeutic implications.
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Affiliation(s)
- Saman Sargazi
- Cellular and Molecular Research Center, Resistant Tuberculosis InstituteZahedan University of Medical SciencesZahedanIran
| | | | - Mohsen Rokni
- Department of Immunology, School of MedicineTehran University of Medical SciencesTehranIran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA)Universal Scientific Education and Research Network (USERN)TehranIran
| | - Milad Shirvaliloo
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
- Faculty of MedicineTabriz University of Medical SciencesTabrizIran
| | - Omolbanin Shahraki
- Pharmacology Research CenterZahedan University of Medical SciencesZahedanIran
| | - Nima Rezaei
- Department of Immunology, School of MedicineTehran University of Medical SciencesTehranIran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA)Universal Scientific Education and Research Network (USERN)TehranIran
- Research Center for Immunodeficiencies, Children's Medical CenterTehran University of Medical SciencesTehranIran
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5
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Retinal toxicities of systemic anticancer drugs. Surv Ophthalmol 2021; 67:97-148. [PMID: 34048859 DOI: 10.1016/j.survophthal.2021.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 01/07/2023]
Abstract
Newer anticancer drugs have revolutionized cancer treatment in the last decade, but conventional chemotherapy still occupies a central position in many cancers, with combination therapy and newer methods of delivery increasing their efficacy while minimizing toxicities. We discuss the retinal toxicities of anticancer drugs with an emphasis on the mechanism of toxicity. Uveitis is seen with the use of v-raf murine sarcoma viral oncogene homolog B editing anticancer inhibitors as well as immunotherapy. Most of the cases are mild with only anterior uveitis, but severe cases of posterior uveitis, panuveitis, and Vogt-Koyanagi-Harada-like disease may also occur. In the retina, a transient neurosensory detachment is observed in almost all patients on mitogen-activated protein kinase kinase (MEK) inhibitors. Microvasculopathy is often seen with interferon α, but vascular occlusion is a more serious toxicity caused by interferon α and MEK inhibitors. Crystalline retinopathy with or without macular edema may occur with tamoxifen; however, even asymptomatic patients may develop cavitatory spaces seen on optical coherence tomography. A unique macular edema with angiographic silence is characteristic of taxanes. Delayed dark adaptation has been observed with fenretinide. Interestingly, this drug is finding potential application in Stargardt disease and age-related macular degeneration.
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Shojaei S, Suresh M, Klionsky DJ, Labouta HI, Ghavami S. Autophagy and SARS-CoV-2 infection: Apossible smart targeting of the autophagy pathway. Virulence 2020; 11:805-810. [PMID: 32567972 PMCID: PMC7549903 DOI: 10.1080/21505594.2020.1780088] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/05/2020] [Indexed: 01/04/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak resulted in 5,993,317 confirmed cases worldwide with 365,394 confirmed deaths (as of May 29th, 2020, WHO). The molecular mechanism of virus infection and spread in the body is not yet disclosed, but studies on other betacoronaviruses show that, upon cell infection, these viruses inhibit macroautophagy/autophagy flux and cause the accumulation of autophagosomes. No drug has yet been approved for the treatment of SARS-CoV-2 infection; however, preclinical investigations suggested repurposing of several FDA-approved drugs for clinical trials. Half of these drugs are modulators of the autophagy pathway. Unexpectedly, instead of acting by directly antagonizing the effects of viruses, these drugs appear to function by suppressing autophagy flux. Based on the established cross-talk between autophagy and apoptosis, we speculate that over-accumulation of autophagosomes activates an apoptotic pathway that results in apoptotic death of the infected cells and disrupts the virus replication cycle. However, administration of the suggested drugs are associated with severe adverse effects due to their off-target accumulation. Nanoparticle targeting of autophagy at the sites of interest could be a powerful tool to efficiently overcome SARS-CoV-2 infection while avoiding the common adverse effects of these drugs.
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Affiliation(s)
- Shahla Shojaei
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Madhumita Suresh
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Daniel J. Klionsky
- Life Sciences Institute and Department of Molecular, Cellular and Developmental Biology, University of Michigan, Ann Arbor, Michigan, USA
| | - Hagar Ibrahim Labouta
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Saeid Ghavami
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
- Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Autophagy Research Centre, Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
- Faculty of Medicine, Katowice School of Technology, Katowice, Poland
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Lewczuk N, Zdebik A, Bogusławska J. Interferon Alpha 2a and 2b in Ophthalmology: A Review. J Interferon Cytokine Res 2019; 39:259-272. [PMID: 30950678 DOI: 10.1089/jir.2018.0125] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Interferon alpha (IFN-α) is a glycoprotein with antitumor, antiviral, and immunomodulatory activity, used widely in the treatment of viral infections (hepatitis B and C, condylomata acuminata, herpes zoster, etc.), hematological disorders (leukemia, multiple myeloma, T cell lymphoma, and essential thrombocythemia), and solid tumors (clear cell carcinoma in the metastatic stage, melanoma, hepatocellular carcinoma, and cervical neoplasia). Studies have proven the effectiveness of IFN-α in the treatment of ophthalmic disorders involving the anterior segment of the eye (conjunctival papilloma, squamous neoplasia, conjunctival mucosa-associated lymphoid tissue, Mooren's ulcer, and vernal keratoconjunctivitis) and the posterior segment of the eye (serpiginous choroidopathy, posterior uveitis, pseudophakic and diabetic cystoid macular edema, and proliferative diabetic retinopathy). The therapy with IFN-α remains a promising alternative in cases of a failing response to conventional therapy, helping to maintain or improve visual acuity, prevent vision loss, and ameliorate the prognosis of the patient. However, clinicians who decide to use IFN-α in their patients must be aware of general and ophthalmological side effects and inform their patients to undergo a systemic evaluation such as a physical examination, blood and serological tests, and a chest X-ray before the beginning of treatment. This review presents the current knowledge of the use of IFN-α, its efficacy, and properties in ophthalmological diseases, and thus may encourage clinicians to administer this drug as a treatment modality in ophthalmological diseases in the future.
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Affiliation(s)
- Natalia Lewczuk
- 1 Department and Clinic of Ophthalmology, University of Wrocław Medical College, Wrocław, Poland
| | - Alexander Zdebik
- 2 Department and Clinic of Dermatology and Allergology, Asklepios Nordseeklinik GmbH, Sylt, Germany
| | - Joanna Bogusławska
- 1 Department and Clinic of Ophthalmology, University of Wrocław Medical College, Wrocław, Poland
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Nicolò M, Artioli S, La mattina G, Ghiglione D, Calabria G. Branch Retinal Artery Occlusion Combined with Branch Retinal Vein Occlusion in a patient with Hepatitis C Treated with Interferon and Ribavirin. Eur J Ophthalmol 2018. [DOI: 10.1177/112067210501500626] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M. Nicolò
- Department of Neuroscience, Ophthalmology and Genetic, University Eye Clinic of Genova, La Spezia
| | - S. Artioli
- Operative Unit of Infective Disease, Felettino Hospital, La Spezia
| | | | - D. Ghiglione
- Department of Neuroscience, Ophthalmology and Genetic, University Eye Clinic of Genova, La Spezia
| | - G. Calabria
- Department of Neuroscience, Ophthalmology and Genetic, University Eye Clinic of Genova, La Spezia
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Mathur G, Singh DV, Singal A. Unusual course of interferon-related retinopathy in chronic hepatitis C. Oman J Ophthalmol 2016; 9:189-190. [PMID: 27843241 PMCID: PMC5084509 DOI: 10.4103/0974-620x.192308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Interferon Alfa retinopathy usually presents as cotton wool spots, superficial hemorrhages and macular edema. We describe a rare case of severe retinopathy involving hard exudates at macula that lead to permanent visual loss in one eye. Elderly male presented with diminution of vision in right eye of 8 month duration. He was a diagnosed case of compensated chronic hepatitis C and had received interferon Alfa therapy before. Fundus examination of both eye showed multiple hard exudates at macula with a plaque involving the foveal center in right eye. OCT and FFA confirmed the findings seen clinically. Patient was advised regular follow up and on 3 months follow up his clinical picture was same. Ours is the first case report where patient had significant visual loss secondary to hard exudate plaque at center of fovea and ischemic fovea in right eye. Presence of hard exudates at any stage of therapy of hepatitis C could be an indicator of the severity of retinopathy with possible indication for stopping the drug.
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Affiliation(s)
- Gaurav Mathur
- Department of Vitreoretina, Eye Q Hospital, New Delhi, India
| | | | - Ayush Singal
- Department of Vitreoretina, Eye Q Hospital, Hisar, Haryana, India
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Su KP. Nutrition, psychoneuroimmunology and depression: the therapeutic implications of omega-3 fatty acids in interferon-α-induced depression. Biomedicine (Taipei) 2015; 5:21. [PMID: 26615538 PMCID: PMC4662939 DOI: 10.7603/s40681-015-0021-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 09/30/2015] [Indexed: 12/16/2022] Open
Abstract
The unmet need of current pharmacotherapy and the high occurrence of somatic symptoms and physical illness in depression imply that the ‘monoamine hypothesis’ is insufficient in approaching the aetiology of depression. Clinically, depressed patients manifest higher levels of inflammatory biomarkers, while proinflammatory cytokines induce neuropsychiatric symptoms (sickness behaviour) as well as major depressive episodes. Indeed, accumulating evidence suggests that inflammation dysregulation plays an important role in the pathophysiology of depression. Biological mechanisms that link inflammation to neuropsychiatric symptoms are vital in the understanding of the “mind-body” interface. IFN-α-induced depression is the most powerful support for the inflammation theory of depression. This clinical observation provides an excellent model for depression research. By comparing subjects with and without major depression induced by the cytokine treatment, statistical powers could be largely increased by reducing phenotypic variation (homogeneity in aetiological factors). In addition, the anti-inflammatory pathway has recently become an important topic in looking for new antidepressant therapies. For example, anti-inflammatory compounds, omega-3 polyunsaturated fatty acids (omega-3 PUFAs or n-3 PUFAs), have been found to be associated with the development and treatment for depression in human and animal models. Here I review recent epidemiological studies, cross-sectional and longitudinal case-controlled studies, interventional clinical trials, as well as basic animal and cellular studies to prove the linkage among omega-3 PUFAs, inflammation, and depression.
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Affiliation(s)
- Kuan-Pin Su
- Graduate Institute of Neural and Cognitive Sciences, School of Medicine, China Medical University, Taichung, Taiwan. .,Department of Psychiatry and Mind-Body Research Center (MBI-Lab), China Medical University Hospital, 404, Taichung, Taiwan.
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Su KP, Matsuoka Y, Pae CU. Omega-3 Polyunsaturated Fatty Acids in Prevention of Mood and Anxiety Disorders. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2015; 13:129-37. [PMID: 26243838 PMCID: PMC4540034 DOI: 10.9758/cpn.2015.13.2.129] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/21/2015] [Accepted: 02/22/2015] [Indexed: 12/16/2022]
Abstract
Psychiatric disorders in general, and major depression and anxiety disorders in particular, account for a large burden of disability, morbidity and premature mortality worldwide. Omega-3 polyunsaturated fatty acids (PUFAs) have a range of neurobiological activities in modulation of neurotransmitters, anti-inflammation, anti-oxidation and neuroplasticity, which could contribute to psychotropic effects. Here we reviewed recent research on the benefits of omega-3 PUFA supplements in prevention against major depression, bipolar disorders, interferon-α-induced depression patients with chronic hepatitis C viral infection, and posttraumatic stress disorder. The biological mechanisms underlying omega-3 PUFAs'psychotropic effects are proposed and reviewed. Nutrition is a modifiable environmental factor that might be important in prevention medicine, which have been applied for many years in the secondary prevention of heart disease with omega-3 PUFAs. This review extends the notion that nutrition in psychiatry is a modifiable environmental factor and calls for more researches on prospective clinical studies to justify the preventive application of omega-3 PUFAs in daily practice.
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Affiliation(s)
- Kuan-Pin Su
- Department of Psychiatry and Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Neural and Cognitive Sciences, China Medical University, Taichung, Taiwan
| | - Yutaka Matsuoka
- Department of Clinical Epidemiology, Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Chi-Un Pae
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Hauser P, Kern S. Psychiatric and substance use disorders co-morbidities and hepatitis C: Diagnostic and treatment implications. World J Hepatol 2015; 7:1921-1935. [PMID: 26244067 PMCID: PMC4517152 DOI: 10.4254/wjh.v7.i15.1921] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 04/01/2015] [Accepted: 07/02/2015] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis C virus (HCV) viral infection is the most common blood-borne viral infection and approximately 2%-3% of the world’s population or 170-200 million people are infected. In the United States as many as 3-5 million people may have HCV. Psychiatric and substance use disorders (SUDs) are common co-morbid conditions found in people with HCV and are factors in predisposing people to HCV infection. Also, these co-morbidities are reasons that clinicians exclude people from antiviral therapy in spite of evidence that people with HCV and co-morbid psychiatric and SUD can be safely and effectively treated. Furthermore, the neuropsychiatric side effects of interferon (IFN), until recently the mainstay of antiviral therapy, have necessitated an appreciation and assessment of psychiatric co-morbidities present in people with HCV. The availability of new medications and IFN-free antiviral therapy medication combinations will shorten the duration of treatment and exposure to IFN and thus decrease the risk of neuropsychiatric side effects. This will have the consequence of dramatically altering the clinical landscape of HCV care and will increase the number of eligible treatment candidates as treatment of people with HCV and co-morbid psychiatric and SUDs will become increasingly viable. While economically developed countries will rely on expensive IFN-free antiviral therapy, less developed countries will likely continue to use IFN-based therapies at least until such time as IFN-free antiviral medications become generic. The current manuscript discusses the efficacy and viability of treating HCV in people with psychiatric and SUDs comorbidities, the treatment of the neuropsychiatric side effects of IFN -based therapies and the impact of new medications and new treatment options for HCV that offer the promise of increasing the availability of antiviral therapy in this vulnerable population.
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Retinal toxicities of cancer therapy drugs: biologics, small molecule inhibitors, and chemotherapies. Retina 2014; 34:1261-80. [PMID: 24949716 DOI: 10.1097/iae.0000000000000242] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To review reported retinal side effects from current cancer therapy drugs. METHODS Retinal toxicities from ophthalmologic or oncologic case reports, case series, and clinical trials were identified by a systematic literature search using Lexicomp and PubMed. RESULTS Four biologics, 8 small molecule inhibitors, and 17 traditional chemotherapy agents had reported retinal side effects. For biologics, interferon alpha 2b was associated with retinopathy, denileukin diftitiox with pigmentary retinopathy, ipilimumab with a Vogt-Koyanagi-Harada-like syndrome, and trastuzumab with retinal ischemia. For small molecule inhibitors, v-raf murine sarcoma viral oncogene homolog B (BRAF) inhibitors were associated with uveitis, mitogen-activated protein kinase/extracellular signal-regulated kinase inhibitors with pigment epithelium detachments, and tyrosine kinase inhibitors with macular edema. Steroid antagonists were associated with crystalline retinopathy and macular edema. Nitrosoureas, platinum analogs, and cytosine arabinoside were associated with retinal vascular occlusions. Antimicrotubular agents were associated with cystoid macular edema but without fluorescein leakage. Retinoic acid derivatives were associated with impaired night vision, and mitotane was associated with a pigmentary retinopathy and papilledema. CONCLUSION Certain agents used in the treatment of systemic cancer are associated with ocular complications. Awareness of these complications will allow early detections and maybe reversal of some of the ocular problems.
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Abstract
BACKGROUND Interferon-associated retinopathy is a rare complication of interferon treatment. It has been well described with the use of interferon-α. METHODS This study reports a retrospective case series of interferon-β-associated retinopathy in three patients that were being treated for multiple sclerosis. RESULTS All cases were characterized by cotton-wool spots or peripheral microaneurysms. One central retinal artery occlusion was observed associated with interferon-β treatment. Findings improved spontaneously in two of three cases; all three patients elected to continue interferon treatment. CONCLUSION Patients being treated with interferon-β should have periodic fundus examinations to determine if they have evidence of interferon-associated retinopathy.
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Su KP, Lai HC, Yang HT, Su WP, Peng CY, Chang JPC, Chang HC, Pariante CM. Omega-3 fatty acids in the prevention of interferon-alpha-induced depression: results from a randomized, controlled trial. Biol Psychiatry 2014; 76:559-66. [PMID: 24602409 DOI: 10.1016/j.biopsych.2014.01.008] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 01/06/2014] [Accepted: 01/11/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Interferon (IFN)-α therapy for chronic hepatitis C virus infection is frequently associated with depression. The routine prophylaxis with antidepressants might expose patients to adverse effects, hence, the need for alternative preventive interventions. Omega-3 polyunsaturated fatty acids are safe and effective essential nutritional compounds used for the treatment of depression, putatively through an anti-inflammatory action. In addition, lower erythrocyte levels of omega-3 polyunsaturated fatty acids have been associated with an increased risk of IFN-induced depression. METHODS We conducted a 2-week, double-blind, placebo-controlled trial comparing eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and placebo for the prevention of IFN-α-induced depression. A total of 162 patients consented to participate and were randomized to the study. All of the patients completed the 2-week trial; 152 participants were followed throughout the 24 weeks of IFN-α treatment and were included in the analysis. RESULTS Compared with placebo, the incident rates of IFN-α-induced depression were significantly lower in EPA-treated but not in DHA-treated patients (10% and 28%, respectively, versus 30% for placebo, p = .037). Both EPA and DHA significantly delayed the onset of IFN-induced depression (week of onset: 12.0 and 11.7, respectively, versus 5.3 for placebo, p = .002). EPA and DHA were both well tolerated in this population. EPA treatment increased both EPA and DHA erythrocyte levels, but DHA only increased DHA erythrocyte levels. CONCLUSIONS EPA is effective in the prevention of depression in hepatitis C virus patients received IFN-α therapy. Our study confirms the notion that anti-inflammatory strategies are effective antidepressants in the context of depression associated with inflammation.
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Affiliation(s)
- Kuan-Pin Su
- Department of Psychiatry & Mind-Body Interface Laboratory, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan; Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Hsueh-Chou Lai
- Department of Hepatogastroenterology, China Medical University Hospital, Taichung, Taiwan
| | - Hui-Ting Yang
- Department of Nutrition, China Medical University, Taichung, Taiwan
| | - Wen-Pang Su
- Department of Hepatogastroenterology, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Yuan Peng
- Department of Hepatogastroenterology, China Medical University Hospital, Taichung, Taiwan
| | - Jane Pei-Chen Chang
- Department of Psychiatry & Mind-Body Interface Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - Hui-Chih Chang
- Department of Psychiatry & Mind-Body Interface Laboratory, China Medical University Hospital, Taichung, Taiwan; School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Carmine M Pariante
- Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, United Kingdom.
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Zhou W, Jiang Z, Li X, Xu Y, Shao Z. Cytokines: shifting the balance between glioma cells and tumor microenvironment after irradiation. J Cancer Res Clin Oncol 2014; 141:575-89. [PMID: 25005789 DOI: 10.1007/s00432-014-1772-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 06/30/2014] [Indexed: 12/13/2022]
Abstract
Malignant gliomas invariably recur after irradiation, showing radioresistance. Meanwhile, cranial irradiation can bring some risk for developing cognitive dysfunction. There is increasing evidence that cytokines play their peculiar roles in these processes. On the one hand, cytokines directly influence the progression of malignant glioma, promoting or suppressing tumor progression. On the other hand, cytokines indirectly contribute to the immunologic response against gliomas, exhibiting pro-inflammatory or immunosuppressive activities. We propose that cytokines are not simply unregulated products from tumor cells or immune cells, but mediators finely adjust the balance between glioma cells and tumor microenvironment after irradiation. The paper, therefore, focuses on the changes of cytokines after irradiation, analyzing how these mediate the response of tumor cells and normal cells to irradiation. In addition, cytokine-based immunotherapeutic strategies, accompanied with irradiation, for the treatment of gliomas are also discussed.
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Affiliation(s)
- Wei Zhou
- Department of Radiation Oncology, Cancer Centre, Qilu Hospital, Shandong University, 44 Wenhuaxi Road, Jinan, 250012, Shandong, China
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Monzon JG, Hammad N, Stevens SD, Dancey J. Retinopathy associated with adjuvant high-dose interferon-α2b in a patient with resected melanoma: a case report and review of the literature. Oncologist 2012; 17:384-7. [PMID: 22334452 DOI: 10.1634/theoncologist.2011-0324] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Interferon is the only accepted adjuvant treatment for patients with melanoma; hence, oncologists should be aware of the possibility of retinal abnormalities resulting from its use. Interferon-associated retinopathy in patients being treated for resected melanoma is a rare phenomenon with a proposed immunological basis. Patients are usually asymptomatic or have mild visual impairments, with cotton wool infarcts and hemorrhages. These symptoms and signs usually resolve with the discontinuation of interferon, but in a few severe presentations the visual impairments and retinal changes can be irreversible.
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Affiliation(s)
- Jose G Monzon
- NCIC Clinical Trials Group, Cancer Research Institute, Queen's University, 10 Stuart Street, Kingston, Ontario K7L 3N6, Canada.
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Van Wie AM. Hepatitis C and interferon-associated retinopathy: A case report. ACTA ACUST UNITED AC 2011; 82:739-43. [DOI: 10.1016/j.optm.2010.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 09/29/2010] [Accepted: 11/16/2010] [Indexed: 10/15/2022]
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Safety and effectiveness of interferon alpha-2a in treatment of patients with Behçet's uveitis refractory to conventional treatments. Ophthalmology 2010; 117:1430-5. [PMID: 20417563 DOI: 10.1016/j.ophtha.2009.11.022] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Revised: 11/10/2009] [Accepted: 11/12/2009] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To evaluate the intermediate-term safety and effectiveness of interferon alpha-2a (IFNalpha2a) in patients with Behçet's uveitis (BU) refractory to corticosteroids and immunosuppressive agents. DESIGN Open, nonrandomized, uncontrolled, interventional, prospective study. PARTICIPANTS Fifty-three patients (106 eyes) with active, vision-threatening BU who failed to respond to conventional treatments. INTERVENTION In 53 patients, acute inflammation was suppressed with effective prednisolone dosage (1-2 mg/kg/day, tapered to 10 mg within 4-6 weeks). The patients were treated with IFNalpha2a 4.5 million international units (MIU) 3 times per week for the first 3 months followed by IFNalpha2a 3 MIU 3 times per week for the next 3 months. Observation or other treatment methods were performed according to the decision tree developed for this study. MAIN OUTCOME MEASURES Remission and complete response (primary outcome measures), frequency of uveitis attacks, visual acuity (VA), and adverse effects (secondary outcome measures). RESULTS During 2 years of follow-up (median 65 months, range 12-130 months), compliance with the therapy was excellent. At the end of 1-year follow-up, treatment response was obtained in 45 of 53 patients (84.9%). The mean attack rate of 3.6+/-1.1 per year (range, 2-8) decreased to 0.56+/-0.75 (range, 0-4) per year (P=0.001). Visual acuity improved (> or = 0.2 logarithm of the minimum angle of resolution units from initial VA) in 30 eyes (28.3%) and worsened in 12 eyes (11.3%). Five patients (9.4%) did not respond to the initial treatment, and 3 patients (5.6%) developed severe adverse effects, including psoriasis, epileptic seizure, and extreme tiredness. Fifteen patients (28.3%) were off treatment for all the medications and disease free for 28+/-13.1 months (range, 12-50 months). CONCLUSIONS These results suggest that IFNalpha2a may be a valuable treatment option in BU that is refractory to corticosteroids and conventional immunosuppressive agents. The possible role of IFNalpha2a as a first-line agent in BU should be validated in randomized controlled clinical trials against newly described biologic agents. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Peponis V, Kyttaris VC, Chalkiadakis SE, Bonovas S, Sitaras NM. Ocular side effects of anti-rheumatic medications: what a rheumatologist should know. Lupus 2010; 19:675-82. [PMID: 20144965 DOI: 10.1177/0961203309360539] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nearly every drug may cause changes to ocular tissues through a variety of mechanisms. Medication overdoses, drug-drug interactions but also chronic administration of medications at the recommended doses may lead to ocular toxicity. The ocular side effects, screening for eye toxicity and treatment guidelines for anti-inflammatory and immunosuppressive drugs commonly used by rheumatologists are reviewed herein.
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Affiliation(s)
- V Peponis
- Athens Eye Hospital, Second Eye Clinic, Athens, Greece
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Rifai MA, Gleason OC, Sabouni D. Psychiatric care of the patient with hepatitis C: a review of the literature. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2010; 12:PCC.09r00877. [PMID: 21494349 PMCID: PMC3067984 DOI: 10.4088/pcc.09r00877whi] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Accepted: 05/07/2010] [Indexed: 02/06/2023]
Abstract
CONTEXT Approximately 1.8% of the US population is chronically infected with the hepatitis C virus (HCV). The prevalence rates of psychiatric illness in patients with HCV infection are higher than those rates in the general US population, and the prevalence of HCV infection in patients with severe mental illness may be as high as 9 times that of the general US population. Primary care physicians and psychiatrists are on the forefront of identifying patients with psychiatric illness who are at risk for HCV infection and can screen for HCV infection. This review summarizes the psychiatric implications of HCV infection and strategies for the management of interferon alfa-induced neuropsychiatric adverse effects. EVIDENCE ACQUISITION English-language studies were identified by computerized searches using the term hepatitis C psychiatric between 1972 and 2009, and further references were obtained from bibliographies of the reviewed articles. Relevant references were reviewed by the authors and included the basis of significance and applicability to practicing psychiatrists and internists. RESULTS Since primary care physicians and psychiatrists are sometimes the only medical link for patients with psychiatric illness, they are expected to provide posttest counseling for their patients with HCV and psychiatric illness. The task of conducting a psychiatric and psychosocial pretreatment risk-benefit assessment to determine whether or not to treat HCV infection is increasingly delegated to primary care providers as well as psychiatrists. The use of interferon alfa-based therapies to eradicate HCV has been associated with frequent neuropsychiatric adverse effects (eg, affective, anxiety, cognitive, and psychotic symptoms) that compromise the management of HCV patients with and without a preexisting history of psychiatric illness. Primary care physicians and psychiatrists are frequently asked to assist in the management of these neuropsychiatric adverse effects and evaluate the risks and benefits of using prophylactic psychotropics. CONCLUSIONS Despite the clinical challenge that interferon alfa treatment for patients with comorbid HCV and psychiatric illness presents, recent research indicates that interferon alfa can be safely administered to HCV-infected patients with psychiatric disorders provided there is a comprehensive pretreatment assessment, a risk-benefit analysis, and intensive ongoing medical and psychiatric follow-up.
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Affiliation(s)
- Muhamad Aly Rifai
- Department of Psychiatry, Lehigh Valley Health Network, Penn State College of Medicine, Bethlehem, Pennsylvania, USA.
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23
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Practical guidelines for the management of interferon-α-2b side effects in patients receiving adjuvant treatment for melanoma. Cancer 2008; 112:982-94. [DOI: 10.1002/cncr.23251] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Morasco BJ, Rifai MA, Loftis JM, Indest DW, Moles JK, Hauser P. A randomized trial of paroxetine to prevent interferon-alpha-induced depression in patients with hepatitis C. J Affect Disord 2007; 103:83-90. [PMID: 17292481 DOI: 10.1016/j.jad.2007.01.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Revised: 12/26/2006] [Accepted: 01/04/2007] [Indexed: 02/01/2023]
Abstract
BACKGROUND Interferon-alpha-(IFN-alpha) induced depression presents a challenge when treating patients with the hepatitis C virus (HCV). Depression occurs in approximately one-third of patients during antiviral therapy and can lead to reduction in treatment dosage or discontinuation of treatment, thus reducing the likelihood of clearing HCV infection. This study examined the efficacy of paroxetine in preventing the development of depression during antiviral therapy. METHODS In a double-blind, placebo-controlled study, 33 patients with HCV were randomly assigned to paroxetine or placebo prior to antiviral therapy. Patients were evaluated for psychiatric symptoms prior, during, and six months after antiviral therapy. RESULTS The rate of IFN-alpha-induced depression for the entire sample was 33.3%. The prophylactic use of paroxetine did not decrease the likelihood of IFN-alpha-induced depression (35.7% in the paroxetine group vs. 31.6% in the placebo group). However, in 10 of 11 patients who developed IFN-alpha-induced depression and entered the rescue arm of the study, open-label treatment with paroxetine helped reduce symptoms of depression. Group assignment did not appear to impact antiviral therapy completion rates, as a similar proportion of patients from each group completed treatment. LIMITATIONS The antiviral treatment was changed during the trial and aspects of the sample limit the generalizability of the results. CONCLUSION A prophylactic approach to interferon-alpha-induced depression may not be indicated in patients with HCV infection.
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Affiliation(s)
- Benjamin J Morasco
- Behavioral Health and Clinical Neurosciences Division, Portland VA Medical Center, Oregon, United States
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25
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Han C, O'Day J. Symptomatic interferon retinopathy successfully treated by hypertension management. Br J Ophthalmol 2007; 91:1250-1. [PMID: 17709590 PMCID: PMC1954887 DOI: 10.1136/bjo.2006.112532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Gleason OC, Fucci JC, Yates WR, Philipsen MA. Preventing relapse of major depression during interferon-alpha therapy for hepatitis C--A pilot study. Dig Dis Sci 2007; 52:2557-63. [PMID: 17436092 DOI: 10.1007/s10620-006-9729-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 12/03/2006] [Indexed: 12/09/2022]
Abstract
Depression is common in hepatitis C, exacerbated by interferon, and is a major reason for discontinuing interferon therapy. We aimed to determine (1) whether patients with a history of major depression could complete a course of peginterferon alpha-2a and ribavirin if pretreated with escitalopram and (2) the relapse rate of depression during the course of therapy in these subjects. Ten patients were enrolled in the study and treated with escitalopram. The Hamilton Depression Rating Scale (Ham-D) and other psychiatric scales were administered throughout the study. There were no statistically significant increases in mean Ham-D scores. No subjects were discontinued from the study due to depression relapse. Nine of 10 subjects maintained remission of depression throughout the study. We conclude that pretreatment with escitalopram in subjects with major depressive disorder in remission may prevent recurrence of major depression during a course of interferon and ribavirin therapy for hepatitis C.
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Affiliation(s)
- Ondria C Gleason
- Department of Psychiatry, The University of Oklahoma College of Medicine, Tulsa, 4502 East 41st Street, Tulsa, Oklahoma 74135, USA
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Lotrich FE, Rabinovitz M, Gironda P, Pollock BG. Depression following pegylated interferon-alpha: characteristics and vulnerability. J Psychosom Res 2007; 63:131-5. [PMID: 17662748 PMCID: PMC2104514 DOI: 10.1016/j.jpsychores.2007.05.013] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Interferon-alpha2 (IFN-alpha) injections may be capable of triggering depression in some individuals. The first objective was to further characterize this depression and, secondly, to examine whether pre-treatment temperament was correlated with subsequent vulnerability to IFN-alpha. METHODS Twenty-three initially euthymic adults undergoing year-long PEG-IFN-alpha treatment for hepatitis C were evaluated at baseline and then prospectively monitored using both the Structured Clinical Interview for DSM-IV (SCID) and self-report questionnaires. RESULTS A major depressive episode developed within 3 months in 39%. Principal component analysis of the change in self-report scores after 1 month of treatment demonstrated three orthogonal factors: (i) a specific increase in depression as manifested in the Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS), (ii) an increase in hostility and anxiety, (iii) and a generalized combination of worse symptoms including somatic symptoms on the Symptom Check List (SCL-90). BDI at 1 month was predicted by baseline BDI (r=0.76, P=.004). Hostility at 1 month was predicted by low baseline agreeableness (r=0.75, P=.01). Controlling for baseline BDI scores, categorical major depression was predicted by combined high baseline neuroticism and low agreeableness (combined r=0.66, P=.03). CONCLUSION These initial results (i) support the depressogenic nature of IFN-alpha treatment in a subset of vulnerable individuals, (ii) indicate that some individuals are also independently vulnerable to worsened hostility, and (iii) suggest that it may be possible to clinically predict these vulnerabilities in initially euthymic subjects.
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Affiliation(s)
- Francis E Lotrich
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Abstract
PURPOSE To describe a case of cotton wool spots associated with interferon beta-1a treatment. METHODS Observational case report. RESULTS A 40-year-old man with a history of multiple sclerosis was on interferon beta-1a. He presented with cotton wool spots on fundus exam, which resolved and then recurred all while on therapy. Interferon was discontinued after the second episode and again the cotton wool spots resolved. Upon restarting the interferon, no further cotton wool spots have recurred. CONCLUSION To our knowledge this represents only the third case of interferon beta-1a associated cotton wool patches and the first in the English-language ophthalmic literature. Unlike interferon alpha therapy, interferon beta 1-a retinopathy is presumed to be extremely rare and more common etiologies for cotton wool spots should be excluded in these patients. Given this limited number of cases versus the relatively frequent use of interferon beta-1a in the management of multiple sclerosis, no conclusions regarding causality or screening can be made but the issue probably deserves further study.
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Affiliation(s)
- Reid Longmuir
- University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
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Trefzer U, Kors C, Voit C, Sterry W. Unmasking of mixed connective tissue disease by adjuvant IFN alpha therapy for melanoma. Int J Dermatol 2006; 45:984-5. [PMID: 16911392 DOI: 10.1111/j.1365-4632.2006.02713.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Neurotoxicity related to cancer therapy is a common problem in oncology practice. Neurologic side effects can be dose-limiting, can inhibit treatment, and can substantially diminish quality of life. Symptoms may appear acutely after treatment, or remotely after therapy has been discontinued. Multiple therapies may share similar toxicities, and certain agents may potentiate symptoms. When faced with the development of neurologic complaints, familiarity with the most common complications is helpful in determining the etiology of these symptoms. This review will discuss the common complications of both established and novel agents used to treat cancer.
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Affiliation(s)
- Joohee K Sul
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Okuse C, Yotsuyanagi H, Nagase Y, Kobayashi Y, Yasuda K, Koike K, Iino S, Suzuki M, Itoh F. Risk factors for retinopathy associated with interferon α-2b and ribavirin combination therapy in patients with chronic hepatitis C. World J Gastroenterol 2006; 12:3756-9. [PMID: 16773695 PMCID: PMC4087471 DOI: 10.3748/wjg.v12.i23.3756] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To elucidate the frequency and risk factors for retinopathy in patients with chronic hepatitis C who are treated by interferon-ribavirin combination therapy.
METHODS: We prospectively analyzed 73 patients with histologically confirmed chronic hepatitis C, who underwent combination therapy for 24 wk. Optic fundi were examined before, and 2, 4, 12 and 24 wk after the start of combination therapy.
RESULTS: Fourteen patients (19%) developed retinopathy, which was initially diagnosed by the appearance of a cotton wool spot in 12 patients. Retinal hemorrhage was observed in 5 patients. No patient complained of visual disturbance. Retinopathy disappeared in 9 patients (64%) despite the continuation of combination therapy. However, retinopathy persisted in 5 patients with retinal hemorrhage. A comparison of the clinical background between the groups with and without retinopathy showed no significant differences in age, gender, viral genotype, RNA level, white blood cell count, platelet count, prothrombin time, complications by diabetes mellitus or hypertension, or pretreatment arteriosclerotic changes in the optic fundi. However, multiple logistic regression analysis revealed that complication by hypertension was observed with a high frequency in the group with retinopathy (P = 0.004, OR = 245.918, 95% CI = 5.6-10786.2).
CONCLUSION: Retinopathy associated with combination therapy of interferon α-2b and ribavirin tends to develop in patients with hypertension.
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Affiliation(s)
- Chiaki Okuse
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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Asnis GM, De La Garza R. Interferon-induced depression: strategies in treatment. Prog Neuropsychopharmacol Biol Psychiatry 2005; 29:808-18. [PMID: 15907352 DOI: 10.1016/j.pnpbp.2005.03.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2005] [Indexed: 12/17/2022]
Abstract
Interferon (IFN) is a pro-inflammatory cytokine that is widely used for the treatment of a number of disorders including viral infections, hematological proliferative disorders, and skin malignancies. Unfortunately, IFN frequently induced depression and has led to compromised tolerability with lowering of the dose of IFN and even discontinuation of treatment. Thus, it is imperative to diagnose IFN-induced depression early, evaluate whether this depression is associated with IFN-induced anemia or thyroid dysfunction, which can be corrected, and if necessary treat with antidepressants. IFN-induced depression is highly responsive to antidepressants with benefits occurring frequently at relatively low doses and after only a few weeks. Although SSRIs have mainly been studied, non-SSRIs appear to be effective also. Antidepressants have a number of risks and side effects that must be considered and may enter into the decision as to which antidepressant to choose. If IFN induces a depression in a patient with a bipolar disorder history, antidepressant treatment must include a mood stabilizer. In the case of vulnerable patients (e.g., those who have significant depressive symptoms prior to IFN or who have had an IFN-induced depression in the past) prophylactic antidepressant treatment appears to decrease the likelihood of having an IFN-induced depression. On the basis of known and effective treatment strategies, IFN-induced depression should not be an obstacle for continued treatment in most patient populations.
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Affiliation(s)
- Gregory M Asnis
- Albert Einstein College of Medicine, Montefiore Medical Center, Anxiety and Depression Program, 111 E. 210th Street, Bronx, NY, USA.
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Chisholm JA, Williams G, Spence E, Parks S, Keating D, Gavin M, Mills PR. Retinal toxicity during pegylated alpha-interferon therapy for chronic hepatitis C: a multifocal electroretinogram investigation. Aliment Pharmacol Ther 2005; 21:723-32. [PMID: 15771758 DOI: 10.1111/j.1365-2036.2005.02365.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Ocular side-effects in the form of retinal ischaemia and haemorrhages have been reported in patients undergoing standard alpha-interferon therapy. AIM To assess the ocular impact of therapy with sustained release pegylated alpha-2a interferon (Pegasys) for chronic hepatitis C. METHODS Ten patients receiving Pegasys and ribavirin and 10 healthy volunteers were recruited. Patients underwent full ophthalmic investigations and multifocal electroretinogram testing at baseline, at regular intervals during treatment and post-treatment. The multifocal electroretinogram maps retinal function. Responses were compared with sequential recordings from healthy volunteers. RESULTS All patients had normal clinical ophthalmic investigations at baseline. During therapy a single patient experienced central visual disturbance lasting 24 h with no prolonged ill effect. No other patient was aware of any change in vision. Fundal abnormalities appeared in five patients during treatment. The multifocal electroretinogram showed reductions in retinal function in five patients. Nine of 10 patients exhibited abnormalities on at least one multifocal electroretinogram or fundoscopic investigation. CONCLUSIONS Subclinical retinal toxicity during anti-viral therapy with pegylated alpha-interferon and ribavirin was frequent in this study and it suggests that patients should be warned of this risk and monitored during therapy.
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Affiliation(s)
- J A Chisholm
- Department of Clinical Physics and Bioengineering, Gartnavel General Hospital, Glasgow G12 0YN, UK.
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Gleason OC, Yates WR, Philipsen MA. Major depressive disorder in hepatitis C: an open-label trial of escitalopram. Prim Care Companion CNS Disord 2005; 7:225-30. [PMID: 16308578 PMCID: PMC1257407 DOI: 10.4088/pcc.v07n0503] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Accepted: 07/18/2005] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Depression is a common condition associated with hepatitis C and may be induced by interferon alfa, the primary treatment for hepatitis C. Depression is also a major barrier to the initiation of such treatment. This study examined the effect of escitalopram on measures of depression, quality of life, and tests of liver function in subjects with comorbid hepatitis C and depression. METHOD Subjects with DSM-IV major depressive disorder and hepatitis C were included in this open-label study. The recruitment period was from October 2002 through February 2004. Treatment status with regard to interferon therapy was neither an inclusion nor an exclusion criterion. Subjects received escitalopram for 8 weeks starting at 10 mg/day. Dosage adjustments up to 20 mg/day were made after week 4, as deemed clinically necessary. Scores on the 17-item Hamilton Rating Scale for Depression (HAM-D-17) and the Clinical Global Impressions-Severity of Illness scale (CGI-S) and results of liver function tests (AST, ALT, GGT) were obtained at baseline, 2 weeks, 4 weeks, and 8 weeks. Medical Outcomes Study Short Form Health Survey (SF-36) ratings and Hopkins Symptom Checklist-90-Revised (SCL-90-R) scores were obtained at baseline and week 8. RESULTS Eighteen subjects (12 female, 6 male) participated in this study. The mean daily dose of escitalopram at endpoint was 12.78 mg. Mean HAM-D-17 scores decreased significantly with treatment (t = 8.535, df = 17, p < .0001). Statistically significant improvement was also demonstrated on many subscales of the SF-36, the SCL-90-R, and the CGI-S. Tests of liver function showed no significant changes. CONCLUSION These results suggest that depression in patients with hepatitis C may be effectively and safely treated with escitalopram.
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Affiliation(s)
- Ondria C Gleason
- Department of Psychiatry, University of Oklahoma College of Medicine, Tulsa, OK, USA.
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Abstract
Ocular toxicity, including retinopathy, optic neuropathy and ocular loss, has been infrequently (<1%) reported as a potentially serious adverse event associated with standard interferon therapy. The new pegylated interferons have improved pharmacokinetics which translates to better antiviral efficacy, however, this improved pharmacokinetic profile also has the potential to alter the frequency and extent of their adverse events. We describe a case of chronic hepatitis C infection that developed visual complaints after one month of pegylated interferon, and retinopathy confirmed on ophthalmologic examination. We place our report in context with a review of the literature related to visual complications associated with interferon therapy. From our compilation of case reports, it is apparent that variable doses and duration of interferon therapy have been associated with ocular toxicity, which in turn suggests an idiosyncratic drug reaction. In as much as this adverse event is unpredictable, and its frequency undefined with pegylated interferon therapy, further surveillance will be required for patients undergoing pegylated-interferon therapy. Although ocular toxicity is uncommon, it should be emphasized that it can occur any time after the start of interferon therapy, and physicians now treating chronic hepatitis C patients with pegylated interferon must be aware of this potentially serious adverse event.
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Kötter I, Vonthein R, Zierhut M, Eckstein AK, Ness T, Günaydin I, Grimbacher B, Blaschke S, Peter HH, Stübiger N. Differential efficacy of human recombinant interferon-α2a on ocular and extraocular manifestations of behçet disease: results of an open 4-center trial. Semin Arthritis Rheum 2004; 33:311-9. [PMID: 15079762 DOI: 10.1016/j.semarthrit.2003.09.005] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Behçet disease (BD) is a multisystem vasculitis of unknown origin. Standard treatment mainly comprises systemic immunosuppressive agents. In a study primarily designed for refractory ocular disease, we additionally evaluated the efficacy of recombinant human interferon-alpha2a (rhIFN-alpha2a) on the extraocular manifestations of BD. METHODS Fifty patients were included in the study. RhIFN-alpha2a was applied at a dose of 6 x 10(6) units subcutaneously daily. Dose reduction was performed according to a decision tree until discontinuation. Disease activity was evaluated by the Behçet's Disease Activity Scoring System and the Uveitis Scoring System. RESULTS Response rate of the ocular manifestations was 92%. Visual acuity rose significantly from 0.56 to 0.84 at week 24 (P <.0001). Mean Behçet's Disease Activity Score fell in a dose-dependent fashion by 1.2 points in the first week (P <.0001) and from 5.8 to 3.3 at week 24 and further to 2.8 at week 52. After a mean observation period of 36.4 months, 17 patients have been off treatment and disease-free for 29.5 months (mean). In the other patients, maintenance IFN dosage is 3 million units 3 times weekly. Whereas extraocular manifestations such as genital ulcerations, arthritis, and skin lesions remitted with IFN, only 36% of oral aphthous ulcers responded. CONCLUSIONS RhIFN-alpha2a is effective in ocular BD, resulting in significant improvement of vision and complete remission of ocular vasculitis in the majority of patients. It is also beneficial for the extraocular manifestations of the disease, although less so for oral aphthous ulcers.
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Affiliation(s)
- Ina Kötter
- University Hospital, Department of Internal Medicine II, Tübingen, Germany.
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Crochet M, Ingster-Moati I, Even G, Dupuy P. Rétinopathie à l’interféron-α associé à la ribavirine : atteinte de l’électro-oculogramme. J Fr Ophtalmol 2004; 27:257-62. [PMID: 15039627 DOI: 10.1016/s0181-5512(04)96127-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM Ophthalmological complications with interferon alpha (INF-alpha) have been described since 1992: toxic retinopathy with cotton-wool spots, retinal hemorrhages, visual evoked potential (VEP) modifications and visual field abnormalities. MATERIAL AND METHOD In 2002, a 44-year-old woman was referred complaining of visual problems. In 1986, she had been diagnosed with chronic hepatitis C and underwent INF-alpha therapy for 6 months with no ophthalmological symptoms. In 2001, she began a second course of INF-alpha therapy along with ribavirin. After 5 months, in February 2002, she developed hypothyroidism induced by INF, received levothyroxine and her treatment for the hepatitis C was stopped. One month later, in March, she complained of visual difficulties in dim light. Clinical ophthalmological examination and Goldmann visual field testing, electroretinogram (ERG) and visual evoked potentials (VEP) were normal but the electro-oculogram (EOG) showed that the light-peak-to-dark-trough ratios were very low: 148% in the right eye, 156% in the left eye. The fluorescein angiography was normal. The patient was followed up 4 months later, in June 2002 (after 5 months without INF-alpha therapy), showing a slight improvement of the EOG and no visual symptoms. Two other follow-up examinations were done in September 2002 and January 2003: the slight improvement persisted but the EOGs remain below the normal range values. DISCUSSION AND CONCLUSION A review of the literature brought out that an EOG is not usually done in the monitoring of patients taking INF-alpha, but we decided to do this examination because of her symptoms, the first case to our knowledge in a patient taking INF-alpha. This case report underlines the necessity of an EOG on patients with INF-alpha therapy. Until now, the pathogenesis of this retinal toxicity has been poorly understood. These results show that the retinal pigmented epithelium is probably implicated at an early stage in this retinal toxicity.
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Loftis JM, Hauser P. Safety of the treatment of interferon-alpha-induced depression. PSYCHOSOMATICS 2003; 44:524-6. [PMID: 14597693 DOI: 10.1176/appi.psy.44.6.524] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hepatitis C in patients with psychiatric disease and substance abuse: Screening strategies and comanagement models of care. ACTA ACUST UNITED AC 2003. [DOI: 10.1007/s11901-003-0002-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Schulman JA, Liang C, Kooragayala LM, King J. Posterior segment complications in patients with hepatitis C treated with interferon and ribavirin. Ophthalmology 2003; 110:437-42. [PMID: 12578794 DOI: 10.1016/s0161-6420(02)01741-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To determine the incidence and type of posterior segment complications associated with the use of interferon alpha 2b and ribavirin in patients with chronic hepatitis C. DESIGN A prospective noncomparative case series. PARTICIPANTS Forty-two patients (84 eyes). METHODS Patients with chronic hepatitis C were evaluated for ocular changes while being treated with interferon alpha 2b and ribavirin. Patients were followed with sequential ocular examinations for 4 to 20 months. MAIN OUTCOME MEASURES Occurrence of posterior segment complications while on interferon and ribavirin therapy. RESULTS Twenty-seven patients developed retinopathy. The retinopathy consisted of single-to-multiple cotton-wool spots and retinal hemorrhage and was transient in all cases. An additional patient (age 46) presented with asymptomatic disc edema and hemorrhage. One other individual developed a symptomatic permanent monocular visual field defect. Therapy was discontinued in three patients because of severe posterior segment pathology. CONCLUSIONS Our study demonstrated that a high incidence of retinopathy is associated with the treatment of hepatitis C using interferon and ribavirin, but that this form of retinopathy is relatively benign. Regular ophthalmic monitoring should be performed in patients undergoing this treatment.
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Affiliation(s)
- Joel A Schulman
- Department of Ophthalmology, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71130, USA
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Furrer H, Barloggio A, Egger M, Garweg JG. Retinal microangiopathy in human immunodeficiency virus infection is related to higher human immunodeficiency virus-1 load in plasma. Ophthalmology 2003; 110:432-6. [PMID: 12578793 DOI: 10.1016/s0161-6420(02)01750-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To evaluate the prevalence of retinal microangiopathy in human immunodeficiency virus (HIV)-1-infected patients and its association with virologic, immunologic, and sociodemographic parameters. DESIGN Single-center cross-sectional study. PARTICIPANTS One hundred eighty-eight HIV-1-positive individuals from a single outpatient clinic. METHODS Human immunodeficiency virus-positive patients were screened for signs of HIV-associated retinal angiopathy. Plasma HIV-1 RNA and CD4-positive cell counts were monitored within 3 months of the ophthalmologic assessment. The absence or presence of angiopathy or of opportunistic viral retinitis was then correlated to data respecting CD4-positive cell count, plasma viral load of HIV-1, and sociodemographic parameters. MAIN OUTCOME MEASURES Association between CD4-positive cell count, HIV-1 plasma viral load, sociodemographic parameters, and the manifestation of retinal microangiopathy. RESULTS At the baseline consultation, 130 (69%) patients exhibited no retinal pathologic features, 45 (24%) manifested retinal angiopathy, and 13 (7%) had opportunistic viral retinitis. In univariate analysis, retinal angiopathy was associated with lower CD4-positive cell count and higher HIV-1 plasma viral load. In a multivariate logistic model, the presence of retinal microangiopathy was associated with higher age (P = 0.02) and higher viral load of HIV-1 (P < 0.005), but not with lower CD4 cell counts (P > 0.05). CONCLUSIONS Human immunodeficiency virus-associated retinal microangiopathy is likely a multifactorial condition. Its presence is associated with higher age and higher replication of HIV-1 as measured by plasma HIV-1 RNA levels. In contrast to opportunistic infectious retinitis, the degree of immunodeficiency does not seem to be independently correlated with retinal angiopathy.
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Affiliation(s)
- Hansjakob Furrer
- Division of Infectious Diseases, University Hospital Bern, Inselspital PKT2 B, CH-3010 Bern, Switzerland.
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Abstract
BACKGROUND Behçet's disease is a vasculitis of unknown origin. Various therapeutic agents have been proposed. Interferon alpha 2a or 2b appear to be the most promising. CURRENT KNOWLEDGE AND KEY POINTS Numerous anecdotal reports and some short series have shown the efficacy of interferon in some cases previously resistant to conventional therapy, particularly to immunosuppressors. Posology, depending on the author, may vary from three million three times a week to 18 million three times a week. Interferon alpha is useful in cases of ocular, muco-cutaneous and articular involvement. Data is lacking for digestive, vascular and neurological manifestations. FUTURE PROSPECTS AND PROJECTS Multicenter trials will nevertheless be required to determine the duration of therapy, risk of relapses, associated therapy and the optimal time to commence interferon treatment.
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Affiliation(s)
- B Wechsler
- Service de médecine interne, CHU Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, Paris, France.
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Perlemuter G, Bodaghi B, Le Hoang P, Izem C, Buffet C, Wechsler B, Piette JC, Cacoub P. Visual loss during interferon-alpha therapy in hepatitis C virus infection. J Hepatol 2002; 37:701-2. [PMID: 12399242 DOI: 10.1016/s0168-8278(02)00243-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
Interferon and ribavirin combination therapy for chronic hepatitis C produces a number of well-described side effects that are dominated by fatigue, influenza-like symptoms, hematologic abnormalities, and neuropsychiatric symptoms. Combination therapy with pegylated interferons (peginterferon alfa-2a and alfa-2b) yields an adverse event profile similar to standard interferon, although the frequency of certain adverse events may vary by preparation. Premature withdrawal from therapy due to adverse events was required in 10% to 14% of participants in registration trials of these agents. Most adverse events were safely and effectively managed by dose reduction using predetermined criteria. The most common indications for dose reduction were hematologic abnormalities, such as anemia and neutropenia, with the latter more frequent in peginterferon treatment arms. Recent data suggest that maintaining adherence to a prescribed treatment regimen can enhance antiviral response. Strategies to maximize adherence are being developed and, in the future, may include early identification of and therapy for depression and the selective use of hematopoietic growth factors to ameliorate hematologic abnormalities.
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Affiliation(s)
- Michael W Fried
- Division of Digestive Diseases, University of North Carolina, Chapel Hill, North Carolina 27599, USA.
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Abstract
Interferon and ribavirin combination therapy for chronic hepatitis C produces a number of well-described side effects that are dominated by fatigue, influenza-like symptoms, hematologic abnormalities, and neuropsychiatric symptoms. Combination therapy with pegylated interferons (peginterferon alfa-2a and alfa-2b) yields an adverse event profile similar to standard interferon, although the frequency of certain adverse events may vary by preparation. Premature withdrawal from therapy due to adverse events was required in 10% to 14% of participants in registration trials of these agents. Most adverse events were safely and effectively managed by dose reduction using predetermined criteria. The most common indications for dose reduction were hematologic abnormalities, such as anemia and neutropenia, with the latter more frequent in peginterferon treatment arms. Recent data suggest that maintaining adherence to a prescribed treatment regimen can enhance antiviral response. Strategies to maximize adherence are being developed and, in the future, may include early identification of and therapy for depression and the selective use of hematopoietic growth factors to ameliorate hematologic abnormalities.
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Affiliation(s)
- Michael W Fried
- Division of Digestive Diseases, University of North Carolina, Chapel Hill, North Carolina 27599, USA.
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Sulkes A, Schachter J. Comment on "Perhaps not everyone knows that...", (Ann Oncol 2001; 12: 1186). Ann Oncol 2002; 13:637. [PMID: 12056717 DOI: 10.1093/annonc/mdf147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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