Epidemiology of drug-induced severe skin reactions

Severe Cutaneous Adverse Drug Reactions Associated with Allopurinol: An Analysis of Spontaneous Reporting System in Southern Italy

Background

Allopurinol can induce severe cutaneous adverse reactions (SCARs), including Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome, Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).

Aims and Methods

We analyzed the Individual Case Safety Reports (ICSRs) sent from January 2001 until April 2019 to the Campania regional Center of Pharmacovigilance (Southern Italy) that reported allopurinol as suspected, with a focus on those reporting at least one serious cutaneous adverse drug reaction (ADR). This study was aimed to describe the main characteristics of all ADRs associated with allopurinol, analyze the proportion of serious cutaneous ADRs of total ICSRs related to allopurinol and to compare the main features (age, sex, seriousness and outcome) of ICSRs that reported serious cutaneous ADRs with those that did not.

Results

The Campania regional Center of Pharmacovigilance received 108 ICSRs that reported allopurinol as suspected. ADRs occurred more frequently in the elderly (median age: 71 years) and female patients (53.7%). Fifty-seven percent of all ADRs were classified as serious and 58% had a favorable outcome. Fifty-six ICSRs reported at least one serious cutaneous ADR; among these ICSRs, 37 cases of SCARs were found [DRESS syndrome (n = 3; 5.4%), SJS (n = 8; 14.3%) and TEN (n = 26; 46.4%)]. Serious cutaneous ADRs commonly occurred in the elderly (median age: 73 years) and female patients (62.5%). They frequently required hospitalization (75%) and had an unfavorable outcome (46%). No statistically significant differences were found between ICSRs that reported serious cutaneous ADRs and ICSRs that did not report serious cutaneous ADRs except for the seriousness degree “Hospitalization or its prolongation” and the outcome degrees “Unfavorable” and “Favorable”.

Conclusion

This study found that 52% (56/108) of all ICSRs having allopurinol as a suspected drug were serious cutaneous ADRs. Serious cutaneous ADRs associated with allopurinol frequently required hospitalization or prolonged hospitalization, and almost half had an unfavorable outcome.

Toxic Epidermal Necrolysis Therapy with TPE and IVIG-10 Years of Experience of the Burns Treatment Center

Toxic epidermal necrolysis (TEN) is a potentially life-threatening, exfoliative disease. It is described as idiosyncratic, severe, skin reaction to drugs. With Stevens-Johnson's Syndrome, it presents as a continuum of a disease being categorized relating to the percentage of affected skin. Without any multicenter trials comparing TEN treatment modalities, there is dearth of strong evidence-based guidelines of care. Total plasma exchange with intravenous immunoglobulin (IVIG) is one among plethora of possible treatment strategies. In our 10-year experience, we have observed 21 patients admitted to our burns center due to TEN. All of them were placed under intensive care with daily plasmapheresis (TPE) and IVIG. We have observed 52% mortality, with observed severe concomitant diseases in every patient in nonsurvivor group (average Acute Physiology and Chronic Health Evaluation II score at admission: 31.5%). We consider that TPE with IVIG might be of use in selected group of patients with TEN without any severe comorbidities. However, further multicenter trials are needed because in some cases it may raise mortality.

Genetic markers of severe cutaneous adverse reactions

Adverse drug reactions can cause considerable discomfort. They can be life-threatening in severe cases, requiring or prolonging hospitalization, impeding proper treatment, and increasing treatment costs considerably. Although the incidence of severe cutaneous adverse reactions (SCARs) is low, they can be serious, have permanent sequelae, or lead to death. A recent pharmacogenomic study confirmed that genetic factors can predispose an individual to SCARs. Genetic markers enable not only elucidation of the pathogenesis of SCARs, but also screening of susceptible subjects. The human leukocyte antigen (HLA) genotypes associated with SCARs include HLA-B*57:01 for abacavir (Caucasians), HLA-B*58:01 for allopurinol (Asians), HLA-B*15:02 (Han Chinese) and HLA-A*31:01 (Europeans and Koreans) for carbamazepine, HLA-B*59:01 for methazolamide (Koreans and Japanese), and HLA-B*13:01 for dapsone (Asians). Therefore, prescreening genetic testing could prevent severe drug hypersensitivity reactions. Large-scale epidemiologic studies are required to demonstrate the usefulness and cost-effectiveness of screening tests because their efficacy is affected by the genetic differences among ethnicities.

Anticancer Drugs Induced Severe Adverse Cutaneous Drug Reactions: An Updated Review on the Risks Associated with Anticancer Targeted Therapy or Immunotherapies

Cutaneous adverse drug reactions are commonly seen in patients with anticancer drug treatment. Anticancer drugs, including chemotherapy, target therapy, and recent immunotherapy causing skin reactions ranging from mild skin rash to life-threatening severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN) with increase morbidity and mortality while they are receiving cancer treatments, have been proposed to be a result of direct skin toxicity or drug hypersensitivity reactions (these are proposed mechanism, not definite). Differentiating SCARs from other more commonly seen reactions with a better outcome help prevent discontinuation of therapy and inappropriate use of systemic immunosuppressants for presumable allergic reactions, of which will affect the clinical outcome. In this article, we have reviewed published articles from 1950 to August 2017 for SJS/TEN associated with anticancer drugs, including chemotherapy, targeted therapy, and immunotherapy. We aimed to provide an overview of SJS/TEN associated with anticancer drugs to increase clinician recognition and accelerate future studies on the pathomechanism and managements.

Adverse Drug Reactions

Adverse events and adverse drug reactions are common in clinical practice. Side effects range from the common to the rare and may be confused with other mucocutaneous manifestations resulting from several medications to treat infections, other medical conditions, and in the clinical setting of oncologic treatment. The objective of this chapter to review current data on adverse drug reactions, here classified as (i) severe adverse drug reactions, (ii) uncomplicated cutaneous adverse drug reactions, and (iii) adverse drug reactions caused by chemotherapy drugs, particularly those cases whereby the dermatologist is requested to issue a report and asked to comment on the safety and viability of readministration of a specific drug. We describe aspects associated with these events, presenting a detailed analysis of each of them.

Analysis of Stevens-Johnson syndrome and toxic epidermal necrolysis using the Japanese Adverse Drug Event Report database

Background

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions associated with fatal disorders. Although many causes of SJS/TEN have been proposed, the time-to-onset for SJS/TEN and the relationship between aging and SJS/TEN are still not clear. Therefore, the aim of this study was to determine the relationship between aging and SJS/TEN using the Japanese Adverse Drug Event Report (JADER) database and analyze the time-to-onset profile of SJS/TEN.

Methods

We analyzed reports of SJS/TEN recorded in the JADER database between 2004 and 2015 using an adjusted reporting odds ratio (ROR). We also used Weibull proportional hazards models for each drug to examine the expression patterns of SJS/TEN. We selected the drugs according to the number of the reports associated with SJS/TEN.

Results

The JADER contained 330,686 reports from April 2004 to April 2015. The adjusted RORs for patients in the 0–19-, 20–39-, 60–79-, and ≥ 80-year-old groups from all data extracted from the JADER database were 1.33 (95 % confidence interval [CI], 1.21–1.45), 1.78 (95 % CI, 1.65–1.93), 0.71 (95 % CI, 0.66–0.75), and 0.72 (95 % CI, 0.66–0.79), respectively. The adjusted ROR tended to be higher in patients aged 0–19 years, particularly in patients using antipyretic analgesics, such as loxoprofen or acetaminophen. More than half of the cases of SJS/TEN onset following administration of loxoprofen and acetaminophen occurred within 4 days of the initiation of treatment. The median times-to-onset were 3 days for loxoprofen and 2 days for acetaminophen. The scale parameter α values of loxoprofen and acetaminophen were 9.44 and 6.17, respectively. The upper 95 % CIs of shape parameter β values for the drugs were all less than 1, with the exceptions of those for carbamazepine, ACE inhibitors, and corticosteroids.

Conclusions

Our results suggested that monitoring of younger patients who frequently use antipyretic analgesics is important. These drugs should be used and monitored within the first 2–3 days of treatment in the Japanese population.

Tear exchangeable limbal rigid contact lens for ocular sequelae resulting from Stevens-Johnson syndrome or toxic epidermal necrolysis

PURPOSE

To evaluate the therapeutic benefits of tear-exchangeable, limbal, rigid contact lenses (limbal CLs) in patients with Stevens-Johnson syndrome- or toxic epidermal necrolysis-associated ocular sequelae.

DESIGN

Noncomparative, retrospective, interventional case series.

METHODS

We enrolled 53 eyes of 42 patients (mean age, 51.8 ± 13.9 years; mean follow-up, 25.7 ± 15.7 months) with Stevens-Johnson syndrome- or toxic epidermal necrolysis-associated ocular sequelae and divided them into 3 groups according to the best-corrected visual acuity (BCVA) before limbal CL fitting: (1) BCVA worse than 20/2000 (11 eyes), (2) BCVA ranging from 20/200 to 20/2000 (31 eyes), and (3) BCVA of 20/200 or better (11 eyes). The BCVA and the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) composite score before fitting and after 3 months of limbal CL use were evaluated. The change in BCVA (in logarithm of the minimal angle of resolution [logMAR] units) and 25-item National Eye Institute Visual Function Questionnaire composite score change were compared among the 3 groups.

RESULTS

Best-corrected visual acuity improved from 1.61 to 0.86 logMAR at 3 months after fitting CL use. Improvement in BCVA in groups 1, 2, and 3 was 0.95 logMAR, 0.82 logMAR, and 0.37 logMAR, respectively. The mean 25-item National Eye Institute Visual Function Questionnaire composite score for the 11 subscales improved from 37.6 ± 16.0 to 58.4 ± 17.4 (P = .000001). All 11 subscores, except that for driving ability, improved significantly. The general vision subscore improved most in group 3, yet the general health subscore improved most in group 1. No serious adverse events attributable to limbal CL use occurred.

CONCLUSIONS

The tear-exchangeable limbal CL is safe and effective for the improvement of vision and quality of life in Stevens-Johnson syndrome or toxic epidermal necrolysis patients with severe ocular sequelae.

Life-threatening dermatologic adverse events in oncology

The incidences of life-threatening toxicities such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are inconsistently reported. The potential association of anticancer agents with SJS or TEN has not been systematically investigated. We searched the literature (Ovid: 1950 to June 2013 and PubMed: 1948 to June 2013) using terms for SJS/TEN and anticancer therapies. Primary case reports, case series, and clinical trials were included. In addition, MedWatch, the Food and Drug Administration Adverse Event Reporting System (FAERS), was searched (1968 to August 2012) for SJS/TEN reports associated with anticancer therapies. Proportional reporting ratios (PRR>2, N>3), empirical Bayes geometric mean (EBGM>2, N>3), and lower 95% confidence interval (EBGM0.05>2) were used as thresholds to constitute a signal of association between SJS/TEN and anticancer drugs. There were 46 SJS and 37 TEN cases associated with 18 and 22 anticancer drugs in the literature, respectively. Among cases in the FAERS, significant signals were associated with SJS for bendamustine and with TEN for bendamustine, busulfan, chlorambucil, fludarabine, lomustine, and procarbazine. Several drugs reported in the published literature to be associated with SJS/TEN were not found to have significant signals in FAERS. Proactive pharmacovigilance to detect and define safety signals serves to aid oncology practitioners in the recognition of possible, yet uncommon, serious, and/or life-threatening skin reactions.

Stevens Johnson Syndrome associated with Lamotrigine

Stevens-Johnsons Syndrome (SJS) is an immune-complex-mediated hypersensitivity reaction and has been linked as an adverse side effects to many drugs. Lamotrigine, an anticonvulsive medication and also a commonly used mood stabiliser, can be associated with this adverse reaction. Although this has not been reported very commonly , SJS has high mortality and morbidity and requires careful attention as the use of Lamotrigine is increasing in clinical practice. We present a case where the patient developed Stevens - Johnson Syndrome three weeks after being started on Lamotrigine. The case is discussed for its relevance to the use of Lamotrigine which is currently prescribed very commonly in psychiatric practices.

Amniotic membrane transplantation as a new therapy for the acute ocular manifestations of Stevens-Johnson syndrome and toxic epidermal necrolysis

Stevens-Johnson syndrome and its more severe variant, toxic epidermal necrolysis, have relatively low overall incidence; however, this disease presents with high morbidity and mortality. The majority of patients develop ocular inflammation and ulceration at the acute stage. Due to the hidden nature of these ocular lesions and the concentration of effort toward life-threatening issues, current acute management has not devised a strategy to preclude blinding cicatricial complications. This review summarizes recent literature data, showing how sight-threatening corneal complications can progressively develop from cicatricial pathologies of lid margin, tarsus, and fornix at the chronic stage. It illustrates how such pathologies can be prevented with the early intervention of cryopreserved amniotic membrane transplantation to suppress inflammation and promote epithelial healing at the acute stage. Significant dry eye problems and photophobia can also be avoided with this intervention. This new therapeutic strategy can avert the catastrophic ophthalmic sequelae of this rare but devastating disease.

Toxic epidermal necrolysis (TEN) Lyell's syndrome

Toxic epidermal necrolysis, a unique rapidly developing mucocutaneous reaction pattern, characterized by sheets of erythema, necrosis and bullous detachment of the epidermis, closely resembling that of scalding of the skin and rapidly fatal, was described by Lyell, and is now recognized as toxic epidermal necrolysis (TEN) Lyell's syndrome. The condition is indistinguishable from staphylococcal scalded skin syndrome (SSSS), and generalized fixed drug eruption. Hence, there has always been controversy as regards terminology. It is well conceived that TEN is equivalent to Stevens-Johnson syndrome (SJS), at its greatest severity. TEN, therefore, is a great challenge and warrants instant attention based on a thorough knowledgeable background covering several related facets including the recent advances in pathogenesis and management strategies. The details contained in the following text should prove very useful in the comprehension of a largely intractable entity.

Analysis of Stevens-Johnson syndrome and toxic epidermal necrolysis in Japan from 2000 to 2006

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe adverse drug reactions with high mortality.

METHODS

To present the current clinical characteristics and treatment of SJS and TEN in Japan, we retrospectively analyzed reports of SJS and TEN published in medical journals from 2000 to 2006.

RESULTS

Fifty-two cases of SJS (19 males and 33 females; mean age, 45.2 years) and 65 cases of TEN (31 males and 34 females; mean age, 45.7 years) were reported. Thirty-six cases of SJS (69.2%) and all cases of TEN were caused by drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, and anticonvulsant drugs. Hepatitis was the most common organ involvement in both SJS and TEN. Renal dysfunction and respiratory disorders were also involved in some cases. The major complication was sepsis, but in only 1.9% of SJS and 10.8% of TEN. Most cases were treated systemically with corticosteroids, and 42 cases (80.8%) of SJS and 39 cases (60.0%) of TEN were treated with corticosteroids alone. Plasmapheresis and/or immunoglobulin therapy was combined with corticosteroid therapy in some cases. The mortality rates for patients with SJS and TEN were 1.9% and 6.2%, respectively. The mortality in TEN decreased remarkably from 21.6% (58/269) during the previous 17 years (1981 to 1997).

CONCLUSIONS

Improvement of treatment may be one of the reasons for the decrease in mortalities of both SJS and TEN.

Nécrolyse épidermique toxique. Revue des cas observés dans le service de réanimation du centre national hospitalier et universitaire de Cotonou

INTRODUCTION

Toxic epidermal necrolysis (TEN) is usually a drug-induced disease, involving vital or functional prognosis with 20 to 30% mortality rates.

OBJECTIVES

The aim was to collect cases of TEN in an intensive care unit in Cotonou National University and Teaching Hospital, and describe epidemiologic, clinical, therapeutic and evolutive patterns.

STUDY DESIGN

Retrospective and descriptive study over five years.

PATIENTS AND METHODS

The medical report-forms of patients admitted between January 1998 and December 2002, for toxic dermatitis with total skin injury area more than 10% were reviewed.

RESULTS

Fourteen patients with TEN were identified. The average incidence was three cases per year, accounting for 0.25% of the admissions in the unit. Sulphonamides (n=4), antituberculous drugs (n=2), penicillin (n=3) were the main cause of TEN. In five patients, the cause was not found. Self-medication was found in 7 patients. Total skin injury area reached from 26 to 87%. Mucosal and viscera injury occurred in respectively 11 and 9 patients. The treatment was usual as in extended burns. Four patients died (28.5%). The average time before hospitalisation was 11.4 days.

CONCLUSION

The growing-awareness of people can prevent/reduce the morbidity and improve the prognosis of TEN.

Lamotrigine-Induced Toxic Epidermal Necrolysis in Three Patients Treated for Bipolar Disorder

Exfoliative dermatitis, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), is a mild-to-life-threatening process that has been described after exposure to many antiepileptic drugs. The increased use of antiepileptic drugs for treatment of bipolar disorder and neurologic disorders has extended the risk of exfoliative disorder to this population of patients, and these patients and their health care providers may not be familiar with the risks involved with these drugs. We describe the cases of a 28-year-old woman with bipolar 1 disorder initially treated with lamotrigine, and two adolescent girls with bipolar 2 disorder treated with lamotrigine after poor responses to other drug regimens. In all three patients, rashes progressed to toxic epidermal necrolysis in spite of treatment with corticosteroids at their local hospitals; thus, they were transferred to our burn treatment center. Response to early corticosteroid treatment in suppressing progression of exfoliation was variable in these patients. Ultimately, two of the three required ventilatory support; their conditions improved within 8-32 days of treatment, and they were discharged from the hospital. Case reports of lamotrigine-induced exfoliative disorder in patients with bipolar disorder have been published. However, these three patients were admitted to our burn treatment center within a 12-month period. Our institution admits approximately 10-12 patients with TEN/year, and the increased use of lamotrigine for treatment of bipolar disorder is likely to result in more patients with TEN. Therefore, health care professionals need to be aware of the early signs and symptoms of exfoliative dermatotoxicity when treating patients with lamotrigine.

Comparison of reporting of Stevens-Johnson syndrome and toxic epidermal necrolysis in association with selective COX-2 inhibitors

BACKGROUND

Stevens-Johnson syndrome and toxic epidermal necrolysis are closely related severe acute life-threatening, drug-induced skin disorders. The US FDA Adverse Events Reporting System (AERS) has received reports of Stevens-Johnson syndrome and toxic epidermal necrolysis associated with the use of the recently introduced selective cyclo-oxygenase (COX)-2 inhibitor NSAIDs, two of which are also sulfonamides.

OBJECTIVE

The objective of this study is to review cases of Stevens-Johnson syndrome and toxic epidermal necrolysis reported to the FDA associated with the use of the selective COX-2 inhibitor NSAIDs celecoxib, rofecoxib and valdecoxib, and to compare reporting rates of the two conditions associated with these drugs to each other, meloxicam (an oxicam NSAID that came on the US market at a similar time) and the background incidence rate.

METHODS

We reviewed all US cases of Stevens-Johnson syndrome and toxic epidermal necrolysis reported to the FDA AERS database associated with the use of celecoxib, rofecoxib, valdecoxib and meloxicam since these agents were first marketed. We utilised AERS and drug use data to calculate reporting rates for each drug after the first 2 years of marketing. We obtained the background rate from the medical literature.

RESULTS

Up to the end of March 2004, there were 63 cases of Stevens-Johnson syndrome/toxic epidermal necrolysis reported with valdecoxib use, 43 with celecoxib, 17 with rofecoxib (the non-sulfonamide coxib) and none for meloxicam. In the first 2 years of marketing the reporting rate for Stevens-Johnson syndrome/toxic epidermal necrolysis with valdecoxib was 49 cases per million person-years of use, 6 cases per million person-years for celecoxib and 3 cases per million person-years for rofecoxib. The reporting rates for the sulfonamide coxibs were substantially higher than the background rate of 1.9 cases per million population per year, with the valdecoxib rate being 8-9 times that of celecoxib and approximately 25 times that of the background rate.

CONCLUSION

There is a strong association between Stevens-Johnson syndrome/toxic epidermal necrolysis and the use of the sulfonamide COX-2 inhibitors, particularly valdecoxib. Physicians should be aware of the possibility of this serious life-threatening event when prescribing these drugs and advise patients to discontinue use at the earliest possible sign or symptom.

Erythema multiforme: a review and contrast from Stevens-Johnson syndrome/toxic epidermal necrolysis

Erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis are separate diseases. Recent evidence suggests that they have different etiologies and require different treatments. This article provides an overview of the two conditions with emphasis on the differences between them. An outline of the diagnosis and management of the diseases is included.

Spectrum of anticonvulsant hypersensitivity syndrome: controversy of treatment

An 18-month-old girl presented with a maculopapular rash 10 days after carbamazepine treatment. Initially, she was suspected of having a viral rash owing to associated fever. She deteriorated rapidly and was suspected of having anticonvulsant hypersensitivity syndrome or Stevens-Johnson syndrome. She developed features compatible with toxic epidermal necrolysis rapidly over 24 to 36 hours. Carbamazepine was then stopped. She responded immediately to high-dose intravenous pulse methylprednisone treatment. We discuss the controversy in the management of anticonvulsant hypersensitivity syndrome, toxic epidermal necrolysis, or Stevens-Johnson syndrome with high-dose corticosteroids, intravenous immunoglobulin, and antibiotics.

Reações cutâneas graves adversas a drogas - aspectos relevantes ao diagnóstico e ao tratamento - Parte I - Anafilaxia e reações anafilactóides, eritrodermias e o espectro clínico da síndrome de Stevens-Johnson & necrólise epidérmica tóxica (Doença de Lyell)

As reações cutâneas graves adversas a droga (RCGAD) são as que geralmente necessitam de internação hospitalar, por vezes em unidade de terapia intensiva ou de queimados, com observação minuciosa dos sinais vitais e da função de órgãos internos. O objetivo é descrever essas reações, facilitando seu reconhecimento e tratamento. Fazem parte desse grupo a anafilaxia, a síndrome de Stevens-Johnson (SSJ), a necrólise epidérmica tóxica (NET) e, dependendo do envolvimento sistêmico, as eritrodermias. Neste artigo, são abordados as características clínicas e o tratamento de algumas reações adversas a droga: anafilaxia, as eritrodermias, a síndrome de Stevens-Johnson (SSJ) e a necrólise epidérmica tóxica (NET).

Evaluation of the Extent of Under-Reporting of Serious Adverse Drug Reactions

INTRODUCTION

Toxic epidermal necrolysis (TEN) is a life-threatening adverse drug reaction (ADR) that is primarily the result of drug exposure (incidence 0.4-1.3 per million person-years). Life-threatening ADRs such as TEN should be reported to ADR monitoring programmes, which collect reports for suspected ADRs and alert the public and medical practitioners to new drug hazards. In Canada, reports are made to the Canadian Adverse Drug Reaction Monitoring Program (CADRMP).

OBJECTIVE

To examine the extent of under-reporting for TEN in Canada.

DESIGN

A retrospective case series design was used to collect all TEN cases for the period January 1995 to December 2000.

METHODS

The CADRMP and 22 burn centres across Canada were contacted for all TEN patients treated during the specified time period. PATIENT GROUPS STUDIED: The study population consisted of patients admitted to burn treatment sites across Canada, patient cases reported to the CADRMP and patient cases recorded by the Canadian Institute for Health Information (CIHI) hospital discharge summaries as the International Classification of Diseases Version 9 Clinical Modification (ICD-9-CM) code 695.1.

RESULTS

Twenty-five TEN cases (six fatal) were reported to CADRMP from January 1995 to December 2000. During this period, 14 (63.6%) burn treatment sites reported admission of 250 TEN cases. Hospital discharge summaries using the ICD-9-CM code 695.1 indicated that 4349 cases were admitted to hospital during this time period and it was estimated that 15.5% (n = 674) of these cases were TEN. Using the burn facility data as the denominator, 10% (25 of 250) of TEN cases were reported to CADRMP. Using CIHI data as a denominator, only 4% (25 of 674) of TEN cases were reported to CADRMP.

CONCLUSIONS

There is serious under-reporting of TEN. Lack of reporting of life-threatening ADRs can compromise population safety. There is a need to increase awareness of ADR reporting programmes.

Erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis in children: a review of 10 years' experience

OBJECTIVE

To review 10 years' experience in a tertiary care paediatric hospital of erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). In addition, to apply a recently described classification system for EM, SJS and TEN in children.

DESIGN

Retrospective study of all children with a discharge diagnosis of EM, SJS or TEN over a 10-year period.

SETTING

A university tertiary care paediatric hospital.

PATIENTS

Sixty-one paediatric patients with a discharge diagnosis of EM, SJS or TEN.

MAIN OUTCOME MEASURES

Epidemiology, laboratory features, causative factors, treatment methods, complications and mortality of EM, SJS and TEN in this group of patients. Comparison of correlation with aetiology of old and new classification systems in a paediatric population.

RESULTS

Mucous membrane involvement was documented in 61% of patients. Ocular involvement was seen in 39%. Complications occurred in 21% cases, all of whom had SJS or TEN. Only one patient died as a result of their skin condition. Corticosteroids were used in 18% of cases; 95% of whom had a discharge diagnosis of SJS or TEN. The drugs most commonly identified as aetiological agents were sulphonamides and penicillins (26% each). The most frequently implicated infectious agent was herpes simplex virus (19.7%). Classification of study cases according to Bastuji-Garin et al. indicates a strong trend toward bullous EM cases being attributable to infection and SJS/TEN cases to drugs. There was no such clear trend with respect to aetiology when diagnosis was done without the classification system.

CONCLUSION

EM, SJS and TEN rarely cause mortality but significant morbidity is seen. Infectious agents, particularly herpes simplex virus, and drugs, especially the sulphonamides and penicillins, are the most common aetiological agents. The classification system proposed by Bastuji-Garin et al. correlates better with aetiology than the practice that preceded it.

Toxic epidermal necrolysis: differential diagnosis of an epidermolytic dermopathy in a hematopoietic stem cell transplant recipient

Toxic epidermal necrolysis (TEN) is an epidermolytic skin disorder associated with drug administration. It is associated with an erythematous rash with full thickness epidermal loss and characteristic histology. A 35-year-old woman underwent allogeneic hematopoietic stem cell transplantation (HSCT) for severe aplastic anemia (SAA). She developed an acute epidermolytic rash and TEN was diagnosed on the basis of skin biopsy. In the HSCT setting, TEN should be thought of as an important differential diagnosis of epidermolytic dermopathies. The most distinctive diagnostic test in the differential diagnosis of these disorders is skin biopsy

Levofloxacin-induced toxic epidermal necrolysis in an elderly patient

Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN) are mild-to-life-threatening adverse reactions that have been described after exposure to fluoroquinolones. No published reports, however, exist of exfoliative disease after treatment with levofloxacin. A 78-year-old woman with many medical problems, including chronic obstructive pulmonary disease, was treated with parenteral levofloxacin for community-acquired pneumonia. She was discharged with oral levofloxacin to complete an additional 3 days of treatment as an outpatient. Two days after completing this regimen, the patient developed a rash with blistering. The rash progressed to TEN in 7 days, and she was transferred to a burn treatment center. She was treated with fluid resuscitation, wound dressing, and antibiotics. Her condition improved, and she was discharged after 22 days. To our knowledge, this case is the first published report of levofloxacin-induced TEN.

Interventions for toxic epidermal necrolysis

BACKGROUND

Toxic epidermal necrolysis is a rare condition where a drug reaction induces skin loss, similar to that seen in extensive burns. It is associated with high morbidity and mortality and there is no clear agreement on effective treatment.

OBJECTIVES

To assess the effects of all interventions for the treatment of toxic epidermal necrolysis.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (March 2001), the Cochrane Controlled Trials Register (March 2001), MEDLINE (1966 to December 2001), EMBASE (1980 to December 2001), DARE (4th Quarter 2001) and CINAHL (1982 to October 2001).

SELECTION CRITERIA

Randomised controlled trials of therapeutic and supportive interventions that included participants clinically diagnosed with toxic epidermal necrolysis were included.

DATA COLLECTION AND ANALYSIS

Two independent reviewers carried out study selection and assessment of methodological quality.

MAIN RESULTS

Only one randomised controlled trial of treatment was identified. This trial compared the effectiveness of thalidomide with placebo and included 22 patients, 12 in the treatment group and 10 in the placebo group. Patients on the treatment arm received thalidomide 200 mg twice daily for 5 days. The main end point was the measurement of the progression of skin detachment after 7 days. Other end points were the overall mortality and severity of the disease evaluated with the simplified acute physiology score. The study was terminated as the mortality on the treatment arm was 83% compared to 30% on the control arm (relative risk 2.78, 95% confidence interval 1.04 to 7.40). No randomised controlled trials of the most commonly used current treatments i.e. systemic steroids, cyclosporin A and intravenous immunoglobulins were found.

REVIEWER'S CONCLUSIONS

Treatment with thalidomide was not shown to be effective and was associated with significantly higher mortality than placebo. There is no reliable evidence on which to base treatment for toxic epidermal necrolysis, a disease commonly associated with mortality rates of around 30%. More research is required to understand the mechanisms of toxic epidermal necrolysis. International multi-centre studies are needed in the form of randomised controlled trials, to evaluate treatments for toxic epidermal necrolysis, especially those using high doses of steroid and intravenous immunoglobulins.

Identification of sulfonamide-like adverse drug reactions to celecoxib in the World Health Organization database

BACKGROUND

The selective COX-2 inhibitor celecoxib has a sulfonamide structure and is contraindicated for patients with known sulfa allergy. However, there is currently no standard available for the identification of sulfonamide-related adverse drug reactions (ADRs) and the occurrence of such ADRs with celecoxib has not been established. THE AIMS OF THIS STUDY WERE: (1) to identify the typical pattern of sulfonamide ADRs from literature and verify this pattern in the World Health Organization (WHO) ADR database; and (2) to examine whether these sulfonamide ADRs occur more frequently with celecoxib than with the non-sulfonamide, COX-2 inhibitor rofecoxib.

METHODS

A sulfonamide ADR pattern was derived from the most extensive textbook source of ADRs and applied to the WHO database for the three groups of sulfonamide drugs: short- and intermediate-acting sulfonamides, and sulfasalazine. ADRs reported three or more times for each of these groups were included in a 'sulfonamide template' comprising 19 ADRs relating to the skin, the blood, the liver, and anaphylaxis. This template was then applied to celecoxib and rofecoxib.

RESULTS

Overall, the relative reporting rate of a sulfonamide-type ADR with celecoxib was 80% higher than with rofecoxib, whether this was based on total number of reports (RR 1.8, 95% Cl 1.6-1.9) or restricted to reports that listed coxibs as the sole suspected drugs (RR 1.8, 95% Cl 1.6-1.9). There were numerically more ADRs for celecoxib than for rofecoxib in 15 of the 19 terms. Within the ADRs in the sulfonamide template, relative reporting rate of fatal reactions was 80% higher with celecoxib (RR 1.8, 95% Cl 0.9-4.0). Even though serious sulfonamide reactions are rare, their clinical impact on patient safety warrants close monitoring as more data becomes available. Physicians should be aware of possible sulfonamide allergy when prescribing celecoxib.

Economic assessment of three antimicrobial therapies for uncomplicated urinary tract infection in women

This retrospective cohort study used North Carolina Medicaid paid-claims data to assess clinical and economic outcomes of treatments for urinary tract infection (UTI). The study population comprised female Medicaid recipients, between 15 and 64 years of age, with a paid claim filed for a primary diagnosis of UTI or acute UTI from January 1 to June 30, 1994, who were treated with ciprofloxacin, nitrofurantoin, or trimethoprim/sulfamethoxazole (TMP/SMZ). Patients had follow-up for 6 months after the primary diagnosis. Patients who did not receive further treatment for UTI with 1 of the 3 drugs within 30 days after initial treatment were assumed to be cured. Costs were measured as the sum of reimbursements for UTI-related medical services and drug treatments. Outcomes for 409 patients were assessed. Cure rates of initial treatment with ciprofloxacin, nitrofurantoin, and TMP/SMZ were 81%, 88%, and 93%, respectively. Cost-effectiveness ratios of initial treatment with the 3 drugs were $150.80, $81.20, and $69.00, respectively. When efficacy rates generated from published randomized clinical studies were applied, cost-effectiveness ratios for the 3 drugs were $130.96, $86.17, and $72.00, respectively. A decision model of treatment pattern and associated costs is presented. Several patient variables indicate that the ciprofloxacin group included more severe cases of UTI than did the other groups. Study limitations, confounders, and future research suggestions are discussed. Our results show that treatment for >7 days results in a better cure rate regardless of the drug used than does treatment for < or =7 days and that TMP/SMZ is the most cost-effective of the 3 drugs for UTI or acute UTI.

[Detection and evaluation of adverse drug reactions]

Adverse drug reactions (ADRs) occur in about 5% of drug-treated patients. Hospital admissions are caused by ADRs in 5% of patients and roughly 2% of hospitalized patients will experience an ADR. The economic burden of ADRs can only be estimated. Type A reactions can be explained by the pharmacological action of the drugs, and are preventable in many cases. However, Type B reactions involving the immune system and/or idiosyncratic reactions occur rarely and most of them are not fully understood. Genotyping represents an elegant method to explain the presence of abnormal enzyme activities and allows prediction of adverse drug effects in individual cases. Typical time frames have been identified for the occurrence of hypersensitivity reactions, although definite causality assessment is often impeded due to the absence or unavailability of specific laboratory tests and the impossibility of rechallenge. Diagnosis of an ADR is often difficult due to comorbidity and polypharmacy, thus causality assessment is often divergent even between specialists. In Germany, ADRs are reported preferably to the manufacturer of the suspicious drug and then collected and evaluated at the Bundesinstitut für Arzneimittel und Medizinprodukte, BfArM. However, total number and quality of reported ADRs could be improved.