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Sugiyama T, Furuno T, Ichinose Y, Iwagami M, Ihana-Sugiyama N, Imai K, Kakuwa T, Rikitake R, Ohsugi M, Higashi T, Iso H, Ueki K. Assessment of cancer risk associated with 7-nitroso-3-(trifluoromethyl)-5,6,7,8-tetrahydro[1,2,4] triazolo-[4,3-a]pyrazine-contaminated sitagliptin use: A retrospective cohort study. J Diabetes Investig 2024. [PMID: 39133197 DOI: 10.1111/jdi.14281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/19/2024] [Indexed: 08/13/2024] Open
Abstract
AIMS/INTRODUCTION A recent US Food and Drug Administration report highlighted concerns over nitrosamine (7-nitroso-3-(trifluoromethyl)-5,6,7,8-tetrahydro[1,2,4] triazolo-[4,3-a]pyrazine [NTTP]) impurities in sitagliptin, prompting investigations into its safety profile. The present study aimed to determine if the use of NTTP-contaminated sitagliptin, in comparison with other dipeptidyl peptidase-4 (DPP-4) inhibitors, is associated with an increased cancer risk. MATERIALS AND METHODS This retrospective cohort study secondarily used the National Database of Health Insurance Claims and Specific Health Checkups of Japan, encompassing data on >120 million individuals. The study involved patients who initiated DPP-4 inhibitor therapy (sitagliptin or other DPP-4 inhibitors) and continued its exclusive use for 3 years. Sitagliptin users were compared with other DPP-4 inhibitor users for assessing the occurrence of cancers, as defined by diagnosis codes. Further analyses focused on specific types of cancer, using either diagnosis codes or a combination of diagnosis and procedure codes. We also carried out various sensitivity analyses, including those with different exposure periods. RESULTS Sitagliptin users (149,120 patients, 388,356 person-years) experienced 9,643 cancer incidences (2,483.0/100,000 person-years) versus 12,621 incidences (2,504.4/100,000 person-years) among other DPP-4 inhibitor users (199,860 patients, 503,952 person-years), yielding a minimal difference (incidence rate ratio 0.99, 95% confidence interval 0.97-1.02). A multiple Cox proportional hazards model showed no significant association between sitagliptin use and overall cancer incidence (hazard ratio 1.01, 95% confidence interval 0.98-1.04). Findings were also consistent across cancer types and sensitivity analyses. CONCLUSIONS We observed no evidence to suggest an increased cancer risk among patients prescribed NTTP-contaminated sitagliptin, although continued investigation is needed.
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Affiliation(s)
- Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
| | - Takashi Furuno
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yuichi Ichinose
- Division of Health Services Research, National Cancer Center, Tokyo, Japan
- Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
| | - Noriko Ihana-Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
- Department of Diabetes, Endocrinology, and Metabolism, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kenjiro Imai
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Tamaki Kakuwa
- Division of Health Services Research, National Cancer Center, Tokyo, Japan
- Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryoko Rikitake
- Division of Health Services Research, National Cancer Center, Tokyo, Japan
- Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsuru Ohsugi
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
- Department of Diabetes, Endocrinology, and Metabolism, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takahiro Higashi
- Division of Health Services Research, National Cancer Center, Tokyo, Japan
- Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyasu Iso
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kohjiro Ueki
- Department of Diabetes, Endocrinology, and Metabolism, National Center for Global Health and Medicine, Tokyo, Japan
- Diabetes Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
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Liu M, Luo D, Jiang J, Shao Y, Dai D, Hou Y, Dou X, Gao X, Zheng B, Liu T. Adverse tumor events induced by ranitidine: an analysis based on the FAERS database. Expert Opin Drug Saf 2024:1-13. [PMID: 38753437 DOI: 10.1080/14740338.2024.2354325] [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: 01/07/2024] [Accepted: 03/28/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Ranitidine induced tumor adverse events remains a contradictory clinical question, due to the limited evidence of tumor risk associated with ranitidine in the real world. The purpose of this study was to evaluate the association of ranitidine with all types of tumors through the FAERS database and to provide a reference for clinical use. RESEARCH DESIGN AND METHODS Cancer cases associated with ranitidine in the FAERS database from the first quarter of 2004 to the fourth quarter of 2023 were extracted to analyze demographic characteristics, and a disproportion analysis was performed. RESULT A total of 662,998 ranitidine-related cancer cases were screened, and the 50-59 and 60-69 groups accounted for the largest proportion. In PT signal detection, ranitidine was associated with 98 PT, including penal cancer stage II, gastric cancer stage II, et al. In terms of outcome events, adverse events were higher in men (20.65%) than in women (18.47%). CONCLUSIONS Ranitidine may induce various tumor-related adverse reactions, especially in long-term users and elderly patients. For these patients, tumor screening should be strengthened, and long-term use of ranitidine should be avoided. Since this study cannot prove causality, further evidence is needed for prospective studies with a larger sample size.
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Affiliation(s)
- ManTing Liu
- Guangzhou University of Chinese Medicine, Clifford Hospital, Guangzhou, China
| | - DongQiang Luo
- Guangzhou University of Chinese Medicine, Clifford Hospital, Guangzhou, China
| | - JiaZhen Jiang
- The first Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ying Shao
- Interventional Vascular Surgery, Fourth Affiliated Hospital of Harbin Medical University, HaErBin, China
| | - DanDan Dai
- The first Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - YiNing Hou
- School of Basic Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - XiangYun Dou
- The first Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - XiaoLu Gao
- The first Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - BoHui Zheng
- Clinical Medical College of Acupuncture and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Tian Liu
- Department of Endocrinology, Foshan Hospital of Traditional Chinese Medicine, FoShan, China
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Zelmat Y, Despas F. Drug-induced tumoral disease: A global pharmacovigilance database analysis. Therapie 2024; 79:189-197. [PMID: 38042752 DOI: 10.1016/j.therap.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/13/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION Cancer remains a worldwide threat, having caused almost 10 million deaths in 2020. The American Cancer Society has identified both known and probable carcinogens, including commonly used drugs. The aim of this study is to describe the drugs most frequently reported in the occurrence of cancer. METHODS Among all individual case safety reports (ICSRs) in the global pharmacovigilance database VigiBase, we searched for the 50 most reported drugs with an adverse drug reaction term belonging to the query "Malignant or unspecified tumors" until June 30, 2023. Then, we extracted the disproportionality measurement data, information component (IC), and reporting odds ratio (ROR) in order to assess a disproportionality signal. RESULTS Among all ICSRs in VigiBase, 871,925 contained an ADR belonging to the SMQ "Malignant or unspecified tumors". Ranitidine was the drug with the most reported ADRs related to cancer (n=106,484), followed by lenalidomide (n=13,466), and etanercept (n=8014). The drugs with the highest IC were ranitidine (IC=5.2, 95% confidence interval [95% CI]=5.2-5.2), pioglitazone (1353 ICSRs, IC=4.2, 95% CI=4.2-4.2), and regorafenib (1272 ICSRs, IC=2.8, 95% CI=2.8-2.8). DISCUSSION Our results show that the main pharmacological mechanisms are associated with ranitidine (link with levels of N-nitrosodimethylamine in ranitidine-based drugs), gene-activating drugs (pioglitazone: link with agonist effects on PPAR-γ gene activation), various pharmacological families with immunosuppressive effects (protein kinase inhibitors, immunomodulators, azathioprine, etc.), certain types of protein kinase inhibitors whose oncogenic mechanisms remain unclear (regorafenib, sorafenib, imatinib, ibrutinib, etc.), and hormone antagonists (tamoxifen, letrozole). Special monitoring of patients exposed to these drugs may be required. Further studies are needed to assess the risk with certain drugs in this ranking.
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Affiliation(s)
- Yoann Zelmat
- Service de pharmacologie médicale et clinique, faculté de médecine, centre hospitalier universitaire, 37, allées Jules-Guesde, 31000 Toulouse, France
| | - Fabien Despas
- Service de pharmacologie médicale et clinique, faculté de médecine, centre hospitalier universitaire, 37, allées Jules-Guesde, 31000 Toulouse, France.
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Paustenbach DJ, Brown SE, Heywood JJ, Donnell MT, Eaton DL. Risk characterization of N-nitrosodimethylamine in pharmaceuticals. Food Chem Toxicol 2024; 186:114498. [PMID: 38341171 DOI: 10.1016/j.fct.2024.114498] [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: 09/28/2023] [Revised: 01/23/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
Since 2018, N-nitrosodimethylamine (NDMA) has been a reported contaminant in numerous pharmaceutical products. To guide the pharmaceutical industry, FDA identified an acceptable intake (AI) of 96 ng/day NDMA. The approach assumed a linear extrapolation from the Carcinogenic Potency Database (CPDB) harmonic-mean TD50 identified in chronic studies in rats. Although NDMA has been thought to act as a mutagenic carcinogen in experimental animals, it has not been classified as a known human carcinogen by any regulatory agency. Humans are exposed to high daily exogenous and endogenous doses of NDMA. Due to the likelihood of a threshold dose for NDMA-related tumors in animals, we believe that there is ample scientific basis to utilize the threshold-based benchmark dose or point-of-departure (POD) approach when estimating a Permissible Daily Exposure limit (PDE) for NDMA. We estimated that 29,000 ng/kg/day was an appropriate POD for calculating a PDE. Assuming an average bodyweight of 50 kg, we expect that human exposures to NDMA at doses below 5800 ng/day in pharmaceuticals would not result in an increased risk of liver cancer, and that there is little, if any, risk for any other type of cancer, when accounting for the mode-of-action in humans.
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Affiliation(s)
- D J Paustenbach
- Paustenbach and Associates, 970 West Broadway, Suite E, Jackson, WY, USA
| | - S E Brown
- Paustenbach and Associates, 207 Canyon Blvd, Boulder, CO, USA.
| | - J J Heywood
- Paustenbach and Associates, 207 Canyon Blvd, Boulder, CO, USA
| | - M T Donnell
- Valeo Sciences LLC, 333 Corporate Drive, Suite 130, Ladera Ranch, CA, USA
| | - D L Eaton
- Professor Emeritus, Department of Environmental & Occupational Health Sciences, University of Washington, Seattle, WA, USA
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You SC, Seo SI, Falconer T, Yanover C, Duarte-Salles T, Seager S, Posada JD, Shah NH, Nguyen PA, Kim Y, Hsu JC, Van Zandt M, Hsu MH, Lee HL, Ko H, Shin WG, Pratt N, Park RW, Reich CG, Suchard MA, Hripcsak G, Park CH, Prieto-Alhambra D. Ranitidine Use and Incident Cancer in a Multinational Cohort. JAMA Netw Open 2023; 6:e2333495. [PMID: 37725377 PMCID: PMC10509724 DOI: 10.1001/jamanetworkopen.2023.33495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/02/2023] [Indexed: 09/21/2023] Open
Abstract
Importance Ranitidine, the most widely used histamine-2 receptor antagonist (H2RA), was withdrawn because of N-nitrosodimethylamine impurity in 2020. Given the worldwide exposure to this drug, the potential risk of cancer development associated with the intake of known carcinogens is an important epidemiological concern. Objective To examine the comparative risk of cancer associated with the use of ranitidine vs other H2RAs. Design, Setting, and Participants This new-user active comparator international network cohort study was conducted using 3 health claims and 9 electronic health record databases from the US, the United Kingdom, Germany, Spain, France, South Korea, and Taiwan. Large-scale propensity score (PS) matching was used to minimize confounding of the observed covariates with negative control outcomes. Empirical calibration was performed to account for unobserved confounding. All databases were mapped to a common data model. Database-specific estimates were combined using random-effects meta-analysis. Participants included individuals aged at least 20 years with no history of cancer who used H2RAs for more than 30 days from January 1986 to December 2020, with a 1-year washout period. Data were analyzed from April to September 2021. Exposure The main exposure was use of ranitidine vs other H2RAs (famotidine, lafutidine, nizatidine, and roxatidine). Main Outcomes and Measures The primary outcome was incidence of any cancer, except nonmelanoma skin cancer. Secondary outcomes included all cancer except thyroid cancer, 16 cancer subtypes, and all-cause mortality. Results Among 1 183 999 individuals in 11 databases, 909 168 individuals (mean age, 56.1 years; 507 316 [55.8%] women) were identified as new users of ranitidine, and 274 831 individuals (mean age, 58.0 years; 145 935 [53.1%] women) were identified as new users of other H2RAs. Crude incidence rates of cancer were 14.30 events per 1000 person-years (PYs) in ranitidine users and 15.03 events per 1000 PYs among other H2RA users. After PS matching, cancer risk was similar in ranitidine compared with other H2RA users (incidence, 15.92 events per 1000 PYs vs 15.65 events per 1000 PYs; calibrated meta-analytic hazard ratio, 1.04; 95% CI, 0.97-1.12). No significant associations were found between ranitidine use and any secondary outcomes after calibration. Conclusions and Relevance In this cohort study, ranitidine use was not associated with an increased risk of cancer compared with the use of other H2RAs. Further research is needed on the long-term association of ranitidine with cancer development.
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Affiliation(s)
- Seng Chan You
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, Korea
| | - Seung In Seo
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Korea
| | - Thomas Falconer
- Department of Biomedical Informatics, Columbia University, New York, New York
| | | | - Talita Duarte-Salles
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain
| | | | - Jose D. Posada
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Nigam H. Shah
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Phung-Anh Nguyen
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taiwan
| | - Yeesuk Kim
- Department of Orthopaedic Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Jason C. Hsu
- International PhD Program in Biotech and Healthcare Management, College of Management, Taipei Medical University, Taipei, Taiwan
| | | | - Min-Huei Hsu
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taiwan
| | - Hang Lak Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Heejoo Ko
- College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woon Geon Shin
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Korea
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Rae Woong Park
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
| | | | - Marc A. Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles
- VA Informatics and Computing Infrastructure, US Department of Veterans Affairs, Salt Lake City, Utah
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, New York
- Medical Informatics Services, New York-Presbyterian Hospital, New York, New York
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Daniel Prieto-Alhambra
- Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Department of Medical Informatics, Erasmus Medical Center University, Rotterdam, Netherlands
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Kwon KW, Jang WY, Kim JW, Noh JK, Yi DK, Cho JY. Anti-Inflammatory Effect of Meriania hexamera Sprague by Targeting Syk Kinase in NF-κB Signaling. PLANTS (BASEL, SWITZERLAND) 2023; 12:3044. [PMID: 37687291 PMCID: PMC10490091 DOI: 10.3390/plants12173044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/04/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023]
Abstract
Inflammation is a protective mechanism against harmful stimuli. There are two types of inflammation, acute and chronic, and severe diseases such as cardiovascular disease and cancer can be caused by chronic inflammation. Therefore, this research was conducted to discover new anti-inflammatory drugs. Meriania hexamera Sprague is a common herb in the Amazon region in South America. It is used as a traditional medical herb by natives, but no studies to date have investigated its anti-inflammatory activity. Using lipopolysaccharide (LPS), pam3CSK4 (Pam3), and poly(I:C), we studied the M. hexamera Sprague-Methanol Extract's (Mh-ME) in vitro anti-inflammatory functions. Using RAW264.7 cells, we detected the released nitric oxide (NO) and mRNA expression extent of inducible nitric oxide synthase (iNOS) with pro-inflammatory proteins like tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and iterleukin-1 beta (IL-1β). It was found that Mh-ME suppressed the inflammatory activities in a dose-dependent manner. In the luciferase assay, the nuclear factor kappa light chain enhancer of the activated B cells (NF-κB) pathway was inhibited by Mh-ME. Mh-ME especially acted as an inhibitor of Syk kinase according to the results from CETSA. We also confirmed that Mh-ME mitigates acute gastritis derived from HCl/EtOH in ICR mice, ameliorating the expression of IL-1β and tumor necrosis factor-alpha (TNF-α). In conclusion, Mh-ME is an herb with anti-inflammatory effects that targets Syk in the NF-κB pathway, suggesting that Mh-ME could be used as an anti-inflammatory herbal medicine.
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Affiliation(s)
- Ki Woong Kwon
- Department of Integrative Biotechnology, Sungkyunkwan University, Suwon 16419, Republic of Korea; (K.W.K.); (W.Y.J.); (J.W.K.)
| | - Won Young Jang
- Department of Integrative Biotechnology, Sungkyunkwan University, Suwon 16419, Republic of Korea; (K.W.K.); (W.Y.J.); (J.W.K.)
| | - Ji Won Kim
- Department of Integrative Biotechnology, Sungkyunkwan University, Suwon 16419, Republic of Korea; (K.W.K.); (W.Y.J.); (J.W.K.)
| | - Jin Kyoung Noh
- Instituto de BioEconomia, El Batan, Quito 170135, Ecuador
| | - Dong-Keun Yi
- International Biological Material Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon 34141, Republic of Korea;
| | - Jae Youl Cho
- Department of Integrative Biotechnology, Sungkyunkwan University, Suwon 16419, Republic of Korea; (K.W.K.); (W.Y.J.); (J.W.K.)
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Hedenmalm K, Quinten C, Kurz X, Bradley M, Lee H, Eworuke E. A collaborative study of the impact of N-nitrosamines presence and ARB recall on ARB utilization - results from IQVIA™ Disease Analyzer Germany. Eur J Clin Pharmacol 2023; 79:849-858. [PMID: 37095262 DOI: 10.1007/s00228-022-03439-3] [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: 11/21/2022] [Accepted: 12/06/2022] [Indexed: 04/26/2023]
Abstract
PURPOSE Regulators are increasingly concerned with the impact of recalls on drug adherence. In 2018, N-nitrosamines impurities were detected in valsartan containing medical products. Concerned products were immediately recalled in July 2018 by regulatory agencies internationally. In Germany, recalls were issued for valsartan, losartan and irbesartan from July 2018 to March 2019. This study examined angiotensin II receptor blocker (ARB) utilization trends and switching patterns in Germany before and after July 2018. METHODS Patients prescribed ARBs from January 2014 to June 2020 in general practices in Germany were included in a collaborative framework common protocol drug utilization study led by the US Food and Drug Administration. Trends in monthly and quarterly proportions of total ARB prescribing were analysed for individual ARBs using descriptive statistics and interrupted time series analysis. The rate of switching to an alternative ARB was analysed before and after the recalls. RESULTS The proportion of valsartan prescriptions immediately decreased from 35.9 to 17.8% following the first recalls in July 2018, mirrored by an increased proportion for candesartan. Increased switching from valsartan to candesartan was observed. No increased switching was observed after losartan recalls, whereas for irbesartan, increased switching was observed 6-12 months after the last recall. Increased switching from ARBs to angiotensin-converting enzyme (ACE) inhibitors or ARB treatment discontinuations were not observed. CONCLUSION This study showed that patients were able to continue ARB treatment despite the July 2018-March 2019 recalls, although many patients needed to switch to an alternative ARB. The duration of the impact of ARB recalls appeared to be limited.
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Affiliation(s)
- Karin Hedenmalm
- Data Analytics Workstream, Data Analytics and Methods Task Force, European Medicines Agency, Amsterdam, Netherlands
- Department of Laboratory Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Chantal Quinten
- Data Analytics Workstream, Data Analytics and Methods Task Force, European Medicines Agency, Amsterdam, Netherlands.
| | - Xavier Kurz
- Data Analytics Workstream, Data Analytics and Methods Task Force, European Medicines Agency, Amsterdam, Netherlands
| | - Marie Bradley
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, USA
| | - Hana Lee
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, USA
| | - Efe Eworuke
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, USA
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Danisman B, Cicek B, Yildirim S, Bolat I, Kantar D, Golokhvast KS, Nikitovic D, Tsatsakis A, Taghizadehghalehjoughi A. Carnosic Acid Ameliorates Indomethacin-Induced Gastric Ulceration in Rats by Alleviating Oxidative Stress and Inflammation. Biomedicines 2023; 11:biomedicines11030829. [PMID: 36979808 PMCID: PMC10045571 DOI: 10.3390/biomedicines11030829] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/19/2023] [Accepted: 03/04/2023] [Indexed: 03/12/2023] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and indomethacin (IND) are the most commonly prescribed for inflammation or pain. However, widespread use causes several adverse effects, such as gastric ulcers, upper gastric system bleeding, and erosions. Carnosic acid (CA) is an important natural antioxidant found in rosemary (Rosmarinus essentials) and exhibits a protective effect by suppressing oxidative stress and inflammation. This study aimed to investigate the impact of CA on IND-induced gastric ulceration. Wistar male rats received CA (100 mg/kg) or esomeprazole (ESP) (20 mg/kg, standard drug) by oral gavage for 14 days, after that gastric ulceration was induced by oral administration of 100 mg/kg IND. CA pretreatment attenuated both gross morphological lesions and histopathological alterations. CA strongly reduced IND-induced oxidative stress, verified by a decrease in MDA (p < 0.001) and TOS levels (p < 0.05). Furthermore, an IND-dependent increase in CAT (p < 0.001) and GPx (p < 0.01) activities, as well as a reduction in GSH levels (p < 0.01), were ameliorated by CA pretreatment. CA also attenuated inflammatory damage by suppressing IL-1β (p < 0.01), IL-6 (p < 0.01), and TNFα (p < 0.001) production and increasing Nrf2/HO-1 (p < 0.05) expressions. In conclusion, CA shows a gastroprotective effect by reducing oxidative stress and attenuating inflammation.
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Affiliation(s)
- Betul Danisman
- Department of Biophysics, Faculty of Medicine, Ataturk University, Erzurum 25240, Turkey
| | - Betul Cicek
- Department of Physiology, Faculty of Medicine, Erzincan Binali Yildirim University, Erzincan 24100, Turkey
| | - Serkan Yildirim
- Department of Pathology, Faculty of Veterinary, Atatürk University, Erzurum 25240, Turkey
| | - Ismail Bolat
- Department of Pathology, Faculty of Veterinary, Atatürk University, Erzurum 25240, Turkey
| | - Deniz Kantar
- Department of Biophysics, Faculty of Medicine, Akdeniz University, Antalya 07058, Turkey
| | - Kirill S. Golokhvast
- Siberian Federal Scientific Centre of Agrobiotechnology, Centralnaya, Presidium, Krasnoobsk 633501, Russia
| | - Dragana Nikitovic
- Laboratory of Histology-Embryology, Medical School, University of Crete, 71003 Heraklion, Greece
- Correspondence: (D.N.); (A.T.)
| | - Aristidis Tsatsakis
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Ali Taghizadehghalehjoughi
- Department of Medical Pharmacology, Faculty of Medicine, Bilecik Seyh Edebali University, Bilecik 11000, Turkey
- Correspondence: (D.N.); (A.T.)
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Wang CH, Chen II, Chen CH, Tseng YT. Pharmacoepidemiological Research on N-Nitrosodimethylamine-Contaminated Ranitidine Use and Long-Term Cancer Risk: A Population-Based Longitudinal Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912469. [PMID: 36231768 PMCID: PMC9566239 DOI: 10.3390/ijerph191912469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/24/2022] [Accepted: 09/27/2022] [Indexed: 05/11/2023]
Abstract
N-Nitrosodimethylamine (NDMA), a carcinogenic chemical, has recently been identified in ranitidine. We conducted a population-based study to explore ranitidine use and cancer emergence over time. Using the Taiwan National Health Insurance Research Database, a population-based cohort study was conducted. A total of 55,110 eligible patients who received ranitidine between January 2000 and December 2018 were enrolled in the treated cohort. We conducted a 1:1 propensity-score-matching procedure to match the ranitidine-treated group with the ranitidine-untreated group and famotidine controls for a longitudinal study. The association of ranitidine exposure with cancer outcomes was assessed. A multivariable Cox regression analysis that compared cancer risk with the untreated groups revealed that ranitidine increased the risk of liver (hazard ratio (HR): 1.22, 95% confidence interval (CI): 1.09-1.36, p < 0.001), lung (HR: 1.17, CI: 1.05-1.31, p = 0.005), gastric (HR: 1.26, CI: 1.05-1.52, p = 0.012), and pancreatic cancers (HR 1.35, CI: 1.03-1.77, p = 0.030). Our real-world observational study strongly supports the pathogenic role of NDMA contamination, given that long-term ranitidine use is associated with a higher likelihood of liver cancer development in ranitidine users compared with the control groups of non-ranitidine users treated with famotidine or proton-pump inhibitors.
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Affiliation(s)
- Chun-Hsiang Wang
- Department of Hepatogastroenterology, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan 701033, Taiwan
- Department of Optometry, Chung Hwa Medical University, Tainan 701033, Taiwan
| | - I-I Chen
- Department of Hepatogastroenterology, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan 701033, Taiwan
| | - Chung-Hung Chen
- Department of Gastroenterology, Chang Bing Show Chwan Memorial Hopital, Changhua 505029, Taiwan
| | - Yuan-Tsung Tseng
- Committee of Medical Research, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan 701033, Taiwan
- Correspondence: ; Tel.: +886-6-2609926
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10
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Nørgaard M, Andersen IT, Heide-Jørgensen U, Erichsen R, Rees JR, Karagas MR, Sørensen HT. Ranitidine and Risk of Bladder and Kidney Cancer: A Population-Based Cohort Study. Cancer Epidemiol Biomarkers Prev 2021; 31:45-50. [PMID: 34649959 DOI: 10.1158/1055-9965.epi-21-0737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/12/2021] [Accepted: 10/04/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In 2019, ranitidine was withdrawn due to high levels of N-nitrosodimethylamine, a probable human carcinogen. The risk of bladder and kidney cancer in ranitidine users, however, remains unclear. METHODS In a Danish nationwide cohort study, we included adults (18 years or older) without previous cancer, who between 1996 and 2008 redeemed at least two prescriptions for ranitidine and, as two separate comparison cohorts, patients with at least two prescriptions for other H2-receptor antagonists (H2-blockers), or proton pump inhibitors (PPI). Follow-up for bladder or kidney cancer started at date of the second prescription and continued to date of cancer, death, emigration, or December 31, 2018, whichever occurred first. We used propensity scores for ranitidine use to compute stabilized inverse probability of treatment (sIPT) weights and used Cox regression to compute crude and weighted HRs. RESULTS We identified 31,393 initiators of ranitidine, 65,384 initiating other H2-blockers, and 509,849 initiating PPI. Compared with other H2-blockers, the crude HR for bladder cancer was 1.33 [95% confidence interval (CI): 1.15-1.55], but sIPT weighting attenuated this to 1.11 (95% CI: 0.95-1.29). Compared with PPI initiators, the weighted HR was 1.24 (95% CI: 1.04-1.48). For kidney cancer, the weighted HR was 0.89 (95% CI: 0.72-1.10) compared with users of H2-blockers and 0.87 (95% CI: 0.67-1.13) compared with users of PPI. CONCLUSIONS Our findings did not suggest a substantial increase in bladder or kidney cancer occurrence in ranitidine users. IMPACT These findings are reassuring for previous ranitidine users.
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Affiliation(s)
- Mette Nørgaard
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
| | - Ina Trolle Andersen
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Uffe Heide-Jørgensen
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Rune Erichsen
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Judy R Rees
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Yoon JY, Kwak MS, Jeon JW, Cha JM. Pretreatment with Ranitidine Bismuth Citrate May Improve Success Rates of Helicobacter pylori Eradication: A Prospective, Randomized, Controlled and Open-Label Study. TOHOKU J EXP MED 2021; 255:41-48. [PMID: 34526429 DOI: 10.1620/tjem.255.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Effective Helicobacter pylori (H. pylori) eradication is a major public health concern; however, eradication failure rates with the standard triple therapy remain high. We aimed to investigate the effectiveness and tolerability of ranitidine bismuth citrate (RBC) pretreatment before standard triple therapy for H. pylori eradication. A prospective, randomized, controlled, and open-label clinical trial was conducted from June to December 2019. H. pylori eradication rate, safety, and tolerability were compared between the standard treatment group (esomeprazole, amoxicillin, and clarithromycin for 7 days) and RBC pretreatment group (RBC for 2 weeks before standard triple therapy). This trial ended earlier than estimated owing to the N-nitrosodimethylamine concerns with ranitidine. Success rates of H. pylori eradication were 80.9% and 67.3% in the RBC pretreatment (n = 47) and standard treatment (n = 52) (p = 0.126) groups, respectively. Our trial was discontinued earlier than planned; however, a statistical significance would be achieved by expansion of our data (p = 0.031) if patient enrollment numbers reached those initially planned. Adverse event rates were comparable between groups (25.5% in the pretreatment group vs. 28.8% in the standard treatment group), without serious event. Tolerability was excellent in both groups, recorded as 97.9% and 100% in the pretreatment and standard treatment groups, respectively. Compared with the standard triple regimen, RBC pretreatment for 2 weeks may achieve higher H. pylori eradication rates, with excellent safety and tolerability. However, this study necessitates further validation as it was discontinued early owing to the N-nitrosodimethylamine issues of ranitidine.
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Affiliation(s)
- Jin Young Yoon
- Department of Internal Medicine, Division of Gastroenterology, Kyung Hee University Hospital at Gang Dong
| | - Min Seob Kwak
- Department of Internal Medicine, Division of Gastroenterology, Kyung Hee University Hospital at Gang Dong
| | - Jung Won Jeon
- Department of Internal Medicine, Division of Gastroenterology, Kyung Hee University Hospital at Gang Dong
| | - Jae Myung Cha
- Department of Internal Medicine, Division of Gastroenterology, Kyung Hee University Hospital at Gang Dong
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12
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Cardwell CR, McDowell RD, Hughes CM, Hicks B, Murchie P. Exposure to Ranitidine and Risk of Bladder Cancer: A Nested Case-Control Study. Am J Gastroenterol 2021; 116:1612-1619. [PMID: 34028367 DOI: 10.14309/ajg.0000000000001310] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/12/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Ranitidine has been shown to contain the carcinogen N-nitrosodimethylamine and increase urinary N-nitrosodimethylamine in humans. We investigated whether ranitidine use is associated with increased bladder cancer risk. METHODS A nested case-control study was conducted within the Primary Care Clinical Informatics Unit Research database which contains general practice records from Scotland. Bladder cancer cases, diagnosed between 1999 and 2011, were identified and matched with up to 5 controls (based on age, sex, general practice, and date of registration). Ranitidine, other histamine-2 receptor agonists, and proton pump inhibitors were identified from prescribing records. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression after adjusting for comorbidities and smoking. RESULTS There were 3,260 cases and 14,037 controls. There was evidence of an increased risk of bladder cancer in ranitidine users, compared with nonusers (fully adjusted OR = 1.22; 95% CI 1.06-1.40), which was more marked with use for over 3 years of ranitidine (fully adjusted OR = 1.43; 95% CI 1.05-1.94). By contrast, there was little evidence of any association between proton pump inhibitor use and bladder cancer risk based on any use (fully adjusted OR = 0.98; 95% CI 0.88-1.11) or over 3 years of use (fully adjusted OR = 0.98; 95% CI 0.80-1.20). DISCUSSION In this large population-based study, the use of ranitidine particularly long-term use was associated with an increased risk of bladder cancer. Further studies are necessary to attempt to replicate this finding in other settings.
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Affiliation(s)
- Chris R Cardwell
- Center for Public Health, Queen's University, Belfast, County Antrim, UK
| | - Ronald D McDowell
- Center for Public Health, Queen's University, Belfast, County Antrim, UK
| | - Carmel M Hughes
- School of Pharmacy, Queen's University, Belfast, County Antrim, UK
| | - Blánaid Hicks
- Center for Public Health, Queen's University, Belfast, County Antrim, UK
| | - Peter Murchie
- Division of Applied Health Sciences Section, Academic Primary Care, Foresterhill, Aberdeen, UK
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Florian J, Matta MK, DePalma R, Gershuny V, Patel V, Hsiao CH, Zusterzeel R, Rouse R, Prentice K, Nalepinski CG, Kim I, Yi S, Zhao L, Yoon M, Selaya S, Keire D, Korvick J, Strauss DG. Effect of Oral Ranitidine on Urinary Excretion of N-Nitrosodimethylamine (NDMA): A Randomized Clinical Trial. JAMA 2021; 326:240-249. [PMID: 34180947 PMCID: PMC8240005 DOI: 10.1001/jama.2021.9199] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE In 2019, the US Food and Drug Administration (FDA) received a citizen petition indicating that ranitidine contained the probable human carcinogen N-nitrosodimethylamine (NDMA). In addition, the petitioner proposed that ranitidine could convert to NDMA in humans; however, this was primarily based on a small clinical study that detected an increase in urinary excretion of NDMA after oral ranitidine consumption. OBJECTIVE To evaluate the 24-hour urinary excretion of NDMA after oral administration of ranitidine compared with placebo. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, placebo-controlled, crossover clinical trial at a clinical pharmacology unit (West Bend, Wisconsin) conducted in 18 healthy participants. The study began in June 2020, and the end of participant follow-up was July 1, 2020. INTERVENTIONS Participants were randomized to 1 of 4 treatment sequences and over 4 periods received ranitidine (300 mg) and placebo (randomized order) with a noncured-meats diet and then a cured-meats diet. The cured-meats diet was designed to have higher nitrites, nitrates (nitrate-reducing bacteria can convert nitrates to nitrites), and NDMA. MAIN OUTCOME AND MEASURE Twenty-four-hour urinary excretion of NDMA. RESULTS Among 18 randomized participants (median age, 33.0 [interquartile range {IQR}, 28.3 to 42.8] years; 9 women [50%]; 7 White [39%], 11 African American [61%]; and 3 Hispanic or Latino ethnicity [17%]), 17 (94%) completed the trial. The median 24-hour NDMA urinary excretion values for ranitidine and placebo were 0.6 ng (IQR, 0 to 29.7) and 10.5 ng (IQR, 0 to 17.8), respectively, with a noncured-meats diet and 11.9 ng (IQR, 5.6 to 48.6) and 23.4 ng (IQR, 8.6 to 36.7), respectively, with a cured-meats diet. There was no statistically significant difference between ranitidine and placebo in 24-hour urinary excretion of NDMA with a noncured-meats diet (median of the paired differences, 0 [IQR, -6.9 to 0] ng; P = .54) or a cured-meats diet (median of the paired differences, -1.1 [IQR, -9.1 to 11.5] ng; P = .71). No drug-related serious adverse events were reported. CONCLUSIONS AND RELEVANCE In this trial that included 18 healthy participants, oral ranitidine (300 mg), compared with placebo, did not significantly increase 24-hour urinary excretion of NDMA when participants consumed noncured-meats or cured-meats diets. The findings do not support that ranitidine is converted to NDMA in a general, healthy population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04397445.
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Affiliation(s)
- Jeffry Florian
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Murali K. Matta
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Ryan DePalma
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Victoria Gershuny
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Vikram Patel
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Cheng-Hui Hsiao
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Robbert Zusterzeel
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Rodney Rouse
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Kristin Prentice
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
- Booz Allen Hamilton, McLean, Virginia
| | | | - Insook Kim
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Sojeong Yi
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Liang Zhao
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Miyoung Yoon
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Susan Selaya
- Office of Testing and Research, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, St Louis, Missouri
| | - David Keire
- Office of Testing and Research, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, St Louis, Missouri
| | - Joyce Korvick
- Division of Gastroenterology, Office of Immunology and Inflammation, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - David G. Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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14
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Bercu JP, Masuda-Herrera M, Johnson G, Czich A, Glowienke S, Kenyon M, Thomas R, Ponting DJ, White A, Cross K, Waechter F, Rodrigues MAC. Use of less-than-lifetime (LTL) durational limits for nitrosamines: Case study of N-Nitrosodiethylamine (NDEA). Regul Toxicol Pharmacol 2021; 123:104926. [PMID: 33862169 DOI: 10.1016/j.yrtph.2021.104926] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 11/30/2022]
Abstract
The ICH M7(R1) guideline describes a framework to assess the carcinogenic risk of mutagenic and carcinogenic pharmaceutical impurities following less-than-lifetime (LTL) exposures. This LTL framework is important as many pharmaceuticals are not administered for a patient's lifetime and as clinical trials typically involve LTL exposures. While there has been regulatory caution about applying LTL concepts to cohort of concern (COC) impurities such as N-nitrosamines, ICH M7 does not preclude this and indeed literature data suggests that the LTL framework will be protective of patient safety for N-nitrosamines. The goal was to investigate if applying the LTL framework in ICH M7 would control exposure to an acceptable excess cancer risk in humans. Using N-nitrosodiethylamine as a case study, empirical data correlating exposure duration (as a percentage of lifespan) and cancer incidence in rodent bioassays indicate that the LTL acceptable intake (AI) as derived using the ICH M7 framework would not exceed a negligible additional risk of cancer. Therefore, controlling N-nitrosamines to an LTL AI based on the ICH M7 framework is thus demonstrated to be protective for potential carcinogenic risk to patients over the exposure durations typical of clinical trials and many prescribed medicines.
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Affiliation(s)
- Joel P Bercu
- Gilead Sciences, Nonclinical Safety and Pathobiology (NSP), Foster City, CA, USA.
| | | | - George Johnson
- Institute of Life Science, Swansea University Medical School, Singleton Park, Swansea, SA3 5DE, UK
| | - Andreas Czich
- Sanofi, R&D Preclinical Safety, D-65926, Frankfurt, Germany
| | | | - Michelle Kenyon
- Pfizer Worldwide Research and Development, Genetic Toxicology, Eastern Point Road, Groton, CT, USA
| | - Rob Thomas
- Lhasa Limited, Granary Wharf House, 2 Canal Wharf, Leeds, LS11 5PS, UK
| | - David J Ponting
- Lhasa Limited, Granary Wharf House, 2 Canal Wharf, Leeds, LS11 5PS, UK
| | - Angela White
- GlaxoSmithKline R&D, Park Road, Ware, Hertfordshire, SG12 0DP, UK
| | - Kevin Cross
- Leadscope Inc. an Instem Company, Columbus, OH, 43215, USA
| | - Fernanda Waechter
- Aché Laboratórios Farmacêuticos S.A., Rodovia Presidente Dutra, km 222,2, Porto da Igreja, 07034-904, Guarulhos, SP, Brazil
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