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Katsaras G, Koutsi S, Psaroulaki E, Gouni D, Tsitsani P. Neutropenia in Childhood-A Narrative Review and Practical Diagnostic Approach. Hematol Rep 2024; 16:375-389. [PMID: 38921186 PMCID: PMC11203312 DOI: 10.3390/hematolrep16020038] [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: 08/28/2023] [Revised: 05/24/2024] [Accepted: 06/14/2024] [Indexed: 06/27/2024] Open
Abstract
Neutropenia refers to a decrease in the absolute neutrophil count according to age and race norms and poses a common concern in pediatric practice. Neutrophils serve as host defenders and act crucially in acute inflammation procedures. In this narrative review, we systematically present causes of neutropenia in childhood, mainly adopting the pathophysiological classification of Frater, thereby studying (1) neutropenia with reduced bone marrow reserve, (2) secondary neutropenia with reduced bone marrow reserve, and (3) neutropenia with normal bone marrow reserve. Different conditions in each category are thoroughly discussed and practically approached from the clinician's point of view. Secondary mild to moderate neutropenia is usually benign due to childhood viral infections and is expected to resolve in 2-4 weeks. Bacterial and fungal agents are also associated with transient neutropenia, although fever with severe neutropenia constitutes a medical emergency. Drug-induced and immune neutropenias should be suspected following a careful history and a detailed clinical examination. Cytotoxic chemotherapies treating malignancies are responsible for severe neutropenia and neutropenic shock. Rare genetic neutropenias usually manifest with major infections early in life. Our review of taxonomies clinical findings and associates them to specific neutropenia disorders. We consequently propose a practical diagnostic algorithm for managing neutropenic children.
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Affiliation(s)
- Georgios Katsaras
- Paediatric Department, General Hospital of Pella—Hospital Unit of Edessa, 58200 Edessa, Greece; (S.K.); (E.P.); (D.G.); (P.T.)
| | - Silouani Koutsi
- Paediatric Department, General Hospital of Pella—Hospital Unit of Edessa, 58200 Edessa, Greece; (S.K.); (E.P.); (D.G.); (P.T.)
| | - Evdokia Psaroulaki
- Paediatric Department, General Hospital of Pella—Hospital Unit of Edessa, 58200 Edessa, Greece; (S.K.); (E.P.); (D.G.); (P.T.)
| | - Dimitra Gouni
- Paediatric Department, General Hospital of Pella—Hospital Unit of Edessa, 58200 Edessa, Greece; (S.K.); (E.P.); (D.G.); (P.T.)
- Paediatric Outpatient Department, Health Care Center of Aridaia, 58400 Aridaia, Greece
| | - Pelagia Tsitsani
- Paediatric Department, General Hospital of Pella—Hospital Unit of Edessa, 58200 Edessa, Greece; (S.K.); (E.P.); (D.G.); (P.T.)
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Salas M, Gossell-Williams M, Yalamanchili P, Dhingra S, Malikova MA, Aimer O, Junaid T. The Use of Biomarkers in Pharmacovigilance: A Systematic Review of the Literature. Biomark Insights 2023; 18:11772719231164528. [PMID: 37077840 PMCID: PMC10108426 DOI: 10.1177/11772719231164528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/02/2023] [Indexed: 04/21/2023] Open
Abstract
Background The use of biomarkers varies from disease etiognosis and diagnosis to signal detection, risk prediction, and management. Biomarker use has expanded in recent years, however, there are limited reviews on the use of biomarkers in pharmacovigilance and specifically in the monitoring and management of adverse drug reactions (ADRs). Objective The objective of this manuscript is to identify the multiple uses of biomarkers in pharmacovigilance irrespective of the therapeutic area. Design This is a systematic review of the literature. Data Sources and Methods Embase and MEDLINE database searches were conducted for literature published between 2010-March 19, 2021. Scientific articles that described the potential use of biomarkers in pharmacovigilance in sufficient detail were reviewed. Papers that did not fulfill the United States Food and Drug Administration (US FDA) definition of a biomarker were excluded, which is based on the International Conference on Harmonisation (ICH)-E16 guidance. Results Twenty-seven articles were identified for evaluation. Most articles involved predictive biomarkers (41%), followed by safety biomarkers (38%), pharmacodynamic/response biomarkers (14%), and diagnostic biomarkers (7%). Some articles described biomarkers that applied to multiple categories. Conclusion Various categories of biomarkers including safety, predictive, pharmacodynamic/response, and diagnostic biomarkers are being investigated for potential use in pharmacovigilance. The most frequent potential uses of biomarkers in pharmacovigilance in the literature were the prediction of the severity of an ADR, mortality, response, safety, and toxicity. The safety biomarkers identified were used to evaluate patient safety during dose escalation, identify patients who may benefit from further biomarker testing during treatment, and monitor ADRs.
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Affiliation(s)
- Maribel Salas
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
- Center for Real-world Effectiveness and Safety of Therapeutics (CREST), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Priyanka Yalamanchili
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
- Rutgers Institute for Pharmaceutical Industry Fellowships, Piscataway, NJ, USA
- Priyanka Yalamanchili, Daiichi Sankyo, Inc., 211 Mount Airy Rd, Basking Ridge, NJ 07920-2311, USA.
| | - Sameer Dhingra
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, India
| | - Marina A Malikova
- School of Medicine, Boston University, Boston, MA, USA
- Department of Surgery, Boston Medical Center, Boston, MA, USA
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Pais GM, Chang J, Barreto EF, Stitt G, Downes KJ, Alshaer MH, Lesnicki E, Panchal V, Bruzzone M, Bumanglag AV, Burke SN, Scheetz MH. Clinical Pharmacokinetics and Pharmacodynamics of Cefepime. Clin Pharmacokinet 2022; 61:929-953. [PMID: 35764774 PMCID: PMC9345683 DOI: 10.1007/s40262-022-01137-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Abstract
Cefepime is a broad-spectrum fourth-generation cephalosporin with activity against Gram-positive and Gram-negative pathogens. It is generally administered as an infusion over 30-60 min or as a prolonged infusion with infusion times from 3 h to continuous administration. Cefepime is widely distributed in biological fluids and tissues with an average volume of distribution of ~ 0.2 L/kg in healthy adults with normal renal function. Protein binding is relatively low (20%), and elimination is mainly renal. About 85% of the dose is excreted unchanged in the urine, with an elimination half-life of 2-2.3 h. The pharmacokinetics of cefepime is altered under certain pathophysiological conditions, resulting in high inter-individual variability in cefepime volume of distribution and clearance, which poses challenges for population dosing approaches. Consequently, therapeutic drug monitoring of cefepime may be beneficial in certain patients including those who are critically ill, have life-threatening infections, or are infected with more resistant pathogens. Cefepime is generally safe and efficacious, with a goal exposure target of 70% time of the free drug concentration over the minimum inhibitory concentration for clinical efficacy. In recent years, reports of neurotoxicity have increased, specifically in patients with impaired renal function. This review summarizes the pharmacokinetics, pharmacodynamics, and toxicodynamics of cefepime contemporarily in the setting of increasing cefepime exposures. We explore the potential benefits of extended or continuous infusions and therapeutic drug monitoring in special populations.
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Affiliation(s)
- Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | - Jack Chang
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | | | - Gideon Stitt
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin J Downes
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Emily Lesnicki
- College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Vaidehi Panchal
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA
| | - Maria Bruzzone
- Division of Neurology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Argyle V Bumanglag
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA
- Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sara N Burke
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA
- Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA.
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA.
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Duwez M, Szymanski G, Carre M, Mallaret M, Lepelley M. [Idiosyncratic drug-induced agranulocytosis: 7 year-analysis in a French university hospital]. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 78:230-241. [PMID: 32248952 DOI: 10.1016/j.pharma.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Idiosyncratic drug-induced agranulocytosis is a rare but potentially serious haematological disorder. The pathophysiological mechanisms are complex and poorly understood. We aimed at investigating agranulocytosis drug related causes from the myelograms with "myeloid maturation arrest" performed in our university hospital over the last seven years. METHODS A retrospective analysis of myelograms collected for agranulocytosis was performed from 1st January 2010 to 31th December 2016. We used the method of Bégaud et al. for drug causality assessment. RESULTS Among the 104 myelograms analysed, 41 agranulocytosis were drug-induced, whose 28 were idiosyncratic. Among these 28 cases, 26 different drugs were involved. Agranulocytosis was a known adverse reaction in the summary of the product characteristics for 24 drugs, mainly associated with undetermined frequency (n=7). Mean onset latency was 38.1 days after starting the drug (calculated for n=23 cases) and granulocyte growth factors were used in 50% of cases without shortening the mean delay of blood count recovery. Bone marrow presented hypereosinophilia in 29% of cases. Pharmacovigilance reporting rate was 48%. CONCLUSION A "maturation arrest" in the myelogram is not pathognomonic for idiosyncratic drug-induced agranulocytosis. This rare event require multidisciplinary care involving haematologists, biologists and pharmacovigilance experts. Agranulocytosis reporting rate was high compared with usual adverse drug reaction reporting rate (5 to 10%), probably related to the potential severity of this event.
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Affiliation(s)
- M Duwez
- Département de pharmacie, CHU de Grenoble-Alpes, 38000 Grenoble, France.
| | - G Szymanski
- Laboratoire d'hématologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Carre
- Clinique universitaire d'hématologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Mallaret
- Centre régional de pharmacovigilance, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Lepelley
- Centre régional de pharmacovigilance, CHU de Grenoble-Alpes, 38000 Grenoble, France
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Revuelta-Herrero JL, García-Sánchez R, Anguita-Velasco J, de Lorenzo-Pinto A, Ortega-Navarro C, Sanjurjo-Sáez M. Drug safety surveillance within a strategy for the management of non-chemotherapy drug-induced neutropenia. Int J Clin Pharm 2019; 41:1143-1147. [PMID: 31256332 DOI: 10.1007/s11096-019-00873-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 06/22/2019] [Indexed: 01/23/2023]
Abstract
Background Severe non-chemotherapy drug-induced neutropenia is a rare idiosyncratic drug reaction that is considered potentially fatal. Objective To report, in terms of drug safety surveillance, the results of an institutional strategy for NCDIN. Method An observational and prospective study including all adult patients who received filgrastim for the treatment of NCDIN from June 2015 to December 2017 was carried out by hematologists and clinical pharmacists. Results 13 patients with severe NCDIN were included in the study. The median age was 51 (range 24-80) years old and 46.2% were male. Seven patients had one or more negative prognostic factors (age > 65 years, renal impairment, autoimmune diseases and/or a neutrophil count at diagnosis < 0.1 × 109 cells/L). A single drug was identified as causative in 3 patients, while in 10 cases, 2-3 drugs were considered as potentially causative. The most frequent drugs were metamizole, piperacillin/tazobactam, dexketoprofen and linezolid, among others. Seven patients developed NCDIN during their hospital stay while 6 were admitted to the emergency department. Patients were using a median of 11 drugs (IQR 8-15) at the time of diagnosis. No deaths were recorded. Conclusion Metamizole and piperacillin/tazobactam are the most common drugs linked to non-chemotherapy drug-induced neutropenia in our cohort.
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Affiliation(s)
- José Luis Revuelta-Herrero
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain.
| | - Raquel García-Sánchez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Javier Anguita-Velasco
- Haematology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, Madrid, 28007, Spain
| | - Ana de Lorenzo-Pinto
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Cristina Ortega-Navarro
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain
| | - María Sanjurjo-Sáez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo 46, 28007, Madrid, Spain
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Curtis BR. Non-chemotherapy drug-induced neutropenia: key points to manage the challenges. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:187-193. [PMID: 29222255 PMCID: PMC6142577 DOI: 10.1182/asheducation-2017.1.187] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Non-chemotherapy idiosyncratic drug-induced neutropenia (IDIN) is a relatively rare but potentially fatal disorder that occurs in susceptible individuals, with an incidence of 2.4 to 15.4 cases per million population. Affected patients typically experience severe neutropenia within several weeks to several months after first exposure to a drug, and mortality is ∼5%. The drugs most frequently associated with IDIN include metamizole, clozapine, sulfasalazine, thiamazole, carbimazole, amoxicillin, cotrimoxazole, ticlopidine, and valganciclovir. The idiosyncratic nature of IDIN, the lack of mouse models and diagnostic testing, and its low overall incidence make rigorous studies to elucidate possible mechanisms exceptionally difficult. An immune mechanism for IDIN involving neutrophil destruction by hapten (drug)-specific antibodies and drug-induced autoantibodies is frequently suggested, but strong supporting evidence is lacking. Although laboratory testing for neutrophil drug-dependent antibodies is rarely performed because of the complexity and low sensitivity of tests currently in use, these assays could possibly be enhanced by using reactive drug metabolites in place of the parent drug. Patients typically experience acute, severe neutropenia, or agranulocytosis (<0.5 × 109 neutrophils/L) and symptoms of fever, chills, sore throat, and muscle and joint pain. Diagnosis can be difficult, but timely recognition is critical because if left untreated, there is an increase in mortality. Expanded studies of the production and mechanistic role of reactive drug metabolites, genetic associations, and improved animal models of IDIN are essential to further our understanding of this important disorder.
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Affiliation(s)
- Brian R Curtis
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
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Sing CW, Wong ICK, Cheung BMY, Chan JCY, Chu JKP, Cheung CL. Incidence and risk estimate of drug-induced agranulocytosis in Hong Kong Chinese. A population-based case-control study. Pharmacoepidemiol Drug Saf 2017; 26:248-255. [DOI: 10.1002/pds.4156] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 11/23/2016] [Accepted: 12/01/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Chor-Wing Sing
- Department of Pharmacology and Pharmacy; The University of Hong Kong; Hong Kong
| | - Ian C. K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy; The University of Hong Kong; Hong Kong
- Centre for Paediatric Pharmacy Research, Research Department of Practice and Policy, School of Pharmacy; University College London; London UK
- The State Key Laboratory of Pharmaceutical Biotechnology, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Hong Kong
| | - Bernard M. Y. Cheung
- The State Key Laboratory of Pharmaceutical Biotechnology, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Hong Kong
- Department of Medicine; The University of Hong Kong; Hong Kong
| | | | - Jody K. P. Chu
- Department of Pharmacology and Pharmacy; The University of Hong Kong; Hong Kong
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy; The University of Hong Kong; Hong Kong
- The State Key Laboratory of Pharmaceutical Biotechnology, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Hong Kong
- Department of Medicine; The University of Hong Kong; Hong Kong
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