Adverse oral reactions associated with the COX-2 inhibitor rofecoxib

Fixed drug eruption secondary to etoricoxib

Fixed drug eruptions (FDE) are adverse cutaneous drug reactions and a form of delayed type 4 hypersensitivity reaction characterised by recurrent lesions at the same site each time a specific drug is taken. They most commonly result in cutaneous lesions presenting as an erythematous round or oval macule or plaque. FDEs have rarely been reported to affect oral mucous membranes and tend to have a bullous or aphthous-like appearance with erythema. Almost half of patients report an increase in the severity of symptoms with prolonged exposure to the offending medication. The most commonly attributed classes of drug are antibiotics (tetracyclines and sulphonamides) alongside non-steroidal anti-inflammatory drugs. Cutaneous adverse reactions to etoricoxib, a highly selective COX-2 inhibitor, have been reported. Here we describe an adverse reaction restricted to the oral mucosa.

Safety evaluation of the interchangeable use of robenacoxib in commercially-available tablets and solution for injection in cats

Background

Robenacoxib (Onsior™) is a non-steroidal anti-inflammatory drug developed for canine and feline use for the control of pain and inflammation. It is available as both tablets and solution for injection.

The objective of this study was to evaluate the safety of the interchangeable use of commercially available robenacoxib formulations when administered to cats orally using 6 mg tablets and subcutaneously using a solution for injection containing 20 mg/mL. Thirty-four naïve healthy 4-month old cats were enrolled in this 37-day study and were randomized to four groups (three robenacoxib and one control). One robenacoxib group received the maximum recommended dose (MRD) rate of each formulation, while the other two received two and three times this dose rate. The cats underwent three 10-day treatment cycles comprised of seven days of once daily oral administration followed by three days of subcutaneous administration. The third cycle was followed by an additional seven days of oral treatment. The control group received oral empty gelatin capsules or subcutaneous saline injections. Assessment of safety was based on general health observations, clinical observations, physical, ophthalmic, electrocardiographic and neurological examinations, clinical pathology evaluations, food consumption, body weight, and macroscopic and microscopic examinations. Blood samples were collected for toxicokinetic evaluation.

Results

Blood concentrations of robenacoxib confirmed systemic exposure of all treated cats. All cats were in good health through study termination and there were no serious adverse events during the study. There were no changes in body weight, food consumption, ophthalmic, physical or neurological examinations during the study. Treatment-related abnormalities were of low occurrence at all doses and included injection site changes (transient edema with minimal or mild, subacute/chronic inflammation histologically) and prolongation of the QT interval. These findings were consistent with previously observed findings in studies with robenacoxib administered separately orally or subcutaneously in cats. Thus, there were no adverse effects that could be attributed specifically to the interchangeable use of oral and injectable robenacoxib.

Conclusions

This 37-day laboratory study supports the safety of interchanging robenacoxib injection at a daily dose of 2 mg/kg with robenacoxib tablets at a daily dose of 1 mg/kg, or vice versa.

Adverse Drug Events in the Oral Cavity

Adverse reactions to medications are common and may have a variety of clinical presentations in the oral cavity. Targeted therapies and new biologic agents have revolutionized the treatment of cancers, autoimmune diseases, and inflammatory and rheumatologic diseases but have also been associated with adverse events in the oral cavity. This review describes the most common clinical presentations of oral mucosal reactions to medications, namely hyposalivation, lichenoid reactions, ulcers, bullous disorders, pigmentation, fibrovascular hyperplasia, reactive keratosis, dysesthesia, osteonecrosis, infection, angioedema, and malignancy.

Dysbiosis of saliva microbiome in patients with oral lichen planus

Background

Oral microbiota is not only important for maintaining oral health but also plays a role in various oral diseases. However, studies regarding microbiome changes in oral lichen planus (OLP) are very limited. To the best of our knowledge, there has been only two studies investigating salivary microbiome changes in OLP. Therefore, the purpose of this study was to identify the characteristic microbial profile in the saliva of OLP patients, with or without erosive lesions, and compare that with recurrent aphthous ulcer (RAU), a common oral immunological disorder that also shows multiple erosive/ulcerative lesions. Whole saliva samples were collected from 20 patients with OLP (erosive E, n = 10 and non-erosive NE, n = 10), 10 patients with RAU (U) and 10 healthy controls (C). DNA was extracted from the saliva samples, and the 16S rDNA gene V4 hypervariable region was analyzed using Illumina sequencing.

Results

We obtained 4949 operational taxonomic units (OTUs) from the V4 region in all saliva samples. Community composition analysis showed a clear decreased relative abundance of genera Streptococcus and Sphingomonas in saliva from RAU patients when compared to the other three groups. Relative abundance of Lautropia and Gemella were higher in E group, whereas relative abundance of Haemophilus and Neisseria were higher in NE group when compared to C group. Abiotrophia and Oribacterium were higher in OLP (combining E and NE groups), while Eikenella and Aggregatibacter were lower when compared to C group. There was statistically significance in α-diversity between E and RAU groups(p < 0.05). Significant differences in β-diversity were detected in bacteria between E and C; NE and C; as well as E and NE groups. The LDA effect size algorithm identified the g_Haemophilus might be the potential biomarker in NE group.

Conclusions

We found that salivary microbiome in erosive OLP was significantly different from that found in RAU; and these changes may be related to the underlying disease process rather than presence of ulcerative/erosive lesions clinically. In addition, our findings in bacterial relative abundance in OLP were significantly different from the previously reported findings, which points to the need for further research in salivary microbiome of OLP.

Correlation of clinicopathological characteristics and direct immunofluorescence studies in oral lichenoid lesion in Thai patients

AIM

To investigate the correlation between the clinicopathological characteristics, serum antinuclear antibody (ANA) and direct immunofluorescence (DIF) findings in oral lichen planus (OLP) and oral lichenoid lesion (OLL).

METHODS

Fifty three Thai patients with red and white lesions were divided into 3 groups: 17 cases of OLP, 19 cases of OLL and 17 cases of oral lichenoid drug reaction (OLDR), respectively. The medical records, photographs, histopathological evaluation and laboratory ANA and DIF results were analyzed.

RESULTS

Atrophic pattern was the most commonly found pattern in the OLDR, OLP and OLL groups. In the OLP group, the DIF interpretation confirmed only 41.2% of cases as OLP, with 23.5% each as lichen planus (LP)/lupus erythematosus (LE) or negative findings. In the OLL group, the most common DIF interpretation (31.6% each) was LP/LE or non-specific finding. In the OLDR group, DIF interpretation was OLP or LP/LE (23.5% each), with 5.9% each of immune complex-mediated disease, compatible with OLP, and mixed connective tissue disease. Interestingly, 1 case in the OLDR group demonstrated mild to moderate dysplasia. There were no significant differences in ANA positivity or patterns between the 3 groups.

CONCLUSION

An OLP-like lesion could be diagnosed as OLP, OLP/LE, chronic ulcerative-like lesion, immune-mediated disease or dysplasia.

A Review of the Effectiveness and Side-Effects of Fluocinolone Acetonide 0.1% in the Treatment of Oral Mucosal Diseases

Topical steroids have been widely used in the treatment of symptomatic oral lesions to reduce pain and inflammation. Potent topical steroids such as clobetasol propionate, fluocinolone acetonide (FA), and fluocinonide have been widely used in the treatment of severe oral mucosal lesions. Many reports have demonstrated that these steroids were effective in treating oral lesions with only minor side-effects. This review describes the effectiveness and side-effects of using FA 0.1% in the treatment of symptomatic oral lichen planus (OLP), oral lichenoid drug reaction (OLDR), oral pemphigus, and herpes associated erythema multiforme (HAEM). FA 0.1% was effective and safe in the treatment of patients with multiple systemic diseases and a pregnant patient with HAEM. Moreover, this topical steroid rapidly reduced pain, inflammation, and enhanced lesion healing with no serious side-effects other than pseudomembranous candidiasis, which is easily treated. In some cases, a long-term treatment with FA 0.1% resulted in hyperpigmentation at the areas of previously healed oral lesions; however, this hyperpigmentation was gradually resolved after discontinuing topical steroid treatment.

Oral and vulvo-vaginal lichenoid reactions due to mitotane (Lysodren): A case report

BACKGROUND

The purpose of pharmacovigilance (drug safety) is collection, detection, assessment, monitoring, and prevention of adverse effects with pharmaceutical products. It is meant to identify, characterize, prevent, or minimize actual or potential risks relating to medicinal products. To prevent these adverse effects and improve our practice, health professionals have a duty to report side effects to assess this risk and evaluate the benefit/risk requirements. Mitotane (Lysodren) is used for treating adrenocortical carcinoma. Currently, no side effects concerning oral and genital mucosa have been reported.

CASE SUMMARY

This case report is about a 50 years old woman. Six months after the initiation on mitotane treatment, she developed erosive lesions located on the oral and vaginal mucosa. These drug reactions were diagnosed as erosive lichen planus by the biopsy. This lichenoid lesions were resistant to the usual treatments, mitotane being at the time not replaceable.

CONCLUSION

This case describes an unreported adverse effect of mitotane, it is - to our knowledge - the 1st description of erosive lichenoid drug reaction due to Mitotane.

Topical Steroids and CO2 Laser in the Treatment of Refractory Oral Lichenoid Drug Reaction and Lichenoid Contact Lesion: a Case Report

A 54-year-old female presented with severe pain on the gingiva and buccal mucosa. Oral findings revealed generalized fiery red gingiva, ulcerative with white striae covered by pseudo-membranes on both buccal mucosae. She had hypertension, dyslipidemia, subclinical hypothyroidism and arthritis. She was treated with atorvastatin, hydrochlorothiazide, valsartan, levothyroxine and non-steroidal anti-inflammatory drug (NSAIDs). Her oral lesions were a slight improvement from a previous treatment with pimecrolimus cream, triamcinolone acetonide 0.1% orabase and injection. After diclofenac was replaced with tenoxicam and oral lesions were treated with various topical steroids, the lesions showed marked improvement. The biopsy from the buccal mucosa revealed oral lichen planus. Patch test showed positivity to mercury, gold sodium thiosulfate and palladium. One year later the left buccal mucosa showed red, round papillomatous-like lesions. The histopathological report showed a non-specific ulcer with chronic inflammation. The lesions flared up after replacing amalgam with crowns. After CO2 laser treatment, the lesions showed some improvement. Direct and indirect immunofluorescence of the lesions proved to be negative. This first case report showed that the palliative treatment of refractory oral lichenoid lesions with potent topical steroids for 7 years had no side-effects. CO2 laser can be an alternative treatment of refractory lesion in this case.

Oral lichenoid lesions - a review and update

Background:

Oral lichenoid lesions or reactions (OLLs/OLRs) are clinical and histological contemporaries of the classical oral lichen planus (OLP) that have generated a lot of debate in literature. In contrast to the idiopathic nature of OLP, OLLs are often associated with a known identifiable inciting factor. A superficial examination of these lesions clinically and histologically often reveals many similarities with OLP, but recent data indicate that distinguishable features do exist and form the basis of most classifications.

Aims and Objectives:

This paper attempts to collate available data in English literature on OLLs, highlight distinguishing features clinically and histologically and reflect on the malignant transformation potential and treatment modalities of the condition.

Materials and Methods:

A comprehensive search of medical and dental databases including PubMed, Ovid, Cochrane, Pubget, Researchgate, and non-medical search engines were utilized for the review. The search words included “oral lichen planus”, “oral lichenoid lesions”, “oral drug reactions”, “lichenoid dysplasia”, and “adverse effects of dental materials”.

Review Results:

OLLs seem to grossly underrated and most cases were clubbed as OLP. Definite clinical and histological features were uncovered to establish the identity of this lesion. Associations with dental restorative materials, drugs, and medications have been conclusively proven in the etiology of this condition. Specific markers are being utilized to diagnose the condition and monitor its progress.

Conclusion:

Substantial differentiating features were uncovered to delineate OLLs as a separate entity with definite etiology, pathogenesis, and a high malignant transformation rate compared with OLP.

Adverse drug events in the oral cavity

Adverse reactions to medications are common and may have a variety of clinical presentations in the oral cavity. Targeted therapies and the new biologic agents have revolutionized the treatment of cancers, autoimmune diseases, and inflammatory and rheumatologic diseases but have also been associated with adverse events in the oral cavity. Some examples include osteonecrosis, seen with not only bisphosphonates but also antiangiogenic agents, and the distinctive ulcers caused by mammalian target of rapamycin inhibitors. As newer therapeutic agents are approved, it is likely that more adverse drug events will be encountered. This review describes the most common clinical presentations of oral mucosal reactions to medications, namely, xerostomia, lichenoid reactions, ulcers, bullous disorders, pigmentation, fibrovascular hyperplasia, white lesions, dysesthesia, osteonecrosis, infection, angioedema, and malignancy. Oral health care providers should be familiar with such events, as they will encounter them in their practice.

Antiretroviral Drug-Associated Oral Lichenoid Reaction in HIV Patient: A Case Report

Antiretroviral therapy has changed the course of HIV disease and improved quality of life in HIV patients. Incidence of an oral lichenoid drug reaction induced by zidovudine is not common. Once it occurs, it affects a patient's well being, in particular their oral functions. Here we report the first case of a 34-year-old Thai man with painful erosive lesions involving the lip and buccal mucosa. Treatment with topical fluocinolone acetonide 0.1% alleviated the patient's oral pain, but it was not until the subsequent withdrawal of zidovudine that the patient showed improvement and resolution of the lesions. Long-term follow-up was useful in the management of this patient, and no recurrence of the lesion was found during 21-month follow-up in this patient.

Oral lichenoid drug eruption: a report of a pediatric case and review of the literature

Lichenoid drug eruptions are seen most frequently on the skin and seldomly affect the mucosal surfaces. Oral involvement-known as oral lichenoid drug eruption-is more common in the adult population and has been associated with numerous medications. Pediatric-onset oral lichenoid drug eruption is an exceptionally rare finding with only isolated cases published in the literature. The nonspecific appearance and latent presentation of pediatric oral lichenoid drug eruption can cause confusion in diagnosis and treatment. We report a case of oral lichenoid drug eruption occurring in a 15-year-old and explore challenges in the clinical and histologic recognition of this condition.

Steriods in the treatment of lichen planus: a review

Steroids have been found to be effective in treating symptomatic oral lichen planus (OLP) by reducing pain and inflammation. In fact, systemic corticosteroids should be reserved for acute exacerbation, and multiple or widespread lesions. They may be indicated in patients whose condition is unresponsive to topical steroids. However, various potent topical steroids have been reported to be effective in the treatment of symptomatic OLP. They can be used as the first line drugs in the treatment of OLP with no serious side-effects. During the therapy, candidiasis was commonly found and in addition, bad taste, nausea, dry mouth, sore throat and swollen mouth may occur as minor side-effects from some topical steroids. Because OLP is a chronic disorder that requires long-term treatment, topical steroids are recommended for the treatment OLP because of minimal side-effects and the cost benefit. This manuscript reviews the use of steroids, especially its topical application, in the treatment of OLP.

Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation

Lichen planus, a chronic autoimmune, mucocutaneous disease affects the oral mucosa (oral lichen planus or OLP) besides the skin, genital mucosa, scalp and nails. An immune mediated pathogenesis is recognized in lichen planus although the exact etiology is unknown. The disease most commonly affects middle-aged females. Oral lichenoid reactions (OLR) which are considered variants of OLP, may be regarded as a disease by itself or as an exacerbation of an existing OLP, by the presence of medication (lichenoid drug reactions) or dental materials (contact hypersensitivity). OLP usually presents as white striations (Wickham's striae), white papules, white plaque, erythema, erosions or blisters. Diagnosis of OLP is established either by clinical examination only or by clinical examination with histopathologic confirmation. Direct immunofluorescence examination is only used as an adjunct to the above method of diagnosis and to rule out specific autoimmune diseases such as pemphigus and pemphigoid. Histopathologic features of OLP and OLR are similar with suggestions of certain discriminatory features by some authors. Topical corticosteroids are the treatment of choice for OLP although several other medications have been studied including retinoids, tacrolimus, cyclosporine and photodynamic therapy. Certain OLP undergo malignant transformation and the exact incidence and mechanisms are still controversial. In this paper, etiopathogenesis, diagnosis, management and malignant transformation of OLP and OLR have been reviewed.