1
|
Zhang Y, Jia X, Shi X, Chen Y, Xue M, Shen G, Wen L, Qiao Y, Yang Y. Mining of neurological adverse events associated with valbenazine: A post-marketing analysis based on FDA adverse event reporting system. Gen Hosp Psychiatry 2024; 90:22-29. [PMID: 38901166 DOI: 10.1016/j.genhosppsych.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 06/10/2024] [Accepted: 06/10/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE Valbenazine is commonly used to treat tardive dyskinesia, and we conducted a pharmacovigilance analysis using the Food and Drug Administration Adverse Event Reporting System (FAERS) to evaluate neurological safety signals associated with valbenazine. METHODS Data was collected in FAERS from the second quarter of 2017 to the fourth quarter of 2023 for data cleaning. Neurological adverse event (AE) signals of valbenazine were mined by calculating reporting odds ratios (ROR), information component (IC) and empirical Bayesian geometric mean (EBGM). The serious and non-serious cases and signals were prioritized using a rating scale. RESULTS The number of neurological AE reports where the primary suspect (PS) drug was 8981 for valbenazine. Significant AE signals were identified by the preferred term (PT) analysis for valbenazine, including somnolence (ROR 19.69), tremor (ROR 15.17), and tardive dyskinesia (ROR 236.91), among which 18 AEs were identified as new signals. Patient age (p < 0.009) and sex (p = 0.197) might be associated with an increased risk of neurological AE severity. Notably, the association between valbenazine and neurological disorders remained when stratified by sex, age, and reporter type. AE timing analysis was performed for the drug and four moderate clinical priority signals [i.e., somnolence, balance disorder, parkinsonism, and akathisia (priorities 7)], showing the same early failure type profiles. CONCLUSIONS The increase in neurological safety signals is identified in the post-marketing research of valbenazine. Clinicians need to pay attention to not only common AEs but also be alert to new neurological AE signals when using valbenazine.
Collapse
Affiliation(s)
- Yi Zhang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| | - Xiaocan Jia
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| | - Xuezhong Shi
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| | - Yongyue Chen
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| | - Mingyi Xue
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| | - Guibin Shen
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| | - Long Wen
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| | - Ying Qiao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| | - Yongli Yang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China.
| |
Collapse
|
2
|
Zhou J, Lai W, Wei Z, Xu B, Liu M, Zhang N, Wu X. Exploring the Link Between Exogenous Thyroid Hormones and Dementia Symptoms: A Real-World Disproportionality Analysis of FDA Adverse Event Reporting System. Ann Pharmacother 2024:10600280241252211. [PMID: 38755964 DOI: 10.1177/10600280241252211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND A growing body of evidence indicates a strong association between exogenous thyroid hormone (ETH) and brain health. Establishing the potential relationship between ETH therapy and dementia symptoms is crucial for patients with thyroid disorders. OBJECTIVE In this study, we investigate the potential association between ETH therapy and dementia symptoms by exploring the Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS Disproportionality analysis (DPA) was conducted using postmarketing data from the FAERS repository (Q1 2004 to Q4 2023). Cases of dementia symptoms associated with ETH therapy were identified and analyzed through DPA using reporting odds ratios and information component methods. Dose and time-to-onset analyses were performed to assess the association between ETH therapy and dementia symptoms. RESULTS A total of 9889 cases of ETH-associated symptoms were identified in the FAERS database. Dementia accounted for a consistent proportion of adverse drug reactions each year (3.4%-6.3%). The DPA indicated an association between ETH therapy and dementia symptoms, which remained significant even across sex, age, and indications. The median time-to-onset of dementia symptoms was 7.5 days, and the median treatment time was 40.5 days. No significant dose-response relationship was observed. CONCLUSION AND RELEVANCE This study provides evidence for a link between ETH therapy and dementia. Clinicians are therefore advised to exercise vigilance, conduct comprehensive monitoring, and consider individualized dosing to mitigate potential reactions to ETH drug administration.
Collapse
Affiliation(s)
- Jianxing Zhou
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Weipeng Lai
- School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Zipeng Wei
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Baohua Xu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Maobai Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Nanwen Zhang
- School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Xuemei Wu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| |
Collapse
|
3
|
Cao B, Gu S, Shen Z, Zhang Y, Shen Y, Chen H. Evaluating Ubrogepant-related adverse events using the FDA adverse event reporting system. Expert Opin Drug Saf 2024; 23:297-303. [PMID: 37608560 DOI: 10.1080/14740338.2023.2251390] [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: 07/04/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Migraine has a high prevalence in the population and accounts for 12% of primary headaches. Ubrogepant is used for the treatment of acute migraine, and although some clinical trials have demonstrated the safety of Ubrogepant, its long-term safety in a large sample of the population remains to be investigated. METHODS We collected data from the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. We used reporting odds ratio (ROR), the proportional reporting ratio (PRR), the information component (IC) and the empirical Bayes geometric mean (EBGM) to evaluate Ubrogepant-induced adverse events (AEs). RESULTS We screened out 2,067 reports of Ubrogepant as primary suspected (PS) and 6,190 reports of Ubrogepant-induced AEs as PS. Our results showed that Ubrogepant-induced AEs targeted 4 system organ classes (SOCs), detected 32 Preferred terms (PTs) signals in 9 SOCs, including common Ubrogepant label consistent with Migraine, Nausea, Somnolence, Paraesthesia oral and Dizziness, It also includes the AEs of Hemiparesis, Mental impairment, Dysstasia, Tinnitus, Chest pain, Cold sweat, Neck pain, etc. that have not been demonstrated in previous studies. CONCLUSIONS Our study identified new AEs that have not been reported, which provides a new guidance to deepen the comprehension of the safety of Ubrogepant.
Collapse
Affiliation(s)
- Bing Cao
- Department of Otorhinolaryngology Head and Neck Surgery, Lihuili Hospital affiliated to Ningbo University, Ningbo, Zhejiang, China
| | - Shanshan Gu
- Department of Otorhinolaryngology Head and Neck Surgery, Lihuili Hospital affiliated to Ningbo University, Ningbo, Zhejiang, China
| | - Zhisen Shen
- Department of Otorhinolaryngology Head and Neck Surgery, Lihuili Hospital affiliated to Ningbo University, Ningbo, Zhejiang, China
| | - Yuna Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Lihuili Hospital affiliated to Ningbo University, Ningbo, Zhejiang, China
| | - Yiming Shen
- Department of Otology and Skull Base Surgery, National Health Commission Key Laboratory of Hearing Medicine (Fudan University), Shanghai City, P. R. China
| | - Hang Chen
- Department of Thoracic surgery, The Affiliated Lihuili Hospital, Ningbo University, Ningbo, Zhejiang Province, P. R. China
| |
Collapse
|
4
|
Zhou J, Zheng Y, Xu B, Long S, Zhu LE, Liu Y, Li C, Zhang Y, Liu M, Wu X. Exploration of the potential association between GLP-1 receptor agonists and suicidal or self-injurious behaviors: a pharmacovigilance study based on the FDA Adverse Event Reporting System database. BMC Med 2024; 22:65. [PMID: 38355513 PMCID: PMC10865629 DOI: 10.1186/s12916-024-03274-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/25/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Establishing whether there is a potential relationship between glucagon-like peptide 1 receptor agonists (GLP-1RAs) and suicidal or self-injurious behaviors (SSIBs) is crucial for public safety. This study investigated the potential association between GLP-1RAs and SSIBs by exploring the FDA Adverse Event Reporting System (FAERS) database. METHODS A disproportionality analysis was conducted using post-marketing data from the FAERS repository (2018 Q1 to 2022 Q4). SSIB cases associated with GLP-1RAs were identified and analyzed through disproportionality analysis using the information component. The parametric distribution with a goodness-of-fit test was employed to analyze the time-to-onset, and the Ω shrinkage was used to evaluate the potential effect of co-medication on the occurrence of SSIBs. RESULTS In total, 204 cases of SSIBs associated with GLP-1RAs, including semaglutide, liraglutide, dulaglutide, exenatide, and albiglutide, were identified in the FAERS database. Time-of-onset analysis revealed no consistent mechanism for the latency of SSIBs in patients receiving GLP-1RAs. The disproportionality analysis did not indicate an association between GLP-1RAs and SSIBs. Co-medication analysis revealed 81 cases with antidepressants, antipsychotics, and benzodiazepines, which may be proxies of mental health comorbidities. CONCLUSIONS We found no signal of disproportionate reporting of an association between GLP-1RA use and SSIBs. Clinicians need to maintain heightened vigilance on patients premedicated with neuropsychotropic drugs. This contributes to the greater acceptance of GLP-1RAs in patients with type 2 diabetes mellitus or obesity.
Collapse
Affiliation(s)
- Jianxing Zhou
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - You Zheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Baohua Xu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Songjun Long
- School of Medical Imaging, Fujian Medical University, Fuzhou, Fujian, China
| | - Li-E Zhu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yunhui Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Chengliang Li
- Department of Respiratory, Shanghai Electric Power Hospital, Shanghai, China
| | - Yifan Zhang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.
| | - Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China.
| |
Collapse
|
5
|
Zhou J, Wei Z, Chen S, Xie H, Huang W, Liu M, Wu X. Movement disorders associated with antiseizure medications: A real-world disproportionality analysis of the Food and Drug Administration Adverse Event Reporting System. Br J Clin Pharmacol 2023; 89:3389-3400. [PMID: 37353394 DOI: 10.1111/bcp.15836] [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: 05/05/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023] Open
Abstract
AIMS Patients with epilepsy often require long-term use of antiseizure medications (ASMs) to control their seizures. However, movement disorders (MDs) related to ASMs can significantly impact their quality of life. This study aims to analyse MDs related to ASMs in the Food and Drug Administration Adverse Event Reporting System database to provide recommendations for safe medication. METHODS All adverse drug reactions associated with 26 marketed ASMs in Food and Drug Administration Adverse Event Reporting System were extracted for analysis. Disproportionality analyses were used to assess the association between ASMs and MDs, and signal colour scale maps were created to identify potential ASM-MD safety signals. RESULTS A total of 1921 cases experienced MDs while taking ASMs were included. A higher prevalence of MDs was observed in females compared to males. The association between specific MDs with ASMs was revealed, including known and unknown MDs such as tremors, Parkinson and paralysis. Lamotrigine and carbamazepine exhibited multiple significant MDs, while levetiracetam and pregabalin were linked to the earlier onset of MDs. Generally, higher doses were linked to a higher incidence of MDs. CONCLUSION MDs were the most obvious adverse drug reactions in the nervous system triggered by using ASMs. Fourteen drugs exhibited positive signals for MDs, including some not previously reported. Conversely, 12 ASMs were deemed to have a lower possibility of inducing MDs. The incidence of MDs can be mitigated by selecting appropriate ASMs for epileptic patients. These findings enhance our understanding of the relationship between ASMs and MDs.
Collapse
Affiliation(s)
- Jianxing Zhou
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Medical University, Fuzhou, Fujian, China
| | - Zipeng Wei
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Medical University, Fuzhou, Fujian, China
| | - Shengyang Chen
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Medical University, Fuzhou, Fujian, China
| | - Helin Xie
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Wei Huang
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Medical University, Fuzhou, Fujian, China
| | - Maobai Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Medical University, Fuzhou, Fujian, China
| | - Xuemei Wu
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Fujian Medical University, Fuzhou, Fujian, China
| |
Collapse
|
6
|
Zhou J, Wei Z, Zheng Y, Xie H, Cao W, Cai X, Huang J, Wu X. Disproportionality Analysis of Lenvatinib-Caused Gastrointestinal Perforation in Cancer Patients: A Pharmacovigilance Analysis Based on the US Food and Drug Administration Adverse Event Reporting System. J Clin Pharmacol 2023; 63:1133-1140. [PMID: 37474123 DOI: 10.1002/jcph.2312] [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: 05/10/2023] [Accepted: 07/17/2023] [Indexed: 07/22/2023]
Abstract
Lenvatinib is a medication that targets multiple tyrosine kinases and is commonly used to treat various types of cancer. With its frequent usage, monitoring and assessing its potential adverse effects has become crucial. This study utilizes the US Food and Drug Administration Adverse Event Reporting System (FAERS) database to analyze the possible link between lenvatinib and gastrointestinal perforation. FAERS was used to analyze adverse drug reactions (ADRs) linked with lenvatinib from the first quarter of 2015 to the last quarter of 2022. The association between lenvatinib and gastrointestinal perforation was evaluated using disproportionality analyses. This study included 464 patients who developed gastrointestinal perforation after using lenvatinib. Perforation involved the entire digestive tract, with the colon among the most commonly affected perforation sites, and previously undetected esophageal perforation was frequently observed. Patients with uterine and liver cancer were at a higher risk of developing gastrointestinal perforation; patients with liver cancer experienced a shorter onset time, whereas patients with endometrial cancer had a slower onset time. Middle-aged and elderly patients exhibited a higher propensity for developing gastrointestinal perforation than younger adults. Patients with gastrointestinal perforation were found to have a significantly higher mortality rate than patients without gastrointestinal perforation. This study has identified several gastrointestinal perforation events not included in the drug instructions. It has also described the perforation site and clinical characteristics based on various types of cancer. These results could provide valuable insights for developing safer and more effective regulatory strategies concerning the use of lenvatinib.
Collapse
Affiliation(s)
- Jianxing Zhou
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Zipeng Wei
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - You Zheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Helin Xie
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Wanxia Cao
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Xinying Cai
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Jialin Huang
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| |
Collapse
|
7
|
Paynter JA, Qin KR, Situ D, Lee CHA. Fournier gangrene with concurrent multifocal necrotizing fasciitis: a systematic review and case report. Ann Coloproctol 2023; 39:421-426. [PMID: 35615761 PMCID: PMC10626333 DOI: 10.3393/ac.2022.00192.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE A patient presented to a regional surgical center with Fournier gangrene (FG) and concurrent multifocal necrotizing fasciitis (NF). Given the rarity, it was decided to undertake a systematic review to investigate the incidence and prevalence of FG with multifocal NF and consequently determine the treatment and approach to management of such presentation. METHODS Firstly, the report of the 56-year-old male patient is discussed regarding his surgical management. Secondly, a systematic review was undertaken according to PRISMA guidelines using MEDLINE, Scopus, and Embase databases. Searches used the following MeSH terms: ("fournier's gangrene") AND ((necrotising fasciitis) OR (necrotising soft tissue infection)). Once the search results were obtained, duplicate articles were removed. Titles, abstracts, and articles were reviewed by 2 authors. RESULTS The search strategy using the 3 databases revealed a total of 402 studies. Fifty-seven studies were removed due to duplication. A total of 345 records were screened via title and abstract, of which 115 were excluded. Two hundred and thirty studies were reviewed for eligibility. A total of all 230 studies were excluded; 169 were excluded as they included the incorrect patient population (patients suffered from FG or NF, but not both collectively), 60 studies were excluded due to incorrect study designs, and 1 report occurred in the wrong setting. CONCLUSION This highlights that while being a relatively known, uncommon infection both FG and NF are well documented separately within the literature. However, FG with concurrent multifocal NF has not been documented within the literature.
Collapse
Affiliation(s)
| | - Kirby R. Qin
- Department of Surgery, Austin Health, Heidelberg, VIC, Australia
| | - Dongrong Situ
- Department of General Surgery, Bendigo Health, Bendigo, VIC, Australia
- Department of Surgery, Austin Health, Heidelberg, VIC, Australia
| | | |
Collapse
|
8
|
Zhou J, Wei Z, Xu B, Liu M, Xu R, Wu X. Pharmacovigilance of triazole antifungal agents: Analysis of the FDA adverse event reporting system (FAERS) database. Front Pharmacol 2022; 13:1039867. [PMID: 36588707 PMCID: PMC9798094 DOI: 10.3389/fphar.2022.1039867] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
Triazole antifungal drugs (TAD) are widely used to treat invasive fungal infections due to their broad antifungal spectrum and low toxicity. Despite their preference in the clinic, multiple Adverse Events (AE) are still reported each year. OBJECTIVE We aimed to characterize the distribution of Adverse Events associated with Triazole antifungal drugs in different systems and to identify Important Medical Events (IME) signals for Triazole antifungal drugs. METHODS The U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) was queried for Adverse Events related to Triazole antifungal drugs from 2012 to 2022. The Adverse Events caused by all other drugs and non-TAD antifungal drugs were analyzed as references. Reporting odds ratio and Bayesian confidence propagation neural network of information components were used to evaluate the association between Triazole antifungal drugs and Important Medical Events. Visual signal spectrum is mapped to identify potential adverse reaction signals. RESULTS Overall, 10,262 Adverse Events were reported to be associated with Triazole antifungal drugs, of which 5,563 cases were defined as Important Medical Events. Common adverse drug reactions (ADR) mentioned in the instructions such as delirium and hypokalemia were detected, as well as unlabeled ADRs such as rhabdomyolysis and hepatitis fulminant. Cholestasis, drug-induced liver injury, QT interval prolongation and renal impairment have notable signals in all Triazole antifungal drugs, with 50 percent of patients developing a severe clinical outcome. Isavuconazole had the lowest signal intensity and demonstrated a superior safety profile. CONCLUSION Most results are generally consistent with previous studies and are documented in the prescribing instructions, but some IMEs are not included, such as hepatitis fulminant. Additional pharmaco-epidemiological or experimental studies are required to validate the small number of unlabeled ADRs. TAD-related Important Medical Eventshave a considerable potential to cause clinically serious outcomes. Clinical use of Triazole antifungal drugs requires more attention.
Collapse
Affiliation(s)
- Jianxing Zhou
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Zipeng Wei
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Baohua Xu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Ruichao Xu
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,*Correspondence: Xuemei Wu,
| |
Collapse
|
9
|
Tang S, Wu Z, Xu L, Wen Q, Zhang X. Adverse reaction signals mining and hemorrhagic signals comparison of ticagrelor and clopidogrel: A pharmacovigilance study based on FAERS. Front Pharmacol 2022; 13:970066. [PMID: 36263117 PMCID: PMC9573960 DOI: 10.3389/fphar.2022.970066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Ticagrelor and clopidogrel are commonly used antiplatelet agents, and we conducted a pharmacovigilance analysis using the Food and Drug Administration Adverse Event Reporting System (FAERS) to provide a reference for safe and reasonable clinical use.Methods: Data were collected in FAERS from 2012 Q1 to 2022 Q2 for data cleaning. We used system organ classes (SOCs) and prefer terms (PTs) from the Medical Dictionary of Regulatory Activity (MedDRA version 25.1). Adverse event reports were retrieved at the PT level. Adverse reaction (ADR) signals of ticagrelor and clopidogrel were mined by calculating reporting odds ratios (ROR), proportional reporting ratios (PRR), information component (IC) and empirical Bayesian geometric mean (EBGM). After that, further analysis of the hemorrhagic signals and their clinical information were performed.Results: The number of ADR reports where the primary suspect (PS) drugs were 15,133 for ticagrelor and 23,860 for clopidogrel. Significant ADR signals were identified by the SOC analysis for ticagrelor including cardiac disorders (ROR 4.87, PRR 4.46), respiratory disorders (ROR 2.45, PRR 2.28), and vascular disorders (ROR 2.22, PRR 2.16). Clopidogrel included blood disorders (ROR 2.86, PRR 2.77), vascular disorders (ROR 2.71, PRR 2.61), and cardiac disorders (ROR 2.29, PRR 2.22). At the PT level, the more frequent ADR signals for ticagrelor were dyspnoea, contusion, and haemorrhage, while clopidogrel were gastrointestinal haemorrhage, anaemia, and drug interaction. The hemorrhagic signals of both were mainly focused on the SOC level of gastrointestinal disorders, injury disorders and vascular disorders and nervous system disorders. The death and life-threatening rate of ticagrelor was 7.76 percentage higher than that of clopidogrel.Conclusion: Clinicians need to pay attention to not only common ADRs but also be alert to new ADR signals when choosing to use ticagrelor and clopidogrel. This study provides a reference for the reasonable and safe clinical use of ticagrelor and clopidogrel.
Collapse
Affiliation(s)
- Shu Tang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Shu Tang, ; Xiaojian Zhang,
| | - Zhanshen Wu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liqing Xu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiang Wen
- Institute of Clinical Pharmacology, Zhengzhou University, Zhengzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Shu Tang, ; Xiaojian Zhang,
| |
Collapse
|
10
|
Jahir T, Hossain S, Bagum M, Saidi A, Risal R, Schmidt M. A Rare but Life-Threatening Case of Fournier’s Gangrene Caused by Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor, Empagliflozin. Cureus 2022; 14:e29264. [PMID: 36262942 PMCID: PMC9576122 DOI: 10.7759/cureus.29264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2022] [Indexed: 11/05/2022] Open
Abstract
Fournier's gangrene (FG) is a rare but severe infection in the soft tissue, leading to necrosis in the perineum, perianal and genitourinary area. This infection can spread rapidly in the body and lead to multi-organ failure, septic shock, and death. This life-threatening infection is usually caused by polymicrobial agents like Group A - Beta Hemolytic Streptococcus- Streptococcus pyogenes, Staphylococcus aureus, Escherichia coli, Klebsiella pneumonia, Proteus, and anaerobes like Bacteroides and Clostridium perfringes. Risk factors related to the development of FG are obesity, uncontrolled diabetes, lack of education, poor personal hygiene, especially in the genital region, history of fungal infection, recurrent urinary tract infection, smoking, immunosuppression, and medication. In 2018, a safety warning was issued by The U.S. Food and Drug Administration (FDA) on sodium-glucose cotransporter-2 (SGLT2) inhibitors, causing a rare but serious adverse outcome of FG in patients with type 2 diabetes mellitus. It is established that the increased urinary glucose concentration caused by SGLT-2 inhibitors creates a suitable environment for the growth of the infection in the urinary and genital area, leading to the development of FG. Here we present a case of life-threatening FG in an obese female with a past medical history of type 2 diabetes mellitus with recurrent history of genital yeast infection four months after starting an SGLT2 inhibitor, empagliflozin. This study aims to understand the relationship between the FG and SGLT-2 inhibitor, overall the benefits of SGLT2 inhibitors outweighs the risk manyfold, therefore, raising awareness among clinician to be vigilant, keep a high index of suspicion and focus on the safe use of SGLT2 inhibitors, especially before and after prescribing SGLT-2 inhibitor with a close follow-up to prevent its serious and life-threatening emergency like Fournier's gangrene and necrotizing fasciitis.
Collapse
|
11
|
Chowdhury T, Gousy N, Bellamkonda A, Dutta J, Zaman CF, Zakia UB, Tasha T, Dutta P, Deb Roy P, Gomez AM, Mainali A. Fournier’s Gangrene: A Coexistence or Consanguinity of SGLT-2 Inhibitor Therapy. Cureus 2022; 14:e27773. [PMID: 36106208 PMCID: PMC9450557 DOI: 10.7759/cureus.27773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are a relatively new class of medications used for the management of type II diabetes mellitus targeting the kidneys. Within the last decade, several warnings have been issued regarding the development of severe genitourinary infections, including necrotizing fasciitis, or Fournier’s gangrene, in those with pre-existing type II diabetes and concomitant use of this drug class. Objective: The purpose of this review is to highlight and discuss the factors contributing to the development of Fournier’s gangrene, its pathogenesis, and a review of existing literature describing patient outcomes, treatment, and future directions regarding early detection of this complication. Methods: Articles and studies addressing effective treatment adherence and key factors contributing to Fournier’s gangrene with SGLT2 inhibitors were identified by effective keyword searches in PubMed Central, Google Scholar, and Cochrane, as well as the references found within these articles. Results: Using the keywords provided, 55 case reports, review articles, and meta-analysis reports written within the last 20 years were utilized as the source of the data presented in this systematic review article.
Collapse
|
12
|
Fournier’s Gangrene under Sodium–Glucose Cotransporter-2 Inhibitors Therapy in Gynecological Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106261. [PMID: 35627798 PMCID: PMC9141785 DOI: 10.3390/ijerph19106261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 01/13/2023]
Abstract
Fournier’s gangrene (FG) is a serious pathology of the soft tissues and fascia of the perineum and genital region with a high morbidity and mortality rate. In recent years, the SGLT-2 inhibitor oral antidiabetic has been related to this entity. According to the new warnings from the main drug agencies, a compilation of cases has been initiated to establish or deny a possible causal relationship. Most of these cases have been reported in men. However, it is important not to underestimate this entity in the gynecological field, since it is extremely serious and requires intense and rapid aggressive treatment based on surgery and empiric antibiotherapy. Later, some cares are needed to involve surgical reconstruction of the defects introduced by debridement. As a result of the low incidence of FG, clinical trials’ data may be insufficient to robustly assess this issue because of the limited numbers of participants. Real-world evidence may help to clarify the association between SGLT2i and FG. The aim of this review is to describe and compare the reported cases of GF in diabetic women who received SGLT2 inhibitors as antiglycemic agents.
Collapse
|
13
|
Emphysematous Cystitis and Urinary Retention in a Male Patient with Diabetes Mellitus Type 2 treated with Empagliflozin. AACE Clin Case Rep 2022; 8:163-165. [PMID: 35959080 PMCID: PMC9363503 DOI: 10.1016/j.aace.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022] Open
|
14
|
Zhou X, Ye X, Guo X, Liu D, Xu J, Hu F, Zhai Y, Gao Y, Xu X, Dong Z, He J. Safety of SGLT2 Inhibitors: A Pharmacovigilance Study from 2013 to 2021 Based on FAERS. Front Pharmacol 2022; 12:766125. [PMID: 34987394 PMCID: PMC8721280 DOI: 10.3389/fphar.2021.766125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/22/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Sodium-glucose co-transporter-2 inhibitors (SGLT2is) are widely used in clinical practice for their demonstrated cardiorenal benefits, but multiple adverse events (AEs) have been reported. We aimed to describe the distribution of SGLT2i-related AEs in different systems and identify important medical event (IME) signals for SGLT2i. Methods: Data from the first quarter (Q1) of 2013–2021 Q2 in FAERS were selected to conduct disproportionality analysis. The definition of AEs and IMEs relied on the system organ classes (SOCs) and preferred terms (PTs) by the Medical Dictionary for Regulatory Activities (MedDRA-version 24.0). Two signal indicators, the reported odds ratio (ROR) and information component (IC), were used to estimate the association between SGLT2is and IMEs. Results: A total of 57,818 records related to SGLT2i, with 22,537 SGLT2i-IME pairs. Most SGLT2i-related IMEs occurred in monotherapy (N = 21,408, 94.99%). Significant signals emerged at the following SOCs: “metabolism and nutrition disorders” (N = 9,103; IC025 = 4.26), “renal and urinary disorders” (3886; 1.20), “infections and infestations” (3457; 0.85). The common strong signals were observed in diabetic ketoacidosis, ketoacidosis, euglycaemic diabetic ketoacidosis and Fournier’s gangrene. Unexpected safety signals such as cellulitis, osteomyelitis, cerebral infarction and nephrolithiasis were detected. Conclusion: Our pharmacovigilance analysis showed that a high frequency was reported for IMEs triggered by SGLT2i monotherapy. Different SGLT2is caused different types and the association strengths of IMEs, while they also shared some specific PTs. Most of the results are generally consistent with previous studies, and more pharmacoepidemiological studies are needed to validate for unexpected AEs. Based on risk-benefit considerations, clinicians should be well informed about important medical events that may be aggravated by SGLT2is.
Collapse
Affiliation(s)
- Xiang Zhou
- School of Medicine, Tongji University, Shanghai, China
| | - Xiaofei Ye
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Xiaojing Guo
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Dongxu Liu
- School of Medicine, Tongji University, Shanghai, China
| | - Jinfang Xu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Fangyuan Hu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yinghong Zhai
- School of Medicine, Tongji University, Shanghai, China
| | - Yongqing Gao
- School of Medicine, Tongji University, Shanghai, China
| | - Xiao Xu
- School of Medicine, Tongji University, Shanghai, China
| | - Ziwei Dong
- School of Medicine, Tongji University, Shanghai, China
| | - Jia He
- School of Medicine, Tongji University, Shanghai, China.,Department of Health Statistics, Second Military Medical University, Shanghai, China
| |
Collapse
|
15
|
Tran BA, Updike WH, Bullers K, Serag-Bolos E. Sodium-Glucose Cotransporter 2 Inhibitor Use Associated With Fournier's Gangrene: A Review of Case Reports and Spontaneous Post-Marketing Cases. Clin Diabetes 2022; 40:78-86. [PMID: 35221476 PMCID: PMC8865791 DOI: 10.2337/cd21-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective for glycemic control and have demonstrated cardiorenal benefits. The U.S. Food and Drug Administration (FDA) released a boxed warning in 2018 regarding the potential development of Fournier's gangrene (FG) with the use of SGLT2 inhibitors. FG is a serious perineal infection with a mortality rate of up to 88% in some cases. OBJECTIVES To report spontaneous post-marketing cases from the FDA Adverse Event Reporting System (FAERS) database and case reports from the literature of FG associated with the use of SGLT2 inhibitors and to determine whether correlations exist with specific agents. METHODS A search of the FAERS database was conducted to identify reported cases of FG associated with the use of any FDA-approved SGLT2 inhibitor between 1 March 2013 and 30 June 2020. Additionally, a literature search was conducted of PubMed, Embase, and the Cochrane library using PRISMA guidelines to identify case reports of FG with the use of SGLT2 inhibitors up to 9 October 2020. RESULTS A total of 491 cases from the FAERS database were included for review. Descriptive analysis depicted more cases in the empagliflozin, canagliflozin, and dapagliflozin groups than in the ertugliflozin group. Nine case reports were included from the literature review; four attributed to dapagliflozin, three to empagliflozin, and two to canagliflozin. The median ages from cases reported in the FAERS database and from the literature review were 54 and 52 years, respectively. In both datasets, males had a higher incidence of FG than females. Additional data reported include clinical outcomes and concomitant antihyperglycemic medications. CONCLUSION Consistent findings are noted in this systematic review and warrant further investigation to elucidate the association between SGLT2 inhibitor use and the development of FG. These results may drive enhanced prescribing patterns to consider patient-specific risk factors and timely monitoring, especially as more indications are approved related to these medications' cardiorenal protective properties.
Collapse
Affiliation(s)
- Bao Anh Tran
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy, University of South Florida, Tampa, FL
| | - Wendy H. Updike
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy, University of South Florida, Tampa, FL
- Department of Family Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
- Corresponding author: Wendy H. Updike,
| | | | - Erini Serag-Bolos
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy, University of South Florida, Tampa, FL
| |
Collapse
|
16
|
Matharu K, Chana K, Ferro CJ, Jones AM. Polypharmacology of clinical sodium glucose co-transport protein 2 inhibitors and relationship to suspected adverse drug reactions. Pharmacol Res Perspect 2021; 9:e00867. [PMID: 34586753 PMCID: PMC8480305 DOI: 10.1002/prp2.867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 12/19/2022] Open
Abstract
Sodium glucose co-transporter 2 inhibitors (SGLT2i) are a promising second-line treatment strategy for type 2 diabetes mellitus (T2DM) with a developing landscape of both beneficial cardio- and nephroprotective properties and emerging adverse drug reactions (ADRs) including diabetic ketoacidosis (DKA), genetic mycotic infections, and amputations among others. A national register study (MHRA Yellow Card, UK) was used to quantify the SGLT2i's suspected ADRs relative to their Rx rate (OpenPrescribing, UK). The polypharmacology profiles of SGLT2i were data-mined (ChEMBL) for the first time. The ADR reports (n = 3629) and prescribing numbers (Rx n = 5,813,325) for each SGLT2i in the United Kingdom (from launch date to the beginning December 2019) were determined. Empagliflozin possesses the most selective SGLT2/SGLT1 inhibition profile at ~2500-fold, ~10-fold more selective than cangliflozin (~260-fold). Canagliflozin was found to also inhibit CYP at clinically achievable concentrations. We find that for overall ADR rates, empagliflozin versus dapagliflozin and empagliflozin versus canagliflozin are statistically significant (χ2 , p < .05), while dapagliflozin versus canagliflozin is not. In terms of overall ADRs, there is a greater relative rate for canagliflozin > dapagliflozin > empagliflozin. For fatalities, there is a greater relative rate for dapagliflozin > canagliflozin > empagliflozin. An organ classification that resulted in a statistically significant difference between SGLT2i was suspected infection/infestation ADRs between empagliflozin and dapagliflozin. Our findings at this stage of SGLT2i usage in the United Kingdom suggest that empagliflozin, the most selective SGLT2i, had the lowest suspected ADR incident rate (relative to prescribing) and in all reported classes of ADRs identified including infections, amputations, and DKA.
Collapse
Affiliation(s)
- Karan Matharu
- School of PharmacyInstitute of Clinical SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Kiran Chana
- School of PharmacyInstitute of Clinical SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Charles J. Ferro
- Birmingham Cardio‐Renal GroupInstitute of Cardiovascular SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Alan M. Jones
- School of PharmacyInstitute of Clinical SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| |
Collapse
|
17
|
Chandrashekar M, Philip S, Nesbitt A, Joshi A, Perera M. Sodium glucose-linked transport protein 2 inhibitors: An overview of genitourinary and perioperative implications. Int J Urol 2021; 28:984-990. [PMID: 34155680 DOI: 10.1111/iju.14624] [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: 12/13/2020] [Accepted: 05/16/2021] [Indexed: 01/04/2023]
Abstract
Sodium glucose-linked transport protein 2 inhibitors are relatively novel drugs, used for the treatment of type 2 diabetes mellitus. Their use since Pharmaceutical Benefits Scheme approval in Australia has increased drastically, possibly due to the low risk of hypoglycemic events and their advertised cardiovascular mortality benefits. However, as with any novel drug, adverse effects regarding their use require medical practitioner awareness for optimal patient outcomes. This paper aims to cover the major urological implications, including those pertinent perioperatively, that concern this class of drugs. There is a clear risk of developing genital mycotic infections with the use of sodium glucose-linked transport protein 2 inhibitors, including serious infections such as Fournier's gangrene. Evidence for developing urinary tract infections has been mixed. Sodium glucose-linked transport protein 2 inhibitor-induced lower urinary tract symptoms may have impacts on quality of life via pollakiuria and nocturia, of which there are increased reports. Perioperative use increases the risk of euglycemic diabetic ketoacidosis. It is recommended that sodium glucose-linked transport protein 2 inhibitors be ceased perioperatively.
Collapse
Affiliation(s)
- Mohit Chandrashekar
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Stuart Philip
- Department of Urology, Mater Hospital, Brisbane, Queensland, Australia
| | - Alexander Nesbitt
- Department of Urology, Mater Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Andre Joshi
- Department of Urology, Mater Hospital, Brisbane, Queensland, Australia
| | - Marlon Perera
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Urology, Mater Hospital, Brisbane, Queensland, Australia.,Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Victoria.,Department of Urology, Western Health, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
18
|
Balkin M. Be Vigilant About Perianal Pain. Am J Med 2021; 134:e233. [PMID: 33341232 DOI: 10.1016/j.amjmed.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Michael Balkin
- Division of Endocrinology, Department of Medicine, Nassau University Medical Center, East Meadow, NY.
| |
Collapse
|