1
|
Manchuri KM, Shaik MA, Gopireddy VSR, Naziya Sultana, Gogineni S. Analytical Methodologies to Detect N-Nitrosamine Impurities in Active Pharmaceutical Ingredients, Drug Products and Other Matrices. Chem Res Toxicol 2024; 37:1456-1483. [PMID: 39158368 DOI: 10.1021/acs.chemrestox.4c00234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
Since 2018, N-nitrosamine impurities have become a widespread concern in the global regulatory landscape of pharmaceutical products. This concern arises due to their potential for contamination, toxicity, carcinogenicity, and mutagenicity and their presence in many active pharmaceutical ingredients, drug products, and other matrices. N-Nitrosamine impurities in humans can lead to severe chemical toxicity effects. These include carcinogenic effects, metabolic disruptions, reproductive harm, liver diseases, obesity, DNA damage, cell death, chromosomal alterations, birth defects, and pregnancy loss. They are particularly known to cause cancer (tumors) in various organs and tissues such as the liver, lungs, nasal cavity, esophagus, pancreas, stomach, urinary bladder, colon, kidneys, and central nervous system. Additionally, N-nitrosamine impurities may contribute to the development of Alzheimer's and Parkinson's diseases and type-2 diabetes. Therefore, it is very important to control or avoid them by enhancing effective analytical methodologies using cutting-edge analytical techniques such as LC-MS, GC-MS, CE-MS, SFC, etc. Moreover, these analytical methods need to be sensitive and selective with suitable precision and accuracy, so that the actual amounts of N-nitrosamine impurities can be detected and quantified appropriately in drugs. Regulatory agencies such as the US FDA, EMA, ICH, WHO, etc. need to focus more on the hazards of N-nitrosamine impurities by providing guidance and regular updates to drug manufacturers and applicants. Similarly, drug manufacturers should be more vigilant to avoid nitrosating agents and secondary amines during the manufacturing processes. Numerous review articles have been published recently by various researchers, focusing on N-nitrosamine impurities found in previously notified products, including sartans, metformin, and ranitidine. These impurities have also been detected in a wide range of other products. Consequently, this review aims to concentrate on products recently reported to contain N-nitrosamine impurities. These products include rifampicin, champix, famotidine, nizatidine, atorvastatin, bumetanide, itraconazole, diovan, enalapril, propranolol, lisinopril, duloxetine, rivaroxaban, pioglitazones, glifizones, cilostazol, and sunitinib.
Collapse
Affiliation(s)
- Krishna Moorthy Manchuri
- Department of Chemistry, Jawaharlal Nehru Technological University Anantapur, Ananthapuramu, Andhra Pradesh 515002, India
| | - Mahammad Ali Shaik
- Department of Chemistry, Jawaharlal Nehru Technological University Anantapur, Ananthapuramu, Andhra Pradesh 515002, India
| | - Venkata Subba Reddy Gopireddy
- Department of Chemistry, Jawaharlal Nehru Technological University Anantapur, Ananthapuramu, Andhra Pradesh 515002, India
| | - Naziya Sultana
- Analytical Research and Development, IPDO, Dr. Reddy's Laboratories Limited, Hyderabad 500090, India
| | - Sreenivasarao Gogineni
- Department of Chemistry, Acharya Nagarjuna University, Nagarjuna Nagar, Guntur, Andhra Pradesh 522510, India
| |
Collapse
|
2
|
Devine JW, Tadrous M, Hernandez I, Mukhopadhyay N, Rothenberger SD, Callaway Kim K, Gellad WF, Suda KJ. Effects of the valsartan recall on heart failure patients: A nationwide analysis. Pharmacoepidemiol Drug Saf 2024; 33:e5777. [PMID: 38511239 DOI: 10.1002/pds.5777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Valsartan is commonly used for cardiac conditions. In 2018, the Food and Drug Administration recalled generic valsartan due to the detection of impurities. Our objective was to determine if heart failure patients receiving valsartan at the recall date had a greater likelihood of unfavorable outcomes than patients using comparable antihypertensives. METHODS We conducted a cohort study of Optum's de-identified Clinformatics® Datamart (July 2017-January 2019). Heart failure patients with commercial or Medicare Advantage insurance who received valsartan were compared to persons who received non-recalled angiotensin receptor blockers (ARBs) and angiotensin converting enzyme-inhibitors (ACE-Is) for 1 year prior and including the recall date. Outcomes included a composite for all-cause hospitalization, emergency department (ED), and urgent care (UC) use and a measure of cardiac events which included hospitalizations for acute myocardial infarction and hospitalizations/ED/UC visits for stroke/transient ischemic attack, heart failure or hypertension at 6-months post-recall. Cox proportional hazard models with propensity score weighting compared the risk of outcomes between groups. RESULTS Of the 87 130 adherent patients, 15% were valsartan users and 85% were users of non-recalled ARBs/ACE-Is. Valsartan use was not associated with an increased risk of all-cause hospitalization/ED/UC use six-months post-recall (HR 1.00; 95% CI 0.96-1.03), compared with individuals taking non-recalled ARBs/ACE-Is. Similarly, cardiac events 6-months post-recall did not differ between individuals on valsartan and non-recalled ARBs/ACE-Is (HR 1.04; 95% CI 0.97-1.12). CONCLUSIONS The valsartan recall did not affect short-term outcomes of heart failure patients. However, the recall potentially disrupted the medication regimens of patients, possibly straining the healthcare system.
Collapse
Affiliation(s)
- Joshua W Devine
- Department of Public Health, Des Moines University, Des Moines, Iowa, USA
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Toronto, Ontario, Canada
| | - Inmaculada Hernandez
- School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Nandita Mukhopadhyay
- Department of Craniofacial and Oral Sciences, Center for Craniofacial and Dental Genetics, University of Pittsburgh School of Dental Medicine, Pittsburgh, Pennsylvania, USA
| | - Scott D Rothenberger
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Katherine Callaway Kim
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Walid F Gellad
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Katie J Suda
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
3
|
Devine JW, Tadrous M, Hernandez I, Callaway Kim K, Rothenberger SD, Mukhopadhyay N, Gellad WF, Suda KJ. A Retrospective Cohort Study of the 2018 Angiotensin Receptor Blocker Recalls and Subsequent Drug Shortages in Patients With Hypertension. J Am Heart Assoc 2024; 13:e032266. [PMID: 38156554 PMCID: PMC10863811 DOI: 10.1161/jaha.123.032266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/21/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Valsartan was recalled by the US Food and Drug Administration in July 2018 for carcinogenic impurities, resulting in a drug shortage and management challenges for valsartan users. The influence of the valsartan recall on clinical outcomes is unknown. We compared the risk of adverse events between hypertensive patients using valsartan and a propensity score-matched group using nonrecalled angiotensin receptor blockers and angiotensin-converting enzyme inhibitors. METHODS AND RESULTS We used Optum's deidentified Clinformatics Datamart (July 2017-January 2019). Hypertensive patients who received valsartan or nonrecalled angiotensin receptor blockers/angiotensin-converting enzyme inhibitors for 1 year before and on the recall date were compared. Primary outcomes were measured in the 6 months following the recall and included: (1) a composite measure of all-cause hospitalization, all-cause emergency department visit, and all-cause urgent care visit, and (2) a composite cardiac event measure of hospitalizations for acute myocardial infarction and hospitalizations/emergency department visits/urgent care visits for stroke/transient ischemic attack, heart failure, or hypertension. We compared the risk of outcomes between treatment groups using Cox proportional hazard models. Of the hypertensive patients, 76 934 received valsartan, and 509 472 received a nonrecalled angiotensin receptor blocker/angiotensin-converting enzyme inhibitor. Valsartan use at the time of recall was associated with a higher risk of all-cause hospitalization, emergency department use, or urgent care use (hazard ratio [HR], 1.02 [95% CI, 1.00-1.04]) and the composite of cardiac events (HR, 1.22 [95% CI, 1.15-1.29]) within 6 months after the recall. CONCLUSIONS The valsartan recall and shortage affected hypertensive patients. Local- and national-level systems need to be enhanced to protect patients from drug shortages by providing safe and reliable medication alternatives.
Collapse
Affiliation(s)
| | - Mina Tadrous
- Leslie Dan Faculty of PharmacyUniversity of TorontoOntarioCanada
- Institute for Health System Solutions and Virtual CareWomen’s College HospitalTorontoOntarioCanada
| | - Inmaculada Hernandez
- University of California San DiegoSchool of Pharmacy and Pharmaceutical SciencesLa JollaCAUSA
| | - Katherine Callaway Kim
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of Health Policy and ManagementUniversity of Pittsburgh School of Public HealthPittsburghPAUSA
| | - Scott D. Rothenberger
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Nandita Mukhopadhyay
- University of Pittsburgh School of Dental MedicineDepartment of Oral and Craniofacial Sciences, Center for Craniofacial and Dental GeneticsPittsburghPAUSA
| | - Walid F. Gellad
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Center for Health Equity Research and PromotionVA Pittsburgh Healthcare SystemPittsburghPAUSA
| | - Katie J. Suda
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Center for Health Equity Research and PromotionVA Pittsburgh Healthcare SystemPittsburghPAUSA
| |
Collapse
|
4
|
Pandey S, Kalaria A, Jhaveri KD, Herrmann SM, Kim AS. Management of hypertension in patients with cancer: challenges and considerations. Clin Kidney J 2023; 16:2336-2348. [PMID: 38046043 PMCID: PMC10689173 DOI: 10.1093/ckj/sfad195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Indexed: 12/05/2023] Open
Abstract
The survival rates of many cancers have significantly improved due to recent advancements in cancer screening and therapeutics. Although better cancer outcomes are encouraging, additional health challenges have surfaced, the utmost of which is the burden imposed by various cardiovascular and renal toxicities of anticancer therapies. To improve the overall outcome of patients with cancer, it is essential to understand and manage these treatment-related adverse effects. The cardiovascular side effects of antineoplastic therapies are well-known and include left ventricular dysfunction, heart failure, myocardial ischaemia, QT prolongation, arrhythmia and hypertension. Among these, hypertension is the most common complication, prevalent in about 40% of all cancer patients, yet frequently overlooked and undertreated. This review explores the intricate connection between cancer and hypertension and provides distinct approaches to diagnosing, monitoring and managing hypertension in patients with cancer. We also outline the challenges and considerations that are relevant to the care of patients receiving anticancer drugs with prohypertensive potential.
Collapse
Affiliation(s)
- Shubhi Pandey
- Department of Internal Medicine, Calhoun Cardiology Center, University of Connecticut Health, Farmington, CT, USA
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Amar Kalaria
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Agnes S Kim
- Department of Internal Medicine, Calhoun Cardiology Center, University of Connecticut Health, Farmington, CT, USA
- University of Connecticut School of Medicine, Farmington, CT, USA
| |
Collapse
|
5
|
Yarala MR, Gummadi S. Determination of Potential Genotoxic Impurities (Orthophenylene Diamine Dihydrochloride), 4'-Bromomethyl-2-Cyanobiphenyl, 4'(Dibromomethyl)[1,1'-Biphenyl]-2-Carbonitrile in Telmisartan by ESI-MS/MS. J Chromatogr Sci 2023; 61:288-295. [PMID: 34965580 DOI: 10.1093/chromsci/bmab139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 10/17/2021] [Indexed: 11/14/2022]
Abstract
A sensitive, simple, rapid and robust LC-MS/MS method was developed for the determination of potential genotoxic impurities OPDA HCl (orthophenylene diamine dihydrochloride), bromo OTBN (4'-bromomethyl-2-cyanobiphenyl), dibromo (4'(dibromomethyl)[1,1'-biphenyl]-2-carbonitrile) in Telmisartan by using ESI-MS/MS Technic; the study was performed with gradient elution (time/% mobile phase B: 0/10, 3/10, 30/80, 35/80, 36/10, 40/10). The mobile phase consisted of a mixture of formic acid, methanol and acetonitrile. The buffer was degassed before running at a flow rate of 1.0 mL/min. The column temperature was at 40°C. The 20 μL volume of sample was injected per run and peaks were detected using DAD detector. The LC-ESI/MS/MS studies were carried out on Ultivo Triple Quadrupole LC/MS/MS (Agilent, USA) G6470A mass spectrometer, ion source voltage 3500 V, de clustering potential 40 V, entrance potential 10 V, with the nebulizer gas as nitrogen at 45 psi. The LC part consisted of Agilent 1260 series HPLC system with binary gradient pump with a degasser and an auto sampler. Inert sustain AQ-C18, 250 × 4.6 mm, 5-μm particle size was used for chromatographic separation. Developed method is validated as per ICH guidelines and found to be linear, accurate, specific, selective, precise and robust. Test solution was found to be stable up to 48 h. This method can be successfully applied for the determination of genotoxic impurities in Telmisarta for routine analysis and stability assessment.
Collapse
Affiliation(s)
- Manikanth Reddy Yarala
- Department of Pharmacy, Gandhi Institute of Technology and Management, Visakhapatnam 530045, Andhra Pradesh, India
| | - Sowjanya Gummadi
- Department of Pharmacy, Gandhi Institute of Technology and Management, Visakhapatnam 530045, Andhra Pradesh, India
| |
Collapse
|
6
|
Trampuž M, Žnidarič M, Gallou F, Časar Z. Does the Red Shift in UV-Vis Spectra Really Provide a Sensing Option for Detection of N-Nitrosamines Using Metalloporphyrins? ACS OMEGA 2023; 8:1154-1167. [PMID: 36643536 PMCID: PMC9835193 DOI: 10.1021/acsomega.2c06615] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/08/2022] [Indexed: 06/17/2023]
Abstract
N-nitrosamines are widespread cancerogenic compounds in human environment, including water, tobacco products, food, and medicinal products. Their presence in pharmaceuticals has recently led to several recalls of important medicines from the market, and strict controls and tight limits of N-nitrosamines are now required. Analytical determination of N-nitrosamines is expensive, laborious, and time-inefficient making development of simpler and faster techniques for their detection crucial. Several reports published in the previous decade have demonstrated that cobalt porphyrin-based chemosensors selectively bind N-nitrosamines, which produces a red shift of characteristic Soret band in UV-Vis spectra. In this study, a thorough re-evaluation of metalloporphyrin/N-nitrosamine adducts was performed using various characterization methods. Herein, we demonstrate that while N-nitrosamines can interact directly with cobalt-based porphyrin complexes, the red shift in UV-Vis spectra is not selectively assured and might also result from the interaction between impurities in N-nitrosamines and porphyrin skeleton or interaction of other functional groups within the N-nitrosamine structure and the metal ion within the porphyrin. We show that pyridine nitrogen is the interacting atom in tobacco-specific N-nitrosamines (TSNAs), as pyridine itself is an active ligand and not the N-nitrosamine moiety. When using Co(II) porphyrins as chemosensors, acidic and basic impurities in dialkyl N-nitrosamines (e.g., formic acid, dimethylamine) are also UV-Vis spectra red shift-producing species. Treatment of these N-nitrosamines with K2CO3 prevents the observed UV-Vis phenomena. These results imply that cobalt-based metalloporphyrins cannot be considered as selective chemosensors for UV-Vis detection of N-nitrosamine moiety-containing species. Therefore, special caution in interpretation of UV-Vis red shift for chemical sensors is suggested.
Collapse
Affiliation(s)
- Marko Trampuž
- Lek
Pharmaceuticals d.d., Sandoz Development
Center Slovenia, Kolodvorska
27, 1234 Mengeš, Slovenia
| | - Mateja Žnidarič
- Lek
Pharmaceuticals d.d., Sandoz Development
Center Slovenia, Kolodvorska
27, 1234 Mengeš, Slovenia
| | - Fabrice Gallou
- Chemical
and Analytical Development, Novartis Pharma
AG, Basel 4056, Switzerland
| | - Zdenko Časar
- Lek
Pharmaceuticals d.d., Sandoz Development
Center Slovenia, Kolodvorska
27, 1234 Mengeš, Slovenia
- Chair
of Medicinal Chemistry, Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia
| |
Collapse
|
7
|
Assessment of a Diverse Array of Nitrite Scavengers in Solution and Solid State: A Study of Inhibitory Effect on the Formation of Alkyl-Aryl and Dialkyl N-Nitrosamine Derivatives. Processes (Basel) 2022. [DOI: 10.3390/pr10112428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The ubiquitous presence of mutagenic and potentially carcinogenic N-nitrosamine impurities in medicines has become a major issue in the pharmaceutical industry in recent years. Rigorous mitigation strategies to limit their amount in drug products are, therefore, needed. The removal of nitrite, which is a prerequisite reagent for the N-nitrosation of amines, has been acknowledged as one of the most promising strategies. We have conducted an extensive literature search to identify nineteen structurally diverse nitrite scavengers and screened their activity experimentally under pharmaceutically relevant conditions. In the screening phase, we have identified six compounds that proved to have the best nitrite scavenging properties: ascorbic acid (vitamin C), sodium ascorbate, maltol, propyl gallate, para-aminobenzoic acid (PABA), and l-cysteine. These were selected for investigation as inhibitors of the formation of N-methyl-N-nitrosoaniline (NMA) from N-methylaniline and N-nitroso-N’-phenylpiperazine (NPP) from N-phenylpiperazine in both solution and model tablets. Much faster kinetics of NMA formation compared to NPP was observed, but the former was less stable at high temperatures. Vitamin C, PABA, and l-cysteine were recognized as the most effective inhibitors under most studied conditions. The nitrite scavenging activity does not directly translate into N-nitrosation inhibitory effectiveness, indicating other reaction pathways may take place. The study presents an important contribution to identifying physiologically acceptable chemicals that could be added to drugs to prevent N-nitrosation during manufacture and storage.
Collapse
|
8
|
Fenna J, Chu C, Hassan R, Gomes T, Tadrous M. Extent of a valsartan drug shortage and its effect on antihypertensive drug use in the Canadian population: a national cross-sectional study. CMAJ Open 2021; 9:E1128-E1133. [PMID: 34876414 PMCID: PMC8673482 DOI: 10.9778/cmajo.20200232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Drug shortages represent a growing global problem, with potentially serious consequences to patients and the health care system. Our study investigates the impacts of a major recall and shortage of valsartan, an angiotensin receptor blocker (ARB), in July 2018 in Canada. METHODS We conducted a time-series analysis of antihypertensive drugs dispensed in Canada between 2015 and 2019 using commercially available retail prescription data. Using autoregressive integrated moving average (ARIMA) modelling, we evaluated the change in valsartan use after the recall. We also measured the overall use of ARBs, angiotensin-converting-enzyme (ACE) inhibitors and other antihypertensive drug classes for the same period. RESULTS After the recall in July 2018, valsartan use decreased 57.8%, from 362 231 prescriptions dispensed in June 2018 to 152 892 in September 2018 (difference = 209 339, p < 0.0001). Overall use of the ARB drug class decreased 2.0%, from 1 577 509 prescriptions dispensed in June 2018 to 1 545 591 in September 2018 (difference = 31 918, p = 0.0003), but use of non-valsartan ARBs increased 14.6%, from 1 215 278 to 1 392 699 prescriptions dispensed (difference = 177 421, p < 0.0001) in the same time frame. Although use of ACE inhibitors initially declined, this reduction was not sustained. The valsartan recall was not associated with a significant impact on use of other antihypertensive drug classes. INTERPRETATION Our findings illustrate the impact of a major drug shortage, with the immediate and substantial reduction of valsartan dispensed and cascading effects on other ARBs, though future research is warranted to understand the consequences of such extensive shortages on clinical outcomes and health system costs. Improved policy strategies are needed to address the underlying causes of drug shortages and to mitigate their effects.
Collapse
Affiliation(s)
- Jennifer Fenna
- Leslie Dan Faculty of Pharmacy (Fenna, Hassan, Gomes, Tadrous), University of Toronto, Toronto, Ont.; Pharmacy Services (Fenna), Alberta Health Services, Edmonton, Alta.; Institute of Health System Solutions and Virtual Care (Chu, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Gomes), University of Toronto, Toronto, Ont
| | - Cherry Chu
- Leslie Dan Faculty of Pharmacy (Fenna, Hassan, Gomes, Tadrous), University of Toronto, Toronto, Ont.; Pharmacy Services (Fenna), Alberta Health Services, Edmonton, Alta.; Institute of Health System Solutions and Virtual Care (Chu, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Gomes), University of Toronto, Toronto, Ont
| | - Rola Hassan
- Leslie Dan Faculty of Pharmacy (Fenna, Hassan, Gomes, Tadrous), University of Toronto, Toronto, Ont.; Pharmacy Services (Fenna), Alberta Health Services, Edmonton, Alta.; Institute of Health System Solutions and Virtual Care (Chu, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Gomes), University of Toronto, Toronto, Ont
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy (Fenna, Hassan, Gomes, Tadrous), University of Toronto, Toronto, Ont.; Pharmacy Services (Fenna), Alberta Health Services, Edmonton, Alta.; Institute of Health System Solutions and Virtual Care (Chu, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Gomes), University of Toronto, Toronto, Ont
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy (Fenna, Hassan, Gomes, Tadrous), University of Toronto, Toronto, Ont.; Pharmacy Services (Fenna), Alberta Health Services, Edmonton, Alta.; Institute of Health System Solutions and Virtual Care (Chu, Tadrous), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Gomes), University of Toronto, Toronto, Ont.
| |
Collapse
|
9
|
Gudsoorkar P, Ruf R, Adnani H, Safdar K, Sparks MA. Onco-hypertension: An Emerging Specialty. Adv Chronic Kidney Dis 2021; 28:477-489.e1. [PMID: 35190114 DOI: 10.1053/j.ackd.2021.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/19/2022]
Abstract
Cancer is one of the leading causes of death worldwide. With the introduction of newer chemotherapeutic agents, targeted therapies, and immunotherapy, the prognosis and survival of patients with cancer has remarkably improved. As a result, patients are living longer and experiencing long-term cardiovascular complications. Hypertension is an important risk factor for cardiovascular diseases. Patients with malignancy have multiple etiologies of hypertension development, worsening, or association. This is because of the complex interplay between cancer type, chemotherapeutic agent, patient age, antihypertensive agent, and preexisting comorbidities in the etiology and pathogenesis of hypertension. Management of hypertension in patients with cancer requires accurate blood pressure measurement and considering factors such as adjuvant therapy and cancer-related pain. There are no set guidelines for management of hypertension in this unique cohort, and the therapy should be individualized based on the treatment guidelines for the general population. Onco-hypertension is an emerging subspeciality and entails a multidisciplinary approach between oncology, primary care physicians, nephrology, and cardiology.
Collapse
|
10
|
Rudolph UM, Enners S, Kieble M, Mahfoud F, Böhm M, Laufs U, Schulz M. Impact of angiotensin receptor blocker product recalls on antihypertensive prescribing in Germany. J Hum Hypertens 2020; 35:903-911. [PMID: 33057175 PMCID: PMC8502678 DOI: 10.1038/s41371-020-00425-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/08/2020] [Accepted: 09/28/2020] [Indexed: 01/12/2023]
Abstract
In Germany, ~8 million patients take angiotensin receptor blockers (ARBs) and 2.25 million of them valsartan. In 2018, contamination of generic ARBs with probable carcinogenic nitrosamines resulted in more than 30 recalls. The impact of such a huge recall has never been explored in Europe. We analyzed the utilization of valsartan, all ARBs, and other alternative antihypertensive drugs in Germany. We used our database of anonymized dispensing data from >80% of community pharmacies at the expense of the statutory health insurance (SHI) funds from January 2017 to December 2019. We analyzed 290.8 million prescriptions, including all oral mono- and fixed-dose combinations of ARBs and plausible alternatives, i.e. ACE inhibitors (ACEi), beta-blockers (BB), and calcium channel blockers (CCB). Utilization was calculated by defined daily doses per 1000 SHI-insured persons per day (DID). Valsartan use decreased substantially after the recalls in July 2018 from 39.0 to 14.2 DID (−64%) in the second quarter of 2019 and to 16.9 DID (−57%) in the fourth quarter of 2019. Simultaneously, the use of alternative ARBs increased from 77.7 DID in the second quarter of 2018 to 121.9 DID (+57%) in the fourth quarter of 2019, mainly due to an increase of candesartan dispensing to 99.8 DID (+73%). There were no changes in the utilization of ACEi, BB, or CCB. The majority of recalled generic valsartan products were replaced by other ARBs, predominantly candesartan, despite documented drug shortages. In contrast to previous safety warnings/recalls, our data do not suggest an under-prescription of antihypertensives during this period.
Collapse
Affiliation(s)
| | - Salka Enners
- German Institute for Drug Use Evaluation, Berlin, Germany
| | - Marita Kieble
- German Institute for Drug Use Evaluation, Berlin, Germany
| | - Felix Mahfoud
- Department of Internal Medicine III-Cardiology, Angiology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Michael Böhm
- Department of Internal Medicine III-Cardiology, Angiology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Martin Schulz
- German Institute for Drug Use Evaluation, Berlin, Germany.,Drug Commission of German Pharmacists, Berlin, Germany.,Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| |
Collapse
|
11
|
Bottino LG, Fuchs FD. The role of angiotensin receptor blockers in CVD risk management. Expert Rev Cardiovasc Ther 2020; 18:181-185. [DOI: 10.1080/14779072.2020.1750369] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Flávio Danni Fuchs
- School of Medicine, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Division of Cardiology, Hospital De Clínicas De Porto Alegre, Universidade Federal Do Rio Grande Do Sul, Brazil
| |
Collapse
|
12
|
Angiotensin Receptor Blockers and the Risk of Cancer: Insights from Clinical Trials and Recent Drug Recalls. Curr Hypertens Rep 2020; 22:20. [PMID: 32114653 DOI: 10.1007/s11906-020-1021-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to familiarize readers with issues surrounding angiotensin receptor blockers (ARBs) and the risk of cancer, both from the perspective of clinical trial data and the more recent concerns about impurities in certain ARB products. RECENT FINDINGS Approximately 45.6% of adults in the USA have hypertension. ARB-containing medications are widely used in the USA, with tens of millions of prescriptions written yearly. Whether exposure to certain ARB drug products contributes to the development of cancer has been the topic of a series of publications. Nonetheless, ARBs' link to cancer, if any, remains inconclusive. Any mechanistic link between ARBs and cancer is poorly understood, with a variety of basic science studies suggesting that ARBs should exert a protective effect. Due to the presence of potentially carcinogenic nitrosamine impurities in certain ARB products, a series of large recalls in the USA and in countries around the world has occurred since 2018. These recalls have occurred in the context of two recent trends affecting antihypertensive drugs: nearly ubiquitous reliance on generic drugs and increased use of manufacturing facilities in China and India to supply the USA. Despite substantial efforts directed toward understanding whether ARBs have the potential to cause cancer, the available studies do not provide a consistent answer, and a causal link remains speculative. The principal conclusion must be that there is not a definitive signal for cancer associated with ARB exposure, although the possibility has not been fully excluded. The problem of nitrosamine impurities in certain ARB products (and some other drug products) is in need of further investigation, so that the risks can be mitigated by eliminating these impurities from the drug supply chain.
Collapse
|
13
|
Buckley LF, Vaduganathan M, Lauffenburger JC, Machado SR, Fanikos J. Unintended Impact of US Food and Drug Administration Recalls on the Use of Contaminated and Non-Contaminated Angiotensin Receptor Blockers Among Medicaid Beneficiaries. Ann Pharmacother 2019; 54:615-616. [DOI: 10.1177/1060028019897388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|