Development of low blood glucose readings in nine non-diabetic patients treated with tumor necrosis factor-alpha inhibitors: a case series

Anti-tumor Necrosis Factor-Alpha Therapy and Hypoglycemia: A Real-World Pharmacovigilance Analysis

INTRODUCTION

An association between tumor necrosis factor (TNF)-α inhibitors and hypoglycemia has been detected in a few case reports and small case series; however, no relevant pharmacovigilance data have been published yet.

OBJECTIVE

The objective of this study was to detect and characterize relevant safety signals between hypoglycemia and TNF-α inhibitor use.

METHODS

Indication-focused disproportionality analysis was conducted to detect increased reporting of TNF-α-associated hypoglycemia compared with all other reports with the same indication during the same time period. Reporting odds ratios (RORs) with 95% confidence intervals (CIs) were calculated to determine disproportionality. To reduce potential confounding factors, adjusted RORs were further calculated by logistic regression to control for age, sex, diabetes status, and concomitant drugs that potentially affect blood glucose levels.

RESULTS

In all, 1086 adverse drug reactions related to TNF-α inhibitors were reported as 'hypoglycemia'. There were no disproportionality signals of hypoglycemia in TNF-α inhibitor users with indication of inflammatory bowel disease. When TNF-α inhibitors were considered as a class, disproportion for hypoglycemia only emerged in indication of psoriasis (n = 267, ROR 1.20, 95% CI 1.02-1.41). In further analyses of specific TNF-α inhibitor type, significant RORs for hypoglycemia were found in indication of rheumatic disease, including adalimumab in ankylosing spondylitis (n = 37, ROR 1.97, 95% CI 1.28-3.04), psoriasis (n = 160, ROR 1.64, 95% CI 1.37-1.97), and rheumatoid arthritis (n = 230, ROR 1.35, 95% CI 1.16-1.56) and infliximab in psoriasis (n = 18, ROR 2.14, 95% CI 1.33-3.42). After adjusting for confounding factors, only the signals of adalimumab were stable.

CONCLUSIONS

Our study identified some potential pharmacovigilance signals between hypoglycemia and TNF-α inhibitors, which warrants further validation.

Effects of Adalimumab, an Anti-tumour Necrosis Factor-Alpha (TNF-α) Antibody, on Obese Diabetic Rats

Background

Diabetes mellitus (DM) represents a major health problem worldwide. Recent studies have confirmed that obesity is a state of chronic inflammation that is characterised by increased concentrations of tumour necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and other inflammatory markers. It has been reported that increased TNF-α and IL-6 cause an immunological disturbance in DM. In the present study, the levels of fasting glucose, TNF-α and IL-6 were estimated in order to determine whether adalimumab can improve the glucose levels in obese diabetic rats.

Materials and methods

Twenty-eight Wistar rats were divided into four groups: obese + diabetes + adalimumab (group 1), obese + diabetes (group 2), obese (group 3) and normal control (group 4), respectively (n = seven per group). Obesity was induced by feeding the rats in groups 1, 2 and 3 with a high-fat diet for four weeks. Some 30 mg/kg of streptozotocin (STZ) was administered to groups 1 and 2 so as to induce diabetes. Adalimumab was administered at a rate of 50 mg/kg to group 1 following the induction of diabetes. The fasting glucose, TNF-α and IL-6 concentrations were determined.

Results

A significant decrease was observed in the glucose levels of the treated rats (6.91 [0.11] mmol/L) when compared to those of the untreated rats (15.43 [0.44] mmol/L) (P < 0.001). The TNF-α levels were lower in group 1 (20.71 [0.35] ng/L) than in groups 2 (37.90 [0.27] ng/L) and 3 (25.89 [0.12] ng/L) (P < 0.001), although they were higher when compared to the levels seen in group 4 (12.44 [0.38] ng/L) (P < 0.001). The IL-6 concentrations were found to be elevated in groups 1 (22.89 [0.45] ng/L), 2 (21.00 [0.40] ng/L) and 3 (31.80 [1.32] ng/L) when compared to the levels seen in group 4 (18.70 [0.37] ng/L) (P < 0.001), although they were lower in group 1 (22.89 [0.45] ng/L) than in group 3 (31.80 [1.32] ng/L) (P < 0.001).

Conclusion

Adalimumab reduced the glucose and TNF-α levels of diabetic rats, which indicates that it has a therapeutic effect in terms of controlling the blood glucose.

Blood glucose changes surrounding initiation of tumor-necrosis factor inhibitors and conventional disease-modifying anti-rheumatic drugs in veterans with rheumatoid arthritis

AIM

To determine the scope of acute hypoglycemic effects for certain anti-rheumatic medications in a large retrospective observational study.

METHODS

Patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry were selected who, during follow-up, initiated treatment with tumor necrosis factor inhibitors (TNFi’s, including etanercept, adalimumab, infliximab, golimumab, or certolizumab), prednisone, or conventional disease-modifying anti-rheumatic drugs (DMARDs), and for whom proximate random blood glucose (RBG) measurements were available within a window 2-wk prior to, and 6 mo following, medication initiation. Similar data were obtained for patients with proximate values available for glycosylated hemoglobin A1C values within a window 2 mo preceding, and 12 mo following, medication initiation. RBG and A1C measurements were compared before and after initiation events using paired t-tests, and multivariate regression analysis was performed including established comorbidities and demographics.

RESULTS

Two thousands one hundred and eleven patients contributed at least one proximate measurement surrounding the initiation of any examined medication. A significant decrease in RBG was noted surrounding 653 individual hydroxychloroquine-initiation events (-3.68 mg/dL, P = 0.04), while an increase was noted for RBG surrounding 665 prednisone-initiation events (+5.85 mg/dL, P < 0.01). A statistically significant decrease in A1C was noted for sulfasalazine initiation, as measured by 49 individual initiation events (-0.70%, P < 0.01). Multivariate regression analyses, using methotrexate as the referent, suggest sulfasalazine (β = -0.58, P = 0.01) and hydroxychloroquine (β = -5.78, P = 0.01) use as predictors of lower post-medication-initiation RBG and A1C values, respectively. Analysis by drug class suggested prednisone (or glucocorticoids) as predictive of higher medication-initiation event RBG among all start events as compared to DMARDs, while this analysis did not show any drug class-level effect for TNFi. A diagnosis of congestive heart failure (β = 4.69, P = 0.03) was predictive for higher post-initiation RBG values among all medication-initiation events.

CONCLUSION

No statistically significant hypoglycemic effects surrounding TNFi initiation were observed in this large cohort. Sulfasalazine and hydroxychloroquine may have epidemiologically significant acute hypoglycemic effects.