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Kowalska J, Wrześniok D. Skin-Related Adverse Reactions Induced by Oral Antidiabetic Drugs-A Review of Literature and Case Reports. Pharmaceuticals (Basel) 2024; 17:847. [PMID: 39065698 PMCID: PMC11280276 DOI: 10.3390/ph17070847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/04/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
Type 2 diabetes (T2DM) is a chronic metabolic disease with a steadily increasing prevalence worldwide. Diabetes affects the function of many organs, including the skin. Pharmacotherapy for T2DM is mainly based on oral hypoglycemic drugs. The therapeutic strategy is chosen taking into account the individual patient's characteristics, among other comorbidities. Antidiabetic drugs can induce cutaneous adverse reactions (CADRs) ranging in severity from mild erythema to serious disorders such as DRESS or Stevens-Johnson syndrome. CADRs can result from hypersensitivity to the drug but can also be related to the mechanism of action of the drug or cross-reactivity with drugs of similar structure. This paper reviews CADRs induced by oral antidiabetic drugs, considering their dermatological manifestations and possible pathomechanisms. Particular attention was paid to specific dermatological conditions such as dipeptidylpeptidase 4 inhibitor-associated bullous pemphigoid or Fournier's gangrene associated with sodium-glucose cotransporter 2 inhibitor therapy. Knowledge of the dermatological manifestations of CADRs is important in clinical practice. Recognition of a skin lesion resulting from an adverse drug reaction allows for appropriate management, which in this case is primarily related to drug discontinuation. This is particularly important in the treatment of T2DM since this disease has a high prevalence in the elderly, who are at higher risk of adverse drug reactions.
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Affiliation(s)
- Justyna Kowalska
- Department of Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Jagiellońska 4, 41-200 Sosnowiec, Poland;
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Sun L, Wang C, Wu C, Zhou Y, Wang C. Analysis of the Clinical Characteristics of Dipeptidyl Peptidase-4 Inhibitor-Induced Bullous Pemphigoid. Ann Pharmacother 2021; 56:205-212. [PMID: 34105395 DOI: 10.1177/10600280211022722] [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] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To analyze and discuss the clinical characteristics of dipeptidyl peptidase-4 inhibitor (DPP4i)-induced bullous pemphigoid (BP). DATA SOURCES We collected case reports of DPP4i-induced BP by searching databases from 2006 to mid-May 2021, as a retrospective analysis. STUDY SELECTION AND DATA EXTRACTION Relevant case reports and case analyses of DPP4i-induced BP were included. DATA SYNTHESIS The median time of symptom onset was 9 months (range 0.5-59 months). BP most often occurred in patients receiving vildagliptin (52.63%) followed by linagliptin (27.19%) and sitagliptin (17.54%). Tense bullae and blisters (85.51%) and erythema (82.61%) on the extremities and trunk were the most common presenting symptoms. In total, 64.06% of BP patients were anti-BP180 autoantibody positive, 58.97% were BP180NC16a autoantibody positive, and 31.25% were anti-BP230 autoantibody positive. Skin biopsy revealed subepidermal bulla eosinophil infiltration in 93.85% of BP patients, lymphocyte infiltration in 56.93%, and neutrophil infiltration in 44.62%. Direct immunofluorescence was positive in 98.94% of BP patients with linear deposition of IgG (97.80%) and/or complement C3 (98.94%) along the basement membrane zone. Indirect immunofluorescence was positive in 87.88% of BP patients. Complete remission of BP was achieved in 83.64% of patients on DPP4i withdrawal and after 4 months (range 0.13-72 months) of follow-up. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review analyzes and discusses the clinical characteristics of DPP4i-induced BP and provides a reference for the safe and reasonable clinical application of DPP4i. CONCLUSIONS DPP4i drugs are related to the occurrence of BP in diabetic patients, especially elderly men taking vildagliptin.
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Affiliation(s)
- Linli Sun
- Department of general surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | | | - Cuifang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yulu Zhou
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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Moro F, Fania L, Sinagra JLM, Salemme A, Di Zenzo G. Bullous Pemphigoid: Trigger and Predisposing Factors. Biomolecules 2020; 10:E1432. [PMID: 33050407 PMCID: PMC7600534 DOI: 10.3390/biom10101432] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/01/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022] Open
Abstract
Bullous pemphigoid (BP) is the most frequent autoimmune subepidermal blistering disease provoked by autoantibodies directed against two hemidesmosomal proteins: BP180 and BP230. Its pathogenesis depends on the interaction between predisposing factors, such as human leukocyte antigen (HLA) genes, comorbidities, aging, and trigger factors. Several trigger factors, such as drugs, thermal or electrical burns, surgical procedures, trauma, ultraviolet irradiation, radiotherapy, chemical preparations, transplants, and infections may induce or exacerbate BP disease. Identification of predisposing and trigger factors can increase the understanding of BP pathogenesis. Furthermore, an accurate anamnesis focused on the recognition of a possible trigger factor can improve prognosis by promptly removing it.
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Affiliation(s)
- Francesco Moro
- Correspondence: (F.M.); (L.F.); Tel.: +39-(342)-802-0004 (F.M.)
| | - Luca Fania
- Correspondence: (F.M.); (L.F.); Tel.: +39-(342)-802-0004 (F.M.)
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Someili A, Azzam K, Hilal MA. Linagliptin-Associated Alopecia and Bullous Pemphigoid. Eur J Case Rep Intern Med 2019; 6:001207. [PMID: 31583211 PMCID: PMC6774654 DOI: 10.12890/2019_001207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/31/2019] [Indexed: 11/08/2022] Open
Abstract
Bullous pemphigoid is a chronic autoimmune blistering disease. Recently, several reports suggested dipeptidyl peptidase 4 (DPP-4) inhibitors, also known as gliptins, were a potential cause of drug-induced bullous pemphigoid but not of both bullous pemphigoid and alopecia areata together. Here we describe the case of a 68-year-old man with type 2 diabetes mellitus who developed new onset diffuse alopecia on the scalp with diffuse tense bullae over his body a few months after linagliptin was introduced for better control of his diabetes. DPP-4 inhibitors are not known to increase the risk of alopecia. To the best of our knowledge, this is the first report of linagliptin-associated alopecia areata and bullous pemphigoid, which may help demonstrate if there are any links between DPP-4 inhibitors and alopecia. LEARNING POINTS This is the first report of linagliptin-associated alopecia areata and bullous pemphigoid (BP), which may help demonstrate a link between DPP-4 inhibitors and alopecia.Since the time of onset of BP after initiation of a DPP-4 inhibitor varies, a high index of suspicion is needed for diagnosis.Early diagnosis is essential as DPP-4 inhibitor withdrawal has a significant effect on disease remission.
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Affiliation(s)
- Ali Someili
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Khalid Azzam
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Tasanen K, Varpuluoma O, Nishie W. Dipeptidyl Peptidase-4 Inhibitor-Associated Bullous Pemphigoid. Front Immunol 2019; 10:1238. [PMID: 31275298 PMCID: PMC6593303 DOI: 10.3389/fimmu.2019.01238] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/16/2019] [Indexed: 12/18/2022] Open
Abstract
Bullous pemphigoid (BP) is an organ-specific autoantibody-mediated blistering skin disease that mainly affects the elderly. Typical clinical features include the widespread blisters, often preceded by and/or associated with itchy urticarial or eczema-like lesions. BP patients have circulating autoantibodies against BP180 and/or the plakin family protein BP230 both of which are components of hemidesmosomes in basal keratinocytes. Most BP autoantibodies particularly target the epitopes within the non-collagenous NC16A domain of BP180. Clinical findings and murine models of BP have provided evidence of a pathogenic role of anti-NC16A autoantibodies. However, it is largely unknown what triggers the breakage of immunotolerance against BP180 in elderly individuals. The incidence of BP has been increased over the past two decades in several countries. Aside from aging populations, the factors behind this phenomenon are still not fully understood. Neurodegenerative diseases such as multiple sclerosis, Parkinson's disease, and certain dementias are independent risk factors for BP. Recently several case reports have described BP in patients with diabetes mellitus (DM) patients who have been treated with dipeptidyl peptidase-4 inhibitors (DPP-4i or gliptins), which are a widely used class of anti-DM drugs. The association between the use of DPP-4is, particularly vildagliptin, and BP risk has been confirmed by several epidemiological studies. Evidence suggests that cases of gliptin-associated BP in Japan display certain features that set them apart from cases of “regular” BP. These include a “non-inflammatory” phenotype, targeting by antibodies of different immunodominant BP180 epitopes, and a specific association with the human leukocyte antigen (HLA) types. However, recent studies in European populations have found no major differences between the clinical and immunological characteristics of gliptin-associated BP and “regular” BP. The DPP-4 protein (also known as CD26) is ubiquitously expressed and has multiple functions in various cell types. The different effects of the inhibition of DPP-4/CD26 activity include, for example, tissue modeling and regulation of inflammatory cells such as T lymphocytes. Although the pathomechanism of gliptin-associated BP is currently largely unknown, investigation of the unique effect of gliptins in the induction of BP may provide a novel route to better understanding of how immunotolerance against BP180 breaks down in BP.
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Affiliation(s)
- Kaisa Tasanen
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Outi Varpuluoma
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Cutaneous Adverse Effects of Diabetes Mellitus Medications and Medical Devices: A Review. Am J Clin Dermatol 2019; 20:97-114. [PMID: 30361953 DOI: 10.1007/s40257-018-0400-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Diabetes mellitus is one of the most prevalent chronic diseases in the USA. If uncontrolled, diabetes can lead to devastating complications. Diabetes medications and medical devices largely contribute to the significant financial expense that the disease inflicts on affected individuals and society. Alongside significant economic burden, there are numerous cutaneous adverse effects associated with diabetes medications and medical devices. Despite the large and increasing number of individuals living with diabetes and the wide use of the related medications and medical devices, there is limited literature that comprehensively documents their cutaneous adverse effects. These cutaneous adverse effects are significant as they can worsen glycemic control, increase disease distress, and may increase risk of associated complications. Thus, it is important that providers can recognize these cutaneous adverse effects, identify the culprit agents, and can properly manage them. In this article, we provide a critical review of the cutaneous adverse effects of medications and devices used in the management of diabetes and provide insight into risk factors and prevention and an overview of therapeutic management. An emphasis is placed on clinical recognition and treatment for use of the medical providers who, regardless of practice setting, will treat patients with diabetes.
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Gaudin O, Seta V, Alexandre M, Bohelay G, Aucouturier F, Mignot-Grootenboer S, Ingen-Housz-Oro S, Bernardeschi C, Schneider P, Mellottee B, Caux F, Prost-Squarcioni C. Gliptin Accountability in Mucous Membrane Pemphigoid Induction in 24 Out of 313 Patients. Front Immunol 2018; 9:1030. [PMID: 29881377 PMCID: PMC5976795 DOI: 10.3389/fimmu.2018.01030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/24/2018] [Indexed: 01/27/2023] Open
Abstract
Mucous membrane pemphigoids (MMPs) and bullous pemphigoid (BP) are autoimmune bullous diseases that share physiopathological features: both can result from autoantibodies directed against BP180 or BP230 antigens. An association has been reported between BP and intake of gliptins, which are dipeptidyl peptidase-IV inhibitors used to treat type 2 diabetes mellitus. Clinical and immunological differences have been reported between gliptin-induced BPs and classical BPs: mucosal involvement, non-inflammatory lesions, and target BP180 epitopes other than the NC16A domain. Those findings accorded gliptins extrinsic accountability in triggering MMP onset. Therefore, we examined gliptin intrinsic accountability in a cohort of 313 MMP patients. To do so, we (1) identified MMP patients with gliptin-treated (challenge) diabetes; (2) selected those whose interval between starting gliptin and MMP onset was suggestive or compatible with gliptin-induced MMP; (3) compared the follow-ups of patients who did not stop (no dechallenge), stopped (dechallenge) or repeated gliptin intake (rechallenge); (4) compared the clinical and immunological characteristics of suggestive-or-compatible-challenge patients to 121 never-gliptin-treated MMP patients serving as controls; and (5) individually scored gliptin accountability as the trigger of each patient's MMP using the World Health Organization-Uppsala Monitoring Center, Naranjo- and Begaud-scoring systems. 17 out of 24 gliptin-treated diabetic MMP patients had suggestive (≤12 weeks) or compatible challenges. Complete remission at 1 year of follow-up was more frequent in the 11 dechallenged patients. One rechallenged patient's MMP relapsed. These 17 gliptin-treated diabetic MMP patients differed significantly from the MMP controls by more cutaneous, less buccal, and less severe involvements and no direct immunofluorescence IgA labeling of the basement membrane zone. Multiple autoantibody-target antigens/epitopes (BP180-NC16A, BP180 mid- and C-terminal parts, integrin α6β4) could be detected, but not laminin 332. Last, among the 24 gliptin-treated diabetic MMP patients, five had high (I4-I3), 12 had low (I2-I1) and 7 had I0 Begaud intrinsic accountability scores. These results strongly suggest that gliptins are probably responsible for some MMPs. Consequently, gliptins should immediately be discontinued for patients with a positive accountability score. Moreover, pharmacovigilance centers should be notified of these events.
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Affiliation(s)
- Olivier Gaudin
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Vannina Seta
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Cochin Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Marina Alexandre
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Gérôme Bohelay
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Françoise Aucouturier
- Department of Immunology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Saint-Louis Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris, France
| | - Sabine Mignot-Grootenboer
- Department of Immunology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Bichat Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris, France
| | - Saskia Ingen-Housz-Oro
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Henri-Mondor Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Créteil, France
| | - Céline Bernardeschi
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Cochin Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Pierre Schneider
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Saint-Louis Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris, France
| | - Benoît Mellottee
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Frédéric Caux
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Catherine Prost-Squarcioni
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
- Department of Histology, UFR Léonard de Vinci, Paris 13 University, Bobigny, France
- Department of Pathology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
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Maki N, Nishie W, Takazawa M, Kakurai M, Yamada T, Umemoto N, Kawase M, Izumi K, Shimizu H, Demitsu T. Dipeptidyl peptidase-4 inhibitor-associated bullous pemphigoid in a patient with acquired reactive perforating collagenosis. J Dermatol 2018; 45:600-602. [PMID: 29446164 DOI: 10.1111/1346-8138.14254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/15/2018] [Indexed: 11/28/2022]
Abstract
Bullous pemphigoid (BP) is a common autoimmune blistering disorder with unknown etiology. Recently, increasing numbers of BP cases which developed under the medication with dipeptidyl peptidase-4 inhibitors (DPP4i), widely used antihyperglycemic drugs, have been reported in published works. Here, we report a case of DPP4i (teneligliptin)-associated BP that developed in a 70-year-old Japanese man. Interestingly, the patient had acquired reactive perforating collagenosis (ARPC), which is also known to be associated with the onset of BP. In the present case, clinical, histopathological and immunological findings suggested that DPP4i rather than ARPC was associated with the onset of BP.
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Affiliation(s)
- Nobuki Maki
- Department of Dermatology, Akita National Hospital, Akita, Japan
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University School of Medicine, Hokkaido, Japan
| | - Maya Takazawa
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Maki Kakurai
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Tomoko Yamada
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Naoka Umemoto
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masaaki Kawase
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kentaro Izumi
- Department of Dermatology, Hokkaido University School of Medicine, Hokkaido, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Hokkaido University School of Medicine, Hokkaido, Japan
| | - Toshio Demitsu
- Department of Dermatology, Jichi Medical University Saitama Medical Center, Saitama, Japan
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