Skin rash during treatment with generic itraconazole

Double Infection in a Patient with Psoriatic Arthritis Under TNF-alpha Blockers Therapy: A Case Report

BACKGROUND

Either direct or indirect tumor necrosis factor (TNF)-alpha blockers are usually used to treat psoriatic arthritis (PA), but their use can increase susceptibility to infectious diseases.

CASE PRESENTATION

We report a rare case of double skin-knee wound and lung non-tubercular infection in a patient with PA under TNF-alpha blockers therapy. About 1 year after the beginning of adalimumab, a 48-year-old smoker suffering of PA was hospitalized for the skin-knee wound.

RESULTS

Clinical evaluation and biochemical markers excluded the presence of a systemic disease, and a skin infection sustained by leishmaniasis probably related to adalimumab was diagnosed (Naranjo score: 6). Adalimumab was discontinued and oral treatment with apremilast and topical treatment with meglumine antimoniate was started with a complete remission of skin wound in 2 weeks. About 7 months later when the patient was under apremilast treatment, he presented to our observation for dyspnea, cough and fever. High-Resolution Computer Tomography (HRCT) chest highlighted alveolar involvement with centrilobular small nodules, branching linear and nodular opacities. Microbiological culture of both broncho-alveolar lavage fluid and sputum documented an infection sustained by nontuberculous mycobacteria. Even if apremilast treatment probably-induced lung infection, we can't exclude that it worsened a clinical condition induced by adalimumab. Apremilast was stopped and an empirical antitubercular treatment was started. Patient's breathlessness and cough improved as confirmed also by HRCT chest.

CONCLUSION

This case highlights the importance to consider the possibility to develop leishmaniasis and/or non-tubercular mycobacterial infection in patients treated with TNF-alpha inhibitors.

Comparison of brand versus generic antiepileptic drug adverse event reporting rates in the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS)

OBJECTIVE

Despite the cost saving role of generic anti-epileptic drugs (AEDs), debate exists as to whether generic substitution of branded AEDs may lead to therapeutic failure and increased toxicity. This study compared adverse event (AE) reporting rates for brand vs. authorized generic (AG) vs. generic AEDs. Since AGs are pharmaceutically identical to brand but perceived as generics, the generic vs. AG comparison minimized potential bias against generics.

METHODS

Events reported to the U.S. Food and Drug Administration Adverse Event Reporting System between January 2004 to March 2015 with lamotrigine, carbamazepine, and oxcarbazepine listed as primary or secondary suspect were classified as brand, generic, or AG based on the manufacturer. Disproportionality analyses using the reporting odds ratio (ROR) assessed the relative rate of reporting of labeled AEs compared to reporting these events with all other drugs. The Breslow-Day statistic compared RORs across brand, AG, and other generics using a Bonferroni-corrected P<0.01.

RESULTS

A total of 27,150 events with lamotrigine, 13,950 events with carbamazepine, and 5077 events with oxcarbazepine were reported, with generics accounting for 27%, 41%, and 32% of reports, respectively. Although RORs for the majority of known AEs were different between brand and generics for all three drugs of interest (Breslow-Day P<0.001), RORs generally were similar for AG and generic comparisons. Generic lamotrigine and carbamazepine were more commonly involved in reports of suicide or suicidal ideation compared with the respective AGs based on a multiple comparison-adjusted P<0.01.

SIGNIFICANCE

Similar AED reporting rates were observed for the AG and generic comparisons for most outcomes and drugs, suggesting that brands and generics have similar reporting rates after accounting for generic perception biases. Disproportional suicide reporting was observed for generics compared with AGs and brand, although this finding needs further study.

A Case of Interstitial Lung Disease Probably Related to Rituximab Treatment

A 44-year-old male developed interstitial lung disease (ILD) during treatment with rituximab (375 mg/m² weekly intravenous × 4 weeks) for the management of immune thrombocytopenia (ITP). After 1 month of treatment he developed dyspnea, fever (38.9 °C), an increase of C-reactive protein (CRP) and white blood cells with hypoxemia, and decreased platelets. Chest X-ray and high-resolution computed tomography revealed diffuse bilateral lung infiltrates. He was diagnosed with severe ILD; rituximab was discontinued, and treatment with fluticasone combined with salmeterol, methylprednisolone, and omeprazole was started, with an improvement of symptoms over 15 days with normalization in CRP at 30 days. A Naranjo assessment score of 6 was obtained, indicating a probable relationship between the patient's symptoms and the suspect drug. In conclusion, in ITP patients treated with rituximab, we suggest evaluating pulmonary endpoints through pharmaco-epidemiological observational studies.

Recurrence of atrial fibrillation after switching from brand to generic atenolol

Beta blockers are the initial treatment for rate control of supraventricular tachyarrhythmia in patients without a history of myocardial infarction or left ventricular dysfunction. In this article we report the recurrence of atrial fibrillation after switching to the generic formulation of atenolol.