Immune-mediated colitis associated with ocrelizumab: A new safety risk

BACKGROUND

An association between certain immunomodulatory therapies (rituximab, ipilimumab, and other immune checkpoint inhibitors) and inflammatory (non-ischemic and non-infectious) colitis in oncologic and non-oncologic patient populations is well documented in the medical literature.

OBJECTIVE

The purpose of this case series is to describe adverse event reports of new onset, inflammatory colitis in association with ocrelizumab in patients with multiple sclerosis submitted to U.S. Food and Drug Administration (FDA) or published in the medical literature.

METHODS

The FDA Adverse Event Reporting System (FAERS) and medical literature were searched.

RESULTS

A review of postmarketing cases from FAERS and published medical literature identified 38 cases consistent with inflammatory, non-ischemic, and non-infectious colitis in association with ocrelizumab. The median time-to-onset was 8 months. Cases were reported using the following diagnostic terms: Crohn's disease (13), unspecified colitis (11), microscopic colitis (5), ulcerative colitis (5), medication-induced colitis (3), and autoimmune colitis (2).

CONCLUSIONS

This case series highlights ocrelizumab induced immune-mediated colitis that can be clinically severe and potentially life-threatening. Based on the findings of this review, the ocrelizumab Prescribing Information was amended to include immune-mediated colitis in the Warnings and Precautions section.

A case series analysis of serious exacerbations of viral hepatitis and non-viral hepatic injuries in tocilizumab-treated patients

BACKGROUND AND AIMS

Reports of moderate to severe liver injury associated with tocilizumab, an interleukin-6 (IL-6) receptor antagonist, have been reported in the post-marketing setting. This case series aims to characterize cases of tocilizumab-associated clinically significant hepatic injury.

METHODS

We analysed cases of severe acute liver injury associated with tocilizumab reported in the FDA Adverse Event Reporting System and the medical literature.

RESULTS

We identified 12 cases in which tocilizumab was a suspected primary cause of liver injury and eight cases in which serious sequelae of underlying or coincident viral hepatitis were temporally associated with its use. Using the Drug-Induced Liver Injury Network (DILIN) severity scale, five of 12 cases were Grade 5 (two liver transplants, three deaths), one was Grade 4 (liver failure) and six were Grade 3 (serious events with elevated bilirubin). Two cases reported liver atrophy with low hepatocellular expression of Ki-67, a marker of cellular proliferation. Among the eight cases of tocilizumab-associated viral hepatitis exacerbation, three were scored as DILIN severity Grade 5 (one liver transplant, two deaths), one was Grade 4 (liver failure), and four were Grade 3. The reported viral hepatitis events were hepatitis B virus (HBV) reactivation (n = 3), hepatitis C virus (HCV) flare (n = 1), cytomegalovirus (CMV)-induced liver failure (n = 1), Epstein-Barr virus hepatitis (n = 1), acute hepatitis E (HEV, n = 1) and HEV-induced macrophage activation syndrome (n = 1).

CONCLUSION

Tocilizumab may be a primary cause of severe liver injury, as well as exacerbate underlying viral hepatitis. The disruption by tocilizumab of IL-6-mediated immune protection and hepatocyte regeneration may aggravate clinical outcomes in some cases.

Hypertension: A new safety risk for patients treated with erenumab

OBJECTIVE

To identify and analyze postmarketing case reports of elevated blood pressure (BP) associated with erenumab use.

METHODS

A retrospective analysis of postmarketing (spontaneous) case reports of erenumab-associated elevated BP submitted to the FDA Adverse Event Reporting System from May 17, 2018 through April 30, 2020. A case of elevated BP was defined as (a) an initiation of a pharmacological intervention or emergency department visit or hospitalization for emergent de novo or worsening of preexisting hypertension, or (b) BP measurement of ≥140 mm Hg systolic or ≥90 mm Hg diastolic with or without baseline BP measurement reported. Reports of elevated BP associated with erenumab use were analyzed for baseline and demographic information, latency, drug-event causal association, and clinical outcome.

RESULTS

Sixty-one cases of elevated BP were identified, 86% (49/57) were women and the median age was 56 [range 24-88] years. Forty-one cases were associated with a serious outcome per regulatory criteria, including seven that specified hospitalization. No case reported an outcome of death. The median systolic BP increase was 39 (interquartile range (IQR) 32, 59) mm Hg and median diastolic BP increase was 28 (IQR 18, 41) mm Hg. A total of 27/61 (44%) cases reported treatment for elevated BP (i.e., pharmacologic intervention or emergency department visit/hospitalization). Elevated BP occurred most frequently (28/61, 46%) within a week of the first dose of erenumab. Nineteen cases (19/61, 31%) reported a history of preexisting hypertension.

CONCLUSIONS

This case series suggest an association between elevated BP and use of erenumab. In light of our findings, the erenumab (Aimovig) prescribing information was amended to include hypertension in the Warnings and Precautions section.

Tumefactive multiple sclerosis in association with fingolimod initiation and discontinuation

BACKGROUND

Tumefactive multiple sclerosis (TMS) is a rare multiple sclerosis (MS) form that usually manifests as the initial presentation or in the early stages of MS.

OBJECTIVE

The aim of this study is to evaluate reports of TMS associated with fingolimod use.

METHODS

The Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database and the medical literature were searched for cases of TMS occurring during or after fingolimod treatment.

RESULTS

We identified 29 TMS cases, 19 following fingolimod initiation and 10 following fingolimod discontinuation. In these cases, a TMS diagnosis occurred at a median of 7 years after MS diagnosis, and a median of 7 and 3 months following initiation and discontinuation of fingolimod, respectively. Twenty-two cases were assessed as possible and seven as probable from a causal association perspective. A much larger crude number of TMS reports was observed for fingolimod compared to other disease-modifying therapies.

CONCLUSION

TMS should be considered when a severe or atypical MS relapse occurs shortly after fingolimod initiation or discontinuation, and should prompt imaging evaluation and appropriate treatment initiation. Prescribers' awareness of the association between TMS and fingolimod may avoid unnecessary diagnostic procedures. In light of our findings, fingolimod (Gilenya) prescribing information was amended to include TMS in the Warnings and Precautions section.

Uptake routes of microplastics in fishes: practical and theoretical approaches to test existing theories

Microplastics are frequently detected in the gastrointestinal tracts of aquatic organisms worldwide. A number of active and passive pathways have been suggested for fish, including the confusion of microplastic particles with prey, accidental uptake while foraging and transfer through the food chain, but a holistic understanding of influencing factors is still lacking. The aim of the study was to investigate frequently suggested theories and identify relevant biotic factors, as well as certain plastic properties, affecting microplastic intake in fish. Four species of freshwater fish, each representing a different combination of foraging style (visual/chemosensory) and domestic status (wild/farmed) were exposed to different realistic plastic concentrations and polymer types with and without the provision of genuine food. As most previous investigations of microplastic uptake routes consider only particles large enough to be perceptible to fish, the potential for accidental intake via drinking water has been somewhat neglected. This route is evaluated in the current study using a model approach. The results show that visually oriented fish forage actively on microplastic particles that optically resemble their usual food, while fish with a predominantly chemosensory foraging style are more able to discriminate inedible food items. Even so, the accidental uptake of microplastics while foraging is shown to be relevant pathway, occurring frequently in both visual and chemosensory foragers alike. Several factors were shown to increase plastic uptake, including microplastic concentration in the water, foraging behaviour promoted by availability of genuine food, and fish size. Although both wild and farmed fish ingested microplastic particles, cultured fish showed less discernment in terms of colour and were more likely to forage actively on microplastics when no food was available. Drinking has been identified as a possible source of microplastic intake specifically for large marine fish species. Particles smaller than <5 µm can pass the gastrointestinal tract wall and bioaccumulation could arise when uptake exceeds release or when particles are assimilated in tissues or organs. The effects of accumulation may be significant, especially in long-living species, with implications for food web transfer and fish as food items.

Association of Noninfectious Pneumonia With Ustekinumab Use

Importance

The US Food and Drug Administration (FDA) conducts ongoing public health safety surveillance for drug and therapeutic biologic products. Identifying cases of acute and subacute noninfectious pneumonia supports the public health mission of the FDA.

Objective

To identify and analyze postmarketing cases of noninfectious pneumonia associated with ustekinumab use.

Design, Setting, and Participants

This retrospective analysis of postmarketing (spontaneous) case reports reviewed the FDA Adverse Event Reporting System (FAERS) and the PubMed databases from September 25, 2009, through November 20, 2017. Twelve cases of new-onset acute and subacute noninfectious pneumonia were identified after general marketing of ustekinumab. Cases were excluded if the time to symptom onset was more than 2 years from ustekinumab initiation and if an alternative origin for the noninfectious pneumonia (other than drug-induced) was reported.

Main Outcomes and Measures

Cases of noninfectious pneumonia associated with ustekinumab use were analyzed for baseline and demographic information, reason for ustekinumab use, symptoms, time to onset, dose sequence, laboratory and diagnostic information, and clinical outcome.

Results

Of the 12 cases, 8 were identified from the FAERS database and 4 from PubMed. The 12 cases (7 men [58%] and 5 women [42%], with a median [range] age of 63 [27-80] years) included 7 interstitial pneumonia (58%), 3 eosinophilic pneumonia (25%), 1 organizing pneumonia (8%), and 1 hypersensitivity pneumonitis (8%) diagnoses. All 12 cases reported a serious outcome, including 7 hospitalizations (58%) and 1 respiratory failure requiring mechanical ventilation (8%). No outcome of death was reported. All 12 cases were supportive of a temporal association; specifically, in 9 cases (75%), the pulmonary symptoms appeared after 1 to 3 doses of ustekinumab. In addition, 7 cases (58%) of positive dechallenge were reported, including 1 case of a positive rechallenge.

Conclusions and Relevance

The postmarketing cases suggest an association between noninfectious pneumonia and use of ustekinumab; these findings have led to the addition of a new warning for ustekinumab users regarding the risk of developing noninfectious pneumonia.

Hemophagocytic lymphohistiocytosis associated with the use of lamotrigine

Objective

To describe adverse event reports of hemophagocytic lymphohistiocytosis (HLH) reported in association with lamotrigine.

Methods

The Food and Drug Administration Adverse Event Reporting System database of spontaneous adverse event reports and medical literature databases were searched for cases of HLH reported in association with lamotrigine. Cases were included if they met the case definition of suspected or confirmed HLH and if causal association was assessed as robust or supportive.

Results

Eight cases met the case definition for HLH and were deemed causally associated with lamotrigine. These 8 cases of HLH had a plausible temporal relationship because they occurred within a 24-day interval from lamotrigine initiation. The doses ranged from 25 mg every other day to 250 mg once daily in the 6 cases that reported this information. Seven patients improved with drug discontinuation and one patient died after drug discontinuation and receiving an unspecified chemotherapy.

Conclusions

Lamotrigine is associated with immune-related adverse reactions including HLH. HLH is a potentially fatal event; prompt recognition and early therapeutic intervention to mitigate the event is important in improving patient outcomes.

Acute acalculous cholecystitis: A new safety risk for patients with MS treated with alemtuzumab

OBJECTIVE

To evaluate acute acalculous cholecystitis (AAC) as a potential safety risk for patients treated with alemtuzumab.

METHODS

The Food and Drug Administration Adverse Event Reporting System and the medical literature were searched for cases of AAC in conjunction with alemtuzumab for all clinical indications.

RESULTS

Eight spontaneously reported cases meeting the case definition of AAC in close temporal association with alemtuzumab use were identified. Based on established criteria within the Food and Drug Administration Division of Pharmacovigilance for causality assessment, 4 cases were assessed as probable while 4 were possible. All cases occurred in patients with relapsing-remitting multiple sclerosis. Seven of the 8 cases presented with AAC during or shortly after alemtuzumab treatment, thereby suggesting an acute cytokine release syndrome as a putative pathogenic mechanism. The cases identified in this review differ from the typical AAC cases described in the medical literature based on female preponderance, lack of concurrent critical illnesses, inconsistent presence of other risk factors, and resolution with conservative treatment in the majority of cases.

CONCLUSIONS

AAC represents a new and potentially life-threatening adverse event associated with alemtuzumab use in relapsing-remitting multiple sclerosis. In cases seen to date, early and conservative treatment resulted in good clinical outcome, although the natural history of AAC in this population without critical illness is not well defined. Awareness of this safety risk by general and specialty neurologists is important for prompt recognition and optimal management.

Postmarketing cases of eluxadoline-associated pancreatitis in patients with or without a gallbladder

BACKGROUND

Cases of pancreatitis were identified in the eluxadoline clinical development program, reflected in initial product labelling, and the subject of postmarketing reports.

AIM

To analyse postmarketing cases of eluxadoline-associated pancreatitis.

METHODS

We retrospectively analysed all US adverse event reports of pancreatitis associated with eluxadoline reported to the FDA Adverse Event Reporting System (FAERS) database from May 27, 2015 through February 15, 2017.

RESULTS

The analysis included 119 cases of pancreatitis associated with eluxadoline; one resulted in death and 75 in hospitalisation. Sixty-seven cases reported the presence (n = 12) or absence (n = 55) of the patient's gallbladder. The eluxadoline dose received in the 55 cases of patients without gallbladders was 75 mg (n = 43), 100 mg (n = 5), or not reported (n = 7). Of the 119 cases, 37 reported the patient did not abuse alcohol and 82 did not report the alcohol abuse status. The single fatal case occurred in a patient without a gallbladder who received eluxadoline 75 mg and did not abuse alcohol. Forty-seven cases reported development of pancreatitis within the first or second dose of eluxadoline initiation. The median time to onset for the development of pancreatitis (n = 83) was 1 day, ranging from 1 to 56 days of continued use of eluxadoline.

CONCLUSION

The FAERS cases suggest that patients with or without a gallbladder receiving eluxadoline are at risk for the development of pancreatitis. However, patients without a gallbladder, despite receiving the recommended lower dose of eluxadoline 75 mg and screening for alcohol abuse, appear to be overrepresented among patients who developed eluxadoline-associated pancreatitis.

Hepatitis B Virus Reactivation Associated With Direct-Acting Antiviral Therapy for Chronic Hepatitis C Virus: A Review of Cases Reported to the U.S. Food and Drug Administration Adverse Event Reporting System

BACKGROUND

Direct-acting antiviral agents (DAAs) are used increasingly to treat hepatitis C virus (HCV) infection. Reports were published recently on hepatitis B virus (HBV) reactivation (HBV-R) in patients with HBV-HCV co-infection. Hepatitis B virus reactivation, defined as an abrupt increase in HBV replication in patients with inactive or resolved HBV infection, may result in clinically significant hepatitis.

OBJECTIVE

To assess whether HBV-R is a safety concern in patients receiving HCV DAAs.

DESIGN

Descriptive case series.

SETTING

U.S. Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS).

PATIENTS

29 patients with HBV-R receiving HCV DAAs.

MEASUREMENTS

Clinical and laboratory data.

RESULTS

The FDA identified 29 unique reports of HBV-R in patients receiving DAAs from 22 November 2013 to 15 October 2016. Two cases resulted in death and 1 case in liver transplantation. Patients in whom HBV-R developed were heterogeneous regarding HCV genotype, DAAs received, and baseline HBV characteristics. At baseline, 9 patients had a detectable HBV viral load, 7 had positive results on hepatitis B surface antigen (HBsAg) testing and had an undetectable HBV viral load, and 3 had negative results on HBsAg testing and had an undetectable HBV viral load. For the remaining 10 patients, data points were not reported or the data were uninterpretable. Despite provider knowledge of baseline HBV, HBV-R diagnosis and treatment were delayed in 7 cases and possibly 7 others.

LIMITATIONS

The quality of information varied among reports. Because reporting is voluntary, HBV-R associated with DAAs likely is underreported.

CONCLUSION

Hepatitis B virus reactivation is a newly identified safety concern in patients with HBV-HCV co-infection treated with DAAs. Patients with a history of HBV require clinical monitoring while receiving DAA therapy. Studies would help determine the risk factors for HBV-R, define monitoring frequency, and identify patients who may benefit from HBV prophylaxis and treatment. DAAs remain a safe and highly effective treatment for the management of HCV infection.

PRIMARY FUNDING SOURCE

None.

Chemical Leukoderma Associated with Methylphenidate Transdermal System: Data From the US Food and Drug Administration Adverse Event Reporting System

OBJECTIVE

To identify and characterize cases of chemical leukoderma, an underrecognized adverse event, associated with the methylphenidate transdermal system (MTS) reported to the US Food and Drug Administration Adverse Event Reporting System (FAERS).

STUDY DESIGN

We searched the Food and Drug Administration Adverse Event Reporting System for reports of chemical leukoderma associated with MTS, received by the Food and Drug Administration from April 6, 2006 to December 23, 2014.

RESULTS

We identified 51 cases of chemical leukoderma reported with the use of MTS. The median age was 11 years; 43 cases reported leukoderma at or near the application site only, and 7 reported leukoderma at other parts of the body in addition to the application site; 1 case did not provide enough information to confirm the affected site. The time to onset ranged from 2 months to 4 years after the initiation of MTS. MTS was discontinued in 31 cases. Thirteen patients were prescribed treatment for repigmentation. Three cases reported continued spread of leukoderma after MTS was discontinued. Nineteen cases were diagnosed as vitiligo, including 5 cases reporting histologic features consistent with vitiligo. Leukoderma was persistent in all cases. The median follow-up interval after the discontinuation of MTS in 23 cases was 14 months.

CONCLUSIONS

As outlined in recent changes to the prescribing information for MTS, health care professionals need to be aware of the potential risk of chemical leukoderma caused by MTS, especially given that chemical leukoderma is often misdiagnosed as idiopathic vitiligo. MTS should be discontinued at the earliest sign of pigment loss and other treatment options considered.

Genetically distinct colour morphs of European perch Perca fluviatilis in Lake Constance differ in susceptibility to macroparasites

The unusual yellow-finned morph of European perch Perca fluviatilis found in Lake Constance suffers more severely from macroparasite infections, including the tapeworm Triaenophorus nodulosus and the gill worm Ancyrocephalus percae, than conspecifics elsewhere. Microsatellite analysis of yellow-finned P. fluviatilis and red-finned variant recently discovered in Lake Constance revealed significant genetic differentiation. Red-finned P. fluviatilis and fish with mixed fin colour, suggested backcrosses between red and yellow-finned colour morphs, exhibit better resilience to parasite infection, suggesting that the inability of the yellow-finned morph to reject macroparasites may have a genetic basis.

Genetic diversity of upper Lake Constance whitefish Coregonus spp. under the influence of fisheries: a DNA study based on archived scale samples from 1932, 1975 and 2006

This investigation examined changes in the genetic diversity of pelagic upper Lake Constance (ULC) whitefish Coregonus wartmanni population before and after the alteration of fishery methods and management from 1932 to 2006. The study spans a period of pronounced changes in trophic status of the lake and transitions from traditional relatively unselective pelagic seine (Klusgarn) fishing to highly size-selective nylon gillnet techniques. In addition, supportive breeding and stocking became most popular during the phase of eutrophication in the 1970s. The main hypothesis is that size-selective fisheries and breeding lead to an overall decrease in genetic variability over time. A total of 215 archived C. wartmanni scale samples from 1932, 1975 and 2006 were analysed by genotyping 11 microsatellite loci. A comparison of population genetic parameters, including allelic richness, observed and expected heterozygosities, and estimates of effective population sizes, suggests that the genetic diversity of C. wartmanni population has not decreased. The appearance of new alleles in the gene pool in 1975 and 2006 may be indicative of admixture with other forms in the lake or with stocked allochthonous forms. Overall, the fisheries management practice in ULC, including the effects of size-selective fisheries, supportive breeding and stocking, have not significantly altered the genetic diversity of Coregonus spp. over an 80 year period.

An invasion record for the swimbladder nematode Anguillicoloides crassus in European eel Anguilla anguilla in a deep warm-monomictic [corrected] lake, from invasion to steady state

This study is the first account of the establishment and development of the neozoic nematode parasite Anguillicoloides crassus in its host, the European eel Anguilla anguilla, in a deep, warm-monomictic [corrected] lake. A 21 year study of A. crassus took place in Upper Lake Constance (ULC), Europe's second largest pre-alpine lake. The study included two extensive surveys, one in 1991 during the initial parasite invasion phase and the second in 2006 when the infection was well established. The subtropical swimbladder nematode A. crassus was first recorded in A. anguilla in ULC in 1989. Prevalence reached 60% in 1992 and remained at this level until 2007. In 2008, prevalence decreased to 48%. Infection intensity peaked in 1993 at a mean value of 16 adult parasites per host fish. Around 90% of all A. anguilla examined displayed swimbladder lesions, with a significant trend to increasing severity over time. Moreover, heavy swimbladder lesions were seen in c. 10% of A. anguilla ready to migrate to their spawning habitat. Both ruffe Gymnocephalus cernuus and sunfish Lepomis gibbosus serve as paratenic hosts for A. crassus in ULC. Gymnocephalus cernuus seems to be the main vector, and infection is especially frequent in spring possibly caused by reduced immune system efficacy of G. cernuus during winter. In 1991, hypochromic anaemia was prevalent in ULC A. anguilla acutely infected with A. crassus, whereas in 2006 blood values were indicative of chronic infection. The growth and survival rates of A. anguilla during their continental phase were not noticeably altered in infected fish, but damage to the swimbladder probably impairs migration potential and thus the subsequent breeding success of the oceanic phase.

Comparison of powered and conventional air-purifying respirators during simulated resuscitation of casualties contaminated with hazardous substances

BACKGROUND

Advanced life support of patients contaminated with chemical, biological, radiological or nuclear (CBRN) substances requires adequate respiratory protection for medical first responders. Conventional and powered air-purifying respirators may exert a different impact during resuscitation and therefore require evaluation. This will help to improve major incident planning and measures for protecting medical staff.

METHODS

A randomised crossover study was undertaken to investigate the influence of conventional negative pressure and powered air-purifying respirators on the simulated resuscitation of casualties contaminated with hazardous substances. Fourteen UK paramedics carried out a standardised resuscitation algorithm inside an ambulance vehicle, either unprotected or wearing a conventional or a powered respirator. Treatment times, wearer mobility, ease of communication and ease of breathing were determined and compared.

RESULTS

In the questionnaire, volunteers stated that communication and mobility were similar in both respirator groups while breathing resistance was significantly lower in the powered respirator group. There was no difference in mean (SD) treatment times between the groups wearing respiratory protection and the controls (245 (19) s for controls, 247 (17) s for conventional respirators and 250 (12) s for powered respirators).

CONCLUSIONS

Powered air-purifying respirators improve the ease of breathing and do not appear to reduce mobility or delay treatment during a simulated resuscitation scenario inside an ambulance vehicle with a single CBRN casualty.

Respiratory protection during high-fidelity simulated resuscitation of casualties contaminated with chemical warfare agents

Emergency room personnel are threatened by secondary poisoning when treating victims affected by chemical warfare agents. Therefore, resuscitation skills practised with respiratory protection equipment in place require evaluation. We investigated the influence of wearing air-purifying respirators on the simulated resuscitation of chemical warfare agent casualties. We studied 22 anaesthetic trainees in a simulated resuscitation scenario requiring five set tasks, either unprotected, wearing a binocular visor respirator or a panoramic visor respirator in a randomised, crossover study. Treatment times did not differ between the three groups, with mean (SD) times to complete the tasks being 122 (8) s without a mask, 126 (7) s when wearing the panoramic visor mask and 129 (8) s when wearing the binocular respirator mask. All anaesthetists preferred the panoramic visor in terms of visual orientation but 88% of them rated the binocular mask as being more comfortable. Modern respirators have a negligible effect on simulated resuscitation scenarios for victims affected by chemical warfare agents. Panoramic visor respirators allow better visual orientation for anaesthetists during simulated resuscitation.

Brief communication: characteristics of spontaneous cases of tuberculosis associated with infliximab

BACKGROUND

A warning for tuberculosis was added to the approved labeling for infliximab in October 2001.

OBJECTIVE

To describe adverse event reports of tuberculosis during infliximab therapy after labeling changes.

DESIGN

Case series.

SETTING

Spontaneous adverse event reports maintained in the Adverse Event Reporting System database in the United States.

PATIENTS

130 patients with infliximab-associated tuberculosis.

MEASUREMENTS

Clinical and laboratory data.

RESULTS

The U.S. Food and Drug Administration received 130 domestic, spontaneous reports of tuberculosis in patients treated with infliximab between 1 November 2001 and 30 May 2006, including 59 (45%) with extrapulmonary disease. The most commonly reported risk factors included concomitant immunosuppressant use (n = 89), history of latent or active tuberculosis (n = 33), and being born into or having spent extensive time in an area where tuberculosis is endemic (n = 25). In the subset of 67 cases with documented initiation of infliximab therapy after the drug labeling change, 34 patients with a negative tuberculin skin test result before initiation of infliximab therapy developed tuberculosis after receiving infliximab.

LIMITATION

Conclusions from spontaneous case reports may not be generalizable to the entire infliximab-receiving population.

CONCLUSION

Clinicians should be vigilant in screening and monitoring for tuberculosis in patients receiving infliximab.

An observational study of cholecystectomy in patients receiving tegaserod

BACKGROUND

Registrational studies of patients treated with tegaserod for irritable bowel syndrome (IBS) suggest an increased risk for cholecystectomy versus treatment with placebo.

OBJECTIVE

To study cholecystectomy rates in association with tegaserod within a large administrative medical claims database.

METHODS

Patients were drawn from a large population within the US with commercial medical insurance. The primary analysis consisted of a comparison of the observed incidence rate for cholecystectomy claims among a large cohort of new-to-therapy tegaserod users with an incidence rate published for tegaserod-naive patients classified with IBS within the same insured population.

RESULTS

An inception cohort of 7475 individuals with up to 103 weeks of claims history following initiation of therapy with tegaserod was identified. After a follow-up of 3 months (and thus similar to the longest registrational trials), the observed cholecystectomy incidence rate was 340 per 10,000 person-years (95% CI 258, 442). The rate of cholecystectomy was highest in the earliest months of observation following initiation of tegaserod. The observed cholecystecomy incidence rate is 2.9 times higher than an IBS-specific rate of 119 per 10,000 person-years as published for patients so classified within the same insured population.

CONCLUSION

Based on a large, inception cohort, we report a strong temporal association between the initiation of tegaserod therapy and an increased rate for cholecystectomy. The effect size at 3 months was similar to the relative risk for cholecystectomy reported in registrational studies comparing tegaserod with placebo. As misclassification of initial diagnosis for patients presenting with biliary colic-like symptoms may occur, precise measurements of tegaserod-related relative risk for cholecystectomy from observational studies are problematic and will require prospective studies.

Indication and use of drug products used to treat attention-deficit/hyperactivity disorder: a cross-sectional study with inference on the likelihood of treatment in adulthood

INTRODUCTION

Published literature suggests that attention-deficit/hyperactivity disorder (ADHD) affects 4% of adults and that as many as 60% of children with a diagnosis of ADHD will continue to have problems with inattention and impulsivity in adulthood. We analyzed cross-sectional prescription claims data and data from a national survey of office-based physicians for further inference on the likelihood of treatment with ADHD medications into adulthood.

METHODS

This study used data from a proprietary, national survey of office-based physicians (the IMS Health National Disease and Therapeutic Index, NDTI) to describe the indication associated with office visits with mention of common stimulant medications and atomoxetine. Enrollment and prescription claims data maintained by a large national health-care company were analyzed for age-specific utilization of these same agents.

RESULTS

Data from the NDTI suggest that the vast majority of visits associated with a stimulant medication or atomoxetine was coded with a diagnosis consistent with a mental health condition and not obesity/weight loss. The health plans included in this study processed 222,096 prescriptions for stimulant medications and atomoxetine among 43,175 unique patients aged 1-64 years during the calendar year 2004. Analyses of pharmacy claims data showed a steep increase in use through age 11 (prevalence=70.3 per 1,000 covered lives) followed by a marked decrease and plateau from age 25 through age 64 years (prevalence=5 to 10 per 1,000 covered lives).

CONCLUSIONS

On the basis of comparison of the prevalence rate peak of 70 per 1,000 around age 11 years to a plateau of 7 per 1,000 during the early career years, our results are consistent with a prediction that at least one child in 10 placed on an ADHD medication in childhood will receive treatment in to adulthood. The decrease in the prevalence of use of these medications with advancing age as seen in this cross-sectional study may reflect upon several clinical and secular factors.

New-onset and idiopathic thrombotic thrombocytopenic purpura: incidence, diagnostic validity, and potential risk factors

OBJECTIVE

The aim of this study was to determine the incidence rate for new-onset and idiopathic thrombotic thrombocytopenic purpura (TTP) among adults 20-64 years old, the validity of diagnostic criteria, and potential risk factors for TTP.

METHODS

This retrospective observational study analyzed automated administrative data from 11 geographically dispersed U.S. health plans. Cases of TTP were identified based on the presence of an inpatient hospital claim for TTP (ICD-9-CM 446.6) between 1/1/97 and 12/31/01 and confirmed by medical record review. Pharmacy and medical claims were used to evaluate outpatient drug exposure and comorbidities preceding hospitalization for TTP. Cases and the base population were screened so as to result in an incidence rate for idiopathic TTP.

RESULTS

We confirmed new-onset and idiopathic TTP in 9 of 15 presumptive cases for an incidence density of 1.4 per million person-years (95% CI: 0.6-2.6). The rate increased to 1.8 per million person-years after projection and age-standardization. The highest incidence rate of TTP was found in patients 50-64 years old (2.8 per million person-years; 95% CI: 0.8-7.1). These 9 patients had no apparent risk factors for TTP based on claims and medical record data.

CONCLUSIONS

In a general U.S. population, the incidence rate of confirmed new-onset and idiopathic TTP was lower than previously reported, but appears to be on the rise. Our findings suggest that administrative claims data are useful for identifying outpatient drug exposures and comorbidities potentially associated with TTP.

Alosetron: ischemic colitis and serious complications of constipation

Drugs such as alosetron that modulate serotonin effects by stimulating or blocking its receptors may play an important role in the treatment of some patients with irritable bowel system. In the case of alosetron, a 5HT-3 antagonist, an analysis of data from randomized clinical trials and postmarketing experiences have demonstrated a causal relationship between this drug and ischemic colitis and serious complications of constipation. Because the mechanism(s) of drug-induced ischemic colitis and possibly other forms of intestinal ischemia associated with alosetron have not been elucidated, there is need to further assess risk with regard to patient susceptibility and other factors.

Comparison of reporting of Stevens-Johnson syndrome and toxic epidermal necrolysis in association with selective COX-2 inhibitors

BACKGROUND

Stevens-Johnson syndrome and toxic epidermal necrolysis are closely related severe acute life-threatening, drug-induced skin disorders. The US FDA Adverse Events Reporting System (AERS) has received reports of Stevens-Johnson syndrome and toxic epidermal necrolysis associated with the use of the recently introduced selective cyclo-oxygenase (COX)-2 inhibitor NSAIDs, two of which are also sulfonamides.

OBJECTIVE

The objective of this study is to review cases of Stevens-Johnson syndrome and toxic epidermal necrolysis reported to the FDA associated with the use of the selective COX-2 inhibitor NSAIDs celecoxib, rofecoxib and valdecoxib, and to compare reporting rates of the two conditions associated with these drugs to each other, meloxicam (an oxicam NSAID that came on the US market at a similar time) and the background incidence rate.

METHODS

We reviewed all US cases of Stevens-Johnson syndrome and toxic epidermal necrolysis reported to the FDA AERS database associated with the use of celecoxib, rofecoxib, valdecoxib and meloxicam since these agents were first marketed. We utilised AERS and drug use data to calculate reporting rates for each drug after the first 2 years of marketing. We obtained the background rate from the medical literature.

RESULTS

Up to the end of March 2004, there were 63 cases of Stevens-Johnson syndrome/toxic epidermal necrolysis reported with valdecoxib use, 43 with celecoxib, 17 with rofecoxib (the non-sulfonamide coxib) and none for meloxicam. In the first 2 years of marketing the reporting rate for Stevens-Johnson syndrome/toxic epidermal necrolysis with valdecoxib was 49 cases per million person-years of use, 6 cases per million person-years for celecoxib and 3 cases per million person-years for rofecoxib. The reporting rates for the sulfonamide coxibs were substantially higher than the background rate of 1.9 cases per million population per year, with the valdecoxib rate being 8-9 times that of celecoxib and approximately 25 times that of the background rate.

CONCLUSION

There is a strong association between Stevens-Johnson syndrome/toxic epidermal necrolysis and the use of the sulfonamide COX-2 inhibitors, particularly valdecoxib. Physicians should be aware of the possibility of this serious life-threatening event when prescribing these drugs and advise patients to discontinue use at the earliest possible sign or symptom.

Trends in adherence to a revised risk management program designed to decrease or eliminate isotretinoin-exposed pregnancies: evaluation of the accutane SMART program

OBJECTIVE

To review adherence to selected procedures outlined in the System to Manage Accutane-Related Teratogenicity (SMART) program during the first year of implementation vs the procedures in effect in the year prior to initiation of the SMART program.

DESIGN

Observational.

SETTING

A novel pharmacy compliance survey and an ongoing, voluntary survey.

PATIENTS

Female recipients of isotretinoin.

INTERVENTION

In April 2002, Hoffmann-La Roche Inc, Nutley, NJ, manufacturer of Accutane brand isotretinoin and at that time the sole source of isotretinoin, revised earlier guidelines and instituted the SMART risk management program, which included the use of qualification stickers to affix to all prescriptions for Accutane to indicate, among other things, a negative pregnancy test just before the prescription was written. The goal of the SMART program was to decrease or eliminate isotretinoin-exposed pregnancies.

MAIN OUTCOME MEASURES

Use and completion of prescription qualification stickers; changes in pretherapy pregnancy testing and birth control use.

RESULTS

The results of the pharmacy compliance survey indicated high (>90%) use of prescription qualification stickers. Results of the patient survey suggested that 9% of prescription qualification stickers within the observed user cohort were issued without a pregnancy test. Furthermore, the pregnancy rate for patients participating in the survey was similar to that reported for cohorts recruited before the SMART program.

CONCLUSIONS

The usefulness of the results derived from 2 surveys designed to evaluate the SMART program is limited by the lack of reliability and validity of the survey instruments and by questionable generalizability to all female recipients of isotretinoin. The presence of a qualification sticker may not have an impact on pregnancy testing or compliance with effective birth control behavior as outlined in the SMART program.

Spontaneous Reports of Hypertension Leading to Hospitalisation in Association with Rofecoxib, Celecoxib, Nabumetone and Oxaprozin

BACKGROUND AND OBJECTIVE

Data on file with the US FDA, and other published studies, suggest that the selective cyclo-oxygenase (COX)-2 inhibitor NSAID rofecoxib has a greater hypertensive adverse effect than other NSAIDs, including celecoxib. In this study we describe a pharmacoepidemiologic analysis of spontaneous adverse event reports of acute, clinically serious hypertension (as defined by hospitalisation) reported in association with rofecoxib, celecoxib, nabumetone and oxaprozin. The objective of this analysis is to assess whether postmarketing data are consistent with results of clinical trials. We also collapse cases into series for the identification of possible risk factors for clinically severe, NSAID-associated hypertension.

METHODS

Domestic (US) cases of apparently unconfounded, acute hypertension leading to hospitalisation were collected and reviewed from the spontaneous adverse events database of the FDA for rofecoxib, celecoxib, nabumetone and oxaprozin for the initial 3 years of marketing. Drug use data for the same intervals enabled calculation of reporting rates.

RESULTS

In an analysis of reporting rates, hospitalisation for acute blood pressure (BP) elevation was reported more frequently (3.8-fold) for rofecoxib compared with celecoxib. A total of 34 cases are collapsed into case series. No cases were identified for either nabumetone or oxaprozin. Inspection of reviewed cases for celecoxib and rofecoxib suggest that these patients (average age 72 years) were potentially high-risk candidates for NSAID therapy.

DISCUSSION AND CONCLUSION

During early marketing, hospitalisation for acute BP elevation appears to have been reported more frequently for rofecoxib compared with celecoxib. This is consistent with clinical trial data on file with the FDA, and other published studies that found rofecoxib to have a greater effect on BP than other NSAIDs, including celecoxib. This finding may be particularly relevant in older patients given the prevalence of hypertension and cardiovascular disease in this age group.

Changes in ciprofloxacin utilization as shown in a large pharmacy claims database: effects of proximity to criminal anthrax exposure in October 2001

OBJECTIVE

Identify, during the period of criminal anthrax exposures in October 2001, changes in utilization of ciprofloxacin and geographic patterns of any identified variations.

DESIGN

Observational.

SETTING

United States.

PATIENTS

Individuals making prescription claims through a pharmacy benefits management company.

INTERVENTIONS

Analysis of AdvancePCS pharmacy claims database.

MAIN OUTCOME MEASURES

Percentage change in ciprofloxacin utilization for 2000 and 2001 and, by locale, for September and October 2001.

RESULTS

Utilization of ciprofloxacin tablets was significantly lower in calendar year 2001 than in calendar year 2000 (median decline, 10.3%) for all months except October, when utilization of ciprofloxacin increased 9.8%. During the period of anthrax exposures (October 2001 versus September 2001), affected geographic areas, including New York (an increase of 62.5%), some other Mid-Atlantic states, and Florida (28.5%), had some of the highest percentage increases in the rate of ciprofloxacin utilization.

CONCLUSION

Many Americans actively sought prophylaxis with ciprofloxacin during the course of the October 2001 anthrax attack and that utilization was higher in, but not limited to, locales with publicized cases of disease. Pharmacists, clinicians, and public health officials should note that such behavior may be expected in the event of a similar attack and should be familiar with current recommendations for the assessment and management of anthrax exposure.

Renal failure associated with the use of celecoxib and rofecoxib

OBJECTIVE

Celecoxib and rofecoxib are two relatively new nonsteroidal anti-inflammatory drugs (NSAIDs) that selectively inhibit the cyclo-oxygenase-2 (COX-2) isoenzyme at therapeutic concentrations. The nephrotoxic potential of selective COX-2 inhibitors has not been clearly established. This study was conducted in order to understand the association between acute renal failure and the two COX-2 inhibitors celecoxib and rofecoxib.

METHODS

A search was performed in the US Food and Drug Administration's (FDA) Adverse Event Reporting System (AERS) to identify cases of renal failure submitted to the FDA. A MEDLINE search of the English language literature was also performed to identify published cases of renal failure associated with celecoxib and rofecoxib.

RESULTS

One hundred twenty-two and 142 domestic US cases of celecoxib and rofecoxib-associated renal failure, respectively, were identified in the AERS database. The literature search identified 19 cases of acute renal impairment in association with celecoxib and rofecoxib. In addition, drug regulatory authorities in the UK, Canada, and Australia have received about 50 reports of renal failure with celecoxib and rofecoxib. Descriptive statistics of the AERS cases have been summarised in this report.

CONCLUSIONS

Data from AERS and published case reports suggest that use of both these drugs is associated with renal effects similar to that of conventional nonselective NSAIDs. Physicians should be aware that serious or life-threatening renal failure has been reported in patients with normal or impaired renal function after short-term therapy with celecoxib and rofecoxib. Patients at greatest risk for renal injury are those with pre-existing renal impairment, heart failure, liver dysfunction, those taking diuretics and/or ACE inhibitors, and the elderly. Kidney function should be monitored closely for any signs of potential renal injuries soon after initiating treatment with these agents, especially in high-risk populations. In addition, healthcare practitioners should adequately warn patients of the signs and symptoms of serious renal toxicity, and of the need for them to see their physician promptly if they occur. Celecoxib and rofecoxib are not recommended for use in patients with advanced renal disease.

New insights into the clinical pharmacokinetics of trofosfamide

OBJECTIVE

This study focuses on the pharmacokinetics of trofosfamide (TRO) and metabolites after oral administration of TRO.

METHODS

Twelve patients with solid tumors and non-Hodgkin lymphomas were treated with 450 mg TRO orally for 7 days. TRO and the stable metabolites ifosfamide (IFO), cyclophosphamide (CYC), 2- and 3-dechloroethylifosfamide (2-DCE, 3-DCE) were determined by GC and the sum of the 4-OH-metabolites was measured by HPLC.

RESULTS

A fast metabolism of TRO with a half-life of about 1 h was observed. IFO was the main stable metabolite, whereas CYC was only detected in minor quantities. The peak levels and the AUC of the 4-OH-metabolites were 9.5 and 4.3 times higher than observed after an equimolar IFO dose. Only 6% of the administered dose was recovered in urine within 24 hours as stable metabolites. TRO was under limit of detection.

CONCLUSIONS

Our results confirm that dechloroethylation of TRO to IFO is a major metabolic pathway. Additionally, we found considerable 4-hydroxylation not shown previously. With respect to the low levels of IFO and CYC observed, the sum of 4-OH-metabolites cannot be explained by hydroxylation of these metabolites only. Hence, we assume a direct 4-hydroxylation of TRO occurring to a high extent. Bioavailability of TRO could not be calculated directly, because TRO is only available as an oral formulation. The bioavailability of oral IFO, however, is reported to be almost 100%. Therefore, after normalization of the dose, a bioavailability of 32% for IFO after oral TRO could be calculated. Thus, in contrast to previous reports, direct 4-hydroxylation of TRO seems to be the main metabolic pathway.

Ambulatory use of ticlopidine and clopidogrel in association with percutaneous coronary revascularization procedures in a national managed care organization

The aim of this study was to quantify ambulatory use of ticlopidine and clopidogrel in association with percutaneous coronary revascularization procedures (PTCA, atherectomy, stent) in a national managed care organization. Retrospective administrative claims data over a 3-year period (1996-1998) from 12 UnitedHealth Group-affiliated health plans in four geographic regions were collected. Pharmacy and medical claims data were used to determine the patients exposed to ticlopidine and clopidogrel between January 1, 1996 and December 31, 1998, the duration of use, prescriptions within 2 weeks of a coronary procedure, and stent patients prescribed either drug within 2 weeks of stent placement in 1998. Substantial short-term use of ticlopidine and clopidogrel was found. The percentage of members with duration of use < or = 30 days ranged from 50.4% in 1996 to 56.9% in 1998 for ticlopidine and was 52.7% for clopidogrel. In 1998, 46% and 33% of ticlopidine and clopidogrel users, respectively, had a medical claim for a coronary procedure that fell within 2 weeks of a prescription. The rate was lower for Medicare beneficiaries. In 1998, 78% of stent patients filled a prescription for either drug within 2 weeks of stent implantation. Although little difference was found overall in the use of these agents across geographic regions, a higher proportion of stent patients in the Southeast were prescribed ticlopidine within this time frame. The findings suggest that during the study time period ticlopidine and clopidogrel are frequently used off-label in association with percutaneous coronary revascularization procedures. These results were important in considering the overall benefit-risk profile.

Use of a spontaneous adverse drug events database for identification of unanticipated drug benefits

We describe an examination of a spontaneous adverse events database in an effort to identify agents with possible hitherto unknown antiangiogenic properties. The surrogate end point was abnormal wound healing. This analysis represents use of this database for identification of a possibly useful in vivo side effect. Through thoughtful choice of end points, we believe spontaneous adverse events databases have the capacity for hypothesis generation in a search for unanticipated beneficial drug properties.