OP0268 COMPARISON OF MAJOR CARDIOVASCULAR AND THROMBOEMBOLIC EVENTS IN SAFETY REPORTS BETWEEN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH JAK INHIBITORS VERSUS ANTI-TNF: RESULTS FROM VigiBase

Background

Recently, awareness has raised regarding JAK inhibitor safety in rheumatoid arthritis (RA), in particular with tofacitinib. Indeed, in a trial involving more than 4,000 patients (ORAL Surveillance), a numerically higher number of major cardiovascular events (MACEs) in patients treated with tofacitinib compared to anti-TNF (1), and a higher risk of venous thromboembolic events (VTE) in patients treated with tofacitinib 10mg twice a day compared to patients treated with tofacitinib 5mg twice a day or anti-TNF was observed. This increased risk of MACEs was also suspected in another study performed on American Health databases (2). Recently, the FDA extended warnings and use’s recommendations to other JAK-inhibitor drugs (3).

Objectives

To corroborate these safety warnings, we compared the reporting MACEs and VTEs with JAK inhibitors versus anti-TNF alpha drugs from the World Health Organization (WHO) Global Individual Case Safety Report (ICSR) database (VigiBase).

Methods

We selected reports in Vigibase of patients aged between 18 and 75 years, between 01/01/2011 and 12/31/2020, with JAK inhibitors (tofacitinib, baricitinib, upadacitinib, filgotinib) or anti-TNF (etanercept, adalimumab, infliximab, certolizumab pegol, golimumab) with a diagnosis of RA. In these reports we selected MACEs including myocardial infarction, strokes and cardiovascular deaths and VTE including deep venous thromboses (DVT) and pulmonary embolisms (PE). Characteristics of reports including age of patients, country of declaration, drug involved, co-reported drugs, and type of event were described. The reporting risk was investigated using disproportionality analyses and expressed as Reporting Odds Ratios (ROR) with 95% Confidence Interval (95%CI). A sensibility analysis was performed stratifying by age category (≥ 65 years, ≥ 50 years), and by sex.

Results

Of the 11,455,891 reports in patients aged between 18 and 75 years in the period of interest, 39,097 of reports were for a JAK-inhibitor in RA (mean age 60.6 years, SD:16.3) and 231,860 of reports were for an anti-TNF in RA (mean age: 57.2 years, SD: 13.0). Most of the reports came from USA and Canada (respectively 77.4% and 12.5% for JAK-inhibitor and 86.4% and 2,6% for anti-TNF). Among the reports, 611 (1.6%) in JAK-inhibitor treated patients and 3240 (1.4%) in anti-TNF treated patients were MACEs while 341 (0.9%) in JAK-inhibitors and 571 (0.2%) in anti-TNF treated patients were VTE. Disproportionality analyses identified an increased risk of reporting VTE events in JAK-inhibitors compared to anti-TNF (DVT: ROR = 3.99 [95%CI: 3.15-5.04], PE: ROR = 3.47 [2.90-4.13], Figure 1). This risk was not modified after stratification by age or sex. No increased ROR for MACE was found.

Figure 1.

Conclusion

Based on real-world data, the analysis did not identify an increase of declaration of MACEs with JAK-inhibitor compared to anti-TNF whereas we could observe more than three times declarations of VTE in Vigibase with JAK-inhibitors compared to anti-TNF.

References

[1]Ytterberg SR, Bhatt DL, Mikuls TR, Koch GG, Fleischmann R, Rivas JL, et al. Cardiovascular and Cancer Risk with Tofacitinib in Rheumatoid Arthritis. N Engl J Med. 2022;386(4):316-26.

[2]Khosrow-Khavar F, Kim SC, Lee H, Lee SB, Desai RJ. Tofacitinib and risk of cardiovascular outcomes: results from the Safety of TofAcitinib in Routine care patients with Rheumatoid Arthritis (STAR-RA) study. Ann Rheum Dis. 2022.

[3]FDA. FDA requires warnings about increased risk of serious heart-related events, cancer, blood clots, and death for JAK inhibitors that treat certain chronic inflammatory conditions. https://wwwfdagov/drugs/drug-safety-and-availability/fda-requires-warnings-about-increased-risk-serious-heart-related-events-cancer-blood-clots-and-death. 2021.

Disclosure of Interests

None declared

Interest of pharmacoepidemiology for the study of psychotropic drugs

In psychiatry, drug evaluation using pharmacoepidemiological methods has been of growing interest in recent decades. Studies based on observational databases are particularly useful for psychotropic drugs due to their important prevalence in populations, and their use over long period. The authors discussed the specific interest of pharmacoepidemiological studies in the field of psychiatry through two examples: first, the use of antidepressants, and, second, the risks associated with antipsychotics.

Serious central nervous system side effects of cephalosporins: A national analysis of serious reports registered in the French Pharmacovigilance Database

INTRODUCTION

Among antibiotics, Central Nervous System (CNS) adverse drug reactions (ADRs) are often under-suspected and overlooked. Cephalosporins are an important cause of drug-induced CNS ADRs but the characteristics of such ADR have not been fully explored. We aimed to characterize the profile of cephalosporins serious CNS ADRs.

METHOD

We performed an analysis of serious reports recorded in the French Pharmacovigilance database from 1987 to 2017.

RESULTS

A total of 511 serious ADRs reports was analyzed. Patients had a mean age of 67.1 years and were mainly men (52.5%), with a mean creatinine clearance of 32.9 ml/min. The most involved molecules were cefepime (33.1%), ceftriaxone (29.7%), ceftazidime (19.6%), cefotaxime (9%) and cefazoline (2.9%), mostly administered intravenously (87.3%). A CNS history was observed in 25% of the reports (n = 128). Patients exhibited encephalopathy (30.3%), confusional state (19.4%), convulsion (15.1%), myoclonia (9.4%), status epilepticus (9.2%), coma (6.3%) and hallucination (4.3%). The mean time of onset was 7.7 days and the mean duration was 6 days. Cephalosporin plasma levels were recorded for 153 patients (29.9%) and 107 were above the standards including 62 (57.9%) related to renal impairment. Electroencephalograms were performed in 38.2% (n = 195) of the patients and 81% (n = 158) were abnormal.

CONCLUSION

This study characterizes an off-target CNS ADRs of several cephalosporins. Ceftriaxone represented a large part of our reports after cefepime and it would be relevant to warn healthcare professionals. Investigations (EEG, though plasma levels and renal function) can be precious tools for clinicians to make a prompt diagnosis and improve patients' outcomes.

Manic switches induced by antidepressants: an umbrella review comparing randomized controlled trials and observational studies

OBJECTIVE

We aimed to explore whether the prevalence of manic switch was underestimated in randomized controlled trials (RCTs) compared to observational studies (OSs).

METHOD

Meta-analyses and simple and systematic reviews were identified by two reviewers in a blinded, standardized manner. All relevant references were extracted to include RCTs and OSs that provided data about manic switch prevalence after antidepressant treatment for a major depressive episode. The primary outcome was manic switch prevalence in the different arms of each study. A meta-regression was conducted to quantify the impact of certain variables on manic switch prevalence.

RESULTS

A total of 57 papers (35 RCTs and 22 OSs) were included in the main analysis. RCTs underestimated the rate of manic switch [0.53 (0.32-0.87)]. Overestimated prevalence was related to imipraminics [1.85 (1.22-2.79)]; to serotonin-norepinephrine reuptake inhibitors [1.74 (1.06-2.86)]; and to other classes of drugs [1.58 (1.08-2.31)], compared to placebo treatment. The prevalence of manic switch was lower among adults than among children [0.2 (0.07-0.59)]; and higher [20.58 (8.41-50.31)] in case of bipolar disorder.

CONCLUSION

Our results highlight an underestimation of the rates of manic switch under antidepressants in RCTs compared to the rates observed in observational studies.