Real-world safety and effectiveness of inhaled nitric oxide therapy for pulmonary hypertension during the perioperative period of cardiac surgery: a post-marketing study of 2817 patients in Japan

OBJECTIVE

To evaluate the real-world safety and effectiveness of inhaled nitric oxide (INOflo® for Inhalation 800 ppm) for perioperative pulmonary hypertension associated with cardiac surgery in Japan.

METHODS

This was a prospective, non-interventional, all-case, post-marketing study of pediatric and adult patients who received perioperative INOflo with cardiac surgery from November 2015-December 2020. Safety and effectiveness were monitored from INOflo initiation to 48 h after treatment completion or withdrawal. Safety outcomes included adverse drug reactions, blood methemoglobin concentrations, and inspired nitrogen dioxide concentrations over time. Effectiveness outcomes included changes in central venous pressure among pediatrics, mean pulmonary arterial pressure among adults, and the partial pressure of arterial oxygen/fraction of inspired oxygen ratio (PaO2/FiO2) in both populations.

RESULTS

The safety analysis population included 2,817 Japanese patients registered from 253 clinical sites (pediatrics, n = 1375; adults, n = 1442). INOflo was generally well tolerated; 15 and 20 adverse drug reactions were reported in 14 pediatrics (1.0%) and 18 adults (1.2%), respectively. No clinically significant elevations in blood methemoglobin and inspired nitrogen dioxide concentrations were observed. INOflo treatment was associated with significant reductions in both central venous pressure among pediatrics and mean pulmonary arterial pressure among adults, and significant improvements in PaO2/FiO2 among pediatrics and adults with PaO2/FiO2 ≤ 200 at baseline.

CONCLUSIONS

Perioperative INOflo treatment was a safe and effective strategy to improve hemodynamics and oxygenation in patients with pulmonary hypertension during cardiac surgery. These data support the use of INOflo for this indication in Japanese clinical practice.

Use of corticosteroids for remission induction therapy in patients with new-onset ulcerative colitis in real-world settings

Background: Corticosteroids may be temporarily effective for ulcerative colitis (UC), but long-term use increases the risk of adverse drug reactions. Objective: The goal of the study was to examine steroid use in remission induction therapy after diagnosis of UC. Study Design: A retrospective observational study using the Japan Medical Data Center (JMDC) Claims Database from January 2008 to December 2014. Setting: Clinics, university hospitals, and national/public hospitals. Intervention: Initiation of steroids after diagnosis of UC. Main outcome measures: Start time and annual rate of steroid use, and use during the first 6 months of remission induction therapy. Results: The subjects were 399 patients were newly diagnosed with UC in the study period. The rate of steroid use after diagnosis was 58.4% in 2009, and showed a significant decreasing trend yearly after 2010 (p ≤ 0.0001). Regarding the start time, 52.2% of patients began steroids within 60 days after diagnosis of UC. At 6 months after initiation, 23.7% continued to use steroids and 73.9% of these patients used high-dose steroids. Conclusion: In treatment of UC after diagnosis, many patients continue to use steroids for >6 months after initiation. Reduced use of steroids based on clinical practice guidelines for UC should be promoted.

Safety of Adalimumab and Predictors of Adverse Events in 1693 Japanese Patients with Crohn's Disease

BACKGROUND AND AIMS

Data from an all-cases post-marketing study were used to evaluate the safety and effectiveness of adalimumab in Japanese patients with Crohn's disease [CD].

METHODS

Patients received adalimumab for 24 weeks. Data from all patients [n = 1693] were used for the safety assessment. Data from patients with CD activity index [CDAI] ≥ 150 at baseline were used for the effectiveness assessment.

RESULTS

The most frequent serious adverse drug reaction [ADR] was infection and infestations [6.6 events/100 patient-years]. The risk of serious infections increased in patients who had a history of malignancy and those with concomitant corticosteroid use. Of 415 patients who had switched from another anti-tumour necrosis factor alpha [TNFα] agent to adalimumab due to ADRs, 7.2% discontinued due to ADRs to adalimumab. Ten of 13 patients with a history of tuberculosis [TB] received prophylactic medication, and none developed TB. TB developed in one patient with no history of TB or anti-TB prophylaxis. Remission rates were 41.3% and 32.4% at 4 and 24 weeks, respectively. Remission rates did not differ between patients with and without concomitant use of immunomodulators. Predictive variables for increased effectiveness were CDAI ≤ 220 and disease duration of ≤ 2 years. Perianal lesions and loss of response to previous anti-TNFα agents affected effectiveness.

CONCLUSIONS

The most frequent serious ADR was infection. Adalimumab significantly reduced disease activity, without any unexpected ADRs. Development of active TB during adalimumab therapy can be prevented through TB screening and prophylaxis. In patients who switched from another anti-TNFα agent to adalimumab due to ADRs, adalimumab was well tolerated.

[Role of plasma histamine and neutrophil chemotactic factor in exercise-induced asthma]

The mechanism of exercise-induced asthma (EIA) is still controversial, although the role of chemical mediator is strongly suspected. In the present study, 50 asthmatic patients were observed after exercise on bicycle ergometer during dry air breathing, and changes of plasma histamine and neutrophil chemotactic factor (NCF) were measured and effect of anti-allergic drugs was examined. 31 patients developed postexertional bronchoconstriction and their % reduction of FEV1 after exercise correlated significantly with the degree of airway hyperresponsiveness to inhaled methacholine determined by Astograph. Plasma histamine levels were examined in 20 EIA positive cases and 13 EIA negative cases, but no significant changes were observed between pre- and post-histamine levels in either group. On the other hand, NCF was elevated significantly after exercise in both EIA positive and negative cases, but postexertional NCF levels were significantly higher in EIA positive than in EIA negative cases. The relationship between % increase of NCF and the % reduction of FEV1 after exercise was significant (r = 0.472, p less than 0.05). DSCG and Azelastine protected the development of EIA in 14 out on 19 cases and 7 out of 12 cases, respectively. Pretreatment with DSCG significantly reduced the increase of NCF after exercise. These results indicates that one of the chemical mediator, NCF, may play an important role in producing postexertional bronchoconstriction in asthmatic patients.

Airway hyperresponsiveness after endotoxin inhalation depends on leukocyte infiltration

We have investigated the relationship between acute airway hyperresponsiveness and polymorphonuclear cell (PMN) migration in airways following saline or endotoxin (ET) aerosol inhalation in 63 guinea pigs. In 20 of these animals, granulocytopenia was induced by prior treatment with hydroxyurea (HU). Airway responsiveness (AR) to inhaled methacholine, together with leukocyte counts in bronchoalveolar lavage fluid (BALF) and in tracheal epithelium, was also examined before and at 30 min, 1, 3 and 6 hr after saline or ET inhalation. In saline inhalation groups, AR and PMN counts in BALF and in tracheal epithelium did not differ from control animals at any time points. However, in ET inhalation groups AR increased significantly at 1 and 3 hr and returned to the pre-exposure level at 6 hr. This period of hyperresponsiveness was associated with an increment of PMN migration into tracheal epithelium. However, the increment of PMN counts in BALF was delayed to 3 and 6 hr after ET. In HU treated animals, AR and PMN counts in BALF and in tracheal epithelium did not change during 6 hr after ET inhalation. These results suggest that the hyperresponsiveness induced by ET inhalation either depends upon PMN migration into the tracheal epithelium.

Temperature affects lung fluid and recoil during high tidal ventilation at low resting volume

Effects of tidal volume (VT), end-expiratory pressure (EEP), and environmental temperature (Tenv) on elastic recoil force (Pel) and edema formation were examined in open-chest anesthetized rabbits. Sixty-two rabbits in four groups were ventilated for 3 h with VT of either 10 or 25 ml/kg body wt, EEP of 0 or 2 cmH2O, and Tenv of 18 or 35 degrees C. After ventilation, Pel at 80% of total lung capacity (P80) was significantly increased when ventilation was performed with the combination of large VT, 0 EEP, and low Tenv. This change was prevented by altering any one of the three conditions, e.g., small VT, positive EEP, or high Tenv. Similarly, elevation of minimum surface tension and reduction of surface activity index of lavages from excised lungs after ventilation were observed only when increased P80 was noted. Additionally, the increase of P80 was well correlated with increment of wet weight-to-dry weight ratio and degree of perivascular cuffing and alveolar edema formation of excised lungs. These results indicate that elevation of Pel after high tidal ventilation in open-chest animals in vivo was influenced by level of EEP and Tenv and that the degree of edema formation was closely related to the increase of Pel. The increased Pel is presumably primary and causes fluid accumulation.

[In vitro sensitivity test of anti-neoplastic agents and their enhancement by biscoclaurine alkaloid]

We tried an in vitro sensitivity test for the purpose of examining the effect of anti-neoplastic agents and their enhancement by Biscolaurine Alkaloid (Cepharanthin). Methods, HeLa cells were synchronized by excess of thymidine and hydroxyurea, and resuspended in Eagle's MEM with 10% FCS. The cells were mixed with Mitomycin C or Bleomycin and added to the wells of a microtiter plate. When required, Cepharanthin (the effect of this drug is considered to change the plasma membrane liquidity) was added to the medium, and then cultured for 24 hours in a CO2 incubator. After culture, each well received 3H-thymidine, and was incubated for 8 hours. The cells were harvested for the assay of 3H-thymidine.

RESULTS

MMC or BLM suppressed the uptake of 3H-thymidine in relation to its concentration. MMC or BLM with various concentrations of Cepharanthin showed strong suppression compared with the same concentrations of MMC or BLM alone. From the above results, this experimental method is regarded as an useful model for selecting sensitive anti-neoplastic agents. In addition, Cepharanthin showed enhancing effects on anti-neoplastic agents.

Comparison of airway responsiveness to exercise and histamine inhalation in asthmatics

In order to investigate the differences between EIA positive and negative subjects, pulmonary function data at rest, atopic tendency and bronchial sensitivity and reactivity were compared. Pulmonary function data revealed no significant difference between two groups except closing volume which was higher in EIA positive patients (p less than 0.01) and also Rrs which was higher in EIA positive patients only in female (p less than 0.05). Incidence of positive skin tests and higher levels of IgE were more frequent in EIA positive, however, IgE was not significantly different. Relationship between % fall of FEV1 after exercise and bronchial sensitivity was examined, however, no correlation was found in two parameters. Bronchial reactivity was not different in two groups. This suggests that EIA positive patients cannot be distinguished from EIA negative by pulmonary function data at rest or by atopic tendency, and also that different mechanisms play a role to produce airway constriction following exercise and inhalation challenge.