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Bui TV, Prot-Bertoye C, Ayari H, Baron S, Bertocchio JP, Bureau C, Davis P, Blanchard A, Houillier P, Prie D, Lillo-Le Louet A, Courbebaisse M. Safety of Inulin and Sinistrin: Combining Several Sources for Pharmacovigilance Purposes. Front Pharmacol 2021; 12:725417. [PMID: 34867328 PMCID: PMC8637630 DOI: 10.3389/fphar.2021.725417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Inulin and its analog sinistrin are fructose polymers used in the food and pharmaceutical industries. In 2018, The French National Agency for the Safety of Medicines and Health Products (ANSM) decided to withdraw products containing sinistrin and inulin due to several reports of serious hypersensitivity reactions, including a fatal outcome. Objective: To assess the safety of inulin and sinistrin use in France. Methods: We searched multiple sources to identify adverse reactions (ARs) to inulin or sinistrin: first, classical pharmacovigilance databases including the French Pharmacovigilance (FPVD) and the WHO Database (VigiBase); second, data from a clinical trial, MultiGFR; third, data regarding current use in an hospital. All potential ARs to inulin or sinistrin were analyzed with a focus on hypersensitivity reactions and relationships to batches of sinistrin. Results: From 1991 to 2018, 134 ARs to inulin or sinistrin were registered in the FPVD or VigiBase. Sixty-three cases (47%) were classified as serious, and 129 cases (96%) were hypersensitivity reactions. We found an association between a batch of sinistrin and the occurrence of hypersensitivity reactions. During the MultiGFR clinical trial, 7 patients (7/163 participants) had an Adverse reaction; of these, 4 were hypersensitivity reactions including one case of grade 4 anaphylactic shock. In the hospital, no ARs were observed. In the literature, ARs to inulin and sinistrin are very rarely reported and mostly benign. Conclusion: Most ARs to inulin and sinistrin are hypersensitivity reactions that appear to be associated with sinistrin batches.
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Affiliation(s)
- T-V Bui
- Assistance Publique-Hôpitaux de Paris, Centre Régional de Pharmacovigilance, Hôpital Européen Georges Pompidou, Paris, France
| | - C Prot-Bertoye
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France.,Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Paris, France.,Centre de Référence des Maladies Rares du Calcium et du Phosphate, Paris, France.,Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France.,CNRS ERL 8228-Laboratoire de Physiologie Rénale et Tubulopathies, Paris, France.,Faculté de Médecine, Université de Paris, Paris, France
| | - H Ayari
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France.,Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Paris, France.,Centre de Référence des Maladies Rares du Calcium et du Phosphate, Paris, France.,Faculté de Médecine, Université de Paris, Paris, France
| | - S Baron
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France.,Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Paris, France.,Centre de Référence des Maladies Rares du Calcium et du Phosphate, Paris, France.,Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France.,CNRS ERL 8228-Laboratoire de Physiologie Rénale et Tubulopathies, Paris, France.,Faculté de Médecine, Université de Paris, Paris, France
| | - J-P Bertocchio
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France.,Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Paris, France.,Centre de Référence des Maladies Rares du Calcium et du Phosphate, Paris, France.,Faculté de Médecine, Université de Paris, Paris, France
| | - C Bureau
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France
| | - P Davis
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France
| | - A Blanchard
- Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Paris, France.,Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France.,CNRS ERL 8228-Laboratoire de Physiologie Rénale et Tubulopathies, Paris, France.,Assistance Publique Hôpitaux des Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Centre d'investigation Clinique, Paris, France.,Institut National de la Santé et de la Recherche Médicale, Paris, France.,Faculté de Médecine, Université de Paris, Paris, France
| | - P Houillier
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France.,Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Paris, France.,Centre de Référence des Maladies Rares du Calcium et du Phosphate, Paris, France.,Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France.,CNRS ERL 8228-Laboratoire de Physiologie Rénale et Tubulopathies, Paris, France.,Faculté de Médecine, Université de Paris, Paris, France
| | - D Prie
- Faculté de Médecine, Université de Paris, Paris, France.,Service des Explorations Fonctionnelles, Hôpital Necker, APHP Centre-Université de Paris, Paris, France.,INEM Unité Inserm U1151, Paris, France
| | - A Lillo-Le Louet
- Assistance Publique-Hôpitaux de Paris, Centre Régional de Pharmacovigilance, Hôpital Européen Georges Pompidou, Paris, France
| | - M Courbebaisse
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France.,Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Paris, France.,Centre de Référence des Maladies Rares du Calcium et du Phosphate, Paris, France.,Faculté de Médecine, Université de Paris, Paris, France.,INEM Unité Inserm U1151, Paris, France
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Berge M, Guillemain R, Boussaud V, Pham MH, Chevalier P, Batisse A, Amrein C, Dannaoui E, Loriot MA, Lillo-Le Louet A, Billaud EM. Voriconazole pharmacokinetic variability in cystic fibrosis lung transplant patients. Transpl Infect Dis 2009; 11:211-9. [PMID: 19302272 DOI: 10.1111/j.1399-3062.2009.00384.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aspergillosis is a high-risk complication in cystic fibrosis (CF) lung transplant patients. Azole antifungal drugs inhibit CYP3A4, resulting in significant metabolic drug-drug interactions. Voriconazole (VRZ) was marketed without therapeutic drug monitoring (TDM) recommendations, consistent with favorable pharmacokinetics, but regular determinations of plasma VRZ concentration were introduced in our center to manage interactions with calcineurin inhibitors and to document the achievement of therapeutic levels. METHODS VRZ TDM data analysis for trough concentration (C0) and peak concentration (C2) was carried out, using validated liquid chromatography assay with ultraviolet detection, for 35 CF lung transplant patients (mean age 25 years, mean weight 47 kg, balanced sex ratio) since 2003. Therapeutic range (C0: 1.5 +/- 0.5 - C2 : 4.0 +/- 1.0 mg/L) was expressed relative to pivotal pharmacokinetic trial data. RESULTS The duration of VRZ treatment ranged from 9 days to 22 months. The recommended standard dose of VRZ (200 mg twice a day, following the loading dose) resulted in significant plasma concentrations (>0.5 mg/L) in 20% of CF lung transplant patients. Therapeutic concentrations were obtained using higher doses (average 570 +/- 160 mg/day, +43%, P<0.01). Despite adaptation, C0 remained <0.5 mg/L (11%), even when the drug was administered intravenously, highlighting the variability of VRZ pharmacokinetics, possibly enhanced by CYP2C19 polymorphism. The risk of inefficacy during periods of underdosage was overcome by treatment with antifungal drug combinations (caspofungin, n=10). The therapeutic index was limited by neurologic effects (14%) and hepatic abnormalities (30%). VRZ concentrations correlated significantly (P<0.01) with aspartate aminotransferase levels but not with bilirubin levels. VRZ acted as a metabolic inhibitor of tacrolimus (C0 to dose ratio 5.8 +/- 2.6, n=31/VRZ versus 1.7 +/- 0.9 alone, P<0.001). Large changes in azole concentration affected the magnitude of the drug-drug interactions and adjustment requirements. CONCLUSIONS TDM is required because VRZ levels are often undetectable in treated CF lung transplant patients, supporting the use of antifungal drug combinations until achievement of VRZ C0 at a steady state between 1 and 2 mg/L. Plasma VRZ concentrations should be determined for the quantitative, individualized management of drug-drug interactions in lung transplant patients, in particular immunosuppressant such as tacrolimus, considering VRZ to be both a target and an inhibitor of CYP3A4.
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Affiliation(s)
- M Berge
- Department of Pharmacology, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Européen Georges Pompidou (HEGP), Faculté de Médecine, Université Paris Descartes, Paris, France
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