[First French-speaking days of users of decision support system in clinical pharmacy: Feedback and perspectives]

Clinical decision support systems (CDSS) are tools that have been used for several years by clinical pharmacy teams to support pharmaceutical analysis, with a perspective of contributing to the quality of care in collaboration with the other health care team members. These tools require both technical, logistical and human resources. The growing use of these systems in different establishments in France and in Europe gave birth to the idea of meeting to share our experiences. The days organized in Lille in September 2021 aimed at proposing a time of exchange and reflection on the use of these CDSS in clinical pharmacy. A first session was devoted to feedback from each establishment. These tools are essentially used to optimize pharmaceutical analysis and to secure patient medication management. This session outlined the clear advantages and common limitations of these CDSS. Two research projects were also presented to put the use of these tools into perspective. The second session of these days, in the form of workshops, addressed 4 themes that surround the implementation of CDSS: their usability, the legal aspect, the creation of rules and their possible valorization. Common problems were raised, the resolution of which requires close collaboration. This is a first step proposing a beginning of harmonization and sharing that should be deepened in order not to lose the dynamics created between the different centers. This event ended with the proposal to set up two working groups around these systems: the creation and structuring of rules for the detection of risk situations and the common valorization of the work.

Ondansetron induced blindness: a pharmacovigilance database study

BACKGROUND

Ondansetron is an antiemetic drug (AED) used to prevent and treat nausea and vomiting. The summary of product characteristics reports a rare risk of transient blindness primarily during IV injections, notably with the concomitant use of chemotherapeutic agents. We aimed to refine the characterization of ondansetron-induced blindness.

RESEARCH DESIGN AND METHODS

We performed a descriptive and a case/non-case analysis using VigiBase®. Cases were defined as reports of adverse drug reactions (ADRs) related to blindness: amaurosis, amaurosis fugax, blindness. Non-cases were all other recorded reactions. Reporting risk of blindness-related ADRs was assessed using a disproportionality analysis and expressed as Reporting Odds Ratios (ROR).

RESULTS

138,315 ADRs were reported with AEDs, including 136 blindness-related ADRs, among them 44 (32.4%) with ondansetron. For ondansetron users, blindness-related ADRs occurred mainly on the first day. Out of the 25 patients with known outcomes, 18 (72.0%) were recovering or had recovered, 7 (28.0%) patients had not recovered There were no statistical differences in the number of cases for IV or oral users and for users or not of chemotherapeutic agents. Compared with other AEDs, ondansetron was associated with an increase in the reporting risk of blindness-related ADRs (ROR = 4.00 [2.79-5.72], p < 0.001).

CONCLUSIONS

Rarely blindness can occur following intravenous or oral administration of ondansetron.

Immunomodulatory or/and immunosuppressive drugs should not avoid skin test for the assessment of drug allergy

The use of immunomodulatory and/or immunosuppressive therapy (IT) is increasingly common in the management of chronic inflammatory disease. Skin reactions to any drug (IT or not) are not rare in these patients, justifying allergological investigations. The influence of IT on allergological tests for drugs is not clearly described. IT cannot be interrupted due to the underlying disease. The data assessing the benefit and the safety of allergological test for drug allergy in patients under IT are missing.

The clinical pharmacist's role in enhancing the relevance of a clinical decision support system

BACKGROUND

Clinical decision support systems (CDSSs) can improve the quality of patient care by helping physicians to review their prescriptions and thus to optimize drug treatments. Nevertheless, the "alert fatigue" brought on by a large number of irrelevant alerts can decrease a CDSS's effectiveness and thus clinical value. Involving a clinical pharmacist in the development and management of a CDSS can reduce the number of irrelevant alerts presented to physicians. Clinical pharmacists screen alerts and suggest PIs for physicians, corresponding to any proposed therapeutic change about health products, only for relevant alerts could improve the relevance and the acceptance of the information given to physicians about the risks faced by their patients.

OBJECTIVE

To assess the value of involving clinical pharmacists in the development and maintenance of decision support rules for generating alerts and pharmaceutical interventions (PIs) and to describe the level of acceptance of these PIs by the physicians.

METHOD

In a retrospective, single-centre study, we evaluated the number of PIs accepted from alerts generated by the CDSS when a clinical pharmacist had developed and managed this tool. During the first 7 months of development of the CDSS, a clinical pharmacist analyzed alerts triggered by the CDSS according to its technical validity and pharmaceutical relevance. Lastly, for alerts that led to a PI, the level of acceptance by physicians was documented.

RESULTS

During the study, 1430 alerts were analysed: 186 (13%) were considered to be technically invalid - mainly due to the characteristics of the interface. Of the 1244 (87.0%) technically valid alerts, 353 (24.6%) were pharmaceutically relevant and led to a PI. The three main causes of pharmaceutical irrelevance were a lack of specificity in the CDSS (70.8%), lack of relevance with regard to the ward's habits (15.6%), and the pharmacist's decision to recommend monitoring for the patient rather than sending a PI immediately (10.8%). 64.6% of the submitted PIs were accepted by the physicians.

CONCLUSION

The standardized analysis of alerts by a clinical pharmacist appears to be a good way of improving the development of CDSS by limiting the generation of irrelevant alerts and the latter's transmission to physicians. The involvement of a clinical pharmacist in the development and implementation of a CDSS appears to be novel and may help to optimize drug treatment.

Metronomic oral vinorelbine in previously untreated advanced non-small-cell lung cancer patients unfit for platinum-based chemotherapy: results of the randomized phase II Tempo Lung trial

Background

To assess the efficacy and safety of a metronomic schedule of oral vinorelbine (mVNR) in advanced non-small-cell lung cancer (NSCLC) in patients unfit for platinum-based combination chemotherapy.

Patients and methods

This was a multicenter, prospective, randomized, open-label phase II study in treatment-naive patients with TNM stage IIIB/IV NSCLC. Patients received mVNR at a fixed dose of 50 mg × 3 or standard schedule 60-80 mg/m² weekly until disease progression or unacceptable toxicity. The primary endpoint was progression-free survival (PFS) without grade 4 toxicity (G4PFS; NCI-CTC v4). Main secondary objectives were safety, disease control rate (DCR) without grade 4 toxicity (G4DCR), DCR, PFS, overall survival (OS) and quality of life (QoL).

Results

A total of 167 patients were included, 83 and 84 patients in the mVNR and standard arms, respectively. The median G4PFS was 4.0 months [95% confidence interval (CI): 2.6-4.3] and 2.2 months (95% CI: 1.5-2.9), hazard ration (HR) = 0.63 (95% CI: 0.45-0.88), P = 0.0068 in favor of metronomic arm; G4DCR was 45.8% and 26.8% in the mVNR and standard arms, respectively. Grade 3-4 treatment-related adverse events were less frequent in the mVNR arm (25.3% versus 54.4%) mainly owing to a reduction in all grades (15.7% versus 51.9%) and grade 3-4 neutropenia (10.8% versus 42%). PFS was 4.3 (95% CI: 3.3-5.1) and 3.9 months (95% CI: 2.8-5.2) in mVNR and standard arms, respectively. No difference in median OS was observed. QoL was comparable between arms.

Conclusions

Metronomic oral vinorelbine significantly prolonged median G4PFS in advanced NSCLC patients unfit for platinum combinations as first-line treatment. It was associated with a clear reduction in toxicity and may be considered as an important option in this challenging population.

•

First-line oral vinorelbine prolonged PFS without grade 4 toxicity in platinum-unfit patients with advanced NSCLC.

•

Metronomic oral vinorelbine is associated with a clear reduction of grade 3-4 toxicities (mainly hematological ones).

•

Metronomic oral vinorelbine allows home treatment and easy tailoring of the treatment according to patient tolerance.

Does helicopter transport delay prehospital transfer for STEMI patients in rural areas? Findings from the CRAC France PCI registry

Aims:

The aim of this study was to analyse delays in emergency medical system transfer of ST-segment elevation myocardial infarction (STEMI) patients to percutaneous coronary intervention (PCI) centres according to transport modality in a rural French region.

Methods and results:

Data from the prospective multicentre CRAC / France PCI registry were analysed for 1911 STEMI patients: 410 transferred by helicopter and 1501 by ground transport. The primary endpoint was the percentage of transfers with first medical contact to primary percutaneous coronary intervention within the 90 minutes recommended in guidelines. The secondary endpoint was time of first medical contact to primary percutaneous coronary intervention. With helicopter transport, time of first medical contact to primary percutaneous coronary intervention in under 90 minutes was less frequently achieved than with ground transport (9.8% vs. 37.2%; odds ratio 5.49; 95% confidence interval 3.90; 7.73; P&lt;0.0001). Differences were greatest for transfers under 50 km (13.7% vs. 44.7%; P&lt;0.0001) and for primary transfers (22.4% vs. 49.6%; P&lt;0.0001). The median time from first medical contact to primary percutaneous coronary intervention and from symptom onset to primary percutaneous coronary intervention (total ischaemic time) were significantly higher in the helicopter transport group than in the ground transport group (respectively, 137 vs. 103 minutes; P&lt;0.0001 and 261 vs. 195 minutes; P&lt;0.0001). There was no significant difference in inhospital mortality between the helicopter and ground transport groups (6.9% vs. 6.6%; P=0.88).

Conclusions:

Helicopter transport of STEMI patients was five times less effective than ground transport in maintaining the 90-minute first medical contact to primary percutaneous coronary intervention time recommended in guidelines, particularly for transfer distances less than 50 km.

Factors Associated with Alzheimer's Disease: An Overview of Reviews

Alzheimer's disease (AD) is a frequent pathology, with a poor prognosis, for which no curative treatment is available in 2018. AD prevention is an important issue, and is an important research topic. In this manuscript, we have synthesized the literature reviews and meta-analyses relating to modifiable risk factors associated with AD. Smoking, diabetes, high blood pressure, obesity, hypercholesterolemia, physical inactivity, depression, head trauma, heart failure, bleeding and ischemic strokes, sleep apnea syndrome appeared to be associated with an increased risk of AD. In addition to these well-known associations, we highlight here the existence of associated factors less described: hyperhomocysteinemia, hearing loss, essential tremor, occupational exposure to magnetic fields. On the contrary, some oral antidiabetic drugs, education and intellectual activity, a Mediterranean-type diet or using Healthy Diet Indicator, consumption of unsaturated fatty acids seemed to have a protective effect. Better knowledge of risk factors for AD allows for better identification of patients at risk. This may contribute to the emergence of prevention policies to delay or prevent the onset of AD.

Q-Methodology Evaluation of a European Health Data Analytic End User Framework

Background

MIDAS (Meaningful Integration of Data Analytics and Services) project is developing a big data platform to use a wide range of health and social care data to support better policy making. As part of the project evaluation, we have used Q-methodology, a well established approach, to understand the perspectives of the individual participants on their needs and how the MIDAS system is meeting them, at its current stage of development.

Methods

We defined a concourse of 36 statements relevant to project implementation and goals, by working from a logic model for the evaluation, and structured interviews with project participants. This was delivered online to participants. Analyses were done in the qmethod package. The first q-sort was done at 14 months into the project.

Results

16 people took part, 6 developers, 5 managers, 2 health professionals and 3 others. Three factors were identified in the data. These were tentatively labelled ‘Technical optimism’, ‘End-user focus’ and ‘End-user optimism’. These loaded well onto individuals, and there were few consensus statements. There were significant differences in perspectives between different groups of participants. In particular, two of the developers held opposite perspectives to most other participants on the third perspective identified. This was drawn to the attention of the participants, and a more intensive process of communication was set-up, seeking to reduce the divergence.

Conclusions

A Q-methodological approach to evaluating the implementation of a large and complex health ICT system showed considerable divergence between the perspectives of users, developers, and managers. Such divergences can lead to project failure. Q-methodology is a valuable tool has seldom been used in public health research.

Keywords: Q-Methodology, Public Health, Data Analytics, Decision Support.

How to engage French professionals to undertake social responsibility at a local level?

Background

In France, primary care is organised according to the principles of private practice: independent providers, payment by fee for service, freedom of settlement... Successive reforms have introduced more regulation i.e. gatekeeping role for GPs, better recognition of professional groups, new forms of payment and promotion of team work and multi-professional practices. Today, the concept of Health Territorial and Professional Communities (HTPC) is becoming a key element of health care reform encouraging primary care professionals to meet with specialists and social workers at a larger level than practice. HTPC should address issues such as access to services, coordination of care and promoting of preventive actions toward populations. This implies change in the roles, skills, methods and resources needed on both professional and regulatory sides. This study explores levers of the professional commitment in the HTPC and resources necessary for it.

Methods

We conducted a qualitative multiple case study in three French regions. Data was collected from thirty semi-structured interviews with key national informants, regional regulators and health professionals themselves.

Results

Professional commitment emerges at a local level on a territory defined by the collaboration practices and habits following a bottom-up process. The integration of care relies on the size of the HTPC which allows them to know each other and to work together to improve access to care and patient’s disease management. In order to achieve that, professionals claim to have access to administrative health data and to be able to analyze it. They need to develop news skills in management and group animation. The function and training of coordination professionals appear to be essential.

Conclusions

The professional commitment in HTPC relies on professional empowerment toward collective activities. This requires autonomy, skills and new roles both for professionals and regulatory authorities.

Key messages

French government relies on professionals’ investment at the territorial level by implementing HTPC to guarantee access to care and respond to population needs in primary care. HTPC implementation implies radical change for the professionals to undertake social and populational responsibility for which public health professionals should help to meet the challenge.

P1739Does helicopter transport delay prehospital transfer for STEMI patients in rural areas? Findings from the CRAC France PCI registry

Background

Whether helicopter transportation for ST-Elevation Myocardial Infarction (STEMI) patients in France is the faster alternative is not known. Data from United States and Europe are controversial and studies have been limited to small series of patients

Purpose

The aim of this study was to analyse delays in emergency medical system (EMS) transfer of STEMI patients from home to the nearest percutaneous coronary intervention (PCI) centre (primary transfer) or from non-PCI centres to PCI centres (secondary transfer) according to transport modalityin a rural French region.

Methods and results

Data from the prospective multicentre CRAC France PCI registrywere analysed for 1911 STEMI patients: 410 transferred by helicopter (HEMS) and 1501 by ground transport (GEMS). The primary endpoint was the percentage of transfers with first medical contact (FMC) to primary PCI (PPCI) within the 90-min recommended in guidelines. The secondary endpoint was time FMC–PPCI. With HEMS,FMC-PPCI <90 min was less frequently achieved than with GEMS (9.8% vs 37.2%; odds ratio 5.49; 95% confidence interval [3.90; 7.73]; p<0.0001). Differences were greatest for transfers <50 km (13.7% vs 44.7%; p<0.0001) and for primary transfers (22.4% vs 49.6%; p<0.0001). Median time from FMC to PPCI and from symptom onset to PPCI (total ischemic time) were significantly higher in HEMS group than in GEMS group (respectively 137 min vs 103 min; p<0.0001 and 261min vs 195 min; p<0,0001). There was no significant difference in in-hospital mortality between the HEMS and GEMS groups (6.9% vs 6.6%; p=0.88).

STEMI patients FMC-PPCI < 90 min

Conclusion

Helicopter transport of STEMI patients was 5 times less effective than ground transport in maintaining the 90-min FMC-PPCI time recommended in guidelines, particularly for transfer distances <50 km.

Acknowledgement/Funding

Regional health agency of CVL, Medtronic, Boston Scientific, Abbot, Biosensor, Terumo, Biotronik, Lilly Daichii Sankyo, Hexacath and Braun.

P6313RAAS inhibition improves event-free survival in cardiac transplant recipients: results of the prospective cohort study

Background

Despite known achievements, long-term survival of heart transplant (HT) recipients still needs to be improved. The Renin-Angiotensin-Aldosterone System (RAAS) hyper-activation could be the result of heart denervation and immune suppressive therapy in these patients. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) have been shown to be beneficial in patients with hypertension, heart failure (HF) and diabetic nephropathy.

Purpose

The study was aimed to assess the effects of ACEI and ARB on the prognosis and cardiac transplant remodelling in HT recipients.

Methods

Four hundred ninety-six critical HF patients had cardiac transplant surgery between January 2012 and December 2016 in Shumakov National Research Centre of Transplantology, and Artificial Organs (Moscow, Russian Federation) which accounted to 57.9% of all heart transplantations (HTx) performed in the country during that period. All patients >18 years old who survived 30 days after the operation without known contraindications for ACEI or ARB were sequentially included in the study. A non-randomised controlled trial study design was used. Study endpoints included death from any cause and re-transplantation due to the irreversible cardiac transplant failure.

Results

385 HT recipients (mean age 46.3±2.3 years, 51 females and 334 males) enrolled in the study. Thirty days after the HTx, a RAAS inhibitor was assigned to 141 recipients. Patients receiving ACEI or ARB had significantly better event-free survival than the control group (log-rank p=0.045) during the follow-up for 1856.5±68.3 days. Unadjusted analysis revealed other factors related to the risk of death or irreversible HT failure: recipient age <37 years old, donor age>44 years old, aortic cross-clamping time >117 min, peri-operational ECMO>3 days of duration, acute renal failure requiring dialysis during first 30 days after the operation, right atrium size, mitral regurgitation 2+, tricuspid regurgitation 1+, donor's heart posterior wall thickness (PWT) >12mm, and left ventricle (LV) end-diastolic dimension (EDD). When adjusted to the RAAS inhibitors use, only the donor's age and early renal failure remained significant. LV EDD did not change over time in both groups, whereas LV PWT in the control group significantly increased from 12.3±0.3 to 13.5±0.5 mm (p<0.05).

Conclusions

Heart transplant recipients who received RAAS inhibitors had better survival and less LV hypertrophy progression that could reflect the beneficial effects of ACEI and ARB after heart transplantation.

Vascular dementia encoding in the French nationwide discharge summary database (PMSI): Variability over the 2007-2017 period

OBJECTIVE

Vascular dementia (VaD) is the second leading cause of dementia. Diagnostic criteria have evolved from the concept of multiple infarctions to different subtypes: acute onset VaD, subcortical VaD, mixed cortical and subcortical VaD. Our aim was to analyze the evolution in the coding of these different subtypes of VaD in the French nationwide exhaustive hospital discharge database (PMSI) between 2007 and 2017.

METHOD

We included all principal diagnoses of VaD in the PMSI hospital stays from 2007 to 2017.

RESULTS

Between 2007 and 2017, we show a relative decrease in the number of hospital stays for VaD compared to all hospital stays (0.0437% to 0.0404%). The 11,654 hospital stays for VaD in 2017 represent 13.5% of mental organic disorders. Subtype analysis shows a decrease in hospital stays for multiple infarctions between 2007 and 2017 (-50%), an increase for subcortical or mixed VaD (+20%), acute onset VaD (+184%) and an increase in "other VaD" (+85%).

CONCLUSION

These data suggest a slight decrease in hospital stays for VaD, possibly related to better control of cardiovascular risk factors. They also suggest that the coding should be consistent with the evolution of diagnostic criteria.

Shift in Hospitalizations for Alzheimer's Disease to Related Dementias in France between 2007 and 2017

INTRODUCTION

Alzheimer's disease (AD) is the first cause of dementia. Diagnostic criteria have evolved: proposals to revise the NINCDS-ADRDA criteria were published in 2007. Our aim was to analyze the evolution in the coding of AD in the French nationwide exhaustive hospital discharge database (PMSI) between 2007 and 2017.

METHODS

We analyzed evolution of International Classification of Diseases and Related Health Problems, 10th edition (ICD-10) coding for AD and AD dementia in the PMSI database from 2008 to 2017 (285,748,938 inpatient stays).

RESULTS

We observed a 44% decrease in the number of inpatient stays with a principal diagnosis of AD or AD dementia from 2007 (46,313 inpatient stays) to 2017 (25,856 inpatient stays) in France. Over the same period, we observed a 49% increase in the number of inpatient stays with a principal diagnosis of related dementias (other organic mental disorders or other degenerative disorders). Overall, the number of inpatient stays for dementia remained stable despite the increase in the total number of inpatient stays: 95,377 in 2007 (0.409% of inpatient stays) and 99,190 in 2017 (0.344%).

CONCLUSION

We therefore note a shift from AD and AD dementia to other dementia diagnoses since 2007. This study suggests a more accurate use of AD related ICD-10 codes since the revised criteria in 2007.

[Non-ST elevation acute coronary syndrome: CRAC register experience]

PURPOSE

To compare the clinical, angiographic, therapeutic and prognostic characteristics of nonagenarians presenting with non-ST elevation acute coronary syndrome with those of patients under 90 years of age.

METHODS

We used the CRAC register database including 6 catheterization laboratories in the Center Val-de-Loire region. Only patients with positive-troponin non-ST elevation ACS included in the registry from 2014 to 2017 were selected for epidemiological and procedural data. Regarding antiplatelet therapy, hospital and one-year follow-up data, only patients in the 2014-2015 period were analyzed.

RESULTS

From January 1st, 2014 to December 31st, 2017, 5.964 patients with a positive-troponin non-ST ACS, including 133 nonagenarians (2.2%) were included in the CRAC registry. Arterial hypertension and the history of coronary angioplasty were more common among nonagenarians. They present more multivessel and left main disease. The use of the bare metal stent was predominant in 2014-2015 and then became marginal in 2016-2017. Clopidogrel was the most widely used anti platelet and more than one in two nonagenarians remain on dual therapy after 12 months. One-year stroke and hospital and one-year mortality were higher in this age group.

CONCLUSIONS

Nonagenarians with a positive-troponin non-ST elevation ACS have more severe coronary artery disease and a poorer prognosis than those younger than 90 years of age.

Treatment by a moisturizer of xerosis and cracks of the feet in men and women with diabetes: a randomized, double-blind, placebo-controlled study

AIM

To evaluate a moisturizer containing urea, glycerine and petrolatum for healing deep open fissures on the feet of people with diabetes. If left untreated, open fissures, an entry point for bacteria, can lead to infection, ulceration and further complications.

METHODS

This randomized, double-blind, multicentre study at 19 hospitals, general practices and diabetologists in France and Belgium included participants with diabetes and a deep open target fissure on their heel. Participants were randomized to test cream or placebo (1 : 1) for 4 weeks. Complete target fissure healing after 4 weeks (primary criterion) and 2 weeks, target fissure closure, overall fissure healing and xerosis were assessed.

RESULTS

Some 167 participants were randomized (80 to test cream; 87 to placebo); all were included in the efficacy analyses. The percentage of participants with complete target fissure healing after 4 weeks was higher with test cream than placebo (46.3% vs. 33.3%): the difference did not reach statistical significance (P = 0.088). Fewer participants still had a deep open target fissure with test cream than placebo, the difference was statistically significant and clinically relevant after 2 (24.7% vs. 42.7%, P = 0.027) and 4 weeks (6.4% vs. 24.1%, P = 0.002). The difference in overall fissure healing between test cream and placebo was significant (P < 0.001) and test cream resulted in greater xerosis improvement (P < 0.001 and P = 0.002 at 2 and 4 weeks, respectively).

CONCLUSION

The activity of the test cream for treating feet fissures of people with diabetes was confirmed by an improvement in open fissure healing and xerosis. The cream was well tolerated.

[Post-licensure safety surveillance for Prevenar 13® in France]

Objectif

Décrire le profil et l’incidence des effets indésirables (EI) notifiés avec Prévenar 13^® depuis sa commercialisation.

Méthode

Analyse de tous les effets indésirables notifiés en France entre le 1^er juillet 2010 et le 31 octobre 2014.

Résultats

En 4 ans et 4 mois, 376 déclarations d’EI dont 252 graves (67 %) ont été enregistrées, parmi lesquels 83 étaient survenus au décours d’une injection de Prévenar 13^® seul. Il s’agissait de 39 EI cutanés et 16 neurologiques, de 4 malaises, de 9 fièvres et d’une thrombopénie. L’évolution a été favorable pour 88 % des EI graves et aucun des 12 décès rapportés n’a été attribué à un EI de la vaccination. Cinquante-neuf cas d’infection pneumococcique faisant suspecter une inefficacité vaccinale ont été rapportés, mais seuls 16 ont pu être considérés comme un réel échec de la vaccination.

Discussion

Dans de nombreux cas, le Prévenar 13^® avait été administré le même jour qu’un vaccin hexavalent avec lequel l’EI rapporté était attendu. Le profil des EI rapportés au décours de l’injection de Prévenar 13^® seul est similaire à celui observé avec le Prévenar 7^®.

Conclusion

Le suivi de pharmacovigilance de Prévenar 13^® mis en place en France depuis sa commercialisation en 2010 et qui porte à ce jour sur plus de 11 800 000 doses distribuées n’a pas mis en évidence de fait nouveau de sécurité.

[Antiemetics and cardiac effects potentially linked to prolongation of the QT interval: Case/non-case analysis in the national pharmacovigilance database]

OBJECTIVES

Observational retrospective studies have linked domperidone and prolonged QT interval, ventricular arrhythmias and risk of sudden death. Since then, antiemetic prescription was applied to other molecules (including metopimazine). The aim of this study was to evaluate the profile of adverse cardiac effects associated with QT prolongation for each antiemetic available in France.

METHODS

We conducted disproportionality analyses (case/non-case method), based on the observations recorded consecutively in the French national pharmacovigilance database between 2004 and 2013. Cases were defined by following MedDRA terms: prolongation of the QT interval, syncope, sudden death, cardiac arrest, ventricular arrhythmias including torsades de pointes; non-cases were other adverse events reported during the same period. We analyzed the presence of each antiemetic among cases and non-cases and measured the disproportionality by reporting odds ratios (ROR). We validate the assay with a positive control (methadone) and a negative control (acetaminophen).

RESULTS

We compared 2093 cases (94 with antiemetics) to 253,665 non-cases (7015 with antiemetics). Among antiemetics, adverse cardiac effects studied were more frequently found with notifications including domperidone (ROR=2.0, 95% CI=[1.3; 3.0]), ondansetron (ROR=1.8, 95% CI=[1.3; 2.6]) and granisetron (ROR=3.4, 95% CI=[1.5; 7.6]). Metopimazine was not statistically associated with that risk (ROR=2.0; 95% CI=[0.8; 4.8]).

CONCLUSION

We confirmed a risk of cardiac adverse event related to prolongation of the QT interval with domperidone and setrons. These results suggest caution when prescribing antiemetics and encourage systematic reporting of adverse cardiac effects observed with these molecules.

[Hydroxychloroquine-induced hearing loss: First case of positive rechallenge and analysis of the French pharmacovigilance database]

INTRODUCTION

Several cases of hearing loss induced by hydroxychloroquine have been reported in the literature but the role of hydroxychloroquine still remains debated.

CASE REPORT

We report the first case, to our knowledge, of hearing loss induced by hydroxychloroquine with a positive re challenge in a woman treated for systemic lupus. An analysis of the French pharmacovigilance database allowed to identify 23 additional cases of hearing loss in patients treated with hydroxychloroquine and, among them, 8 had systemic lupus.

CONCLUSION

Despite an excellent tolerance and high efficacy-side effect ratio, this case report adds some evidence for an otoxicity of hydroxychloroquine.

Bullous pemphigoid and dipeptidyl peptidase IV inhibitors: a case-noncase study in the French Pharmacovigilance Database

BACKGROUND

Inhibitors of dipeptidyl peptidase (DPP)-IV have been suspected in the onset of bullous pemphigoid for several years now. However, comparative studies assessing the link between DPP-IV inhibitor exposure and bullous pemphigoid have not yet been performed.

OBJECTIVES

To detect, from the French Pharmacovigilance Database (FPVD), a signal of risk of bullous pemphigoid during DPP-IV inhibitor exposure by comparative study.

METHODS

All spontaneous reports of DPP-IV inhibitor-related bullous pemphigoid recorded in the FPVD between April 2008 and August 2014 were described. We conducted disproportionality analyses (case-noncase method) to assess the link between DPP-IV inhibitors and bullous pemphigoid, calculating reporting odds ratios (RORs). We also compared DPP-IV inhibitor-induced bullous pemphigoid reports rated per million defined daily doses dispensed during the study period.

RESULTS

Among 217 331 spontaneous adverse drug reaction reports registered in the FPVD, 1297 involved DPP-IV inhibitors. Among these observations, 42 were bullous pemphigoid (vildagliptin, n = 31; sitagliptin, n = 10; saxagliptin, n = 1). The ROR for pooled DPP-IV inhibitors was 67·5 [95% confidence interval (CI) 47·1-96·9]. Disproportionality was also observed for each DPP-IV inhibitor: vildagliptin (ROR 225·3, 95% CI 148·9-340·9), sitagliptin (ROR 17·0, 95% CI 8·9-32·5) and saxagliptin (ROR 16·5, 95% CI 2·3-119·1). Analyses adjusted on dispensing data led to similar results.

CONCLUSIONS

These data confirm a strong signal for an increased risk of bullous pemphigoid during DPP-IV inhibitor exposure. This adverse drug reaction is observed for each DPP-IV inhibitor, suggesting a class effect. The signal was higher with vildagliptin than with the other DPP-IV inhibitors.

Early treatment with atorvastatin exerts parenchymal and vascular protective effects in experimental cerebral ischaemia

BACKGROUND AND PURPOSE

From the clinical and experimental data available, statins appear to be interesting drug candidates for preventive neuroprotection in ischaemic stroke. However, their acute protective effect is, as yet, unconfirmed.

EXPERIMENTAL APPROACH

Male C57Bl6/JRj mice were subjected to middle cerebral artery occlusion and treated acutely with atorvastatin (10-20 mg·kg(-1) day(-1) ; 24 or 72 h). Functional recovery (neuroscore, forelimb gripping strength and adhesive removal test) was assessed during follow-up and lesion volume measured at the end. Vasoreactivity of the middle cerebral artery (MCA), type IV collagen and FITC-dextran distribution were evaluated to assess macrovascular and microvascular protection. Activated microglia, leucocyte adhesion and infiltration were chosen as markers of inflammation.

KEY RESULTS

Acute treatment with atorvastatin provided parenchymal and cerebral protection only at the higher dose of 20 mg·kg(-1) ·day(-1) . In this treatment group, functional recovery was ameliorated, and lesion volumes were reduced as early as 24 h after experimental stroke. This was associated with vascular protection as endothelial function of the MCA and the density and patency of the microvascular network were preserved. Acute atorvastatin administration also induced an anti-inflammatory effect in association with parenchymal and vascular mechanisms; it reduced microglial activation, and decreased leucocyte adhesion and infiltration.

CONCLUSIONS AND IMPLICATIONS

Acute atorvastatin provides global cerebral protection, but only at the higher dose of 20 mg·kg(-1) ·day(-1) ; this was associated with a reduction in inflammation in both vascular and parenchymal compartments. Our results suggest that atorvastatin could also be beneficial when administered early after stroke.

Effect of a fungal chitosan preparation on Brettanomyces bruxellensis, a wine contaminant

AIM

To investigate the action mechanisms of a specific fungal origin chitosan preparation on Brettanomyces bruxellensis.

METHODS AND RESULTS

Different approaches in a wine-model synthetic medium were carried out: optical and electronic microscopy, flow cytometry, ATP flow measurements and zeta potential characterization. The inactivation effect was confirmed. Moreover, fungal origin chitosan induced both physical and biological effects on B. bruxellensis cells. Physical effect led to aggregation of cells with chitosan likely due to charge interactions. At the same time, a biological effect induced a leakage of ATP and thus a viability loss of B. bruxellensis cells.

CONCLUSIONS

The antimicrobial action mode of chitosan against B. bruxellensis is not a simple mechanism but the result of several mechanisms acting together.

SIGNIFICANCE AND IMPACT OF THE STUDY

Brettanomyces bruxellensis, a yeast responsible for the production of undesirable aromatic compounds (volatile phenols), is a permanent threat to wine quality. Today, different means are implemented to fight against B. bruxellensis, but are not always sufficient. The chitosan of fungal origin is introduced as a new tool to control B. bruxellensis in winemaking and has poorly been studied before for this application.

Risk factors associated with a thrombotic or bleeding event in patients treated with vitamin K antagonists

AIM

To identify, in a case-control study, the risk factors associated with a thrombotic or bleeding event in patients treated with vitamin K antagonists.

MATERIALS AND METHODS

We performed a single-centre observational study during a three-month period where we consecutively included patients admitted to the emergency department of a secondary-level hospital and treated with vitamin K antagonists, regardless the reason for admission. Patients admitted for a thrombotic or bleeding event were included as cases and the other patients served as controls. Main thrombotic or bleeding risk factors during vitamin K antagonist therapy were a priori identified in literature and tested in conditional logistic regression.

RESULTS

Two hundred and forty subjects were identified, 40 of which (17%) were admitted for a bleeding event, 19 (8%) for a thrombotic event and 181 (75%) for another reason. Over 85% of patients were treated with fluindione. No risk factor was significantly associated with bleeding or thrombotic event in patients treated with vitamin K antagonist. Patients presenting a thrombotic event were however more likely to have a chronic respiratory disease.

CONCLUSIONS

In this study, no risk factor significantly associated with a bleeding or thrombotic event in patients treated with vitamin K antagonist were identified. The occurrence of these events supposes other risk factors, including potential genetic polymorphisms that should be considered in future studies.