A method for estimating the probability of adverse drug reactions

Attention to the interactions between vincristine and triazole antifungals: perspectives from real-world retrospective analysis and pharmacovigilance assessment

BACKGROUND

In patients with hematologic malignancies, the combination of triazole antifungals and vincristine can lead to severe neurological toxicity. We attempted to assess the adverse events (AEs) associated with these interactions, particularly ileus.

RESEARCH DESIGN AND METHODS

We retrieved AEs data from FAERS database (2004-2023) focusing on the combination of four triazoles (fluconazole, itraconazole, voriconazole, posaconazole) with vincristine. Case reports of AEs were collected for retrospective analysis up to 31 December 2023.

RESULTS

The FAERS database indicated that neurological and gastrointestinal systems were most commonly involved systems when combined use triazole antifungals and vincristine, with ileus being the most frequently reported AE. The highest signal strengths for ileus were with itraconazole. AEs associated with concomitant use of triazole antifungal drugs and vincristine were identified through retrospective analysis of 42 clinical case reports, of which itraconazole, posaconazole, and voriconazole were involved in 66.7%, 28.6%, and 4.8% of cases, respectively. Patients who received the two-drug combination experienced AEs within one month in 88.1% of cases. Almost all patients improved within one month after discontinuing or switching antifungal drugs.

CONCLUSIONS

Ileus is the most common AE associated with the combination of triazole antifungals and vincristine, with itraconazole showing the highest risk.

Baclofen-Induced Pancreatitis

Acute pancreatitis is an inflammatory condition of the pancreas that can result from various aetiologies, one of them being drug-induced pancreatitis, a relatively rare cause. Drug-induced pancreatitis should be considered in patients presenting with epigastric pain, elevated pancreatic enzymes, and imaging findings consistent with acute pancreatitis, in the absence of any common precipitants such as alcohol, gallstones, trauma. We report a case of acute pancreatitis following the initiation of baclofen therapy, with no other identifiable risk factors. A probable drug adverse reaction was established through the Naranjo Adverse Drug Reaction Probability Scale. This case highlights the need for physicians to consider baclofen as a potential cause of acute pancreatitis.

LEARNING POINTS

Given the patient's presentation following baclofen initiation and absence of other identifiable causes, this case suggests a probable association between baclofen and acute pancreatitis.Physicians should recognize the potential of baclofen to cause this inflammation when prescribing it and consider it as a differential diagnosis in cases of unexplained acute pancreatitis.

Complete Heart Block Triggered by Nirmatrelvir-Ritonavir and Verapamil

Ritonavir-boosted nirmatrelvir (Paxlovid) is a treatment for COVID-19. However, ritonavir, a cytochrome P450 (CYP) CYP3A4 inhibitor, poses a risk of significant drug-drug interactions. In our case, coprescribed nirmatrelvir-ritonavir and verapamil, with concomitant acute kidney injury, resulted in complete heart block and shock. Following fluid resuscitation, blood pressure support with norepinephrine, and calcium therapy for verapamil toxicity, the patient recovered and was discharged home in normal sinus rhythm. To our knowledge, only 2 cases with this drug-drug interaction have been documented, making this a rare, but serious interaction poorly described in the literature. Understanding the pharmacokinetic relationship between these 2 medications and the risks of coprescribing them is crucial for both diagnosing toxicity and reducing preventable morbidity and mortality.

Levodopa and nutrition support: A case report of Parkinsonism-hyperpyrexia syndrome

Levodopa is competitively inhibited by amino acids for absorption across the intestinal wall and blood-brain barrier. An acute withdrawal of levodopa increases the risk of Parkinsonism-hyperpyrexia syndrome, a life-threatening condition characterized by muscular rigidity, mental status changes, hyperthermia, and autonomic instability. This report discusses the case of a patient with Parkinson's disease who was critically ill who developed Parkinsonism-hyperpyrexia syndrome while receiving enteral and parenteral nutrition support. Clinicians should be aware of this potential drug-nutrient interaction when prescribing nutrition support to patients taking levodopa.

Drug-Related Gastric Perforation Secondary to Prolonged Febuxostat Administration: A Case Report

Febuxostat, a selective xanthine oxidase inhibitor, is regarded as the first-line therapeutic option for gout and hyperuricemia. With its extensive application, there has been a growing number of reports regarding associated adverse reactions. In this case, a 71-year-old male patient, who had been under long-term febuxostat treatment for gout, was admitted to the hospital approximately one year later due to persistent upper abdominal pain. Abdominal CT imaging revealed thickening of the gastric antrum wall, accompanied by peripheral exudation and the presence of free gas in the abdominal cavity, which was diagnosed as gastric perforation. After excluding other potential causative factors of gastric perforation, the serious adverse reaction potentially induced by febuxostat was taken into consideration.

The effect of calcitriol and cholecalciferol on inflammatory markers in periprocedural myocardial injury: A randomized controlled trial

BACKGROUND

Inflammation is an important factor in the development of cardiac injury during and after percutaneous coronary intervention (PCI). Vitamin D receptors play a significant role in the cardiovascular system and have anti-inflammatory effects. Hence, our goal was to evaluate the impact of calcitriol and cholecalciferol as vitamin D receptors agonists on inflammatory biomarkers in patients who are undergoing elective PCI.

METHODS

In this controlled clinical trial, patients undergoing elective PCI were randomly assigned to receive either calcitriol and cholecalciferol or were placed in the control group from July 2021 to November 2022. Calcitriol and cholecalciferol were administered at doses of 1 mcg and 300,000 international units, respectively, before the procedure. High-sensitive C-reactive protein (hs-CRP) was evaluated as the main inflammatory biomarker and other relevant clinical and laboratory data were also included.

RESULTS

During the study, 180 patients were allocated into three groups, each consisting of 60 patients, with a mean age of 62.26 ± 8.73 years. The prevalence of the underlying conditions was not different among the groups. After 24 hours, hs-CRP levels were lower (P = .012), and a significantly lower increase from baseline was observed (P = .003) in the group that received calcitriol. However, no significant differences were observed in Troponin I and creatine kinase-MB levels (P > .05).

CONCLUSIONS

Administration of calcitriol was associated with significantly lower levels of hs-CRP, the main cardiac inflammatory marker, in patients undergoing elective PCI. Further clinical studies with a larger sample size are needed to assess the clinical impact of this anti-inflammatory effect.

Heparin-Induced Hyperkalemia Assessment Utilizing the Naranjo Adverse Drug Reaction Probability Scale: A 40-Year Systematic Review

BACKGROUND

Adverse drug reactions have been reported as leading causes of morbidity and mortality. Unfractionated heparin- and low-molecular-weight heparin-induced hyperkalemia are side effects that have been reported in approximately 7 to 8% of heparin-treated patients. Algorithms, assessment tools, and decision aids are needed to assist in determining the causality of these adverse drug reactions.

AIM

The aim of this study was to determine the number of case reports of hyperkalemia resulting from unfractionated heparin or low-molecular-weight heparin use by utilizing the Naranjo Adverse Drug Reaction Probability Scale.

METHODS

PubMed, International Pharmaceutical Abstracts, and the Cochrane Library were searched for relevant publications. Search terms and Boolean operators, including "hyperkalemia AND heparin", "hyperkalemia AND low molecular weight heparin", "heparin AND hypoaldosteronism", and "low molecular weight heparin AND hypoaldosteronism", were used. Searches were limited to case reports and human specimens.

RESULTS

A total of 29 case reports were identified, incorporating 38 patient cases. Of the 38 patient cases, 5 [4 involving unfractionated heparin and 1 involving low-molecular-weight heparin] (13.2%) utilized the Naranjo Adverse Drug Reaction Probability Scale to identify the possibility of an adverse drug reaction occurring due to exposure to unfractionated or low-molecular-weight heparin as probable.

CONCLUSIONS

The available evidence suggests that clinicians' use of the Naranjo Adverse Drug Reaction Probability Scale to determine the potential of hyperkalemia occurring due to exposure to unfractionated heparin and low-molecular-weight heparin is limited. Clinicians should be encouraged to utilize an objective monitoring tool to help standardize assessment of causality for all adverse drug reactions.

Prevalence and factors associated with adverse drug reactions among patients on highly active antiretroviral therapy at a tertiary hospital in south western Uganda: A cross-sectional study

BACKGROUND

HIV/AIDS remains a global health challenge, with significant prevalence in sub-Saharan Africa. Highly active antiretroviral therapy (HAART) is the mainstay treatment for HIV, and the number of people living with HIV (PLWHIV) on HAART has considerably increased worldwide. The use of HAART has led to improved patient outcomes; however, it is associated with adverse drug reactions (ADRs) and drug-drug interactions (DDIs), which pose serious concerns in the management of patients with HIV. The aim of the study was to determine the prevalence and factors associated with ADRs among patients on HAART.

METHODOLOGY

This was a hospital-based cross-sectional study carried out among 312 HIV patients on HAART attending HIV clinics at Mbarara Regional Hospital. Data was collected using an interviewer-administered, semi-structured questionnaire and a review of patient charts. ADRs were assessed for causality and categorized using Naranjo ADR assessment scale into probable, possible and definite, for severity using the modified Hartwig and Siegel criteria into mild, moderate and Severe, and for preventability using Schumock and Thornton criteria into definite, probable and non-preventable. Lexicomp® Drug Interaction Checker software was used to identify and rate clinically significant drug-drug interactions. The prevalence of ADRs and potential DDI was analyzed using descriptive statistics while logistic regression analysis was used to establish the association of variables.

RESULTS

312 patients were interviewed and their records reviewed. The prevalence of ADRs during this study was 76.0%. On assessment, 78.3% of the ADRs were mild and 76.6% of ADRs were definitely preventable. CD4 count below 200 cells/mm3 (AOR = 1.00, 95% CI: 1.00-1.02; p value = 0.04), primary education level (AOR = 3.27, 95% CI: 1.34-7.95; p value = 0.009), and secondary education level (AOR = 3.64, 95% CI: 1.39-9.52; p value = 0.009) were identified as independent risk factors. Patients who experienced a significant DDI were 5.66 times more likely to experience an ADR (p value = 0.02, 95% CI: 1.32-24.18).

CONCLUSION

There is a high prevalence of adverse drug reactions among patients with HIV on HAART. Low CD4 count and lower education levels are risk factors for ADRs in this population; therefore, tailored interventions to these subgroups should be implemented for early ADR identification and management. Significant drug-drug interactions are highly associated with the occurrence of ADRs among HIV patients on HAART, which calls for intensified pharmacovigilance and pharmaceutical care in this population.

Potential inappropriate medications and drug-drug interactions in adverse drug reactions in the elderly: a retrospective study in a pharmacovigilance database

Introduction

Potential inappropriate medications (PIMs) and potential drug-drug interactions (pDDIs) are important factors leading to adverse drug reactions (ADRs) in the elderly. This study aimed to evaluate the incidence and pattern of PIMs and pDDIs in the elderly based on a real-world pharmacovigilance database and identify the variables associated with them.

Methods

This retrospective study evaluated PIMs and pDDIs by updated Beers criteria and Lexi-Interact online, respectively, using ADRs reported for those aged ≥65 years submitted between 2011 and 2023 from a real-world database of a tertiary care teaching hospital. Correlation factors were investigated by binary and multiple logistic regression analyses.

Results

A total of 1,423 ADRs were included and involved 2,238 prescribed drugs; 54.11% of the total were men, and 23.47% were classified as serious. The most commonly implicated pharmacological group was antimicrobial agents. Aspirin and clopidogrel emerged as the drugs causing the majority of ADRs. PIMs were detected in 32.04% of all ADR reports. Aspirin and diclofenac were the most common active pharmaceutical ingredients involved, and gastrointestinal bleeding was the primary clinical manifestation of severe ADRs caused by PIMs or involved in PIM-related risk factors. Age, number of diagnosed diseases and prescribed drugs, ADR severity and preventability, hypertension, coronary heart disease, and arthritis were independent influencing factors of PIMs. Among 498 ADR reports with ≥2 prescribed drugs, 202 cases (14.20%) had pDDIs. Blood and hematopoietic organ and cardiovascular agents were the most commonly involved categories. The most frequent drug combinations in classes C, D, and X were aspirin-clopidogrel, aspirin-heparin, and potassium chloride-promethazine, respectively. The majority of pDDIs increased the risk of bleeding through pharmacodynamic mechanisms. The number of prescribed drugs and diagnosed diseases, ADR severity and preventability, stroke, diabetes, and coronary heart disease, along with PIM use, were independent predictors of pDDIs.

Conclusion

The incidence of PIMs and pDDIs was found to be relatively high in the elderly, especially in the treatment of cardiovascular and cerebrovascular diseases and non-steroidal anti-inflammatory drugs (NSAIDs), and relevant factors have been identified. Healthcare institutions should reinforce the management of rational drug use in the elderly to mitigate the occurrence of PIMs and pDDIs, thereby enhancing medication safety.

The Influence of Frailty on Pharmacotherapy Adherence and Adverse Drug Reactions in Older Psychiatric Patients

Aim/Objectives: To investigate whether frailty predicts adherence to psychotropic drug treatment or adverse drug reactions, within 6 months after treatment initiation. Methods: A prospective cohort study including 77 patients over the age of 65, treated in one large psychiatric institute in the Netherlands. Patients were assessed at baseline for their frailty status, using different operationalizations of the Fried frailty criteria. Data on duration of psychotropic drug treatment and number of reported adverse drug reactions were retrieved from electronic patient files. Regression analyses were adjusted for age, sex, patient setting, and polypharmacy as potential confounders. Results: Frail patients were not significantly more likely to discontinue psychotropic treatment than non-frail patients (OR = 1.4; 95% CI 0.6-3.7, p = 0.468). Time to treatment discontinuation was also not statistically different between both study groups (HR = 0.8; 95% CI 0.4-1.6, p = 0.498), and neither was the number of adverse drug reactions (OR = 1.6, 95% CI 0.6-4.1, p = 0.345). Conclusions: We could not demonstrate a statistically significant effect of frailty as predictor of discontinuing psychotropic treatment or adverse drug reactions, but a lack of power may also explain our results. A more comprehensive frailty assessment may be needed to predict treatment adherence or adverse drug reactions in psychiatric patients.

Case Report: Methimazole-Induced Parotitis - An Unusual Presentation

A 56-year-old female with a medical history of unspecified hyperthyroidism and a recent thyroid storm presented to the ED with tachycardia, hypertension, and bilateral enlarged parotid glands. During a previous hospitalization, she was diagnosed with unspecified hyperthyroidism and started on methimazole. During hospitalization, laboratory findings suggested Graves' disease with an acute thyroid storm. The patient also complained of enlarged parotid glands bilaterally. CT tomography of the neck revealed no calculi of the parotid glands but showed extensive fatty replacement, possibly related to methimazole use. Treatment with propranolol and IV hydrocortisone improved thyroid function. Due to the suspicion of methimazole-induced parotitis, she was transitioned to a reduced methimazole dosage for treatment of Graves' disease, which subsequently improved her parotitis. Methimazole, the standard initial treatment for Graves' disease, is generally well-tolerated. It can cause adverse reactions; however, parotitis is very rare and has been documented in only a few case reports. Owing to the limited number of reports, its incidence is currently unknown. Here, we present a case of methimazole-induced parotitis as an unusual presentation of thyroid storm. Drug-induced reactions can only be considered once common causes of parotitis such as viral infection, obstruction, and autoimmune diseases are ruled out. Treatment involves dosage adjustments and supportive care. Methimazole-induced parotitis is often misdiagnosed and overlooked because of the lack of reported cases. This necessitates future research into the reaction mechanisms and optimal treatment.

Self-reporting of adverse drug reactions of nonsteroidal anti-inflammatory drugs in community pharmacies

Background

Ibuprofen and diclofenac are nonsteroidal anti-inflammatory drugs widely used worldwide. Spontaneous reporting often results in an underestimation of the incidence of adverse drug reactions (ADRs), and a few studies have been conducted in community settings, particularly in community pharmacies. This study aimed to determine the frequency and characteristics of short-term ADRs associated with ibuprofen and diclofenac in community pharmacy patients.

Methods

This prospective cohort study was conducted in 15 community pharmacies. A questionnaire from a previous study was modified and tested for content validity. Community pharmacists distributed the questionnaire after dispensing ibuprofen or diclofenac and followed non-responders via telephone and online media platforms. The returned questionnaires were assessed for causality by a pharmacist and three researchers. Descriptive analyses and comparisons between reports on ibuprofen and diclofenac were performed using chi-square and independent t-tests for appropriate outcomes.

Results

Of the 590 distributed questionnaires, 279 were included in the analysis. The percentage of participants who reported ADRs to ibuprofen and diclofenac was 33.3%. Among participants with suspected ADRs, the average number of suspected ADRs from diclofenac was higher than from ibuprofen; however, no significant difference was observed (5.5 ± 8.9 and 3.1 ± 3.0, p > 0.05). Of the 347 self-reported ADRs, 45.2% were assessed as probable and possible ADRs. The highest rate of suspected ADRs was in Mental Health (14.4%), followed by the Nose, Throat, Neck, or Voice (9.8%), and the Stomach or Digestive Systems (8.9%), respectively.

Conclusions

Diclofenac showed more suspected ADRs than ibuprofen in a community setting. Almost half of the self-reported ADRs were assessed as probable or possible. Strategies for sustaining community pharmacists in monitoring patients and reporting ADRs should be supported.

Does Aripiprazole Increase Compulsive Urges to Use Substances? Case Reports and Literature Review

PURPOSE/BACKGROUND

Aripiprazole is commonly used to treat schizophrenia, bipolar disorder, and major depressive disorder and is preferred because of its relatively favorable side-effect profile. In 2016, the Food and Drug Administration released a warning regarding the risk of new impulse control problems with aripiprazole, including urges to gamble, binge eat, shop, and engage in sexual intercourse. These problems are rare but may cause significant harm if not recognized in time.

METHODS

This report presents 2 clinical cases to hypothesize that aripiprazole may increase urges and compulsive use of substances in some patients with a history of substance use disorders.

RESULTS

Both individuals had a previous history of substance use disorder before starting aripiprazole; they felt unable to stop using, as if compelled to use the substances while on aripiprazole, despite having good motivation to change. They reported a decreased urge to use substances after discontinuation of aripiprazole and were able to abstain from substances for sustained periods.

IMPLICATIONS/CONCLUSIONS

These case reports suggest that aripiprazole may increase urges and compulsive substance use in patients with a history of substance use disorders. The findings emphasize the importance of a thorough preprescription assessment, education, informed consent, and regular monitoring of patients prescribed aripiprazole for increased urges or compulsions to use substances, in addition to other impulsive-compulsive behaviors. Further research is needed to confirm the association.

Polymyalgia Rheumatica (PMR) and Polymyalgia Rheumatica-like (PMR-like) Manifestations in Cancer Patients Following Treatment with Nivolumab and Pembrolizumab: Methodological Blurred Points Identified Through a Systematic Review of Published Case Reports

Background: Among rheumatologic diseases following therapy with immune checkpoint inhibitors (ICIs), the cases of cancer patients diagnosed as having polymyalgia rheumatica (PMR), particularly with nivolumab and pembrolizumab, has been steadily rising in published reports. Objectives: We performed a systematic review of published case reports with the aim of answering these questions: (1) Is PMR following therapy with nivolumab and pembrolizumab an adverse drug reaction (ADR)? (2) Is there a difference between cases of PMR following therapy with nivolumab and those following therapy with pembrolizumab? Methods: Based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a comprehensive literature search in three main bibliographic databases: MEDLINE (Ovid interface), EMBASE, and COCHRANE Library was carried out on 27 December 2024. This systematic review has no registration number. Results: Data were extracted from 12 patients. Namely, 5 cases followed treatment with nivolumab and 7 with pembrolizumab. Validated scales for ADR assessment-such as Naranjo's scale-were not used in 10 out of the 12 patients. Additionally, validated diagnostic or classification criteria for PMR were used in the majority of case reports related to nivolumab. On the contrary, clinical judgment alone was the rule in almost all case reports on pembrolizumab. Finally, the time interval between PMR manifestations and nivolumab/pembrolizumab therapy ranged from one to 14 cycles (fully compatible with pharmacokinetics). Conclusions: Our literature review highlighted significant methodological blurred lines in the categorization of PMR following therapy with nivolumab or pembrolizumab.

Nearly complete hair re-pigmentation in an older patient treated with hydroxyurea for essential thrombocytosis

IntroductionEmployed in the treatment of malignancies and non-neoplastic conditions, hydroxyurea is associated with integumentary adverse effects, including skin discoloration, xerosis, pruritus, cutaneous atrophy, chronic leg ulcers, oral ulcerations, alopecia, and some nail abnormalities.Case ReportA 77-year-old woman was diagnosed with essential thrombocytosis and started on low dose hydroxyurea. After 20 weeks of treatment, she experienced an unexpected change in hair color from gray to dark brown, without using hair dye or supplements. She later developed bilateral dorsal hand melanoderma, melanonychia, and onychodystrophy.Management and outcomeIt was decided to monitor the patient with no action taken as she was happy with this side effect of hydroxyurea. The platelet count has remained in excellent control. The dark brown hair color persisted over time.Discussion/ConclusionHair hyperpigmentation likely occurred through melanocyte activation via hydroxyurea. Severe side effects may require dosage adjustments, while milder effects can be monitored closely. The newly observed hair color restoration in this case highlights potential dual (therapeutic and aesthetic) applications of this class of agents.

Adverse drug reactions and events in an Ageing PopulaTion risk Prediction (ADAPTiP) tool: the development and validation of a model for predicting adverse drug reactions and events in older patients

PURPOSE

Older people are at an increased risk of developing adverse drug reactions (ADR) and adverse drug events (ADE). This study aimed to develop and validate a risk prediction model (ADAPTiP) for ADR/ADE in older populations.

METHODS

We used the adverse drug reactions in an Ageing PopulaTion (ADAPT) cohort (N = 798; 361 ADR-related admissions; 437 non-ADR-related admissions), a cross-sectional study designed to examine the prevalence and risk factors for ADR-related hospital admissions in patients aged ≥ 65 years. Twenty predictors (categorised as sociodemographic-related, functional ability-related, disease-related, and medication-related) were considered in the development of the model. The model was developed using multivariable logistic regression and was internally validated by fivefold cross-validation. The model was externally validated in a separate prospective cohort from the Centre for Primary Care Research (CPCR) study of ADES. The cross-validated and externally validated model performance was evaluated by discrimination and calibration.

RESULTS

The final prediction model, ADAPTiP, included nine predictors: age, chronic lung disease, the primary presenting complaints of respiratory, bleeding and gastrointestinal disorders and syncope on hospital admission and antithrombotics, diuretics, and renin-angiotensin-aldosterone system drug classes. ADAPTiP demonstrated good performance with cross-validated area under the curve of 0.75 [95% CI 0.72;79] and 0.83 [95% CI 0.80;0.87] in the external validation.

CONCLUSION

Using accessible information from medical records, ADAPTiP can help clinicians to identify those older people at risk of an ADR/ADE who should be monitored and/or have their medications reviewed to avoid potentially harmful prescribing.

Neuropsychiatric Side Effects of Hydroxychloroquine in a Patient With Idiopathic Pulmonary Hemosiderosis

BACKGROUND

Idiopathic pulmonary hemosiderosis (IPH) is a rare interstitial lung disease. Glucocorticosteroids and hydroxychloroquine are the most commonly used treatments. Although neuropsychiatric side effects related to hydroxychloroquine use are seen in adult cases, only one paediatric patient has been reported in the literature.

CASE PRESENTATION

We report a case of a 6-year-old girl with IPH, who developed neuropsychiatric symptoms, including restlessness, confusion and myoclonic movements, after the therapeutic use of hydroxychloroquine.

CONCLUSION

With increasing knowledge and experience of interstitial lung disease, the use of hydroxychloroquine treatment is increasing. It is important to remember that hydroxychloroquine is a central nervous system stimulant, and neuropsychiatric side effects may be seen in children. This report highlights the importance of recognising potential neuropsychiatric side effects in paediatric patients using hydroxychloroquine, especially when combined with corticosteroids or other risk factors.

Exploring the association of adverse drug reactions with medication adherence and quality of life among hypertensive patients: a cross-sectional study

BACKGROUND

Effective hypertension management requires medication adherence to prevent complications. However, adverse drug reactions (ADRs) can undermine adherence and negatively affect patients' quality of life. Limited research has explored the association between ADRs, medication adherence, and health-related quality of life (HRQoL) in individuals with hypertension.

AIM

To investigate the association between ADRs, medication adherence, and HRQoL among patients with hypertension.

METHOD

A cross-sectional study using telephone interviews and medical record reviews was conducted in 11 primary care facilities in Indonesia. The causality of reported ADRs was assessed using the Naranjo algorithm, validated by a panel of experts in pharmacy practice and medication safety. The severity of ADRs was classified using the Hartwig scale. Adherence to antihypertensive drugs was estimated using the Medication Adherence Report Scale-5 (MARS-5). The EuroQoL EQ-5D-5L was used to measure HRQoL. The association between ADRs and medication adherence was assessed using multivariate logistic regression, while the association with HRQoL was evaluated through the Tobit regression model.

RESULTS

A total of 507 patients were included in this study. We found that 20.32% (n = 103) of the patients experienced ADRs, with the most commonly reported ADRs being polyuria and urgency, gastrointestinal symptoms, leg swelling, dizziness/hypotension, palpitations, and dry cough. The majority experienced mild ADRs (n = 75, 72.82%), while 27.18% (n = 28) had reactions of moderate severity. Experiencing ADRs was associated with reduced medication adherence (adjusted odds ratio (OR) 7.15, 95% CI 4.07-12.55) and decreased HRQoL (coefficient: - 0.037).

CONCLUSION

Patients experiencing ADRs were seven times more likely to be non-adherent to their medication regimen and reported a reduced quality of life compared to those without ADRs, placing them at a higher risk of suboptimal treatment outcomes. This finding highlights the need for additional monitoring and education for patients affected by ADRs, particularly through more frequent clinical and laboratory assessments, timely management of ADRs, and personalized education on the importance of adherence to prevent hypertension-related complications.

Bilateral epithelial keratopathy and punctate keratitis due to ribociclib

IntroductionThis report describes a rare occurrence of corneal epithelial keratopathy associated with ribociclib, a cyclin-dependent kinase 4/6 (CDK4/6) inhibitor widely used in breast cancer treatment.Case reportAn 83-year-old female with a recent breast cancer diagnosis presented with blurred vision during the third cycle of ribociclib treatment. Ocular examination revealed corneal epitheliopathy and fluorescein staining findings. Detailed assessments and comparisons were made with existing literature, identifying a few reported cases of vortex keratopathy linked to ribociclib. To the best of our knowledge, this is the first reported case of epitheliopathy.Management and OutcomeSince it decreased visual acuity, ribociclib treatment was discontinued in consultation with oncology. There was no regression in epithelopathy findings and visual acuity did not improve during follow-up visits.DiscussionThis report underscores the uncommon association between ribociclib and corneal epithelial keratopathy, emphasizing the need for comprehensive monitoring and collaboration between oncologists and ophthalmologists.

Drug-Induced Lichenoid Photosensitivity: A Case Report

Tuberculosis (TB) is a highly contagious airborne bacterial infection and continues to be one of the leading causes of mortality worldwide. First-line antitubercular therapy (ATT), including isoniazid, rifampicin, pyrazinamide, and ethambutol, is essential for TB management but is associated with adverse drug reactions (ADRs), including severe cutaneous manifestations. Managing these ADRs poses significant challenges, as discontinuation of ATT, combined with systemic steroid use, may increase the risk of disease progression and multidrug resistance. Drug-induced lichenoid photosensitivity is an uncommon yet clinically significant skin-related adverse reaction to ATT. Its unpredictable onset and clinical resemblance to autoimmune disorders make early recognition and accurate diagnosis essential to avoid mismanagement or delays in treatment. Timely identification and appropriate intervention are critical not only for minimizing complications but also for maintaining uninterrupted TB therapy. This case report highlights the importance of recognizing and effectively managing drug-induced lichenoid photosensitivity associated with antitubercular agents. We describe a 62-year-old male diagnosed with cervical tuberculous lymphadenitis who developed this rare cutaneous adverse reaction during ATT. The case underscores the need for early diagnosis, individualized treatment strategies, and the vital role of pharmacovigilance in promoting patient safety and ensuring the uninterrupted continuation of TB management.

The Acute Kidney Intervention and Pharmacotherapy (AKIP) List: Standardized List of Medications That Are Renally Eliminated and Nephrotoxic in the Acutely Ill

The objective of this project was to develop a standardized list of renally eliminated and potentially nephrotoxic drugs that will help inform initiatives to improve medication safety. Several available lists of medications from the published literature including original research articles and reviews, and from regulatory agencies, tertiary references, and clinical decision support systems were compiled, consolidated, and compared. Only systemically administered medications were included. Medication combinations were included if at least 1 active ingredient was considered renally dosed or potentially nephrotoxic. The medication list was reviewed for completeness and clinical appropriateness by a multidisciplinary team of individuals with expertise in critical care, nephrology, and pharmacy. An initial list of renally dosed and nephrotoxic drugs was created. After reconciliation and consensus from clinical experts, a standardized list of 681 drugs is proposed. The proposed evidence-based standardized list of renally dosed and potentially nephrotoxic drugs will be useful to harmonize epidemiologic and medication quality improvement studies. In addition, the list can be used for clinical purposes with surveillance in nephrotoxin stewardship programs. We suggest an iterative re-evaluation of the list with emerging literature and new medications on an approximately annual basis.

Late-onset recurrent immune checkpoint inhibitor-related pneumonitis after cessation of pembrolizumab: a case report

Immune-related adverse events typically occur during the early phases of immune checkpoint inhibitor therapy. However, late-onset immune-related adverse events can still arise long after the immune checkpoint inhibitor therapy has ended. Immune checkpoint inhibitor-related pneumonitis warrants special attention for risk assessment and early detection due to its potential for serious outcomes, including hospitalization and death. Despite its rarity, late-onset immune checkpoint inhibitor-related pneumonitis should be considered in the differential diagnosis for dyspnea in patients with a history of immune checkpoint inhibitor therapy to prevent morbidity and mortality. In this case report, we present a case of an 84-year-old female patient suffering from locally advanced triple-negative breast cancer and late-onset immune checkpoint inhibitor-related pneumonitis requiring hospitalization 104 days after the last cycle of pembrolizumab. Following successful treatment of late-onset immune checkpoint inhibitor-related pneumonitis with corticosteroids, a recurrence of immune checkpoint inhibitor-related pneumonitis occurred a month later. Corticosteroid therapy was reinitiated, gradually tapered after radiological improvement, and eventually discontinued. The patient remains in remission from breast cancer. For patients with a history of immune checkpoint inhibitor therapy, medical vigilance, accurate diagnosis, and timely management of late-onset immune checkpoint inhibitor-related pneumonitis are crucial.

Recurrent, multisystem angioedema induced by 5-azacitidine

Introduction5-azacitidine is a hypomethylating agent (HMA) used for treating myelodysplastic syndrome (MDS) and certain myeloproliferative neoplasms (MPNs). Common side effects include myelosuppression, nausea and injection site reactions. Serious allergic reactions are rare with this class of agents.Case ReportWe describe a 71-year-old man with MDS/MPN who developed repeated episodes of angioedema after starting treatment with subcutaneous 5-azacitidine. Angioedema involved multiple body areas including the neck, genitalia, lower back and gastrointestinal system. Causality assessment linked this entity to 5-azacitidine via the Naranjo nomogram questionnaire, by scoring 9.Management and Outcome5-azacitidine was discontinued due to recurrent episodes of angioedema that occurred even after dose reduction. Steroids were helpful in terms of reversing this reaction. Afterwards, no further episodes of angioedema have been documented. The patient's thrombocytosis is currently well-controlled with low dose hydroxyurea.Discussion/ConclusionWe report herein a unique case of recurrent, multisystem angioedema likely related to 5-azacitidine. The exact mechanism of azacitidine-induced angioedema is not currently known. Symptoms, clinical findings and timing of presentation are not always clear-cut, and it may take more than one cycle of 5-azacitidine before the diagnosis is made. Supportive and symptomatic treatment will be provided based on the severity of the reaction. Future studies may offer more insights into the mechanism underlying this rare and serious, yet intriguing side effect.

Recrudescence of Natalizumab-Induced Pneumonitis and Peripheral Hypereosinophilia: Case Report and Literature Review

We report a rare case of recrudescence of natalizumab-induced pneumonitis and peripheral hypereosinophilia, hence uniquely satisfying the re-exposure principle outlined by the Naranjo Adverse Drug Reaction Probability Scale. A 57-year-old female with relapsing-remitting multiple sclerosis presented with acute respiratory symptoms, eosinophilia of 2.08 × 109/L, and chest computed tomography showing consolidation of the right upper and lower lobes. Her septic and autoimmune work-up was negative. She did not improve with broad-spectrum antibiotics. Bronchoalveolar lavage revealed 75% lymphocytes. Upon discussion at a multi-disciplinary meeting, her antibiotics were discontinued and she was commenced on prednisolone, which resulted in immediate improvement. She experienced two further recurrences of pneumonitis during her prednisolone tapering. After a two-year remission, she was re-started on natalizumab due to adverse events related to alternative biologic agents. Her pneumonitis and peripheral hypereosinophilia recurred. She responded well to another course of prednisolone, and subsequent follow-up revealed complete recovery off natalizumab.

Serious Adverse Events: A Replicability and Validation Study of Naranjo Causality Assessment Tool in a Canadian Clinical Setting

RATIONALE

Patient safety has become a major concern in healthcare today as 5%-10% of patients experience serious adverse events (SAE) during their hospital stay. The causal assessment of SAE is the responsibility of healthcare professionals (HCP), who use their judgment or a standardize tool. Whether those two methods are replicable to provide similar results remains unclear.

OBJECTIVE

Our aim was to evaluate if causality assessment performed by HCP is replicable when systematically assessed with the Naranjo tool and to validate its performance in Canadian clinical context.

METHODS

We performed pilot retrospective cohort study which included patients with SAE admitted to a Quebec hospital in 2021. Twelve SAE were randomly selected, and two reviewers independently assessed their causality using Naranjo tool. Inter-rater reliability among two reviewers and between HCP was evaluated. Along with criterion validity, sensitivity and specificity were calculated for validation study.

RESULTS

Weighted kappa was 0.92 (good inter-rater reliability) where kappa was 0.84 (good agreement between reviewers). No causality assessment by HCP was documented leading to impossibility in computing replicability. The Naranjo tool showed positive monotonic correlation with expert opinion resulting in rs = 0.208 (p < 0.001). Classification of Naranjo scores to binary variables resulted in sensitivity of 1.00 and specificity of 0.31.

CONCLUSION

Our study suggested that Naranjo tool is reliable and valid to be used in a clinical setting and was able to classify all drug products involved in the occurrence of SAE. Larger scale studies need to be conducted in real-time clinical settings to investigate its performance and utility.

Pulmonary Coccidioidomycosis Occurring in a Patient Treated With Acalabrutinib for Chronic Lymphocytic Leukemia

Acalabrutinib is a Bruton tyrosine kinase inhibitor (BTKi) approved for use in the treatment of chronic lymphocytic leukemia (CLL). Herein, we present a patient successfully treated with reduced-dose acalabrutinib for CLL, with pre-existing hypogammaglobulinemia-type immunoglobulin G (IgG) and immunoglobulin M (IgM). Twenty-four months into therapy, he developed a right upper lobe infiltrate due to pulmonary coccidioidomycosis; the Naranjo causality assessment score was 4 (probable). The patient received monthly intravenous IG (IVIG) infusions and antifungal therapy, with significant clinical improvement. Acalabrutinib was restarted, along with close clinical monitoring. The extent to which invasive fungal infections can be attributed to acalabrutinib alone is not always straightforward due to the presence of immune defects associated with CLL, endemic zip codes, and a prior exposure to ibrutinib. Physicians should remain vigilant in assessing and managing invasive fungal infections in these patients in order to optimize patient safety and clinical outcomes.

Periorbital edema and phototoxic rash associated with dasatinib: A case report

Dasatinib is an effective agent in the treatment of bcr-abl positive acute lymphoblastic leukemia and chronic myeloid leukemia cases. Various skin reactions may occur when tyrosine kinase inhibitors are used. The severity of side effects increases in phototoxic reactions with sunlight. In this case, a phototoxic rash that developed in a 78-year-old bcr-abl positive acute lymphoblastic leukemia patient is presented. This case supports that phototoxic reactions may occur with dasatinib and emphasizes that clinicians should be alert for this side effect.

Catastrophic antiphospholipid antibody syndrome provoked by eltrombopag

Antiphospholipid antibody syndrome (APS) may rarely present with isolated thrombocytopenia that may be diagnosed and treated as immune thrombocytopenic purpura. A 32-year-old woman was given eltrombopag (a thrombopoietin receptor agonist) to treat presumed immune thrombocytopenic purpura. She developed catastrophic APS, with multiple ischaemic infarcts, microvascular coronary thrombosis and digital gangrene. She improved after stopping eltrombopag and starting immunotherapy (corticosteroids, intravenous immunoglobulin and rituximab) but was left with significant neurological morbidity.

Treatment rechallenge is safe and leads to better survival in pancreatic cancer patients with interstitial pneumonitis

BACKGROUND AND AIMS

Interstitial pneumonitis is a potentially fatal complication of cancer-related therapy. However, data regarding the risk factors, prognosis and safety and benefit of rechallenge treatment are scarce.

METHODS

Patients diagnosed with pancreatic cancer were retrospectively enrolled, and those with pneumonitis were identified. We investigated the incidence and etiology of pneumonitis, potential risk factors, and impact of treatment rechallenge on clinical outcomes.

RESULTS

A total of 809 patients were diagnosed with pancreatic cancer, among whom 62 (7.7%) were diagnosed with interstitial pneumonitis. Risk factors identified through competing risk analysis included nab-paclitaxel, gemcitabine, erlotinib, and previous lung diseases such as pre-existing ILD, asthma, chronic obstructive pulmonary disease, tuberculosis, primary lung cancer, metastasis, or pneumonia. Among these patients, 33 experienced acute respiratory distress syndrome, resulting in 15 deaths during pneumonitis episodes. After rechallenge therapy in 33 patients, pneumonitis recurred in 3 (9%). The median overall survival was longer in patients with pneumonitis than in those without. Subgroup analysis further revealed that overall survival was significantly better in the rechallenge group.

CONCLUSIONS

Most cases of pneumonitis are not directly induced by cancer therapy. Therefore, treatment rechallenge is considered a reasonable approach, potentially resulting in improved survival outcomes.

Substandard antibiotics and their clinical outcomes among hospitalized patients in southern Malawi: a pilot study

Background

The burden of substandard antibiotics is high in low-middle income countries including Malawi. These poor-quality antibiotics may cause deleterious effects on patients and promote drug resistance. We assessed the quality of antibiotics and the associated clinical outcomes among hospitalized patients in southern Malawi.

Methods

A cross-sectional study involving review of retrospective records was conducted among hospitalized adult patients at Zomba central, Machinga and Nsanje district hospitals in October 2022 and January 2024. Trained pharmacy personnel recorded the parenteral antibiotics that were issued to the medical wards. We used these records for matching and sampling of the administered medicine batches to the patient files. In total, we reviewed 224 patient management files for eligible patients, aiming to assess the patient recovery and the occurrence of adverse drug reactions (ADRs) using a global trigger tool. We collected nine medicine samples of ceftriaxone and benzylpenicillin which were administered to these patients and subjected them to tests for the content of active pharmaceutical ingredients using methods adapted from the United States Pharmacopeia. For each sample, we collected at least ten dosage units and used Agilent® 1120 High Performance Liquid Chromatography for quality analysis.

Results

Of the 224 reviewed files, ADRs occurred in 18.3% % (n = 41) of patients while 12.05% (n = 27) did not recover from their illness. One benzylpenicillin sample was found out of specifications with only 61.8% of declared amount of active ingredients. Among patients who received benzylpenicillin with optimal API content, 15.8% experienced ADRs while 10.5% failed to recover from illness. For patients who received benzylpenicillin containing lower than required amount of API, only 7.1% experienced an ADR while 14.3% failed to recover from illness. These differences were, however, not statistically significant. Patient outcomes were significantly associated with the patient's age and Charlson comorbidity index (CCI), p < 0.05.

Conclusion

The present findings did not reveal statistically significant differences in patient outcomes based on the assessed medicine quality. Therefore, we recommend a larger prospective study to further validate these results and encourage stakeholders to be more vigilant on the quality of antibiotic medicines, as this is a crucial measure for improving clinical outcomes and preventing antibiotic resistance in Malawi.

Caffeine-induced fixed drug eruption: evidence from a positive patch test

Caffeine-induced fixed drug eruption has not been previously reported. Clinicians should be aware of the possibility of this adverse effect secondary to caffeine present in some foods and drugs.

Priapism Associated With the Rapid Titration of Prazosin: A Case Report

Priapism is a urologic emergency that is defined as a prolonged erection in the absence of sexual stimulation. Ischemic priapism is the most common form and is characterized by low arterial blood flow and absent venous outflow. Some potential triggers of ischemic priapism include malignancy, sickle cell disease, illicit drug use, and certain medications. Prazosin, an alpha-1 adrenergic antagonist, is used for the treatment of chronic hypertension, benign prostate hyperplasia, and (post-traumatic stress disorder (PTSD) related nightmares. The alpha-adrenergic antagonistic effect of prazosin results in decreased venous blood flow, including to the smooth muscle tissue located within the corpus cavernosum. Slowly titrating prazosin allows the body to adapt to the vasodilatory effects of the medication. Without titration, a dysregulation in blood flow to the penile vasculature can result in prolonged erection. We report a case of priapism that resulted due to rapid titration of prazosin.

Thrombosis Secondary to Intravenous Dicyclomine Administration: A Case Report and Literature Review

Introduction: Dicyclomine is an antimuscarinic agent approved for treatment of irritable bowel syndrome-associated abdominal pain. Intravenous (IV) administration should be avoided due to potential for thrombosis, but real-world evidence is generally lacking. This case report presents a thrombotic complication associated with inadvertent IV administration of dicyclomine. Case: A 43-year-old man with chronic colitis and recurrent Clostridioides difficile infections presented to a community hospital complaining of moderate-severe suprapubic abdominal pain and nausea/vomiting/diarrhea for 5 days. Computed tomography showed descending colonic wall thickening and proctitis, without perforation or abscess. Initial orders consisted of ketorolac 15 mg IV and dicyclomine 20 mg intramuscularly. The nurse inadvertently mixed ketorolac and dicyclomine in the same syringe and administered them simultaneously. Ultrasound subsequently confirmed a non-occlusive right axillary vein thrombosis and an occlusive superficial right basilic vein thrombosis. The patient was started on therapeutic enoxaparin subcutaneously. He was enrolled in a patient assistance program and was discharged on rivaroxaban dispensed from the hospital's outpatient pharmacy. Discussion: Dicyclomine is more selective for the M1 and M3 receptors, and the M3 receptor causes nitric oxide activation. As dicyclomine was unintentionally administered IV, the inhibition of nitric oxide could potentially lead to clotting. The simultaneous administration of ketorolac promoted a pro-thrombotic state, via cyclo-oxygenase-2-mediation vasoconstriction. Naranjo algorithm assessment indicated "possible" potential for a drug-induced adverse event. The pharmacist submitted an adverse drug event report and revisions to barcode medication administration were implemented. Conclusion: Thrombotic complications are possible following IV dicyclomine administration and pharmacy personnel must implement safeguards to prevent inadvertent administration.

Vogt-Koyanagi-Harada-like disease secondary to anticancer treatment: a multicentre case series

OBJECTIVE

To describe the clinical features of a case series of patients with Vogt-Koyanagi-Harada (VKH)-like disease secondary to anticancer treatment.

METHODS

Retrospective, non-interventional multicentre case-series study. Seventeen patients (34 eyes) with VKH-like disease secondary to anticancer treatment, seen between 2014 and 2023. Main outcome measures were patients' extraocular and ophthalmic clinical features, treatment, visual outcome, and complications.

RESULTS

Fourteen out of 17 patients presented with skin melanoma. The main anticancer therapies were BRAF/MEK inhibitor (8/17 patients) and PD1 inhibitor (4/17 patients). Fifteen patients presented with ocular symptoms within 16 weeks after initiating anticancer therapy. Most of the eyes exhibited anterior chamber cells (n = 30), flare (n = 20), and vitritis (n = 11). All patients had subretinal fluid, and 24/34 eyes had foveal involvement. The mean subfoveal choroidal thickness measured by EDI-OCT was 483.42 ± 262.46 µm. In 12 cases, the oncology team decided to stop the anticancer therapy, and all but one patient was treated with high-dose oral corticosteroids for a median of 16 weeks. At the last follow-up visit, control of ocular inflammation had been achieved in 16 cases (median follow-up: 62 weeks, range 16-104 weeks). The most common complications were cataract and ocular hypertension (10 patients).

CONCLUSIONS

VKH-like features in the context of emerging novel anticancer therapies represent a unique clinical phenotype in which the cornerstone of management should include high doses of systemic corticosteroids, using immunomodulatory therapy as a second-line treatment in patients with a refractory disorder. In addition, a comprehensive multidisciplinary approach, including an oncologist, should consider the safety of anticancer treatment cessation.

Minding the gap. Drug-related problems among breastfeeding women

Introduction

Drug-related problems (DRPs) are a significant concern in many patient populations, including breastfeeding women. This study aimed to identify and characterize those problems in a group of breastfeeding women seeking specialized pharmaceutical care.

Materials and methods

A prospective observational study was conducted among women who registered for a pharmacist's online consultation regarding medication safety in lactation. 200 patients were enrolled. Patient medical history, medication use, breastfeeding practices, and DRPs were assessed. DRPs were classified using the Pharmaceutical Care Network Europe Association (PCNE) classification system. Causality assessment for adverse events was performed using the Naranjo algorithm and the Liverpool Causality Assessment Tool (LCAT).

Results

This study found a high prevalence of DRPs among 190 out of 200 breastfeeding women. Of these, 27 experienced potential DRPs, and 163 manifested actual DRPs. A total of 218 DRPs were identified, with ineffective therapy being the most frequent (63.3%, n = 138). Among all identified causes (n = 265), the most common were patient-related factors (47.5%, n = 126) and dispensing-related issues, particularly regarding the information provided to patients about medication safety during lactation. Pharmacist interventions were accepted by 79.5% (n = 151) of patients, with 70% (n = 133) of DRPs successfully resolved.

Conclusion

This study highlights the significant burden of DRPs among breastfeeding women and the potential for medical professionals to improve patient outcomes through evidence-based interventions. Future research should focus on developing evidence-based guidelines for medication use during lactation and improving healthcare provider education to optimize maternal and infant health.

Vancomycin- induced leukocytoclastic vasculitis in a patient with end-stage renal disease: a case report and literature review

INTRODUCTION

Leukocytoclastic vasculitis (LCV) is a small-vessel inflammatory condition that can rarely occur as an adverse drug reaction (ADR). Vancomycin-induced LCV is an uncommon but potentially serious complication, particularly in patients with pre-existing renal impairment.

REASON FOR THE REPORT

This case report describes a patient with end-stage renal disease (ESRD) who developed LCV following vancomycin therapy for a catheter-related infection. The report emphasizes the diagnostic challenges and the importance of prompt and appropriate management of this ADR. A 53-year-old male with ESRD developed skin lesions and systemic symptoms after receiving vancomycin for catheter-related infection. The diagnosis of LCV was confirmed through a skin biopsy. Discontinuation of vancomycin with initiation of mycophenolate mofetil and prednisolone resulted in significant improvement in the patient's condition.

OUTCOME

The presented case underlines the recognition of vancomycin-induced LCV, especially in the vulnerable population of patients with ESRD. It emphasizes the need for a high degree of suspicion of drug-related adverse events and early diagnosis and management to achieve good outcomes.

CLINICAL TRIAL NUMBER

Not applicable.