Bullous pemphigoid associated with the use of dipeptidil peptidase-4 inhibitors: analysis from studies based on pharmacovigilance databases

Association of statins, gliptins, and antipsychotics with bullous pemphigoid: A case-control study in the Cretan population

Bullous pemphigoid (BP) is an autoimmune blistering disorder predominantly affecting the elderly. Recently, many studies have shed light on the effect of specific drug intake and comorbidities on the development of BP. The purpose of this study was to investigate the association of specific drug class intake and comorbidities with the development of BP in the Cretan population. Significant associations with BP were found for statins (odds ratio [OR] = 4.06, 95% confidence interval [CI] 1.99-8.27, P < 0.001), gliptins (OR = 4.27, 95% CI 2.33-7.83, P < 0.001), and antipsychotics (OR = 3.33, 95% CI 1.36-8.11, P = 0.006). Higher proportions of use in the BP group vs. control group were found for atorvastatin (OR = 1.86, 95% CI 1.04-3.32, P = 0.035), linagliptin (OR = 6.63, 95% CI 2.17-20.23, P < 0.001), vildagliptin (OR = 3.20, 95% CI 1.73-5.91, P < 0.001), alogliptin (OR = 5.11, 95% CI 1.19-22.04, P = 0.016), and quetiapine (OR = 4.21, 95% CI 1.5-11.85, P = 0.004). The presence of diabetes mellitus in the absence of gliptins did not show any significant effect on BP (OR = 1.60, 95% CI 0.79-3.23, P = 0.188). Metformin intake showed no significant association with BP (OR = 0.48, 95% CI 0.18-1.28, P = 0.143). Our findings confirm and extend previous studies reporting the association of gliptins and antipsychotics on BP in other European populations. The association found for statins is new, thus more studies are needed to corroborate its validity.

Drug associated bullous pemphigoid: what's new?

Bullous pemphigoid (BP) is considered to be one of the most common autoimmune diseases affecting the skin. Drug associated BP (DABP) is a subset of BP that is caused by the ingestion of specific types of medications. Until this point more than 80 medications have been associated with this condition that only recently has started to be better described. DABP has a better clinical course and prognosis compared to that of idiopathic BP, especially when the suspected inciting medication is discontinued in a timely manner. Therefore, it is very important to obtain detailed medical histories from BP patients especially if they are receiving multiple medications and also to be vigilant for subtle, but important, indications in histopathological, ELISA and immunofluorescence findings as well as in the clinical manifestations of the disorder.

The effect of dipeptidyl peptidase-4 inhibitor on incidence and clinical course in bullous pemphigoid patients in a tertiary medical center

Several studies have reported an association between dipeptidyl peptidase 4 inhibitor (DPP4i), a commonly prescribed second-line oral antihyperglycemic drug, and bullous pemphigoid (BP). However, the benefits of DPP4i withdrawal in patients with BP remain controversial. This study primarily aimed to evaluate the clinical severity of DPP4i-associated BP by comparing it to those without Type 2 diabetes mellitus (DM). The secondary objective was to determine whether cessation of DPP4i is necessary for all patients with BP. This retrospective case-control study included 83 patients. The participants were divided into three groups according to their diabetic status and the status of discontinuance or continuance of DPP4i. The 12-month follow-up of the monthly dosage of systemic steroids per body weight (kg) and the percentage of systemic steroid off-therapy in these participants were recorded since the diagnosis of BP. Compared to patients with BP without DM, the 1st, 3rd, and 12th systemic prednisolone doses were significantly lower in the DPP4i group (p = 0.01684, 0.02559, and 0.009336, respectively). The 12th systemic prednisolone dose was significantly lower in patients who discontinued DPP4i (p = 0.0338). Nevertheless, several spontaneous remissions with systemic steroid off-therapy were also noted in the DPP4i-continuance group within 12 months of follow-up. This article supports the favorable impact of DPP4i withdrawal in patients with BP and shows that DPP4i may incite or aggravate BP, resulting in a milder disease course.

Bullous Drug Reaction with Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

Hypoglycemic drugs in the dipeptidyl peptidase-4 (DPP-4) inhibitor class are used as a second-line treatment for type 2 diabetes mellitus. With DPP-4 inhibitors, there have been a few reports of cutaneous side effects such as bullous response, fixed drug eruption, and photosensitivity. There is no definitive pathophysiology for the above mentioned allergic reactions. Sitagliptin phosphate belongs to the DPP-4 inhibitor class. This is a case report of a sitagliptin-induced bullous drug reaction manifesting three weeks after starting therapy. He had bullous pemphigoid-like eruptions all over the body. The patient showed improvement once sitagliptin was discontinued alon with oral and topical steroid treatment.

DPP-4 Inhibitors and Increased Reporting Odds of Bullous Pemphigoid: A Pharmacovigilance Study of the FDA Adverse Event Reporting System (FAERS) from 2006 to 2020

BACKGROUND

In recent years, an association between dipeptidyl peptidase-4 (DPP-4) inhibitors and bullous pemphigoid has been detected in pharmacovigilance studies in European and Asian countries; however, no pharmacovigilance data have been published yet in the USA.

OBJECTIVE

The objective of this study was to examine the relationship between bullous pemphigoid and DPP-4 inhibitors and other oral diabetes mellitus medications in the FDA Adverse Event Reporting System (FAERS).

METHODS

Case/non-case analyses were performed in the FAERS using data from 2006 to 2020 to examine the reporting odds ratio (ROR) signal for bullous pemphigoid for all classes of oral diabetes medications. These analyses were performed under multiple conditions to control for bias: (1) comparison to all other drugs in the FAERS; (2) comparison to other diabetes medications; and (3) comparison to all other diabetes medications where only a single agent was implicated.

RESULTS

A statistically significant ROR for bullous pemphigoid was found for DPP-4 inhibitors under all conditions: (1) 109.79 (95% confidence interval [CI] 101.61-118.62); (2) 74.46 (95% CI 60.58-91.52); and (3) 35.94 (95% CI 27.91-46.28). A larger signal was seen for non-US Food and Drug Administration (FDA)-approved (anagliptin, vildagliptin, teneligliptin) vs FDA-approved DPP-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin), likely because of an overestimation of the ROR for non-FDA-approved drugs. The largest signal was seen under conditions 1 and 2 with vildagliptin (1) 1022.83 (95% CI 909.45-1150.35) and (2) 158.84 (95% CI 127.01-198.66) followed by anagliptin (1) 628.63 (95% CI 221.36-1785.24) and (2) 60.64 (95% CI 20.98-175.26), alogliptin, teneligliptin, linagliptin, sitagliptin, and saxagliptin. Under condition 3, the largest signal was seen with linagliptin 122.25 (95% CI 93.96-159.07). Both metformin and the sulfonylureas had a significant ROR under condition 2 [3.42 (95% CI 3.01-3.89) and 2.07 (95% CI 1.66-2.57) respectively]; however, this association was not present under condition 3 as only confounded cases occurred, and a large majority of reported cases had concurrent exposure to a DPP-4 inhibitor.

CONCLUSIONS

Our findings support an association between DPP-4 inhibitors and bullous pemphigoid. This association was maintained under controls to limit bias and falsely elevated signal, including controlling for disease state and cases with multiple drug exposures. Non-FDA-approved DPP-4 inhibitors had a larger ROR compared with FDA-approved DPP-4 inhibitors, likely owing to fewer reported adverse effects overall for non-FDA-approved drugs in FAERS.

Dipeptidyl peptidase-4 inhibitor-induced autoimmune diseases: Current evidence

Dipeptidyl peptidase-4 inhibitors (DPP-4i) have an important place in the management of type 2 diabetes. The DPP-4 enzyme is ubiquitously distributed throughout the human body and has multiple substrates through which it regulates several important physiological functions. DPP-4 regulates several immune functions, including T-cell activation, macrophage function, and secretion of cytokines. Studies have reported an increase in autoimmune diseases like bullous pemphigoid, inflammatory bowel disease, and arthritis with DPP-4i use. The relationship of DPP-4i and autoimmune diseases is a complex one and warrants further research into the effect of DPP-4 inhibition on the immune system to understand the pathogenesis more clearly. Whether a particular cluster of autoimmune diseases is associated with DPP-4i use remains an important contentious issue. Nevertheless, a heightened awareness from the clinicians is required to identify and treat any such diseases. Through this review, we explore the clinical and pathophysiological characteristics of this association in light of recent evidence.

The Role of Advanced Technologies Supplemented with Traditional Methods in Pharmacovigilance Sciences

BACKGROUND

The immediate automatic systemic monitoring and reporting of adverse drug reactions, improving the efficacy is the utmost need of the medical informatics community. The venturing of advanced digital technologies into the health sector has opened new avenues for rapid monitoring. In recent years, data shared through social media, mobile apps, and other social websites has increased manifolds requiring data mining techniques.

OBJECTIVE

The objective of this report is to highlight the role of advanced technologies together with the traditional methods to proactively aid in the early detection of adverse drug reactions concerned with drug safety and pharmacovigilance.

METHODS

A thorough search was conducted on papers and patents regarding pharmacovigilance. All articles with respect to the relevant subject were explored and mined from public repositories such as Pubmed, Google Scholar, Springer, ScienceDirect (Elsevier), Web of Science, etc. Results: The European Union's Innovative Medicines Initiative WEB-RADR project has emphasized the development of mobile applications and social media data for reporting adverse effects. Only relevant data has to be captured through the data mining algorithms (DMAs) as it plays an important role in timely prediction of risk with high accuracy using two popular approaches; the frequentist and Bayesian approach. Pharmacovigilance at the pre-marketing stage is useful for the prediction of adverse drug reactions in the early developmental stage of a drug. Later, post-marketing safety reports and clinical data reports are important to be monitored through electronic health records, prescription-event monitoring, spontaneous reporting databases, etc. Conclusion: The advanced technologies supplemented with traditional technologies are the need of the hour for evaluating a product's risk profile and reducing risk in population especially with comorbid conditions and on concomitant medications.

Defining dipeptidyl peptidase-4 inhibitors-related bullous pemphigoid: A single-centre retrospective study

BACKGROUND

Many studies have corroborated the association of dipeptidyl peptidase-4 inhibitors (DPP4i) use with bullous pemphigoid (BP). It has been speculated that this drug-induced variant presents with a different clinical spectrum than conventional BP.

OBJECTIVE

To determine the prevalence of DPP4i-induced cases of BP and to evaluate whether gliptin-related BP has specific clinicopathological and immunological features.

METHODS

We conducted a retrospective, observational study of BP cases attended at our centre between January 2000 and June 2020. Epidemiological, clinical, histopathological and laboratory data were collected.

RESULTS

A total of 257 cases of BP were collected; 51 (24.3%) were on treatment with DPP4i. When analysing DPP4i-induced BP cases, generalized BP was the predominant pattern and scalp/mucosal involvement was found in 13 patients. Gliptin-related BP cases were associated to a decrease in the eosinophilic infiltrate (p = 0.000) and both the detection rate and concentration of anti-BP180 IgG were lower (p = 0.004, p = 0.001, respectively) than non-DPP4i cases.

LIMITATIONS

Retrospective, single-centre study.

CONCLUSION

Our large DPP4i-induced BP case series has highlighted that DPP4i-induced BP is characterized by generalized lesions and scalp involvement. Lower titres of anti-BP180 antibodies and a decrease in eosinophils infiltrating into the skin may be distinct features of DPP4i-related BP.

Bullous Pemphigoid and Diabetes medications: A disproportionality analysis based on the FDA Adverse Event Reporting System

Background: The world's first Diabetes Medications (Insulin) was marketed in October 1923. Some studies suggested the association of diabetes medications with Bullous Pemphigoid (BP), especially the Dipeptidyl Peptidase 4 (DPP-4) inhibitors. The study aims to detect an association between diabetes medications (focusing on DPP-4 inhibitors) and bullous pemphigoid based on FDA Adverse Event Reporting System (FAERS). Methods: All spontaneous reports of diabetes medications inhibitors-related BP recorded in the FAERS between March 2004 and August 2020 were included in the present study. Disproportionality analysis was performed to find the signal between diabetes medications and BP. The Chi-Squared with Yates' correction (χ² _Yates), proportional reporting ratio (PRR) and the lower limit of the 95% confidence interval of the Reporting Odds Ratio (ROR₀₂₅) were calculated as a measure. A signal was detected when ROR₀₂₅ > 1, PRR > 2, χ² _Yates > 4 and at least 3 cases. Results: There were 3770 reports for BP in FAERS. The strongest signal for diabetes medications-BP association were DDP-4 inhibitors (ROR₀₂₅: 13.700, PRR: 15.408), followed by Meglitinides (ROR₀₂₅: 12.708, PRR: 16.777), Non-sulfonylureas (ROR₀₂₅: 6.434, PRR: 7.016), Alpha-glucosidase inhibitors (ROR₀₂₅: 6.105, PRR: 10.738), Sulfonylureas (ROR₀₂₅:2.655, PRR: 3.200). Conclusions: This study detected a strong signal between BP and DDP-4 inhibitors, alpha-glucosidase inhibitors, meglitinides, non-sulfonylureas, and sulfonylureas in FAERS. The signal was significantly higher with alogliptin than with the other DPP-4 inhibitors. The study doesn't suggest the association between the incretin mimetics, insulin, SGLT-2 inhibitors, thiazolidinediones and BP in FAERS.

Gliptin-Induced Bullous Pemphigoid: Canadian Case Series of 10 Patients

BACKGROUND

Bullous pemphigoid (BP) is a chronic immune-mediated vesiculobullous disorder. Recently, several reports have described dipeptidyl peptidase-4 inhibitors, also known as gliptins, as causative agents for drug-induced BP.

OBJECTIVE

To report and describe clinical and histologic characteristics of 10 cases of gliptin-induced BP.

RESULTS

We identified 10 patients with gliptin-induced BP. Nine were secondary to linagliptin, and 1 case was attributed to sitagliptin. All patients showed significant improvement after withdrawal of gliptin medications and proper medical treatment. There has been no evidence of relapse after 4 months of follow-up.

CONCLUSION

This report supports the proposed association between gliptins and BP. Physicians should be aware of this potential adverse effect, as gliptin-induced BP can be reversible once identified and the responsible medication is stopped. Early withdrawal of the offending drug and proper treatment can lead to rapid improvement and reduced morbidity.