Severe cutaneous adverse reactions in Asians: Trends observed in culprit anti-seizure medicines using VigiBase®

Post-marketing safety of antiseizure medications: Focus on serious adverse effects including drug reaction with eosinophilia and systemic symptoms (DRESS)

PURPOSE

On November 28, 2023, the U.S. FDA issued a Drug Safety Communication, warning that antiseizure medications (ASMs) levetiracetam and clobazam can cause a rare but serious reaction, drug reaction with eosinophilia and systemic symptoms (DRESS). However, the risk of DRESS from other ASMs remains unclear. This observational study examined post-marketing safety of ASMs focusing on serious adverse events (AEs) reporting including DRESS.

METHODS

This retrospective, cross-sectional study analyzed the U.S. FDA Adverse Event Reporting System (FAERS) data from January 1, 2004, to March 31, 2024. Ten older (valproic acid, carbamazepine, oxcarbazepine, phenytoin, and phenobarbital) and newer (zonisamide, topiramate, lamotrigine, lacosamide, and brivaracetam) frequently used ASMs and three benzodiazepines (lorazepam, chlordiazepoxide, and diazepam) in clinical practice as alternative treatments were examined together with levetiracetam and clobazam, respectively. Disproportionality analysis, reporting odds ratio (ROR), was used to detect reporting risk signals of DRESS along with serious AE, hospitalization, death, and Stevens-Johnson Syndrome (SJS) for levetiracetam/clobazam and alternative treatments. A statistically significant reporting risk signal was detected when the lower boundary of the 95 % confidence interval for the RORs exceeded 1.

RESULTS

Levetiracetam had significant reporting risks of serious AE, hospitalization, DRESS, and SJS. Older ASMs including valproic acid, carbamazepine, oxcarbazepine, phenytoin, and phenobarbital all had significant reporting risks of DRESS and SJS. Newer ASMs including zonisamide and lamotrigine had significant reporting risks of DRESS and SJS, while topiramate, lacosamide, and brivaracetam did not exhibit reporting risk for DRESS. Clobazam had significant reporting risks of serious AE, DRESS, and SJS. Lorazepam, chlordiazepoxide, and diazepam did not exhibit reporting risks for DRESS or SJS.

CONCLUSIONS

Findings highlighted reporting risk signals of DRESS for levetiracetam/clobazam and alternative ASMs. Given the limitations from passive surveillance nature of FAERS, further surveillance and longitudinal studies are essential to evaluate and confirm our findings.

Toxic epidermal necrolysis caused by phenobarbital: a case report and literature review

Background

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are rare, life-threatening immunologic reactions. Previous relevant literature has provided limited information regarding this disease's genetic susceptibility and management principles.

Objectives

This study aimed to describe a phenobarbital-induced TEN case report with HLA-B*15:02 and HLA-B*58:01 negative, CYP2C19*1/*2. In addition, we revised the existing literature on phenobarbital-induced SJS/TEN to explore its clinical characteristics.

Methods

We describe a woman undergoing treatment with Phenobarbital for status epilepticus who developed classic cutaneous findings of TEN. A systematic search was conducted in the PubMed, Medline, WanFang, and CNKI databases from 1995 to 2023. The search terms used were "Stevens-Johnson Syndrome," "Toxic Epidermal Necrolysis," and "Phenobarbital."

Results

We report a case of TEN resulting from phenobarbital; it tested negative for the HLA-B*15:02 and HLA-B*58:01 allele and CYP2C19*1/*2 intermediate metabolism. Supportive treatment with steroids and antihistamines resulted in complete resolution of the skin lesions and improvement in clinical symptoms after 14 days. Physicians and clinical pharmacists should be aware of these potential phenobarbital-related adverse events and closely monitor patients with first-time use of phenobarbital. Among 19 cases were identified in the literature, with 11 (57.9%) cases of SJS, 6 (31.6%) cases of TEN, and 2 (7.2%) cases of SJS-TEN/DRESS overlap. A total of 5 (26.3%) did not survive, of which 4 (21.1%) were under 12 years old and 1 (5.3%) was over 12 years old.

Conclusion

Phenobarbital-induced SJS/TEN may still occur in patients who test negative for HLA-B*15:02 and HLA-B*58:01, CYP2C19*1/*2. Most cutaneous adverse events occur early in the course of Phenobarbital therapy and should be closely monitored early in the course of treatment. In addition, Phenobarbital should be used with caution in patients with a history of asthma and allergy to antipyretics and analgesics.

Clinical observation and analysis of rash caused by lacosamide in children with epilepsy

PURPOSE

To draw clinical attention to rashes caused by lacosamide.

METHODS

This retrospective analysis included patients admitted to the Department of Pediatrics, Second Affiliated Hospital of Xi'an Jiaotong University between January 2021 and September 2023. We focused on patients who developed rashes after lacosamide treatment and analyzed all patients who exhibited rashes after lacosamide treatment to analyze the risk factors.

RESULTS

In total, 190 patients received lacosamide, of whom four developed allergies (2.1 %). Three patients had severe rashes, and two patients had high fever. All of these adverse events improved after the withdrawal of lacosamide. Of the 13 patients reported to date, including the four patients in this study, eight used various antiseizure medicines, including seven patients who used four or more antiseizure medicines. Four patients underwent testing for HLA-B*1502, and two patients were positive. Patients developed rashes within 1-10 days after treatment initiation, and the duration of the rash ranged 2-37 days.

CONCLUSIONS

Lacosamide-induced rash was detected in 2.1 % of patients in our cohort. Rashes are potentially serious, and prompt evaluation is required. Rashes are more likely to occur when multiple antiseizure medicines are used simultaneously, typically within 10 days of treatment initiation.

Clinical and Liver Biochemistry Phenotypes, and Outcome in 133 Patients with Anti-seizure Drug-Induced Liver Injury

AIMS AND OBJECTIVE

Anti-seizure drugs that cause idiosyncratic drug-induced liver injury (DILI) are an important cause of morbidity and mortality in individuals exposed to these drugs. The clinical and demographic characteristics, the liver injury pattern, the outcome, and the agents responsible for hepatotoxicity have not been thoroughly studied. We investigated the aforementioned characteristics in a large cohort of DILI registry patients.

METHODS

Patients with anti-seizure DILI were studied from a large single-center DILI registry between 1998 and 2021. DILI was defined by international working group criteria with at least a probable relation with RUCAM. Immunoallergic features and organ-specific contribution to outcome were investigated.

RESULTS

Anti-seizure drugs accounted for 133 patients (12.5%) among 1067 patients with idiosyncratic DILI. Compared to other agents, patients with anti-seizure DILI were younger (31 vs 41 years; p = 0.31), were more often females (52% vs 46%; p = 0.19) and had a lower frequency of jaundice (41% vs 59%, p = 0.001), MELD score (14.5 vs 16.5; p = 0.02) and mortality (9.8% vs 15.7%, p = 0.03). Anti-seizure DILI exhibited a greater frequency of hypersensitivity skin rashes (75% vs 22%, p < 0.001), including DRESS (51% vs 13%, p < 0.001) and SJS/TEN (19% vs1%, p < 0.001). A total of 18 different anti-seizure agents were responsible for DILI, largely contributed by carbamazepine (n = 36), phenytoin (n = 71), phenobarbitone (n = 8) and valproate (n = 14) which accounted for 89% of cases and 85% of 13 deaths.

CONCLUSIONS

Anti-seizure DILI are caused predominantly by first generation drugs. Newer agents account for < 10% of cases. Hypersensitivity reaction is the most common phenotypic presentation. Both severity and mortality are lower with anti-seizure DILI.

Severe cutaneous adverse reactions to drugs: A real-world pharmacovigilance study using the FDA Adverse Event Reporting System database

Background: Sound drug safety information is important to optimize patient management, but the widely recognized comprehensive landscape of culprit-drugs that cause severe cutaneous adverse reactions (SCARs) is currently lacking.

Objective: The main aim of the study is to provide a comprehensive landscape of culprit-drugs for SCARs to guide clinical practice.

Methods: We analyzed reports associated with SCARs in the FDA Adverse Event Reporting System database between 1 January 2004 and 31 December 2021 and compiled a list of drugs with potentially serious skin toxicity. According to this list, we summarized the reporting proportions of different drugs and drug classes and conducted disproportionality analysis for all the drugs. In addition, the risk characteristic of SCARs due to different drugs and drug classes was summarized by the positive–negative distribution based on the results of the disproportionality analysis.

Results: A total of 77,789 reports in the FDA Adverse Event Reporting System database were considered SCAR-related, of which lamotrigine (6.2%) was the most reported single drug followed by acetaminophen (5.8%) and allopurinol (5.8%) and antibacterials (20.6%) was the most reported drug class followed by antiepileptics (16.7%) and antineoplastics (11.3%). A total of 1,219 drugs were reported as culprit-drugs causing SCARs in those reports, and the largest number of drugs belonged to antineoplastics. In disproportionality analysis, 776 drugs showed at least one positive pharmacovigilance signal. Drugs with the most positive signals were lamotrigine, acetaminophen, furosemide, and sulfamethoxazole/trimethoprim.

Conclusion: Our study provided a real-world overview of SCARs to drugs, and the investigation of SCAR positive–negative distribution across different drugs revealed its risk characteristics, which may help optimize patient management.

Prescription trends in anti-seizure medications for adult patients with epilepsy in Japan: A retrospective cohort study using the database of health insurance claims between 2015 and 2019

OBJECTIVE

To investigate whether newer anti-seizure medications (ASMs) are widely prescribed for a range of adult patients in Japan, including patients with previously and newly diagnosed epilepsy, or with focal and generalized epilepsies.

METHODS

A retrospective cohort study was conducted using the Japanese insurance claims database including 8.4 million people to identify adults (≥16 years of age) with epilepsy diagnosis code identified between January 2015 and December 2018. Patients were included in the prevalent population if epilepsy was already diagnosed at baseline, and in the incident population if prior baseline data for at least 12 months included no epilepsy diagnosis code or ASM prescription. Patients were followed up from the month when the initial oral ASM was prescribed for up to 4 years until the end of 2019 as long as at least one ASM was prescribed. Proportions of prescribed oral ASMs were analyzed by population with epilepsy (prevalent vs. incident) and classification (focal vs. generalized). Anti-seizure medications were classified into older vs. newer ASMs according to the date of approval before and after 1990, respectively.

RESULTS

A total of 24,691 patients fulfilled the eligibility criteria for the analysis. Of these, 21,046 and 3,645 were included in the prevalent and incident populations, respectively. The proportion of older ASMs significantly decreased, whereas the proportion of newer ASMs significantly increased (p < 0.0001) during the study period. This trend was more apparent in the population with incident epilepsy than in that with prevalent epilepsy, and was also apparent in the subgroup of focal epilepsy, but not in that of generalized epilepsy. Levetiracetam was the most frequently prescribed of the newer ASMs.

CONCLUSION

Newer ASMs became more widely prescribed throughout the study period in populations with both prevalent and incident epilepsies, as well as the subpopulation with focal epilepsy. The advantages of newer ASMs such as better safety profiles may have led to the increasing proportions of prescriptions and newer ASMs may increase the treatment options for patients.

Incidence of Anti-Seizure Medication-Induced Severe Cutaneous Adverse Reactions in Malaysia

Anti-seizure medication (ASM) can potentially cause severe cutaneous adverse reactions (SCAR), and certain ASM-induced SCAR is associated with specific HLA alleles. This caused a change in ASM prescribing pattern, which may influence the incidence of ASM-induced SCAR. Thus, we aimed to determine the incidence of ASM-induced SCAR and its change over 15 years (2006-2019) in Malaysia. This retrospective analysis combined ASM-induced SCAR cases from the national Adverse Drug Reaction (ADR) database in the National Pharmaceutical Regulatory Agency (NPRA), ASM-drug utilisation data from the Malaysian Statistics of Medicine, and prescribing data from UMMC, a national level tertiary hospital to calculate ASM-induced SCAR incidence in Malaysia. We observed an upward trend in reported ASM-induced SCAR cases from 28 cases in 2006 to 92 in 2016. The incidence of carbamazepine (CBZ)-induced SCAR increased from 7.5 per 1,000 person-year (2006) to 17.8 per 1,000 person-year (2016) but dropped to 7.2 per 1,000 person-year (2019) subsequently. Concurrently, there was an increase in the incidence of SCAR secondary to phenytoin and lamotrigine. The prevalent users of CBZ had reduced from 22.8% (2006) to 14.1% (2016), whereas the levetiracetam and sodium valproate users increased by 5.5% and 4.8%, respectively. The incidence of CBZ-induced SCAR had reduced since 2016, probably related to the implementation of HLA-B*1502 screening in Malaysia or substitution of CBZ with other ASM. However, this was accompanied with an increase of SCAR incidence related to phenytoin and lamotrigine. This article is protected by copyright. All rights reserved.