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Devasenapathy N, Chu A, Wong M, Srivastava A, Ceccacci R, Lin C, MacDonald M, Wen A, Steen J, Levine M, Pyne L, Schneider L, Chu DK. Cancer risk with topical calcineurin inhibitors, pimecrolimus and tacrolimus, for atopic dermatitis: a systematic review and meta-analysis. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:13-25. [PMID: 36370744 DOI: 10.1016/s2352-4642(22)00283-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Atopic dermatitis is a prevalent condition in children and can be effectively managed with medications such as topical calcineurin inhibitors (pimecrolimus or tacrolimus). A key unresolved safety concern is whether use of topical calcineurin inhibitors is associated with cancer. We systematically reviewed the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors. METHODS As part of the 2022 American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters atopic dermatitis guidelines, we searched MEDLINE, Embase, the Latin American and Caribbean Health Sciences Literature database, the Índice Bibliográfico Espanhol de Ciências da Saúde database, the Global Resource of Eczema Trials database, WHO's International Clinical Trials Registry Platform, the US Food and Drug Administration database, the European Medicines Agency database, company registers, and relevant citations from inception to June 6, 2022. We included randomised controlled trials and comparative and non-comparative non-randomised studies in any language addressing cancer risk in patients with atopic dermatitis using topical calcineurin inhibitors. We excluded split-body studies and studies with less than 3 weeks of follow-up. Paired reviewers independently screened records, extracted data, and assessed risk of bias in duplicate. We used Bayesian models to estimate the probability for cancer due to topical calcineurin inhibitor exposure and the GRADE approach to determine the certainty of the evidence. Patients, advocacy groups, and care providers set a priori thresholds of important effects. This study is registered with Open Science Framework, https://osf.io/v4bfc. FINDINGS We identified and analysed 110 unique studies (52 randomised controlled trials and 69 non-randomised studies [11 were non-randomised study extensions of randomised controlled trials]) including 3·4 million patients followed up for a mean of 11 months (range 0·7-120). The absolute risk of any cancer with topical calcineurin inhibitor exposure was not different from controls (absolute risk 4·70 per 1000 with topical calcineurin inhibitors vs 4·56 per 1000 without; odds ratio 1·03 [95% credible interval 0·94-1·11]; moderate certainty). For all age groups and using data from observational studies and randomised controlled trials, the use of pimecrolimus (OR 1·05 [95% credible interval 0·94-1·15]) or tacrolimus (0·99 [0·89-1·09]) is likely to have had little to no association with cancer compared with no topical calcineurin inhibitor exposure. For pimecrolimus versus tacrolimus, the finding was similar (0·95 [95% credible interval 0·83-1·07]). Findings were similar in infants, children, and adults, and robust to trial sequential, subgroup, and sensitivity analyses. INTERPRETATION Among individuals with atopic dermatitis, moderate-certainty evidence shows that topical calcineurin inhibitors do not increase the risk of cancer. These findings support the safe use of topical calcineurin inhibitors in the optimal treatment of patients with atopic dermatitis. FUNDING American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology via the Joint Task Force on Practice Parameters.
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Affiliation(s)
| | - Alexandro Chu
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Melanie Wong
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Renata Ceccacci
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Clement Lin
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Aaron Wen
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jeremy Steen
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mitchell Levine
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lonnie Pyne
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | | | - Derek K Chu
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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Draelos ZD, Feldman SR, Berman B, Olivadoti M, Sierka D, Tallman AM, Zielinski MA, Ports WC, Baldwin S. Tolerability of Topical Treatments for Atopic Dermatitis. Dermatol Ther (Heidelb) 2019; 9:71-102. [PMID: 30680551 PMCID: PMC6380975 DOI: 10.1007/s13555-019-0280-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Indexed: 11/29/2022] Open
Abstract
Atopic dermatitis (AD) is a common inflammatory skin disease that is accompanied by increased sensitivity to itch-provoking and pain-provoking stimuli. Patients with AD experience skin pain before initiation of therapy and have also reported painful application site reactions in clinical trials of emollients and prescription topical therapies, including topical corticosteroids (TCSs), topical calcineurin inhibitors (TCIs), and a topical phosphodiesterase 4 (PDE4) inhibitor. To compare the sensory tolerability of prescription topical therapies for AD, a comprehensive literature search and analysis of published clinical trials was conducted. Sensory tolerability issues such as application site pain, burning, stinging, and pruritus were often among the most common adverse events or treatment-related adverse events in clinical trials for prescription topical therapies. Tolerability issues occurred at highest rates in trials of TCIs, followed by trials of the PDE4 inhibitor crisaborole and TCSs, although direct comparisons are not possible because of differences in study design. Tolerability issues in these clinical trials were generally mild to moderate and transient. This article also reviews published strategies for managing sensory tolerability issues in AD patients during treatment with topical therapies. Funding: Pfizer Inc., New York, NY.
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Affiliation(s)
- Zoe D Draelos
- Dermatology Consulting Services, High Point, NC, USA.
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Siegfried EC, Jaworski JC, Mina-Osorio P. A Systematic Scoping Literature Review of Publications Supporting Treatment Guidelines for Pediatric Atopic Dermatitis in Contrast to Clinical Practice Patterns. Dermatol Ther (Heidelb) 2018; 8:349-377. [PMID: 29858763 PMCID: PMC6109028 DOI: 10.1007/s13555-018-0243-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Treatment guidelines endorse a variety of strategies for atopic dermatitis (AD) which may vary from published data and clinical practice patterns. The objective of this review was to quantify the volume of available medical literature supporting pediatric AD treatments and compare these patterns to those recommended by published guidelines and/or clinical practice patterns. METHODS Searches of Embase (2005-2016) and abstracts from selected meetings (2014-2016) related to AD treatment in patients younger than 17 years of age yielded references that were assessed by study design, primary treatment, age groups, and AD severity. RESULTS Published literature partially supports clinical guidelines, with emollients and topical medications being the most investigated. There were disproportionately more publications for topical calcineurin inhibitors (TCI) compared with topical corticosteroids (TCS); however, the search interval may have biased the results toward treatments approved near the beginning of the time frame. In contrast, publications documenting clinical practice patterns reflect greater use of emollients and TCS (over TCI), as well as systemic corticosteroids. Data is relatively limited for long-term and combination treatment, treatment of severe AD, and patients younger than 2 years of age, and completely lacking for systemic corticosteroids. CONCLUSION This scoping review demonstrates that available medical literature largely supports published guidelines for topical therapy; however, clinical practice patterns are less aligned. There is a lack of data for older, more frequently used generic treatments, including oral antihistamines, oral antibiotics, and systemic corticosteroids. Overall, literature is lacking for long-term treatment, treatment for patients younger than 2 years of age, and for systemic treatment for severe disease. FUNDING Regeneron Pharmaceuticals Inc.
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Affiliation(s)
- Elaine C Siegfried
- Saint Louis University and Cardinal Glennon Children's Hospital, St. Louis, MO, USA
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Abstract
Atopic dermatitis is associated with significant patient burden, with impacts from symptoms and visible physical manifestations of the disease. Consequences include detrimental effects on quality of life (QoL), sleep, self-esteem, interpersonal relationships, participation in leisure and sports, and attendance or performance at school or work. Patients also spend a significant amount of time on treatments and care. Worsening severity of disease appears to be associated with a higher risk of impaired QoL, and pharmacologic and educational interventions that improve disease severity appear to, for the most part, simultaneously improve QoL.
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Affiliation(s)
- Cathryn Sibbald
- Division of Dermatology, University of Toronto, 2075 Bayview Avenue M1-700, Toronto, Ontario M4N 3M5, Canada; Division of Dermatology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue M1-700, Toronto, Ontario M4N 3M5, Canada
| | - Aaron M Drucker
- Department of Dermatology, Warren Alpert Medical School, Brown University, Box G-D, Providence, RI 02912, USA.
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Chernyshov P, Tomas-Aragones L, Manolache L, Marron S, Salek M, Poot F, Oranje A, Finlay A. Quality of life measurement in atopic dermatitis. Position paper of the European Academy of Dermatology and Venereology (EADV) Task Force on quality of life. J Eur Acad Dermatol Venereol 2017; 31:576-593. [DOI: 10.1111/jdv.14058] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/31/2016] [Indexed: 12/17/2022]
Affiliation(s)
- P.V. Chernyshov
- Department of Dermatology and Venereology; National Medical University; Kiev Ukraine
| | - L. Tomas-Aragones
- Aragon Health Sciences Institute; University of Zaragoza; Zaragoza Spain
| | | | - S.E. Marron
- Department of Dermatology; Aragon Health Sciences Institute (IACS); Alcañiz Hospital; Alcañiz Spain
| | - M.S. Salek
- University of Hertfordshire; Hatfield UK
| | - F. Poot
- Department of Dermatology; ULB-Erasme Hospital; Brussels Belgium
| | - A.P. Oranje
- Dermicis Skin Hospital, Alkmaar, and (Kinder)huid; Rotterdam The Netherlands
| | - A.Y. Finlay
- Division of Infection and Immunity; Department of Dermatology and Wound Healing; School of Medicine; Cardiff University; Cardiff UK
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Abstract
Topical pimecrolimus 1% cream (Elidel) [hereafter referred to as topical pimecrolimus] is a nonsteroidal alternative in the treatment of pediatric atopic dermatitis. In vehicle-controlled, short-term, continuous-use trials in pediatric patients with mild to moderate atopic dermatitis, topical pimecrolimus was effective in treating disease symptoms. Topical pimecrolimus was effective in preventing disease flares and reducing the need for topical corticosteroids in longer term, intermittent-use trials. In addition, topical pimecrolimus was associated with improvements in the health-related quality of life of pediatric patients with atopic dermatitis and their parents. In vehicle-controlled trials, topical pimecrolimus was generally as well tolerated as vehicle. Topical pimecrolimus showed similar efficacy to topical tacrolimus 0.03% ointment in a short-term, continuous-use trial and the two agents had a generally similar tolerability profile. Although comparative data between topical pimecrolimus and topical corticosteroids are lacking in pediatric patients, and the long-term tolerability (beyond 1-2 years) of topical pimecrolimus is yet to be established, topical pimecrolimus is a useful agent in the management of pediatric patients with mild to moderate atopic dermatitis who do not achieve satisfactory treatment with other topical pharmacologic treatments, including topical corticosteroids.
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Affiliation(s)
- Lily P H Yang
- Adis, a Wolters Kluwer Business, Auckland, New Zealand.
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Yang LPH, Curran MP. Topical pimecrolimus: a review of its use in the management of pediatric atopic dermatitis. Paediatr Drugs 2010; 11:407-26. [PMID: 19877726 DOI: 10.2165/10481960-000000000-00000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Topical pimecrolimus 1% cream (Elidel) [hereafter referred to as topical pimecrolimus] is a nonsteroidal alternative in the treatment of pediatric atopic dermatitis. In vehicle-controlled, short-term, continuous-use trials in pediatric patients with mild to moderate atopic dermatitis, topical pimecrolimus was effective in treating disease symptoms. Topical pimecrolimus was effective in preventing disease flares and reducing the need for topical corticosteroids in longer term, intermittent-use trials. In addition, topical pimecrolimus was associated with improvements in the health-related quality of life (HR-QOL) of pediatric patients with atopic dermatitis and their parents. In vehicle-controlled trials, topical pimecrolimus was generally as well tolerated as vehicle. Topical pimecrolimus showed similar efficacy to topical tacrolimus 0.03% ointment (hereafter topical tacrolimus) in a short-term, continuous-use trial and the two agents had a generally similar tolerability profile. Although comparative data between topical pimecrolimus and topical corticosteroids are lacking in pediatric patients, and the long-term tolerability (beyond 1-2 years) of topical pimecrolimus is yet to be established, topical pimecrolimus is a useful agent in the management of pediatric patients with mild to moderate atopic dermatitis who do not achieve satisfactory treatment with other topical pharmacologic treatments, including topical corticosteroids.
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Affiliation(s)
- Lily P H Yang
- Adis, a Wolters Kluwer Business, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore 0754, Auckland, New Zealand.
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