[Drug-induced lung diseases]

Drug-induced lung disease adverse effect with Ledipasvir Acetonate/Sofosbuvir

Background

Interferon and ribavirin have been used as therapeutic agents for chronic hepatitis C infection or C-compensated cirrhosis in the conventional treatment. Hepatitis C virus (HCV) -specific direct-acting antiviral agents that directly inhibit the growth process of HCV have been approved since 2011. However, in the early post-marketing vigilance phase of ledipasvir acetonate/sofosbuvir (LDV/SOF), there were reports of interstitial lung disease in 4 out of 32,700 cases with death in 1 case; the onset mechanism is unknown.

Case presentation

Treatment for hepatitis C was deemed to be necessary, and the patient was referred to our hospital. Oral administration of LDV/SOF was started. On day 8 of administration, a fever of 38–39 °C and coughing were observed followed by the gradual appearance of shortness of breath. As there was no improvement, the patient visited her primary care physician on day 16 of administration and the patient was brought urgently to our hospital on the same day. Blood tests and imaging tests were conducted at our hospital on the day of emergency transport; inflammatory response markers showed abnormal values, and sialylated carbohydrate antigen Krebs von den Lungen-6 was within the normal value range at 303 U/mL. Because the possibility of infection was low based on results of imaging and bronchoalveolar lavage, drug-induced lung disease was suspected, LDV/SOF administration was discontinued, and steroid administration was started. Following steroid pulse therapy, treatment with oral prednisolone tablets was gradually tapered. The patient’s symptoms were relieved and she was discharged.

Conclusions

The patient’s medication history in this case indicated that there were no drugs taken before or after administration of LDV/SOF until the adverse reaction occurred, and there were no supplements or dietary supplements taken. Therefore, LDV/SOF has been proposed as the cause of the suspected adverse effect. Pharmacists should try to collect adverse effect reports to identify adverse effects early.

Assessment of statin-induced interstitial pneumonia in patients treated for hyperlipidemia using a health insurance claims database in Japan

PURPOSE

This study aimed to determine the frequency and risk factors for statin-induced interstitial pneumonia (IP).

METHOD

We conducted a retrospective cohort study using a large Japanese health insurance claims database. We determined the statin-induced IP incidence in patients treated with statins for hyperlipidemia (n = 194,814) with 12-month screening and 3-month observation periods. Statin-induced IP was defined as: (1) diagnosis with IP (ICD-10 codes: J70.2-J70.4, J84.1, and J84.9) within 3 months after starting statins; (2) steroid administration starts after starting statins; (3) undergoing laboratory tests for sialylated carbohydrate antigen Krebs von den Lungen-6 or pulmonary surfactant protein-D; and (4) undergoing high-resolution computed tomography (HRCT). Risk factors for IP were defined as presence of lung-related diseases including lung cancer and IP (ICD-10 codes: A15-16, J12-18, 43-46, 60-70, and 80-99) that were known to the risk factors inducing IP during the screening period.

RESULTS

Cohort 1 had no IP-inducing risk factors; based on lung-related disease history, we identified 4 cases (male/female: 0/4, 61 ± 2.5 years) and 46,574 controls (male/female: 29,677/16,897, 51.3 ± 9.5 years). In cohort 1, all cases were female and average age was older than that of controls (p < 0.01). Cohort 2 had lung-related disease history that were known to the risk factors inducing IP; we identified 25 cases (male/female: 11/14, 52.8 ± 11.3 years) and 4005 controls (male/female: 2305/1,700, 51.0 ± 10.4 years). IP incidence was higher in cohort 2 than in cohort 1, who had no IP risk factors (0.6% vs. 0.009%, p < 0.01). The adjusted case/control odds ratio in cohort 2 was 3.8 (1.7-8.5) in patients who had taken atorvastatin and 2.5 (1.1 - 5.6) with diabetes mellitus.

DISCUSSION

We clarified the incidence (0.009% and 0.6% in patients without and with lung-related disease history that were known to the risk factors inducing IP, respectively) and risk factors for statin-induced IP (elderly females without lung-related disease history; atorvastatin administration in those with lung-related disease history). Physicians and pharmacists should pay close attention to female patients starting atorvastatin, especially those with past histories of lung-related diseases that were known to the risk factors for IP.

[Adverse Event Trends Associated with Over-the-counter Drugs: Data Mining of the Japanese Adverse Drug Event Report Database]

Over-the-counter (OTC) drugs play an important role in self-medication. To ensure patient safety, pharmacists should ask patients to pay attention to possible adverse events (AE) associated with OTC drugs and educate patients about the symptoms related to those AEs. The aims of the present study were as follows: (1) to assess the tendency of AEs to occur with OTC drug use in Japan; (2) to detect a safety signal for OTC drugs using the reporting odds ratio (ROR); and (3) to evaluate clustery features, which include suspected drugs and therapeutic classifications, and safety signal indices (number of reports and the ROR), using cluster analysis. The number of reports of AEs following use of combination cold remedy, antipyretic and analgesic remedy, and herbal medicine was 1007, 566, and 221, respectively. We set the cluster number at five; clustery features obtained were as follows: (1) high reporting rate for skin and subcutaneous tissue disorder AEs was the largest group related to combination cold remedy; (2) high reporting rate for nervous system disorder AEs including dizziness was the second largest group. The same medicinal ingredient may demonstrate similar tendencies of the occurrence of AEs and similar clustery features in the Japanese Adverse Drug Event Report database. Our analysis of AEs associated with OTC drugs may be useful for pharmacists and patients alike. Further studies are required to draw better-informed conclusions.

Comparison of the major flavonoid content of S. baicalensis, S. lateriflora, and their commercial products

According to the notification for definition of pharmaceuticals from the Director-General of the Pharmaceutical and Food Safety Bureau, Ministry of Health Labour and Welfare of Japan, the roots of Scutellaria baicalensis (Chinese skullcap) and S. lateriflora (skullcap) are classified as "the raw materials exclusively used as pharmaceuticals", but their aerial parts are classified as "non-pharmaceuticals" so, in principle, there are no health claims for these materials and no descriptions of drug-like dosages or administration directions. Dried root of S. baicalensis is also registered in Japanese Pharmacopoeia XV as scutellaria root. Scutellaria root is considered to have the adverse drug reactions of interstitial pneumonia and drug-induced hepatopathy in kampo medicines (Japanese traditional herbal formulations), and baicalin, its major constituent, is considered to be the cause of the adverse reaction. This study was conducted to evaluate the validity of this borderline between pharmaceuticals and non-pharmaceuticals by analyzing the amounts of four flavonoids, including baicalin, in the roots, stems, and leaves of S. baicalensis and S. lateriflora, and in the commercial products herbal tea and dietary supplements prepared from S. lateriflora. These flavonoids were found in the root of S. baicalensis; its aerial parts, however, did not contain them. On the other hand, the amounts of those flavonoids in the aerial parts of S. lateriflora were larger than in the root. Herbal tea and dietary supplements of S. lateriflora obtained commercially also contained those flavonoids, and the dietary supplements contained amounts of them comparable with that in kampo medicine. These results suggest that classification that the aerial parts of S. lateriflora as non-pharmaceuticals in Japan needs reconsideration.