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Umemori Y, Handa K, Yoshimura S, Kageyama M, Iijima T. Development of a Novel In Silico Classification Model to Assess Reactive Metabolite Formation in the Cysteine Trapping Assay and Investigation of Important Substructures. Biomolecules 2024; 14:535. [PMID: 38785942 PMCID: PMC11117661 DOI: 10.3390/biom14050535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
Predicting whether a compound can cause drug-induced liver injury (DILI) is difficult due to the complexity of drug mechanism. The cysteine trapping assay is a method for detecting reactive metabolites that bind to microsomes covalently. However, it is cumbersome to use 35S isotope-labeled cysteine for this assay. Therefore, we constructed an in silico classification model for predicting a positive/negative outcome in the cysteine trapping assay. We collected 475 compounds (436 in-house compounds and 39 publicly available drugs) based on experimental data performed in this study, and the composition of the results showed 248 positives and 227 negatives. Using a Message Passing Neural Network (MPNN) and Random Forest (RF) with extended connectivity fingerprint (ECFP) 4, we built machine learning models to predict the covalent binding risk of compounds. In the time-split dataset, AUC-ROC of MPNN and RF were 0.625 and 0.559 in the hold-out test, restrictively. This result suggests that the MPNN model has a higher predictivity than RF in the time-split dataset. Hence, we conclude that the in silico MPNN classification model for the cysteine trapping assay has a better predictive power. Furthermore, most of the substructures that contributed positively to the cysteine trapping assay were consistent with previous results.
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Affiliation(s)
| | - Koichi Handa
- DMPK Research Department, Teijin Institute for Bio-Medical Research, TEIJIN PHARMA LIMITED, 4-3-2 Asahigaoka, Hino-shi, Tokyo 191-8512, Japan; (Y.U.); (S.Y.); (M.K.); (T.I.)
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Koga T, Sahara Y, Ohtani T, Yosuke K, Umehara K. Possible nonimmunological toxicological mechanisms of vesnarinone-associated agranulocytosis in HL-60 cells: role of reduced glutathione as cytotoxic defense. J Toxicol Sci 2024; 49:95-103. [PMID: 38432956 DOI: 10.2131/jts.49.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
This study was conducted as part of an investigation into the cause of vesnarinone-associated agranulocytosis. When HL-60 cells were exposed to vesnarinone for 48 hr, little cytotoxicity was observed, although reduced glutathione (GSH) content decreased in a concentration-dependent manner. Significant cytotoxicity and reactive oxygen species (ROS) production were observed when intracellular GSH content was reduced by treatment with L-buthionine-(S, R)-sulphoximine. The involvement of myeloperoxidase (MPO) metabolism was suggested, as when HL-60 cells were exposed to a reaction mixture of vesnarinone-MPO/H2O2/Cl-, cytotoxicity was also observed. In contrast, the presence of GSH (1 mM) protected against these cytotoxic effects. Liquid chromatography-mass spectrometry analysis of the MPO/H2O2/Cl- reaction mixture revealed that vesnarinone was converted into two metabolites, (4-(3,4-dimethoxybenzoyl)piperazine [Metabolite 1: M1] and 1-chloro-4-(3,4-dimethoxybenzoyl)piperazine [Metabolite 2: M2]). M2 was identified as the N-chloramine form, a reactive metabolite of M1. Interestingly, M2 was converted to M1, which was accompanied by the conversion of GSH to oxidized GSH (GSSG). Furthermore, when HL-60 cells were exposed to synthetic M1 and M2 for 24 hr, M2 caused dose-dependent cytotoxicity, whereas M1 did not. Cells were protected from M2-derived cytotoxicity by the presence of GSH. In conclusion, we present the first demonstration of the cytotoxic effects and ROS production resulting from the MPO/H2O2/Cl- metabolic reaction of vesnarinone and newly identified the causative metabolite, M2, as the N-chloramine metabolite of M1, which induces cytotoxicity in HL-60 cells. Moreover, a protective role of GSH against the cytotoxicity was revealed. These findings suggest a possible nonimmunological cause of vesnarinone agranulocytosis.
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Affiliation(s)
- Toshihisa Koga
- Department of Drug Metabolism and Pharmacokinetics, Nonclinical Research Center, Tokushima Research Institute, Otsuka Pharmaceutical Co., Ltd
| | - Yuko Sahara
- Department of Drug Metabolism and Pharmacokinetics, Nonclinical Research Center, Tokushima Research Institute, Otsuka Pharmaceutical Co., Ltd
| | - Tadaaki Ohtani
- Department of Drug Metabolism and Pharmacokinetics, Nonclinical Research Center, Tokushima Research Institute, Otsuka Pharmaceutical Co., Ltd
| | - Kaneko Yosuke
- Department of Drug Metabolism and Pharmacokinetics, Nonclinical Research Center, Tokushima Research Institute, Otsuka Pharmaceutical Co., Ltd
| | - Ken Umehara
- Department of Drug Metabolism and Pharmacokinetics, Nonclinical Research Center, Tokushima Research Institute, Otsuka Pharmaceutical Co., Ltd
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Kamitani F, Nishioka Y, Koizumi M, Nakajima H, Kurematsu Y, Okada S, Kubo S, Myojin T, Noda T, Imamura T, Takahashi Y. Antithyroid drug-induced leukopenia and G-CSF administration: a long-term cohort study. Sci Rep 2023; 13:19336. [PMID: 37935745 PMCID: PMC10630492 DOI: 10.1038/s41598-023-46307-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 10/30/2023] [Indexed: 11/09/2023] Open
Abstract
Although antithyroid drug (ATD)-induced agranulocytosis is a significant concern, its risks associated with long-term use and re-administration are not fully elucidated. Therefore, we performed this study to determine the incidence of ATD-induced leukopenia and G-CSF administration using administrative claims database. Retrospective cohort study. This study was performed using the DeSC Japanese administrative claims database. A total of 12,491 patients with newly diagnosed Graves' disease (GD) who received methimazole or propylthiouracil between April 2014, and February 2021 among 3.44 million patients in the database were included in the study. We measured the six-year incidence of leukopenia and granulocyte colony-stimulating factor (G-CSF) administration. The incidence of leukopenia and G-CSF administration was 1.34% (168 patients) and 0.30% (38 patients), respectively. Leukopenia had a dose-dependent and biphasic incidence. The incidence of leukopenia and G-CSF administration was 37.2 (0.7%) and 8.0 (0.2%) per 1000 person-years during the first 72 days of ATD initiation, whereas it was 3.1 and 0.7 per 1000 person-years during the subsequent 6 years, respectively. The incidence of both outcomes was comparable between first administration and re-administration of ATD. The incidence of ATD-induced leukopenia and G-CSF administration was high in the first 72 days, with a reduced risk for at least 6 years thereafter. The incidence was similar between first administration and re-administration. ATD, a standard therapy, is often administered for a long period; therefore, our findings can guide the treatment of GD.
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Affiliation(s)
- Fumika Kamitani
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Yuichi Nishioka
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan.
| | - Miyuki Koizumi
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Hiroki Nakajima
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Yukako Kurematsu
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Sadanori Okada
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Shinichiro Kubo
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Tomoya Myojin
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Tatsuya Noda
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Tomoaki Imamura
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
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Shale WT, Umer KM, Tola GG, Guluju FA. Asymptomatic Propylthiouracil Induced Agranulocytosis in a Patient with Toxic Nodular Goiter: A Rare Case Report. Int Med Case Rep J 2023; 16:503-512. [PMID: 37701536 PMCID: PMC10493100 DOI: 10.2147/imcrj.s424053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
Background Agranulocytosis is a rare but fatal side effect of antithyroid drugs (ATDs) with incidence reported at 0.1%-1%. Agranulocytosis is defined as a granulocyte count <500 cells/μL following the use of ATDs and is an absolute contraindication to the use of these drugs; in this case, radioactive iodine (RAI) or surgery are therapeutic options. Case Presentation A 28-year-old female patient was on follow-up at our clinic after she presented with anterior neck swelling of 4 years. The patient was started on propylthiouracil (PTU) and propranolol based on clinical symptoms of hyperthyroidism and low thyroid stimulating hormone (TSH) levels. After taking the ATDs for 7 months, she came to the clinic for her regular follow-up. At this point, she was declared euthyroid and booked for surgery. Investigations were sent and the complete blood count (CBC) result showed leucopenia with agranulocytosis, even though she was completely asymptomatic. The offending ATD was immediately discontinued. The patient was kept inpatient for monitoring, and lugol's iodine and propranolol were initiated. Eight days after discontinuing the ATD, the CBC profile was determined once again, showing normalized total leukocyte, as well as, absolute neutrophil count. Eventually, the multinodular goiter (MNG) was managed with subtotal thyroidectomy. Conclusion Despite the fact that agranulocytosis is an extremely rare side effect of ATDs, most often PTU; it is a potentially fatal complication when it occurs. Patient education at the time of prescription should not be overlooked, and systematic programs should be put in place. The baseline granulocyte count should be determined and monitored on a regular basis.
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Affiliation(s)
- Wongel Tena Shale
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
| | - Keno Mohammed Umer
- Department of General Surgery, Dire Dawa University, Dire Dawa, Ethiopia
| | - Gutu Ganati Tola
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
| | - Fayera Abetu Guluju
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
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The Role of Myeloperoxidase in Clozapine-Induced Inflammation: A Mechanistic Update for Idiosyncratic Drug-Induced Agranulocytosis. Int J Mol Sci 2023; 24:ijms24021243. [PMID: 36674761 PMCID: PMC9862306 DOI: 10.3390/ijms24021243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/11/2023] Open
Abstract
The risk of idiosyncratic drug-induced agranulocytosis (IDIAG) markedly constrains the use of clozapine, a neuroleptic with unparalleled efficacy. Most clozapine patients experience an early inflammatory response, likely a necessary step in IDIAG onset. However, most patients do not progress to IDIAG, presumably because of the requirement of specific human leukocyte antigen (HLA) haplotypes, T cell receptors, and other unknown factors. We established that clozapine activates inflammasomes and that myeloperoxidase bioactivation of clozapine generates neoantigens, but the connection between these early mechanistic events remained unknown and, thus, was the aim of this work. We found that the myeloperoxidase inhibitor PF-1355 attenuated myeloperoxidase activity in phorbol myristate acetate (PMA)-differentiated THP-1 macrophages, and it also attenuated clozapine-induced release of inflammatory mediators (e.g., IL-1β, CXCL1, and C-reactive protein). In vivo, pretreatment of Sprague Dawley rats with PF-1355 significantly attenuated clozapine-induced increases in neutrophil mobilization from the bone marrow to the blood and spleen, as determined using differential blood counts and flow cytometry. Moreover, the clozapine-triggered release of inflammatory mediators (e.g., IL-1β, calprotectin, CXCL1, and α-1-acid glycoprotein) from the liver, spleen, and bone marrow was dampened by myeloperoxidase inhibition. These data support the working hypothesis that oxidation of clozapine to a reactive metabolite by myeloperoxidase is critical for induction of the inflammatory response to clozapine. Ultimately, a better mechanistic understanding of the early events involved in the immune response to clozapine may elucidate ways to prevent IDIAG, enabling safer, more frequent therapeutic use of this and potentially other highly efficacious drugs.
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Glocker C, Grohmann R, Burkhardt G, Seifert J, Bleich S, Held T, Toto S, Stübner S, Schüle C. Antipsychotic drug-induced neutropenia: results from the AMSP drug surveillance program between 1993 and 2016. J Neural Transm (Vienna) 2023; 130:153-163. [PMID: 36653686 PMCID: PMC9902410 DOI: 10.1007/s00702-023-02589-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/09/2023] [Indexed: 01/20/2023]
Abstract
Neutropenia and agranulocytosis (N&A) are relatively rare, but potentially fatal adverse drug reactions (ADR). This study presents cases of N&A related to one or more antipsychotic drugs (APDs) in psychiatric inpatients. Data on APD utilization and reports of N&A caused by APDs were analyzed by using data from an observational pharmacovigilance program in German-speaking countries-Arzneimittelsicherheit in der Psychiatrie (AMSP)-from 1993 to 2016. 333,175 psychiatric inpatients were treated with APDs for schizophrenia and other indications during the observation period. A total of 124 cases of APD-induced N&A were documented, 48 of which fulfilled the criteria for agranulocytosis, corresponding to a rate of 0.37, respectively, 0.14 in 1000 inpatients treated with APDs. Neutropenia was more often detected in women, whereas there was no difference regarding sex in cases of agranulocytosis. Clozapine had the highest relative risk for inducing N&A and was imputed alone as a probable cause of N&A in 60 cases (1.57‰ of all patients exposed). Perazine showed the second highest relative risk with 8 cases and an incidence 0.52‰, followed by quetiapine (15 cases resp. 0.23‰ of all patients exposed) and olanzapine (7 cases; 0.13‰ of all patients exposed). N&A most often occurred during the first 3 months of treatment. Overall N&A are severe and potentially fatal complications that can occur during treatment with APDs. The results from this study largely agree with the currently available literature, highlighting the positive effects of alertness and established appropriate monitoring.
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Affiliation(s)
- Catherine Glocker
- Department of Psychiatry und Psychotherapy, LMU Klinikum, Nußbaumstraße 7, 80336, Munich, Germany.
| | - R. Grohmann
- Department of Psychiatry und Psychotherapy, LMU Klinikum, Nußbaumstraße 7, 80336 Munich, Germany
| | - G. Burkhardt
- Department of Psychiatry und Psychotherapy, LMU Klinikum, Nußbaumstraße 7, 80336 Munich, Germany
| | - J. Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - S. Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - T. Held
- Department of Hematology and Cell Therapy, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - S. Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - S. Stübner
- Department of Forensic Psychiatry, Bezirksklinikum Ansbach, Feuchtwanger Str. 38, 91522 Ansbach, Germany
| | - C. Schüle
- Department of Psychiatry und Psychotherapy, LMU Klinikum, Nußbaumstraße 7, 80336 Munich, Germany
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Koraysh S, Koleri J, Ali M. Cefepime-Induced Neutropenia: A Case Report and Literature Review. Clin Pharmacol 2023; 15:33-40. [PMID: 37155501 PMCID: PMC10122991 DOI: 10.2147/cpaa.s406139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/13/2023] [Indexed: 05/10/2023] Open
Abstract
Cefepime is a fourth-generation cephalosporin utilized in treatment of multiple Gram-negative and -positive infections. The current report presents a case of 50-year-old man admitted with epidural abscess who developed neutropenia after prolonged use of cefepime. The neutropenia developed after 24 days of cefepime treatment and resolved 4 days after cessation of cefepime. Assessment of the patient's profile indicated no other possible cause for neutropenia. A literature review was done, and is presented herein to compare and identify the pattern of cefepime-induced neutropenia in 15 patients. The data presented in this article highlight that despite its rarity, cefepime-induced neutropenia should be considered by clinicians when planning a prolonged course of cefepime.
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Affiliation(s)
- Somaya Koraysh
- Department of Pharmacy, Hamad Bin Khalifa Medical City, Hamad Medical Corporation, Doha, Qatar
- Correspondence: Somaya Koraysh, Tel +974 5546 5857, Email
| | - Junais Koleri
- Department of Infectious Disease, Communicable Disease Center, Hamad Medical Corporation, Doha, Qatar
| | - Maisa Ali
- Department of Infectious Disease, Communicable Disease Center, Hamad Medical Corporation, Doha, Qatar
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Li J, Zhang X, Li L, Zhu Q, Ge W, Ji C. Risk Factors for Granulocytopenia in Patients with Graves' Disease Receiving Antithyroid Drugs. Int J Endocrinol 2023; 2023:9935195. [PMID: 37077285 PMCID: PMC10110372 DOI: 10.1155/2023/9935195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/10/2023] [Accepted: 03/27/2023] [Indexed: 04/21/2023] Open
Abstract
Objective To study the risk factors for granulocytopenia caused by antithyroid drugs. Methods Patients who were diagnosed with Graves' hyperthyroidism and regularly treated with antithyroid drugs (ATDs) from January 2010 to July 2022 at Nanjing Drum Tower Hospital, aged >18 years, were selected for general information and laboratory tests and divided into two groups according to the occurrence of granulocytopenia. Independent risk factors for the development of granulocytopenia in patients treated with ATDs were analyzed using one-way and multiway logistic regression analyses, and the predictive value of each index was evaluated using the receiver operating characteristic (ROC) curve and the area under the curve (AUC). Results A total of 818 patients were enrolled, of which 95 developed granulocytopenia. Univariate analysis revealed that sex, white blood cell (WBC) counts, neutrophil-to-lymphocyte ratio (NLR), glutamic-pyruvic transaminase (ALT), aspartate transaminase (AST), free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone (TSH) before medication were risk factors for ATD-induced granulocytopenia (P < 0.05). The abovementioned indicators were taken as independent variables, and multivariate logistic regression analysis showed that female sex, higher ALT levels before medication, and lower NLR and WBC levels were independent risk factors for granulocytopenia using ATDs (P < 0.05). ROC curve analysis showed that sex, NLR, ALT, and WBC count had significant predictive values (P < 0.05), and NLR and WBC count had higher predictive values (AUC = 0.916 and 0.700, respectively). Conclusion Sex, NLR, ALT, and WBC were the main risk factors for granulocytopenia in patients with ATD.
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Affiliation(s)
- Jiaxi Li
- Department of Pharmacy, China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Xiaowen Zhang
- Department of Endocrinology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lintong Li
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Qiaoling Zhu
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Cheng Ji
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Neutropenia: diagnosis and management. World J Pediatr 2022; 18:771-777. [PMID: 35962272 DOI: 10.1007/s12519-022-00593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/05/2022] [Indexed: 10/15/2022]
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Saito T, Usui T, Inada H, Miyawaki I, Mizuno K, Ikeda M, Iwata N. Clozapine-specific proliferative response of peripheral blood-derived mononuclear cells in Japanese patients with clozapine-induced agranulocytosis. J Psychopharmacol 2022; 36:1087-1094. [PMID: 35861221 DOI: 10.1177/02698811221112937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although clozapine-induced granulocytopenia (CIG) is less severe than clozapine-induced agranulocytosis (CIA), and some patients with CIG may not go on to develop serious complications, clozapine is discontinued in cases of both CIA and CIG. Understanding the pathogenic mechanisms of CIA/CIG could provide better management of clozapine therapy. Recently, as a mechanistic insight into adaptive immune systems, European groups reported clozapine-specific proliferative responses and clozapine-specific T cells using blood taken from patients with CIA and/or CIG. AIMS The aims of our study are to support this mechanistic evidence and to investigate the difference in the lymphocyte response to clozapine between patients with CIG and those with CIA. METHODS Lymphocyte stimulation tests (LSTs) were conducted using CD25-positive cell-depleted peripheral blood-derived mononuclear cells (PBMCs) isolated from blood of four Japanese patients with CIA, four patients with CIG, and nine clozapine-tolerant subjects. RESULTS Three of four patients with CIA and one of four patients with CIG showed proliferative responses to clozapine with a stimulation index of greater than 2. In contrast, none of the nine clozapine-tolerant subjects showed any response to clozapine. Olanzapine did not stimulate PBMCs of patients with CIA, patients with CIG, or clozapine-tolerant subjects. CONCLUSIONS Clozapine- and CIA-specific lymphocyte reactions in a Japanese population provided supportive evidence that the pathogenesis of CIA is based on adaptive immune reactions. In addition, patients with CIG who show a positive response to an LST may at the very least not be chosen for clozapine-rechallenge and further prospective studies are desirable to verify this hypothesis.
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Affiliation(s)
- Takeo Saito
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Toru Usui
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Hiroshi Inada
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Izuru Miyawaki
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | | | - Masashi Ikeda
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Nakao Iwata
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
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Battini V, Mari A, Gringeri M, Casini F, Bergamaschi F, Mosini G, Guarnieri G, Pozzi M, Nobile M, Zuccotti G, Clementi E, Radice S, Fabiano V, Carnovale C. Antibiotic-Induced Neutropenia in Pediatric Patients: New Insights From Pharmacoepidemiological Analyses and a Systematic Review. Front Pharmacol 2022; 13:877932. [PMID: 35721197 PMCID: PMC9201445 DOI: 10.3389/fphar.2022.877932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
Aim: to characterize pediatric cases of antibiotic-associated neutropenia through a multidisciplinary approach, focusing on the temporal association between the wide spectrum of treatment options and the occurrence of this relatively uncommon but potentially clinically relevant adverse event. Methods: we carried out a pharmacoepidemiological analysis based on the FDA Adverse Event Reporting System (FAERS) database, a retrospective chart review and a systematic review of the literature, focusing on the time to onset (TTO) of this side effect, in the pediatric clinical setting. Results: A total of 281 antibiotic-related neutropenia events, involving 11 categories of antibiotics, were included in the time to onset analysis. The median TTO ranged from 4 to 60 days after the start of the therapy. A shorter median TTO was found from the retrospective chart review [16 patients: median days (25th-75th percentiles) = 4 (3–5)], compared to 15 (9–18) vs. 10 (6–18) for literature (224 patients) and FAERS (41 cases), respectively. The Anatomical Therapeutic Chemical classes, J01X, J01F, J01E and J04A, and the median TTOs retrieved from more than one source revealed high accordance (p > 0.05), with J01X causing neutropenia in less than a week and J01F/J01E/J04A in more than 10 days. Antibiotics were discontinued in nearly 34% of cases. In FDA Adverse Event Reporting System reports, half of the patients experiencing neutropenia were hospitalized. Conclusion: Whereas antibiotic associated neutropenia is benign in the majority of cases, yet it should not be neglected as, even if rarely, it may put children at higher risk of clinical consequences. Clinicians’ awareness of antibiotic-associated neutropenia and its mode of presentation contributes to the continuous process of monitoring safety of antibiotics.
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Affiliation(s)
- Vera Battini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Alessandra Mari
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Michele Gringeri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Francesca Casini
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Francesco Bergamaschi
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Giulia Mosini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Greta Guarnieri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Marco Pozzi
- Scientific Institute IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Maria Nobile
- Scientific Institute IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Gianvincenzo Zuccotti
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Emilio Clementi
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy.,Scientific Institute IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Valentina Fabiano
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
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12
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Munir F, Javaid HW, Rana MBM, Shaukat F. Ceftriaxone-Induced Reversible Agranulocytosis: A Case Report and Review of Drug-Induced Agranulocytosis. Cureus 2022; 14:e23226. [PMID: 35449634 PMCID: PMC9012477 DOI: 10.7759/cureus.23226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/05/2022] Open
Abstract
In the modern era of medicine, agranulocytosis is a rare occurrence. Despite significant improvement in patient survival, it still carries significant mortality. Agranulocytosis is most commonly caused by chemotherapeutic agents and numerous non-chemo drugs. As it can develop anytime during treatment and patients can remain asymptomatic, frequent cell count monitoring is an essential tool to make a timely diagnosis. An appropriate drug switch, work up to rule out infection and granulocyte colony-stimulating factor (G-CSF) injection in high-risk cases is the management. The patient should be kept under observation till the resolution of agranulocytosis. We present a case of ceftriaxone-induced agranulocytosis which was completely reversible upon stoppage of drug and granulocyte colony-stimulating factor administration. The pathogenesis of ceftriaxone-induced agranulocytosis is unknown. It is suggested to occur either by an immunologic mechanism or because of direct drug toxicity.
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13
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Treatment for Severe Malaria: Post-Artesunate Delayed Haemolysis and Neutropenia. Healthcare (Basel) 2022; 10:healthcare10030413. [PMID: 35326891 PMCID: PMC8949445 DOI: 10.3390/healthcare10030413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 02/06/2023] Open
Abstract
Parenteral artesunate (AS) is the WHO first-line treatment recommended in adults and children for severe malaria. Post-artesunate delayed haemolysis (PADH) is an uncommon adverse reaction to AS with a mechanism that is not fully understood, occurring in adults and children. Neutropenia is another possible finding after AS treatment, albeit rare. We present the case of a child who experienced both effects after treatment with AS for imported severe Falciparum malaria with very high parasitaemia. In addition, thirty-five paediatric cases of PADH, five cases of delayed anaemia without known haemolysis, and fourteen cases of neutropenia after artesunate treatment were identified from the literature review. PADH seems to be a dose-independent reaction and is not strongly related to hyperparasitaemia, although it is more frequent in this case. To date, the benefits of AS outweigh its potential side effects. However, haematological follow-up is mandatory to avoid possible complications from anaemia and neutropenia, especially in children treated with other contemporary drugs.
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14
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Metamizole Use in Children: Analysis of Drug Utilisation and Adverse Drug Reactions at a German University Hospital between 2015 and 2020. Paediatr Drugs 2022; 24:45-56. [PMID: 34877625 PMCID: PMC8651268 DOI: 10.1007/s40272-021-00481-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Metamizole use is controversially discussed due to its potentially serious adverse drug reactions (ADRs). In Germany, however, it remains a popular analgesic and antipyretic drug. OBJECTIVE The aim of this study was to discuss the safety profile of metamizole in children by analysing the inpatient prescription patterns and presenting the metamizole-related ADRs at a paediatric hospital between 2015 and 2020. METHODS Metamizole utilisation data were retrospectively analysed from electronic medical records. ADRs were prospectively recorded via the hospital's stimulated reporting system and analysed accordingly. Patients aged < 18 years admitted to one of the general wards of the department of paediatrics and adolescent medicine of a German university hospital between June 2015 and May 2020 who received at least one drug therapy within their inpatient stay were included in the analysis. Causality of ADRs was rated according to the World Health Organisation causality assessment. RESULTS In 31.7% (3759/11,857) of the inpatient stays of 7809 patients, metamizole was administered. Metamizole exposure was highest in adolescents (37.9%) and lowest in newborns (9.9%). Overall, metamizole was administered parenterally in about 90%. Three cases of agranulocytosis, one allergic shock and one rash with possible or higher causality to metamizole treatment were reported. Three of these occurred prior to hospitalisation. All patients recovered without remaining harm. DISCUSSION Metamizole is commonly used in paediatric inpatients in Germany. Serious ADRs occur but rarely. Continuous monitoring of drug therapy through, for example, stimulated reporting systems ensures that serious ADRs are detected, and appropriate interventions can be introduced.
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15
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Sernoskie SC, Lobach AR, Kato R, Jee A, Weston JK, Uetrecht J. Clozapine induces an acute proinflammatory response that is attenuated by inhibition of inflammasome signaling: implications for idiosyncratic drug-induced agranulocytosis. Toxicol Sci 2021; 186:70-82. [PMID: 34935985 PMCID: PMC8883353 DOI: 10.1093/toxsci/kfab154] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Although clozapine is a highly efficacious schizophrenia treatment, it is under-prescribed due to the risk of idiosyncratic drug-induced agranulocytosis (IDIAG). Clinical data indicate that most patients starting clozapine experience a transient immune response early in treatment and a similar response has been observed in clozapine-treated rats, but the mechanism by which clozapine triggers this transient inflammation remains unclear. Therefore, the aim of this study was to characterize the role of inflammasome activation during the early immune response to clozapine using in vitro and in vivo models. In both differentiated and nondifferentiated human monocytic THP-1 cells, clozapine, but not its structural analogues fluperlapine and olanzapine, caused inflammasome-dependent caspase-1 activation and IL-1β release that was inhibited using the caspase-1 inhibitor yVAD-cmk. In Sprague Dawley rats, a single dose of clozapine caused an increase in circulating neutrophils and a decrease in lymphocytes within hours of drug administration along with transient spikes in the proinflammatory mediators IL-1β, CXCL1, and TNF-α in the blood, spleen, and bone marrow. Blockade of inflammasome signaling using the caspase-1 inhibitor VX-765 or the IL-1 receptor antagonist anakinra attenuated this inflammatory response. These data indicate that caspase-1-dependent IL-1β production is fundamental for the induction of the early immune response to clozapine and, furthermore, support the general hypothesis that inflammasome activation is a common mechanism by which drugs associated with the risk of idiosyncratic reactions trigger early immune system activation. Ultimately, inhibition of inflammasome signaling may reduce the risk of IDIAG, enabling safer, more frequent use of clozapine in patients.
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Affiliation(s)
| | - Alexandra R Lobach
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada
| | - Ryuji Kato
- Department of Cardiovascular Pharmacotherapy and Toxicology, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University, Osaka, 569-1094, Japan
| | - Alison Jee
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - J Kyle Weston
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada
| | - Jack Uetrecht
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada.,Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada
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16
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Rattay B, Benndorf RA. Drug-Induced Idiosyncratic Agranulocytosis - Infrequent but Dangerous. Front Pharmacol 2021; 12:727717. [PMID: 34483939 PMCID: PMC8414253 DOI: 10.3389/fphar.2021.727717] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022] Open
Abstract
Drug-induced agranulocytosis is a life-threatening side effect that usually manifests as a severe form of neutropenia associated with fever or signs of sepsis. It can occur as a problem in the context of therapy with a wide variety of drug classes. Numerous drugs are capable of triggering the rare idiosyncratic form of agranulocytosis, which, unlike agranulocytosis induced by cytotoxic drugs in cancer chemotherapy, is characterised by “bizzare” type B or hypersensitivity reactions, poor predictability and a mainly low incidence. The idiosyncratic reactions are thought to be initiated by chemically reactive drugs or reactive metabolites that react with proteins and may subsequently elicit an immune response, particularly directed against neutrophils and their precursors. Cells or organs that exhibit specific metabolic and biotransformation activity are therefore frequently affected. In this review, we provide an update on the understanding of drug-induced idiosyncratic agranulocytosis. Using important triggering drugs as examples, we will summarise and discuss the chemical, the biotransformation-related, the mechanistic and the therapeutic basis of this clinically relevant and undesirable side effect.
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Affiliation(s)
- Bernd Rattay
- Department of Clinical Pharmacy and Pharmacotherapy, Institute of Pharmacy, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Ralf A Benndorf
- Department of Clinical Pharmacy and Pharmacotherapy, Institute of Pharmacy, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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17
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Abstract
OBJECTIVE Agranulocytosis is a rare but serious adverse drug reaction (ADR) of thionamide antithyroid drugs (ATDs). We explored the characteristics of ADRs in patients with hyperthyroidism. METHODS This retrospective study included 3558 inpatients with Graves disease treated in a Class A Grade 3 hospital between 2015 and 2019. The clinical presentation and laboratory workup of patients with antithyroid drug (ATD)-induced agranulocytosis was analyzed. RESULTS Agranulocytosis was thought to be caused by ATDs in 36 patients. The hospital length of stay was 12 (10-16) days, and hospitalization costs were approximately $2810.89 ($2156.50-$4164.67). The median duration of ATD therapy prior to agranulocytosis development was 30 (20-40) days. Fever (83.33%) and sore throat (75%) were the most common symptoms as early signs of agranulocytosis. The lowest neutrophil counts were 0.01 (0.00-0.03) × 109/L and 0.14 (0.02-0.29) × 109/L in the methimazole and propylthiouracil groups, respectively (P = .037). The recovery times of agranulocytosis were 9.32 ± 2.89 days and 5.60 ± 4.10 days in the methimazole and propylthiouracil groups, respectively (P = .016). Patients with severe agranulocytosis required a longer time to recover (P < .001) and had closer to normal serum thyroxine and triiodothyronine levels. The interval between the first symptom of agranulocytosis and ATD withdrawal was 1 (0-3) day. CONCLUSIONS Patients with agranulocytosis needed a long hospital length of stay and incurred high costs. Methimazole was prone to causing a more serious agranulocytosis than propylthiouracil. High thyroid hormone was unlikely to play a role in adverse drug reactions. Patient education is important.
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18
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Sernoskie SC, Jee A, Uetrecht JP. The Emerging Role of the Innate Immune Response in Idiosyncratic Drug Reactions. Pharmacol Rev 2021; 73:861-896. [PMID: 34016669 DOI: 10.1124/pharmrev.120.000090] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Idiosyncratic drug reactions (IDRs) range from relatively common, mild reactions to rarer, potentially life-threatening adverse effects that pose significant risks to both human health and successful drug discovery. Most frequently, IDRs target the liver, skin, and blood or bone marrow. Clinical data indicate that most IDRs are mediated by an adaptive immune response against drug-modified proteins, formed when chemically reactive species of a drug bind to self-proteins, making them appear foreign to the immune system. Although much emphasis has been placed on characterizing the clinical presentation of IDRs and noting implicated drugs, limited research has focused on the mechanisms preceding the manifestations of these severe responses. Therefore, we propose that to address the knowledge gap between drug administration and onset of a severe IDR, more research is required to understand IDR-initiating mechanisms; namely, the role of the innate immune response. In this review, we outline the immune processes involved from neoantigen formation to the result of the formation of the immunologic synapse and suggest that this framework be applied to IDR research. Using four drugs associated with severe IDRs as examples (amoxicillin, amodiaquine, clozapine, and nevirapine), we also summarize clinical and animal model data that are supportive of an early innate immune response. Finally, we discuss how understanding the early steps in innate immune activation in the development of an adaptive IDR will be fundamental in risk assessment during drug development. SIGNIFICANCE STATEMENT: Although there is some understanding that certain adaptive immune mechanisms are involved in the development of idiosyncratic drug reactions, the early phase of these immune responses remains largely uncharacterized. The presented framework refocuses the investigation of IDR pathogenesis from severe clinical manifestations to the initiating innate immune mechanisms that, in contrast, may be quite mild or clinically silent. A comprehensive understanding of these early influences on IDR onset is crucial for accurate risk prediction, IDR prevention, and therapeutic intervention.
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Affiliation(s)
- Samantha Christine Sernoskie
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy (S.C.S., J.P.U.), and Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (A.J., J.P.U.)
| | - Alison Jee
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy (S.C.S., J.P.U.), and Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (A.J., J.P.U.)
| | - Jack Paul Uetrecht
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy (S.C.S., J.P.U.), and Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (A.J., J.P.U.)
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19
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Lapostolle A, Delion T, Arnaud S, Manceau P, Degos B. Thrombocytopenia and agranulocytosis in a FXTAS choreic patient treated with tetrabenazine. Neurol Sci 2021; 42:3475-3477. [PMID: 33970378 DOI: 10.1007/s10072-021-05310-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Arnaud Lapostolle
- Service de Neurologie, APHP, Hôpital Avicenne, Hôpitaux Universitaires de Paris, Seine Saint Denis, Sorbonne Paris Nord, Bobigny, France
| | - Timo Delion
- Service de Neurologie, APHP, Hôpital Avicenne, Hôpitaux Universitaires de Paris, Seine Saint Denis, Sorbonne Paris Nord, Bobigny, France
| | - Souraya Arnaud
- Service de Neurologie, APHP, Hôpital Avicenne, Hôpitaux Universitaires de Paris, Seine Saint Denis, Sorbonne Paris Nord, Bobigny, France
| | - Philippe Manceau
- Service de Neurologie, APHP, Hôpital Avicenne, Hôpitaux Universitaires de Paris, Seine Saint Denis, Sorbonne Paris Nord, Bobigny, France
| | - Bertrand Degos
- Service de Neurologie, APHP, Hôpital Avicenne, Hôpitaux Universitaires de Paris, Seine Saint Denis, Sorbonne Paris Nord, Bobigny, France. .,Dynamics and Pathophysiology of Neuronal Networks Team, Center for Interdisciplinary Research in Biology, Collège de France, CNRS UMR7241/INSERM U1050, Université PSL, 75005, Paris, France.
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20
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Pattanaik S, Jain A, Ahluwalia J. Evolving Role of Pharmacogenetic Biomarkers to Predict Drug-Induced Hematological Disorders. Ther Drug Monit 2021; 43:201-220. [PMID: 33235023 DOI: 10.1097/ftd.0000000000000842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/21/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Drug-induced hematological disorders constitute up to 30% of all blood dyscrasias seen in the clinic. Hematologic toxicity from drugs may range from life-threatening marrow aplasia, agranulocytosis, hemolysis, thrombosis to mild leukopenia, and thrombocytopenia. Pathophysiologic mechanisms underlying these disorders vary from an extension of the pharmacological effect of the drug to idiosyncratic and immune-mediated reactions. Predicting these reactions is often difficult, and this makes clinical decision-making challenging. Evidence supporting the role of pharmacogenomics in the management of these disorders in clinical practice is rapidly evolving. Despite the Clinical Pharmacology Implementation Consortium and Pharmacogenomics Knowledge Base recommendations, few tests have been incorporated into routine practice. This review aims to provide a comprehensive summary of the various drugs which are implicated for the hematological adverse events, their underlying mechanisms, and the current evidence and practical recommendations to incorporate pharmacogenomic testing in clinical care for predicting these disorders.
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Affiliation(s)
| | - Arihant Jain
- Internal Medicine, Hematology and Bone Marrow Transplantation, and
| | - Jasmina Ahluwalia
- Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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21
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Amoateng R, Hardman B, Liu C, Austin S. Rare case of pancrelipase therapy-induced neutropaenia. BMJ Case Rep 2021; 14:14/3/e241799. [PMID: 33753395 PMCID: PMC7986883 DOI: 10.1136/bcr-2021-241799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 61-year-old man was transferred to our facility from an outside hospital due to refractory neutropaenia of unknown aetiology. The patient presented to the referring hospital with a 5-day history of worsening diarrhoea and abdominal pain. Initial lab results at presentation showed severe neutropaenia with an absolute neutrophil count of 0. Investigations included a bone marrow biopsy which showed slightly hypocellular marrow with near absence of granulocytic precursors. A CT without contrast showed evidence of chronic pancreatitis and acute colitis. The patient's neutropaenia persisted despite granulocyte colony-stimulating factor therapy. The patient was, thus, transferred to our facility for a higher level of care. At our facility, the patient had rapid correction of neutropaenia after discontinuation of pancrelipase therapy. The patient's abdominal pain and diarrhoea also improved while off pancrelipase. Neutropaenia has completely resolved 6 weeks after discharge without any further therapy.
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Affiliation(s)
- Richard Amoateng
- Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Brent Hardman
- Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Catherine Liu
- School Of Medicine, Drexel University, Philidelphia, Pennsylvania, USA
| | - Scarlett Austin
- Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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22
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Ayuso P, García-Martín E, Agúndez JAG. Variability of the Genes Involved in the Cellular Redox Status and Their Implication in Drug Hypersensitivity Reactions. Antioxidants (Basel) 2021; 10:antiox10020294. [PMID: 33672092 PMCID: PMC7919686 DOI: 10.3390/antiox10020294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 12/13/2022] Open
Abstract
Adverse drug reactions are a major cause of morbidity and mortality. Of the great diversity of drugs involved in hypersensitivity drug reactions, the most frequent are non-steroidal anti-inflammatory drugs followed by β-lactam antibiotics. The redox status regulates the level of reactive oxygen and nitrogen species (RONS). RONS interplay and modulate the action of diverse biomolecules, such as inflammatory mediators and drugs. In this review, we address the role of the redox status in the initiation, as well as in the resolution of inflammatory processes involved in drug hypersensitivity reactions. We summarize the association findings between drug hypersensitivity reactions and variants in the genes that encode the enzymes related to the redox system such as enzymes related to glutathione: Glutathione S-transferase (GSTM1, GSTP, GSTT1) and glutathione peroxidase (GPX1), thioredoxin reductase (TXNRD1 and TXNRD2), superoxide dismutase (SOD1, SOD2, and SOD3), catalase (CAT), aldo-keto reductase (AKR), and the peroxiredoxin system (PRDX1, PRDX2, PRDX3, PRDX4, PRDX5, PRDX6). Based on current evidence, the most relevant candidate redox genes related to hypersensitivity drug reactions are GSTM1, TXNRD1, SOD1, and SOD2. Increasing the understanding of pharmacogenetics in drug hypersensitivity reactions will contribute to the development of early diagnostic or prognosis tools, and will help to diminish the occurrence and/or the severity of these reactions.
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Affiliation(s)
- Pedro Ayuso
- Correspondence: ; Tel.: +34-927257000 (ext. 51038)
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23
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Kahaly GJ. Management of Graves Thyroidal and Extrathyroidal Disease: An Update. J Clin Endocrinol Metab 2020; 105:5905591. [PMID: 32929476 PMCID: PMC7543578 DOI: 10.1210/clinem/dgaa646] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/11/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Invited update on the management of systemic autoimmune Graves disease (GD) and associated Graves orbitopathy (GO). EVIDENCE ACQUISITION Guidelines, pertinent original articles, systemic reviews, and meta-analyses. EVIDENCE SYNTHESIS Thyrotropin receptor antibodies (TSH-R-Abs), foremost the stimulatory TSH-R-Abs, are a specific biomarker for GD. Their measurement assists in the differential diagnosis of hyperthyroidism and offers accurate and rapid diagnosis of GD. Thyroid ultrasound is a sensitive imaging tool for GD. Worldwide, thionamides are the favored treatment (12-18 months) of newly diagnosed GD, with methimazole (MMI) as the preferred drug. Patients with persistently high TSH-R-Abs and/or persistent hyperthyroidism at 18 months, or with a relapse after completing a course of MMI, can opt for a definitive therapy with radioactive iodine (RAI) or total thyroidectomy (TX). Continued long-term, low-dose MMI administration is a valuable and safe alternative. Patient choice, both at initial presentation of GD and at recurrence, should be emphasized. Propylthiouracil is preferred to MMI during the first trimester of pregnancy. TX is best performed by a high-volume thyroid surgeon. RAI should be avoided in GD patients with active GO, especially in smokers. Recently, a promising therapy with an anti-insulin-like growth factor-1 monoclonal antibody for patients with active/severe GO was approved by the Food and Drug Administration. COVID-19 infection is a risk factor for poorly controlled hyperthyroidism, which contributes to the infection-related mortality risk. If GO is not severe, systemic steroid treatment should be postponed during COVID-19 while local treatment and preventive measures are offered. CONCLUSIONS A clear trend towards serological diagnosis and medical treatment of GD has emerged.
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Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- Correspondence and Reprint Requests: George J. Kahaly, MD, PhD, JGU Medical Center, Mainz 55101, Germany. E-mail:
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24
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Cimino C, Allos BM, Phillips EJ. A Review of β-Lactam-Associated Neutropenia and Implications for Cross-reactivity. Ann Pharmacother 2020; 55:1037-1049. [PMID: 33215507 DOI: 10.1177/1060028020975646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To review the incidence, management, and current understanding of the pathophysiology of β-lactam-induced neutropenia and to critically evaluate the practicality and safety of direct substitution to an alternative β-lactam in the setting of this reaction. DATA SOURCES A literature analysis using the PubMed and Ovid search engines (July 1968 to October 2020) was performed using the search terms neutropenia, leukopenia, β-lactam, nonchemotherapy, agranulocytosis, and G-CSF (granulocyte colony-stimulating factor). STUDY SELECTION AND DATA EXTRACTION The included English-language studies evaluated the incidence, mechanism, and/or management of β-lactam-induced neutropenia in pediatric or adult patients. DATA SYNTHESIS Drug-induced neutropenia is a well-documented adverse reaction of β-lactam antibiotics, with an incidence of approximately 10% following at least 2 weeks of intravenous therapy. However, multiple gaps in knowledge remain in the mechanism of pathophysiology and optimal management of this reaction. Both direct toxic and immune-mediated mechanisms have been implicated. Although the cornerstone of management includes cessation of the offending agent, controversy exists on the appropriateness of direct substitution or future use of an alternative β-lactam. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Given the frequency of use and superiority of β-lactams over alternative therapy for several infectious disease states, practical recommendations are needed on the management and safe use of β-lactams following β-lactam-induced neutropenia. CONCLUSION Future use of β-lactams with differing R1 side chains, particularly those from a separate class, should not be deemed contraindicated following β-lactam-induced neutropenia and may be considered when indicated, with close laboratory monitoring.
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Affiliation(s)
- Christo Cimino
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ban M Allos
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Vanderbilt University Medical Center, Nashville, TN, USA.,Murdoch University, Murdoch, WA, Australia
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25
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Cismaru AL, Rudin D, Ibañez L, Liakoni E, Bonadies N, Kreutz R, Carvajal A, Lucena MI, Martin J, Sancho Ponce E, Molokhia M, Eriksson N, Krähenbühl S, Largiadèr CR, Haschke M, Hallberg P, Wadelius M, Amstutz U. Genome-Wide Association Study of Metamizole-Induced Agranulocytosis in European Populations. Genes (Basel) 2020; 11:genes11111275. [PMID: 33138277 PMCID: PMC7716224 DOI: 10.3390/genes11111275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
Agranulocytosis is a rare yet severe idiosyncratic adverse drug reaction to metamizole, an analgesic widely used in countries such as Switzerland and Germany. Notably, an underlying mechanism has not yet been fully elucidated and no predictive factors are known to identify at-risk patients. With the aim to identify genetic susceptibility variants to metamizole-induced agranulocytosis (MIA) and neutropenia (MIN), we conducted a retrospective multi-center collaboration including cases and controls from three European populations. Association analyses were performed using genome-wide genotyping data from a Swiss cohort (45 cases, 191 controls) followed by replication in two independent European cohorts (41 cases, 273 controls) and a joint discovery meta-analysis. No genome-wide significant associations (p < 1 × 10−7) were observed in the Swiss cohort or in the joint meta-analysis, and no candidate genes suggesting an immune-mediated mechanism were identified. In the joint meta-analysis of MIA cases across all cohorts, two candidate loci on chromosome 9 were identified, rs55898176 (OR = 4.01, 95%CI: 2.41–6.68, p = 1.01 × 10−7) and rs4427239 (OR = 5.47, 95%CI: 2.81–10.65, p = 5.75 × 10−7), of which the latter is located in the SVEP1 gene previously implicated in hematopoiesis. This first genome-wide association study for MIA identified suggestive associations with biological plausibility that may be used as a stepping-stone for post-GWAS analyses to gain further insight into the mechanism underlying MIA.
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Affiliation(s)
- Anca Liliana Cismaru
- Department of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.L.C.); (C.R.L.)
- Graduate School for Cellular and Biomedical Sciences, University of Bern, 3012 Bern, Switzerland
| | - Deborah Rudin
- Department of Clinical Pharmacology & Toxicology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (D.R.); (S.K.)
- Department of Biomedicine, University of Basel, 4051 Basel, Switzerland
| | - Luisa Ibañez
- Clinical Pharmacology Service, Hospital Universitari Vall d’Hebron, Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Fundació Institut Català de Farmacología, 08035 Barcelona, Spain;
| | - Evangelia Liakoni
- Department of Clinical Pharmacology & Toxicology, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.L.); (M.H.)
- Institute of Pharmacology, University of Bern, 3012 Bern, Switzerland
| | - Nicolas Bonadies
- Department of Hematology and Central Hematology Laboratory, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Reinhold Kreutz
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, 10117 Berlin, Germany;
| | - Alfonso Carvajal
- Centro de Estudios sobre la Seguridad de los Medicamentos, Universidad de Valladolid, 47005 Valladolid, Spain;
| | - Maria Isabel Lucena
- Servicio Farmacologia Clinica, Instituto de Investigación Biomedica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain;
| | - Javier Martin
- Instituto de Parasitología y Biomedicina Lopez-Neyra, Consejo Superior de Investigaciones Cientiíficas, 18016 Granada, Spain;
| | - Esther Sancho Ponce
- Servei d’Hematologia i Banc de Sang, Hospital General de Catalunya, 08190 Sant Cugat del Vallès, Spain;
| | - Mariam Molokhia
- Department of Population Health Sciences, King’s College London, London WC2R 2LS, UK;
| | - Niclas Eriksson
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden;
| | | | - Stephan Krähenbühl
- Department of Clinical Pharmacology & Toxicology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (D.R.); (S.K.)
| | - Carlo R. Largiadèr
- Department of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.L.C.); (C.R.L.)
| | - Manuel Haschke
- Department of Clinical Pharmacology & Toxicology, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.L.); (M.H.)
- Institute of Pharmacology, University of Bern, 3012 Bern, Switzerland
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, 751 85 Uppsala, Sweden; (P.H.); (M.W.)
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, 751 85 Uppsala, Sweden; (P.H.); (M.W.)
| | - Ursula Amstutz
- Department of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.L.C.); (C.R.L.)
- Correspondence:
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de With SAJ, Man WH, Maas C, ten Berg M, Cahn W, Koekman AC, van Solinge WW, Tak T. Neutrophil fluorescence in clozapine users is attributable to a 14kDa secretable protein. Pharmacol Res Perspect 2020; 8:e00627. [PMID: 32812697 PMCID: PMC7437349 DOI: 10.1002/prp2.627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 02/28/2020] [Accepted: 03/04/2020] [Indexed: 11/06/2022] Open
Abstract
Clozapine is the only antipsychotic agent with demonstrated efficacy in refractory schizophrenia. However, use of clozapine is hampered by its adverse effects, including potentially fatal agranulocytosis. Recently, we showed an association between neutrophil autofluorescence and clozapine use. In this study, we evaluated the subcellular localization of clozapine-associated fluorescence and tried to elucidate its source. Neutrophils of clozapine users were analyzed with fluorescence microscopy to determine the emission spectrum and localization of the fluorescence signal. Next, these neutrophils were stimulated with different degranulation agents to determine the localization of fluorescence. Lastly, isolated neutrophil lysates of clozapine users were separated by SDS-PAGE and evaluated. Clozapine-associated fluorescence ranged from 420 nm to 720 nm, peaking at 500-550 nm. Fluorescence was localized in a large number of small loci, suggesting granular localization of the signal. Neutrophil degranulation induced by Cytochalasin B/fMLF reduced fluorescence, whereas platelet-activating factor (PAF)/fMLF induced degranulation did not, indicating that the fluorescence originates from a secretable substance in azurophilic granules. SDS-PAGE of isolated neutrophil lysates revealed a fluorescent 14kDa band, suggesting that neutrophil fluorescence is likely to be originated from a 14kDa protein/peptide fragment. We conclude that clozapine-associated fluorescence in neutrophils is originating from a 14kDa soluble protein (fragment) present in azurophilic granules of neutrophils. This protein could be an autofluorescent protein already present in the cell and upregulated by clozapine, or a protein altered by clozapine to express fluorescence. Future studies should further explore the identity of this protein and its potential role in the pathophysiology of clozapine-induced agranulocytosis.
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Affiliation(s)
- Sera A. J. de With
- Department of PsychiatryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Wai H. Man
- Department of Clinical PharmacyUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of Clinical PharmacyMeander Medical CenterAmersfoortThe Netherlands
| | - Coen Maas
- Department of Clinical Chemistry and HaematologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Maarten ten Berg
- Department of Clinical Chemistry and HaematologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Wiepke Cahn
- Department of PsychiatryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Arnold C. Koekman
- Department of Clinical Chemistry and HaematologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Wouter W. van Solinge
- Department of Clinical Chemistry and HaematologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Tamar Tak
- Department of Respiratory MedicineLaboratory of Translational ImmunologyUniversity Medical Center UtrechtUtrechtThe Netherlands
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Drug-Induced Neutropenia During Treatment of Non-Neoplastic Dermatologic Diseases: A Review. Clin Drug Investig 2020; 40:915-926. [PMID: 32691244 DOI: 10.1007/s40261-020-00956-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Idiosyncratic drug-induced neutropenia (DIN) is a rare, potentially fatal adverse reaction. A literature search was performed on Pubmed and Embase, targeting articles indicating neutropenia as a complication during the treatment of non-neoplastic dermatological disorders. In 66 identified articles, the common incriminated drugs included conventional oral immunomodulators, topical cytotoxic agents, antibacterials, antifungals, biologics and targeted synthetic disease-modifying antirheumatic drugs, non-steroidal anti-inflammatory drugs, and retinoids, with dapsone being reported most often. The duration of drug exposure before the diagnosis of neutropenia varied, but mostly ranged from days to weeks. The majority of patients recovered after drug discontinuation and supportive management including antibiotics and granulocyte colony-stimulating factor, but fatal cases were reported. The proposed pathogenesis of DIN consists of direct drug toxicity and immune-mediated reaction. Certain genetic variants, individual variability in enzyme efficiency, and concomitant use of other drugs may increase the risk of DIN. Being familiar with the most commonly implicated agents and risk factors helps early identification and prompt management of this potentially fatal complication.
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Idiosyncratic Drug-Induced Neutropenia and Agranulocytosis in Elderly Patients. J Clin Med 2020; 9:jcm9061808. [PMID: 32531979 PMCID: PMC7356965 DOI: 10.3390/jcm9061808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023] Open
Abstract
Agranulocytosis is a rare, but serious and life-threatening hematologic disorder in elderly patients. Idiosyncratic drug-induced agranulocytosis (IDIA) has been classically defined by a neutrophil count below 0.5 × 109/L. The annual incidence of IDIA in Europe is about 1.6–9.2 cases per million inhabitants. Increasing age and female sex have been considered as risk factors for the development of this condition. Besides, it is well known that older people take on average more drugs than younger people. This condition is most often associated with the intake of antibacterial agents, antiplatelets, antithyroids, antipsychotics, antiepileptics and nonsteroidal anti-inflammatory drugs (NSAIDs). Initially, agranulocytosis may present without symptoms, but may quickly progress to a severe infection and sepsis. The causative drug should be immediately stopped. In febrile patients, blood cultures and where indicated, site-specific cultures should be obtained and early treatment with empirical broad-spectrum antibiotics started. Even with adequate treatment, the mortality rate is higher in elderly patients reaching up to 20%. Hematopoietic growth factors have proven to be useful as they shorten the duration of neutropenia. However, data on neutropenia and agranulocytosis in the elderly meeting the criteria of evidence-based medicine are still poor in the literature. This review analyzes the results of our experience as well as other published studies of the universal literature.
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Boegeholz J, Brueggen CS, Pauli C, Dimitriou F, Haralambieva E, Dummer R, Manz MG, Widmer CC. Challenges in diagnosis and management of neutropenia upon exposure to immune-checkpoint inhibitors: meta-analysis of a rare immune-related adverse side effect. BMC Cancer 2020; 20:300. [PMID: 32290812 PMCID: PMC7155336 DOI: 10.1186/s12885-020-06763-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 03/17/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Cancer immunotherapy via immune-checkpoint inhibition (ICI) by antibodies against cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and cell death protein 1 (PD-1) have significantly improved the outcome of metastasized melanoma and of a rapidly increasing number of other cancer types. The anti-tumor effect is often accompanied by immune-related adverse events (irAE). Hematological irAE, specifically neutropenia, are rarely observed. However, neutropenia is associated with high morbidity and mortality due to infection complications. Thus, early detection and treatment is crucial. METHODS We present the clinical course of two patients with severe neutropenia after ICI therapy and demonstrate the difficulty of the diagnosis when a comedication of metamizole, a well-known analgesic drug used to treat cancer pain, is present. Further, we provide a comprehensive descriptive and statistical analysis of published data on diagnostics, treatment and infection complication in patients with at least grade 4 neutropenia by a systematic database search. RESULTS Finally, 34 patients were analyzed, including the two case reports from our cohort. The median onset of neutropenia was 10.5 weeks after first ICI administration (interquartile range: 6 weeks). In 76% (N = 26), a normalization of the neutrophil count was achieved after a median duration of neutropenia of 13 days. In a subsample of 22 patients with detailed data, the infection rate was 13%, proven by positive blood culture in 3 cases, but 68% (N = 15) presented with fever > 38 °C. Treatment regime differed relevantly, but mainly included G-CSF and intravenous corticosteroids. Death was reported in 14 patients (41%), 3 of whom (9%) were associated with hematological irAE but only two directly associated with neutropenia. CONCLUSION With an increasing number of cancer patients eligible to ICI therapy, the incidence of severe hematological toxicities may rise substantially over the next years. Clinicians working in the field of cancer immune therapies should be aware of neutropenia as irAE to provide immediate treatment.
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Affiliation(s)
- J Boegeholz
- Department of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | - C S Brueggen
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - C Pauli
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - F Dimitriou
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - E Haralambieva
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - R Dummer
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - M G Manz
- Department of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | - C C Widmer
- Department of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland.
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31
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Francis T, Francis N, Lazarus JH, Okosieme OE. Safety of antithyroid drugs in pregnancy: update and therapy implications. Expert Opin Drug Saf 2020; 19:565-576. [PMID: 32223355 DOI: 10.1080/14740338.2020.1748007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: The thionamide antithyroid drugs, methimazole (MMI), its pro-drug derivative carbimazole (CMZ), and propylthiouracil (PTU) are the mainstay of treatment for hyperthyroidism in pregnancy. However, antithyroid drugs carry risks of adverse effects that can affect fetal and maternal well-being.Areas covered: This review provides an update on the safety of antithyroid drugs in pregnancy, focusing on the most serious concerns of severe liver disease and congenital anomalies.Expert opinion: PTU-induced liver disease is uncommon but can run a catastrophic course in pregnancy with a risk of liver failure and threats to maternal or fetal survival. Acute pancreatitis is a relatively rare occurrence that has been linked to thionamide use in a handful of reports in non-pregnant individuals. Observational studies on the risk of birth defects with antithyroid drug exposure in pregnancy overall show an increase in birth defect risk with exposure to CMZ/MMI, and to a lesser extent, PTU. Further studies are required to determine whether the currently recommended approach of switching between thionamide drugs in pregnancy improves outcomes. Ultimately, a preventative strategy of offering definitive therapy to hyperthyroid women of childbearing potential offers the best approach to truly reduce the risks of antithyroid drug adverse effects in pregnancy.
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Affiliation(s)
- Thanuya Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Niroshan Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - John H Lazarus
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Onyebuchi E Okosieme
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK.,Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
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Duwez M, Szymanski G, Carre M, Mallaret M, Lepelley M. [Idiosyncratic drug-induced agranulocytosis: 7 year-analysis in a French university hospital]. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 78:230-241. [PMID: 32248952 DOI: 10.1016/j.pharma.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Idiosyncratic drug-induced agranulocytosis is a rare but potentially serious haematological disorder. The pathophysiological mechanisms are complex and poorly understood. We aimed at investigating agranulocytosis drug related causes from the myelograms with "myeloid maturation arrest" performed in our university hospital over the last seven years. METHODS A retrospective analysis of myelograms collected for agranulocytosis was performed from 1st January 2010 to 31th December 2016. We used the method of Bégaud et al. for drug causality assessment. RESULTS Among the 104 myelograms analysed, 41 agranulocytosis were drug-induced, whose 28 were idiosyncratic. Among these 28 cases, 26 different drugs were involved. Agranulocytosis was a known adverse reaction in the summary of the product characteristics for 24 drugs, mainly associated with undetermined frequency (n=7). Mean onset latency was 38.1 days after starting the drug (calculated for n=23 cases) and granulocyte growth factors were used in 50% of cases without shortening the mean delay of blood count recovery. Bone marrow presented hypereosinophilia in 29% of cases. Pharmacovigilance reporting rate was 48%. CONCLUSION A "maturation arrest" in the myelogram is not pathognomonic for idiosyncratic drug-induced agranulocytosis. This rare event require multidisciplinary care involving haematologists, biologists and pharmacovigilance experts. Agranulocytosis reporting rate was high compared with usual adverse drug reaction reporting rate (5 to 10%), probably related to the potential severity of this event.
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Affiliation(s)
- M Duwez
- Département de pharmacie, CHU de Grenoble-Alpes, 38000 Grenoble, France.
| | - G Szymanski
- Laboratoire d'hématologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Carre
- Clinique universitaire d'hématologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Mallaret
- Centre régional de pharmacovigilance, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Lepelley
- Centre régional de pharmacovigilance, CHU de Grenoble-Alpes, 38000 Grenoble, France
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Development and validation of an LC–MS/MS method for the bioanalysis of the major metamizole metabolites in human plasma. Bioanalysis 2020; 12:175-189. [PMID: 32052638 DOI: 10.4155/bio-2019-0251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Aim: Metamizole is a frequently used antipyretic and analgesic prodrug, yet its pharmacokinetics has not been thoroughly studied in infants and with coadministered medications. Thus, an LC–MS/MS method was developed to quantify the four major metamizole metabolites in human plasma. Methodology: Pre- and postcolumn infusion was installed to enable robust analyte retention and electrospray ionization following deproteinization of plasma samples. Results: The method was linear (R > 0.996), accurate (93.1–106.0%) and precise (≤12.7%). Mean recovery was more than 91.8% and ion suppression less than 13.1% for all analytes. Pharmacokinetic profiles were reproducible after 4 years at -80°C except for the formylated metabolite (-22.2%). Conclusion: The method fulfilled pertinent criteria of validation guidelines and required only little sample volume. The method therefore qualifies for metamizole analyses in children.
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Elzagallaai AA, Sultan EA, Bend JR, Abuzgaia AM, Loubani E, Rieder MJ. Role of Oxidative Stress in Hypersensitivity Reactions to Sulfonamides. J Clin Pharmacol 2019; 60:409-421. [PMID: 31709574 DOI: 10.1002/jcph.1535] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/26/2019] [Indexed: 12/16/2022]
Abstract
Antimicrobial sulfonamides are important medications. However, their use is associated with major immune-mediated drug hypersensitivity reactions with a rate that ranges from 3% to 4% in the general population. The pathophysiology of sulfa-induced drug hypersensitivity reactions is not well understood, but accumulation of reactive metabolites (sulfamethoxazole [SMX] hydroxylamine [SMX-HA] and SMX N-nitrosamine [SMX-NO]) is thought to be a major factor. These reactive metabolites contribute to the formation of reactive oxygen species (ROS) known to cause cellular damage and induce cell death through apoptosis and necroptosis. ROS can also serve as "danger signals," priming immune cells to mount an immunological reaction. We recruited 26 sulfa-hypersensitive (HS) patients, 19 healthy control subjects, and 6 sulfa-tolerant patients to this study. Peripheral blood monocytes and platelets were isolated from blood samples and analyzed for in vitro cytotoxicity, ROS and carbonyl protein formation, lipid peroxidation, and GSH (glutathione) content after challenge with SMX-HA. When challenged with SMX-HA, cells isolated from sulfa-HS patients exhibited significantly (P ≤ .05) higher cell death, ROS and carbonyl protein formation, and lipid peroxidation. In addition, there was a high correlation between cell death in PBMCs and ROS levels. There was also depletion of GSH and lower GSH/GSSG ratios in peripheral blood mononuclear cells from sulfa-HS patients. The amount of ROS formed was negatively correlated with intracellular GSH content. The data demonstrate a major role for oxidative stress in in vitro cytotoxicity of SMX reactive metabolites and indicate increased vulnerability of cells from sulfa-HS patients to the in vitro challenge.
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Affiliation(s)
- Abdelbaset A Elzagallaai
- Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.,Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Elham A Sultan
- Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - John R Bend
- Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Awatif M Abuzgaia
- Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Eman Loubani
- Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Michael J Rieder
- Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.,Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Amoxicillin/Clavulanic Acid-Induced Agranulocytosis: A Case Report and Review of the Literature. Case Rep Hematol 2019; 2019:5718716. [PMID: 31781425 PMCID: PMC6855031 DOI: 10.1155/2019/5718716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/22/2019] [Accepted: 10/01/2019] [Indexed: 11/18/2022] Open
Abstract
Amoxicillin/clavulanic acid is one of the widely prescribed antibiotics in the outpatient setting giving excellent antimicrobial coverage and relatively safe profile in terms of adverse reactions. Gastrointestinal and cutaneous reactions are among the commonly reported. Our goal is to describe a case of agranulocytosis induced by amoxicillin/clavulanic acid in a previously healthy patient and review prior reports with similar presentation.
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Extended Requirement of Granulocyte Colony-Stimulating Factor for Clozapine-Associated Neutropenia. J Clin Psychopharmacol 2019; 39:169-172. [PMID: 30811374 DOI: 10.1097/jcp.0000000000001017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Andrès E, Lorenzo Villalba N, Zulfiqar AA, Serraj K, Gottenberg JE. Biotherapies-induced neutropenia in autoimmune and auto-inflammatory disorders and other orphan diseases. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1663172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Emmanuel Andrès
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, Strasbourg, France
| | - Noel Lorenzo Villalba
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, Strasbourg, France
| | - Abrar-Ahmad Zulfiqar
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, Strasbourg, France
| | - Khalid Serraj
- Departments of Internal Medicine, University Hospital of Oujda, Oujda, Morocco
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Andrès E, Villalba NL, Zulfiqar AA, Serraj K, Mourot-Cottet R, Gottenberg AJE. State of Art of Idiosyncratic Drug-Induced Neutropenia or Agranulocytosis, with a Focus on Biotherapies. J Clin Med 2019; 8:jcm8091351. [PMID: 31480527 PMCID: PMC6788182 DOI: 10.3390/jcm8091351] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Idiosyncratic drug-induced neutropenia and agranulocytosis is seldom discussed in the literature, especially for new drugs such as biotherapies outside the context of oncology. In the present paper, we report and discuss the clinical data and management of this relatively rare disorder, with a focus on biotherapies used in autoimmune and auto-inflammatory diseases. MATERIALS AND METHODS A review of the literature was carried out using the PubMed database of the US National Library of Medicine. We searched for articles published between January 2010 and May 2019 using the following key words or associations: "drug-induced neutropenia", "drug-induced agranulocytosis", and "idiosyncratic agranulocytosis". We included specific searches on several biotherapies used outside the context of oncology, including: tumor necrosis factor (TNF)-alpha inhibitors, anti-CD20 agents, anti-C52 agents, interleukin (IL) 6 inhibitors, IL 1 inhibitors, and B-cell activating factor inhibitor. RESULTS Idiosyncratic neutropenia remains a potentially serious adverse event due to the frequency of severe sepsis with severe deep tissue infections (e.g., pneumonia), septicemia, and septic shock in approximately two-thirds of all hospitalized patients with grade 3 or 4 neutropenia (neutrophil count (NC) ≤ 0.5 × 109/L and ≤ 0.1 × 109/L, respectively). Over the last 20 years, several drugs have been strongly associated with the occurrence of idiosyncratic neutropenia, including antithyroid drugs, ticlopidine, clozapine, sulfasalazine, antibiotics such as trimethoprim-sulfamethoxazole, and deferiprone. Transient grade 1-2 neutropenia (absolute blood NC between 1.5 and 0.5 × 109/L) related to biotherapy is relatively common with these drugs. An approximate 10% prevalence of such neutropenia has been reported with several of these biotherapies (e.g., TNF-alpha inhibitors, IL6 inhibitors, and anti-CD52 agents). Grade 3-4 neutropenia or agranulocytosis and clinical manifestations related to sepsis are less common, with only a few case reports to date for most biotherapies. Special mention should be made of late onset and potentially severe neutropenia, especially following anti-CD52 agent therapy. During drug therapy, several prognostic factors have been identified that may be helpful when identifying 'susceptible' patients. Older age (>65 years), septicemia or shock, renal failure, and a neutrophil count ≤0.1 × 109/L have been identified as poor prognostic factors. Idiosyncratic neutropenia should be managed depending on clinical severity, with permanent/transient discontinuation or a lower dose of the drug, switching from one drug to another of the same or another class, broad-spectrum antibiotics in cases of sepsis, and hematopoietic growth factors (particularly G-CSF). CONCLUSION Significant progress has been made in recent years in the field of idiosyncratic drug-induced neutropenia, leading to an improvement in their prognosis (currently, mortality rate between 5 and 10%). Clinicians must continue their efforts to improve their knowledge of these adverse events with new drugs as biotherapies.
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Affiliation(s)
- Emmanuel Andrès
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, 67084 Strasbourg, France.
| | - Noel Lorenzo Villalba
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, 67084 Strasbourg, France
| | - Abrar-Ahmad Zulfiqar
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, 67084 Strasbourg, France
| | - Khalid Serraj
- Departments of Internal Medicine, University Hospital of Oujda, 59000 Oujda, Morocco
| | - Rachel Mourot-Cottet
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, 67084 Strasbourg, France
| | - And Jacques-Eric Gottenberg
- Department of Rheumatology, University Hospital of Strasbourg, 67084 Strasbourg, France
- Referral Center of Immune Cytopenias, University Hospital of Strasbourg, 67084 Strasbourg, France
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Aster RH. Beta-lactam-induced severe neutropenia: a descriptive study. Fundam Clin Pharmacol 2019; 33:223-224. [PMID: 30860628 DOI: 10.1111/fcp.12449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Richard H Aster
- Blood Research Institute, BloodCenter of Wisconsin, part of Versiti, Medical College of Wisconsin, PO Box 2178, Milwaukee, WI, 53202, USA
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40
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Chen WT, Chi CC. Associations of HLA genotypes with antithyroid drug-induced agranulocytosis: A systematic review and meta-analysis of pharmacogenomics studies. Br J Clin Pharmacol 2019; 85:1878-1887. [PMID: 31108563 DOI: 10.1111/bcp.13989] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/26/2019] [Accepted: 05/08/2019] [Indexed: 12/13/2022] Open
Abstract
AIMS Antithyroid drug (ATD)-induced agranulocytosis is a life-threatening adverse drug reaction. Previous studies suggested that HLA genotypes may play an important role in ATD-induced agranulocytosis. To examine the associations between HLA genotypes and ATD-induced agranulocytosis, we conducted a systematic review and meta-analysis of pharmacogenomics studies. METHODS We searched the MEDLINE, Embase and CENTRAL databases on 16 June 2018 for case-control studies on the associations between HLA genotypes with ATD-induced agranulocytosis. The Newcastle-Ottawa scale was used to evaluate the risk of bias of included studies. We conducted random-effects model meta-analysis to obtain pooled odds ratios (ORs) with 95% confidence intervals (CIs) to determine the associations between HLA genotypes and ATD-induced agranulocytosis. RESULTS We included 5 studies with 142 ATD-induced agranulocytosis cases, 1529 matched ATD-tolerant controls and 5945 healthy controls. The risk of bias of included studies was generally low. ATD-induced agranulocytosis was associated with HLA-B*27:05 (OR 10.97; 95% CI 0.75-159.99), HLA-B*38:02 (OR 19.85; 95% CI 7.94-49.57) and HLA-DRB1*08:03 (OR 5.29; 95% CI 3.44-8.14). After excluding propylthiouracil, the associations of ATD-induced agranulocytosis with HLA-B*27:05 and HLA-B*38:02 were strengthened (OR being 20.61 (95% CI 5.21-81.58) and 40.59 (95% CI 13.24-124.47), respectively). The associations of ATD-induced agranulocytosis with HLA-B*27:05, HLA-B*38:02 and HLA-DRB1*08:03 remained significant when compared to population controls (OR being 7.37 (95% CI 3.86-14.07), 36.43 (95% CI 12.80-103.70) and 5.42 (95% CI 2.36-12.47), respectively). HLA-B*27:05, HLA-B*38:02, and HLA-DRB1*08:03 alleles were associated with ATD-induced agranulocytosis, especially in carbimazole/methimazole-induced agranulocytosis. CONCLUSIONS HLA-B*27:05, HLA-B*38:02 and HLA-DRB1*08:03 alleles were associated with ATD-induced agranulocytosis, especially in carbimazole/methimazole-induced agranulocytosis.
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Affiliation(s)
- Wei-Ti Chen
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Chi Chi
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Ameri AH, Curtis BR, Sykes DB. Immune neutropenia mediated by micafungin. Am J Hematol 2019; 94:830-832. [PMID: 30945326 DOI: 10.1002/ajh.25483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/30/2019] [Accepted: 04/01/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Amir H. Ameri
- Division of HematologyMassachusetts General Hospital Cancer Center Boston Massachusetts
| | - Brian R. Curtis
- Platelet and Neutrophil Immunology LaboratoryBlood Research Institute, BloodCenter of Wisconsin Milwaukee Wisconsin
| | - David B. Sykes
- Division of HematologyMassachusetts General Hospital Cancer Center Boston Massachusetts
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Abstract
Unexplained cytopenia is one of the most common indications for performing trephine bone marrow (BM) biopsy (BMB). The histopathological examination in this regard must be seen in the broader context of a multimodal approach in order to reach an as entity-specific as possible diagnosis, considering medical history, physical examination, laboratory data, peripheral blood morphology, BM aspiration smear, flow cytometry results and, if indicated, cytogenetics and molecular genetics. The particular irreplaceability of the histopathological work-up and the expectations to the BMB lie especially in the detection of fibrosing and/or focal processes (e.g. localized islets of blasts) and disorders extrinsic to the BM such as e.g. metastases, thrombotic microangiopathies, granulomatous myelitides etc. We propose a systematic combined histopathological pattern-based and blood count-based approach that can be applied in such circumstances to achieve a precise diagnosis or, at least, a clinically useful differential diagnosis, particularly taking into consideration specific morphologic pitfalls and application of ancillary techniques. Constitutional BM failure syndromes will not be profoundly addressed.
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Seeman MV. Men and women respond differently to antipsychotic drugs. Neuropharmacology 2019; 163:107631. [PMID: 31077728 DOI: 10.1016/j.neuropharm.2019.05.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/19/2019] [Accepted: 05/07/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Because women are often perceived as having better outcomes than men in psychotic illnesses such as schizophrenia - women are less often in hospital, have a lower suicide rate, are less often involved with the law, enjoy better relationships with family and friends - the question arises as to whether or not this apparent advantage is attributable to a gender difference in antipsychotic response. OBJECTIVE The aim of this paper is to critically review the quantitative and qualitative literature on gender difference in antipsychotic response sourced mainly from medical databases of the last ten years. FINDINGS There are theoretical reasons why women's effective doses of antipsychotics might need to be lower than guidelines recommend for men, especially as regards olanzapine and clozapine, but, because there are so many variables that impinge on antipsychotic response, it is difficult to provide definitive guidance. What is evident is that some antipsychotic side effects, weight gain for instance, are more worrisome for women than for men. It is also evident that, after menopause, women need an increase in their antipsychotic dose; other reproductive stages in women's lives require special prescribing considerations as well. CONCLUSION There is a science, and an art, to prescribing antipsychotics, which needs to take gender into account. This article is part of the issue entitled 'Special Issue on Antipsychotics'.
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Affiliation(s)
- Mary V Seeman
- Department of Psychiatry, University of Toronto, 260 Heath St. West, Toronto, Ontario, M5P 3L6, Canada.
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44
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Masuka JT, Muzopambwa G, Khoza S, Chibanda D. An Interesting Case of Carbamazepine-Induced Stevens-Johnson Syndrome. DRUG SAFETY - CASE REPORTS 2018; 6:1. [PMID: 30535610 PMCID: PMC6288101 DOI: 10.1007/s40800-018-0095-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A 29-year-old Black female patient was admitted to a psychiatric ward with symptoms of major depressive disorder with psychosis. The patient was started on amitriptyline 50 mg/day and haloperidol 10 mg/day. On day 4 post-admission, the preferred first-line antidepressant, fluoxetine, became available and the patient was switched from amitriptyline to fluoxetine 20 mg/day. On the same day, the dose of haloperidol was reduced to 5 mg/day. Thirteen days post-initiation of these medications the patient became talkative, associated with emotional lability, an expansive mood, irritability and restlessness. The working diagnosis was changed to bipolar affective disorder in the manic phase. Fluoxetine was discontinued and carbamazepine 600 mg/day was added to the patient's treatment regimen. Her manic symptoms started to resolve; however, 14 days post-initiation of carbamazepine, the patient had a fever; itchy, discharging eyes; respiratory distress; generalised symmetrical erythematosus rash; buccal ulceration; and conjunctival injection with difficulty opening her eyes. Carbamazepine was immediately discontinued and the patient received intravenous fluid resuscitation. The patient recovered considerably after 12 days of symptomatic and supportive management, and was transferred back to the psychiatric ward for the continuation of bipolar disorder management. Lithium therapy was instituted and the patient was subsequently discharged. Using the Algorithm of Drug causality for Epidermal Necrolysis (ALDEN) Stevens-Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN) drug causality scoring system, carbamazepine and fluoxetine were evaluated as 'very probable' and 'possible' causes of SJS, respectively, in this patient. Fluoxetine-induced SJS was considered on account of previous case reports, however no evidence of causality was found in this patient. Consecutive administration with a potential increase in carbamazepine due to inhibition of cytochrome P450 (CYP) 3A4 metabolism by fluoxetine was also not ruled out. A diagnosis of carbamazepine-induced SJS was made and was considered an idiosyncratic adverse drug reaction.
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Affiliation(s)
- Josiah Tatenda Masuka
- Division of Psychiatry, Harare Central Hospital, PO Box ST 14, Southerton, Harare, Zimbabwe.
| | - Garikai Muzopambwa
- Division of Psychiatry, Harare Central Hospital, PO Box ST 14, Southerton, Harare, Zimbabwe
| | - Star Khoza
- Department of Clinical Pharmacology, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe.,Discipline of Pharmacology and Clinical Pharmacy, School of Pharmacy, Faculty of Natural Sciences, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa
| | - Dixon Chibanda
- Division of Psychiatry, Harare Central Hospital, PO Box ST 14, Southerton, Harare, Zimbabwe.,Department of Psychiatry, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe
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45
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Vial T, Bailly H, Perault-Pochat MC, Default A, Boulay C, Chouchana L, Kassai B. Beta-lactam-induced severe neutropaenia: a descriptive study. Fundam Clin Pharmacol 2018; 33:225-231. [PMID: 30289173 DOI: 10.1111/fcp.12419] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/19/2018] [Accepted: 10/01/2018] [Indexed: 12/31/2022]
Abstract
The objectives of this study were to describe the characteristics and natural history of beta-lactam-induced severe neutropaenia and to evaluate the risk of recurrences after another beta-lactam readministration. Reports of pure agranulocytosis associated with a beta-lactam exposure within the 10 days preceding the neutropaenia were extracted from the French Pharmacovigilance Database over the year 2010. Cases with another evident cause or more likely attributable to another drug were excluded. Data were analyzed for demographics, clinical and biological features, prognosis factors, granulocyte colony stimulating factors administration and outcome. Sixty-two cases were included (median age: 65 years). The median duration of treatment before neutropaenia was 16 days. In 47% of cases, the diagnosis was made on a systematic blood cell count. The median neutrophil count at nadir was 0.125 × 109 /L, and bone marrow examination evidenced features of neutrophilic maturation arrest or aplasia in 21 patients, hyperplasia of granulopoietic cells in three and normal findings in five. Three patients developed severe sepsis. All but one recovered a normal blood cell count within 2-56 days after beta-lactam discontinuation. The last patient died from recurrent severe septic shock. No significant effect of granulocyte colony stimulating factor on the mean duration of haematological recovery was found. Among the 21 patients who later received another beta-lactam, two experienced recurrence of the neutropaenia after receiving a beta-lactam from another subfamily. Beta-lactam-induced agranulocytosis was usually observed after prolonged treatment, and severe complications are uncommon. In most patients, a subsequent treatment with another beta-lactam was well tolerated.
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Affiliation(s)
- Thierry Vial
- Centre Régional de Pharmacovigilance, Hospices Civils de Lyon, Service Hospitalo-Universitaire de Pharmacotoxicologie, 162 avenue Lacassagne, Lyon, 69424, France
| | - Henry Bailly
- Centre Régional de Pharmacovigilance, Hospices Civils de Lyon, Service Hospitalo-Universitaire de Pharmacotoxicologie, 162 avenue Lacassagne, Lyon, 69424, France
| | | | - Anne Default
- Centre Régional de Pharmacovigilance Marseille - Provence - Corse, Hôpital Sainte-Marguerite AP-HM, 270 boulevard de Saint-Marguerite, 13274, Marseille Cedex 9, France
| | - Charlène Boulay
- Centre Régional de Pharmacovigilance, Institut de Biologie Clinique, Hôpital Charles Nicolle, CHU de Rouen, 76031, Rouen cedex, France
| | - Laurent Chouchana
- Centre Régional de Pharmacovigilance, Hôpitaux Universitaires Paris Centre, Site Hôpital Cochin, 27 rue du faubourg Saint Jacques, 75014, Paris, France
| | - Behrouz Kassai
- Centre Régional de Pharmacovigilance, Hospices Civils de Lyon, Service Hospitalo-Universitaire de Pharmacotoxicologie, 162 avenue Lacassagne, Lyon, 69424, France
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46
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Abstract
The thionamide antithyroid drugs were discovered in large part following serendipitous observations by a number of investigators in the 1940s who found that sulfhydryl-containing compounds were goitrogenic in animals. This prompted Prof. Edwin B Astwood to pioneer the use of these compounds to treat hyperthyroidism in the early 1940s and to develop the more potent and less toxic drugs that are used today. Despite their simple molecular structure and ease of use, many uncertainties remain, including their mechanism(s) of action, clinical role, optimal use in pregnancy and the prediction and prevention of rare but potentially life-threatening adverse reactions. In this review, we summarize the history of the development of these drugs and outline their current role in the clinical management of patients with hyperthyroidism.
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Affiliation(s)
- Henry B Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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47
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Shah RR. Metamizole (dipyrone)-induced agranulocytosis: Does the risk vary according to ethnicity? J Clin Pharm Ther 2018; 44:129-133. [DOI: 10.1111/jcpt.12768] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 12/30/2022]
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48
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Yang J, Lv Y, Zhang Y, Li J, Chen Y, Liu C, Zhong J, Xiao X, Liu J, Wen G. Decreased miR-17-92 cluster expression level in serum and granulocytes preceding onset of antithyroid drug-induced agranulocytosis. Endocrine 2018; 59:218-225. [PMID: 29255972 DOI: 10.1007/s12020-017-1481-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE We aimed to determine changes in miR-17-92 cluster expression in serum and granulocytes from patients with antithyroid drug (ATD)-induced agranulocytosis. METHODS In this study, real-time polymerase chain reaction (PCR) was used to detect serum miR-17-92 expression levels in 20 ATD-induced agranulocytosis and 16 control patients. Importantly, dynamic changes in neutrophil counts from granulocytopenia to agranulocytosis were observed in 6 of the 20 patients. miR-17-92 expression levels in granulocytes of those six patients under the granulocytopenia condition were measured and compared with corresponding granulocyte samples after recovery. Additionally, the expression levels of these miRNAs in patients with type I or type II bone marrow characteristics were analyzed, and the correlation between miR-17-92 and serum free thyroxine level was analyzed. RESULTS We found that levels of miR-17-92 expression decreased in both serum and pre-agranulocytosis granulocytes from patients with ATD-induced agranulocytosis compared with those in serum and granulocytes from both recovered patients and control patients. However, no difference among patients with either type of bone marrow characteristics was observed, and no correlation between serum miR-17-92 and free thyroxine levels was found. CONCLUSION In ATD-induced agranulocytosis, expression of the miR-17-92 cluster is reduced in both serum and granulocytes, though this alteration does not correlate with bone marrow characteristics or thyroid function.
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Affiliation(s)
- Jing Yang
- Department of Metabolism & Endocrinology, the First Affiliated Hospital of University of South China, 69 Chuanshan Road, Hengyang, 421001, China
| | - Yuncheng Lv
- Clinical Anatomy & Reproductive Medicine Application Institute, University of South China, 28 Changsheng West Road, Hengyang, 421001, China
| | - Yi Zhang
- Department of Metabolism & Endocrinology, the First Affiliated Hospital of University of South China, 69 Chuanshan Road, Hengyang, 421001, China
| | - Jiaoyang Li
- Department of Metabolism & Endocrinology, the First Affiliated Hospital of University of South China, 69 Chuanshan Road, Hengyang, 421001, China
| | - Yajun Chen
- Department of Metabolism & Endocrinology, the Second Affiliated Hospital of University of South China, 30 Jiefang Road, Hengyang, 421001, China
| | - Chang Liu
- Department of Metabolism & Endocrinology, the Chenzhou Affiliated Hospital of University of South China, 102 Luojiajing Road, Chengzhou, 423000, China
| | - Jing Zhong
- Department of Clinical Research, the First Affiliated Hospital of University of South China, 69 Chuanshan Road, Hengyang, 421001, China
| | - Xinhua Xiao
- Department of Metabolism & Endocrinology, the First Affiliated Hospital of University of South China, 69 Chuanshan Road, Hengyang, 421001, China
| | - Jianghua Liu
- Department of Metabolism & Endocrinology, the First Affiliated Hospital of University of South China, 69 Chuanshan Road, Hengyang, 421001, China
| | - Gebo Wen
- Department of Metabolism & Endocrinology, the First Affiliated Hospital of University of South China, 69 Chuanshan Road, Hengyang, 421001, China.
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49
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Curtis BR. Non-chemotherapy drug-induced neutropenia: key points to manage the challenges. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:187-193. [PMID: 29222255 PMCID: PMC6142577 DOI: 10.1182/asheducation-2017.1.187] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Non-chemotherapy idiosyncratic drug-induced neutropenia (IDIN) is a relatively rare but potentially fatal disorder that occurs in susceptible individuals, with an incidence of 2.4 to 15.4 cases per million population. Affected patients typically experience severe neutropenia within several weeks to several months after first exposure to a drug, and mortality is ∼5%. The drugs most frequently associated with IDIN include metamizole, clozapine, sulfasalazine, thiamazole, carbimazole, amoxicillin, cotrimoxazole, ticlopidine, and valganciclovir. The idiosyncratic nature of IDIN, the lack of mouse models and diagnostic testing, and its low overall incidence make rigorous studies to elucidate possible mechanisms exceptionally difficult. An immune mechanism for IDIN involving neutrophil destruction by hapten (drug)-specific antibodies and drug-induced autoantibodies is frequently suggested, but strong supporting evidence is lacking. Although laboratory testing for neutrophil drug-dependent antibodies is rarely performed because of the complexity and low sensitivity of tests currently in use, these assays could possibly be enhanced by using reactive drug metabolites in place of the parent drug. Patients typically experience acute, severe neutropenia, or agranulocytosis (<0.5 × 109 neutrophils/L) and symptoms of fever, chills, sore throat, and muscle and joint pain. Diagnosis can be difficult, but timely recognition is critical because if left untreated, there is an increase in mortality. Expanded studies of the production and mechanistic role of reactive drug metabolites, genetic associations, and improved animal models of IDIN are essential to further our understanding of this important disorder.
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Affiliation(s)
- Brian R Curtis
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
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50
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Wadelius M, Eriksson N, Kreutz R, Bondon-Guitton E, Ibañez L, Carvajal A, Lucena MI, Sancho Ponce E, Molokhia M, Martin J, Axelsson T, Kohnke H, Yue QY, Magnusson PKE, Bengtsson M, Hallberg P. Sulfasalazine-Induced Agranulocytosis Is Associated With the Human Leukocyte Antigen Locus. Clin Pharmacol Ther 2017; 103:843-853. [PMID: 28762467 PMCID: PMC5947520 DOI: 10.1002/cpt.805] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 12/12/2022]
Abstract
Agranulocytosis is a serious, although rare, adverse reaction to sulfasalazine, which is used to treat inflammatory joint and bowel disease. We performed a genome-wide association study comprising 9,380,034 polymorphisms and 180 HLA alleles in 36 cases of sulfasalazine-induced agranulocytosis and 5,170 population controls. Sulfasalazine-induced agranulocytosis was significantly associated with the HLA region on chromosome 6. The top hit (rs9266634) was located close to HLA-B, odds ratio (OR) 5.36 (95% confidence interval (CI) (2.97, 9.69) P = 2.55 × 10-8 ). We HLA-sequenced a second cohort consisting of 40 cases and 142 treated controls, and confirmed significant associations with HLA-B*08:01, OR = 2.25 (95% CI (1.02, 4.97) P = 0.0439), in particular the HLA-B*08:01 haplotype HLA-DQB1*02:01-DRB1*03:01-B*08:01-C*07:01, OR = 3.79 (95% CI (1.63, 8.80) P = 0.0019), and with HLA-A*31:01, OR = 4.81 (95% CI (1.52, 15.26) P = 0.0077). The number needed to test for HLA-B*08:01 and HLA-A*31:01 to avoid one case was estimated to be 1,500. We suggest that intensified monitoring or alternative treatment should be considered for known carriers of HLA-B*08:01 or HLA-A*31:01.
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Affiliation(s)
- Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Niclas Eriksson
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - Emmanuelle Bondon-Guitton
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire, Faculté de Médecine de l'Université de Toulouse, Toulouse, France
| | - Luisa Ibañez
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Fundació Institut Català de Farmacologia, Barcelona, Spain
| | - Alfonso Carvajal
- Centro de Estudios sobre la Seguridad de los Medicamentos, Universidad de Valladolid, Valladolid, Spain
| | - M Isabel Lucena
- S Farmacologia Clinica, Instituto de Investigación Biomedica de Málaga (IBIMA), H Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Madrid, Spain
| | - Esther Sancho Ponce
- Servei d'Hematologia i Banc de Sang, Hospital General de Catalunya, Sant Cugat del Vallès, Spain
| | - Mariam Molokhia
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London Department of Primary Care and Public Health Sciences, London, UK
| | - Javier Martin
- Instituto de Parasitologia y Biomedicina Lopez-Neyra, CSIC, Granada, Spain
| | - Tomas Axelsson
- Department of Medical Sciences, Molecular Medicine and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Hugo Kohnke
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | | | - Patrik K E Magnusson
- Swedish Twin Registry, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mats Bengtsson
- Department of Immunology, Genetics and Pathology, Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
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