Duloxetine and Angiotensin II Receptor Blocker Combination Potentially Induce Severe Hyponatremia in an Elderly Woman

A real-world pharmacovigilance analysis of adverse events associated with irbesartan using the FAERS and JADER databases

Objective

Hypertension is a leading global risk factor for disability and death. Irbesartan, a potent angiotensin II receptor blocker, requires continuous safety monitoring. We conducted a disproportionality analysis of irbesartan-related adverse drug events (ADEs) using the FDA's FAERS and Japan's JADER databases.

Methods

We extracted irbesartan-related ADE reports from FAERS (Q1 2004 to Q1 2024) and JADER (Q2 2008 to Q4 2023). We used Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Empirical Bayesian Geometric Mean (EBGM) for signal detection. Sensitivity analyses were conducted to exclude comorbid medications, and subgroup analyses by age and gender were performed to explore ADE occurrence in specific populations. Th time to onset (TTO) of ADEs was assessed using Weibull distribution test and Kaplan-Meier curves.

Results

A total of 5,816 (FAERS) and 366 (JADER) reports were analyzed, with irbesartan-related preferred terms (PTs) involving 27 System Organ Classes (SOCs) in FAERS and 22 in JADER. Three SOCs met detection thresholds in both databases: "metabolism and nutrition disorders," "cardiac disorders," and "renal and urinary disorders." We identified 219 positive signals in FAERS and 20 in JADER, including known signals like hyperkalemia, hypotension, and acute kidney injury. Notably, newly identified signals such as acute pancreatitis (n = 50, ROR: 7.76 [5.88-10.25]) and rhabdomyolysis (n = 50, ROR: 7.76 [5.88-10.25]) in FAERS and respiratory failure (n = 7, ROR: 6.76 [3.20-14.26]) in JADER could have significant clinical implications, as they may lead to severe outcomes if not recognized and managed promptly. Subgroup analyses revealed both similarities and differences in signal detection across gender and age groups. Sensitivity analyses, excluding concomitant medications, confirmed the persistence of key positive signals, including hyperkalemia, angioedema, acute pancreatitis, and agranulocytosis. ADEs mainly occurred within 1 month (34.14%) and after 1 year (32.32%) after dosing, with a median onset of 107 days.

Conclusion

This study provides valuable real-world evidence on the safety profile of irbesartan. The identification of new safety signals underscores the necessity of updating drug labels, particularly for assessing and managing high-risk patients. Additionally, the TTO analysis emphasizes the importance of sustained vigilance for adverse events over time. In conclusion, our findings contribute to a more comprehensive understanding of irbesartan's safety, aiding healthcare professionals in optimizing its use in clinical practice.

Hyponatremia with Antidepressant: A Rare Side Effect from Duloxetine in a Child with Acute Leukemia

Duloxetine is indicated for the treatment of chemotherapy-induced neuropathic pain in adults. It is also indicated for anxiety, depression, and fibromyalgia in children. A rare side effect of syndrome of inappropriate antidiuretic hormone (SIADH) secretion has been reported in adults, but not in pediatrics or pediatric oncology patients. We present the case of a 10-year-old child with acute lymphoblastic leukemia, who developed SIADH after duloxetine was given for chemotherapy-induced neuropathic pain and comorbid anxiety. The SIADH resolved after duloxetine was stopped. This case highlights a rare side effect of duloxetine and caution should be taken when prescribing duloxetine to children.

Duloxetine-induced Syndrome of Inappropriate Secretion of Antidiuretic Hormone in a Super-elderly Patient

Duloxetine is widely used for pain control and depressive syndromes. One of its potential side effects is syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Duloxetine-induced SIADH causes hyponatremia, which leads to a variety of symptoms and has previously been reported in the elderly. In the present case, we experienced a case of the rapid onset of SIADH in a super-elderly woman receiving low-dose duloxetine. Elderly patients tend to have lower duloxetine doses and an earlier onset than non-elderly patients. When hyponatremia occurs after duloxetine administration, duloxetine-induced SIADH should be considered, especially in high-risk elderly patients, regardless of the duloxetine dose or duration of treatment.

Analysis of the Frequency and Onset Time of Hyponatremia/Syndrome of Inappropriate Antidiuretic Hormone Induced by Antidepressants or Antipsychotics

BACKGROUND

Hyponatremia and syndrome of inappropriate antidiuretic hormone (SIADH) is a potentially fatal adverse effect of antidepressants (ADs) and antipsychotics (APs), although its frequency and onset time have not been well documented.

OBJECTIVE

To analyze the frequency and onset time of AD- or AP-induced hyponatremia/SIADH.

METHODS

We used plural data-mining techniques to search the US Food and Drug Administration Adverse Event Reporting System (FAERS) database for reports on hyponatremia/SIADH induced by psychotropic drugs from January 2004 to June 2020. For each item, we assessed the reporting odds ratio, 95% CI, median onset time, and Weibull distribution parameters.

RESULTS

We identified 36 422 reports related to hyponatremia/SIADH. Signals were detected for all psychotropic drugs that we analyzed, except for clozapine. The median onset time of total AD-induced hyponatremia/SIADH was shorter than that of AP. For all ADs and APs except clozapine, hazards were considered to be the early failure type. In contrast, the hazard of clozapine was considered to be the random failure type. The limitations of this study included several reporting biases and the presence of confounding variables, particularly age.

CONCLUSION AND RELEVANCE

Most ADs and APs were found to be associated with a risk for hyponatremia/SIADH. In addition, sufficient attention should be paid to signs of hyponatremia/SIADH in the early phase when most ADs and APs are administered. These data are potentially useful for determining AD- or AP-induced hyponatremia/SIADH in the early stage and for preventing its further aggravation into a serious condition.

The potential efficacy of serotonin noradrenaline reuptake inhibitor duloxetine in dropped head syndrome: A case report and review of the literature

A 78 year-old female presented with dropped head syndrome (DHS). Three months before her initial visit to our hospital, the patient noticed a pronounced flexion of her head and neck with subsequent deterioration of symptoms, which included neck pain, difficulty with forward gaze, and gait disturbance. Cervical radiographs demonstrated scoliotic and kyphotic changes, and her symptom deteriorated over time, especially in the standing position. Duloxetine was administered for her low back pain because nonsteroidal anti-inflammatory drugs deemed ineffective. The patient demonstrated marked improvements in both radiographic and clinical appearances after 4 months. Her neck pain decreased from 8 to 2 out of 10 in the Numeric Rating Scale, and her symptoms such as difficulty with forward gaze and gait disturbance had also resolved. Duloxetine is a serotonin noradrenaline reuptake inhibitor that is usually used for chronic musculoskeletal pain, neuropathic pain, or depression. In this report, we present another potential application of duloxetine in the treatment of DHS. The following possibilities were considered for the improved outcomes: (1) pain relief may have helped the patient feel comfortable enough to move her neck, and (2) we suppose that serotonin and noradrenaline reuptake may contribute to the improvement of DHS, because there might be a potential disequilibrium of neurotransmitters such as serotonin, dopamine and noradrenaline in DHS patients. Although further investigation is needed to clarify the mechanism, duloxetine should be considered as one of the optional treatments for DHS.