AB1428 CONTRAINDICATIONS, BOXED WARNINGS AND SPECIAL WARNINGS OF BIOLOGICAL AND TARGETED SYNTHETIC DMARDS

Background

The list of biological DMARDs (bDMARDS) and targeted synthetic DMARDs (tsDMARDs) approved to treat synovitis and extra-articular manifestations is long and constantly expanding. The choice of drug for the individual patient depends on multiple factors. 1) Among these, contraindications and warnings are pivotal to consider. 2), 3) However, a systematic collection of drug class specific warnings for the b/tsDMARDs based on regulatory drug approvals is lacking.

Objectives

Our aim was to make an overview of the different contraindications, boxed warnings and special warnings listed in the European Medicines Agency (EMA) summaries of product characteristics (SmPCs) and the U.S. Food and Drug Administration (FDA) Prescribing Information (PI) for b/tsDMARDs.

Methods

We included all b/tsDMARDs with an FDA and/or EMA approval for any of the diagnoses: rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondylarthritis (SpA), juvenile idiopathic arthritis (JIA), uveitis, plaque psoriasis, inflammatory bowel diseases (IBD). The included drugs were tumor necrosis factor (TNF) inhibitors (inh), anti-CD20 (rituximab), inhibitors of interleukin (IL)-6 receptor (6R), IL-1, IL-17, IL-12/23, IL-23, CD80/86 (abatacept), janus kinase (JAK), the phosphodiesterase 4 (PDE4) (apremilast), and the α4β7 antibody (vedolizumab)

We used the most recent SmPCs and PIs for the reference products in case of existing biosimilar products and extracted the information listed in the categories; contraindications, boxed warnings, and special warnings.

Results

There was a big difference between the year of first approval of the drugs spanning from 1998 to 2017. All drug classes except apremilast had warnings about infection. A warning about herpes zoster was listed specifically for rituximab, inhibitors of IL-6R, IL-1, IL-12/23 and JAK, while warning about hepatitis was listed for TNF inhibitors, rituximab, IL-6R inh., IL-1 inh., abatacept and JAK inh. All drug classes except IL-17 inh., IL-12/23 inh. and apremilast had warnings about malignancy. A warning about demyelinating disease was listed for TNF inh., IL-6R inh., and abatacept. Heart failure was specific for TNF inh. and rituximab while risk of major adverse cardiac events and venous thromboembolism was listed only for JAK inh. A recommendation regarding monitoring lipids was listed for inhibitors of IL-6R and JAK, monitoring liver enzymes was listed for all drug classes except IL-17 inh., IL-12/23 inh., abatacept and apremilast. Development of IBD was listed for IL-17 inh. and risk of diverticulitis was listed for inhibitor of IL-6R and JAK. Cytopenia was listed for rituximab, inhibitors of TNF, IL-6R, IL-1 and JAK. Depression was listed for IL-17 inh. and apremilast.

Conclusion

We made a systematic description of contraindications, boxed warnings and special warnings for b/tsDMARDs with a focus on drugs approved for use in chronic inflammatory arthritis and related disease entities. There were some associations between time of first drug approval and number of listed concerns. This, we presume, is because some of the rare events will not be found before several years after marketing. Group effects and specific concerns for individual drugs were identified.

Based on the warnings, we made a figure with clinically relevant conditions to consider when choosing a drug.

This systematic data collection could prove to be a useful decision tool for clinical practice to ensure patient safety and improve personalized drug choices.

References

[1]Smolen JS, et al. Ann Rheum Dis 2020;79:685–699. doi:10.1136/annrheumdis-2019-216655

[2]Sepriano A, et al. Ann Rheum Dis 2020;79:760–770. doi:10.1136/annrheumdis-2019-216653

[3]Holroyd CR, et al. Rheumatology, Volume 58, Issue 2, February 2019, Pages e3–e42, https://doi.org/10.1093/rheumatology/key208

Figure 1.

Disclosure of Interests

Lykke Skaarup: None declared, Tue Wenzel Kragstrup Shareholder of: Co-founder and clinical developer in iBio tech ApS., Speakers bureau: Speaking fees from Pfizer, Bristol-Myers Squibb, Eli Lilly, Novartis, UCB, and Abbvie., Consultant of: Consultancy fees from Bristol-Myers Squibb and Gilead., Grant/research support from: Research grants from Gilead.

Use of psychotropic drugs during pregnancy and breast-feeding

OBJECTIVE

To write clinical guidelines for the use of psychotropic drugs during pregnancy and breast-feeding for daily practice in psychiatry, obstetrics and paediatrics.

METHOD

As we wanted a guideline with a high degree of consensus among health professionals treating pregnant women with a psychiatric disease, we asked the Danish Psychiatric Society, the Danish Society of Obstetrics and Gynecology, the Danish Paediatric Society and the Danish Society of Clinical Pharmacology to appoint members for the working group. A comprehensive review of the literature was hereafter conducted.

RESULTS

Sertraline and citalopram are first-line treatment among selective serotonin reuptake inhibitor for depression. It is recommended to use lithium for bipolar disorders if an overall assessment finds an indication for mood-stabilizing treatment during pregnancy. Lamotrigine can be used. Valproate and carbamazepin are contraindicated. Olanzapine, risperidone, quetiapine and clozapine can be used for bipolar disorders and schizophrenia.

CONCLUSION

It is important that health professionals treating fertile women with a psychiatric disease discuss whether psychotropic drugs are needed during pregnancy and how it has to be administered.