Online information discrepancies regarding safety of medicine use during pregnancy and lactation: an IMI ConcePTION study.

Background: Inconsistencies in information on safety of medicine use during pregnancy and lactation can result in sub-optimal treatment for pregnant and lactating women, risks to the fetus or child and unnecessary weaning off breastfeeding. The objective of this study was to analyze information discrepancies regarding medicine use during pregnancy and lactation between on-line sources for patients and health care professionals (HCPs) in four European languages.Research design and methods: The medicines analyzed were ibuprofen, ondansetron, olanzapine, fingolimod, methylphenidate and adalimumab. Recommendations were classified into different data source categories, for patients and for HCPs, and compared between the data source categories for each medicine and language.Results: For patients, 11/24 (46%) and 4/24 (17%) comparisons of the pregnancy and lactation recommendations, respectively, were consistent between all sources. The corresponding figures for HCP-sources were 13/24 (54%) and 5/24 (21%). Regulatory sources had generally more restrictive recommendations. Teratology Information Services (TIS) centers' recommendations for medicine use during pregnancy and lactation were consistent in 25/27 (93%) and 15/22 (68%) of cases respectively.Conclusion: Discrepancies between online information sources regarding medicine use during pregnancy and lactation are common, especially for lactation. TIS centers recommendations were more aligned. Additional work is needed to harmonize information within and between countries to avoid conflicting messages.

Principles and Considerations for Responsible Sharing of Safety Information Via the Medical Information Channel.

The approach used by medical information services in answering unsolicited safety-related questions from health care professionals regarding prescription medicines varies widely across the pharmaceutical industry. A significant amount of information is available in the public domain, but this can be difficult to filter and determine what is most appropriate for a given situation. A team representing the medical information group MILE (Medical Information Leaders Europe) and European Federation of Pharmaceutical Industries and Associations Pharmacovigilance Expert Group have partnered to develop principles and considerations on how to answer unsolicited safety questions. Essentially two key principles are important in ensuring success: (1) Effective collaboration between medical information and patient safety teams is important for an optimal outcome providing accurate, useful, and timely information. This article discusses considerations for an effective, efficient collaboration between medical information and patient safety and suggests a way of working. (2) Collaborating teams will need to evaluate and select the most appropriate sources of information to answer the question. Sources of information that may or may not be in the public domain are discussed. Adoption of principles and considerations discussed in this article may be expected to improve current safety information-sharing practices that tend to be conservative and risk averse. In addition, this presents the opportunity to initiate discussions with regulatory authorities to realize the benefits that will come through greater transparency and communication to support safe and effective use of medicines.

Principles and Considerations for Responsible Sharing of Safety Information Via the Medical Information Channel.

The approach used by medical information services in answering unsolicited safety-related questions from health care professionals regarding prescription medicines varies widely across the pharmaceutical industry. A significant amount of information is available in the public domain, but this can be difficult to filter and determine what is most appropriate for a given situation. A team representing the medical information group MILE (Medical Information Leaders Europe) and European Federation of Pharmaceutical Industries and Associations Pharmacovigilance Expert Group have partnered to develop principles and considerations on how to answer unsolicited safety questions. Essentially two key principles are important in ensuring success: (1) Effective collaboration between medical information and patient safety teams is important for an optimal outcome providing accurate, useful, and timely information. This article discusses considerations for an effective, efficient collaboration between medical information and patient safety and suggests a way of working. (2) Collaborating teams will need to evaluate and select the most appropriate sources of information to answer the question. Sources of information that may or may not be in the public domain are discussed. Adoption of principles and considerations discussed in this article may be expected to improve current safety information-sharing practices that tend to be conservative and risk averse. In addition, this presents the opportunity to initiate discussions with regulatory authorities to realize the benefits that will come through greater transparency and communication to support safe and effective use of medicines.

Efficacy and safety of the direct switch to indacaterol/glycopyrronium from salmeterol/fluticasone in non-frequently exacerbating COPD patients: The FLASH randomized controlled trial.

BACKGROUND AND OBJECTIVE: Combination long-acting ß2 -agonist/long-acting muscarinic antagonist (LABA/LAMA) has demonstrated superior clinical outcomes over LABA/inhaled corticosteroid (ICS) in chronic obstructive pulmonary disease (COPD) patients; however, data from blinded randomized controlled trials on direct switching from LABA/ICS to LABA/LAMA are lacking. FLASH (Assessment of switching salmeterol/Fluticasone to indacateroL/glycopyrronium in A Symptomatic COPD patient coHort) investigated if direct switch, without a washout period, from salmeterol/fluticasone (SFC) to indacaterol/glycopyrronium (IND/GLY) in COPD patients improves lung function and is well tolerated. METHODS: In this 12-week, multicentre, double-blind study, patients with moderate-to-severe COPD and up to one exacerbation in previous year, receiving SFC for ≥3 months, were randomized to continue SFC 50/500 µg twice daily (bd) or switch to IND/GLY 110/50 µg once daily (od). Primary endpoint was pre-dose trough forced expiratory volume in 1 s (FEV1 ) at Week 12. RESULTS: In total, 502 patients were randomized (1:1) to IND/GLY or SFC. Patients switched to IND/GLY demonstrated superior lung function (pre-dose trough FEV1 ) versus SFC at Week 12 (treatment difference (Δ) = 45 mL; P = 0.028). IND/GLY provided significant improvements in pre-dose trough forced vital capacity (FVC; Δ = 102 mL; P = 0.002) and numerical improvements in transition dyspnoea index (TDI; Δ = 0.46; P = 0.063). Rescue medication use and COPD assessment test (CAT) scores were comparable between groups. Both treatments had similar safety profiles. CONCLUSION: FLASH demonstrated that a direct switch to IND/GLY from SFC improved pre-dose FEV1 and FVC in COPD patients with up to one exacerbation in the previous year. No new safety signals were identified.

Effectiveness and safety of aliskiren and aliskiren hydrochlorothiazide (HCT) in a multiethnic, real-world setting.

INTRODUCTION: Numerous randomized clinical trials have demonstrated the efficacy and tolerability of aliskiren and aliskiren hydrochlorothiazide (aliskiren HCT) single-pill combination therapy in patients with hypertension. The objective of the present study was to evaluate the effectiveness and safety of aliskiren-based therapy under daily life conditions in a multiethnic population. METHODS: This observational, multicenter, noninterventional study, conducted at 420 centers in Asia and the Middle East, included adult patients with hypertension who received treatment with aliskiren or aliskiren HCT as single or add-on therapy for a planned treatment period of at least 26 weeks. The main effectiveness assessments included the proportion of patients achieving therapeutic blood pressure (BP) goal (defined as systolic BP [SBP]/diastolic BP [DBP]<140/90 mmHg, or <130/80 mmHg in patients with diabetes) and BP response, and change in mean sitting BP from baseline to study end. RESULTS: Of 4,826 patients (mean age 51.4 years, 65.9% male, 64.5% Asian, 41.5% diabetic) included in the study, 3,473 received aliskiren and 1,353 received aliskiren HCT. Almost half the study population (48.1%) received aliskiren or aliskiren HCT as add-on therapy. The therapeutic BP goal was achieved in 49.5% of patients treated with aliskiren and 48.3% of patients receiving aliskiren HCT; attainment of BP goal increased to more than 70% when a classic BP target of <140/90 mmHg was applied for all patients. Reductions in mean sitting SBP/DBP were significantly lower versus baseline for both aliskiren (24.1/12.2 mmHg) and aliskiren HCT (27.6/14.1 mmHg) and BP response rates were consistently achieved in more than 80% of all patients during the study. Aliskiren treatment was well tolerated with only a small proportion of patients experiencing adverse events (AEs; 2.1%) and serious AEs (0.3%). CONCLUSION: In this real-world, naturalistic setting, antihypertensive treatment with an aliskiren-based regimen was effective and well-tolerated in this multiethnic population with arterial hypertension.

The chromatin of differentiating erythroblasts is cleaved into large size fragments independent of caspase activated DNase and apoptosis inducing factor.

Erythroblast cell differentiation involves self-controlled and limited nuclear proteolysis prior nucleus loss. Early evidence suggests that apoptotic-like pathways are activated during this process. The chromatin of developing erythroblasts becomes fragmented in vivo, however, the exact mechanisms and molecules involved remain elusive. In this study, erythroblasts were differentiated in culture from CD34-enriched umbilical cord blood progenitor cells and the characteristics of DNA fragmentation were examined. This analysis shows that the chromatin of differentiating erythroblasts is cleaved into discrete fragments of 50-200 kb. This process most likely involves one or several endonucleases as we detect in vivo double strand DNA cleavage. However, major players of the apoptotic DNA degradation, caspase activated DNase and apoptosis inducing factor, are not activated in these cells. Therefore, our data suggests that erythroblast chromatin degradation may involve enzymes distinct form those active in apoptotic cells.

Human mature erythroblasts are resistant to apoptosis.

Apoptosis plays an important role in red blood cell development, notably by regulating the fate of early erythroid progenitors. We show here that, by contrast, mature erythroblasts are resistant to apoptosis. Treatment of these cells with several apoptosis-inducing agents failed to trigger caspase activation and oligonucleosomal DNA fragmentation. Interestingly, we find that cytochrome c levels are dramatically reduced even though the cells contain mitochondria. Supplementation of cytosolic extracts from mature erythroblasts with cytochrome c, however, did not rescue caspase activation. This was not due to the presence of inhibitors of apoptosis, as these proteins were also missing in these cells. We also show that cytochrome c depletion is a normal event during erythroblast differentiation, which follows transient, developmentally induced caspase activation and correlates with the loss of response to cytokine withdrawal or drug-induced apoptosis. Our data therefore suggest that erythroblasts acquire resistance to apoptosis during maturation through the developmentally induced depletion of cytochrome c and other crucial regulators of the apoptotic machinery.

Macrophage migration inhibition factor is elevated in pregnancy, but not to a greater extent in preeclampsia.

BACKGROUND: Maternal serum concentrations of macrophage migration inhibitory factor (MIF) have recently been reported to be elevated in cases with preeclampsia. These findings may be important in increasing our understanding of the underlying events leading to the development of preeclampsia, as this cytokine is also expressed in the placenta, where it has been shown to possess immunemodulatory activities. For this reason we attempted to independently verify this report. METHODS: Plasma levels of MIF were assessed by ELISA in plasma samples collected from normal healthy male and female blood donors (n=20 per group), as well as healthy normal pregnant women in all three trimesters of pregnancy (n=60). In addition, MIF levels were examined from cases with mild and severe preeclampsia (n=20 per study cohort) and matched normotensive pregnancies (n=20). RESULTS: MIF levels were found to be elevated in pregnancy (median=10.1 ng/ml) when compared to non-pregnant controls (median=1.7 ng/ml). A moderate, but not significant, elevation was found to occur from the first to the third trimester of pregnancy. No significant difference was found to occur between the two preeclampsia study groups when compared to the normotensive control group. CONCLUSIONS: Our data suggest that circulatory MIF concentrations are elevated throughout pregnancy, but are not further increased in preeclampsia.

Numerous erythroblasts in maternal blood are impervious to fluorescent in situ hybridization analysis, a feature related to a dense compact nucleus with apoptotic character.

BACKGROUND AND OBJECTIVES: The analysis by fluorescence in situ hybridization (FISH) of fetal erythroblasts enriched from maternal blood remains an attractive alternative for risk-free prenatal diagnosis of aneuploidies. However, current results are discouraging because of the low levels of sensitivity or the inability to detect fetal erythroblasts by FISH. DESIGN AND METHODS: Erythroblasts were enriched from 35 maternal blood samples by magnetic cell sorting (MACS), identified morphologically following May-Grünwald Giemsa staining and examined by FISH for chromosomes X, Y and 18. RESULTS: We observed that circulating erythroblasts comprised two distinct groups: one was clearly of maternal origin and could be reliably analyzed by FISH, whereas the other, which appeared to be of fetal origin, was largely impervious to FISH analysis. This latter feature seemed to be related to an abnormally dense nucleus with an apoptotic character. Since the oxygen tension in the maternal circulation is higher than that in the fetus, we cultured fetal cord blood erythroblasts in conditions mimicking this difference in oxygen concentrations and found that high oxygen concentrations rapidly induced shrinkage of the erythroblast nucleus, rendering it impervious to FISH analysis. INTERPRETATION AND CONCLUSIONS: Our data show that circulating erythroblasts of presumed fetal origin cannot be reliably analyzed by FISH because of an abnormally dense nucleus. This nuclear phenotype appears to be induced by the higher oxygen tension present in the maternal circulation than in fetal blood.

Anti-phospholipid and anti-DNA antibodies are not associated with the elevated release of circulatory fetal DNA in pregnancies affected by preeclampsia.

OBJECTIVES: We have previously shown that the levels of circulatory fetal DNA are elevated in preeclampsia and that these increases correspond to disease severity. Several reports have indicated that increased levels of antiphospholipid (anti-PL) and anti-DNA antibodies may be associated with preeclampsia, in particular with the severe forms of the disorder. Since the release of cell-free DNA by the placenta is attributed to some form of cell death or damage and as anti-PL and anti-double-stranded DNA (dsDNA) antibodies have been proposed to lead to placental damage, we have studied the relationship between these parameters in preeclampsia. METHODS: Circulating fetal DNA levels in samples taken from pregnant women with mild (n = 12) or severe (n = 12) preeclampsia and from normal pregnant controls (n = 35) were quantified using a Taqman real-time Polymerase Chain Reaction (PCR) assay. The Anti-PL antibodies (IgG and IgM) were assayed by anticardiolipin ELISA and by commercial anti-beta2-Glycoprotein I (GPI) ELISA kits. Anti-dsDNA antibodies (IgG and IgM) were analyzed by a commercially available anti-dsDNA ELISA kit. RESULTS: No correlation could be drawn with the quantity of circulatory fetal DNA in the samples analyzed and corresponding anti-PL or anti-dsDNA antibody levels. Furthermore, no significant difference existed between the levels of these antibodies in the two study groups and the control cohort. CONCLUSION: Our data suggest that the mechanism leading to the increased release of cell-free circulatory DNA from the placenta does not involve trophoblast damage mediated by these agents. Our analysis also questions the reported involvement of anti-PL and anti-DNA antibodies in preeclampsia.