The Risk of Infections Associated With JAK Inhibitors in Rheumatoid Arthritis: A Systematic Review and Network Meta-analysis.

BACKGROUND/OBJECTIVE: The Janus kinases (JAKs) are cytoplasmic tyrosine kinases associated with membrane cytokine receptors that mediate signaling of multiple cytokines and growth factors, contributing to the pathogenesis of multiple autoimmune disorders. The JAK inhibitors are a new class of targeted therapies with proven efficacy in treating rheumatoid arthritis but are associated with an increased risk of infections. This study is aimed at comparing the relative safety of the different JAK inhibitors with regard to the risk of serious infections in patients with rheumatoid arthritis. METHODS: PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov were searched to identify randomized controlled trials evaluating the efficacy and safety of JAK inhibitors in patients with rheumatoid arthritis. The outcomes assessed were the risk of total and serious infections, tuberculosis, and herpes zoster. Sensitivity analysis disaggregated the results according to background therapy and licensed doses of JAK inhibitors. RESULTS: Thirty-seven randomized controlled trials that were included met the inclusion criteria. Compared with filgotinib, adalimumab (4.81; 95% confidence interval [CI], 1.39-16.66), etanercept (6.04; 95% CI, 1.79-20.37), peficitinib (7.56; 95% CI, 1.63-35.12), tofacitinib (4.29; 95% CI, 1.43-12.88), and upadacitinib (4.35; 95% CI, 1.46-13.00) have an increased risk of herpes zoster infection. Risk differences between the drugs became statistically nonsignificant when the sensitivity analysis was conducted. CONCLUSIONS: The risk of infections seems to be similar among the currently approved JAK inhibitor drugs. Although the initial results suggested that filgotinib could have a reduced risk of herpes zoster, the sensitivity analyses did not support those findings.

Risk of Cardiovascular and Venous Thromboembolic Events Associated With Janus Kinase Inhibitors in Rheumatoid Arthritis: A Systematic Review and Network Meta-analysis.

BACKGROUND/OBJECTIVE: The Janus kinases are cytoplasmic tyrosine kinases associated with membrane cytokine receptors that mediate signaling of multiple cytokines and growth factors, contributing to the pathogenesis of multiple autoimmune disorders. Janus kinase inhibitors (JKIs) are a new class of targeted therapies with proven efficacy in treating rheumatoid arthritis but are associated with an increased risk of infections. This study is aimed at assessing the risk of cardiovascular and venous thromboembolic events associated with JKIs in patients with rheumatoid arthritis. METHODS: PUBMED, EMBASE, Cochrane Library, and clinicaltrials.gov were searched to identify randomized controlled trials evaluating the efficacy and safety of JKIs in patients with rheumatoid arthritis. The outcomes assessed were the risk of major adverse cardiovascular events, venous thromboembolic events, and any cardiovascular event. Sensitivity analysis disaggregated the results according to background therapy, JKI licensed doses, and studies' methodological quality. RESULTS: Forty-two randomized controlled trials met the inclusion criteria. No statistically significant risk differences were observed between the JKIs for any of the assessed outcomes. Compared with placebo, tofacitinib (odds ratio, 0.32; 95% confidence interval, 0.11-0.89) reduces the risk of venous thromboembolism. The results of the sensitivity analysis are in line with the initial findings. CONCLUSIONS: Current evidence suggests that the risk of cardiovascular and venous thromboembolic events is similar among the JKIs. Postmarketing pharmacovigilance evidence will be of utmost importance in confirming the cardiovascular safety of these drugs.

Fluoroquinolones and the risk of tendon injury: a systematic review and meta-analysis.

PURPOSE: Tendinopathy is a known adverse reaction associated to fluoroquinolones, but a meta-analysis was not yet published. The aim of this study was to conduct a systematic review and a meta-analysis of the scientific evidence evaluating the risk of tendon injury associated with fluoroquinolones. METHODS: A literature search was conducted to identify observational studies which reported results on the risk of Achilles tendon rupture (ATR), risk of Achilles tendinitis (AT), or risk of any tendon disorders (ATD). A meta-analysis was performed by pooling odds ratios (ORs) with their 95% confidence intervals (CIs). RESULTS: Fifteen studies were included in the meta-analysis. Treatment with fluoroquinolones was associated with an increased risk of ATR (OR 2.52 (95% CI 1.81-3.52), p < 0.001, I2 = 76.7%), an increased risk of AT (OR 3.95 (95% CI 3.11-5.01), p < 0.001, I2 = 0%), and increased risk of ATD (OR 1.98 (95% CI 1.62-2.43), p < 0.001, I2 = 84.5%). The initial risk estimates remained statistically significant among patients aged ≥ 60 years old. Risk estimates did not significantly change after depending on the concomitant use of corticosteroids or studies methodological quality assessment. The analysis according to the type of fluoroquinolones was only possible for ATR, which were ofloxacin and norfloxacin were found to increase the risk of this outcome, but not ciprofloxacin and levofloxacin. CONCLUSIONS: The results of this meta-analysis confirm the risk of tendon injuries associated with fluoroquinolones. Older age and concomitant use of corticosteroids seem to be additional risk factors for tendinopathy.

Drug-induced ocular adverse reactions: review of the safety alerts issued during the last decade.

PURPOSE: The purpose of this study was to evaluate ocular-related adverse events associated with the use of drugs by analyzing the content of safety alerts issued by major regulatory authorities during the last decade. METHODS: The websites of 4 health regulatory authorities were reviewed to identify safety alerts issued on ocular adverse events. Safety alerts were included if they have been issued between January 2005 and December 2014. Only safety alerts on drugs with market authorization were considered for inclusion. RESULTS: Thirty-eight safety alerts were included in the study. Urologicals (n = 11; 29%), followed by drugs used in diabetes, antibacterials for systemic use, antineoplastic agents, and ophthalmologicals were the most frequently suspected drugs evaluated in the safety alerts (n = 4; 10%, each). The most frequently evaluated adverse events were visual disorders NEC (n = 12; 32%), including visual impairment, diplopia, and blurred vision. The majority (n = 25; 66%) of the safety alerts were supported by postmarketing spontaneous reports. The most commonly updated drug label section was the Warnings and Precautions section (n = 33; 87%), followed by the Adverse Reactions section (n = 26; 68%). CONCLUSIONS: Ocular adverse events, newly identified during this decade, come mostly from systemic drugs, some of them marketed for several years. Physicians should be aware of drug-induced adverse events in the eye to avoid, as soon as possible, their progression, which can lead to visual impairment.

Drug-safety alerts issued by regulatory authorities: usefulness of meta-analysis in predicting risks earlier.

PURPOSE: The purpose of this study was to evaluate how risk estimates generated from cumulative meta-analysis performs over time for drugs having their benefit/risk ratio re-evaluated due to safety issues and, additionally, assess whether results are consistent with regulatory authorities' conclusions. METHODS: Four major regulatory authorities were searched for their issued safety alerts supported by longitudinal, comparative studies (experimentals and/or observationals). The random-effects model was used to pooled odds ratios (OR) over time by including studies according to the year they first became available. RESULTS: Seventeen safety alerts were included in this study. In 2008, proton-pump inhibitors (PPIs) were associated with an increased risk for bone fractures [OR 1.25, 95 % confidence interval (CI) 1.00-1.55, P = 0.049); the US Food and Drug Association (FDA) issued a safety alert in 2010 and added warnings to the label. An increased risk for Clostridium-difficile-associated diarrhea was pooled for PPIs in 2004 (OR 1.89, 1.19-3.02, P = 0.007); US FDA issued a safety alert in 2012, adding warnings to the label. PPIs were associated with pneumonia in 2009 (OR 1.40, 1.06-1.85, P = 0.017); US FDA issued an alert in 2012 but concluded that the benefit/risk (B/R) ratio remains positive. Statins were associated with an increased risk for diabetes (OR 1.07, 1.01-1.15, P = 0.033) in 2008. The European Medicines Agency (EMA) issued an alert in 2012, including warnings to the label. The remaining cumulative meta-analyses did not estimate increased risks in advance of regulatory decisions. CONCLUSION: This study demonstrates that meta-analysis may help predict iatrogenic risks. However, between-study heterogeneity can considerably affect the estimated results, and therefore, this technique should not replace further assessments during BR ratio re-evaluations.

Sources of information used by regulatory agencies on the generation of drug safety alerts.

PURPOSE: The study of the grounds on which data regulatory authorities base their decisions on drug safety evaluations is an important clinical and public health issue. The aim of this study was to review the type and publication status of data sources supporting benefit/risk ratio re-evaluations conducted by the major regulatory authorities on safety issues. METHODS: A website search was carried out to identify all safety alerts published by the U.S Food and Drugs Administration, Health Canada, European Medicines Agency and the Australian Therapeutics Goods Administration. Safety alerts were included if the causal relation between a suspected drug exposure and the occurrence of an adverse event was evaluated for the first time between 2010 and 2012. Type of data sources evaluated by these regulatory authorities, publication status of the data sources and status of the drug label section with respect to updating were evaluated. RESULTS: A total of 59 safety alerts were included in this study. Of these, 33 (56%) were supported by post-marketing spontaneous reports, 24 (41%) evaluated randomized clinical trials, 16 evaluated cohort studies (27%), 13 were case-control studies (22%) and 11 evaluated case report/case series (17%). Twenty-three safety alerts (39%) were issued based. on unpublished evidence, corresponding mainly to post-marketing spontaneous reports. The "Warnings and precautions section" was the drug label section most frequently updated (n = 40; 68%). CONCLUSION: Despite the different lengths of time taken by the different regulatory authorities to come to similar decisions on the same issues-an issue which would seem to deserve further harmonization-post-marketing spontaneous reports have supported most of the benefit/risk ratio re-evaluations, thereby confirming the value of such re-evaluations in detecting unknown adverse events.

Multiple drug exposure as a risk factor for the seriousness of adverse drug reactions.

AIM: The aim of the present study was to validate the hypothesis that multiple drug exposure is an independent risk factor for serious adverse drug reactions (ADRs). BACKGROUND: Adverse drug reactions (ADRs) are an important cause of iatrogenic disease, the majority being preventable. Multiple drug exposure, ageing and female gender have been identified as important risk factors for an increased incidence of ADRs. METHOD: ADR reports received by the central Portugal Regional Pharmacovigilance Unit, between January 2001 and December 2009, were studied. RESULTS: Nearly half (47.4%) of ADRs reports were considered serious, from which 66.7% reported multiple drug exposure (mean 3.07 ± 2.2; maximum 13). After adjusting for gender, simultaneous exposure to three or more drugs was significantly associated with an increased risk of serious ADRs [odds ratio (OR) 1.23; 95% confidence interval (CI) 1.02-1.51]. CONCLUSIONS: The present results support that multiple drug exposure is an independent risk factor for serious ADRs. Such findings are of importance in both medicines benefit/risk ratio evaluations and patient safety monitoring. IMPLICATIONS FOR NURSING MANAGEMENT: A new level of nursing involvement is needed in both the detection of ADRs and prevention of serious outcomes, particularly in high-risk patients.

Causality assessment of adverse drug reactions: comparison of the results obtained from published decisional algorithms and from the evaluations of an expert panel.

PURPOSE: To compare the results of causality assessments of reported adverse drug reactions (ADR's) obtained from decisional algorithms with those obtained from an expert panel using the WHO global introspection method (GI) and to further evaluate the influence of confounding variables on algorithms ability in assessing causality. METHOD: Two hundred sequentially reported ADR's were included in this study. An independent researcher used algorithms, while an expert panel assessed the same reports using the GI, both aimed at evaluating causality. Reports were divided into three groups according to the presence, absence or lack of information on confounding variables. RESULTS: For the total sample, observed agreements between decisional algorithms compared with GI varied from 21% to 56%, average of 47%. When confounding variables were taken into account, agreements varied between 41% and 69%, average of 58%; 8% and 65%, average of 46% and 15% and 53%, average of 42% accordingly to the absence, lack of information or presence of confounding variables, respectively. The extend of reproducibility beyond chance was low for the total sample (average Kappa = 0.26) and within the groups considered. CONCLUSION: The overall observed agreement between algorithm and GI was moderate although poorly different from chance, confounding variables being a shortcoming of algorithms ability in assessing causality.