Hpra Drug Safety Newsletter 9499Th Edition

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Hpra Drug Safety Newsletter 9499Th Edition September 2020 HPRA DRUG SAFETY NEWSLETTER 9499TH EDITION In this Edition • Erythromycin – Updated warnings • Insulin-containing medicines – Risk of • Xeljanz (tofacitinib) – Updated regarding cardiovascular risks and cutaneous amyloidosis and potential recommendations due to increased infantile hypertrophic pyloric stenosis for associated changes in glycaemic risk of venous thromboembolism and • Vascular Endothelial Growth Factor control serious and fatal infections (VEGF) pathway inhibitors – Risk of • Leuprorelin-containing depot • Risk of respiratory depression and aneurysm and artery dissection medicines – Risk of lack of efficacy sedation associated with Epaclob • Implanon NXT (etonogestrel implant) due to incorrect reconstitution and 1mg/ml and 2mg/ml oral suspension – Updated insertion and removal administration (clobazam) instructions due to risk of neurovascular injury and implant migration Erythromycin – Updated warnings regarding cardiovascular risks and infantile hypertrophic pyloric stenosis Erythromycin* is a macrolide antibiotic and as such is known to be associated with a risk of QT-prolongation and cardiac arrhythmia, as reflected in the approved product information (Summary of Product Characteristics (SmPC) and Package Leaflet (PL)) for these medicinal products. As part of a recent routine periodic assessment of erythromycin-containing medicines, the European Medicines Agency’s (EMA’s) Pharmacovigilance Risk Assessment Committee (PRAC) considered data from observational studies that identified a rare, short-term risk of cardiovascular events associated with macrolides, including erythromycin.1,2,3 These cardiovascular events include arrhythmia, myocardial infarction and cardiovascular mortality. Based on the available data, the PRAC recommended that consideration of cardiovascular risks should be balanced with known treatment benefits when prescribing erythromycin-containing medicines, particularly in patients at high risk of cardiovascular events. Erythromycin should not be given to patients with a history of QT prolongation or ventricular cardiac arrhythmia, nor should it be given to patients with electrolyte disturbances. Similar recommendations were previously introduced for clarithromycin-containing medicines, as highlighted in the 88th Edition of the HPRA’s Drug Safety Newsletter. As part of the PRAC’s assessment, an extensive literature review was undertaken and it was considered that there was consistent evidence across a reasonable body of literature to support an association between exposure to erythromycin in infants and the risk of infantile hypertrophic pyloric stenosis (IHPS). Data from three meta-analyses suggested that erythromycin exposure was associated with a two- to three-fold increase in the risk of IHPS in children less than 6 months of age, particularly in those exposed during the first 14 days of life.4,5,6 The available data suggest a risk of 2.6% following exposure to erythromycin during this time period, while the risk of IHPS in the general population is estimated to be 0.1-0.2%. The product information for erythromycin-containing medicines that are systemically absorbed has been updated to reflect current knowledge regarding the risks associated with treatment, as described above, while details of a recently identified increased risk of bleeding associated with concomitant use of the direct acting oral anticoagulant, rivaroxaban, has also been included. Advice to Healthcare Professionals • Erythromycin should not be given to patients with a history of QT prolongation or ventricular cardiac arrhythmia, nor should it be given to patients with electrolyte disturbances. • Consideration of the cardiovascular risks associated with macrolide antibiotics should be balanced with known treatment benefits when prescribing erythromycin-containing medicines. • The product information for erythromycin-containing medicines that are systemically absorbed has been updated to reflect current knowledge regarding the risks associated with treatment, including cardiovascular risk, risk of IHPS, and bleeding risk in association with concomitant rivaroxaban treatment. 1 Kevin O’Malley House, Earlsfort Centre, Earlsfort Terrace, Dublin 2, Ireland. T: +353 1 676 4971 E: [email protected] www.hpra.ie Key messages Observational studies have identified a rare, short-term risk of arrhythmia, myocardial infarction and cardiovascular mortality associated with macrolide antibiotics, including erythromycin. Consideration of these findings should be balanced with treatment benefits when prescribing erythromycin in patients at high risk of cardiovascular events. There is evidence of an increased risk of bleeding when erythromycin is used concomitantly with the direct acting oral anticoagulant, rivaroxaban. Epidemiological studies including data from meta-analyses suggest a two- to three-fold increase in the risk of infantile hypertrophic pyloric stenosis (IHPS) following exposure to erythromycin in infancy. Suspected adverse reactions should be reported to the HPRA via the available methods (www.hpra.ie/report). References 1) Cheng YJ, Nie XY, Chen XM et al. The role of macrolide antibiotics in increasing cardiovascular risk. J Am Coll Cardiol. 2015;66(20):2173-84. 2) Gorelik E, Masarwa R, Perlman A, Rotshild V, Muszkat M, Matok I. Systematic Review, Meta-analysis, and Network Meta-analysis of the Cardiovascular Safety of Macrolides. Antimicrob Agents Cemother. 2018 May 25;62(6). 3) Wong AYS, Chan EW, Anand S et al. Managing Cardiovascular Risk of Macrolides: Systematic Review and Meta-Analysis. Drug Saf. 2017 Aug;40(8):663-677. 4) Murchison L, De Coppi P, Eaton S. Post-natal erythromycin exposure and risk of infantile hypertrophic pyloric stenosis: a systematic review and meta- analysis. Pediatr Surg Int. 2016 Dec;32(12):1147-1152. 5) bdellatif M, Ghozy S, Kamel MG et al. Association between exposure to macrolides and the development of infantile hypertrophic pyloric stenosis: a systematic review and meta-analysis. Eur J Pediatr. 2018;178(3):301-314. 6) Almaramhy HH, Al-Zalabani AH. The association of prenatal and postnatal macrolide exposure with subsequent development of infantile hypertrophic pyloric stenosis: a systematic review and meta-analysis. Ital J Pediatr. 2019 Feb 4;45(1)20. Vascular Endothelial Growth Factor (VEGF) pathway inhibitors – Risk of aneurysm and artery dissection Angiogenesis is a complex process by which new blood vessels are formed from the endothelium of a pre-existing vasculature. This process plays a role in both physiological and pathological conditions. Vascular Endothelial Growth Factor (VEGF) and its receptors have a central role in tumour angiogenesis and tumour growth, and it is thought that VEGF pathway inhibitors* exert an effect through blockage of the signal transduction pathways. However, given the crucial physiological role of VEGF in vascular protection and vascular homeostasis, inhibition of VEGF activity may compromise these protective and homeostatic mechanisms and affect the integrity of the vascular matrix. The European Medicines Agency’s (EMA) Pharmacovigilance Risk Assessment Committee (PRAC) has completed a review of VEGF pathway inhibitors with respect to the potential risk of aneurysm and artery dissection. Prior to this review, the product information (Summary of Product Characteristics (SmPC) and Package Leaflet (PL)) for a number of VEGF pathway inhibitors already included warnings regarding the risk of aneurysm and/or artery dissection. Similarly, the product information for VEGF pathway inhibitors for systemic administration already described the risk of hypertension, which is an important predisposing factor for artery dissection and aneurysm. Having considered reports of aneurysm and artery dissection in the EMA’s adverse reaction database (EudraVigilance), some of which were fatal, as well as the totality of available evidence, the product information for all VEGF pathway inhibitors for systemic administration have recently been updated to reflect this risk. However, the review concluded that based on the available evidence, a causal association could not be established between these risks and the two VEGF pathway inhibitors that are authorised for use in ocular conditions and administered by intravitreal injection, ranibizumab (Lucentis) and aflibercept (Eylea). Advice to Healthcare Professionals • The use of VEGF pathway inhibitors for systemic administration in patients with or without hypertension may promote the formation of aneurysm and/or artery dissection, which may be fatal in some cases. • Before initiating treatment, this risk should be carefully considered in patients with additional risk factors such as hypertension or history of aneurysm. • Any modifiable risk factors such as hypertension should be reduced as far as possible in patients treated with VEGF pathway inhibitors for systemic administration. • Monitor and treat patients for hypertension in accordance with recommendations in the Summary of Product Characteristics (SmPC) for the relevant VEGF pathway inhibitors for systemic administration. • The product information for VEGF pathway inhibitors for systemic administration has recently been updated to provide further information on the risk of aneurysm and artery dissection. 2 Kevin O’Malley House, Earlsfort Centre, Earlsfort Terrace, Dublin 2, Ireland. T: +353 1 676 4971 E: [email protected] www.hpra.ie Key messages The use of VEGF pathway inhibitors for systemic administration in patients with or without hypertension may promote
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