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Biological and Pharmaceutical Bulletin Regular Article Association Biological and Pharmaceutical Bulletin Advance Publication by J-STAGE Advance Publication DOI:10.1248/bpb.b17-00547 November 28, 2017 Biological and Pharmaceutical Bulletin Regular article Association Between Concomitant Use of Acyclovir or Valacyclovir with NSAIDs and an Increased Risk of Acute Kidney Injury:Data Mining of FDA Adverse Event Reporting System Zhihua Yue1, Jinhai Shi2 , Haona Li3 ,Huiyi Li1 1Chinese Pharmacopoeia Commission, Beijing, China 2Tianjin international Joint Academy of Biotechnology & Medicine, Tianjin, China 3Huaihe Hospital of Henan University, Kaifeng, China. Corresponding Author: Zhihua Yue, Ph.D. Chinese Pharmacopoeia Commission, Beijing, China, No.11 Fahua Nanli, Dongcheng District, Beijing,100061, P.R.China E-Mail: [email protected] Ⓒ 2017 The Pharmaceutical Society of Japan SUMMARY NSAIDs are likely to be used concomitantly with acyclovir or valacyclovir in clinical practice, but the study on the safety of such combinations was seldom reported. The objective of the study was to investigate reports of acute kidney injury(AKI) events associated with the concomitant use of oral acyclovir or valacyclovir with an NSAID by using the United States Food and Drug Administration(FDA) Adverse Event Reporting System (AERS) database between January 2004 and June 2012. The frequency of AKI events in patients while simultaneously taking either acyclovir or valacyclovir and an NSAID was compared using the Chi-square test. The effect of concomitant use of acyclovir or valacyclovir and individual NSAIDs on AKI was analyzed by the reporting odds ratio (ROR).The results showed that AKI was reported as the adverse event in 8.6% of the 10,923 patients taking valacyclovir compared with 8.7% of the 2,556 patients taking acyclovir (p=NS).However, AKI was significantly more frequently reported in patients simultaneously taking valacyclovir and an NSAID(19.4%)than in patients simultaneously taking acyclovir and an NSAID(10.5%)(p<0.01). The results also suggested that increased risk of AKI was likely associated with the concomitant use of valacyclovir and some NSAIDs such as loxoprofen, diclofenac, etodolac, ketorolac, piroxicam or lornoxicam. The case series from the AERS indicated that compared with acyclovir, valacyclovir is more likely to be affected by NSAIDs, and the concomitant use of valacyclovir with some NSAIDs might be associated with increased risk of AKI. The drug interactions with this specific combination of medications are worth exploring further. Keywords acyclovir, valacyclovir, NSAID, acute kidney injury, drug interactions, pharmacovigilance, data mining, FAERS Biological and Pharmaceutical Bulletin Advance Publication OBJECTIVE Acyclovir and valacyclovir (the L-valyl ester of acyclovir, converted into acyclovir in vivo) are widely used to treat herpes simplex virus (HSV) and herpes zoster virus (HZV) infections. Clinical trials have shown that acyclovir and valacyclovir can lessen the symptoms of the infection and reduce the formation of new lesions.1,2) Whereas nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for the treatment of acute or chronic conditions where pain and inflammation are present. Due to the current use profile of NSAIDs, either as prescription or over-the-counter drugs, NSAIDs are likely to be used concomitantly with acyclovir or valacyclovir in clinical practice such as rheumatoid arthritis and herpes zoster virus infection, while the study on the safety of such combinations was hardly reported. It’s known that both oral acyclovir(or valacyclovir) and NSAIDs have the potential to affect kidney function, and in rare instances these drugs may cause more severe renal conditions such as acute kidney injury(AKI).3,4) Our previous research has revealed that the concomitant use of loxoprofen (a non-selective NSAID) and valacyclovir might lead to an increase in reports of AKI.5) However, it’s not known whether the combination therapy of other NSAIDs with acyclovir or valacyclovir is associated with increased risk of AKI , and we also need to know the differences of drug interactions between acyclovir and valacyclovir. In the present study, we examined the United States Food and Drug Administration (FDA) database to determine the frequency of AKI adverse events in patients taking both acyclovir or valacyclovir and an NSAID, and the differences of drug interactions between acyclovir and valacyclovir. METHODS We used the public release of the FDA’s Adverse Event Reporting System (AERS) database6) which covers the period from January 2004 to June 2012. The AERS contains reports of adverse drug events spontaneously submitted by physicians, pharmacists, other health care professionals, manufacturers, and consumers from the US and other countries. From the first quarter (Q1) of 2004 through the second quarter (Q2) of 2012, tables including demographic information—DEMO file; drug information—DRUG file and adverse events coded according to the Medical Dictionary for Regulatory Activities (MedDRA) terminology—REAC file for the reported drugs were considered. A unique ISR number allows linking all information from different tables. As the AERS database has some duplicate reports, we removed the older ones from duplicate reports by sorting case identification numbers.7) All reports containing oral acyclovir or valacyclovir were included in the analysis, no matter whether the drug was reported as suspect (‘‘PS’’ or ‘‘SS’’), interacting (‘‘I’’) or concomitant (‘‘C’’) in causing the adverse event. We excluded intravenous acyclovir because our focus was on outpatient-dispensed preparations. The number of patients with adverse events while simultaneously taking either acyclovir or valacyclovir and an NSAID was determined. We selected the most widely used NSAIDs as Biological and Pharmaceutical Bulletin Advance Publication following: propionic acid derivatives(ibuprofen, naproxen, Ketoprofen, flurbiprofen, loxoprofen and oxaprozin), acetic acid derivatives(diclofenac, indomethacin,ketorolac,sulindac,etodolac,nabumetone and tolmetin) enolic acid derivatives i.e.Oxicams (meloxicam,piroxicam,lornoxicam and tenoxicam) and selective COX-2 inhibitors i.e.Coxibs (celecoxib and rofecoxib). Aspirin was excluded in this study because many people take aspirin for disease prevention. The Standard MedDRA Queries (SMQs) are groupings of PT terms, which relate to defined medical conditions or areas of interest.8) In this study, acute kindey injury(AKI) cases were represented by 17 narrow Preferred Terms (PTs) in the SMQ[20000003]: “Acute phosphate nephropathy”, “Acute prerenal failure”, “Anuria”, “Azotaemia”, “Continuous haemodiafiltration”, “Dialysis” ,“Haemodialysis”, “Neonatal anuria”, “Nephropathy toxic”, “Oliguria”, “Peritoneal dialysis”, “Prerenal failure”, “Renal failure”, “Renal failure acute”, “Renal failure neonatal”, “Renal impairment” and “Renal impairment neonatal”. Non-cases were defined as reports that did not contain such PTs. The effect of concomitant use of acyclovir or valacyclovir and individual NSAIDs on AKI was analyzed by the reporting odds ratio (ROR) which was based of case/non-case methodology.9,10) ROR estimates >1 depict exposure-event safety signals and was considered reliable if the number of cases was >3. Frequencies for categorical variables were compared using the Chi-square test, and a p value <0.05 was considered statistically significant. The statistical analysis was performed using R version 2.15.2 software. RESULTS From January 2004 to June 2012, AERS included almost 3 million case reports. A total of 2,556 patients were reported to have had an adverse event while taking acyclovir and a total of 10,923 patients were reported to have had an adverse event while taking valacyclovir. AKI was reported as the adverse event in 8.7% of the 2,556 patients taking acyclovir compared with 8.6% of the 10,923 patients taking valacyclovir (p=NS). The number of patients with adverse events while simultaneously taking either acyclovir or valacyclovir and an NSAID was shown in Table 1. Coadministration of an NSAID was noted in 10.6% of the 10,923 patients who had an adverse event while taking valacyclovir, compared with 7.8% of the 2,556 patients who had an adverse event while taking acyclovir. It revealed that patients who had an adverse event while taking valacyclovir were significantly more likely to also be taking an NSAID than were patients who had an adverse event while taking acyclovir (RR 1.4, 95% confidence intervals 1.2 to 1.6, p<0.001). Although there were no statistically significant differences in patients who had an adverse event while taking valacyclovir in combination with acetic acid derivatives and those who taking acyclovir in combination with acetic acid derivatives. (P=0.100). --Table 1-- Biological and Pharmaceutical Bulletin Advance Publication The characteristics of the patients with adverse events while simultaneously taking either acyclovir or valacyclovir and an NSAID were examined in greater detail. As shown in Table 2, the proportion of female patients in valacyclovir/NSAID group (n = 822, 71.2 %) appeared higher than that in acyclovir/NSAID group (n = 100, 50.0 %). There were no significantly differences in the proportion of patients of each age stage between valacyclovir/NSAID group and acyclovir/NSAID group. The majority of reports came from United States and was posted by health professionals. When considering AKI adverse effects, we found that AKI was significantly more frequently reported in valacyclovir/NSAID group than in acyclovir/NSAID group (19.4%
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