2016 WHO Pharmaceuticals

NEWSLETTER No.1

Prepared in collaboration with the WHO Collaborating Centre for International Drug Monitoring, Uppsala Sweden

The WHO Pharmaceuticals Newsletter provides you The aim of the Newsletter is to with the latest information on the safety of medicines disseminate information on the and legal actions taken by regulatory authorities across safety and efficacy of pharmaceutical products, based on the world. It also provides signals based on information communications received from our derived from Individual Case Safety Reports (ICSRs) network of "drug information available in the WHO Global ICSR database, officers" and other sources such as specialized bulletins and journals, VigiBase®. as well as partners in WHO. This issue includes recommendations from the working groups of the Thirty-eighth Annual Meeting of The information is produced in the Representatives of National Pharmacovigilance form of résumés in English, full Centres that was held in 2015, in Delhi, India. texts of which may be obtained on request from: Safety and Vigilance, EMP-HIS, World Health Organization, 1211 Geneva 27, Switzerland, E-mail address: [email protected]

This Newsletter is also available on our Internet website: http://www.who.int/medicines

Further information on adverse Contents reactions may be obtained from the WHO Collaborating Centre for International Drug Monitoring Box 1051 Regulatory matters 751 40 Uppsala Tel: +46-18-65.60.60 Safety of medicines Fax: +46-18-65.60.80 E-mail: [email protected] Signal Internet: http://www.who-umc.org

Feature

© World Health Organization 2016

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Table of Contents

Regulatory Matters Amlodipine besilate ...... 5 Antiretroviral medicines ...... 5 Atovaquone ...... 5 Azilsartan ...... 6 Benzoyl peroxide and salicylic acid topical products ...... 6 ...... 6 Deferasirox ...... 7 Elvitegravir/ cobicistat/ emtricitabine/ tenofovir disoproxil fumarate and anti-epileptic medications ...... 7 Fluoroquinolones oral antibiotics ...... 7 Fomepizole ...... 8 Fingolimod ...... 8 Interferon beta-1a ...... 8 Itraconazole ...... 9 Lenvatinib ...... 9 Levonorgestrel intrauterine contraceptive device (IUCD) ...... 9 Mycophenolate mofetil ...... 10 Nintedanib ethanesulfonate ...... 10 Nivolumab ...... 10 Ombitasvir hydrate/paritaprevir hydrate/ritonavir ...... 10 Peginterferon alfa-2a ...... 11 Piperacillin sodium ...... 11 Posaconazole ...... 11 Repaglinide and clopidogrel ...... 12 Sodium glucose co-transporter 2 (SGLT2) inhibitors ...... 12 Thalidomide ...... 12 Varenicline and alcohol ...... 13

Safety of Medicines Allopurinol ...... 14 Bevacizumab ...... 14 Codeine ...... 14

WHO Pharmaceuticals Newsletter No. 1, 2016  3

Table of Contents

Finasteride ...... 15 Melatonin ...... 15 Pazopanib ...... 15 Proton pump inhibitors ...... 16 ...... 16

Signal Vemurafenib and Atrial fibrillation: Signal strengthening ...... 17

Feature Recommendations from the 38th Annual Meeting of Representatives of the National Pharmacovigilance Centres participating in the WHO Programme for International Drug Monitoring ...... 24

WHO Pharmaceuticals Newsletter No. 1, 2016  4

Regulatory Matters

Amlodipine besilate Antiretroviral treatment with any HIV medicine. However, these Risk of fulminant medicines changes are partly linked to hepatitis, underlying disease control Updated advice on body- and lifestyle in addition to agranulocytosis and fat changes and lactic antiretroviral treatment; rhabdomyolysis acidosis • retaining warnings for lipoatrophy and Japan. The Ministry of Health, The United Kingdom. The lipoaccumulation only for Labour and Welfare (MHLW) Medicines and Healthcare , stavudine, and and the Pharmaceuticals and Products Regulatory Agency didanosine; Medical Devices Agency (MHRA) has notified health- • removing warnings about (PMDA) have advised that the care professionals that the lactic acidosis for nucleoside package inserts for amlodipine product information for and nucleotide analogues, and amlodipine combinations antiretrovirals will be updated with the exception of containing: azilsartan; aliskiren to reflect current knowledge products that contain fumarate; irbesartan; about lipodystrophy and lactic zidovudine, stavudine, or telmisartan; candesartan; acidosis. didanosine. valsartan; and atorvastatin hydrate should list: Class warnings about Reference: fulminant hepatitis; lipodystrophy (lipatrophy, Drug Safety Update, MHRA, agranulocytosis (except for lipoaccumulation, changes in Volume 9, issue 5: preparations with candesartan weight and metabolism) were 14 December 2015 and valsartan); and being routinely applied to all (www.gov.uk/mhra) rhabdomyolysis as clinically antiretroviral agents, and significant adverse reactions. warnings of lactic acidosis were applied to nucleoside and Atovaquone Amlodipine is indicated for nucleotide analogue medicines. hypertension and angina These warnings may not Cases of agranulocytosis pectoris. Amlodipine in accurately reflect current and leukopenia combination with atorvastatin scientific understanding. is used in patients with Japan. The MHLW and the hypercholesterolemia or Following an EU-wide review, it PMDA have announced that the familial hypercholesterolemia was noted that lipoatrophy was product labels for atovaquone in addition to hypertension or related only to substances with (Samitrel®) and atovaquone/ angina pectoris. The remaining a high risk of mitochondrial proguanil combination combination products listed toxicity (zidovudine, stavudine, (Malarone®) have been above are indicated for didanosine), and not seen in revised to include hypertension only. regimens with other nucleoside reverse transcriptase inhibitor agranulocytosis and leukopenia Two cases of fulminant products. In addition, evidence as adverse reactions. hepatitis, one case of of disproportional body-fat Atovaquone as a single agent agranulocytosis, and three redistribution in relation to is indicated for the treatment cases of rhabdomyolysis have antiretroviral treatment was and prevention of been reported in patients not clear. Effects on blood pneumocystis pneumonia. In taking amlodipine in Japan lipids and glucose may occur combination with proguanil during the last three years. A with any HIV medicine and are hydrochloride, it is used in the causal relationship could not not restricted to protease prophylaxis and treatment of be ruled out in some of these inhibitors, nucleoside and malaria. cases. In addition, there were nucleotide analogues. The risk a total of six cases of of lactic acidosis was A total of 11 cases of rhabdomyolysis reported in considered to differ across agranulocytosis and leukopenia patients taking the amlodipine nucleoside and nucleotide have been reported in patients and atorvastatin combination. analogues, being most strongly taking atovaquone. The causal Following investigations and associated with zidovudine, relationship to atovaquone advice from experts, the stavudine, and didanosine. could not be ruled out in five of MHLW/PMDA have decided that these cases. Two cases were revision of the package insert To be consistent with current fatal (a causal relationship is necessary. HIV treatment guidelines and could not be established). evidence, product information Following investigations and Reference: will be amended by: advice from experts, the Revision of Precautions, • including advice that weight MHLW/PMDA decided that MHLW/PMDA, 12 January 2016 gain and metabolic changes revision of the package insert (www.pmda.go.jp/english/) (such as lipid and glucose was necessary. increases) may occur during WHO Pharmaceuticals Newsletter No. 1, 2016  5

Regulatory Matters

“Agranulocytosis and Benzoyl peroxide and Reference: leukopenia” have been added Summary Safety Review, to the “Clinically significant salicylic acid topical Health Canada, 10 December adverse reaction” section of 2015 (www.hc-sc.gc.ca) the product label for products atovaquone and in the Risk of serious allergic “pancytopenia” subsection in reactions Bisphosphonates the atovaquone/ proguanil preparation. Canada. Health Canada has Risk of osteonecrosis of the external auditory Reference: informed health-care Revision of Precautions, professionals and consumers canal MHLW/PMDA, 12 January 2016 about the risk of serious The United Kingdom. The (www.pmda.go.jp/english/) hypersensitivity reactions, and changes to product information MHRA has announced that the for over-the-counter (OTC) product information for bisphosphonates will be Azilsartan topical acne products containing either benzyl updated to advise health-care professionals and patients of Risk of rhabdomyolysis peroxide or salicylic acid. the possibility of osteonecrosis Health Canada has conducted Japan. The MHLW and the of the external auditory canal a health review and concluded PMDA have announced that the with use. that there is evidence to product information for support a link between the use Bisphosphonates (alendronic azilsartan (Azilva®) and of OTC benzyl peroxide or acid, ibandronic acid, azilsartan/amlodipine salicylic acid topical acne pamidronate disodium, preparation (Zacras®) have products and serious risedronate sodium, sodium been revised to include hypersensitivity reactions clodronate, ) rhabdomyolysis as an adverse including anaphylaxis. Health are used to treat effect. Canada received 10 and 16 and Paget’s disease, and are Azilsartan is an angiotensin II cases of serious part of some cancer regimens receptor antagonist used in the hypersensitivity reactions to (particularly metastatic bone treatment of hypertension. In OTC benzyl peroxide and cancer and multiple myeloma). Japan, a total of five cases in salicylic acid products Individual bisphosphonates patients taking azilsartan as a respectively of which five have different indications. single preparation associated (benzyl peroxide) and four Benign idiopathic osteonecrosis with rhabdomyolysis have (salicylic acid) were of the external auditory canal been reported (including four anaphylaxis. is a rare condition that can cases for which a causal As a result Health Canada will occur in the absence of relationship to the product update the directions of use antiresorptive therapy (therapy could not be ruled out). One and warning sections of the to increase bone strength) and case of rhabdomyolysis Health Canada Acne Therapy is sometimes associated with associated with use of Monograph for topical OTC local trauma. azilsartan/amlodipine acne products containing these combination has also been At the time of the components. reported. announcement, there were 29 An information update will be reports of osteonecrosis of the Following investigations and published and will provide the external auditory canal in advice from experts, the following consumer advice in association with MHLW/PMDA decided that the event of an anaphylactic bisphosphonates (oral and changes to the package insert reaction: intravenous forms) for use in were necessary. both cancer related and “Rhabdomyolysis” will be  if you develop severe osteoporosis indications, that added in the “Clinically itching and hives, with have been identified globally significant adverse reaction” swelling on the face, eyes, and 11 cases reported in the section. lips, mouth or throat; literature. Most cases were associated with long term Reference: difficulty breathing, throat bisphosphonate therapy (≥2 Revision of Precautions, tightness or hoarseness; MHLW/PMDA, 12 January 2016 years) and included possible and/or fainting, please see (www.pmda.go.jp/english/) risk factors, for example emergency medical steroid use. Evidence from services. cases reported and from the literature supports a causal association between

WHO Pharmaceuticals Newsletter No. 1, 2016  6

Regulatory Matters bisphosphonates and Acute pancreatitis is fosphenytoin (phenytoin osteonecrosis of the external characterized by an increase in prodrug). Stribild® is indicated canal, however evidence is pancreatic enzymes in the for the treatment of human insufficient with use of higher blood and urine. immunodeficiency virus-1 bisphosphonate doses for (HIV-1) infection. A signal of pancreatitis cancer-related conditions. associated with deferasirox The results of a The MHRA provides health-care was published in June 2015. have shown that concomitant professionals with the following There have been 14 reports use of carbamazepine advice: globally in children and significantly reduces blood • The possibility of adolescents aged 2-16 years concentrations of elvitegravir osteonecrosis of the (until March 2015), for this and cobicistat, which could external auditory canal suspected adverse reaction. result in loss of therapeutic should be considered in effect. Phenobarbital and Health-care professionals are patients receiving phenytoin are also potent advised to take into bisphosphonates who inducers of CYP3A comparable consideration the potential risk present with ear symptoms, to carbamazepine. Based on of acute pancreatitis in including chronic ear available evidence and advice patients who are prescribed infections, or in patients from experts, the MHLW/PMDA deferasirox, and to monitor for with suspected have decided that it was signs and symptoms which cholesteatoma. necessary to revise the could be suggestive of • Possible risk factors include package insert for Stribild® as pancreatitis, such as steroid use and follows: abdominal pain, nausea, chemotherapy, with or “Carbamazepine, vomiting or tenderness of the without local risk factors phenobarbital, phenytoin, abdomen to touch, particularly such as infection or trauma. fosphenytoin” should be added in paediatric patients. • Patients should be advised to the contraindications section to report any ear pain, (See WHO Pharmaceuticals under “Patients being discharge from the ear, or Newsletter No.6, 2015: Signal- administered the following an ear infection during Deferasirox and pancreatitis in drugs”. “Carbamazepine, bisphosphonate treatment. paediatric patients) phenobarbital, phenytoin” should be deleted from Reference: Reference: Precautions for concomitant Drug Safety Update, MHRA Product Safety, HSA, use subsection, and added to Volume 9, issue 5: 30 December 2015 the “Contraindications for 14 December 2015 (http://www.hsa.gov.sg/) concomitant use” subsection in (www.gov.uk/mhra) the “Interactions” section. Elvitegravir/ Reference: Deferasirox Revision of Precautions, cobicistat/ MHLW/PMDA, Risk of pancreatitis in emtricitabine/ 24 November 2015 paediatric patients (www.pmda.go.jp/english/) tenofovir disoproxil Singapore. The Health fumarate and anti- Sciences Authority (HSA) has Fluoroquinolones oral announced that the package epileptic medications insert for deferasirox antibiotics (Exjade®) will be Potential reduction of strengthened to include blood concentration by Risk of retinal warnings on the risk of acute drug-drug interaction detachment pancreatitis. Japan. The MHLW and the Canada. Health Canada Deferasirox is an oral iron PMDA have announced recommends that product chelator used for treatment of changes in the product label labels for oral fluoroquinolones chronic iron overload due to: for the antiretroviral should be revised to highlight frequent blood transfusions combination the urgency of seeking advice (patients aged ≥6 years, or 2- elvitegravir/cobicistat/ from health-care professionals years if other treatments are emtricitabine/tenofovir if patients experience vision contraindicated), beta disoproxil fumarate (Stribild®) problems during or following thalassaemia (patients aged to include warnings of the use of fluoroquinolones. ≥10 years), and non interaction between Stribild® Retinal detachment is a transfusion dependant and carbamazepine, painless separation of the thalassaemia syndromes. phenobarbital, phenytoin, retina from the layer of WHO Pharmaceuticals Newsletter No. 1, 2016  7

Regulatory Matters support tissue and blood Japan, there have been a There have been 151 vessels at the back of the eye number of reported adverse international cases of basal cell that provide the retina with reactions including fatal cases, carcinoma reported with oxygen and nourishment. but no cases associated with exposure to fingolimod Retinal detachment is a anaphylaxis. Based on (February 2015). medical emergency and available evidence and advice The EMA recommends that symptoms include sudden of experts, the MHLW/PMDA patients should be evaluated appearance of debris in the have decided that it was before and during treatment field of vision, the perception necessary to revise the with fingolimod to allow early of flashes of light in the package insert. identification of signs and affected eye, sensation of a “Anaphylaxis” will be added to symptoms that could be linked shadow or curtain over the the “Clinically significant to PML or basal cell carcinoma portion of the visual field, and adverse reaction” subsection in and they should be treated sudden or complete loss of the “adverse reaction” section accordingly. Before starting vision. in the package insert. treatment with fingolimod, a Oral fluoroquinolones baseline MRI scan should be Reference: (ciprofloxacin, levofloxacin, available (usually within three Revisions of Precautions, moxifloxacin, norfloxacin, and months) as a reference. If PML MHLW/PMDA, ofloxacin) are used to treat is suspected, a MRI should be 24 November 2015 bacterial infections, in performed immediately and (www.pmda.go.jp/english/) particular respiratory and treatment with fingolimod urogenital system infections. should be suspended until PML The recommendations follow a has been excluded. With follow-up review of evidence. Fingolimod regard to the risk of basal cell At the time of the review 22 carcinoma, a medical Recommendations to reports of retinal detachment evaluation of the skin is linked to oral fluoroquinolones minimise progressive recommended before starting were reported internationally, multifocal treatment, after at least one and three reports were leukoencephalopathy year and then at least yearly received in Canada. A causal (PML) and skin cancer during treatment. Fingolimod relationship between the must not be used in patients Canadian reports could not be EU: The European Medicines with basal cell carcinoma, or established. In the literature Agency (EMA) has announced any other type of cancer. two of four observational that product information for fingolimod (Gilenya®) will be (See WHO Pharmaceuticals studies found a modest link Newsletter No.5, 2015: Risk of updated with information between retinal detachments progressive multifocal and use of fluoroquinolones. about risk of progressive leukoencephalopathy in USA and Health Canada concluded that multifocal Japan.) a link cannot be ruled out at leukoencephalopathy (PML) present. and basal cell carcinoma. Reference:

Fingolimod is used to treat Press release, EMA, Reference: multiple sclerosis and works by 18 December 2015 Summary Safety Review, reducing activity of the (http://www.ema.europa.eu/) Health Canada, 8 January immune system, in particular 2016 (www.hc-sc.gc.ca) T-cells which are involved in fighting infection. Interferon beta-1a Fomepizole PML is a rare brain infection caused by John Cunningham Risk of thrombotic Risk of anaphylaxis virus. Basal cell carcinoma is a microangiopathy slow-growing skin cancer. Japan. The MHLW and the Canada. Health Canada has PMDA have announced that the There have been 17 previous requested manufacturers to revision of the package insert cases of PML reported in update prescribing information for fomepizole should include patients taking fingolimod with for interferon beta-1a anaphylaxis as an adverse prior exposure to other (Avonex®) to include the risk reaction. immunosuppressive therapy of thrombotic microangiopathy, (natalizumab). Recently there following a safety review. Fomepizole is used as an have been three cases of PML Rebif®, another brand of Type antidote for ethylene glycol reported in patients that were 1a interferon already includes and methanol poisoning. A treated with fingolimod and prescribing information on case of anaphylaxis has been had not received previous thrombotic microangiopathy. reported outside Japan. In treatment with natalizumab. WHO Pharmaceuticals Newsletter No. 1, 2016  8

Regulatory Matters

Avonex® interferon beta-1a is used for prophylaxis in certain fatal cases have been reported used to slow the progression of patients at risk of neutropenia (no established causal multiple sclerosis by reducing (hematopoietic stem cell relationship with). damage to the central nervous transplant patients); the Based on available evidence system. injection is used to treat febrile and advice from experts the neutropenia. Thrombotic microangiopathy MHLW/PMDA have decided that involves the formation of clots A total of two cases associated it is necessary to revise the in the small blood vessels with interstitial pneumonia package insert for lenvatinib as which block blood flow and have been reported in patients follows: cause life-threatening damage using itraconazole in Japan. In • “Patients with tumour to organs and body systems. one of these cases a causal invasion in the carotid relationship could not be ruled arteries, veins, etc.” should A report of cases of thrombotic out, however itraconazole was be added in the “Careful microangiopathy identified in indicated for a condition Administration” section. the Avonex Global Safety outside the licensed • Precautions regarding Database from the recommendations. None of the “carotid artery exposure, manufacturers triggered the cases were fatal. Following carotid artery haemorrhage, safety review, which investigations and advice from and tumour haemorrhage considered information from experts, the MHLW/PMDA have associated with tumour scientific and medical decided that revision of the shrinkage or necrosis” literature, Canadian and package insert was necessary. should be added in the international adverse reaction “Important Precautions” reports. The MHLW/PMDA recommend section and the that “Interstitial pneumonia” The review concluded that “Haemorrhage” subsection should be added in the there might be a possible link in the “Clinically significant “Clinically significant adverse between the Avonex® adverse reaction” section. reaction” section. preparation and thrombotic Reference: microangiopathy. Health Reference: Revisions of Precautions, Canada will continue to Revisions of Precautions, MHLW/PMDA, monitor adverse effects, and MHLW/PMDA, 12 January 2016 24 November 2015 will take appropriate and (www.pmda.go.jp/english/) (www.pmda.go.jp/english/) timely action if and when any new health risks are identified. Reference: Lenvatinib Levonorgestrel Summary Safety Review, Risk of tumour Health Canada, intrauterine haemorrhage, carotid 23 December 2015 contraceptive device (www.hc-sc.gc.ca) artery exposure and haemorrhage. (IUCD) Risk of uterine Itraconazole Japan. The MHLW and the PMDA have announced the perforation Reports of interstitial addition of cautionary advice in Australia. The Therapeutic pneumonia the package insert for lenvatinib (Lenvima®) Goods Administration (TGA) has announced that the Japan. The MHLW and the capsules. The advice warns product information for the PMDA have recommended that health-care professionals of intrauterine contraceptive the product label for the possible association with device (IUCD) containing 52mg itraconazole capsules, oral tumour haemorrhage, carotid of levonorgestrel (Mirena®) solution and injections are artery exposure and will be revised to include revised to include interstitial haemorrhage. increased uterine perforation pneumonia as an adverse Lenvatinib is used to treat risk for lactating women during reaction. radically unresectable thyroid the first 36 weeks postpartum. Itraconazole is used for cancer. In Japan, a total of 14 A recent European study treatment and prophylaxis of cases associated with carotid (n=61 446 levonorgestrel or fungal infections. Different artery exposure, carotid artery copper IUCD users) resulted in formulations target different haemorrhage and tumour 61 cases of perforations with forms of fungal infections, for haemorrhage have been levonorgestrel IUCD users. The example: the capsules are reported (including five cases risk is increased for lactating used for dermatophytosis type for which a causal relationship women and during the first 36 infections; the oral solution is to the product could not be ruled out). Of the 14 cases, six weeks postpartum. WHO Pharmaceuticals Newsletter No. 1, 2016  9

Regulatory Matters

The updated product highly effective contraceptives Reference: information will also advise (two forms) in female patients, Revision of Precautions, that there is an increased risk female partners of male MHLW/PMDA, 12 January 2016 for women with a fixed, patients, and use of condoms (www.pmda.go.jp/english/) retroverted uterus. in male patients during and for 90 days after treatment. Reference: Medicines Safety Update, TGA, Dear doctor letters have been Nivolumab Vol.6, No.6, 6 December 2015 sent out to health-care Reports of type-1 (www.tga.gov.au) professionals informing them diabetes mellitus of this advice. Reference: Japan. The MHLW and the Mycophenolate Drug Safety Update, MHRA, PMDA have announced that the mofetil Vol.9, No.5, 14 December product label for nivolumab 2015 (www.gov.uk/mhra) (Opdivo®) has been revised to include type-1 diabetes New pregnancy- mellitus as an adverse prevention advice for Nintedanib reaction. women and men ethanesulfonate Nivolumab is used to treat The United Kingdom. The radically unresectable MHRA has updated new Precaution in patients malignant melanoma. pregnancy-prevention advice with moderate to severe There have been five cases of for women and men prescribed hepatic function disorder type 1 diabetes mellitus mycophenolate mofetil. associated with the use of Japan. The MHLW and the Mycophenolate mofetil nivolumab reported in Japan. PMDA have recommended that (CellCept®), a prodrug of In four of these cases a causal the product labels for mycophenolic acid is an relationship between the nintedanib ethanesulfonate immunosuppressive agent product could not be ruled out. (Ofev®) should include a used in combination with precautionary warning for “Type 1 diabetes mellitus” will cyclosporin and corticosteroids patients with moderate to be added to the Clinically for the prevention of acute severe hepatic function significant adverse reaction transplant rejection in patients disorder (Child-Pugh B and C). section of the product label. who have received , heart, or liver transplants. Nintedanib ethanesulfonate is Reference: indicated for treatment of Revision of Precautions, Mycophenolate mofetil is a idiopathic pulmonary fibrosis. MHLW/PMDA, known teratogen associated 24 November 2015 with a high rate of serious This recommendation follows (www.pmda.go.jp/english/) birth defects and increased risk results of a clinical of spontaneous abortion. pharmacokinetic study, Previously only ear conducted among patients with Ombitasvir malformations had been hepatic function disorder. The recognised, but prospectively study was on-going at the time hydrate/paritaprevir gathered data have now nintedanib was approved and identified a range of disorders showed that blood hydrate/ritonavir such as congenital heart concentrations of nintedanib Risk of hepatic failure disease, facial malformations, ethanesulfonate increased in eye abnormalities, finger patients with hepatic function Japan. The MHLW and the malformation and others. disorder. PMDA have announced that the The MHRA advises that before Following investigations and product information for starting mycophenolate mofetil advice from experts, the ombitasvir hydrate/paritaprevir treatment, women of MHLW/PMDA have decided that hydrate/ritonavir preparation childbearing potential should revision of the package insert (Viekirax®) will be revised to have a negative pregnancy was necessary. include patients with hepatic test result to exclude dysfunction (Child-Pugh Class It is advised that “Patients with unintended exposure of the B) as a contradiction. moderate to severe hepatic embryo to mycophenolate. function disorder (Child-Pugh B This preparation is used to Two serum or pregnancy tests and C)” should be newly added improve symptoms of viraemia are recommended. Results of in the “Important Precautions” in patients with serogroup 1 all pregnancy tests should be section. (genotype 1) chronic hepatitis discussed with patients. Further advice includes: use of WHO Pharmaceuticals Newsletter No. 1, 2016  10

Regulatory Matters

C or compensated cirrhosis suspected medicine. Based on Reference: type C. this safety concern, and using Revision of Precautions, information provided MHLW/PMDA, 12 January 2016 There have been cases of internationally, the TGA has (www.pmda.go.jp/english/) hepatic failure with the worked with the sponsor to Viekirax® preparation reported update the product in other countries, and in information. Facial palsy has Japan there have been three Posaconazole been listed in the adverse reports of fatal adverse effect observed in post- Dosing errors while reactions (not associated with marketing setting. switching formulations hepatic failure). Following investigation of the available At this stage there have been USA. The US Food and Drug evidence and based on no reports of facial palsy for Administration (FDA) has consideration of advice from Pegasys-RBV® or the other six approved of label changes in experts, the MHLW/PMDA have pegylated and non-pegylated prescribing and patient decided that it was necessary interferon products available in information to alert health-care to revise the package insert. Australia. professionals and patients that In addition to the contra- Reference: two oral formulations of indication, hepatic failure will Medicines Safety Update, TGA, posaconazole (Noxafil®) be listed as an adverse effect Vol.6, No.6, 6 December 2015 cannot be directly substituted in the “Clinically significant (www.tga.gov.au) for each other and require a adverse reaction” section, and dosage adjustment when will be added to the relevant switching formulations. This section in the “Important Piperacillin sodium measure was taken to prevent precautions” section. medication errors. Risk of acute generalised Reference: Posaconazole is an antifungal exanthematous Revision of Precautions, used to prevent invasive fungal MHLW/PMDA, pustulosis infections caused by 26 November 2015 Aspergillus and Candida in Japan. The MHLW and the (www.pmda.go.jp/english/) patients with a weakened PMDA have announced that the immune system, and to treat product information for fungal infections caused by Peginterferon alfa-2a piperacillin sodium products Candida in the mouth and has been revised to include throat. It is available in two acute generalised Reports of facial palsy oral formulations: an oral exanthematous pustulosis as suspension and a delayed Australia. The TGA advises an adverse effect. release tablet. health professionals that the Piperacillin sodium is an At the time of the alert, the product information for antibiotic used to treat FDA had received 11 reports of peginterferon alfa-2a has been infections susceptible to strains wrong formulations being updated to state that facial of microorganisms such as prescribed/dispensed to palsy has been reported. Staphylococcus, Streptococcus, patients, two of which had Peginterferon alfa-2a is a and Klebsiella genus. It is serious outcomes. Lack of recombinant interferon alfa-2a indicated for infections of the knowledge for the need to protein conjugated with a lung, intra-abdominal adjust the dosage with single branched polyethylene infections, complicated urinary different oral formulation glycol chain. It is marketed in tract infection and others. resulted in these errors. Australia as Pegasys® and in There have been cases of The FDA recommends: combination with ribavirin as acute generalised Prescribers should specify the Pegasys-RBV®. Peginterferon exanthematous pustulosis in dosage form, strength, and alfa-2a is indicated for use, patients treated with frequency on all prescriptions under specific circumstances, piperacillin and they write for posaconazole. in treatment of chronic tazobactam/piperacillin Pharmacists should request hepatitis C and chronic hydrate preparations in Japan clarification from prescribers hepatitis B. (none in the last 3 years). when the dosage form, Up until 19 August 2015, the Based on available evidence strength, or frequency is not TGA had received five reports and advice from experts the specified. Patients should talk of VIIth nerve paralysis MHLW/PMDA have decided that to a health-care professional associated with peginterferon it was necessary to revise the before they switch from one alfa-2a, including three cases package inserts for piperacillin oral formulation to the other. in which it was the sole sodium products. WHO Pharmaceuticals Newsletter No. 1, 2016  11

Regulatory Matters

Reference: The HSA is working with the requested that manufacturers Safety Alerts for Human pharmaceutical companies to conduct a postmarket study to Medical Products, US FDA, strengthen the local package investigate these safety issues 4 January 2016 (www.fda.gov) inserts of both products to further. include warnings and The US FDA recommends that precautions with regard to the patients should stop taking potential risk of hypoglycaemia Repaglinide and their SGLT2 inhibitor and seek arising from their drug-drug medical attention immediately clopidogrel interactions. if they have any symptoms of Risk of hypoglycaemia Reference: ketoacidosis. by drug-drug interaction Product Safety, HSA, Health-care professionals 30 December 2015 should assess for ketoacidosis Singapore. The HSA is (http://www.hsa.gov.sg/) strengthening local package and urinary tract infections in inserts for repaglinide patients taking SGLT2 (Novonorm®) and clopidogrel Sodium glucose co- inhibitors who present with (Plavix®) to include warnings suggestive symptoms (nausea, and precautions with regard to transporter 2 (SGLT2) vomiting, abdominal pain, tiredness, and trouble the potential risk of inhibitors hypoglycaemia in patients breathing). taking concomitant repaglinide Risk of acid in blood and Reference: and clopidogrel. serious urinary tract Safety Alerts for Human Repaglinide is an oral infections Medical Products, US FDA, antidiabetic agent used for the 4 December 2015 treatment of adults with type-2 USA. The US FDA has updated (www.fda.gov) diabetes mellitus as the product labels (Warnings monotherapy or in combination and Precautions) of sodium- with metformin. glucose cotransporter-2 Thalidomide (SGLT2) inhibitors to include Clopidogrel is an antiplatelet warnings about risk of too Reduced starting dose in used for the prevention of much acid in the blood and patients >75 years of atherothrombotic events in serious urinary tract infections. age adults with a recent myocardial Prescribing and monitoring infarct, stroke, established recommendations were also The United Kingdom. The peripheral arterial disease or added. MHRA has recommended that acute coronary syndrome, as the starting dose of well as in combination with SGLT2 inhibitors (canagliflozin, thalidomide in patients aged aspirin for the prevention of dapagliflozin, and over 75 years should be atherothrombotic and empagliflozin) are indicated for reduced to 100 mg/day. The thromboembolic events in use with diet and exercise to recommended starting dose of selected adult patients with lower blood sugar in adults thalidomide remains 200 mg atrial fibrillation. with type-2 diabetes. once a day for patients aged 75 years or younger. In a study using nine healthy High levels of blood acid are a subjects, co-administration of result of ketoacidosis. Thalidomide combined with repaglinide and clopidogrel was Symptoms of ketoacidosis melphalan and prednisolone is shown to result in an increase include nausea, vomiting, indicated as first-line in repaglinide systemic abdominal pain, tiredness, and treatment of patients with exposure compared with trouble breathing. untreated multiple myeloma who are aged 65 years or older placebo. The elimination half- The changes to these product or who are ineligible for high- life of repaglinide was also labels follow a review of the dose chemotherapy. observed to be prolonged. The FDA Adverse Event Reporting study authors recommended System (FAERS), which This recommendation follows that concomitant use of identified 73 cases of results of two clinical trials repaglinide and clopidogrel is ketoacidosis in patients with which showed that the best avoided. They also type-1 and -2 diabetes treated frequency of serious or fatal postulated that clopidogrel is with SGLT2 inhibitors (March adverse reactions was higher likely to cause drug-drug 2013-May 2015), and 19 cases in patients older than 75 years interactions with other CYP2C8 (March 2013-October 2014) of who received thalidomide substrates, such as life-threatening blood 100 mg once daily than in montelukast, paclitaxel and infections (urosepsis) and younger patients who received pioglitazone, which warrant Kidney infections thalidomide 200 mg once daily further clinical studies. (pyelonephritis). The FDA has (56.5% vs 46.5% for serious WHO Pharmaceuticals Newsletter No. 1, 2016  12

Regulatory Matters reactions and 10.3% vs 5.3% symptoms and include the Effects” sections of the product for fatal reactions, potential interaction with information have also been respectively). There were no alcohol. updated to advise patients that clinically relevant differences in consuming alcohol may Varenicline is used to reduce frequency of specific adverse increase the risk of psychiatric nicotine cravings and effects or primary causes of symptoms. withdrawal symptoms in adults death between both age attempting to stop smoking. The updated product groups. information also includes Psychiatric symptoms can Reference: information from clinical trials involve: changes in behaviour, Drug Safety Update, MHRA, and observational studies, thinking or mood, depression, Volume 9, issue 5: which found similar incidence anxiety, agitation, aggression, 14 December 2015 rates of suicidal thoughts mood swings, self-harm, (www.gov.uk/mhra) and/or behaviour, and other thoughts of self-harm, psychiatric symptoms, in hallucinations and delusions. patients treated with Varenicline and The TGA advises health-care varenicline compared to those alcohol professionals to discuss the treated with placebo or benefits and risks of treatment alternative treatments. with varenicline, including Risk of psychiatric The TGA will continue to potential psychiatric symptoms symptoms by drug- monitor this issue. alcohol interaction before initiation. Reference: Psychiatric symptoms are now Safety Information Alerts, Australia. The TGA has in bold at the beginning of the TGA, 2 December 2015 announced the revision of the Precautions section (under (www.tga.gov.au) product information for ‘Psychiatric symptoms’). The varenicline (Champix®) to “Precautions, Interactions With reinforce the risk of psychiatric Other Medicines and Adverse

Correction: We regret the typographic error in WHO Pharmaceuticals Newsletter No. 6, 2015, pg 9, Line 40. The sentence should read “Roxithromycin is an antimicrobial used for treatment…”

WHO Pharmaceuticals Newsletter No. 1, 2016  13

Safety of Medicines

Allopurinol Bevacizumab Codeine Interaction with 6- Risk of irreversible vocal Risk of serious breathing mercaptopurine and cord damage problems in children and azathioprine adolescents Canada. Health Canada has Australia. The TGA has issued informed health professionals Canada Health Canada a reminder to health of findings from a safety maintains its recommendation professionals that concomitant review that assessed the that codeine prescription use of allopurinol with 6- potential risk of irreversible products should not be mercaptopurine or azathioprine vocal cord damage with use of recommended in children less should be avoided, due to bevacizumab (Avastin®). than 12 years of age following increased risk of potentially a new review assessing the Bevacizumab by itself is used fatal bone marrow toxicities risk of breathing problems in to treat patients with a specific and blood dyscrasias. children and adolescents type of aggressive brain cancer treated with codeine Allopurinol is an anti-uricaemic who have not improved prescription products for agent used to treat gout, uric enough with other treatments. cough. acid nephrolithiasis and In combination with other anti- hyperuricaemia, including the cancer drugs, it is used to treat Codeine containing products prevention of tumour-lysis a specific type of lung cancer (alone or in combination with syndrome. Azathioprine is used or large bowel cancer acetaminophen or aspirin in as an immunosuppressant and metastases. some cough and cold 6-mercapotpurine as a medication) are approved for Health Canada initiated a cytotoxic agent. use in adults and children ≥12 review into this potential years to treat pain and reduce Allopurinol reduces metabolism adverse effect following a case cough. Caution is advised of 6-mercaptopurine and of vocal cord necrosis after regarding the use of codeine in azathioprine, increasing the exposure to bevacizumab and patients with breathing risk of bone marrow toxicities another anti-cancer drug. conditions, including children. and blood dyscrasias, such as Internationally, from the years leukopenia, thrombocytopenia 2000 to 2014, there were 14 Codeine is converted to and pancytopenia. reports of adverse effects morphine in the liver. Due to related to the vocal cord, of genetic variations of liver If co-administration of which three were for vocal cord enzymes some people can allopurinol with 6- necrosis. In international convert codeine to morphine mercaptopurine or azathioprine clinical studies (n=26 420 faster and more completely is necessary, the dose of 6- patients) there were 11 reports than others, which can result mercaptopurine or azathioprine of possible vocal cord necrosis. in high levels of morphine in should be reduced to one In the scientific and medical the blood leading to breathing quarter of the normal dose and literature there were 16 cases difficulties and death. the patient's complete blood of damage to the vocal cords, count should be closely three of which were confirmed Health Canada conducted a monitored in accordance with cases of irreversible damage. new safety review to further the product information. assess the risk of serious Health Canada concluded that breathing problems in children The TGA recommends that, there is not enough evidence and adolescents treated with health professionals should to link bevacizumab treatment codeine prescription products check if patients are being with an increased risk of vocal for cough following emergence treated with allopurinol when cord necrosis. Health Canada of new evidence. At the time of prescribing azathioprine or 6- will continue to monitor for the current review, no cases of mercaptopurine, and they information about this safety these drug-adverse events in should educate patients about issue. children and adolescents were this medicine interaction. reported. Since the initial Reference: review in 2013, one Reference: Summary Safety Review, international case was Medicines Safety Update, TGA, Health Canada, published in the literature, Vol. 6, No. 6, December 2015 30 November 2015 which resulted in the death of (www.tga.gov.au) (www.hc-sc.gc.ca) a six-year old patient, however a causal link could not be concluded.

WHO Pharmaceuticals Newsletter No. 1, 2016  14

Safety of Medicines

No modifications were Reference: function that affect emotion, recommended to the Canadian Summary Safety Review, learning and memory prescribing information. Health Canada, 17 December (attention deficit hyperactivity 2015 (www.hc-sc.gc.ca) disorder and autism spectrum Reference: disorders) are limited. The Summary Safety Review, impact on psychological Health Canada, 9 December development and long term 2015 (www.hc-sc.gc.ca) Melatonin risk on growth in the paediatric Neurological adverse population is still uncertain. effects in children and Finasteride Health Canada will continue to adolescents, conflicting evaluate this safety issue and Risk of suicidal thoughts evidence will proactively monitor for and behaviour Canada. Health Canada safety information related to concludes that the information the use of melatonin in the Canada. A Health Canada available on neurological general paediatric population review of data considers that adverse effects associated with Reference: the evidence of suicidal use of melatonin (N-acetyl-5- thoughts and behaviour Summary Safety Review, methoxytryptamine) in Health Canada, associated with use of children is conflicting. Parents finasteride (Proscar® and 11 December 2015 and caregivers are encouraged (www.hc-sc.gc.ca) Propecia®) is limited. to consult a health-care Finasteride is used to treat and professional before giving control benign prostatic melatonin to children and Pazopanib hyperplasia (non-cancerous adolescents. enlargement of the prostate Melatonin is a naturally Risk of pericardial gland). In addition, at a lower occurring hormone used to effusion: lack of dose, it is used to treat male help adults, adolescents and information pattern hair loss. children with sleep problems Canada. Health Canada has At the time of the review, 11 as an OTC natural health concluded that there is not reports of suicide related product in Canada. enough information to support adverse effects were reported International reports of a link between the risk of to Health Canada, and 170 to neurological defects such as pericardial effusion and use of the WHO global database of anxiety, panic reaction, visual pazopanib (Votrient®), Individual Case Safety Reports hallucinations and seizures in following a safety review of (ICSRs). Six of the cases children and adolescents evidence. reported to Health Canada (newborn to 18 years) led described factors that Health Canada to conduct a Pazopanib is used to treat appeared to be related to review of scientific and medical metastatic cancer of the kidney finasteride, however the literature in this age group. and advanced soft tissue remaining reports and reports cancers (cancer occurs in soft in the WHO global database Eighteen reports from Canada tissues such as fat, muscle, data were not robust to form a Vigilance Program and 163 tendon and nerves). conclusion. reports (8 from Canada) in the WHO global database of Pericardial effusion is a serious Reports in the medical suspected adverse reaction condition, involving the literature describe a potential associated with the use of accumulation of fluid around link between finasteride and melatonin in the paediatric the heart which can cause suicidality, however studies population were identified. The heart problems and/or lead to were few, used small number most common adverse effects death. of patients, had limitations and reported in the WHO global were inconclusive. At the time of the review no database were: general cases of pericardial effusion Currently, the prescribing fatigue, aggression, abnormal linked with pazopanib were information for finasteride lists dreams, and headache. reported in Canada. Health depression as an adverse Serious cases could not be Canada’s review of reported effect. Health Canada will linked to melatonin as cases in the literature and from publish a Health Product information in reports were not manufacturers were limited by InfoWatch article to inform complete. factors such as the progression Canadians of the safety The benefits of treating sleep of the cancer, and concluded review, and will continue to disorders with short term use that there is not enough monitor safety information of melatonin (< 4 months) in information to support a link involving finasteride. those with disorders of brain between the risk of pericardial WHO Pharmaceuticals Newsletter No. 1, 2016  15

Safety of Medicines effusion and use of pazopanib. limitations, these two studies The FDA continued to monitor Health Canada will continue to did not demonstrate an these medicines and identified monitor adverse effect increased cardiovascular risk no new pertinent safety information on pazopanib. for PPIs that was independent information. As a result, the of the patient population in FDA concludes that the REMS (See WHO Pharmaceuticals Newsletter No.6, 2013: Signal - which they were being used. is no longer necessary to ensure that the benefits of Pazopanib and pericardial effusion) Reference: rosiglitazone medicines Medicines Safety Update, TGA, outweigh their risks. Reference: Vol. 6, No. 6, December 2015 Summary Safety Review, (www.tga.gov.au) Reference: Health Canada, Safety Alerts for Human 30 November 2015 Medical Products, US FDA, (www.hc-sc.gc.ca) Rosiglitazone 16 December 2015 (www.fda.gov) Removal of risk Proton pump evaluation and inhibitors mitigation strategy (REMS) Lack of evidence for increased risk of USA. The US FDA has cardiovascular risk announced that they are eliminating the Risk Evaluation Australia. The TGA has and Mitigation Strategy concluded that available (REMS) for rosiglitazone- evidence does not adequately containing type-2 diabetes demonstrate an increased risk medicines. of cardiovascular risk in patients taking proton pump Type-2 diabetes is a disease inhibitors (PPIs). that can lead to serious complications such as kidney PPIs include esomeprazole, failure, blindness, and lansoprazole, omeprazole, premature death. Rosiglitazone pantoprazole and rabeprazole can be used along with diet and are a class of drugs that and exercise to control blood reduce production of gastric sugar in adults with the acid. disease. Two studies were investigated: In 2013, the FDA removed the The first study used national prescribing suspension and Danish data (n=56 406), and dispensing restrictions for found a 29% increase in rosiglitazone medicines that cardiovascular death or were introduced in 2010, after rehospitalisation for stroke or determining that data for myocardial infraction in rosiglitazone containing patients taking a PPI. The medicines do not show an second used two sources of increased risk of heart attack. electronic health records, and Due to previous suggestions of found an increase in odds ratio an elevated risk of heart attack for myocardial infarction in an REMS was required. This patients taking PPIs (odds restricted the use of ratios 1.16 [95% CI 1.09- rosiglitazone medicines to help 1.24]) compared to H 2 ensure that their benefits antagonists (1.19 [95% CI outweighed the risks. The FDA 1.09-1.24]). However, authors also requested that the drug concluded that these findings manufacturers provide can be explained by educational training to differences in baseline health-care professionals about comorbid conditions (e.g. the current state of knowledge smoking status, lipid levels) regarding the heart risks of that were missed or not rosiglitazone medicines. sufficiently measured and lack Manufacturers have since of consideration of important fulfilled these requirements. confounding factors in study design. Because of these WHO Pharmaceuticals Newsletter No. 1, 2016  16

Signal

A signal is defined by WHO as reported information on a possible causal relationship between an adverse event and a drug, the relationship being unknown or incompletely documented previously. Usually more than a single report is required to generate a signal, depending upon the seriousness of the event and the quality of the information. A signal is a hypothesis together with data and arguments and it is important to note that a signal is not only uncertain but also preliminary in nature.

The signals in this Newsletter are based on information derived from Individual Case Safety Reports (ICSRs) available in the WHO Global ICSR database, VigiBase®. The database contains over 10 million reports of suspected adverse drug reactions, submitted by National Pharmacovigilance Centres participating in the WHO Programme for International Drug Monitoring. VigiBase® is, on behalf of the WHO, maintained by the Uppsala Monitoring Centre (UMC) and periodic analysis of VigiBase® data is performed in accordance with UMC’s current routine signal detection process. More information regarding the ICSRs, their limitations and proper use, is provided in the UMC Caveat document available at the end of Signal (page 23). For information on the UMC Measures of Disproportionate Reporting please refer to WHO Pharmaceuticals Newsletter Issue No. 1, 2012.

UMC, a WHO Collaborating Centre, is an independent foundation and a centre for international service and scientific research within the field of pharmacovigilance. UMC’s vision is to improve worldwide patient safety and welfare by reducing the risk of medicines. For more information, visit www.who-umc.org. To leave a comment regarding the signals in this Newsletter, please contact: the Uppsala Monitoring Centre, Box 1051, SE-751 40 Uppsala, Sweden. E-mail: [email protected].

Vemurafenib and Atrial fibrillation: Signal strengthening Dr Ruth Savage, New Zealand

Summary suggests a dose-response relationship. The reports do represent a signal and add another reason, as Vemurafenib, a tyrosine kinase inhibitor, is a well as QT prolongation, for cardiovascular suspect medicine in 29 reports of atrial fibrillation monitoring before and after treatment with in the WHO Global Individual Case Safety Report vemurafenib is commenced. The reports also Database, VigiBase®, and the sole suspect in 27. suggest that the risk might be greatest in the first Vemurafenib is indicated for metastatic or month and, possibly, after an increased dose or unresectable malignant melanoma with the BRAF the addition of potentially interacting medicines. V600E mutation. Atrial fibrillation can be triggered by a range of underlying pathologies and drugs and needs to be treated promptly when it is Introduction deemed likely to increase the risk of stroke. Thus, assessment of a causal relationship with a Vemurafenib is a tyrosine kinase inhibitor. It particular medicine is complex. Product inhibits some mutated forms of BRAF serine- information and literature sources indicate that threonine kinase, including BRAF V600E. It is atrial fibrillation occurred in patients taking indicated in the treatment of patients with vemurafenib in phase II and III clinical trials but unresectable or metastatic melanoma with BRAF no published evidence of causality has been V600E mutation as detected by an FDA approved identified. In the VigiBase® reports older patients test. The recommended dose is 960 mg twice daily were most often affected and a high proportion and patients should be treated with vemurafenib were taking medicines usually prescribed for co- until disease progression or unacceptable toxicity morbidities likely to increase the risk of atrial occurs.1 fibrillation. However, seven of the VigiBase® reports recorded improvement on dechallenge with Atrial fibrillation is caused by a variety of clinical little evidence of alternative explanations. In four conditions. These can be divided into structural of these reports time to onset was 19 days or less heart disease such as myocardial infarction, and the same was true in a fifth report when a cardiomyopathy, cardiac valve disorders, potentially interacting medicine, , was hypertensive heart disease; right atrial stretch added to vemurafenib. One patient being treated caused by pulmonary disorders; high adrenergic for atrial fibrillation with amiodarone experienced a states such as thyrotoxicosis, major surgery and recurrence when vemurafenib was commenced. alcohol withdrawal; anomalous conduction Vemurafenib is a CYP3A4 and P-glycoprotein pathways and sinus node dysfunction; acute substrate and a CYP3A4 inducer. Carvedilol is a P- alcohol intoxication and drugs such as anti- glycoprotein inhibitor and amiodarone is a CYP3A4 arrhythmics, other cardiovascular medicines, inhibitor which may be explanations for these medicines that alter sympathetic or vagal drive, possible interactions. One other patient recovered cardiotoxic cytostatic medicines, diuretics causing on vemurafenib dose reduction. This report, hypokalaemia and others with unidentified together with the carvedilol/vemurafenib report, mechanisms. Because of the underlying clinical WHO Pharmaceuticals Newsletter No. 1, 2016  17

Signal conditions that may cause atrial fibrillation its and seven months for seven patients. Time to prevalence increases with age. Atrial fibrillation is onset for the two other patients was 60 days (but the commonest supraventricular tachycardia and 18 days from addition of a potentially interacting predisposes patients to systemic embolism and medicine) and 37 days. There were no consistently therefore stroke.2,3 reported concomitant medicines that may have contributed. One patient was taking amiodarone Assessment of a causal relationship between a for atrial fibrillation. A pharmacokinetic interaction drug and atrial fibrillation is complicated by the with vemurafenib is theoretically possible. need to consider all the possible alternative or contributory causes of atrial fibrillation for a Adverse reaction terms that were co-reported with particular patient, its frequently paroxysmal nature atrial fibrillation that may have been the trigger for and the need for prompt treatment to avoid atrial fibrillation, rather than a direct effect of systemic embolism without sufficient time to vemurafenib on cardiac conduction, were pleural assess the outcome when the suspected drug is effusion (2 reports), pericardial effusion (1), withdrawn, especially if it has, like vemurafenib, a pneumothorax (1), electrolyte abnormalities (2), long elimination half-life.1 myocardial infarction (1) and cardiomegaly (1). Other co-reported adverse reaction terms were There is a small amount of information about hypotension and cardiac failure, known vemurafenib and atrial fibrillation in the literature consequences of atrial fibrillation although one of but comparative rates with placebo or published these patients also had multi-organ failure. Four case reports have not been identified. The case patients developed arthralgia and three fever, reports in the WHO Global Individual Case Safety these are recognised vemurafenib adverse Report (ICSR) Database, VigiBase®, were reactions. therefore examined for evidence of causality and the characteristics of the patients affected. Table 1 shows reports that recorded recovery on dechallenge or a stop date and recovery. The first

three provide best evidence of causality as there Reports in VigiBase® were no clear alternative explanations for the atrial fibrillation. In case 1, after developing atrial Vemurafenib is a suspect medicine in 30 reports of fibrillation, the patient was treated with atrial fibrillation. The reports were submitted from antithrombotic but not anti-arrhythmic agents so eight countries. The drug/ADR combination was 4 that the treatment is not an explanation for identified using the vigiRank method. One report recovery. Case 3 suggests a dose-response was excluded from the assessment as it originated relationship. Case 4 and 5 both contain evidence from a double-blind placebo-controlled study and of a drug interaction. Carvedilol is a substrate and both the placebo and vemurafenib were listed as inhibitor of the efflux transporter P-glycoprotein suspect. and there is in vitro evidence that vemurafenib has 1 In the 29 reports assessed 15 females and 14 the same characteristics. It is possible, in case 4, males developed atrial fibrillation with an age that carvedilol increased the of range, recorded for 17 patients, of 39 to 87 years, vemurafenib and this is supported by the median 71 years. Indication for vemurafenib use observation that the patient also developed fever was recorded in 20 reports. Eighteen patients were with no evidence of infection, a documented being treated for malignant melanoma. Eleven of adverse reaction to vemurafenib. Case 5 is of these were reported to have metastatic disease. interest as the patient had pre-existing atrial For two patients the indication was thyroid cancer. fibrillation treated with amiodarone. Both One patient had pre-existing atrial fibrillation and vemurafenib and amiodarone are substrates for hypertension and one had recently diagnosed CYP3A4. Amiodarone is an inhibitor and there is 1 mitral insufficiency. Eight patients were taking evidence that vemurafenib is an inducer. medicines indicative of hypertension, angina, Theoretically therefore, atrial fibrillation may have arrhythmia or cardiac failure (diuretics, , recurred because amiodarone clearance was ACE inhibitors, angiotensin II receptor blockers, increased thus reducing its therapeutic effect and beta-blockers, calcium channel blockers). Three of vemurafenib clearance reduced thus increasing its these patients and one other patient were taking a postulated pro-arrhythmic effect. statin. One was taking warfarin and a beta- Two other reports also recorded that the patient adrenergic blocking agent suggesting that they recovered on dechallenge but these were not might have pre-existing atrial fibrillation. included in the Table. The narratives were Vemurafenib was the sole suspect medicine in 27 complex, one patient recovered from atrial flutter reports. Only one patient of 19 for whom daily but atrial fibrillation recurred the following day and doses were recorded exceeded the recommended the outcome was not recorded. In the other report daily dose. Time from starting vemurafenib to there are contradictory statements about recovery onset of atrial fibrillation ranged from 12 days to and mitral insufficiency had been diagnosed the seven months (15 reports). The time to onset was same year. 12 to 19 days for six patients and between three WHO Pharmaceuticals Newsletter No. 1, 2016  18

Signal

Table 1. VigiBase® reports of vemurafenib and atrial fibrillation with recovery on dechallenge

Case Age/ Medical history Other concomitant Indication Daily Reactions (WHO- Time to onset Dechallenge/ Outcome Comments Sex medicines dose ART preferred Rechallenge terms) 1 74/F - - Metastatic 1920 mg Fibrillation atrial, 19 days Dechallenged/ Recovering/ Treated with antithrombotic melanoma hyperpyrexia, Rechallenged Unknown for agent synovitis, vomiting, rechallenge asthenia 2 78/F - Enoxaparin, Metastatic 960 mg Fibrillation atrial 15 days Dechallenged/ Recovered/Unknown “Ambulatory treatment” simvastatin, melanoma Rechallenged for rechallenge given, the atrial fibrillation omeprazole did not recur. Indication for enoxaparin was “prophylaxis”

3 82/F Unspecified Unspecified medication Malignant 1920 mg Fibrillation atrial 12 days Dose reduction Recovered on Treated with metoprolol underlying melanoma unknown date conditions 4 72/M Hypertension Carvedilol Malignant 1920 mg Fibrillation atrial, fever 2 months Dechallenged/ Recovered from Possible interaction with melanoma of skin Rechallenged atrial fibrillation on carvedilol via P- Atrial fibrillation unknown date after glycoprotein. 18 days and vemurafenib and fever 13 days carvedilol stopped** Vemurafenib restarted after after carvedilol and from fever nine 15 days.** Treated with metoprolol and warfarin. started days after/Unknown for rechallenge ECG 7 days after vemurafenib re-started showed sinus rhythm

5 62/F Hypertension, atrial Amiodarone, nebivolol, Malignant 1920 mg Fibrillation atrial, 16 days Dechallenged/ Recovered/Unknown Cardioversion fibrillation, lisinopril, melanoma hypotension Reintroduction for reintroduction hypernatraemia, hydrochlorothiazide, at lower dose Vemurafenib half-life of 59 cholecystolithiasis, metronidazole, hours may explain Dupuytren’s permethrin persistence for 4 days. contracture, Amiodarone inhibition of anaemia, rosacea vemurafenib CYP3A4 metabolism possible.

6 72/F Mitral insufficiency - Skin melanoma, 960 mg Fibrillation atrial, 4.5 months Dechallenged Recovered Treated with rivaroxaban, metastatic or un- (paroxysmal) metoprolol. ECHO- LVEF resectable 55%, moderate tricuspid and mild aortic insufficiency 7 64/M - - Malignant 1440 mg Fibrillation atrial 7 months Dechallenged Recovered Treated with amiodarone melanoma stage 4

Of the patients not discussed above, three others syndrome with progressive regression of signs recovered, one while vemurafenib was continued. after vemurafenib was stopped. Sick sinus For the other two, action with vemurafenib was syndrome can lead to atrial fibrillation. not recorded or was discontinued 45 days before

onset of atrial fibrillation. Two patients did not recover and the action with vemurafenib was not Literature and Labelling recorded. Four patients died. Outcome was not recorded in the remaining reports. The FDA label indicates that atrial fibrillation was an adverse event observed in < 10% of patients in Of the four reports recording death as the phase II and III clinical trials.1 A veterans affairs outcome, two patients appeared to have disease summary of vemurafenib randomised clinical trials progression and were seriously unwell and one indicates that nine patients developed atrial had a pneumothorax and multi-organ failure. fibrillation.5 Neither source discusses causality or There was no evidence that atrial fibrillation was observed rates with vemurafenib compared with the direct cause of death in these reports. One placebo. There is no mention of atrial fibrillation in patient had hypotension, which may have been a the EMA Summary of Product Characteristics. result of atrial fibrillation, and increased hepatic transaminases. In this case, atrial fibrillation may In a review of cardiac adverse effects of tyrosine have contributed to death although the patient kinase inhibitors (TKIs) the authors state that the was taking morphine which could indicate type of cardiovascular side effect differs between advanced malignancy. TKIs based on which cellular signalling pathways they inhibit.6 They divided the agents into two Related reports in VigiBase® clinical groups: At the time of assessment there were 47 reports (i) the VSP (VEGF signalling pathway) inhibitors of prolonged QT interval, a recognised adverse and reaction to vemurafenib. There were also 15 (ii) the non-VSP inhibitor agents (which include reports of arrhythmia. One recorded recovery on vemurafenib). dechallenge. This was a report of sick sinus

WHO Pharmaceuticals Newsletter No. 1, 2016  19

Signal

They went on to state that VSP inhibitors are be more likely to experience adverse events, typically associated with hypertension, including cardiac disorders.1 cardiomyopathy and arterial ischemia. Non-VSP It is interesting to note that vemurafenib, if inhibitors are more commonly associated with QT causal, appeared to overcome the anti-arrhythmic prolongation, arrhythmia, fluid retention and effect of beta-adrenergic-blocking agents in some rarely cardiomyopathy. However, only patients. However, in most of these reports the vemurafenib was linked with atrial fibrillation in a evidence for causality was weak or absent. Of table of reported cardiac adverse effects greater importance is the co-prescription of associated with TK inhibitors. The incidence was amiodarone or carvedilol because of the possible reported as 5% but without a reference or pharmacokinetic interactions increasing exposure discussion. to vemurafenib. Furthermore both vemurafenib and amiodarone can prolong the QT interval and product information recommends against Discussion and Conclusion prescribing QT prolonging medicines with In a 2004 review of drug-induced atrial fibrillation vemurafenib.1 As a substrate for CYP3A4 and P- the authors found that the evidence for causality glycoprotein vemurafenib is particularly vulnerable for the wide range of suspect medicines came to drug interactions. from published case reports rather than clinical Even in the reports with best evidence of causality studies.3 The clinical management of patients with shown in Table 1 the majority of patients were serious disease requiring medicines that are treated for atrial fibrillation on stopping verapamil reported to be pro-arrhythmic is particularly and this is a limitation when assessing causality. difficult if atrial fibrillation develops. It is important However, the consistent time to onset within three that the best evidence is available to aid decisions weeks in most of the reports that contained the about drug discontinuation. For this reason, given best evidence of causality in other respects, the scant data in the literature regarding vemurafenib evidence of a dose response and the evidence for and atrial fibrillation, the VigiBase® reports were interactions with biological plausibility all support assessed. there being a signal for vemurafenib and atrial Table 1 shows the seven reports providing the fibrillation. However, it is not a strong signal and best evidence of causality. Of note is the further investigation would be useful. The advice possibility of a dose response in case 3. Although to undertake cardiovascular monitoring before and not strong evidence because metoprolol was after treatment with vemurafenib3 is important to commenced, the observation is supported by the detect both prolonged QT interval and atrial onset of atrial fibrillation after carvedilol, a P- fibrillation. The VigiBase® reports with best glycoprotein inhibitor, was added to vemurafenib evidence of causality suggest that the greatest risk in case 4. It is interesting to note that four of the is within a month of starting vemurafenib and, reports in Table 1 are in the group of six with a possibly, after a dose increase or after prescription time to onset of 12 to 19 days. Also, in case 4, of a potentially interacting medicine. although the time to onset of atrial fibrillation was two months after vemurafenib was started, it was 18 days after carvedilol was added. One other References report with time to onset 13 days did not contain 1. US FDA product label for vemurafenib. URL: any other possible explanations for the development of atrial fibrillation but it is not http://www.accessdata.fda.gov/drugsatfda_ included in Table 1 as there was no dechallenge docs/label/2014/202429s006lbl.pdf. information. These reports with a short time to Accessed: March 2015. onset and evidence of causality suggest the 2. Sanoski CA BJ. The arrhythmias. In possibility that atrial fibrillation is more likely to be Pharmacotherapy: a pathophysiologic due to vemurafenib if it occurs within the first approach. In: DiPiro JT, Talbert RL, Yee GC et month after vemurafenib is commenced or exposure to it is increased. al., editors. 9th ed 2014. 3. van der Hooft CS, Heeringa J, van Herpen G, The patient aged 39 years was an outlier and the Kors JA, Kingma JH, Stricker BH. Drug- remainder of the 17 patients with age recorded induced atrial fibrillation. J Am Coll Cardiol. were 62 to 87 years. There is an increasing prevalence of atrial fibrillation with age. The 2004;44(11):2117-24. question is whether older age and the co- 4. Caster O, Juhlin K, Watson S, Noren GN. morbidities many of the patients experienced were Improved statistical signal detection in the sole cause of the atrial fibrillation or whether pharmacovigilance by combining multiple vemurafenib contributed. The FDA product strength-of-evidence aspects in vigiRank. information states that phase III study data Drug Saf. 2014;37(8):617-28. showed that elderly patients (≥ 65 years old) may

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5. VA Pharmacy Benefits Management Services An analysis of the Truven Healthcare MarketScan® Medical Advisory Panel, and VISN Pharmacist Commercial Claims and Encounters database Executives. Vemurafenib (Zelboraf), National estimates the overall prevalence of AF following a diagnosis of mM at 12.5%. The overall incidence Drug Monograph 2012. URL: rate in mM was estimated as 30.9 (CI 28.77- http://www.pbm.va.gov/pbm/clinicalguidance 33.24) per 1000 patient years and significantly /drugmonographs/vemurafenibdrugmonograph. higher in patients > 60 years. pdf. Accessed: March 2015. In comparison, the incidence of AF among 6. Mouhayar E, Durand JB, Cortes J. vemurafenib patients in the Phase III clinical study Cardiovascular toxicity of tyrosine kinase was 3.5% (12 out of 337) with a median age of inhibitors. Expert Opin Drug Saf. 70.5 years (range 58-78). All 12 patients had 2013;12(5):687-96. confounding/risk factors for AF such as medical history of AF or unspecified arrhythmia (n=4), mitral valve prolapse (n=1) and concurrent medical conditions of hypertension (n=1), Response from Roche myocardial infarction (n=1) and pericardial The WHO Collaborating Centre in Uppsala invited effusion (n=2). In the dacarbazine arm, the Roche to comment on a signal of atrial fibrillation incidence was 0.34% (1 out of 294, aged 82). (AF) in patients treated with vemurafenib based on Latency for the 12 cases ranged from 9-952 days 29 cases in the VigiBase®. (median 63). In ten of the 12 cases, vemurafenib was maintained and the event resolved in 7 cases, AF is the most common pathologic persisted in one case even when vemurafenib was supraventricular tachycardia affecting more than 3 eventually discontinued, and unknown outcome in million people in the US and many more the remaining cases. In two of the 12 cases, worldwide. Risk factors for AF include older age, vemurafenib was interrupted and dose reduced male sex, hypertension, and underlying cardiac with resolution of events. disease. The incidence increases with age with up to 4% of the adult population >60 years will In the Phase IV safety study (MO25515), 54 out of experience arrhythmia (Stricker, van der Hooft, & the 3222 (1.7%) patients reported AF. Median age Al, 2004). was 68.5 years (range 36-84) with 49 patients (90%) >60 years. Median latency was 78 days The incidence of drug induced atrial fibrillation (range 2-659). The majority of patients (83%) had (DIAF) is unknown but is likely very low, and no risk/contributing factors such as hypertension, risk factors have been characterized. Cancer itself thyroid disease, structural heart disease, creates an arrhythmogenic environment and is myocardial infarction, systemic infection/sepsis, difficult to determine whether AF reflects the and pericardial effusion. disease or is an adverse effect of the treatment. The onset of DIAF is variable depending on the As of May 19, 2015, there are 68 cases of AF inducing drug. The correlation is easy to reported with vemurafenib use in the Roche safety demonstrate in healthy individuals when AF database. Twenty-seven cases (40%) were from appears after drug administration with close company sponsored interventional clinical trials temporal relationship between drug (15 of the 27 from the MO25515 phase IV study) and initiation/termination of AF and 41 cases were from other sources. Age was (Tamargo, Caballero, & Delpon, 2012). Possible reported in 63 of the 68 cases with a median of 71 mechanisms of DIAF are adrenergic or vagal years (range 39-85), and 55 patients (87%) > 60 stimulation, direct cardiotoxicity, coronary years. Thirty-three were male (49%), 34 (51%) vasoconstriction/ischemia, and electrolyte were female, and one unreported gender. Seven disturbances (Stricker, van der Hooft, & Al, 2004). patients (10%) have a medical history of AF. Latency was provided in 52 of the 68 cases with a Vemurafenib inhibits mutant BRAFV600 approved median of 84 days (range 1-952). for the treatment of metastatic melanoma (mM) harbouring this mutation. There has been no Based on Roche’s medical review of the 68 AF described association between the RAF/MEK/ERK cases, causal association cannot be excluded in 5 pathway and AF. The current vemurafenib label cases based on latency, absence of reported risk does not include AF as an ADR, however factors, and positive dechallenge (Table 1). The prolongation of QT interval, which could potentially remaining cases had inadequate case information, cause ventricular tachyarrhythmias is a known or had strong alternative etiology for AF, had ADR of vemurafenib. Vemurafenib (a CYP 3A4 longer than expected latency relative to substrate/inducer and P-gp substrate) (Roche, vemurafenib’s pharmacokinetic profile (>200 2015) may also potentially interact with days), or had negative dechallenge/rechallenge. concomitant medications in patients with cardiac conditions and exacerbate pre-existing cardiac pathology putting patient at risk for AF.

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Table 1. Cases of interest in Roche Safety Database

MCN/ Age/ Total daily Latency Vemurafenib Event Relatedness Dechallenge Rechallenge Origin Gender dose (days) outcome outcome

1065081 74 1920 mg 28 Interrupted / Resolved Related Positive Not reported CT F dose reduced

1071170 82 1920 mg 12 Dose reduced Resolving Unknown Positive Not applicable Spont F

1293946 62 1920 mg 15 Interrupted/ Resolved Related Positive Not reported Spont F dose reduced

1327287 53 1920 mg 13 Interrupted/ Resolved Related Positive Not reported CT M dose reduced

1418386 78 960 mg 14 D/C Resolving Related Positive Not applicable Spont F

CT: Clinical Trial, Spont: Spontaneous, D/C: Discontinued

The incidence rate of AF for vemurafenib based on 3. Stricker, B., van der Hooft, C., & Al. (2004). the 27 cases from clinical trials is estimated at Drug- induced Atrial Fibrillation. Journal of the 7.05 cases per 1000 patient years*. The 54 cases American College of Cardiology , 44 (11), in the MO25515 Phase IV study yield an incidence 2117-24. rate of 17.5 per 1000 patient years. Both rates are significantly lower when compared to the 4. Tamargo, J., Caballero, R., & Delpon, E. background incidence for the mM population in a (2012). Drug Induced Atrial Fibrillation. commercial claims and reimbursement database Expert Opinion on Drug Safety , 11 (4), (30.9 per 1000 patient years). In addition, the 615-34. cases had wide latency ranging from 1 to 965 days, with majority of the cases (88%) having pre-existing risk factors or a negative dechallenge. Our review of the literature also did not provide any evidence on plausible mechanism of action of vemurafenib/BRAF inhibitors causing cardiac arrhythmias. Roche acknowledges the signal for atrial fibrillation raised by the WHO. Although there are 5 cases of AF where causal association cannot be excluded, our overall assessment showed that there is no convincing evidence supporting a causal association between vemurafenib and AF based on low statistical strength, negative dechallenge in majority of cases, wide latency, and lack of plausible mechanism. This signal is monitored through routine pharmacovigilance. *estimated cumulative patient exposure = 3828 patient years

References 1. Link, M. (2012). Evaluation and Initial Treatment of Supraventricular Tachycardia.

New England Journal of Medicine , 367, 1438-48. 2. Roche, (2015). Zelboraf Summary of Product Chracteristics.

http://www.ema.europa.eu/docs/en_GB/ document_library/EPAR_-_Product_Information/ human/002409/WC500124317.pdf

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CAVEAT DOCUMENT

Accompanying statement to data released from the Uppsala Monitoring Centre, WHO Collaborating Centre for International Drug Monitoring

Uppsala Monitoring Centre (UMC) in its role as the WHO Confidential data Collaborating Centre for International Drug Monitoring According to WHO policy and UMC Guidelines, receives reports of suspected adverse reactions to ICSRs sent from the WHO PIDM member medicinal products from National Centres in countries countries to VigiBase® are anonymized, but they participating in the WHO pharmacovigilance network, are still to be considered sensitive due to the the WHO Programme for International Drug Monitoring. nature of the data. Limited details about each suspected adverse reaction are received by the UMC. The information is stored in When receiving and using adverse reaction data the WHO Global Individual Case Safety Report (“Data”), the user agrees and acknowledges that database, VigiBase®. It is important to understand the it will be the controller of any such Data. limitations and qualifications that apply to this Accordingly, the user shall adhere to all information and its use. applicable legislation such as, but not limited to, EU and national legislation regarding protection The reports submitted to UMC generally describe no of personal data (e.g. the Data Protection more than suspicions which have arisen from Directive 95/46/EC and Regulation (EC) No observation of an unexpected or unwanted event. In 45/2001, as applicable). As the controller of the most instances it cannot be proven that a specific Data, the user shall be liable for any and all medicinal product (rather than, for example, underlying processing of the Data and shall indemnify and illness or other concomitant medication) is the cause of hold the UMC harmless against any claim from a an event. data subject or any other person or entity due to a breach of any legislation or other regulation Reports submitted to National Centres come from both regarding the processing of the Data. regulated and voluntary sources. Some National Centres accept reports only from medical practitioners; Non-permitted use of VigiBase® Data includes, other National Centres accept reports from a broader but is not limited to: range of reporters, including patients. Some National  patient identification or patient targeting Centres include reports from pharmaceutical companies  identification, profiling or targeting of in the information submitted to UMC; other National general practitioners or practice Centres do not. Some National Centres strongly recommend that The volume of reports for a particular medicinal product anyone who intends to use their information should may be influenced by the extent of use of the product, contact them for interpretation. publicity, the nature of the reactions and other factors. No information is provided on the number of patients Any publication, in whole or in part, of information exposed to the product. obtained from UMC must include a statement:

Some National Centres that contribute information to (i) regarding the source of the information, VigiBase® make an assessment of the likelihood that a (ii) that the information comes from a variety of medicinal product caused the suspected reaction, while sources, and the likelihood that the suspected others do not. adverse reaction is drug-related is not the same in all cases, Time from receipt of a report by a National Centre until (iii) that the information does not represent the submission to UMC varies from country to country. opinion of the World Health Organization. Information obtained from UMC may therefore differ from those obtained directly from National Centres. UMC may, in its sole discretion, provide further instructions to the user, responsible person For the above reasons interpretations of adverse and/or organization in addition to those specified reaction data, and particularly those based on in this statement and the user, responsible comparisons between medicinal products, may be person and/or organization undertakes to comply misleading. The supplied data come from a variety of with all such instructions. sources. The likelihood of a causal relationship is not the same in all reports. Any use of this information must take these factors into account. Omission of this statement may exclude the responsible person or organization from receiving

further information from VigiBase®.

WHO Collaborating Centre for International Drug Monitoring, Box 1051, SE-751 40 Uppsala, Sweden

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Recommendations from the 38th Annual Meeting of Representatives of the National Pharmacovigilance Centres participating in the WHO Programme for International Drug Monitoring

The annual meeting of National Pharmacovigilance Centres (NPCs) participating in the WHO Programme for International Drug Monitoring Selection of topics provides a platform for representatives from around the world to meet for working groups and discuss pharmacovigilance (PV) issues. Representatives of Member at the WHO annual States have the opportunity to interact with WHO and WHO Collaborating meeting of National Centres (WHO CCs) face to face, exchange information on country needs, Pharmacovigilance and propose how WHO and WHO CCs can support them. One of the most Centres important outcomes from this meeting is the formation of recommendations which shape the direction of future PV activities. Recommendations are made by delegates through group work. The thirty- eighth annual meeting of representatives of National Pharmacovigilance The format of the WHO Centres participating in the WHO Programme for International Drug National Pharmacovigilance Monitoring was held from 4 to 6 November 2015, at New Delhi, India. The Centres meeting is structured meeting included eight working groups that discussed various issues in into three components: PV. The topics for the working groups had been suggested by National PV plenaries, group exercises Centres. The summary of discussions and the recommendations are (working groups) and update described below. sessions. The topics of these meetings are proposed by Member States at the end of

the annual meeting for Annual National National Pharmacovigilance Pharmacovigilance Centres meeting Member Centres. WHO then WHO States distributes a questionnaire with the proposed topics to all Member States participating in the

Agenda Feedback programme during the first quarter of every year. By completing the questionnaire topics can be prioritised to fit WHO and WHO country’s requirements WHO provides Collaborating preliminary ensuring the forthcoming Centres review meeting agenda has a good list of topics mix of subjects that are of More topics, interest and relevance in both Questionnaire prioritize Member advanced and resource States limited settings.

Generation of Recommendations The annual meetings of National Pharmacovigilance Centres usually have eight working groups, run in parallel on two days. Delegates are provided with a list of objectives and expected outcomes prior to the working groups. During these sessions a moderated discussion is conducted and attendees formulate and agree on a list of recommendations that are specifically targeted at WHO, WHO CCs and / or the National Pharmacovigilance Centres. A rapporteur is delegated from amongst the workshop participants and recommendations are then presented to the whole delegation in a plenary session. Following this, recommendations are finalized and confirmed.

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Practicalities of establishing and running a pregnancy register to follow outcomes of drug exposure Moderators: A Kant and N Iessa

The session started with an overview of outcomes discussed in the previous year’s working group on pregnancy registers. Participants agreed that information from spontaneous reporting is not enough to monitor safety of medication during pregnancy. Amongst the representatives, two countries (Malaysia and Armenia) had a check box to indicate pregnancy in their adverse drug reaction (ADR) reporting forms. Two NPCs with pregnancy registries were identified; Lareb (the Netherlands), and South Africa. During discussions representatives from these two centres explained how pregnancy registers were initiated, and challenges and opportunities that were encountered. Challenges included: lack of financial support, late presentation of pregnant patient (i.e. first appointment is time of birth with no prior clinical visits throughout the pregnancy), and loss of patients to follow-up. South Africa shared how they sought and obtained political will and funding to set up their pregnancy register: at first the records covered a population in a small area, later this extended to cover a district and now there is a plan to expand coverage of pregnancies for the whole population.

Recommendations from the working group on practicalities of establishing and running a pregnancy register to follow outcomes of drug exposure

For WHO CCs and WHO:  Lareb (the WHO Collaborating Centre for Pharmacovigilance in Education and Patient Reporting) to provide technical support, with WHO as lead, in the development of tools (which would include specific guidelines, communication and training materials) that would be used by other countries. The developed tools should take into account the differences between countries.  WHO to support model National Pharmacovigilance Centres in the process of developing tools. For National Pharmacovigilance Centres:  To support the integration of ‘pregnancy PV activities’ into their public health programmes.  Countries that would like to develop registries should start on a small scale and expand gradually.

Reporting and learning systems for medication errors, the role of national centres, WHO Collaborating Centres and WHO Moderators: S Pal and S Olsson

The workshop started with a presentation that outlined: the extended scope of PV, frequency of preventable adverse drug reactions (ADRs); current projects investigating the detection of Medication Errors (ME); the WHO publication “Reporting and learning systems for medication errors: The role of pharmacovigilance centres”. Discussions centred around: the need to modify definitions used for relevant terms (e.g. adverse event, preventable ADR); the need to modify reporting forms to allow for collection of ME reports; validating the P-method for detecting preventable ADRs; communication to potential reporters, the need to encourage the submission of information on MEs; and collaboration with other organizations or groups within countries to strengthen the work for prevention of medication errors. Participants proposed that forms for collecting Individual Case Safety Reports (ICSRs) could be improved to optimize detection of MEs. Items such as: patient weight, relevant medical history, suspected and concomitant medications, and room for narratives could be present on the ICSR form.

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Recommendations from working group on reporting and learning systems for medication errors, the role of national centres, WHO Collaborating Centres and WHO

For National Pharmacovigilance Centres:  To increase capacity and competence of the National PV Centres to identify and analyze Medication Errors (ME). ○ Identify obstacles to reporting ME and learning ○ Document procedures ○ Investigate if funds from public health programmes may be used to support MEs Reporting and Learning Systems ○ Invest in research on ME, to find out the burden of MEs in public health programmes.  To optimize the Individual Case Safety Reporting Forms to capture MEs.  To focus on reporting and publishing.  To adapt definitions of adverse drug reaction and medication errors for the local legal situation (e.g. in the EU, medication errors are included in the definition of ADR).  To improve individual record-keeping in medical facilities.  To pursue regional collaboration between centres for competence-sharing and training on ME analysis.  To make ADR/ME reporting one of the criteria in the private health care sector for accreditation.  To follow the US model of getting hands-on training for pharmacists joining the PV centre, to get 6 months training in the FDA and six months in the Institute for Safe Medication Practices (ISMP).  To conduct a study with volunteer countries to validate the ‘P method’ for detecting preventable ADRs.

For WHO and WHO CCs:  To propose a Council for International Organizations of Medical Sciences (CIOMS) working group, to clarify discrepancies in definitions between patient safety and PV networks.

Data mining/signal detection at national centres: when, how, why Moderators: YK Gupta and Laura Sottosanti

The signal process in Italy was shared. During the reports; hence databases are small, making it discussions it was agreed that there is no specific difficult to detect signals statistically. In this case, number of reports needed for data mining. There software and sophisticated data-mining methods needs to be a balance between quality, quantity and may not be useful. However, data can be pulled critical mass of information for signal detection. In from other countries. In addition LMICs may lack addition, statistical evidence may not be needed if expertise and knowledge. In terms of software, the clinical evidence is overwhelming and it is important WHO CCs can provide support through online- to confirm statistical reports with clinical analysis webinars and face to face meetings. Countries and obtain expert opinions. It was suggested that should not be deprived of this support due to lack of Standard Operating Procedures (SOPs) for signal funds. In high income countries, statistical software detection should be country specific and should be is often developed internally or purchased. different for vaccines and medicines. It is critical to identify experts who are trained and knowledgeable, with different medical backgrounds. Predefined criteria should be set and different data sources such as literature, VigiBase® and national databases should be used. Communication of signals was discussed, for example when to communicate and to whom. All stakeholders should be informed and communication methods include ‘Dear health-care professional’ letters and websites. Countries with less established PV systems, in particular Low-and Middle– Income Countries (LMICs) might lack the capacity for using and analyzing data mining software. In some Member States there may be a relatively small number of

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Recommendations from working group on data mining/signal detection at national centres: when, how, why

For WHO and WHO CCs:  To help with capacity building in NPCs for data-mining and signal detection.  To facilitate training through e-training and e-fora.  To develop standardized tools for data-mining and signal generation (incorporating VigiLyzeTM).  To help develop a template/generic SOP for signal detection to be adopted by interested countries.  To help build data-mining and signal detection into public health programmes at the point of inception, and to advise on/provide software to assist this process.  To continue to develop and increase awareness of software, in particular VigiLyzeTM, for data-mining and signal detection and make these freely available to the countries (downloadable on the internet) to help compare national data with that of other countries.  To support NPCs with a strategy for raising funds for this area of work.

How can PV centres work with any relevant associations that can provide data and/or insights, including patient organizations and public health programmes Moderators: V M Šarinić and A Mengistu

This session started by discussing collaborations with public health programmes (PHP) and patient involvement in countries represented in the working group. Many stories were shared. In some countries, although effort was invested, outcomes were not as anticipated. These stories were used to draw up recommendations. Representatives from 14 different countries attended this working group.

Recommendations from working group on how can PV centres work with any relevant associations that can provide data and/or insights, including patient organizations and public health programmes National PV Centres should consider the following in their collaborations with: 1. Public health programmes (PHPs)  Collaborations should be beneficial for both parties  Make best use of the available resources ○ PHP infrastructure to promote reporting ○ PV centre knowledge for designing reporting form for PHPs (which might need modification from the spontaneous reporting form) and signal detection  Schedule regular meetings where information is exchanged, so that all information can be used both by PHP and PV centres in their decision making  Define roles and responsibilities clearly  Keep scientific independence  Document agreements (memorandum of understanding)  Consider that different PHP programmes in one country may require a different approach.

2. Patient organizations  Collaboration should be beneficial for both parties  Listen to what patient organizations want  clarify what can and cannot be done  Use patient organizations as ambassadors for National Pharmacovigilance Centres  Also involve other organizations, for example women’s associations or consumer organizations.

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For contacting patient organizations  Raise the awareness about PV centres and what is being done in media directed to the public (this will encourage patient organizations to contact or invite National Pharmacovigilance Centres to collaborate)  Choose either an umbrella organization or the biggest/most active organizations and approach these actively.

WHO and WHO CCs are recommended to:  Create a platform where experiences (success stories but also initiatives that failed) can be shared. The stories should be practical, so that readers can try and adopt them in their own setting  Modify existing platforms such as Vigimed and Uppsala Reports instead of creating new ones  Include these subjects (PHPs, patient organizations) in training, using experienced organizations as trainers.

Where is PV heading / the future of PV Moderators: B Medhi and M Lindquist

This working group had 28 participants from 16 countries. The PV vision in ten years was discussed to include: a broader field of action for PV, integration of PV in all health-care aspects, and routine PV education. PV should be supported by legislation in all countries, with predictable, sufficient and sustainable funding. Prescribing should be rational and, preventable ADRs and medications errors should be minimised. PV needs to be cost-effective, responsive, and supported by the best of modern technology and media. Methods and tools for this vision were discussed. These include, raising awareness, establishing universal reporting, decentralising, work-sharing, refined benefit-harm assessment, clinical guidance for management of ADRs, metrics for PV, creating smart and agile systems to prepare for emergencies and integrating PV into Public Health Programmes.

Recommendations from working group on where is PV heading / the future of PV For all:  Develop and promote education and training for health-care professionals and pharmacovigilance staff ○ Support and streamline existing curriculum initiatives (including WHO-ISoP and Lareb curricula) to meet the needs of basic medical and PV education  Explore innovative methods for raising public awareness of pharmacovigilance. ○ Facilitate the collection of best practice examples for sharing among member countries (including the dissemination of ‘Take&Tell’)  Implement the WHO pharmacovigilance indicators in member countries using a standard protocol ○ Assess impact of pharmacovigilance activities  Explore new sources and new methods for collection of patient safety data  Explore the benefits of engaging professionals from other disciplines such as psychologists, health economists, social scientists, implementation scientists, communications experts, eco-pharmacologists, and others For WHO CC UMC:  Find a technical solution for reporting adverse drug reactions in situations without internet access  Develop Vigimed as a user-friendly collaboration portal and encourage its use  Familiarise all member countries with the use of database tools such as VigiLyzeTM, VigiGrade, etc.

The working group recognises and commends the Sierra Leone Pharmacovigilance Centre for its courage and persistence they displayed in the Ebola epidemic in their country; the working group proposes that such vivid examples of the robust effectiveness of PV should be collected and used at the highest levels for the purposes of advocacy and fund-raising.

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The need for quantitative benefit-risk assessment in PV Moderators: R Savage and E van Puijenbroek

This working group consisted of 40 participants. The challenges and advantages of qualitative and quantitative approaches to risk benefit assessments were discussed. Qualitative is more subjective, whereas quantitative can be used to compare. However this approach can be complex and requires expertise. Many of the representatives attending this working group had experience using qualitative assessments (Namibia, Republic of Korea, Thailand, Turkey, Chile, Vietnam, India, Belgium) but none had quantitative experience. The opportunities and challenges for qualitative risk benefit assessments were identified. For qualitative assessments, an example of an opportunity is access to global data. Challenges include variation between populations, lack of efficacy data and potential bias (due to subjective nature). Challenges of quantitative assessment included lack of expertise and manpower. Data and skills needed to perform risk benefit analysis were listed.

Recommendations from working group on the need for quantitative benefit-risk assessment in PV For WHO and WHO CCs  Provide training (capacity building)  Provide technical guidance  Include benefit-risk information in newsletters

For National Pharmacovigilance Centres  Regulators such as FDA and EMA should share how they reach benefit-risk conclusions

Revisiting the WHO Minimum PV Requirements Moderators: A Dodoo and H B Ndagije

Twenty participants from seven countries attended this working group. Current minimum requirements are available on the WHO website: http://www.who.int/medicines/areas/quality_safety/ safety_efficacy/saf_pub/en/. The PV landscape has changed since the WHO minimum requirements for NPC were proposed in 2009. They need to be made clearer, simple and measurable. They should not give the impression that they are the only requirements. Additional requirements should be added to the existing ones. New requirements should have accompanying guidelines and explanatory notes.

Recommendations from working group on revisiting the WHO Minimum PV Requirements For WHO:  WHO should develop the new set of minimum requirements for PV and detailed guidelines to accompany the minimum PV requirements, and submit these to the 2016 National Centres meeting for approval

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Proposed Minimum Requirements for National Pharmacovigilance Centres  A National Pharmacovigilance Centre collaborating with the WHO Programme for International Drug Monitoring and implementing at least a spontaneous reporting system  National spontaneous reporting system with form(s) for capturing and reporting adverse events to medical products including medicines, vaccines, medical devices etc.  A national database or system for collating, managing and sharing PV data  A functional national advisory body for pharmacovigilance  A communication plan for stakeholders in pharmacovigilance (to include over-the counter, internet- purchases and non-medicinal drugs)  Legislation on pharmacovigilance  Formal link to National Regulatory Authority  Established procedures for measuring impact of the national pharmacovigilance system  Designated full-time staff to fulfil the minimum requirements of national PV centre  Dedicated financial and technical resources to fulfil the minimum requirements of national PV centre

How to capture adverse events due to over-the–counter (OTC), internet purchased (IP) and non-medicinal drugs (NMD) Moderators: B Harvey and M Dheda

The working group consisted of 40 participants. ADRs include: patients, face-to-face meetings, help Discussions included information sources, lines, health-care professionals, PV networks (some experiences of NPCs in capturing ADRs due to over- countries may detect ADRs faster, related to the-counter (OTC), internet-purchased (IP) and specific products than others), social media and non-medicinal products (NMDs). Most countries do collaborations with other stakeholders. Vigimed not have a specific system to capture ADRs from needs to be made more user-friendly to improve OTC, IP and NMDs. The Republic of Korea has a communications between countries. The public can specific system for reporting and analysing reports be educated and awareness built through: social (many OTC medications are available in media, patient-targeted portals, websites of convenience stores). Such reports can be used for regulators, awareness campaigns (television and consumer education (e.g. liver toxicity). Generally radio, print media). Health-care professionals consumers do not link ADRs to these products and should be trained to ask patients if they are taking many believe natural ingredients are safe. Access OTC and IP medications and NMDs. This will give to the internet has increased and it is difficult to the opportunity to educate the patient. Challenges regulate internet sales of medicines. Regulations include: lack of funding, lack of cooperation from are less stringent for OTCs and herbal medicines. consumers, inability to trace source of supply. There may be many drug-drug interactions and Opportunities include: presence of existing patients may use products with similar ingredients. systems, sources such as herbal pharmacopoeia. Sources of information that can be used to capture

Recommendations from working group on how to capture adverse events due to over-the–counter (OTC), internet purchased (IP) and non-medicinal drugs (NMD)  Set up a website of agents/groups that are accredited for online sale of medicines.  Develop a tool that can help NPCs to detect adverse events online e.g. stories shared on social media  Make Vigimed more user-friendly

WHO Pharmaceuticals Newsletter No. 1, 2016  30