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Safety issues are a major concern for patients considering treatments for inflammatory bowel disease (IBD). Researchers performed a systematic review and meta-analysis to determine whether biologic agents affect the risk of infection or malignancy in adults with IBD.

The therapeutic armamentarium for inflammatory bowel disease (IBD) is rapidly growing. During recent years, novel biologic treatments have been developed for Crohn’s disease (CD) and ulcerative colitis (UC), some of which are currently approved for the treatment of IBD refractory to standard medications: 4 anti–tumor necrosis factor (anti-TNF) agents, infliximab, adalimumab, golimumab, certolizumab pegol, and 2 anti-integrin molecules, natalizumab and vedolizumab.

Although their clinical efficacy in IBD has been clearly established, it remains uncertain to what extent biologic therapies might be associated with increases in the rate of infections and malignancies. This uncertainty reflects the difficulties of analyzing and interpreting sparse adverse event (AE) data derived from randomized controlled trials (RCTs) that have not been adequately powered to detect potentially small increases in the risk of infections or cancer. In addition, post-marketing observational studies lack the experimental random allocation that is necessary to optimally test exposure-outcome hypotheses and leave open to discussion whether events are associated with the biologic agent or with IBD itself.

Because of the wide use of biologic drugs as induction and maintenance therapy for adults with CD or UC, Researchers conducted a systematic review and meta-analysis of RCTs to examine the effects of the different anti-TNF and anti-integrin agents used in IBD on the risk of developing infections (primary outcome) and malignancies (secondary outcome). In addition to traditional meta-analytic techniques, network meta-analysis was performed, allowing adjusted indirect comparisons relative to a common comparator (placebo) and yielding estimates of comparative harm. Researchers aimed to provide a clinically useful summary of the existing evidence to assist physicians in the decision-making process.

On the basis of a systematic review and meta-analysis, biologic agents increase the risk of opportunistic infections in patients with IBD, but not the risk of serious infections. It is necessary to continue to monitor the comparative and long-term safety profiles of these drugs.

 

 

Three injections of a therapeutic vaccine may control genital herpes as effectively as daily pills for at least a year, a new study suggests.

Researchers tested the experimental vaccine in 310 people with herpes from 17 centers around the United States. The three shots, administered three weeks apart, appeared to reduce patients’ genital lesions and the process of “viral shedding” in which they can spread the disease through sexual contact.

Infectious disease experts hailed the vaccine as a promising development in the treatment of genital herpes. The incurable disease affects about one in every six people ages 14 to 49 in the United States, according to the U.S. Centers for Disease Control and Prevention.

“In general terms, people receiving [the vaccine] have greater than 50 percent fewer days in which virus is present in their genital tracts, which in theory may reduce transmission,” said study author Jessica Baker Flechtner. She’s chief scientific officer at Genocea Biosciences, the Cambridge, Mass., manufacturer of the vaccine.

Currently named GEN-003, the vaccine is believed to work by prompting a type of white blood cell known as a T-cell to recognize and kill cells in which the virus lives, Flechtner explained.

Current herpes treatment involves taking antiviral pills that can control the length and severity of symptoms and reduce patients’ outbreaks. But many patients struggle with taking their treatments regularly, infectious disease experts said.

“Herpes is an uncomfortable, embarrassing disease,” Hoffman said. “This [vaccine] offers the opportunity to protect people going into new relationships.

“As you can imagine, if one partner has six to 10 episodes of herpes per year and the other partner is unaffected, it can really change the nature of the relationship,” he added. “But if that number goes down to one to two episodes per year based on immunization, it can help protect the other partner.”

Stanberry predicted that future research would look at combining the vaccine with antiviral pills to gauge the impact on reducing sexual transmission. On its own, the vaccine “is likely to reduce the risk, but the likelihood of eliminating the risk is exceedingly small,” he said.

The study was presented at the Infectious Disease Society of America’s annual meeting in New Orleans that ended Oct. 30. Research presented at conferences typically hasn’t been peer-reviewed or published, and results are considered preliminary.

Twice-yearly dental check-ups appear to protect against developing pneumonia compared with less frequent dental visits, according to an analysis of national survey data. The findings further support the link between poor dental hygiene and bacterial infection.

“The risk of pneumonia appears to be decreased in those who customarily attend routine dental check-ups,” said Michelle Doll, MD, MPH, an assistant professor of medicine at Virginia Commonwealth University School of Medicine, Richmond. “There may be a relatively simple intervention, routine preventive dental care, that can assist in achieving pneumonia prevention.”

Dr Doll noted that previous studies have suggested a link between dental care and bacterial pneumonia risk. “We wanted to examine a larger population to see if dental care, overall, is preventive. We found that people who visited their dentist more frequently were protected against pneumonia. Compared to visits at least twice a year, persons who never saw a dentist had an 86% increased risk,” she said.

Dr Doll presented the findings here at IDWeek 2016, the joint annual meeting of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

Dental Care a Significant Factor in Pneumonia Diagnosis

Pneumonia was significantly associated with decreased frequency of dental check-ups. Compared with persons who visited the dentist at least twice a year, persons who had dental check-ups less than once a year had a 49% increased risk for pneumonia (P = .0373) and persons reporting never having visited a dentist had an 86% risk (P = .0008).

The mechanism of protection may be related to influx of pathogenic organisms from the mouth into the lung. “It is believed that in persons with good oral hygiene, there is less potentially pathogenic bacteria tracking into the lung and causing disease,” Dr Doll explained. Even in healthy persons, small quantities of saliva can aspirate into the lung. “The content of that saliva depends on one’s overall oral health. If there are pathogenic bacteria, this could cause pneumonia,” she said.

Dr Doll and her team acknowledged that frequent routine dental visits may indicate more long-term healthy oral behaviors or better general health.

 

New findings from a large national claims database show the use of cholesterol-lowering statin drugs to be associated with an increased risk for Parkinson’s disease (PD), contrary to previous research suggesting the drugs have a protective effect for PD.

For the new study, presented here at the American Neurological Association (ANA) 2016 Annual Meeting, the researchers turned to data from the MarketScan Commercial Claims and Encounters database, including information on 30,343,035 persons aged 40 to 65 years between January 1, 2008, and December 31, 2012.

In the cross-sectional analysis, the use of cholesterol-lowering drugs, including statins or nonstatins, was associated with a significantly higher prevalence of Parkinson’s disease (odds ratio [OR], 1.61 – 1.67; P < .0001) after adjustment for age, sex, and other comorbidities, such as hyperlipidemia, diabetes, hypertension, and coronary artery disease.

For a comparative neurodegenerative group, the researchers also looked at the association of statin with diagnosis of Alzheimer’s disease but found only a minimal association (OR, 1.01 – 1.12; P = .055).

The associations of cholesterol-lowering medications with PD were strongest among patients with hyperlipidemia, and there were no significant differences between lipophilic or hydrophilic statins, as well as the other nonstatin cholesterol-lowering drugs, in their effect on PD risk.

“We know that overall weight of the literature favors that higher cholesterol is associated with beneficial outcomes in Parkinson’s disease, so it’s possible that statins take away that protection by treating the high cholesterol,” Dr Huang explained.

“Another possibility is that statins can block not only the cholesterol synthesis but also synthesis of coenzyme Q10 that is essential for cell function.”

The researchers also stratified persons according to how long they had been receiving treatment by using a lagged matched case-control analysis of 2458 pairs of PD cases and controls.

In the cross-sectional analysis, both statins and nonstatin cholesterol-lowering drugs were associated with PD, but in the lagged case-control analysis of treatment duration, only statins remained significantly associated with PD risk.

The highest risk was linked to the earlier period after starting statins (OR, 1.93 for less than 1 year of use; 1.83 for 1 to 2.5 years; and 1.37 for 2.5 years or more; P trend < .0001).

“The increased risk of Parkinson’s is more likely when statins are first used, so we think it could be that the statins ‘unmasked’ Parkinson’s,” Dr. Huang said. “Namely, people may be already on the way to Parkinson’s and when they use statins to control the high cholesterol, it gives Parkinson’s a push to reveal its clinical symptoms.

“Based on this data, we think caution should be taken before advancing statins to be protective of Parkinson’s disease,” she added. “The data are not clear yet.”

American Neurological Association (ANA) 2016 Annual Meeting. Abstract S137. Presented October 16, 2016.

 

Major implicated agents include anabolic steroids, green tea, multi-ingredient nutritional supplements

Herbal and dietary supplement (HDS)-induced liver injury accounts for 20 percent of cases of hepatotoxicity in the United States, according to research published online Sept. 27 inHepatology.

Victor Navarro, M.D., from Einstein Healthcare Network in Philadelphia, and colleagues examine the current challenges in the diagnosis and management of HDS-induced liver injury.

The researchers note that HDS-induced liver injury accounts for one in five cases of hepatotoxicity in the United States. Anabolic steroids, green tea extract, and multi-ingredient nutritional supplements (MINS) are the major implicated agents. Anabolic steroids, which are marketed as bodybuilding supplements, tend to induce a prolonged cholestatic, self-limiting liver injury, characterized by a distinctive biochemical and histological phenotype. In contrast, green tea extracts and other products cause an acute hepatitis-like injury. MINS account for most cases of HDS-associated liver injury; the causative agent is usually unknown or can only be suspected.

“The confident identification of injurious ingredients within HDS will require strategic alignments among clinicians, chemists, and toxicologists,” the authors write. “The ultimate goal should be to prohibit or more closely regulate potentially injurious ingredients and thus promote public safety.”

The US Food and Drug Administration (FDA) has approved a new version of a recombinant, egg-free influenza vaccine called Flublok (Protein Sciences) that will protect against four strains of the virus, the manufacturer announced today.

The current version of Flublok, available during the 2016-2017 flu season, is designed for three strains: an A/California/7/2009 (H1N1)-like virus, an A/Hong Kong /4801/2014 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus (B/Victoria lineage). The new formulation, Flublok Quadrivalent, protects against these as well as the B/Phuket/3073/2013-like virus (B/Yamagata lineage). Both are injectables.

A company spokesperson told Medscape Medical News that  Flublok Quadrivalent would be available for the 2017-2018 flu. Like its trivalent predecessor, Flublok Quadrivalent is indicated for adults 18 years of age and older.

Approved in 2013, trivalent Flublok is the only influenza vaccine on the market fashioned through recombinant DNA technology. The manufacturer isolates a hemagglutinin (HA) protein found on the surface of a naturally occurring flu virus that, as an antigen, triggers an immune response. These HA proteins are combined with portions of another virus, and the mix is grown in insect cells. The HA protein is then harvested and purified.

The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommended trivalent Flublok in 2013 as a vaccine alternative for individuals who have an egg allergy. The two other current ways of making flu vaccines involve eggs. In egg-based manufacturing, inactivated or live attenuated vaccine viruses are grown in eggs. In the cell-based process, vaccine viruses first are grown in eggs and then combined with mammalian cells to replicate. Vaccine antigen is purified from this mix.

In a news release, Protein Sciences called Flublok Quadrivalent a “good choice” for seniors and individuals with compromised immune systems because it contains three times more active ingredient than other quadrivalent flu vaccines, compensating for a weaker immune response.

A clinical study of 9000 adults 50 years of age and older showed that individuals who received Flublok Quadrivalent were more than 40% less likely to come down with a confirmed case of influenza than those who received Fluarix Quadrivalent (Glaxo SmithKline), according to the manufacturer.

Injection-site tenderness and pain, headache, and fatigue are among the most common adverse events associated with Flublok Quadrivalent.

Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), can significantly disrupt sleep architecture in elderly patients and may contribute to early signs of neurodegeneration that can progress to dementia, new research shows.

“We take into account other side effects of antidepressants, including weight gain and sexual side effects, but we are less concerned about sleep, especially when we use the SSRIs,” Muhammad Tahir, MD, psychiatry resident, SUNY Upstate Medical University, Syracuse, New York, told Medscape Medical News.

“But the SSRIs increase sleep latency in the elderly and decrease REM [rapid eye movement] sleep duration and are also associated with REM sleep behavioral disorders, including nightmares,” he added.

“So our literature review suggests that we should be careful about using SSRIs in the elderly population and not underestimate the effectiveness of psychotherapy and other holistic care approaches for the elderly,” Dr Tahir said.

The study was presented here at the Institute of Psychiatric Services (IPS): The Mental Health Services 2016 Conference.

The literature review included 10 studies published within the past 5 years. The studies included systemic reviews, retrospective studies, and prospective studies, and patients had to be at least 50 years of age and receiving an antidepressant, largely an SSRI, for the treatment of depression.

Analyses revealed that not only did the SSRIs in particular change sleep architecture in older patients, they also appeared to increase the risk for REM behavioral disorders.

REM sleep behavioral disorders are characterized by normal brain activity, but the body is agitated and is not sleeping. This may be an early sign of neurodegeneration, said Dr Tahir.

Changes in the sleep architecture brought on by antidepressant therapy may result in agitation, Dr Tahir noted, which may prompt further treatment with further side effects.

Unfortunately, there is little evidence to support the use of any treatment other than the SSRIs for depression in the elderly.

Both the tricyclic antidepressants and the monoamine oxidase inhibitors are associated with too many side effects, especially in the elderly, and are generally not used in older patients.

Benzodiazepines in turn are associated with an increased risk for falls and again are inappropriate for use in the elderly.

Dr Tahir suggested that psychiatrists screen their elderly patients for any signs and symptoms of neurodegenerative disorders and, if an SSRI is prescribed, ask detailed questions about sleep quality on all follow-up visits.

SSRI Dosing Important

Commenting on the findings for Medscape Medical News, Peter Yellowlees, MD, professor of psychiatry, University of California, Davis, said the analysis, though interesting, does not include information on the doses of the SSRIs used in the studies that were included for review.

“In the elderly, these doses should be a maximum of half of the usual dose prescribed for younger patients,” Dr Yellowlees observed.

As for the possible association between SSRI use and neurodegenerative disease, Dr Yellowlees also noted that SSRIs are not necessarily causative.

“Rather, it may simply be that in the early stages of these diseases, depression and agitation are more common, and hence antidepressants are more commonly prescribed,” he noted.

In fact, the same association has been reported between the benzodiazepines and neurodegenerative disease that has been reported in the new study with respect to SSRIs, Dr Yellowlees pointed out.

“The jury is definitely out on the connection between degenerative disorders and medications, but in my view, there is not a lot of evidence to suggest that there is a causative link, although there does seem to be an association,” Dr Yellowlees suggested.

“The key issue here is that depression in the elderly is common and can be debilitating and is very treatable with both medications in lower doses than usually prescribed in younger patients along with behavioral interventions.”