Saturday, November 19, 2016

Otezla® and an increased risk of suicide



Otezla® (active ingredient: Apremilast from Celgene) has been given a "Red Hand Letter" this month. In a "red hand letter" all physicians in Germany get important communications about a drug (e.g. new discovered side effects of a drug).
In the summary the letter reads: "Occasional cases of suicidal thoughts and suicidal behavior (with or without history of depression) have been reported in clinical trials and after market introduction (frequency ≥1/1,000 to ≤1/100). Cases of successful suicide have been reported after market introduction in patients treated with Apremilast."
The following background information has been given: "Notes on suicide thoughts and suicide behaviors: - The data collected after market launch by 20th March 2016 included 65 reported cases with 5 suicides completed, 4 suicide trials, 50 cases with suicide thoughts, 5 cases with depression and suicide thoughts, and 1 case with suicidal behavior. (...)"
Perhaps I’m too skeptical about small molecules, but I had argued already years ago that a change in communication within the cell could lead to more problems in regard to side effects than the interruption of communication between cells (e.g. by biologics). For the biologics used up to date in rheumatology, I do not know an increase in suicide and suicidal ideation; however, Amgen had withdrawn from the development of brodalumab (anti-IL-17R autoantibody). Brodalumab is already available in the US as Siliq, an introduction to Europe is expected for the first quarter of 2017. More about this has been discussed in the psoriasis network (in German!). For Tofacitinib, two suicides were listed in 2012, "ADVISORY COMMITTEE MEETING TOFACITINIB FOR THE TREATMENT OF RHEUMATOID ARTHRITIS". For baricitinib the number of patients tested may still be too low to answer this question.
I have used Otezla® very rarely since I have preferred other drugs, which were approved earlier, because of better knowledge and more experience. I won’t change this attitude. On the other hand, a danger that is known is also a lesser danger. 


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