Pro-arrhythmic potential of oral antihistamines (H1): combining adverse event reports with drug utilization data across Europe

Abstract

Background: There is appreciable utilisation of antihistamines (H1) in European countries, either prescribed by physician and purchased by patients for self-medication. Terfenadine and astemizole underwent regulatory restrictions in '90 because of their cardiac toxicity, but only scarce clinical data are available on other antihistamines.

Aim: To investigate the pro-arrhythmic potential of antihistamines by combining safety reports of the FDA Adverse Event Reporting System (FAERS) with drug utilization data from 13 European Countries.

Methods: We identified signals of antihistamine arrhythmogenic potential by analyzing FAERS database for all cases of Torsades de Pointes (TdP), QT abnormalities (QTabn), ventricular arrhythmia (VA) and sudden cardiac death/cardiac arrest (SCD/CA). Number of cases ≥3 and disproportionality were used to define alert signals: TdP and QTabn identified stronger signals, whereas SCD/CA identified weaker signals. Drug utilization data from 2005 to 2010 were collected from administrative databases through health authorities and insurance.

Results: Antihistamines were reported in 109 cases of TdP/QT prolongation, 278 VA and 610 SCD/CA. Five agents resulted in stronger signals (cetirizine, desloratadine, diphenhydramine, fexofenadine, loratadine) and 6 in weaker signals (alimemazine, carbinoxamine, cyclizine, cyproeptadine, dexchlorpheniramine and doxylamine). Exposure to antihistamines with stronger signal was markedly different across European countries and was at least 40% in each Country. Cetirizine was >29 Defined Daily Doses per 1000 inhabitants per day (DID) in Norway, desloratadine >11 DID in France and loratadine >9 DID in Sweden and Croatia. Drugs with weaker signals accounted for no more than 10% (in Sweden) and in most European countries their use was negligible.

Conclusions: Some second-generation antihistamines are associated with signal of torsadogenicity and largely used in most European countries. Although confirmation by analytical studies is required, regulators and clinicians should consider risk-minimisation activities. Also antihistamines without signal but with peculiar use in a few Countries (e.g., levocetirizine) or with increasing consumption (e.g., rupatadine) deserve careful surveillance.

Fig 1. Cross-National Comparison: time trend.

AUT: Austria; CRO: Croatia; EST: Estonia; FRA: France; IT: Italy; LIT: Lithuania; NOR: Norway; SPA: Spain (Catalonia); SCO: Scotland; SER: Serbia; SLO: Slovenia; SWE: Sweden. ENG: 2008–2010; EST: 2006–2010; FRA: 2005–2008; ITA: 2006–2010; SPA: 2006–2010; SWE: 2007–2010. Data from Norway and Sweden include also hospital data. Data from Sweden also includes OTC data.

Fig 2. Antihistamine utilisation on the basis of pharmacovigilance signals.

Fig 3. Utilisation of different antihistamines with stronger signals.