Special Edition 2021

Funded by subscribers. No advertising, no grants, no shareholders I NT E RNAT I ONA L

SPECIAL EDITION

TOP TEXTS OF 2021

Prescrire International • 2021 • SPECIAL EDITION

Specially selected to introduce you to this wholly independent monthly drug bulletin , written by and for healthcare professionals

Illustration José David

Who are we? Prescrire is a French non-profit continuing education organisation, committed to better patient care Prescrire International is a monthly drug bulletin with selected texts translated from the French journal La Revue Prescrire

INTERNATIONAL

engl i sh.prescri re .org

President of Association Mieux Prescrire: Pierre Chirac, pharmacist ASSOCIATION MIEUX PRESCRIRE “To work, in all independence, in favour of quality healthcare, first and foremost in the interest of patients (...)” (Article 1 of the Association Mieux Prescrire bylaws). Prescrire International is published 11 times a year by Association Mieux Prescrire, a non-profit continuing education organisation (N° 11 711 075) under the French law of 1901. EDITORIAL STAFF Members of the Prescrire Editorial Staff sign a yearly declaration of absence of conflicts of interest, in accordance with Prescrire’s “Non merci...” Charter. Members are free from any interest contrary to Association Mieux Prescrire’s objectives (the Charter and the Declaration are available online at english.prescrire.org). Publishing reliable reviews that are easy to use and adapted to readers’ needs depends upon complex editorial procedures, all initiated and overseen by the members of Prescrire’s Editorial Staff. Members of the Editorial Staff define editorial goals.They oversee the literature search, the writing and rewriting of texts, and the review by a panel of outside experts (medical specialists, methodologists, representatives of Prescrire’s subscriber base…).They organise internal and external quality control procedures, and edit the final copy. Every draft is submitted, before publication, to a large number of external reviewers. Copyright Prescrire www.prescrire.org Registered address: 83, bd Voltaire 75011 Paris France Tel.: 33 01 49 23 72 80 E-mail: contact@prescrire.org Postal address: Prescrire - 83, bd Voltaire 75558 PARIS CEDEX 11 - FRANCE - Around 150 members of the Prescrire team - Around 100 external reviewers, experts in the subjects discussed and practising healthcare professionals For each issue, readers are provided with a list of the contributors to that issue. Around 250 people participate in the production and distribution of every issue of La Revue Prescrire , including:

patients – with the clear, comprehen- sive and reliable information they need about drugs and therapeutic and dia- gnostic strategies. Association Mieux Prescrire publishes a monthly journal in French, and an edition in English 11 times a year. A non-profit organisation, Prescrire is wholly financed by its subscribers, and accepts no advertising or other outside support. Reliable and relevant content Prescrire has the editorial and research capabilities necessary to ensure the accuracy of its reviews. Prescrire’s editors are healthcare professionals, specially trained in Prescrire’s editorial methods and free from conflicts of interest. Exacting quality-control procedures are applied to all editorial content.

The Association Mieux Prescrire (AMP), a non-profit organisation registered under the French law of 1901, manages all of Prescrire’s programmes and publ ications. The AMP is structured so as to be free of any influence from pharma- ceutical companies or healthcare institutions. Independent information Prescrire’ s purpose is stated in Article 1 of the AMP bylaws: “To work, in all independence, in favour of quality health- care, first and foremost in the interest of patients (...).” Prescrire offers continuing education and professional practice improvement programmes specifically adapted to the needs of healthcare professionals. Since 1981, Prescrire has provided healthcare professionals – and via them,

Subscribers can download any of the thousands of detailed reviews produced by Prescrire’s multidisciplinary team of healthcare professionals, and all including complete notes and references. All are available instantly , via an online table of contents going back to 1992, or via a search function.

SUBSCRIBE NOW FOR FULL ACCESS TO ONLINE CONTENT

Prescrire is a founder and member of ISDB, a network of drug bulletins that are independent of drug companies, which aims to promote international exchange of quality information on drugs and therapeutics. Website: www.isdbweb.org

Reliable, rigorously independent information on treatments and healthcare strategies, to enable fully informed decision-making. No grants, no advertising. No shareholders, no sponsors. Prescrire is funded by its subscribers.

Printed by Bulls Market Group/TPI

Editorial Doing one’s job TOP TEXTS OF 2021 SPECIAL EDITION How we work Prescrire’s rigorous, collective editorial process has been fine-tuned over the years NEW PRODUCTS

2

Ebola vaccine rVSV-Zebov( ervebo °) in an outbreak of Ebola virus disease Major reduction in incidence among those at risk for this often-fatal infection Fexinidazole ( fexinidazole winthrop °) and sleeping sickness caused by Trypanosoma brucei gambiense Effective and more convenient than injectable treatments Polatuzumab vedotin ( polivy °) and large B-cell lymphoma Remdesivir ( veklury °) and covid-19 Too many uncertainties over its efficacy as well as its harms Authorisation of remdesivir in the European Union: EMA needs to prioritise patients’ interests Dasatinib in children ( sprycel ° and other brands ) with acute lymphoblastic leukaemia Failure to demand solid evidence for marketing authorisation spells danger for patients ADVERSE EFFECTS VEGF inhibitors : arterial aneurysm and dissection Apixaban, edoxaban, rivaroxaban: situations with a high risk of bleeding or thrombosis Liposomal forms of drugs: now specified in the brand name, but no improvement to the INN REVIEWS Medical cannabis in chronic pain An option for some types of pain, while awaiting further evaluation Hydrochlorothiazide in hypertension An acceptable first choice OUTLOOK Towards better patient care: drugs to avoid in 2021 Drugs in 2020: a brief review Drug shortages : a (big) thorn in the side of pharmacists Towards transparency in the research costs of new drugs

3

4

Prescrire’s reviews, written by specially trained health professionals, are based on an exhaustive search of the literature, and undergo scrutiny by a large panel of outside reviewers plus rigorous quality-control procedures.

5

6

Editors free from conflicts of interest The absence of any direct or indirect financial links to the pharmaceutical industry is an absolute requirement to be a member of the Prescrire team. Any such link would be cause for dismissal from the Prescrire Editorial Staff. A vast network of reviewers Once they are in an advanced stage of editing and quality control, all draft reviews are sent to outside reviewers (10 to 40 reviewers read each draft at this stage). These reviewers critique each article in terms of content, style, relevance, newsworthiness, presenta- tion of arguments and usefulness in daily practice. The reviewers are spe- cialists in the subject being discussed, methodologists, or healthcare profes- sionals representative of Prescrire’s readers (and chosen from their midst).

All the reviews published in La Revue Prescrire (aside from a few clearly labelled exceptions, such as readers’ letters) are written by Prescrire’s Edi- torial Staff. Prescrire does not publish unsolicited manuscripts from outside contributors. The production of reviews draws upon a wide range of skills, all exer- cised under the supervision of Prescrire’s editors. This team approach is reflected in the collective byline “©Prescrire”. Written and edited by healthcare professionals Most of Prescrire’s editors are physicians (both in individual prac- tice or on hospital staff), pharma- cists (working in pharmacies or hos- pitals), nurses and dentists. A few are economists or journalists with specific expertise in the area of health- care. All Prescrire editors have received extensive in-house training in Prescrire’s editorial production process.

7

8

9

10

11

12

13

14

Follow Prescrire International on Facebook andTwitter

15-17

Keep up with the latest from Prescrire’s editors, and support our values of independence and quality information, first and foremost in the interest of patients. Follow us

18-19

19

20

P rescrire I nternational S pecial E dition 2021 • P age 1

Doing one’s job

Patients and healthcare professionals need to be able to count on an effective pharmaceutical industry. On pharmaceutical companies that market thoroughly evaluated drugs. Drugs that are more useful than dangerous and represent a tangible therapeutic advance in the indications for which they have been approved. Patients and healthcare professionals should be able to count on pharmaceutical companies to consistently produce drugs that meet high quality standards. At the right strength. Easily stored. Available on demand, supplied reliably and predictably, without delays, shortages or stockouts. Patients and healthcare professionals should be able to count on pharmaceutical companies to supply their drugs in safe, informative and functional packaging that does not take up more of their time than necessary. In which the drug is clearly identified with its international nonproprietary name (INN), dose strength, and so on. In which the drug is accompanied, where appropriate, by a suitable device for its accurate preparation and administration. Together with a patient leaflet containing all the information patients need to have about their treatment, without alarming them, so that they can understand, monitor and benefit from it. And all this must be achieved at prices that are reasonable, affordable and sustainable for health insurers and society as a whole. Without harming the environment. It’s a valuable job that requires expertise. Every year, the Prescrire Awards honour specific pharmaceutical companies that did their job, in a responsible manner, and provided a valuable service to healthcare professionals and patients (see Prescrire Int n° 224, pp. 77-81). But what a shame it is when pharmaceutical companies stray beyond their remit! When they take control of the most critical clinical research, influence the initial and continuing education of healthcare professionals in universities and healthcare establishments (see Prescrire Int n° 224, pp. 82), openly or surreptitiously advertise their products directly to patients, draining the resources of health insurers at the risk of compromising patients’ access to health care, or put pressure on health authorities to rush their drugs onto the market despite the risks. The entire health system should be able to count on pharmaceutical companies to do their job, no more, no less. When the roles within the system become blurred, the quality of health care and patients’ freedom to choose according to their needs both suffer. Prescrire ▶ Translated from Rev Prescrire February 2021 Volume 41 N° 448 • Page 81

EDITORIAL

Prescrire Int • March 2021

P age 2 • P rescrire I nternational S pecial E dition 2021

NEW PRODUCTS

polatuzumab vedotin ( polivy °) and large B-cell lymphoma

NOT ACCEPTABLE A single randomised comparative trial with numerous methodological flaws evaluated the addition of polatuzumab vedotin to a drug combination which is relevant in this situation.

patient characteristics and the imbalance between the groups favoured polatuzumab vedotin (espe- cially with regard to the reasons for ineligibility for transplantation and factors linked to disease prog- nosis); and there were no statistical hypotheses in the trial protocol, reducing the reliability of the statistical tests performed. After a median follow-up of 22 months, median survival appeared longer in the polatuzumab vedotin group. But given the comparator that was chosen, this finding does not show whether or not polatuzumab vedotin is useful in this clinical situation (6,7). The main adverse effects of microtubule-disrupting cytotoxic drugs, such as taxanes, are: neuropathy; haematological, cutaneous and gastrointestinal disorders; and arthralgia and myalgia (5). Allergic reactions are likely due to the protein portion (the monoclonal antibody) of polatuzumab vedotin . In the trial mentioned above, serious adverse events were reported in 64.4% of patients in the polatu- zumab vedotin group, versus 61.5% of those in the comparator group. The adverse events reported more frequently with polatuzumab vedotin than with the comparator were mainly: anaemia (47% versus 26%), thrombocytopenia (47% versus 28%), neutropenia (47% versus 39%), diarrhoea (38% versus 28%), infusion reactions (33% versus 23%), peripheral neuropathy (20% versus 3%) and pneu- monia (16% versus 10%) (6). Polatuzumab vedotin is metabolised by the cytochrome P450 isoenzyme CYP3A4. It is also a P-glycoprotein substrate. Numerous pharmacokinetic interactions are to be expected (6). ©Prescrire ▶ Translated from Rev Prescrire December 2020 Volume 40 N° 446 • Pages 893-894 Literature search up to 7 October 2020 In response to our request for information, Roche provided us with administrative documents, published articles and packaging items. 1- Prescrire Editorial Staff “Axicabtagene ciloleucel - Yescarta°. In certain types of lymphoma when other treatment options have been exhausted: a CAR T-cell therapy that increases the chances of sur- vival but frequently provokes serious adverse effects” Prescrire Int 2019; 28 (208): 229-231. 2- BMJ Best Practice “Non-Hodgkin’s lymphoma” 15 March 2019: 96 pages. 3- Freedman AS et al. “Treatment of relapsed or refractory diffuse large B cell lymphoma” UpToDate. www.uptodate.com accessed 2 October 2020: 46 pages. 4- Tilly Het al. “Diffuse large B-cell lymphoma: ESMOClinical Practice Guidelines” Ann Oncol 2015; 26 (suppl. 5): v116-v125. 5- Prescrire Rédaction “Brentuximab védotine (Adcetris°). Un intérêt à mieux cerner” Rev Prescrire 2012; 32 (349): 814-818. 6- EMA - CHMP “Public assessment report for Polivy. EMEA/H/ C/004870/0000” 14 November 2019: 159 pages. 7- HAS - Commission de laTransparence “Avis-Polivy” 10 June 2020: 29 pages.

POLIVY° - polatuzumab vedotin powder for concentrate for solution for intravenous infusion • 140 mg of polatuzumab vedotin per vial ■ antineoplastic; cytotoxic drug conjugated to an anti-CD79b monoclonal antibody ■ Indication : relapsed or refractory diffuse large B-cell lymph- oma, in combination with bendamustine and rituximab, in adults who are not candidates for haemopoietic stem cell transplantation. [EU centralised procedure - orphan drug] Diffuse large B-cell lymphoma is an aggressive form of non-Hodgkin lymphoma.The first-line treatment is R-CHOP chemotherapy, a combination of rituximab + cyclophosphamide + doxorubicin + vincristine + prednisolone . If the disease is refractory to or relapses after this first line of treatment, a second chemotherapy regimen is used, often containing a platinum compound and rituximab . A haemopoi- etic stem cell transplant is sometimes offered.There is no consensus over which chemotherapy regimen to use after several successive relapses. CART-cell therapy (a type of immunotherapy in which patients are injected with their own T cells that have been genetically modified to destroy the malignant cells) is sometimes an option in this situation (1,2). The bendamustine + rituximab combination has not been evaluated in comparative randomised trials in this situation. It has not been shown to extend survival. And, as of autumn 2020, it is not included among the options recommended in European guidelines (2-4). Polatuzumab vedotin is an anti-CD79b monoclo- nal antibody conjugated to monomethyl auristatin E, a drug, like the taxanes, whose cytotoxic action is based on microtubule disruption. Polatuzumab vedotin (Polivy°, Roche) as an adjunct to benda- mustine + rituximab has been granted conditional European marketing authorisation for use in adults with relapsed or refractory diffuse large B-cell lym- phoma who are not candidates for haemopoietic stem cell transplantation (5,6). Clinical evaluation of polatuzumab vedotin in this situation is mainly based on one non-blinded ran- domised trial in 80 patients that compared polatu- zumab vedotin + bendamustine + rituximab versus bendamustine + rituximab .The strength of evidence provided by this trial was greatly reduced by its numerous methodological flaws: an irrelevant comparator was used; the highly heterogeneous

Prescrire Int • March 2021

P rescrire I nternational S pecial E dition 2021 • P age 5

NEW PRODUCTS

remdesivir ( veklury °) and covid-19

Too many uncertainties over its efficacy as well as its harms

JUDGEMENT RESERVED The results of the main randomised placebo-­ controlled trial of remdesivir in adults hospi- talised for Sars-CoV-2 infection affecting their lungs (usually severely) showed no reduction in mortality, despite the inclusion of about 1000 patients. In this trial, remdesivir short- ened the “recovery” time in patients whose condition warranted supplemental oxygen or mechanical ventilation. Remdesivir can provoke hypersensitivity reactions and pos- sibly kidney and liver damage. The decision to authorise this product in July 2020, while so many uncertainties surrounded its harms and benefits, due to gaps in its evaluation, was very premature, if not reckless. Remde- sivir is still an experimental treatment; its evaluation in clinical trials should continue. VEKLURY° - remdesivir concentrate for solution for intravenous infusion, or powder for concentrate for solution for intravenous infusion • 100 mg of remdesivir per vial (both forms) ■ antiviral; adenosine nucleotide analogue ■ Indication : “ covid-19 in adults and adolescents (aged 12 years and older with body weight at least 40 kg) with pneumonia requiring supplemental oxygen ”. [EU centralised procedure]

Abstract

● The severity of covid-19, the disease caused by infection with the Sars-CoV-2 virus, varies greatly between patients. Most patients have a mild form that resolves without treatment. Other patients develop serious, and sometimes fatal, respiratory disorders and complications. ● Standard care as of mid-2020 mainly consists of treatments to relieve symptoms and other treatments to prevent certain complications. In a non-blinded randomised trial, 6 mg of dexa- methasone per day for up to 10 days, added to usual care, reduced mortality in patients receiv- ing invasive mechanical ventilation and, to a lesser degree, in those receiving oxygen . ● Remdesivir (Veklury°, Gilead Sciences) is a drug that disrupts the replication of viral RNA. It has been authorised in the European Union for use in adults and adolescents with covid-19 that is sufficiently severe to warrant supplemental oxygen . ● One double-blind placebo-controlled trial in 1062 adults hospitalised for covid-19 with pul- monary involvement found no statistically sig- nificant difference in mortality between the rem- desivir and placebo groups. ● In this trial, the median time to clinical improvement, mainly defined as the time to clinical discharge, was 10 days in the remdesivir group versus 15 days in the placebo group (p<0.001). Remdesivir had no effect on this end- point in patients with covid-19 considered mild or moderate. Remdesivir showed no efficacy in another double-blind placebo-controlled clin­ ical trial that included only 237 adults. ● The data concerning the drug’s adverse effects are extremely limited, leaving many questions unanswered. Remdesivir can provoke hyper- sensitivity reactions and possibly liver and kid- ney damage. ● As remdesivir is a substrate for various enzymes in vitro, many pharmacokinetic inter- actions are to be expected. Little is known about remdesivir’s potential effects on the metabolism of other drugs. No interaction studies have been conducted in humans.

©Prescrire ▶ Excerpt from Rev Prescrire November 2020 Volume 40 N° 445 • Pages 808-811

P age 6 • P rescrire I nternational S pecial E dition 2021

NEW PRODUCTS

EDITORS’ OPINION

Authorisation of remdesivir in the European Union: EMA needs to prioritise patients’ interests

Some of the reactions to the covid-19 pandemic have been irrational and harmful to society, particularly in the field of health care: reliable methods for evaluating drugs have been challenged; crackpot theories have been widely circu- lated; study results have been released prematurely with no quality control; poorly designed studies and trials abound, and so on. On 19 March 2020, the EMA rightly urged the scientific community to conduct randomised comparative trials, designed to generate robust evidence, when evaluating potential treatments for covid-19 (1). Yet on 25 June 2020, the EMA recommended the authorisation of remdesivir for certain covid-19 patients, despite the absence of robust evi- dence and many deficiencies in the data submitted by the pharmaceutical company: no detailed reports of the clinical trials; tenuous results; unknowns concerning the drug’s metabolism and potential interactions; incomplete toxicol­ ogy study results; etc. (2). Expedited analysis of drug evaluation data makes sense in a pandemic, so that a decision can be reached on its harm-benefit balance before all the usual data have been collated. But only if the preliminary clinical evaluation data available suggest that the drug is sufficiently effective to justify taking a certain amount of risk. This is certainly not the case for remdesivir .The data provided by the company point only to the need to continue its evaluation until its

harm-benefit balance is sufficiently clear (see “Remdesivir (Veklury°) and covid-19” p. 14). By granting marketing authorisation, the EMA might give some people the impression that it has fulfilled its role by expediting authorisation for a drug against a disease that is a major public health problem. But the reality is quite different. By accepting this unsound evaluation from Gilead, the company that markets remdesivir , and granting condi- tional marketing authorisation, EMA has hindered its evalu­ ation. Although it is conditional and will be reviewed in a year’s time, this authorisation removes the company’s main incentive to thoroughly evaluate the drug in comparative randomised trials, using clinically critical endpoints (inten- sive care procedures and mortality). Yet again, the EMA lacked rigour in its relationship with a pharmaceutical com- pany, and the price will be paid by patients and healthcare professionals, left in the dark over the harms and benefits of this treatment. ©Prescrire ▶ Translated from Rev Prescrire November 2020 Volume 40 N° 445 • Page 810 1- Prescrire Editorial Staff “Evidence required: for covid-19 too” Prescrire Int 2020; 29 (218): 199. 2- EMA - CHMP “Summary of opinion (initial authorisation) for Veklury” 25 June 2020: 1 page.

Prescrire Int • March 2021

COVID-19 UPDATE

Follow Prescrire’s independent, evidence-based analysis of the pandemic

Recent subjects include: • “Covid-19 vaccine Ad26.CoV2S (by Janssen): as with the other covid-19 vaccines, effective in the short term but unknowns remain” (23 March 2021) • “The AstraZeneca covid-19 vaccine: British epidemiological data on the vaccination of older adults, and reassuring pharmacovigilance data” (15 March 2021) • “Messenger RNA covid-19 vaccines: Prescrire’s in-depth analysis as of end February 2021” (2 March 2021)

english.prescrire.org/covid

P rescrire I nternational S pecial E dition 2021 • P age 7

NEW PRODUCTS

dasatinib ( sprycel ° and other brands ) in children with acute lymphoblastic leukaemia

NOTHING NEW Bias in the comparison with imatinib makes the favourable results obtained for dasatinib impossible to intepret. More than two years after its authorisation, the oral liquid form of dasatinib , for children unable to swallow tab- lets, is still not marketed in France. SPRYCEL° - dasatinib tablets and powder for oral suspension • 20 mg , 50 mg , 70 mg , 100 mg or 140 mg of dasatinib per tablet • 10 mg of dasatinib per ml of reconstituted suspension. The tablets and oral suspension are not bioequivalent. ■ antineoplastic; tyrosine kinase (including BCR-ABL) inhibitor ■ New indication : newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukaemia in combination with chemotherapy in children. [EU centralised procedure] Acute lymphoblastic leukaemia is the most common childhood cancer and accounts for about 80% of childhood leukaemias. In about 5% of cases, the malignant cells contain an abnormal chromosome called the Philadelphia chromosome. Its presence is associated with a poor prognosis. First-line treat- ment in this situation is generally chemotherapy divided into several phases (induction, consolidation, maintenance) with imatinib , a tyrosine kinase in- hibitor that includes the kinase BCR-ABL among its targets (1-3). Dasatinib (Sprycel°, Bristol Myers Squibb) is another tyrosine kinase inhibitor that includes BCR- ABL among its targets. It has been granted market- ing authorisation in the European Union as first-line therapy added to chemotherapy for children with Philadelphia chromosome-positive acute lympho- blastic leukaemia (3,4). The application to obtain marketing authorisation for dasatinib in this situation was based on data from a non-comparative trial. An indirect compari­ son of these data with those from a cohort of his- torical controls who received imatinib added to chemotherapy did not show dasatinib to be an advance over imatinib (4). Since this evaluation, additional data have become available from a ran- domised, non-blinded, head-to-head trial of dasat- inib versus imatinib , added to chemotherapy (see “Failure to demand solid evidence for marketing authorisation spells danger for patients” p. 13). This comparative trial included 189 children (me- dian age 8 years) with Philadelphia chromosome-­

positive acute lymphoblastic leukaemia (5).The daily dose of imatinib in this trial was 300 mg/m 2 , which is less than the minimum dose of 340 mg/m 2 per day recommended in the European marketing author­ isation.This biased the comparison in favour of da- satinib and weakens the quality of the evidence (3,5). After a median follow-up of about 26 months for the 161 patients still alive at the time of the analysis, the estimated 4-year overall survival was about 88%with dasatinib versus 69% with imatinib (p=0.04) (5). The known adverse effects of dasatinib are similar to those of imatinib and include: bleeding events, gastrointestinal disorders, sodium and water reten- tion and oedema, pleural effusion, haematological disorders, myalgia, heart failure, arrhythmias, infec- tions (including hepatitis B reactivation), dyspnoea, interstitial lung disease, pulmonary arterial hyper- tension, hepatic and pancreatic disorders, and skin disorders (including Stevens-Johnson syndrome). There have also been reports of nephrotic syndrome, thrombotic microangiopathy and, in children, abnor- mal bone growth or development.The trial compar- ing dasatinib versus imatinib added no new infor- mation to this adverse effect profile (3,5,6). For children who find it difficult to swallow tablets, imatinib tablets can be dispersed in water or apple juice, which is not the case with dasatinib tablets. If tablets of differing strengths are present in the home (due to the dose adjustment required as the child’s body weight increases), it is important to warn the child’s carers about the risk of dosing errors. The different packaging colours for the various dose strengths help to distinguish between doses (3). More than 2 years have elapsed since the oral liquid form of dasatinib was authorised in the Euro­ pean Union in mid-2018, yet it has still not been marketed in France (3). ©Prescrire ▶ Translated from Rev Prescrire October 2020 Volume 40 N° 444 • Pages 734-735 Literature search up to 31 July 2020 In response to our request for information, Bristol Myers Squibb provided uswith no documentation on its product. 1- Prescrire Editorial Staff“Imatinib and acute lymphoblastic leukaemia in children. Prolonged survival in Philadelphia chromosome-positive cases” Prescrire Int 2015; 24 (157): 38-39. 2- National Comprehensive Cancer Network“Pediatric acute lympho- blastic leukemia” 25 November 2019: 118 pages. 3- European Commission “SPC-Sprycel” 13 February 2020 + “SPC- Glivec” 3 April 2020: 150 pages. 4- EMA - CHMP “Public assessment report for Sprycel. EMEA/ H/C/000709/II/0059” 13 December 2018: 80 pages. 5- Shuhong S et al. “Effect of dasatinib vs imatinib in the treatment of pediatric Philadelphia chromosome-positive acute lymphoblastic leukemia. A randomized clinical trial” JAMAOncol 2020; 6 (3): 358-366 + supplementary material: 53 pages. 6- Prescrire Rédaction “Dasatinib (Sprycel°) et leucémie myeloïde chronique chez certains enfants et adolescents” Rev Prescrire 2019; 39 (433): 816-817.

P age 8 • P rescrire I nternational S pecial E dition 2021

NEW PRODUCTS

EDITORS’ OPINION

Failure to demand solid evidence for marketing authorisation spells danger for patients

In order to minimise the dangers of drugs, marketing author­ isation should be granted on the basis of a rigorous evalu- ation, which in most cases will involve double-blind ran- domised trials comparing the drug against a standard treatment, showing that the drug represents a tangible therapeutic advance for patients. And at least two trials are required to ensure that the findings are reproducible (1,2). Unfortunately, in 2020, it is clear that pharmaceutical com- panies generally do not respect these requirements, and the European Medicines Agency (EMA) does not insist that they do so. Consequently, most applications are based on a single clinical trial. The application to extend dasatinib ’s indications to include children with acute lymphoblastic leukaemia illustrates this issue: the extension of indication was approved on the basis of non-comparative data alone, without the EMA demand- ing more information (see “Dasatinib in children with acute lymphoblastic leukaemia” p. 12). In certain very specific situations, non-comparative data are sometimes acceptable, for example in a condition for which an urgent, unmet medical need exists or a serious condition that is so rare that it is impossible to recruit enough patients for a comparative trial (1). The use of dasatinib in children with acute lymphoblastic leukaemia does not meet these criteria. A treatment of the same type with a favour- able harm-benefit balance is already available for these

children. Furthermore, a randomised comparative trial ver- sus imatinib has now been conducted. Its results were pub- lished just a few months after dasatinib was granted mar- keting authorisation in this situation, thus proving that a comparative evaluation would have been feasible (3). In March 2020, the EMA rightly urged the scientific com- munity to conduct randomised comparative trials designed to generate robust evidence on covid-19 (4). It would be helpful if the EMA adopted the same attitude towards other clinical situations, to better serve patients and build con­ fidence in its work. ©Prescrire ▶ Translated from Rev Prescrire October 2020 Volume 40 N° 444 • Page 735 1- Prescrire Editorial Staff “Adaptive pathways: EMA’s dangerous plan” Prescrire Int 2016; 25 (174): 223. 2- Prescrire Rédaction “Évaluer le progrès thérapeutique: avec méthode, au service des patients” Rev Prescrire 2015; 35 (382): 565-569. 3- Shuhong S et al. “Effect of dasatinib vs imatinib in the treatment of pedi- atric Philadelphia chromosome-positive acute lymphoblastic leukemia. A randomized clinical trial” JAMAOncol 2020; 6 (3): 358-366 + supplementary material: 53 pages. 4- Prescrire Editorial Staff “Evidence required: for covid-19 too” Prescrire Int 2020; 29 (218): 199.

Prescrire Int • January 2021

PRESCRIRE’S RATINGS Our judgement is based on the therapeutic advance of the new product. It considers not only the inherent value of each product in terms of its harm-benefit balance, but also its advantages and disadvantages relative to existing products available in France. Note that the relative value of new products can vary from one country to another.

Quality of information from pharmaceutical companies In response to our systematic requests

BRAVO The product is a major therapeutic advance in an area where previously no treatment was available.

NOTHING NEW The product is a new substance but with no evidence that it has more clinical value than other substances of the same group. It can be a me-too or a near me-too.

Company provided detailed information including unpublished

data and packaging items.

A REAL ADVANCE The product is an important therapeutic advance but has certain limitations.

Company provided information limited to published administrative data or packaging items.

NOT ACCEPTABLE Product without evident benefit but with potential or real disadvantages.

OFFERS AN ADVANTAGE The product has some value but does not fundamentally change the present therapeutic practice. POSSIBLY HELPFUL The product has minimal additional value, and should not change prescribing habits except in rare circumstances.

Company provided minimal information, mainly administrative

JUDGEMENT RESERVED The editors postpone their rating until better data and a more thorough evaluation of the drug are available.

and packaging items.

Company provided no information.

P rescrire I nternational S pecial E dition 2021 • P age 9

ADVERSE EFFECTS VEGF inhibitors:

arterial aneurysm and dissection

exposed patients (10 cases). The median time to onset was 105 days (range: 4 days to 1363 days) (7). A retrospective study conducted in Latin America in 1173 patients treated with intravitreal bevacizumab for eye disorders identified 2 iliac artery aneurysms (5). Disruption of vessel remodelling. VEGF induces the formation of new blood vessels by stimulating endothelial cell proliferation. VEGF inhibitors on the other hand contribute to endothelial cell apoptosis (genetically programmed cell death).VEGF inhibitors can therefore alter the structure of vascular endo­ thelium, exposing patients to the risk of haemor­ rhagic and thrombotic complications (6). Hypertension, which can be caused by VEGF in­ hibitors, is another major risk factor for aortic dis­ section (7,8,10). In practice VEGF inhibitors can cause arterial an­ eurysm and dissection.This risk should be taken into account and warrants careful monitoring of exposed patients, especially those with other cardiovascular risk factors. Urgent investigation is required when a patient receiving aVEGF inhibitor develops abdom­ inal or chest pain or signs of ischaemia. ©Prescrire ▶ Translated from Rev Prescrire May 2020 Volume 40 N° 439 • Page 353 Literature search up to 20 January 2020 1- PrescrireRédaction“Médicaments anti-VEGF: deseffets indésirables cardiovasculaires et rénaux fréquents” RevPrescrire 2015; 35 (375): 30. 2- EMA“Minutes of PRACmeeting on 26-29November 2018” 17 Janu­ ary 2019: 105 pages. 3- EMA “Scientific conclusions and grounds for the variation to the terms of themarketing authorisation(s). Active substance(s): sunitinib” 13 December 2018: 2 pages. 4- Wiegering A et al. “Early development of a celiac trunk aneurysm during anti-vascular endothelial growth factor receptor therapy” Surgery 2014; 155 : 729-730. 5- Wu L et al. “Twelve-month safety of intravitreal injections of bevaci- zumab (Avastin): resultsof thePan-AmericanCollaborativeRetinaStudy Group (PACORES)” GraefesArchClinExpOphthalmol 2008; 246 : 81-87. 6- Baxi SS et al. “Hemorrhagic pseudoaneurysm in a patient receiving aflibercept formetastatic thyroid cancer” Thyroid 2012; 22 (5): 552-555. 7- OshimaY et al. “Association between aortic dissection and system- ic exposure of vascular endothelial growth factor pathway inhibitors in the Japanese Adverse Drug Event Report database” Circulation 2017; 135 : 815-817. 8- Aragon-Ching JB et al. “Acute aortic dissection in a hypertensive patient with prostate cancer undergoing chemotherapy containing bevacizumab” Acta Oncol 2008; 47 (8): 1600-1601. 9- Serrano C et al.“Acute aortic dissection during sorafenib-containing therapy” Ann Oncol 2010; 21 : 181-190. 10- Edeline J et al. “Aortic dissection in a patient treated by sunitinib for metastatic renal cell carcinoma” Ann Oncol 2010; 21 (1): 186-187. 11- FormigaMN et al. “Aortic dissection during antiangiogenic therapy with sunitinib. A case report” Sao PauloMed J 2015; 133 (3): 275-277. 12- TakadaMet al.“Aortic dissection and cardiac dysfunction emerged coincidentally during the long-term treatment with angiogenesis inhibitors for metastatic renal cell carcinoma. A case report of onco-­ cardiology” Int Heart J 2018; 59 : 1174-1179.

● Cases of arterial aneurysm or dissection have been reported withVEGF inhibitors, such as beva­ cizumab , used to treat cancer. Systemic adminis- tration and hypertension, a known adverse effect of these anti-angiogenic drugs, are risk factors. ● In practice, monitoring is warranted for patients treated withVEGF inhibitors, especially those with cardiovascular risk factors. D rugs that target vascular endothelial growth factor (VEGF) inhibit angiogenesis and are mainly used to treat diseases involving vas­ cular proliferation, in particular cancer and certain eye conditions (by intravitreal administration).They can provoke cardiovascular disorders such as hyper­ tension, heart failure and arterial or venous thrombo­ embolic events (1). In 2019, the European Pharmacovigilance Risk Assessment Committee (PRAC) reported arterial dissections or aneurysms linked to the use of VEGF inhibitors (2). Hundreds of cases, sometimes fatal. In late 2018, the European pharmacovigilance database contained several hundred cases of arterial dissection or an­ eurysm, recorded since the market introduction of the variousVEGF inhibitors: 256 cases were report­ ed with bevacizumab , 249 with ranibizumab , 79 with sunitinib and 43 with sorafenib. Fewer cases were described with other VEGF inhibitors (2). A PRAC report published in late 2018 mentioned 26 fatal cases of aortic dissection or aneurysm at­ tributed to sunitinib (3). Our literature search identified about 15 case reports of arterial aneurysm, pseudoaneurysm or dissection in patients treated with aVEGF inhibitor.They occurred at various sites: the coeliac trunk, inferior pancreatico­ duodenal artery, aorta or cervical artery (4-12). In most cases, theVEGF inhibitor had been used to treat cancer. Some patients had no history of cardiovas­ cular disease, but at least two patients had hyper­ tension before exposure to the VEGF inhibitor. The time to diagnosis of the disorders ranged from about 20 days to several months after startingVEGF inhibi­ tor therapy; in several cases, the disorders resolved after discontinuing the VEGF inhibitor (4-11). 20-fold risk of aortic dissection. In a study based on data froma Japanese pharmacovigilance database, 91 055 patients were identified as having undergone treatment for cancer; 16 441 of these patients had been treated with at least one VEGF inhibitor, and 74 614 of them had not been exposed to this type of drug.The risk of aortic dissection was about 20 times greater (95% confidence interval: 10-41) in patients exposed to VEGF inhibitors (49 cases) than in un­

Prescrire Int • September 2020

P age 10 • P rescrire I nternational S pecial E dition 2021

ADVERSE EFFECTS

Liposomal forms of drugs: now specified in the brand name, but no improvement to the INN

As of 13 October 2020, the pharmaceutical com­ panies we approached informed us that the quali- fier “pegylated liposomal” is displayed in English on the packaging of products marketed in France: “Ambisome° liposomal” for the liposomal form of amphotericin B , “Caelyx° pegylated liposomal” for the pegylated liposomal form of doxorubicin , “Onivyde° pegylated liposomal” for the pegylated liposomal form of irinotecan , and “Vyxeos° liposo- mal” for the liposomal form of the daunorubicin + cytarabine combination (3). Some of these names have not yet been updated on the website of the French Health Products Agency (ANSM) as of 13 October 2020 (7-9). Conventional forms of doxorubicin and irinotecan are also marketed in France (2,5-11). In practice A half measure. A drug’s real name is its international nonproprietary name (INN).When the INN is insufficiently informative, any modifica- tions required to prevent errors would be better added to the INN than to a brand name that conveys no information about the product’s composition. Adding the qualifier to the brand name does not eliminate the risk of confusing one product for another, for example when selecting a treatment from a drop-down menu in an electronic prescribing system. Healthcare professionals must take great care at every stage of the medication-use process when dealing with drugs that are available in liposomal and non-liposomal forms. In such cases, it is advis- able to refer to the product by its INN + form + brand name on prescriptions, and to make sure that the form being dispensed or administered is the pre- scribed form, and that the dose and method of administration match. ©Prescrire ▶ Translated from Rev Prescrire November 2020 Volume 40 N° 445 • Pages 822-823 Sources 1- “Liposomes, pegylation, and pegylated liposomes” Prescrire Int 2003; 12 (68): 209. 2- “Liposomal daunorubicin + cytar- abine -Vyxeos liposomal° and acutemyeloid leukaemia” Prescrire Int 2020; 29 (215): 120. 3- EMA “Names of liposomal medicines to be changed to avoidmedication errors” 31 July 2019 +“Change of name of liposomal medicines at high risk of medication errors” 26 Septem- ber 2019+“Email to Prescrire ” 20September 2019: 6 pages. 4- “Inject- able amphotericinB: mix-ups between lipid and non-lipid formulations” Prescrire Int 2009; 18 (104): 258-260. 5- “Amphotericin B: confusion between pharmaceutical formulations” Prescrire Int 2018; 27 (192): 98. 6- ISMP“Doxorubicin liposomal mix-up” ISMPMedication Safety Alert! 2015; 20 (5): 3. 7- ANSM“RCP-Adriblastine 50mg poudre pour solution injectable en flacon” 11 May 2020 + “RCP-Ambisome lipo- somal” 23 December 2019: 19 pages. 8- European Commission “SPC-Caelyx (doxorubicin)” 23 September 2019 + “SPC-Onivyde” 31 January 2019 +“SPC-Onivyde pegylated liposomal” 23 April 2020 + “SPC-Vyxeos” 23 August 2018: 82 pages. 9- EMA “SPC-Caelyx pegylated liposomal” 2 March 2020 + “SPC-Vyxeos liposomal” 25 October 2019: 42 pages. 10- “Doxorubicin liposomal pegylated, breast cancer: not just a question of short-term cardiac effects” Prescrire Int 2004; 13 (71): 90-91.

● Some drugs, such as injectable amphotericin B , doxorubicin and irinotecan , are marketed in lipo- somal and non-liposomal forms, but these forms are not interchangeable.The European Union has taken action to prevent errors in this situation, by adding “liposomal” or “pegylated liposomal” to the brand name. As an added precaution, it is use- ful to refer to these drugs on prescriptions and in other healthcare documents by their INN + the form (liposomal or non-liposomal) + the brand name. L iposomes are small spherical vesicles with a lipid bilayer wall enclosing an internal aqueous cavity, in which drugs can be encapsulated to obtain a liposomal form of the drug. As of 2020, this technique is mainly used for injectable antineoplastic or anti-­ infective drugs. Another technique involves incorp­ orating polyethylene glycol (PEG) into the lipid bi- layer, to form pegylated liposomes. The intention behind the liposomal or pegylated liposomal form of a drug is generally to modify its pharmacokinet- ics, for example to increase the concentration of the drug in a target tissue or prolong its duration of action (1,2). Liposomal and non-liposomal forms of the same drug are not interchangeable . Some drugs are marketed in the European Union in conventional (non-liposomal), liposomal and pegylated liposomal forms. These products are not interchangeable. Confusion between these products can cause dos- ing errors or administration errors with potentially serious consequences (3-6). For example, three injectable forms of amphotericin B are marketed in France: a conventional, amphotericin B deoxycholate form (Fungizone°), and two lipid forms, one liposo- mal (Ambisome°) and one non-liposomal, in which amphotericin B is incorporated into a phospholipid matrix (Abelcet°). Cases of confusion between the three forms of this antifungal drug have been re- ported since the late 1990s, including overdose caused by the use of conventional amphotericin B at doses prescribed for a lipid form, resulting in serious or even fatal renal and cardiac disorders. These errors occurred at the prescribing, dispensing, preparation and administration stages of the medi­ cation use process (4,5). Brand names indicate whether the product is a liposomal form. In 2019, the European Medicines Agency (EMA) asked pharmaceutical companies that market liposomal or pegylated liposomal forms of drugs to modify the brand name of the products concerned if a risk of medication errors through confusion with non-liposomal forms had been identified.This involved adding the qualifier “lipo- somal” or “pegylated liposomal” to the brand name.

Prescrire Int • February 2021

P age 12 • P rescrire I nternational S pecial E dition 2021

REVIEWS

REVIEWS

©Rolf Schulten/Buchcover/Photononstop

Medical cannabis in chronic pain An option for some types of pain, while awaiting further evaluation

● In three randomised trials in a total of 686 patients with multiple sclerosis, the oromucosal spray containing a mixture of standardised Can- nabis sativa extracts was more effective than pla- cebo in relieving painful muscle spasms for about 10% of patients. ● Adverse effects were common in the clinical trials, and were consistent with those known to occur with recreational cannabis use, primarily dizziness and psychiatric disorders. Many drug interactions are foreseeable with cannabinoids. ● Withdrawal symptoms have been observed in newborns exposed to cannabis in utero. A poten- tial long-term effect on neuropsychological devel- opment after in utero exposure has not been ruled out. Cannabinoids pass into breast milk in consid- erable quantities. ● In practice, the adverse effects of cannabis are quite well known, except in pregnancy. They are frequent and sometimes severe, but reversible. Despite little evidence of their efficacy, cannabis-­ derived drugs sometimes appear to be an option to consider to produce a feeling of wellbeing in patients with neuropathic pain, cancer pain or spasticity-related pain. Rev Prescrire 2021; 41 (448): 116-121 Full review (5 pages) available to subscribers at english.prescrire.org ▶ Translated from Rev Prescrire February 2021 Volume 41 N° 448 • Pages 116-121

ABSTRACT

● France has announced the start of an experimen- tal programme in 2021 involving the use of medical cannabis for certain painful conditions. How effect- ive are cannabis and its derivatives in these situ- ations?And what are their adverse effects?To answer these questions, we reviewed the available evidence using the standard Prescrire methodology . ● The main cannabis-derived substances that have been evaluated in these situations are: a mix- ture of standardised Cannabis sativa extracts, con- taining delta-9-tetrahydrocannabinol ( THC ) and cannabidiol ; THC or preparations containing THC ; and the synthetic THC analogue nabilone . ● In an analysis of 16 double-blind randomised trials, including a total of 1750 adults with neuro- pathic pain, the analgesic effect of the cannabis derivatives evaluated appeared to be tangibly superior to placebo in only about 5% of treated patients. Possible publication bias reduces the strength of this evidence. ● The mixture of standardised Cannabis sativa extracts in oromucosal spray form has been evalu- ated in five double-blind randomised trials in a total of 1539 patients with cancer-related pain. No anal- gesic effect beyond that of a placebo was found.

Prescrire Int • May 2021

P rescrire I nternational S pecial E dition 2021 • P age 13

REVIEWS

ly exposed to chlorthalidone and those regularly exposed to hydrochlorothiazide (2). The risk of hypokalaemia was 3-fold higher in patients exposed to chlorthalidone (a statistically significant difference), and the risks of hyperkal­ aemia, hyponatraemia, renal failure and type 2 di- abetes were around 25% to 35% higher in patients exposed to chlorthalidone , compared to patients exposed to hydrochlorothiazide (statistically signifi­ cant differences) (2). In practice Despite the limitations of this retro- spective study carried out using databases, there appears to be no clear difference in the incidence of cardiovascular events between hypertensive patients taking chlorthalidone and those taking hydrochlorothiazide . In the absence of a direct comparison with a higher level of evidence, these data support the pragmatic choice of hydrochloro­ thiazide as the first-line thiazide diuretic for most hypertensive patients in countries where chlor­ thalidone is not available, especially since this drug appears to cause fewer electrolyte abnormalities and renal adverse effects than chlorthalidone . ©Prescrire ▶ Translated from Rev Prescrire December 2020 Volume 40 N° 446 • Page 926 a- The determination of a propensity score is based on a statisticalmethod employed inobservational studies, which aims to correct for intergroup differences, in the absence of randomisation, so as to limit bias due to confounding fac­ tors (ref 3). Selected references from Prescrire’s literature search 1- Prescrire Editorial Staff “Treating essential hypertension. The first choice is usually a thiazide diuretic” Prescrire Int 2014; 23 (152): 215- 220. 2- HripcsakGet al.“Comparison of cardiovascular and safety outcomes of chlorthalidone vs hydrochlorothiazide to treat hypertension” JAMA Intern Med 2020; 180 (4): 542-551. 3- Moulis G et Lapeyre-Mestre M “Score de propension: intérêts, utilisation et limites. Un guide pratique pour le clinicien” Rev Med Interne 2018; 39 (10): 805-812.

Hydrochlorothiazide in hypertension An acceptable first choice

● A pharmacoepidemiological study of about 700 000 hypertensive patients exposed to either chlorthalidone or hydrochlorothiazide did not show any significant difference in the incidence of cardio­ vascular events and mortality between these two groups of patients. Electrolyte abnormalities and renal disorders were less frequent with hydro­ chlorothiazide. I n adults with hypertension and no other cardio- vascular risk factor, taking a blood pressure-­ lowering drug has a favourable harm-benefit balance once blood pressure reaches or exceeds 160/100 mm Hg. In countries where it is available, chlorthalidone is the first-choice thiazide diuretic. Its efficacy in preventing cardiovascular events has been reliably demonstrated (1). In France, where there is no available medicinal product containing chlorthalidone alone, the first-line thiazide diuretic is hydrochlorothiazide . Hydrochlorothiazide has been less well evaluated than chlorthalidone , al- though given the lack of any randomised trial directly comparing these two drugs in hypertension, there is no evidence that it has lower efficacy (1,2). A retrospective pharmacoepidemiological study compared the incidence of cardiovascular events and adverse effects in hypertensive patients regu- larly exposed to chlorthalidone or hydrochloro­ thiazide (2). The authors of this study analysed three US data­ bases containing information on a total of about 730 000 hypertensive patients, aged 51 years on average. In these patients, blood pressure-lowering treatment was started with one of the two drugs between 2001 and 2018. About 37 000 patients were exposed to chlorthalidone and about 690 000 to hydrochlorothiazide . The regularity of exposure to these drugs was assessed on the basis of dispensed prescriptions. The primary outcomes, which were pre-specified, were hospitalisation for myocardial infarction, heart failure or stroke, and a composite outcome including these 3 outcomes and sudden cardiac death. The authors also looked for the oc- currence of about fifty pre-specified potential adverse effects. In order to limit inherent bias from con- founding factors due to the lack of randomisation (such as the presence of conditions in addition to hypertension, or treatment with drugs other than one of the two blood pressure-lowering drugs), analysis of the data was carried out after stratifica- tion according to so-called propensity scores ( a )(2). Based on this analysis, neither mortality nor the occurrence of cardiovascular events was statistical- ly different between the group of patients regular-

Prescrire Int • April 2021

P age 14 • P rescrire I nternational S pecial E dition 2021