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In the study by Marechaux et al., the authors performed a prospective multi-centre observational and cross-sectional study evaluating the presence of mitral- and/or aortic valve disease in a large number of patients exposed to valvulopathic drugs (mainly benfluorex) compared with a control group of diabetics not exposed. For the diagnosis of drug-induced valvular heart disease (DIVHD), they used an integrative approach combining both colour Doppler and valvular morphological characteristics as a ‘gold standard’ in contrast to the classical Food and Drug Administration (FDA) criteria used in other studies with fenfluramine, MDMA (Ecstasy), pergolide, and cabergoline. They conclude that FDA criteria solely based on Doppler detection underestimate the frequency of mitral valve and overestimate aortic DIVHD.1

Although most of these toxic drugs (including benfluorex) have subsequently been withdrawn from the market, several cases of patients requiring valve surgery late after the cessation of therapy have been reported, emphasizing the long-term implications of DIVHD.2,3 Moreover, the exact incidence of patients presenting DIHVD is difficult to establish. The clinical presentation is variable, and some patients were taking multiple anorectic drugs. Reporting of echocardiographically detected DIVHD was highest in the USA when funding became available after several damage claims and has dramatically decreased after reimbursement was suppressed. In the particular case of benfluorex, the number of out of label prescriptions in obese patients without diabetes is not precisely known, making the definition of an appropriate control group even more difficult. Although for benfluorex, the relationship with the development of DHIVD is clearly established, the causality is less well demonstrated than for other drugs.4

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