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Journal of Pharmaceutical Health Care and Sciences logoLink to Journal of Pharmaceutical Health Care and Sciences
. 2015 Apr 16;1:15. doi: 10.1186/s40780-015-0015-6

Hyperglycemic adverse events following antipsychotic drug administration in spontaneous adverse event reports

Yamato Kato 1, Ryogo Umetsu 1, Junko Abe 1,2, Natsumi Ueda 1, Yoko Nakayama 1, Yasutomi Kinosada 3, Mitsuhiro Nakamura 1,
PMCID: PMC4728749  PMID: 26819726

Abstract

Background

Antipsychotics are potent dopamine antagonists used to treat schizophrenia and bipolar disorder. The aim of this study was to evaluate the relationship between antipsychotic drugs and adverse hyperglycemic events using the FDA Adverse Event Reporting System (FAERS) database. In particular, we focused on adverse hyperglycemic events associated with atypical antipsychotic use, which are major concerns.

Findings

We analyzed reports of adverse hyperglycemic events associated with 26 antipsychotic drugs in the FAERS database from January 2004 to March 2013. The Standardized Medical Dictionary for Regulatory Activities Queries (SMQ) preferred terms (PTs) was used to identify adverse hyperglycemic events. The number of adverse hyperglycemic reports for the top eight antipsychotic drugs, quetiapine, olanzapine, risperidone, aripiprazole, haloperidol, clozapine, prochlorperazine, and chlorpromazine was 12,471 (28.9%), 8,423 (37.9%), 5,968 (27.0%), 4,045 (23.7%), 3,445 (31.5%), 2,614 (14.3%), 1,800 (19.8%), and 1,003 (35.7%), respectively. The reporting ratio increased with co-administration of multiple antipsychotic drugs. For example, adverse hyperglycemic events represented 21.6% of reports for quetiapine monotherapy, 39.9% for two-drug polypharmacy, and 66.3% for three-drug polypharmacy.

Conclusion

Antipsychotic drug polypharmacy may influence signal strength, and may be associated with hyperglycemia. After considering the causality restraints of the current analysis, further robust epidemiological studies are recommended.

Keywords: Antipsychotic drugs, Hyperglycemic adverse events, Adverse event reporting system, Antipsychotic polypharmacy, Antipsychotic monotherapy

Findings

Background

Antipsychotics are potent dopamine antagonists used to treat schizophrenia and bipolar disorder [1]. Antipsychotics are categorized as first-generation antipsychotics (typical) and second-generation antipsychotics (atypical). Several studies have reported abnormal glucose metabolism during antipsychotic drug treatment [2-4]. In 2002, diabetic ketoacidosis and coma were reported after olanzapine and quetiapine treatment in Japan [5]. Furthermore, the Food and Drug Administration (FDA) asked manufacturers of atypical antipsychotic (AAP) drugs to add a warning to drug labels regarding the increased risk of hyperglycemia and diabetes in 2004 [6]. Thus, hyperglycemia due to antipsychotic drug administration is a serious clinical problem.

According to clinical practice guidelines, AAPs should be used as the first and second line of treatment following the first schizophrenic episode [7-10]. However, treatment resistance and poor efficacy continue to be a significant clinical problem [2,11,12]. Since antipsychotic polypharmacy is suggested after failure of antipsychotic monotherapy [7,9,10], multiple antipsychotic drugs have been frequently prescribed [2,11,13]. A case-control study indicated that the administration of multiple antipsychotics increases the risk of diabetes mellitus when using AAPs [1]. Several studies also demonstrated the effect of antipsychotic polypharmacy on the adverse events; however, the effect of antipsychotic polypharmacy on hyperglycemia remains unclear [11-14].

The FDA Adverse Event Reporting System (FAERS) is a spontaneous reporting system for adverse events. It is the largest and best-known database worldwide, and reflects the realities of clinical practice. Therefore, the FAERS database is one of the primary tools used in pharmacovigilance. The aim of this study was to evaluate the relationship between antipsychotic drugs and adverse hyperglycemic events using the FAERS database. To our knowledge, this study is the first to evaluate the effect of antipsychotic polypharmacy on adverse hyperglycemic events using the FAERS database.

Methods

Data from the FAERS database from January 2004 to March 2013 were obtained from the FDA website. The FAERS database structure complies with the International Conference on Harmonization (ICH) E2B. We analyzed 26 antipsychotic drugs associated with hyperglycemia (Table 1). Since drug names in the FAERS database are registered arbitrarily, DrugBank, a reliable drug database, was utilized as a dictionary for the batch conversion and compilation of drug names (Table 2). We followed the FDA’s recommendation to adopt the most recent case number in order to identify duplicate reports from the same patient and excluded these from analysis.

Table 1.

Characteristics of antipsychotics in the FDA adverse event reporting system database

Drugs Total Cases * Reporting ratio (%) ROR (95%CI)
Atypical 96841 21151 21.8 2.5 (2.4-2.5)
Aripiprazole 17093 4045 23.7 2.6 (2.5-2.7)
Clozapine 18217 2614 14.3 1.4 (1.3-1.5)
Olanzapine 22200 8423 37.9 5.3 (5.1-5.4)
Quetiapine 43169 12471 28.9 3.5 (3.4-3.6)
Perospirone 83 26 31.3 3.8 (2.4-6.1)
Risperidone 22121 5968 27.0 3.1 (3.0-3.2)
Zotepine 134 31 23.1 2.5 (1.7-3.8)
Typical 19569 3948 20.2 2.1 (2.1-2.2)
Bromperidol 48 11 22.9 2.5 (1.3-4.9)
Chlorpromazine 2812 1003 35.7 4.6 (4.3-5.0)
Fluphenazine 923 234 25.4 2.8 (2.4-3.3)
Haloperidol 10922 3445 31.5 3.9 (3.7-4.0)
Levomepromazine 799 166 20.8 2.2 (1.8-2.6)
Moperone 0 0 - -
Nemonapride 4 1 25.0 2.8 (0.3-26.8)
Perphenazine 911 341 37.4 5.0 (4.4-5.7)
Pimozide 246 65 26.4 3.0 (2.3-4.0)
Pipamperone 207 26 12.6 1.2 (0.8-1.8)
Prochlorperazine 9103 1800 19.8 2.1 (2.0-2.2)
Propericiazine 190 45 23.7 2.6 (1.9-3.6)
Spiperone 1 0 - -
Sulpiride 1809 331 18.3 1.9 (1.7-2.1)
Sultopride 97 11 11.3 1.1 (0.6-2.0)
Thioridazine 574 160 27.9 3.2 (2.7-3.9)
Tiapride 336 81 24.1 2.7 (2.1-3.4)
Timiperone 15 4 26.7 3.0 (1.0-9.5)
Trifluoperazine 619 274 44.3 6.6 (5.7-7.8)

*With adverse events of interest.

Table 2.

Generic names and brand names of antipsychotics in the DrugBank

Generic name Brand name
Atypical
Aripiprazole Abilify, Aripiprazole
Clozapine Clozapin, Clozapine, Clozaril, Fazaclo odt, Leponex
Olanzapine Olansek, Olanzapine, Symbyax, Zydis, Zyprexa, Zyprexa intramuscular, Zyprexa zydis
Quetiapine Quetiapine, Quetiapine fumarate, Seroquel, Seroquel xr
Risperdone Risperdal, Risperdal consta, Risperdal m-tab, Risperdone, Risperidona, Risperidone, Risperidonum, Risperin, Rispolept
Typical
Chlorpromazine Chlorpromanyl, Chlorpromazine, Largactil, Thorazine
Haloperidole Aloperidin, Aloperidol, Aloperidolo, Apo-haloperidol, Haldol, Haldol la, Haldol solutab, Haloperidol, Haloperidol decanoate, Haloperidol lactate, Halopidol, Halosten, Keselan, Linton, Novo-peridol, Peridol, Serenace
Prochloroperazine Buccastem, Chlorperazine, Combid, Compazine, Compro, Emetiral, Novamin, Pasotomin, Prochloroperazine, Prochlorpemazine, Prochlorperazin, Prochlorperazine, Prochlorperazine edisylate, Prochlorperazine maleate, Prochlorpromazine, Procloperazine, Proclorperazine, Stemetil, Stemzine, Vertigon

Adverse events in the FAERS database are coded according to the terminology preferred by the Medical Dictionary for Regulatory Activities (MedDRA). The Standardized MedDRA Queries (SMQ) index is widely accepted and utilized in the analysis of the FAERS database [15]. We utilized the SMQ for hyperglycemia/new onset diabetes mellitus events (SMQ code: 20000041). We selected 93 Preferred Terms (PTs), which are summarized in Table 3.

Table 3.

Preferred terms associated with adverse hyperglycemia in the Standardized MedDRA Queries (SMQ; 20000041)

Preferred terms Code Total Atypical Typical
Cases * Reporting ratio (%) Cases * Reporting ratio (%)
Total 241478 21151 8.8 3948 1.6
Abnormal loss of weight 10000159 532 28 5.3 9 1.7
Abnormal weight gain 10000188 134 33 24.6 0 0
Acidosis 10000486 1956 102 5.2 44 2.2
Altered state of consciousness 10001854 3306 303 9.2 111 3.4
Anti-GAD antibody positive 10059728 23 2 8.7 0 0
Anti-insulin antibody increased 10053815 51 0 0 0 0
Anti-insulin antibody positive 10053814 115 0 0 0 0
Anti-insulin receptor antibody increased 10068226 0 0 0 0 0
Anti-insulin receptor antibody positive 10068225 3 0 0 0 0
Anti-islet cell antibody positive 10049439 4 1 25 0 0
Blood 1,5-anhydroglucitol decreased 10065367 0 0 0 0 0
Blood cholesterol increased 10005425 10887 1648 15.1 63 0.6
Blood glucose abnormal 10005554 1547 116 7.5 12 0.8
Blood glucose fluctuation 10049803 2267 76 3.4 6 0.3
Blood glucose increased 10005557 35838 1398 3.9 241 0.7
Blood insulin abnormal 10005606 7 0 0 0 0
Blood insulin decreased 10005613 23 1 4.3 1 4.3
Blood lactic acid increased 10005635 826 47 5.7 6 0.7
Blood osmolarity increased 10005697 112 16 14.3 3 2.7
Blood triglycerides increased 10005839 5404 1199 22.2 35 0.6
Body mass index decreased 10005895 59 14 23.7 0 0
Body mass index increased 10005897 112 29 25.9 0 0
Central obesity 10065941 81 7 8.6 1 1.2
Coma 10010071 10703 1018 9.5 253 2.4
Dehydration 10012174 27804 1067 3.8 1025 3.7
Depressed level of consciousness 10012373 10200 819 8 333 3.3
Diabetes complicating pregnancy 10012596 3 1 33.3 0 0
Diabetes mellitus 10012601 15780 5523 35 98 0.6
Diabetes mellitus inadequate control 10012607 3689 825 22.4 25 0.7
Diabetes with hyperosmolarity 10012631 27 8 29.6 0 0
Diabetic coma 10012650 1045 551 52.7 1 0.1
Diabetic hepatopathy 10071265 0 0 0 0 0
Diabetic hyperglycaemic coma 10012668 80 7 8.8 1 1.3
Diabetic hyperosmolar coma 10012669 170 66 38.8 7 4.1
Diabetic ketoacidosis 10012671 2725 1090 40 26 1
Diabetic ketoacidotic hyperglycaemic coma 10012672 32 6 18.8 0 0
Fructosamine increased 10017395 5 0 0 0 0
Gestational diabetes 10018209 594 140 23.6 15 2.5
Glucose tolerance decreased 10018428 13 0 0 0 0
Glucose tolerance impaired 10018429 1058 260 24.6 6 0.6
Glucose tolerance impaired in pregnancy 10018430 3 1 33.3 0 0
Glucose tolerance test abnormal 10018433 36 3 8.3 0 0
Glucose urine present 10018478 318 23 7.2 15 4.7
Glycosuria 10018473 384 140 36.5 5 1.3
Glycosuria during pregnancy 10018475 1 0 0 0 0
Glycosylated haemoglobin increased 10018484 2569 171 6.7 11 0.4
Hunger 10020466 1575 142 9 8 0.5
Hypercholesterolaemia 10020603 2210 256 11.6 26 1.2
Hyperglycaemia 10020635 7844 1382 17.6 129 1.6
Hyperglycaemic hyperosmolar nonketotic syndrome 10063554 184 98 53.3 7 3.8
Hyperglycaemic seizure 10071394 5 0 0 0 0
Hyperglycaemic unconsciousness 10071286 10 0 0 0 0
Hyperlactacidaemia 10020660 333 13 3.9 5 1.5
Hyperlipidaemia 10062060 4585 747 16.3 45 1
Hyperosmolar state 10020697 113 24 21.2 3 2.7
Hyperphagia 10020710 632 157 24.8 4 0.6
Hypertriglyceridaemia 10020869 1127 154 13.7 14 1.2
Hypoglycaemia 10020993 10839 672 6.2 99 0.9
Hypoinsulinaemia 10070070 1 0 0 0 0
Impaired fasting glucose 10056997 67 22 32.8 0 0
Impaired insulin secretion 10052341 21 0 0 0 0
Increased appetite 10021654 2646 494 18.7 21 0.8
Increased insulin requirement 10021664 31 2 6.5 0 0
Insulin autoimmune syndrome 10022472 23 0 0 0 0
Insulin resistance 10022489 297 75 25.3 0 0
Insulin resistance syndrome 10022490 18 6 33.3 0 0
Insulin resistant diabetes 10022491 27 8 29.6 0 0
Insulin tolerance test abnormal 10022494 3 0 0 0 0
Insulin-requiring type 2 diabetes mellitus 10053247 122 60 49.2 0 0
Ketoacidosis 10023379 640 250 39.1 3 0.5
Ketonuria 10023388 188 63 33.5 5 2.7
Ketosis 10023391 100 13 13 3 3
Lactic acidosis 10023676 4561 119 2.6 61 1.3
Latent autoimmune diabetes in adults 10066389 16 0 0 0 0
Lipids increased 10024592 368 57 15.5 1 0.3
Loss of consciousness 10024855 28249 1750 6.2 355 1.3
Metabolic acidosis 10027417 5512 253 4.6 121 2.2
Metabolic syndrome 10052066 392 197 50.3 2 0.5
Neonatal diabetes mellitus 10028933 3 0 0 1 33.3
Obesity 10029883 2787 1211 43.5 23 0.8
Overweight 10033307 442 114 25.8 3 0.7
Pancreatogenous diabetes 10033660 6 2 33.3 0 0
Polydipsia 10036067 1026 271 26.4 16 1.6
Polyuria 10036142 1444 197 13.6 27 1.9
Slow response to stimuli 10041045 161 37 23 7 4.3
Thirst 10043458 2595 224 8.6 40 1.5
Type 1 diabetes mellitus 10067584 1252 590 47.1 7 0.6
Type 2 diabetes mellitus 10067585 5272 2862 54.3 16 0.3
Underweight 10048828 111 8 7.2 2 1.8
Unresponsive to stimuli 10045555 5657 442 7.8 123 2.2
Urine ketone body present 10057597 304 31 10.2 13 4.3
Weight decreased 10047895 42275 1765 4.2 466 1.1
Weight increased 10047899 30417 5070 16.7 867 2.9

*With adverse events of interest.

For signal detection, we calculated the reporting odds ratio (ROR), an established pharmacovigilance index, using a disproportionality analysis. The ROR is calculated as a*d/b*c (Figure 1). The ROR is the ratio of the odds of reporting a specific adverse event versus all other adverse events for a given drug (antipsychotics), compared to the reporting odds for all other drugs present in the database. RORs were expressed as point estimates with 95% confidence intervals (CI). The detection of a signal was dependent on the signal indices exceeding a predefined threshold. Safety signals were considered significant when the ROR estimates and the lower limits of the 95% CI were greater than 2 [16]. We analyzed the effects of monotherapy, two-drug polypharmacy, and three-drug polypharmacy. Data analyses were performed using JMP 9.0 (SAS Institute Inc., Cary, NC, USA).

Figure 1.

Figure 1

Two by two contingency table for analysis.

Results

The FAERS database contains 4,746,890 reports from January 2004 to March 2013. After excluding duplicates according to the FDA’s recommendation and extracting the reports with complete age and gender information, 2,257,902 reports were analyzed. Using the SMQ “hyperglycemia/new onset diabetes mellitus” (SMQ20000041), we identified 241,478 adverse hyperglycemic events. The reporting ratios and RORs (95% CI) for adverse hyperglycemic events are summarized in Table 1. The reporting ratios of adverse hyperglycemic events in AAPs and typical antipsychotics (TAPs) were 21.8% (21151/96841) and 20.2% (3948/19569), respectively. The number of adverse hyperglycemic events among the top eight reported drugs, quetiapine, olanzapine, risperidone, aripiprazole, haloperidol, clozapine, prochlorperazine, and chlorpromazine, was 12,471 (28.9%), 8,423 (37.9%), 5,968 (27.0%), 4,045 (23.7%), 3,445 (31.5%), 2,614 (14.3%), 1,800 (19.8%), and 1,003 (35.7%), respectively. Each reporting ratio and ROR was analyzed based on administration (monotherapy, two-drug combination, and three-drug combination; Table 4). The RORs (95% CI) for monotherapy with quetiapine, olanzapine, risperidone, aripiprazole, haloperidol, clozapine, prochlorperazine, and chlorpromazine were 2.3 (95% CI: 2.3-2.4), 3.7 (95% CI: 3.6-3.8), 1.5 (95% CI: 1.5-1.6), 1.4 (95% CI: 1.3-1.5), 2.8 (95% CI: 2.7-3.0), 1.1 (95% CI: 1.0-1.1), 2.0 (95% CI: 1.9-2.1), and 1.6 (95% CI: 1.3-1.8), respectively. In contrast, the RORs (95% CI) for three-drug combination therapy were 16.5 (95% CI: 15.1-18.0), 12.0 (95% CI: 11.0-13.2), 12.0 (95% CI: 10.9-13.1), 10.3 (95%: CI 9.1-11.6), 5.9 (95% CI: 5.3-6.7), 2.3 (95% CI: 2.0-2.8), 6.0 (95% CI: 3.6-10.0), and 5.6 (95% CI: 4.5-6.9), respectively.

Table 4.

Reporting ratio and ROR for antipsychotic polypharmacy

Drugs * Total Cases ** Reporting ratio (%) ROR (95%CI)
Atypical
Aripiprazole
mono 11457 1645 14.4 1.4(1.3-1.5)
two 3499 927 26.5 3.0(2.8-3.3)
three 1099 606 55.1 10.3(9.1-11.6)
Clozapine
mono 13466 1515 11.3 1.1(1.0-1.1)
two 3486 584 16.8 1.7(1.5-1.8)
three 750 164 21.9 2.3(2.0-2.8)
Olanzapine
mono 13935 4226 30.3 3.7(3.6-3.8)
two 4862 1908 39.2 5.4(5.1-5.8)
three 1904 1121 58.9 12.0(11.0-13.2)
Quetiapine
mono 32942 7114 21.6 2.3(2.3-2.4)
two 6413 2556 39.9 5.6(5.3-5.9)
three 2175 1441 66.3 16.5(15.1-18.0)
Risperidone
mono 13820 2154 15.6 1.5(1.5-1.6)
two 4860 1476 30.4 3.7(3.4-3.9)
three 1917 1128 58.8 12.0(10.9-13.1)
Typical
Chlorpromazine
mono 1117 175 15.7 1.6(1.3-1.8)
two 724 179 24.7 2.7(2.3-3.2)
three 355 142 40.0 5.6(4.5-6.9)
Haloperidol
mono 5604 1420 25.3 2.8(2.7-3.0)
two 3102 704 22.7 2.5(2.3-2.7)
three 1079 448 41.5 5.9(5.3-6.7)
Prochlorperazine
mono 8514 1634 19.2 2.0(1.9-2.1)
two 487 111 22.8 2.5(2.0-3.0)
three 62 26 41.9 6.0(3.6-10.0)

*Monotherapy and polypharmacy of each antipsychotic.

**With adverse events of interest.

Discussion

Our results suggest that several antipsychotics increase adverse hyperglycemic events, and that antipsychotic polypharmacy may influence these events using the FAERS database.

In a previous cohort study, olanzapine and clozapine were associated with increased risk for type 2 diabetes [1,2,17]. Citrome et al. suggested that exposure to multiple AAPs significantly increased the risk of treatment-emergent diabetes mellitus, as compared to TAPs [1]. However, they discussed that their study design does not permit the quantification of differences between AAPs and the risk of emergent diabetes [1]. Another research group reported that AAP administration results in a small increase, as compared to TAP administration [18]. In our study, the reporting ratio of adverse hyperglycemic events in AAPs (21.8% [21151/96841]) and TAPs (20.2% [3948/19569]) were similar. Thus, we could not obtain meaningful results regarding the difference between AAP administration and TAP administration using the reporting ratio of hyperglycemic adverse events.

The lower limits of the ROR 95% CI for olanzapine, quetiapine, and haloperidol monotherapy were greater than 2 (Table 4). Baker et al. reported that olanzapine (AAP), clozapine (AAP), and risperidone (AAP) were associated with hyperglycemic adverse events, whereas aripiprazole (AAP), haloperidol (TAP), and ziprasidone (AAP) had a low association in the FAERS database. We do not have a conclusive explanation for the differences in reporting ratio between the previous report [19] and our findings. One plausible reason could be differences in the terms selected for adverse hyperglycemic events in the MedDRA database. Our study used 93 PTs, whereas Baker et al. used 24. Additionally, different datasets were used for the analyses. Baker et al. performed their analysis using cumulative subsets from 1968 to 2006, whereas our group utilized datasets from 2004 to 2013.

In this study, each reporting ratio and ROR increased with increasing number of drugs administered (Table 4). The ROR of the three-drug polypharmacy had the highest value for every antipsychotic. Therefore, antipsychotic-induced adverse hyperglycemic events may be influenced by the number of drugs administered. However, the lower limit of the clozapine ROR 95% CI was less than 2. Since the administration of clozapine is not recommended as a first-line treatment [20], physicians may be unlikely to use clozapine in diabetic patients. Therefore, the signal for adverse hyperglycemic events following clozapine might be not detected. Antipsychotic monotherapy and polypharmacy to treat schizophrenia and bipolar disorder has been compared to understand its risk-benefit profile [11,14]. In general, polypharmacy using antipsychotics is not recommended [7-9]. Baker et al. evaluated the adverse events signals for each AAP. However, they did not evaluate the effect of antipsychotic polypharmacy on hyperglycemia. Our results suggest that antipsychotic polypharmacy may influence adverse hyperglycemic events. Therefore, clinician should comply with guidelines [7-10] and monitor for adverse polypharmacy-induced hyperglycemic events.

The mechanism by which antipsychotics induce adverse hyperglycemic events remains unclear. AAPs are associated with clinically significant weight gain, and have raised significant concerns regarding possible association with hyperglycemia and type 2 diabetes [1,11,18,19]. Obesity or diabetes may be confounders for adverse hyperglycemic events. However, detailed information, including patient background and diagnosis, is not included in the FAERS database. Therefore, it is difficult to define and stratify the patients investigated.

The FAERS database is subject to various biases, including the exclusion of healthy individuals, the lack of denominator, and confounding factors [21]. Because of these deficits within the spontaneous reporting, ROR do not allow for risk quantification. Rather, the RORs offer a rough indication of the signal strength [21]. Therefore, special attention has to be paid to the interpretation of results from the FAERS database. Other epidemiological studies are required to determine the true risk of adverse hyperglycemic events.

Despite the limitations inherent to spontanesous reporting, we obtained reasonable results in the context of the reported literature. The reporting ratio and ROR suggested an association between antipsychotic drugs and hyperglycemic adverse events, and the reporting ratio was increased with an increase in the number of co-administered antipsychotic drugs. Our study indicates the importance of comparing drug safety profiles using post-marketing real-world data. This information could be useful to improve schizophrenia and bipolar disorder management.

Acknowledgements

This research was partially supported by JSPS KAKENHI Grant Number, 24390126.

Abbreviations

FDA

The Food and Drug Administration

AAP

Atypical antipsychotic

FAERS

The FDA adverse event reporting system

ICH

The International Conference on Harmonization

MedDRA

The medical dictionary for regulatory activities

SMQ

The Standardized MedDRA queries

PT

Preferred terms

ROR

Reporting odds ratio

CI

Confidence intervals

TAP

Typical antipsychotic

Footnotes

Competing interests

JA is an employee of Medical Database. The rest of the authors have no competing interests.

Authors’ contributions

YK: conceived of the study and conducted the statistical analysis and manuscript writing. RU: helped to interpretation of data and conduct statistical analyses. JA: participated in the design of the study and helped to conduct statistical analyses. NU: helped to conduct statistical analyses. YN: participated in the design of the study. YK: made contributions to conception and design of the study. MN: conceived of the study, and participated in its design and helped to draft the manuscript. All authors read and approved the final manuscript.

Contributor Information

Yamato Kato, Email: 105029@gifu-pu.ac.jp.

Ryogo Umetsu, Email: umetsur.ayni@gmail.com.

Junko Abe, Email: junko.a822@gmail.com.

Natsumi Ueda, Email: 105017@gifu-pu.ac.jp.

Yoko Nakayama, Email: 105065@gifu-pu.ac.jp.

Yasutomi Kinosada, Email: ykns@gifu-u.ac.jp.

Mitsuhiro Nakamura, Email: mnakamura@gifu-pu.ac.jp.

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