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Teschke R. Idiosyncratic DILI: Analysis of 46,266 Cases Assessed for Causality by RUCAM and Published From 2014 to Early 2019. Front Pharmacol 2019; 10:730. [PMID: 31396080 PMCID: PMC6664244 DOI: 10.3389/fphar.2019.00730] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/05/2019] [Indexed: 12/12/2022] Open
Abstract
One of the most difficult challenges in clinical hepatology is the diagnosis of a drug-induced liver injury (DILI). The timing of the events, exclusion of alternative causes, and taking into account the clinical context should be systematically assessed and scored in a transparent manner. RUCAM (Roussel Uclaf Causality Assessment Method) is a well-established diagnostic algorithm and scale to assess causality in patients with suspected DILI. First published in 1993 and updated in 2016, RUCAM is now the worldwide most commonly used causality assessment method (CAM) for DILI. The following manuscript highlights the recent implementation of RUCAM around the world, by reviewing the literature for publications that utilized RUCAM, and provides a review of “best practices” for the use of RUCAM in cases of suspected DILI. The worldwide appreciation of RUCAM is substantiated by the current analysis of 46,266 DILI cases, all tested for causality using RUCAM. These cases derived from 31 reports published from 2014 to early 2019. Their first authors came from 10 countries, with China on top, followed by the US, and Germany on the third rank. Importantly, all RUCAM-based DILI reports were published in high profile journals. Many other reports were published earlier from 1993 up to 2013 in support of RUCAM. Although most of the studies were of high quality, the current case analysis revealed shortcomings in few studies, not at the level of RUCAM itself but rather associated with the work of the users. To ensure in future DILI cases a better performance by the users, a list of essential elements is proposed. As an example, all suspected DILI cases should be evaluated 1) by the updated RUCAM to facilitate result comparisons, 2) according to a prospective study protocol to ensure complete data sets, 3) after exclusion of cases with herb induced liver injury (HILI) from a DILI cohort to prevent confounding variables, and 4) according to inclusion of DILI cases with RUCAM-based causality gradings of highly probable or probable, in order to increase the specificity of the results. In conclusion, RUCAM benefits from its high appreciation and performs well provided the users adhere to published recommendations to prevent confounding variability.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt, Germany
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Nicoletti P, Barrett S, McEvoy L, Daly AK, Aithal G, Lucena MI, Andrade RJ, Wadelius M, Hallberg P, Stephens C, Bjornsson ES, Friedmann P, Kainu K, Laitinen T, Marson A, Molokhia M, Phillips E, Pichler W, Romano A, Shear N, Sills G, Tanno LK, Swale A, Floratos A, Shen Y, Nelson MR, Watkins PB, Daly MJ, Morris AP, Alfirevic A, Pirmohamed M. Shared Genetic Risk Factors Across Carbamazepine-Induced Hypersensitivity Reactions. Clin Pharmacol Ther 2019; 106:1028-1036. [PMID: 31066027 PMCID: PMC7156285 DOI: 10.1002/cpt.1493] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/17/2019] [Indexed: 12/19/2022]
Abstract
Carbamazepine (CBZ) causes life‐threating T‐cell‐mediated hypersensitivity reactions, including serious cutaneous adverse reactions (SCARs) and drug‐induced liver injury (CBZ‐DILI). In order to evaluate shared or phenotype‐specific genetic predisposing factors for CBZ hypersensitivity reactions, we performed a meta‐analysis of two genomewide association studies (GWAS) on a total of 43 well‐phenotyped Northern and Southern European CBZ‐SCAR cases and 10,701 population controls and a GWAS on 12 CBZ‐DILI cases and 8,438 ethnically matched population controls. HLA‐A*31:01 was identified as the strongest genetic predisposing factor for both CBZ‐SCAR (odds ratio (OR) = 8.0; 95% CI 4.10–15.80; P = 1.2 × 10−9) and CBZ‐DILI (OR = 7.3; 95% CI 2.47–23.67; P = 0.0004) in European populations. The association with HLA‐A*31:01 in patients with SCAR was mainly driven by hypersensitivity syndrome (OR = 12.9; P = 2.1 × 10−9) rather than by Stevens‐Johnson syndrome/toxic epidermal necrolysis cases, which showed an association with HLA‐B*57:01. We also identified a novel risk locus mapping to ALK only for CBZ‐SCAR cases, which needs replication in additional cohorts and functional evaluation.
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Affiliation(s)
- Paola Nicoletti
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Sema4, a Mount Sinai Venture, Stamford, Connecticut, USA
| | - Sarah Barrett
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laurence McEvoy
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Ann K Daly
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Guruprasad Aithal
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Unit, Center at the Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
| | - M Isabel Lucena
- UGC Digestivo, Clinical Pharmacology Service, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Raul J Andrade
- UGC Digestivo, Clinical Pharmacology Service, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Mia Wadelius
- Department of Medical Sciences, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Camilla Stephens
- UGC Digestivo, Clinical Pharmacology Service, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Einar S Bjornsson
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Peter Friedmann
- Dermatology Unit, School of Medicine, University of Southampton, Southampton, UK
| | - Kati Kainu
- Clinical Research Unit for Pulmonary Diseases, Helsinki University Central Hospital, Helsinki, Finland
| | - Tarja Laitinen
- Clinical Research Unit for Pulmonary Diseases, Helsinki University Central Hospital, Helsinki, Finland
| | - Anthony Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Mariam Molokhia
- School of Population Sciences and Health Services Research, King's College, London, UK
| | - Elizabeth Phillips
- Departiment of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Neil Shear
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Graeme Sills
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Ashley Swale
- Department of Systems Biology, Columbia University, New York, New York, USA
| | - Aris Floratos
- Department of Systems Biology, Columbia University, New York, New York, USA
| | - Yufeng Shen
- Department of Systems Biology, Columbia University, New York, New York, USA
| | | | - Paul B Watkins
- Eshelman School of Pharmacy, University of North Carolina Institute for Drug Safety Sciences, Chapel Hill, North Carolina, USA
| | - Mark J Daly
- Analytic and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew P Morris
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.,Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Ana Alfirevic
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Khan DA, Banerji A, Bernstein JA, Bilgicer B, Blumenthal K, Castells M, Ein D, Lang DM, Phillips E. Cephalosporin Allergy: Current Understanding and Future Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:2105-2114. [PMID: 31495420 PMCID: PMC6955146 DOI: 10.1016/j.jaip.2019.06.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/29/2019] [Accepted: 06/02/2019] [Indexed: 01/13/2023]
Abstract
Cephalosporins are commonly used antibiotics both in hospitalized patients and in outpatients. Hypersensitivity reactions to cephalosporins are becoming increasingly common with a wide range of immunopathologic mechanisms. Cephalosporins are one of the leading causes for perioperative anaphylaxis and severe cutaneous adverse reactions. Patients allergic to cephalosporins tend to tolerate cephalosporins with disparate R1 side chains but may react to other beta-lactams with common R1 side chains. Skin testing for cephalosporins has not been well validated but appears to have a good negative predictive value for cephalosporins with disparate R1 side chains. In vitro tests including basophil activation tests have lower sensitivity when compared with skin testing. Rapid drug desensitization procedures are safe and effective and have been used successfully for immediate and some nonimmediate cephalosporin reactions. Many gaps in knowledge still exist regarding cephalosporin hypersensitivity.
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Affiliation(s)
- David A. Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8859
| | - Aleena Banerji
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Cox 201, MGH, 55 Fruit St, Boston, MA 02114
| | - Jonathan A. Bernstein
- Department of Internal Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML#563, Cincinnati, OH 45267-0563
| | - Basar Bilgicer
- Department of Chemical and Biomedical Engineering, 205 McCourtney Hall, Notre Dame, IN 46556-5637
| | - Kimberly Blumenthal
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Cox 201, MGH, 55 Fruit St, Boston, MA 02114
| | - Mariana Castells
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Brigham and Women’s Hospital, 60 Fenwood Rd Hale Building, Boston, MA 02115
| | - Daniel Ein
- Department of Internal Medicine, George Washington University Medical Center, 2300 M St. NW, Washington DC 20037
| | - David M. Lang
- Department of Internal Medicine, Cleveland Clinic, Respiratory Institute, Department of Allergy and Clinical Immunology, 9500 Euclid Ave-A90, Cleveland, OH 44195
| | - Elizabeth Phillips
- Department of Medicine, Vanderbilt University Medical Center, 1161-21 St Ave S, A-2200 MCN, Nashville, TN 3732-2582
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Teschke R. Idiosyncratic DILI: Analysis of 46,266 Cases Assessed for Causality by RUCAM and Published From 2014 to Early 2019. Front Pharmacol 2019. [PMID: 31396080 DOI: 10.389/fphar.2019.00730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
One of the most difficult challenges in clinical hepatology is the diagnosis of a drug-induced liver injury (DILI). The timing of the events, exclusion of alternative causes, and taking into account the clinical context should be systematically assessed and scored in a transparent manner. RUCAM (Roussel Uclaf Causality Assessment Method) is a well-established diagnostic algorithm and scale to assess causality in patients with suspected DILI. First published in 1993 and updated in 2016, RUCAM is now the worldwide most commonly used causality assessment method (CAM) for DILI. The following manuscript highlights the recent implementation of RUCAM around the world, by reviewing the literature for publications that utilized RUCAM, and provides a review of "best practices" for the use of RUCAM in cases of suspected DILI. The worldwide appreciation of RUCAM is substantiated by the current analysis of 46,266 DILI cases, all tested for causality using RUCAM. These cases derived from 31 reports published from 2014 to early 2019. Their first authors came from 10 countries, with China on top, followed by the US, and Germany on the third rank. Importantly, all RUCAM-based DILI reports were published in high profile journals. Many other reports were published earlier from 1993 up to 2013 in support of RUCAM. Although most of the studies were of high quality, the current case analysis revealed shortcomings in few studies, not at the level of RUCAM itself but rather associated with the work of the users. To ensure in future DILI cases a better performance by the users, a list of essential elements is proposed. As an example, all suspected DILI cases should be evaluated 1) by the updated RUCAM to facilitate result comparisons, 2) according to a prospective study protocol to ensure complete data sets, 3) after exclusion of cases with herb induced liver injury (HILI) from a DILI cohort to prevent confounding variables, and 4) according to inclusion of DILI cases with RUCAM-based causality gradings of highly probable or probable, in order to increase the specificity of the results. In conclusion, RUCAM benefits from its high appreciation and performs well provided the users adhere to published recommendations to prevent confounding variability.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt, Germany
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