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Petrović S, Kovačević M, Kovačević SV, Miljković B. Hepatotoxicity of newer antiseizure medications in children: an overview and disproportionality analysis of VigiBase. Expert Opin Drug Metab Toxicol 2024; 20:165-173. [PMID: 38380611 DOI: 10.1080/17425255.2024.2322114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/16/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND We aimed to characterize newer antiseizure medications (ASMs)-induced hepatotoxicity in children and identify signals of disproportionate reporting of hepatotoxicity-related adverse drug events (ADEs). RESEARCH DESIGN AND METHODS Case reports reported to VigiBase were accessed using Empirica™ Signal software. To summarize characteristics of the retrieved cases, descriptive statistics were used. A disproportionality analysis was conducted using the Multi-item Gamma Poisson Shrinker algorithm, which calculates Empirical Bayesian Geometric Mean value and its lower and upper 95% confidence limits (EB05 and EB95, respectively). EB05 > 2, N > 0 was considered a signal. RESULTS Based on 870 analyzed cases, a higher proportion of cases was reported in girls than in boys and in patients aged 2-11 years than in other age groups. Most cases were serious. In 25 cases, hepatotoxicity resulted in death. A high proportion of patients (n = 275, 31.61%) experienced hypersensitivity reactions, mostly due to lamotrigine. The disproportionality analysis yielded 17 signals concerning felbamate, lamotrigine, levetiracetam, oxcarbazepine, stiripentol, and topiramate. Four signals were for severe liver injury and concerned felbamate, lamotrigine, levetiracetam, and topiramate. Gender-biased reporting frequency was detected for four ASM-ADE combinations. CONCLUSION Our results should serve to raise clinicians' awareness about the potential association between several newer ASMs and drug-induced liver injury in children.
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Affiliation(s)
| | - Milena Kovačević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Pharmacy, Belgrade, Serbia
| | - Sandra Vezmar Kovačević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Pharmacy, Belgrade, Serbia
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Pharmacy, Belgrade, Serbia
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Teschke R, Danan G. Advances in Idiosyncratic Drug-Induced Liver Injury Issues: New Clinical and Mechanistic Analysis Due to Roussel Uclaf Causality Assessment Method Use. Int J Mol Sci 2023; 24:10855. [PMID: 37446036 DOI: 10.3390/ijms241310855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Clinical and mechanistic considerations in idiosyncratic drug-induced liver injury (iDILI) remain challenging topics when they are derived from mere case narratives or iDILI cases without valid diagnosis. To overcome these issues, attempts should be made on pathogenetic aspects based on published clinical iDILI cases firmly diagnosed by the original RUCAM (Roussel Uclaf Causality Assessment Method) or the RUCAM version updated in 2016. Analysis of RUCAM-based iDILI cases allowed for evaluating immune and genetic data obtained from the serum and the liver of affected patients. For instance, strong evidence for immune reactions in the liver of patients with RUCAM-based iDILI was provided by the detection of serum anti-CYP 2E1 due to drugs like volatile anesthetics sevoflurane and desflurane, partially associated with the formation of trifluoroacetyl (TFA) halide as toxic intermediates that form protein adducts and may generate reactive oxygen species (ROS). This is accompanied by production of anti-TFA antibodies detected in the serum of these patients. Other RUCAM-based studies on serum ANA (anti-nuclear antibodies) and SMA (anti-smooth muscle antibodies) associated with AIDILI (autoimmune DILI) syn DIAIH (drug-induced autoimmune hepatitis) provide additional evidence of immunological reactions with monocytes as one of several promoting immune cells. In addition, in the blood plasma of patients, mediators like the cytokines IL-22, IL-22 binding protein (IL-22BP), IL-6, IL-10, IL 12p70, IL-17A, IL-23, IP-10, or chemokines such as CD206 and sCD163 were found in DILI due to anti-tuberculosis drugs as ascertained by the prospective updated RUCAM, which scored a high causality. RUCAM-based analysis also provided compelling evidence of genetic factors such as HLA (human leucocyte antigen) alleles contributing to initiate iDILI by a few drugs. In conclusion, analysis of published RUCAM-based iDILI cases provided firm evidence of immune and genetic processes involved in iDILI caused by specific drugs.
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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/Main, Leimenstrasse 20, D-63450 Hanau, Germany
| | - Gaby Danan
- Pharmacovigilance Consultancy, Rue des Ormeaux, 75020 Paris, France
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Teschke R. Molecular Idiosyncratic Toxicology of Drugs in the Human Liver Compared with Animals: Basic Considerations. Int J Mol Sci 2023; 24:ijms24076663. [PMID: 37047633 PMCID: PMC10095090 DOI: 10.3390/ijms24076663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/16/2023] [Accepted: 03/27/2023] [Indexed: 04/05/2023] Open
Abstract
Drug induced liver injury (DILI) occurs in patients exposed to drugs at recommended doses that leads to idiosyncratic DILI and provides an excellent human model with well described clinical features, liver injury pattern, and diagnostic criteria, based on patients assessed for causality using RUCAM (Roussel Uclaf Causality Assessment Method) as original method of 1993 or its update of 2016. Overall, 81,856 RUCAM based DILI cases have been published until mid of 2020, allowing now for an analysis of mechanistic issues of the disease. From selected DILI cases with verified diagnosis by using RUCAM, direct evidence was provided for the involvement of the innate and adapted immune system as well as genetic HLA (Human Leucocyte Antigen) genotypes. Direct evidence for a role of hepatic immune systems was substantiated by (1) the detection of anti-CYP (Cytochrome P450) isoforms in the plasma of affected patients, in line with the observation that 65% of the drugs most implicated in DILI are metabolized by a range of CYP isoforms, (2) the DIAIH (drug induced autoimmune hepatitis), a subgroup of idiosyncratic DILI, which is characterized by high RUCAM causality gradings and the detection of plasma antibodies such as positive serum anti-nuclear antibodies (ANA) and anti-smooth muscle antibodies (ASMA), rarely also anti-mitochondrial antibodies (AMA), (3) the effective treatment with glucocorticoids in part of an unselected RUCAM based DILI group, and (4) its rare association with the immune-triggered Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) caused by a small group of drugs. Direct evidence of a genetic basis of idiosyncratic DILI was shown by the association of several HLA genotypes for DILI caused by selected drugs. Finally, animal models of idiosyncratic DILI mimicking human immune and genetic features are not available and further search likely will be unsuccessful. In essence and based on cases of DILI with verified diagnosis using RUCAM for causality evaluation, there is now substantial direct evidence that immune mechanisms and genetics can account for idiosyncratic DILI by many but not all implicated drugs, which may help understand the mechanistic background of the disease and contribute to new approaches of therapy and prevention.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, D-63450 Hanau, Germany
- Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, D-60590 Frankfurt am Main, Germany
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Chipangura JK, Ntamo Y, Mohr B, Chellan N. A review of challenges and prospects of 3D cell-based culture models used for studying drug induced liver injury during early phases of drug development. Hum Exp Toxicol 2023; 42:9603271221147884. [PMID: 36879529 DOI: 10.1177/09603271221147884] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Drug-induced liver injury (DILI) is the leading cause of compound attrition during drug development. Over the years, a battery of in-vitro cell culture toxicity tests is being conducted to evaluate the toxicity of compounds prior to testing in laboratory animals. Two-dimensional (2D) in-vitro cell culture models are commonly used and have provided a great deal of knowledge; however, these models often fall short in mimicking natural structures of tissues in-vivo. Testing in humans is the most logical method, but unfortunately there are ethical limitations associated with human tests. To overcome these limitations better human-relevant, predictive models are required. The past decade has witnessed significant efforts towards the development of three-dimensional (3D) in-vitro cell culture models better mimicking in-vivo physiology. 3D cell culture has advantages in being representative of the interactions of cells in-vivo and when validated can act as an interphase between 2D cell culture models and in-vivo animal models. The current review seeks to provide an overview of the challenges that make biomarkers used for detection of DILI not to be sensitive enough during drug development and explore how 3D cell culture models can be used to address the gap with the current models.
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Affiliation(s)
- John K Chipangura
- Faculty of Health Science, University of Cape Town Research Animal Facility, South Africa
| | - Yonela Ntamo
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg, South Africa
| | - Bert Mohr
- Faculty of Health Science, University of Cape Town Research Animal Facility, South Africa
| | - Nireshni Chellan
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg, South Africa
- Centre for Cardio-metabolic Research in Africa (CARMA), Division of Medical Physiology, Faculty of Health Sciences, Stellenbosch University, South Africa
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Idiosyncratic Drug-Induced Liver Injury Associated With and Without Drug Reaction With Eosinophilia and Systemic Symptoms. Am J Gastroenterol 2022; 117:1709-1713. [PMID: 35862835 DOI: 10.14309/ajg.0000000000001913] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/24/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Immunoallergic drug-induced liver injury (DILI) presenting with features of drug reaction with eosinophilia and systemic symptoms (DRESS) is a distinct phenotype. We describe the clinical characteristics, hepatitis pattern, severity, complications, and implicated medications in DILI patients with and without DRESS. METHODS Using established criteria, we analyzed DILI registry patients with and without DRESS from 1998 to 2021. RESULTS DILI associated with DRESS (DwD) comprised 179 among 943 cases (19%) of DILI. Compared with the cohort without DRESS, patients with DwD are more often women and have shorter latency, lesser degrees of injury ( P < 0.01), and lower mortality (7.8%) than those without DRESS (16%). Antiepileptic drugs (36%), sulfonamides (19%), antituberculosis drugs (14%), antibiotics (10%), and antiretroviral drugs (8%) account for 87% of the cases of DwD. DISCUSSION A limited number of drugs cause DwD, representing a fifth of patients with DILI. DwD is characterized by lesser degrees of liver injury and mortality likely because of earlier presentation.
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Saito T, Usui T, Inada H, Miyawaki I, Mizuno K, Ikeda M, Iwata N. Clozapine-specific proliferative response of peripheral blood-derived mononuclear cells in Japanese patients with clozapine-induced agranulocytosis. J Psychopharmacol 2022; 36:1087-1094. [PMID: 35861221 DOI: 10.1177/02698811221112937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although clozapine-induced granulocytopenia (CIG) is less severe than clozapine-induced agranulocytosis (CIA), and some patients with CIG may not go on to develop serious complications, clozapine is discontinued in cases of both CIA and CIG. Understanding the pathogenic mechanisms of CIA/CIG could provide better management of clozapine therapy. Recently, as a mechanistic insight into adaptive immune systems, European groups reported clozapine-specific proliferative responses and clozapine-specific T cells using blood taken from patients with CIA and/or CIG. AIMS The aims of our study are to support this mechanistic evidence and to investigate the difference in the lymphocyte response to clozapine between patients with CIG and those with CIA. METHODS Lymphocyte stimulation tests (LSTs) were conducted using CD25-positive cell-depleted peripheral blood-derived mononuclear cells (PBMCs) isolated from blood of four Japanese patients with CIA, four patients with CIG, and nine clozapine-tolerant subjects. RESULTS Three of four patients with CIA and one of four patients with CIG showed proliferative responses to clozapine with a stimulation index of greater than 2. In contrast, none of the nine clozapine-tolerant subjects showed any response to clozapine. Olanzapine did not stimulate PBMCs of patients with CIA, patients with CIG, or clozapine-tolerant subjects. CONCLUSIONS Clozapine- and CIA-specific lymphocyte reactions in a Japanese population provided supportive evidence that the pathogenesis of CIA is based on adaptive immune reactions. In addition, patients with CIG who show a positive response to an LST may at the very least not be chosen for clozapine-rechallenge and further prospective studies are desirable to verify this hypothesis.
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Affiliation(s)
- Takeo Saito
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Toru Usui
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Hiroshi Inada
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Izuru Miyawaki
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | | | - Masashi Ikeda
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Nakao Iwata
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
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Ao S, Gao X, Zhan J, Ai L, Li M, Su H, Tang X, Chu C, Han J, Wang F. Inhibition of tumor necrosis factor improves conventional steroid therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis in a cohort of patients. J Am Acad Dermatol 2022; 86:1236-1245. [PMID: 35121075 DOI: 10.1016/j.jaad.2022.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/04/2022] [Accepted: 01/19/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Systemic steroid therapies for Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) have been challenged because of their limited benefits. Whether additional tumor necrosis factor (TNF) α inhibition provides an optimized approach remains unexplored. OBJECTIVE To investigate the efficacy of TNF-α inhibition combined with a steroid to treat SJS/TEN and to identify potential biomarkers. METHODS Twenty-five patients with SJS/TEN were recruited and divided into 2 groups: 10 patients received methylprednisolone and 15 patients received etanercept plus methylprednisolone. Serum levels of granzyme B, perforin, interferon-γ, interleukin (IL) 6, IL-15, IL-18, macrophage inflammatory protein 1α, macrophage inflammatory protein 1β, and TNF-α were measured by multiplex cytokine analysis kits during the acute and resolution phases. RESULTS Compared with the steroid monotherapy, the combination therapy significantly shortened the course of the initial steroid treatment and the duration of the acute stage, hospitalization stay, and skin re-epithelialization. Although both therapies significantly reduced IL-15 levels; the combination therapy also decreased IL-6 and IL-18 levels. While the level of IL-15 was positively correlated with skin re-epithelialization time in both groups, the level of IL-6 served as an additional marker for the course of the disease in the combination therapy group. LIMITATIONS The cohort size is relatively small. CONCLUSION Additional TNF-α inhibition to steroid treatment appeared to improve outcomes for SJS/TEN.
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Affiliation(s)
- Suiting Ao
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xuemei Gao
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Jipang Zhan
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Lu Ai
- Department of Laboratory Medicine, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Minyi Li
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Huilin Su
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xuhua Tang
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Coco Chu
- Jill Roberts Institute for Research in Inflammatory Bowel Disease, Weill Cornell Medicine, Cornell University, New York, New York
| | - Jiande Han
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Fang Wang
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
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Devarbhavi H, Ghabril M, Barnhart H, Patil M, Raj S, Gu J, Chalasani N, Bonkovsky HL. Leflunomide-induced liver injury: Differences in characteristics and outcomes in Indian and US registries. Liver Int 2022; 42:1323-1329. [PMID: 35129282 PMCID: PMC9187582 DOI: 10.1111/liv.15189] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/10/2022] [Accepted: 01/26/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND Leflunomide, a disease-modifying anti-rheumatic drug, has been associated with elevations of serum aminotransferases. Herein, we describe the clinical, laboratory features and outcomes of 17 patients with leflunomide/teriflunomide hepatotoxicity from two large drug-induced liver injury (DILI) registries. METHODS Consecutive, adjudicated cases of leflunomide (n = 16)-or teriflunomide (n = 1)-related DILI from a single centre in Bangalore, India and the multicentre US Drug-Induced Liver Injury Network (DILIN) were reviewed. RESULTS Nine (0.8%) of the 1070 Indian patients and 8 (0.5%) of the 1400 DILIN patients fulfilled the criteria for DILI because of leflunomide- or teriflunomide. 89% of the Indian cases were women and all were associated with severe cutaneous adverse reaction (SCAR) and a median drug latency of 49 days, whereas 37.5% of the DILIN cases were female, none exhibited SCAR and the median drug latency was 166 days. Hepatocellular injury (70%) was more common in women than men (92% vs. 20%) and was associated with younger mean age (41 vs. 59 years), higher peak INR (2.3 vs. 1.2) and higher mortality (58% vs. 0%). Mortality was observed in six patients from India (2 of the three with myocarditis) and one received liver transplantation from the USA. CONCLUSION Leflunomide-induced liver injury is predominantly hepatocellular. Leflunomide hepatotoxicity is more likely accompanied by SCAR, a short latency and a higher mortality in the Indian cohort, with a predominance of females, compared to US DILIN patients. The differences in skin involvement, immunoallergic features and outcomes among subjects from India vs. the USA suggest that genetic or environmental factors are important in the pathogenesis of liver injury.
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Affiliation(s)
- Harshad Devarbhavi
- Dept. of Gastroenterology and Hepatology, St. John’s Medical College Hospital, Bangalore, India
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, United States
| | | | - Mallikarjun Patil
- Dept. of Gastroenterology and Hepatology, St. John’s Medical College Hospital, Bangalore, India
| | - Sujata Raj
- Dept. of Dermatology, St. John’s Medical College Hospital, Bangalore, India
| | - Jiezhun Gu
- Duke Clinical Research Institute, Durham, NC, United States
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, United States
| | - Herbert L. Bonkovsky
- Section on Gastroenterology & Hepatology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States
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Segovia-Zafra A, Di Zeo-Sánchez DE, López-Gómez C, Pérez-Valdés Z, García-Fuentes E, Andrade RJ, Lucena MI, Villanueva-Paz M. Preclinical models of idiosyncratic drug-induced liver injury (iDILI): Moving towards prediction. Acta Pharm Sin B 2021; 11:3685-3726. [PMID: 35024301 PMCID: PMC8727925 DOI: 10.1016/j.apsb.2021.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 02/08/2023] Open
Abstract
Idiosyncratic drug-induced liver injury (iDILI) encompasses the unexpected harms that prescription and non-prescription drugs, herbal and dietary supplements can cause to the liver. iDILI remains a major public health problem and a major cause of drug attrition. Given the lack of biomarkers for iDILI prediction, diagnosis and prognosis, searching new models to predict and study mechanisms of iDILI is necessary. One of the major limitations of iDILI preclinical assessment has been the lack of correlation between the markers of hepatotoxicity in animal toxicological studies and clinically significant iDILI. Thus, major advances in the understanding of iDILI susceptibility and pathogenesis have come from the study of well-phenotyped iDILI patients. However, there are many gaps for explaining all the complexity of iDILI susceptibility and mechanisms. Therefore, there is a need to optimize preclinical human in vitro models to reduce the risk of iDILI during drug development. Here, the current experimental models and the future directions in iDILI modelling are thoroughly discussed, focusing on the human cellular models available to study the pathophysiological mechanisms of the disease and the most used in vivo animal iDILI models. We also comment about in silico approaches and the increasing relevance of patient-derived cellular models.
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Affiliation(s)
- Antonio Segovia-Zafra
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga 29071, Spain
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid 28029, Spain
| | - Daniel E. Di Zeo-Sánchez
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga 29071, Spain
| | - Carlos López-Gómez
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Málaga 29010, Spain
| | - Zeus Pérez-Valdés
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga 29071, Spain
| | - Eduardo García-Fuentes
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Málaga 29010, Spain
| | - Raúl J. Andrade
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga 29071, Spain
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid 28029, Spain
| | - M. Isabel Lucena
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga 29071, Spain
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid 28029, Spain
- Platform ISCIII de Ensayos Clínicos, UICEC-IBIMA, Málaga 29071, Spain
| | - Marina Villanueva-Paz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga 29071, Spain
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Villanueva-Paz M, Niu H, Segovia-Zafra A, Medina-Caliz I, Sanabria-Cabrera J, Lucena MI, Andrade RJ, Alvarez-Alvarez I. Critical Review of Gaps in the Diagnosis and Management of Drug-Induced Liver Injury Associated with Severe Cutaneous Adverse Reactions. J Clin Med 2021; 10:5317. [PMID: 34830594 PMCID: PMC8618381 DOI: 10.3390/jcm10225317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 12/12/2022] Open
Abstract
Drug-induced liver injury (DILI) encompasses the unexpected damage that drugs can cause to the liver. DILI may develop in the context of an immunoallergic syndrome with cutaneous manifestations, which are sometimes severe (SCARs). Nevirapine, allopurinol, anti-epileptics, sulfonamides, and antibiotics are the most frequent culprit drugs for DILI associated with SCARs. Interestingly, alleles HLA-B*58:01 and HLA-A*31:01 are associated with both adverse reactions. However, there is no consensus about the criteria used for the characterization of liver injury in this context, and the different thresholds for DILI definition make it difficult to gain insight into this complex disorder. Moreover, current limitations when evaluating causality in patients with DILI associated with SCARs are related to the plethora of causality assessment methods and the lack of consensual complementary tools. Finally, the management of this condition encompasses the treatment of liver and skin injury. Although the use of immunomodulant agents is accepted for SCARs, their role in treating liver injury remains controversial. Further randomized clinical trials are needed to test their efficacy and safety to address this complex entity. Therefore, this review aims to identify the current gaps in the definition, diagnosis, prognosis, and management of DILI associated with SCARs, proposing different strategies to fill in these gaps.
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Affiliation(s)
- Marina Villanueva-Paz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
| | - Hao Niu
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Antonio Segovia-Zafra
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Inmaculada Medina-Caliz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
| | - Judith Sanabria-Cabrera
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Plataforma ISCIII de Ensayos Clinicos, UICEC-IBIMA, 29071 Malaga, Spain
| | - M. Isabel Lucena
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Plataforma ISCIII de Ensayos Clinicos, UICEC-IBIMA, 29071 Malaga, Spain
| | - Raúl J. Andrade
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Ismael Alvarez-Alvarez
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
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11
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Huang YS, Wu CY, Chang TT, Peng CY, Lo GH, Hsu CW, Hu CT, Huang YH. Drug-induced liver injury associated with severe cutaneous adverse drug reactions: A nationwide study in Taiwan. Liver Int 2021; 41:2671-2680. [PMID: 34153177 DOI: 10.1111/liv.14990] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/30/2021] [Accepted: 06/18/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Severe cutaneous adverse drug reactions (SCARs) including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP) are high-mortality adverse drug reactions. The risk factors and prognosis of drug-induced liver injury (DILI) concomitant with SCAR warrant clarification. We aimed to evaluate the characteristics and outcomes of DILI with SCAR. METHODS We analysed the database of a 10-year multi-centre prospective study in Taiwan from 2011 to 2020. RESULTS A total of 1415 patients with DILI were enrolled, including 81 cases combined with SJS/TEN, 74 with DRESS, 3 with AGEP and 1257 with pure DILI. Approximated 11.2% of patients had SCAR, of which allopurinol was the leading incriminated drug, followed by sulphonamides and carbamazepine. The SJS/TEN group had the highest mortality (34.6%). Jaundice, acute kidney injury and SJS/TEN were independent risk factors of mortality (odds ratio: 29.54, 4.43 and 4.86, respectively, P < .003). Chronic kidney disease with high-dose allopurinol also contributed to high mortality (78.9%) in cases of allopurinol-induced DILI with SCAR. The HLA-B*5801 was associated with a high risk and mortality of allopurinol-induced DILI with SCAR. Likewise, the HLA-B*1502 was closely related to carbamazepine-induced DILI with SCAR. CONCLUSIONS DILI patients combined with SCAR are common and have a high mortality in Taiwan. Allopurinol is the leading incriminated drug. Jaundice, acute kidney injury and SJS/TEN are risk factors of mortality. HLA-B*5801, chronic kidney disease and high drug dosage also contribute to high mortality in allopurinol-induced DILI with SCAR.
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Affiliation(s)
- Yi-Shin Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, & National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
| | - Chen-Yi Wu
- Department of Dermatology, Taipei Veterans General Hospital, & National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
| | - Ting-Tsung Chang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Yuan Peng
- Department of Internal Medicine, Center for Digestive Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Gin-Ho Lo
- Department of Medical Research, Digestive Center, E-DA Hospital, Kaohsiung, Taiwan
| | - Chao-Wei Hsu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Lin-Kou, Taiwan
| | - Chi-Tan Hu
- Division of Gastroenterology and Hepatology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, & National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
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12
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Devarbhavi H. Drug-Induced Liver Injury Unique to India. Clin Liver Dis (Hoboken) 2021; 18:108-110. [PMID: 34691395 PMCID: PMC8518348 DOI: 10.1002/cld.1120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and HepatologySt. John’s Medical College HospitalBangaloreIndia
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13
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Pattern and impact of drug induced liver injury in South African patients with Steven Johnson syndrome/toxic epidermal necrolysis and a high burden of HIV. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4483-4485.e1. [PMID: 34384931 DOI: 10.1016/j.jaip.2021.07.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 06/29/2021] [Accepted: 07/23/2021] [Indexed: 11/23/2022]
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14
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Xiong H, Liu T, Xiao J, Wan J, Yang J, Huang G, Han Y, Liu G, Dong X. Warfarin-induced Stevens-Johnson syndrome with severe liver injury. J Int Med Res 2021; 49:3000605211033196. [PMID: 34311601 PMCID: PMC8320577 DOI: 10.1177/03000605211033196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening mucocutaneous disease that is predominantly drug-induced. Warfarin is the most commonly used drug for long-term anti-coagulant therapy; however, warfarin-induced SJS/TEN is seldom reported. In this study, we presented the case of a 61-year-old man who developed SJS after receiving multiple-drug therapy following aortic valve replacement surgery. The patient was diagnosed with drug-induced liver injury (DILI) based on significantly abnormal liver function test results. Warfarin was identified as the culprit drug using the algorithm of drug causality for epidermal necrolysis (ALDEN) score, enzyme-linked immunospot (ELISPOT) assay, and Roussel Uclaf Causality Assessment Method (RUCAM). After warfarin discontinuation and corticosteroid therapy, the lesions and liver function test findings improved. Human leukocyte antigen typing was conducted to detect the risk allele. To our knowledge, this is the first reported case of warfarin-induced SJS/TEN with DILI. This case suggests that commonly used and safe pharmaceutical agents such as warfarin can potentially cause serious adverse events, including SJS/TEN and DILI. The application of ALDEN, the ELISPOT assay, and RUCAM could be useful in identifying culprit drugs.
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Affiliation(s)
- Hao Xiong
- Department of Dermatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tao Liu
- Department of Dermatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jieping Xiao
- Department of Dermatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jianji Wan
- Department of Dermatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jie Yang
- Department of Dermatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Gengshi Huang
- Department of Dermatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yongzhi Han
- Department of Dermatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guangren Liu
- Department of Dermatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiuqin Dong
- Department of Dermatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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15
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Karunarathne A, Bhalla A, Sethi A, Perera U, Eddleston M. Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review. BMC Public Health 2021; 21:1441. [PMID: 34294076 PMCID: PMC8296580 DOI: 10.1186/s12889-021-11156-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 05/27/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Poisoning is a major problem in India. However, there is little systematic information on the key poisons responsible for most deaths by geographical area and over time. We aimed to review the literature to identify the poison classes causing the greatest number of deaths in India over the last 20 years. METHODS We performed a systematic literature review in Medline, Embase and Google Scholar (1999-2018), and Indian online medical journals, to find papers that reported deaths from all forms of poisoning in India, with last search 20 April 2020. We included epidemiological studies, observational studies, randomised trials, interventional studies, and case series published from 1999 to 2018 that showed the number of deaths and autopsy studies indicating the specific poisons or poison classes. Studies providing the case fatality for specific poisons or classes, which enabled calculation of the number of deaths, were also included. We excluded deaths due to animal bites and stings, ethanol or methanol poisoning, and gas inhalation as well as papers reporting a single death (case study of single patient). We grouped the papers into 5-year intervals and identified the two most common poison classes in each paper. We used descriptive statistics to summarise the findings over time based on the causative poison and the location of the study. RESULTS We identified 186 papers reporting 16,659 poisoning deaths between 1999 and 2018. The number of publications per 5-year interval showed no clear trend over the period (48, 38, 67, and 36 for consecutive periods). Half of the deaths (n = 8338, 50.0%) were reported during the first 5 years of the study (1999-2003), the number of deaths declining thereafter (to n = 1714 in 2014-2018). Deaths due to pesticide poisoning (94.5%) were dominant across the study period compared to other classes of poison [hair dye paraphenylenediamine poisoning (2.6%), medicine overdose (1.4%) or plant poisoning (1.0%)]. Among the pesticides, aluminium phosphide was the most important lethal poison during the first 10 years before declining markedly; organophosphorus insecticides were important throughout the period, becoming dominant in the last decade as aluminium phosphide cases declined. Unfortunately, few papers identified the specific organophosphorus insecticide responsible for deaths. CONCLUSION Use of the published literature to better understand the epidemiology of lethal poisoning in India has clear limitations, including secular variation in publishing practices and interest in poisoning. Unfortunately, there are no long-term detailed, combination hospital and community studies from India to provide this information. In their absence, our review indicates that pesticides are the most important poison in India, with organophosphorus insecticides replacing aluminium phosphide as the key lethal poison after government regulatory changes in 2001 reduced the latter's lethality. Plant and hair dye poisoning and medicines overdose caused few deaths. Aluminium phosphide deaths mostly occurred in northern Indian states, whereas deaths from organophosphorus insecticide poisoning occurred throughout India. Paraquat poisoning has become a clinical problem in the last 10 years. Lethal pesticide poisoning remains alarmingly common, emphasising the need for additional regulatory interventions to curtail the burden of pesticide poisoning deaths in India. More detailed reporting about the specific pesticide involved in lethal poisoning will be helpful to guide regulatory decisions.
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Affiliation(s)
- Ayanthi Karunarathne
- Centre for Pesticide Suicide Prevention, and Pharmacology, Toxicology & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Ashish Bhalla
- Department of Internal Medicine, Nehru Hospital, Institute of Medical Education and Research, Chandigarh, India
| | - Aastha Sethi
- Centre for Pesticide Suicide Prevention, and Pharmacology, Toxicology & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Government of Maharashtra, Mumbai, Maharashtra, India
| | - Uditha Perera
- Usher Institute for Population Health Sciences & Informatics, University of Edinburgh, Edinburgh, UK
| | - Michael Eddleston
- Centre for Pesticide Suicide Prevention, and Pharmacology, Toxicology & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
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16
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Soni A, Mane A. Fluoxetine-induced liver injury and skin reaction: A case report. Indian J Psychiatry 2021; 63:405-406. [PMID: 34456358 PMCID: PMC8363897 DOI: 10.4103/psychiatry.indianjpsychiatry_320_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 08/13/2020] [Accepted: 10/29/2020] [Indexed: 01/15/2023] Open
Affiliation(s)
- Abhijeet Soni
- Department of Psychiatry, Amaltas Institute of Medical Sciences, Indore, Madhya Pradesh, India. E-mail:
| | - Astik Mane
- Department of Psychiatry, H.B.T. Medical College and Dr. R.N. Cooper Hospital, Mumbai, Maharashtra, India
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17
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Villanueva-Paz M, Morán L, López-Alcántara N, Freixo C, Andrade RJ, Lucena MI, Cubero FJ. Oxidative Stress in Drug-Induced Liver Injury (DILI): From Mechanisms to Biomarkers for Use in Clinical Practice. Antioxidants (Basel) 2021; 10:390. [PMID: 33807700 PMCID: PMC8000729 DOI: 10.3390/antiox10030390] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/02/2021] [Indexed: 12/11/2022] Open
Abstract
Idiosyncratic drug-induced liver injury (DILI) is a type of hepatic injury caused by an uncommon drug adverse reaction that can develop to conditions spanning from asymptomatic liver laboratory abnormalities to acute liver failure (ALF) and death. The cellular and molecular mechanisms involved in DILI are poorly understood. Hepatocyte damage can be caused by the metabolic activation of chemically active intermediate metabolites that covalently bind to macromolecules (e.g., proteins, DNA), forming protein adducts-neoantigens-that lead to the generation of oxidative stress, mitochondrial dysfunction, and endoplasmic reticulum (ER) stress, which can eventually lead to cell death. In parallel, damage-associated molecular patterns (DAMPs) stimulate the immune response, whereby inflammasomes play a pivotal role, and neoantigen presentation on specific human leukocyte antigen (HLA) molecules trigger the adaptive immune response. A wide array of antioxidant mechanisms exists to counterbalance the effect of oxidants, including glutathione (GSH), superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPX), which are pivotal in detoxification. These get compromised during DILI, triggering an imbalance between oxidants and antioxidants defense systems, generating oxidative stress. As a result of exacerbated oxidative stress, several danger signals, including mitochondrial damage, cell death, and inflammatory markers, and microRNAs (miRNAs) related to extracellular vesicles (EVs) have already been reported as mechanistic biomarkers. Here, the status quo and the future directions in DILI are thoroughly discussed, with a special focus on the role of oxidative stress and the development of new biomarkers.
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Affiliation(s)
- Marina Villanueva-Paz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, 29071 Málaga, Spain; (M.V.-P.); (M.I.L.)
| | - Laura Morán
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (L.M.); (N.L.-A.)
- Health Research Institute Gregorio Marañón (IiSGM), 28009 Madrid, Spain
| | - Nuria López-Alcántara
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (L.M.); (N.L.-A.)
| | - Cristiana Freixo
- CINTESIS, Center for Health Technology and Services Research, do Porto University School of Medicine, 4200-319 Porto, Portugal;
| | - Raúl J. Andrade
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, 29071 Málaga, Spain; (M.V.-P.); (M.I.L.)
| | - M Isabel Lucena
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, 29071 Málaga, Spain; (M.V.-P.); (M.I.L.)
| | - Francisco Javier Cubero
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (L.M.); (N.L.-A.)
- 12 de Octubre Health Research Institute (imas12), 28041 Madrid, Spain
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18
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Devarbhavi H, Aithal G, Treeprasertsuk S, Takikawa H, Mao Y, Shasthry SM, Hamid S, Tan SS, Philips CA, George J, Jafri W, Sarin SK. Drug-induced liver injury: Asia Pacific Association of Study of Liver consensus guidelines. Hepatol Int 2021; 15:258-282. [PMID: 33641080 DOI: 10.1007/s12072-021-10144-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/16/2021] [Indexed: 02/06/2023]
Abstract
Idiosyncratic drug-induced liver injury mimics acute and chronic liver disease. It is under recognized and underrecognised because of the lack of pathognomonic diagnostic serological markers. Its consequences may vary from being asymptomatic to self-limiting illness to severe liver injury leading to acute liver failure. Its incidence is likely to be more common in Asia than other parts of the world, mainly because of hepatotoxicity resulting from the treatment of tuberculosis disease and the ubiquitous use of traditional and complimentary medicines in Asian countries. This APASL consensus guidelines on DILI is a concise account of the various aspects including current evidence-based information on DILI with special emphasis on DILI due to antituberculosis agents and traditional and complementary medicine use in Asia.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St John's Medical College Hospital, Bangalore, India.
| | - Guruprasad Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | | | - Hajime Takikawa
- Faculty of Medical Technology, Emeritus Professor, School of Medicine, Tokyo, Japan
| | - Yimin Mao
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, and Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Saggere M Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Saeed Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Bata Caves, Selangor, Malaysia
| | - Cyriac Abby Philips
- The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Jacob George
- Department of Gastroenterology and Hepatology, Westmead Hospital and Sydney West Local Health District, Sydney, Australia
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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Singh GK, Mitra B, Arora S, Akhoon N, Verma R, Sharma P, Mitra D. A retrospective, 5-year, clinicoepidemiological study of severe cutaneous adverse reactions (SCARs). Int J Dermatol 2021; 60:579-588. [PMID: 33454956 DOI: 10.1111/ijd.15416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/21/2020] [Accepted: 12/16/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND A severe cutaneous adverse reaction (SCAR) is a rare, clinically heterogeneous, life-threatening phenomenon that results in serious skin damage, systemic complications, and significant morbidity or mortality comprising of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), or SJS-TEN overlap, acute generalized exanthematous pustulosis (AGEP), exfoliative dermatitis, and drug rash with eosinophilia and systemic symptoms (DRESS). MATERIALS AND METHODS A retrospective study was conducted on all cases of SCARs admitted in a tertiary care referral hospital from January 2015 to December 2019. Clinical and epidemiological details were retrieved from the records of patients as per predesigned proforma. The data collected were analyzed and statistically evaluated. RESULTS AND ANALYSIS A total of 142 patients (67 males, 75 females) with SCARs, constituting 0.08% of total hospital admission and 0.027% of total dermatology outpatient department (OPD), were studied. Age group ranged from 2 to 61 years, with the mean age of 33.6 years (SD = 17.43). Most patients belonged to SJS-TEN complex (75 cases; SJS 48, SJS-TEN 18, TEN nine) followed by exfoliative dermatitis (27 cases/19%), AGEP (26 cases/18.3%), and DRESS (14 cases/9.8%). Anticonvulsants were most commonly implicated (22%) followed by antibiotics (20%), nonsteroidal anti-inflammatory drugs (NSAIDs) (17%), and ayurvedic (7%). There was only single mortality in a DRESS patient. CONCLUSION SCAR has considerable disease burden with marginal female preponderance in SJS/TEN and exfoliative dermatitis and can involve even the pediatric population. Anticonvulsants followed by antibiotics, NSAIDs, and ayurvedic medicines are common groups known to cause SCARs. To date, there are no definitive recommendations regarding their optimal treatment regimen, hence early diagnosis, prompt withdrawal of culprit drug, high standard of nursing care, and interdisciplinary consultations are vital steps to avoid disease progression and restore health.
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Affiliation(s)
- Gautam K Singh
- Dermatology, Venereology and Leprosy, Base Hospital Delhi Cantt, Affiliated Faculty, Army College of Medical Sciences Delhi, New Delhi, India
| | - Barnali Mitra
- Paediatrics, Base Hospital Delhi Cantt, Affiliated Faculty Army College of Medical Sciences Delhi, New Delhi, India
| | - Sandeep Arora
- Dermatology, Venereology and Leprosy, Base Hospital Delhi Cantt, Affiliated Faculty, Army College of Medical Sciences Delhi, New Delhi, India
| | - Neha Akhoon
- Pharmacology, Military Hospital Khadki, Affiliated to AFMC Pune, Pune, 410040, India
| | - Rajesh Verma
- Dermatology, Venereology and Leprosy, Dept of Dermatology, Commandant Armed Forces Medical Depot Delhi, New Delhi, India
| | - Puja Sharma
- Dermatology, Venereology and Leprosy, Base Hospital Delhi Cantt, Affiliated Faculty, Army College of Medical Sciences Delhi, New Delhi, India
| | - Debdeep Mitra
- Dermatology, Venereology and Leprosy, Base Hospital Delhi Cantt, Affiliated Faculty, Army College of Medical Sciences Delhi, New Delhi, India
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20
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Shanbhag SS, Koduri MA, Kannabiran C, Donthineni PR, Singh V, Basu S. Genetic Markers for Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis in the Asian Indian Population: Implications on Prevention. Front Genet 2021; 11:607532. [PMID: 33510770 PMCID: PMC7837290 DOI: 10.3389/fgene.2020.607532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/14/2020] [Indexed: 12/11/2022] Open
Abstract
This review attempts to collate all the studies performed in India or comprising a population originating from India and to find out if there is an association between the HLA (human leucocyte antigen) type of individual and development of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) subsequent to medication use. The authors performed a PubMed search of all articles published in English from 2009 to 2019 for articles that studied HLA type in patients who developed SJS/TEN after intake of a specific drug in the Asian Indian population or in individuals of Asian Indian origin. The selection criteria were satisfied by a total of 11 studies that reported HLA associations with specific drugs, which induced SJS/TEN, mainly anti-epileptic drugs, and cold medicine/non-steroidal anti-inflammatory drugs. These studies involved a small number of patients, and hence, there is limited evidence to conclude if these associations can be extrapolated to a larger population of the same ethnicity. Similar multi-center studies need to be conducted with a larger sample size to confirm these associations. This would have implications in policy making and for understanding the potential of using genetic markers as a screening tool before prescribing a drug to a patient, which might make them susceptible to developing a potentially life-threatening disease such as SJS/TEN. This is possibly the only mode of primary prevention for this potentially fatal severe cutaneous adverse drug reaction.
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Affiliation(s)
| | - Madhuri A Koduri
- Brien Holden Eye Research Centre (BHERC), L.V. Prasad Eye Institute, Hyderabad, India.,Manipal Academy of Higher Education, Manipal, India
| | - Chitra Kannabiran
- Brien Holden Eye Research Centre (BHERC), L.V. Prasad Eye Institute, Hyderabad, India.,Kallam Anji Reddy Molecular Genetics Laboratory, L.V. Prasad Eye Institute, Hyderabad, India
| | | | - Vivek Singh
- Brien Holden Eye Research Centre (BHERC), L.V. Prasad Eye Institute, Hyderabad, India.,Center for Ocular Regeneration (CORE), L.V. Prasad Eye Institute, Hyderabad, India
| | - Sayan Basu
- The Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India.,Brien Holden Eye Research Centre (BHERC), L.V. Prasad Eye Institute, Hyderabad, India.,Center for Ocular Regeneration (CORE), L.V. Prasad Eye Institute, Hyderabad, India
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21
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Lu J, Dong L, Zhang L, Zhang H, Wang L, Zhang J, Wan C. Toxic epidermal necrolysis after therapeutic plasma exchange in pediatric lupus patients and associated risk factors analysis. Lupus 2021; 30:465-472. [PMID: 33413003 DOI: 10.1177/0961203320981128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) is an effective means of treating systemic lupus erythematosus in children and is safe for most pediatric patients with systemic lupus erythematosus, but severe complications such as toxic epidermal necrolysis (TEN) may occur, which is a life-threatening condition. METHODS In this study, three systemic lupus erythematosus (SLE) children developed toxic epidermal necrolysis after TPE. We analyzed their medical history, clinical manifestations, SLEDAI scores, and immunological characteristics, compared to 117 cases of SLE patients without TEN after TPE, trying to find the possible risk factors. RESULTS The three children with TEN after plasma exchange appeared to have a higher proportion of male (male: female = 2:1), fever (100% Vs 32.5%), erythema on the cheek (100% Vs 54.7%), itching rash (100% Vs 54.7%), ruptured rash (100% Vs 54.7%), oral ulcer (100% Vs 54.7%) and higher LDH level (1826.0 ± 1113.1 Vs 721.1 ± 799.5 U/L), but lower white blood cell count (5.5 ± 3.3 Vs 7.2 ± 4.2 × 109/L), neutrophil count (4.7 ± 3.7 Vs 5.2 ± 3.6 × 109/L), lymphocyte count (0.6 ± 0.5 Vs 1.5 ± 0.8 × 109/L), platelet count (133.7 ± 58.1 Vs 178.5 ± 103.1 × 109/L) and C-reactive protein (all normal Vs 47.9% elevated). Autoantibody spectrum revealed that positive anti-SSA seemed more common (100% Vs 42.7%) in the three children. Relative risk analysis revealed that male (OR 21.4, 95%CI 1.78-257.186), ruptured skin rash (OR 56.5, 95%CI 4.199-760.196) and rash with itching (OR 24, 95%CI 1.98-290.896) are the risk factors of SLE patients developing TEN after plasma exchange. CONCLUSIONS We should pay particular attention to TEN after plasma exchange in SLE patients (3/120, 2.5%). This condition may be related to male, ruptured skin rash and rash with itching. For SLE patients with risk factors. We should arrange plasmapheresis more carefully.
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Affiliation(s)
- Jing Lu
- Department of pediatric nephrology, West China Second Hospital of Sichuan University, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Liqun Dong
- Department of pediatric nephrology, West China Second Hospital of Sichuan University, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Lijuan Zhang
- Department of pediatric nephrology, West China Second Hospital of Sichuan University, Sichuan, China
| | - Hui Zhang
- Department of pediatric nephrology, West China Second Hospital of Sichuan University, Sichuan, China
| | - Lin Wang
- Dermatology Department, West China Hospital of Sichuan University, Sichuan, China
| | - Junqing Zhang
- The Third Affiliated Hospital of Zhengzhou University, Maternal and Child Health Hospital of Henan Province, Henan, China
| | - Chaomin Wan
- Department of pediatric nephrology, West China Second Hospital of Sichuan University, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
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22
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Abstract
Drug induced liver injury (DILI) is a relatively rare hepatic condition in response to the use of medications, illegal drugs, herbal products or dietary supplements. It occurs in susceptible individuals through a combination of genetic and environmental risk factors believed to modify drug metabolism and/or excretion leading to a cascade of cellular events, including oxidative stress formation, apoptosis/necrosis, haptenization, immune response activation and a failure to adapt. The resultant liver damage can present with an array of phenotypes, which mimic almost every other liver disorder, and varies in severity from asymptomatic elevation of liver tests to fulminant hepatic failure. Despite recent research efforts specific biomarkers are not still available for routine use in clinical practice, which makes the diagnosis of DILI uncertain and relying on a high degree of awareness of this condition and the exclusion of other causes of liver disease. Diagnostic scales such as the CIOMS/RUCAM can support the causality assessment of a DILI suspicion, but need refinement as some criteria are not evidence-based. Prospective collection of well-vetted DILI cases in established DILI registries has allowed the identification and validation of a number of clinical variables, and to predict a more severe DILI outcome. DILI is also in need of properly designed clinical trials to evaluate the efficacy of new DILI treatments as well as older drugs such as ursodeoxycholic acid traditionally used to ameliorate cholestasis or corticosteroids now widely tried in the oncology field to manage the emergent type of hepatotoxicity related to immune checkpoint inhibitors.
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23
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Sanabria-Cabrera J, Medina-Cáliz I, Stankevičiūtė S, Rodríguez-Nicolás A, Almarza-Torres M, Lucena MI, Andrade RJ. Drug-Induced liver Injury Associated with Severe Cutaneous Hypersensitivity Reactions: A Complex Entity in Need of a Multidisciplinary Approach. Curr Pharm Des 2020; 25:3855-3871. [PMID: 31696806 DOI: 10.2174/1381612825666191107161912] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/06/2019] [Indexed: 12/12/2022]
Abstract
Idiosyncratic drug-induced liver injury (DILI) occasionally occurs in the setting of severe cutaneous adverse reactions (SCARs), including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and drug reaction with eosinophilia and systemic symptoms (DRESS). This strengthens the proposed immunologic mechanism associated with this adverse reaction. DRESS exhibits the most common association with DILI. SCARs have a wide spectrum of heterogeneous clinical presentations and severity, and genetic predisposition has been identified. In the context of SCARs, DILI present a different clinical picture, ranging from mild injury to acute liver failure. Elucidating the role of DILI in the clinical presentation and outcome of SCARs represents a challenge due to limited information from published studies and the lack of consensus on definitions. The cholestatic and mixed pattern of liver damage typically predominates in the case of DILI associated with SCARs, which is different from DILI without SCARs where hepatocellular is the most common injury pattern. Only a few drugs have been associated with both DILI and SCARs. Is this article, the criteria used for DILI recognition among SCARS have been revised and discussed, along with the drugs most commonly involved in these syndromes as well as the outcome, prognostic factors and the need for a multidisciplinary approach to improve the management of DILI in the context of SCARs.
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Affiliation(s)
- Judith Sanabria-Cabrera
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain.,UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Madrid, Spain
| | - Inmaculada Medina-Cáliz
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | - Marina Almarza-Torres
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain
| | - M Isabel Lucena
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain.,UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Raúl J Andrade
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
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24
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Zhang Z, Li S, Zhang Z, Yu K, Duan X, Long L, Zhang S, Jiang M, Liu O. Clinical Features, Risk Factors, and Prognostic Markers of Drug-Induced Liver Injury in Patients with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. Indian J Dermatol 2020; 65:274-278. [PMID: 32831367 PMCID: PMC7423232 DOI: 10.4103/ijd.ijd_217_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The liver and skin are the most common organs involved in Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). Drug reactions rarely affect both organs concurrently. The clinical features, risk factors, and prognostic markers of drug-induced liver injury (DILI) in patients with SJS/TEN are not well studied. Materials and Methods: The clinical features, risk factors, and prognostic markers of DILI in patients with SJS/TEN hospitalized at the dermatology department of our hospital from January 2009 to December 2018 were retrospectively analyzed. Results: A total of 298 patients with SJS/TEN were enrolled in this study. Of them, 40 had liver injury and the rest served as control. Causative drugs mainly included antipodagrics (xanthine oxidase inhibitors occupying 100% among antipodagrics), anticonvulsants (dibenzazepine occupying 76.92% among anticonvulsants), and traditional Chinese medicines. There was a statistically significant difference between the patients with liver injury and the control group in the history of liver disease, diabetes, and hyperlipidemia (P < 0.05). Nine of the 40 patients with liver injury died. High serum total bilirubin and creatinine levels were significantly associated with poor prognosis of DILI in patients with SJS/TEN (P < 0.05). Conclusion: DILI usually occurs in patients with SJS/TEN. Pre-existing liver disease, diabetes, and hyperlipidemia are independent risk factors for DILI in patients with SJS/TEN. High serum total bilirubin and creatinine levels may be useful prognostic markers for DILI in patients with SJS/TEN.
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Affiliation(s)
- Zhibin Zhang
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Sisi Li
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhixiong Zhang
- Department of Biology, Taiyuan Normal University, Taiyuan, Shanxi, China
| | - Kaihui Yu
- Medical Department of Graduate School, Nanchang University, Nanchang, China
| | - Xunxin Duan
- Department of Laboratory, The Affiliated Hospital of Jiujiang University, Jiujiang, Jiangxi, China
| | - Lin Long
- Department of Hepatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shulan Zhang
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Meiying Jiang
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ougen Liu
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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25
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Danjuma MIM, Sajid J, Fatima H, Elzouki AN. Novel biomarkers for potential risk stratification of drug induced liver injury (DILI): A narrative perspective on current trends. Medicine (Baltimore) 2019; 98:e18322. [PMID: 31852121 PMCID: PMC6922486 DOI: 10.1097/md.0000000000018322] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Drug induced liver injury (DILI) is an increasing cause of acute liver injury especially with increasing need for pharmacotherapy of widening comorbidities amongst our ever-aging population. Uncertainty however remains regarding both acceptable and widely agreeable diagnostic algorithms as well a clear understanding of mechanistic insights that most accurately underpins it. In this review, we have explored the potential role of emerging novel markers of DILI and how they could possibly be integrated into clinical care of patients. METHODS We explored PUBMED and all other relevant databases for scientific studies that explored potential utility of novel biomarkers of DILI, and subsequently carried out a narrative synthesis of this data. As this is a narrative review with no recourse to patient identifiable information, no ethics committee's approval was sought or required. RESULTS Novel biomarkers such as microRNA-122 (miR-122) profiles, high mobility group box-1 (HMGB1), glutamate dehydrogenase (GLDH), and cytokeratin-18 (K-18), amongst others do have the potential for reducing diagnostic uncertainties associated with DILI. CONCLUSION With the increasing validation of some of the novel liver biomarkers such as K-18, mir-122, HMGB-1, and GLDH, there is the potential for improvement in the diagnostic uncertainty commonly associated with cases of DILI.
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Affiliation(s)
| | - Jamal Sajid
- Hamad General Hospital, Hamad Medical Corporation (HMC)
| | - Haajra Fatima
- Internal Medicine Residency Program, Hamad Medical Corporation
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26
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Nipate SS, Yelmar PS. Therapeutic potential of ethyl acetate fraction of Tephrosia purpurea Linn. leaves in a rat model of gout. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2019; 17:455-460. [DOI: 10.1016/j.joim.2019.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/18/2019] [Indexed: 11/25/2022]
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27
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Andrade RJ, Chalasani N, Björnsson ES, Suzuki A, Kullak-Ublick GA, Watkins PB, Devarbhavi H, Merz M, Lucena MI, Kaplowitz N, Aithal GP. Drug-induced liver injury. Nat Rev Dis Primers 2019; 5:58. [PMID: 31439850 DOI: 10.1038/s41572-019-0105-0] [Citation(s) in RCA: 323] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 02/06/2023]
Abstract
Drug-induced liver injury (DILI) is an adverse reaction to drugs or other xenobiotics that occurs either as a predictable event when an individual is exposed to toxic doses of some compounds or as an unpredictable event with many drugs in common use. Drugs can be harmful to the liver in susceptible individuals owing to genetic and environmental risk factors. These risk factors modify hepatic metabolism and excretion of the DILI-causative agent leading to cellular stress, cell death, activation of an adaptive immune response and a failure to adapt, with progression to overt liver injury. Idiosyncratic DILI is a relative rare hepatic disorder but can be severe and, in some cases, fatal, presenting with a variety of phenotypes, which mimic other hepatic diseases. The diagnosis of DILI relies on the exclusion of other aetiologies of liver disease as specific biomarkers are still lacking. Clinical scales such as CIOMS/RUCAM can support the diagnostic process but need refinement. A number of clinical variables, validated in prospective cohorts, can be used to predict a more severe DILI outcome. Although no pharmacological therapy has been adequately tested in randomized clinical trials, corticosteroids can be useful, particularly in the emergent form of DILI related to immune-checkpoint inhibitors in patients with cancer.
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Affiliation(s)
- Raul J Andrade
- Unidad de Gestión Clínica de Enfermedades Digestivas, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Malaga, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
| | - Naga Chalasani
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Einar S Björnsson
- Department of Gastroenterology, Landspitali University Hospital Reykjavik, University of Iceland, Reykjavík, Iceland.,Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Ayako Suzuki
- Gastroenterology, Duke University, Durham, NC, USA.,Gastroenterology, Durham VA Medical Centre, Durham, NC, USA
| | - Gerd A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Mechanistic Safety, CMO & Patient Safety, Global Drug Development, Novartis Pharma, Basel, Switzerland
| | - Paul B Watkins
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA.,University of North Carolina Institute for Drug Safety Sciences, Research Triangle Park, Chapel Hill, NC, USA
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Michael Merz
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Patient Safety, AstraZeneca, Gaithersburg, MD, USA
| | - M Isabel Lucena
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain. .,Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, UICEC SCReN, Universidad de Málaga, Málaga, Spain.
| | - Neil Kaplowitz
- Division of Gastroenterology and Liver Diseases, Department of Medicine, Keck School of Medicine, Los Angeles, CA, USA
| | - Guruprasad P Aithal
- National Institute for Health Research (NIHR) Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
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28
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Affiliation(s)
- Jay H Hoofnagle
- From the Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD (J.H.H.); and the Department of Internal Medicine, National University Hospital of Iceland, and the Faculty of Medicine, University of Iceland - both in Reykjavík (E.S.B.)
| | - Einar S Björnsson
- From the Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD (J.H.H.); and the Department of Internal Medicine, National University Hospital of Iceland, and the Faculty of Medicine, University of Iceland - both in Reykjavík (E.S.B.)
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29
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Abstract
Idiosyncratic (unpredictable) drug-induced liver injury is one of the most challenging liver disorders faced by hepatologists, because of the myriad of drugs used in clinical practice, available herbs and dietary supplements with hepatotoxic potential, the ability of the condition to present with a variety of clinical and pathological phenotypes and the current absence of specific biomarkers. This makes the diagnosis of drug-induced liver injury an uncertain process, requiring a high degree of awareness of the condition and the careful exclusion of alternative aetiologies of liver disease. Idiosyncratic hepatotoxicity can be severe, leading to a particularly serious variety of acute liver failure for which no effective therapy has yet been developed. These Clinical Practice Guidelines summarize the available evidence on risk factors, diagnosis, management and risk minimization strategies for drug-induced liver jury.
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30
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Devarbhavi H, Raj S. Drug-induced liver injury with skin reactions: Drugs and host risk factors, clinical phenotypes and prognosis. Liver Int 2019; 39:802-811. [PMID: 30515930 DOI: 10.1111/liv.14004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/30/2018] [Accepted: 11/07/2018] [Indexed: 02/13/2023]
Abstract
While dermatologic manifestations of adverse drug reactions are frequent, drug-induced liver injury is rare. Numerous drugs are implicated in either Drug-Induced Liver Injury or Drug-Induced Skin Injury. However, concomitant Drug-Induced Liver Injury and Drug-Induced Skin Injury are uncommon, not well characterized and appear to be caused by a limited number of drugs. These are often associated with immuno-allergic or hypersensitivity features such as fever, skin rash, blisters or peeling of skin, eosinophilia, lymphadenopathy and mucositis. Liver injury can range from asymptomatic elevation of liver biochemical tests to severe hepatitis and acute liver failure needing liver transplantation. Severe cutaneous adverse reaction, particularly drug reaction with eosinophilia and systemic symptoms is commonly associated with internal organ involvement, the liver being the most frequently involved in approximately 90% of the cases. In Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis, abnormalities in liver biochemistry tests are common but severe liver disease is rare. There is a strong association of Human Leukocyte Antigen genotype with both drug reaction with eosinophilia and systemic symptoms and Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. It is likely that the delayed immune-mediated reaction triggering skin reaction is also responsible for hepatitis. Drug-specific lymphocytes are found in the organs involved and also in circulating blood, which along with the cytokines and chemokines play a role in pathogenesis. Anti-epileptic drugs, allopurinol, sulfonamides, antibiotics and nevirapine are the top five causes of concomitant liver and skin injury. This review will focus on drug and host factors causing concomitant Drug-Induced Skin Injury and Drug-Induced Liver Injury and discuss the characteristics of liver involvement in patients with severe cutaneous adverse reaction.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Sujata Raj
- Department of Dermatology, St. John's Medical College Hospital, Bangalore, India
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31
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Docetaxel-Induced Stevens-Johnson Syndrome in a Patient with Metastatic Prostate Adenocarcinoma. Case Rep Oncol Med 2019; 2019:7928752. [PMID: 30729055 PMCID: PMC6341237 DOI: 10.1155/2019/7928752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 12/09/2018] [Indexed: 01/25/2023] Open
Abstract
Docetaxel is a commonly used chemotherapeutic agent in a variety of cancer treatment regimens. We present a case of apparent docetaxel-induced Stevens-Johnson syndrome (SJS) in a patient recently treated for metastatic prostate cancer. This medication is not classically associated with the development of SJS but in our case, along with a number of other case reports, and a single phase II clinical trial, an association was recognized. We encourage clinicians who employ the use of this medication to be aware of this relationship.
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32
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Agrawal R, Almoghrabi A, Attar BM, Gandhi S. Fluoxetine-induced Stevens-Johnson syndrome and liver injury. J Clin Pharm Ther 2018; 44:115-118. [PMID: 30296343 DOI: 10.1111/jcpt.12760] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/05/2018] [Accepted: 08/20/2018] [Indexed: 02/05/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Drug-induced liver injuries (DILI) are overall rare and often associated with use of medications. Medications are also the most common aetiology of Stevens-Johnson syndrome (SJS), but SJS is seldom seen concomitantly with liver injury. Many common drugs can cause either one of these conditions; however, there are no reported cases of concomitant DILI and SJS secondary to fluoxetine. CASE SUMMARY A 41-year-old female presented with a skin rash and abnormal liver function tests after the recent initiation of fluoxetine. Skin and liver biopsies showed features of SJS and DILI, respectively. Fluoxetine was stopped, following which there was improvement in her liver function tests and skin rash, without progression to fulminant hepatic failure. WHAT IS NEW AND CONCLUSION Commonly used and safe pharmaceuticals such as fluoxetine have the potential for serious adverse events affecting the skin and liver.
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Affiliation(s)
- Rohit Agrawal
- Department of Medicine, Cook County Health and Hospital System, Chicago, Illinois
| | - Anas Almoghrabi
- Division of Gastroenterology and Hepatology, Department of Medicine, Cook County Health and Hospital System, Chicago, Illinois
| | - Bashar M Attar
- Division of Gastroenterology and Hepatology, Department of Medicine, Cook County Health and Hospital System, Chicago, Illinois
| | - Seema Gandhi
- Division of Gastroenterology and Hepatology, Department of Medicine, Cook County Health and Hospital System, Chicago, Illinois
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33
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Fang WC, Adler NR, Graudins LV, Goldblatt C, Goh MSY, Roberts SK, Trubiano JA, Aung AK. Drug-induced liver injury is frequently associated with severe cutaneous adverse drug reactions: experience from two Australian tertiary hospitals. Intern Med J 2018; 48:549-555. [PMID: 29316113 DOI: 10.1111/imj.13734] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/15/2017] [Accepted: 01/04/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Drug-induced liver injury (DILI) can be associated with certain cutaneous adverse drug reaction (cADR). AIMS To demonstrate the prevalence of DILI in patients with cADRs. Severity and patterns of liver injury, risk factors, causal medications and outcomes are also examined. METHODS A retrospective cohort study of patients with cADRs was conducted across two hospitals in Australia. Patients were identified through cross-linkage of multiple databases. RESULTS One hundred and four patients with cADRs were identified. Of these, 33 (31.7%) had liver injury, representing 50% of patients with drug reaction with eosinophilia and systemic symptoms, and 30.2% of patients with Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). Most cases of liver injury (69.7%) were of a cholestatic/mixed pattern with severe disease in 18.2%. No significant risk factors for development of liver injury were noted, but peripheral lymphocytosis may represent a risk in patients with SJS (odds ratio, OR = 6.0, 95% confidence interval, CI: 1.8-19.7, P = 0.003). Antimicrobials were the most common class to be implicated in DILI. The median length of inpatient stay was longer in patients with liver injury compared to those without (19 vs 11 days, P = 0.002). The mortality rate in those with liver injury was 15.2% and 9.9% in those without. No patients required liver transplantation. CONCLUSIONS DILI commonly occurs in patients with cADRs and is associated with longer inpatient stay. Patients with SJS/TEN and peripheral lymphocytosis appear to be at higher risk for developing associated liver injury.
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Affiliation(s)
- Wendy C Fang
- Department of Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Nikki R Adler
- Victorian Melanoma Service, Alfred Health, Melbourne, Victoria, Australia.,School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Linda V Graudins
- Department of Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - Caitlin Goldblatt
- Department of Pharmacy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Michelle S Y Goh
- Department of Dermatology, Alfred Health, Melbourne, Victoria, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
| | - Jason A Trubiano
- Department of Infectious Disease, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ar Kar Aung
- Department of Medicine, Alfred Health, Melbourne, Victoria, Australia.,School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
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34
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
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Devarbhavi H, Patil M, Reddy VV, Singh R, Joseph T, Ganga D. Drug-induced acute liver failure in children and adults: Results of a single-centre study of 128 patients. Liver Int 2018; 38:1322-1329. [PMID: 29222960 DOI: 10.1111/liv.13662] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/30/2017] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Drugs producing acute liver failure (ALF) are uncommon and vary geographically. Here we review the implicated drugs, clinical features, laboratory characteristics and outcome of patients with drug-induced ALF (DIALF). We analysed the predictors of mortality and their relationship with MELD, King's College criteria (KCC) and ALFSG prognostic index. METHODS We identified DIALF patients from our drug-induced liver injury (DILI) registry (1997-2017). RUCAM was used for case adjudication. Patients who fulfilled criteria for acute liver failure and drug-induced liver injury were included. Primary outcome measure was spontaneous survival or death. RESULTS There were 128 cases of DIALF (14%) among 905 patients with DILI. Mean age was 38 years, 68 (53%) female and 21(16.4%) children <18 years. Combination anti-TB drugs (ATD) (n = 92, 72.4%) accounted for a majority of DIALF. Others were anti-epileptic drugs (AED, n = 11, 10%), dapsone (n = 7, 5.5%), hormones (n = 2), ferrous sulphate overdose (n = 2), acetaminophen (APAP) (n = 2), antiretroviral (n = 2), CAM (N = 2), chemotherapy agents (N = 3), amoxicillin-clavulanic acid (n = 2) and others (n = 3). Forty-four patients (34%) recovered spontaneously and 84(66%) including 13 children (62%) died. Females, ascites, albumin, bilirubin, INR and MELD were significantly associated with mortality. Mortality was 79% for ATD and 100% for APAP and iron overdose. Area under ROC was 0.76 for MELD and ALFSG index and 0.51 for KCC. CONCLUSIONS Fourteen percent of DILI resulted in DIALF. ATD, AED, dapsone and antiretroviral drugs are most common agents. Spontaneous survival was only 34% with an even higher mortality with ATD. Non-ATD and non-APAP drugs had a better survival (51%).INR and MELD predicted mortality.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
| | - Mallikarjun Patil
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
| | - Vishnu V Reddy
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
| | | | - Tarun Joseph
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
| | - Deepak Ganga
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
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Sousa-Pinto B, Araújo L, Freitas A, Correia O, Delgado L. Stevens-Johnson syndrome/toxic epidermal necrolysis and erythema multiforme drug-related hospitalisations in a national administrative database. Clin Transl Allergy 2018; 8:2. [PMID: 29387340 PMCID: PMC5776772 DOI: 10.1186/s13601-017-0188-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/19/2017] [Indexed: 12/17/2022] Open
Abstract
Background Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and erythema multiforme (EM) are immunologically-mediated dermatological disorders commonly triggered by drug exposure and/or other external agents. We aimed to characterise SJS/TEN- and EM-drug-related hospitalisations in a nationwide administrative database, focusing on demographic and clinical characteristics, and in the most frequently implicated drug classes. Methods We analysed all drug-related hospitalisations with associated diagnosis of SJS/TEN or EM in Portuguese hospitals between 2009 and 2014. We compared gender, age, comorbidities, length of stay, and in-hospital mortality and estimated the number of episodes per million packages sold of drug classes. Predictors of in-hospital mortality were investigated in both conditions by logistic regression. Results There were 132 SJS/TEN-related and 122 EM-related hospitalisations. Incidence and in-hospital mortality of SJS/TEN episodes (24.2%) were consistent with previous studies. HIV co-infection was more common among SJS/TEN hospitalisations (9 vs. 2% with EM; P = 0.009). Liver disease, advanced age, and a TEN diagnosis, were significantly associated with higher risk of mortality in patients with SJS/TEN. The highest numbers of SJS/TEN and EM episodes per million drug packages sold were observed for antivirals (8.7 and 1.5, respectively), antineoplastic/immunosuppressive drugs (5.6 and 3.9, respectively) and hypouricaemic drugs (5.0 and 2.4, respectively). Conclusions SJS/TEN in-hospital mortality is high, and its risk factors include advanced age, liver disease, and TEN diagnosis. The drug classes most frequently associated with these conditions include antivirals, hypouricaemic drugs and antineoplastic/immunosuppressive drugs. Administrative databases seem useful in the study of SJS/TEN drug-related hospitalisations, yielding results consistent with previous studies and on a nationwide basis. Electronic supplementary material The online version of this article (10.1186/s13601-017-0188-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bernardo Sousa-Pinto
- 1Basic and Clinical Immunology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.,2MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal
| | - Luís Araújo
- 1Basic and Clinical Immunology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,Allergy Unit, CUF Institute, Porto, Portugal
| | - Alberto Freitas
- 2MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal
| | - Osvaldo Correia
- 1Basic and Clinical Immunology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,Epidermis Dermatology Center, CUF Institute, Porto, Portugal
| | - Luís Delgado
- 1Basic and Clinical Immunology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Rua Dr. Placido da Costa, 4200-450 Porto, Portugal.,Allergy Unit, CUF Institute, Porto, Portugal
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38
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Björnsson ES, Björnsson HK. Mortality associated with drug-induced liver injury (DILI). Transl Gastroenterol Hepatol 2017; 2:114. [PMID: 29354771 DOI: 10.21037/tgh.2017.11.16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/24/2017] [Indexed: 11/06/2022] Open
Affiliation(s)
- Einar S Björnsson
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Helgi K Björnsson
- Department of Internal Medicine, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
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Acute Liver Failure/Injury Related to Drug Reaction With Eosinophilia and Systemic Symptoms: Outcomes and Prognostic Factors. Transplantation 2017; 101:1830-1837. [PMID: 28207633 DOI: 10.1097/tp.0000000000001655] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare severe adverse drug-induced reaction with multiorgan involvement. The outcome and prediction of those patients who develop severe acute liver injury (sALI) or acute liver failure (ALF) remain little known. METHODS A multicenter retrospective study of patients admitted with a diagnosis of DRESS-related sALI or ALF. Histological review was performed on liver core biopsies from native livers. RESULTS Sixteen patients (11 women, 5 men; mean age, 39±17.2 years) were classified as having definite (n=13) or probable (n=3) DRESS. At admission, 3 patients had hepatic encephalopathy; median levels of prothrombin time, INR, and total bilirubin were, respectively, 33% (Q1-Q3, 21-41), 2.74 (1.98-4.50), and 94 μmol/L (Q1-Q3, 39.5-243.5). Nine patients received corticosteroid therapy. Overall, 9 patients improved spontaneously and 7 worsened (liver transplantation [LT] (n=5), deceased (n=2)). Transplantation-free and post-LT survival was 56% and 60%, respectively. After LT, DRESS recurrence was observed in 3 of 5 patients. Systemic corticosteroid therapy was not significantly associated with a clinical improvement. In the multivariate analysis, factor V level less than 40% at day 0 and factor V levels of 40% or greater at admission but decreasing at day 2 were associated with worse outcome. Pathological findings (n=7) revealed atypical lymphoid infiltrates, Kupffer cell hyperplasia with erythrophagocytosis, and an inconstant presence of eosinophils. CONCLUSIONS The spontaneous prognosis of patients with sALI/ALF due to DRESS is poor and was not improved by corticosteroid therapy. Histology is helpful to establish diagnosis. Dynamic variables regarding factor V values are predictive of a poor outcome.
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Hunt CM, Papay JI, Stanulovic V, Regev A. Drug rechallenge following drug-induced liver injury. Hepatology 2017; 66:646-654. [PMID: 28295448 DOI: 10.1002/hep.29152] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/29/2017] [Accepted: 03/02/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED Drug-induced hepatocellular injury is identified internationally by alanine aminotransferase (ALT) levels equal to or exceeding 5× the upper limit of normal (ULN) appearing within 3 months of drug initiation, after alternative causes are excluded. Upon withdrawing the suspect drug, ALT generally decrease by 50% or more. With drug readministration, a positive rechallenge has recently been defined by an ALT level of 3-5× ULN or greater. Nearly 50 drugs are associated with positive rechallenge after drug-induced liver injury (DILI): antimicrobials; and central nervous system, cardiovascular and oncology therapeutics. Drugs associated with high rates of positive rechallenge exhibit multiple risk factors: daily dose >50 mg, an increased incidence of ALT elevations in clinical trials, immunoallergic clinical injury, and mitochondrial impairment in vitro. These drug factors interact with personal genetic, immune, and metabolic factors to influence positive rechallenge rates and outcomes. Drug rechallenge following drug-induced liver injury is associated with up to 13% mortality in prospective series of all prescribed drugs. In recent oncology trials, standardized systems have enabled safer drug rechallenge with weekly liver chemistry monitoring during the high-risk period and exclusion of patients with hypersensitivity. However, high positive rechallenge rates with other innovative therapeutics suggest that caution should be taken with rechallenge of high-risk drugs. CONCLUSION For critical medicines, drug rechallenge may be appropriate when 1) no safer alternatives are available, 2) the objective benefit exceeds the risk, and 3) patients are fully informed and consent, can adhere to follow-up, and alert providers to hepatitis symptoms. To better understand rechallenge outcomes and identify key risk factors for positive rechallenge, additional data are needed from controlled clinical trials, prospective registries, and large health care databases. (Hepatology 2017;66:646-654).
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Affiliation(s)
- Christine M Hunt
- Department of Medicine, Duke University Medical Center, Durham, NC.,Durham Veterans Administration Medical Center, Durham, NC
| | - Julie I Papay
- Global Patient Safety, UCB BioSciences, Research Triangle Park, NC
| | - Vid Stanulovic
- Accelsiors Clinical Research Organization and Consultancy, Budapest, Hungary.,Semmelweis University School of Pharmacy, Budapest, Hungary
| | - Arie Regev
- Global Patient Safety, Eli Lilly and Company, Indianapolis, IN
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Kullak-Ublick GA, Andrade RJ, Merz M, End P, Benesic A, Gerbes AL, Aithal GP. Drug-induced liver injury: recent advances in diagnosis and risk assessment. Gut 2017; 66:1154-1164. [PMID: 28341748 PMCID: PMC5532458 DOI: 10.1136/gutjnl-2016-313369] [Citation(s) in RCA: 302] [Impact Index Per Article: 43.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/24/2017] [Accepted: 02/28/2017] [Indexed: 12/12/2022]
Abstract
Idiosyncratic drug-induced liver injury (IDILI) is a rare but potentially severe adverse drug reaction that should be considered in patients who develop laboratory criteria for liver injury secondary to the administration of a potentially hepatotoxic drug. Although currently used liver parameters are sensitive in detecting DILI, they are neither specific nor able to predict the patient's subsequent clinical course. Genetic risk assessment is useful mainly due to its high negative predictive value, with several human leucocyte antigen alleles being associated with DILI. New emerging biomarkers which could be useful in assessing DILI include total keratin18 (K18) and caspase-cleaved keratin18 (ccK18), macrophage colony-stimulating factor receptor 1, high mobility group box 1 and microRNA-122. From the numerous in vitro test systems that are available, monocyte-derived hepatocytes generated from patients with DILI show promise in identifying the DILI-causing agent from among a panel of coprescribed drugs. Several computer-based algorithms are available that rely on cumulative scores of known risk factors such as the administered dose or potential liabilities such as mitochondrial toxicity, inhibition of the bile salt export pump or the formation of reactive metabolites. A novel DILI cluster score is being developed which predicts DILI from multiple complimentary cluster and classification models using absorption-distribution-metabolism-elimination-related as well as physicochemical properties, diverse substructural descriptors and known structural liabilities. The provision of more advanced scientific and regulatory guidance for liver safety assessment will depend on validating the new diagnostic markers in the ongoing DILI registries, biobanks and public-private partnerships.
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Affiliation(s)
- Gerd A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich and University of Zurich, Zurich, Switzerland,Drug Safety and Epidemiology, Novartis Pharma, Basel, Switzerland
| | - Raul J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Málaga, Spain
| | - Michael Merz
- Novartis Institutes for BioMedical Research, Novartis Campus, Basel, Switzerland
| | - Peter End
- Novartis Institutes for BioMedical Research, Novartis Campus, Basel, Switzerland
| | - Andreas Benesic
- Department of Medicine II, Klinikum Grosshadern of the University of Munich (KUM), University of Munich, Munich, Germany,MetaHeps GmbH, Planegg/Martinsried, Germany
| | - Alexander L Gerbes
- Department of Medicine II, Klinikum Grosshadern of the University of Munich (KUM), University of Munich, Munich, Germany
| | - Guruprasad P Aithal
- National Institute for Health Research (NIHR), Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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Human leukocyte antigen and idiosyncratic adverse drug reactions. Drug Metab Pharmacokinet 2017; 32:21-30. [DOI: 10.1016/j.dmpk.2016.11.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/08/2016] [Accepted: 11/09/2016] [Indexed: 12/17/2022]
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Hirashima R, Itoh T, Tukey RH, Fujiwara R. Prediction of drug-induced liver injury using keratinocytes. J Appl Toxicol 2017; 37:863-872. [PMID: 28138970 DOI: 10.1002/jat.3435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 12/06/2016] [Accepted: 12/12/2016] [Indexed: 01/07/2023]
Abstract
Drug-induced liver injury (DILI) is one of the most common adverse drug reactions. DILI is often accompanied by skin reactions, including rash and pruritus. However, it is still unknown whether DILI-associated genes such as S100 calcium-binding protein A and interleukin (IL)-1β are involved in drug-induced skin toxicity. In the present study, most of the tested hepatotoxic drugs such as pioglitazone and diclofenac induced DILI-associated genes in human and mouse keratinocytes. Keratinocytes of mice at higher risk for DILI exhibited an increased IL-1β basal expression. They also showed a higher inducibility of IL-1β when treated by pioglitazone. Mice at higher risk for DILI showed even higher sums of DILI-associated gene basal expression levels and induction rates in keratinocytes. Our data suggest that DILI-associated genes might be involved in the onset and progression of drug-induced skin toxicity. Furthermore, we might be able to identify individuals at higher risk of developing DILI less invasively by examining gene expression patterns in keratinocytes. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Rika Hirashima
- School of Pharmacy, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan
| | - Tomoo Itoh
- School of Pharmacy, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan
| | - Robert H Tukey
- Laboratory of Environmental Toxicology, Department of Pharmacology, University of California San Diego, La Jolla, CA, USA
| | - Ryoichi Fujiwara
- School of Pharmacy, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan
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Medina-Cáliz I, Robles-Díaz M, Lucena MI, Andrade RJ. Drug-induced liver and skin reactions: In need of a consensus definition. Hepatology 2017; 65:391. [PMID: 27618725 DOI: 10.1002/hep.28808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 08/03/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Inmaculada Medina-Cáliz
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, 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
| | - Mercedes Robles-Díaz
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, 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
| | - M Isabel Lucena
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, 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
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, 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
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Devarbhavi H, Raj S. Reply. Hepatology 2017; 65:392. [PMID: 27618570 DOI: 10.1002/hep.28806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 08/19/2016] [Indexed: 12/07/2022]
Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
| | - Sujata Raj
- Department of Dermatology, St. John's Medical College Hospital, Bangalore, India
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Yoon IS, Park DH, Ki SH, Cho SS. Effects of extracts from Corylopsis coreana Uyeki (Hamamelidaceae) flos on xanthine oxidase activity and hyperuricemia. J Pharm Pharmacol 2016; 68:1597-1603. [DOI: 10.1111/jphp.12626] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 07/26/2016] [Indexed: 11/30/2022]
Abstract
Abstract
Objectives
This study aims to investigate xanthine oxidase (XO) inhibitory activity and antihyperuricemic effects of Corylopsis coreana Uyeki flos extracts and the phytochemicals contained therein.
Methods
Ethanolic extracts of the plant were prepared, and the extraction process was optimized with respect to flavonoid content and XO inhibitory activity. The optimized ethanolic extract was tested for its XO inhibitory activity and antihyperuricemic effects in potassium oxonate-induced hyperuricemic mice.
Key findings
The 80% ethanolic extract showed the highest total flavonoid content and in-vitro XO inhibitory activity. In-vivo studies demonstrated that the optimized 80% ethanolic extract could inhibit hepatic XO activity and significantly alleviate hyperuricemia at a relatively low oral dose (50 mg/kg) in mice. Additionally, an in-vitro enzyme inhibition study showed that phytochemicals such as bergenin, isosalipurposide, quercetin and quercitrin may be the key constituents responsible for the observed antihyperuricemic effects of the extract.
Conclusions
This study is the first report on the XO inhibitory and antihyperuricemic effects of C. coreana Uyeki flos extract, which can be therapeutically applied in treating hyperuricemia and gout.
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Affiliation(s)
- In-Soo Yoon
- Department of Pharmacy, College of Pharmacy, Mokpo National University, Muan, Jeonnam, Korea
| | - Dae-Hun Park
- Department of Oriental Medicine Materials, Dongshin University, Naju, Jeonnam, Korea
| | - Sung-Hwan Ki
- Department of Pharmacy, Chosun University, Gwangju, Korea
| | - Seung-Sik Cho
- Department of Pharmacy, College of Pharmacy, Mokpo National University, Muan, Jeonnam, Korea
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49
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Björnsson ES, Ólafsson JH. Concomitant drug-induced liver and skin reactions: An Indian experience. Hepatology 2016; 63:700-2. [PMID: 26598803 DOI: 10.1002/hep.28361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/20/2015] [Indexed: 12/07/2022]
Affiliation(s)
- Einar S Björnsson
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The National University Hospital of Iceland, Reykjavik, Iceland.,Medical Faculty, University of Iceland, Reykjavik, Iceland
| | - Jon Hjaltalin Ólafsson
- Department of Dermatology, University of Iceland, Reykjavik, Iceland.,Medical Faculty, University of Iceland, Reykjavik, Iceland
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