Efficacy and Safety of Intravenous S-Adenosyl-L-Methionine Therapy in the Management of Intrahepatic Cholestasis of Pregnancy

S-adenosylmethionine (SAMe) therapy in liver disease: a review of current evidence and clinical utility

S-adenosyl-L-methionine (SAMe; AdoMet) is an important, metabolically pleiotropic molecule that participates in multiple cellular reactions as the precursor for the synthesis of glutathione and principle methyl donor required for methylation of nucleic acids, phospholipids, histones, biogenic amines, and proteins. SAMe synthesis is depressed in chronic liver disease and so there has been considerable interest in the utility of SAMe to ameliorate disease severity. Despite encouraging pre-clinical data confirming that SAMe depletion can exacerbate liver injury and supporting a hepatoprotective role for SAMe therapy, to date no large, high-quality randomised clinical trials have been performed that establish clinical utility in specific disease states. Here, we offer an in-depth review of the published scientific literature relating to the physiological and pathophysiological roles of SAMe and its therapeutic use in liver disease, critically assessing implications for clinical practice and offering recommendations for further research.

A randomised placebo-controlled trial of ursodeoxycholic acid and S-adenosylmethionine in the treatment of intrahepatic cholestasis of pregnancy

A randomised placebo controlled study was performed in 32 women with intrahepatic cholestasis of pregnancy. The population was divided into four groups: for 20 days each group was treated only with ursodeoxycholic acid, or S-adenosylmethionine, or a combination of both drugs, or a placebo (vitamin). Itching, standard liver function tests and serum total bile acids were measured before, during, and after treatment. Itching improved in all the women as well as the biochemical abnormalities. No side-effects in the mother or in the infant were recorded during and after therapy. A combination of ursodeoxycholic acid and S-adenosylmethionine is more effective than placebo and than either drug alone.

Evidence that S-adenosyl-L-methionine diastereoisomers may reduce ischaemia-reperfusion injury by interacting with purinoceptors in isolated rat liver

1. Mechanisms underlying the haemodynamic activity of diastereoisomers of S-adenosyl-L-methionine (SAM) were investigated using inhibitors of purinoceptors and nitric oxide (NO) synthase in perfused rat livers damaged by sequential 24 h cold and 20 min rewarming ischaemia + reperfusion. 2. Stored livers were flushed with 10 ml saline alone (control) or with added (R,S) or (S,S) SAM (100 microM) and reperfused in the absence (control) or presence of 10 microM 8-phenyltheophylline (8-PT) or 100 microM L-N-monomethylarginine (L-NMMA). 3. Both SAM diastereoisomers rapidly increased blood flow and bile production versus controls (P<0.001) but the (R,S) isomer induced greater increases in blood flow and the (S,S) isomer greater increases in bile production: 625 versus 596 versus 518 ml blood flow and 100 versus 119 versus 56 mg bile production per g liver over 3 h in (R,S), (S,S) and control, respectively. 4. 8-PT prevented the enhancement of blood flow by (S,S) SAM (529 versus 596 ml g(-1) liver over 3 h for (S,S) SAM alone, P<0.001), but was without effect in control livers. 8-PT also reduced SAM-enhanced bile production: 51 versus 119 mg g(-1) liver over 3 h, P<0.001. L-NMMA reduced blood flow and bile production similarly in the absence or presence of (S,S) SAM. 5. Thus, SAM may improve liver perfusion after ischaemia-reperfusion injury via stimulation of P, (A2) purinoceptors at which SAM shows activity. The choleretic activity of (S,S) SAM is disproportionately greater than enhanced blood flow and may occur independently of a NO-dependent component of bile production.

S-adenosylmethionine versus ursodeoxycholic acid in the treatment of intrahepatic cholestasis of pregnancy: preliminary results of a controlled trial

OBJECTIVES

To evaluate the efficacy of S-adenosylmethionine (SAMe) and ursodeoxycholic acid (UDCA) in intrahepatic cholestasis of pregnancy (ICP).

METHODS

Twenty patients in the last trimester of pregnancy were randomly assigned to receive either SAMe (1000 mg/day i.m.) or UDCA (450 mg/day) until delivery; the treatment lasted at least 15 days in all cases.

RESULTS

After UDCA the women exhibited significantly lower levels of total bile acids (P < 0.02), but no significant differences were noted in AST, ALT, or alkaline phosphatase. All ten patients showed a complete resolution of pruritus. After SAMe no significant changes were noted in pruritus, total bile acids or liver function tests. No adverse reactions on mother or child were recorded during either UDCA or SAMe treatment and the outcome of pregnancy was favorable in both groups.

CONCLUSIONS

These findings show that UDCA is more effective than SAMe in controlling pruritus and total bile acids, which are considered a prognostic parameter in ICP with respect to the fetus. Nevertheless, before UDCA is introduced as an effective and safe treatment for ICP, which also has a beneficial effect on fetal prognosis, we believe these results should be confirmed and extended in other clinical trials.