Cyclophosphamide-induced severe acute hepatitis in a rheumatic disease: case-based review

Cyclophosphamide in refractory autoimmune hepatitis and autoimmune hepatitis coexisting extrahepatic autoimmune disorders: A review

INTRODUCTION AND OBJECTIVES

Despite tacrolimus (TAC) or mycophenolate mofetil (MMF) for alternate approaches, a proportion of patients still required further exploration of other therapeutic options due to uncontrolled autoimmune hepatitis(AIH). The role of cyclophosphamide (CYC) for AIH has been explored in isolated case reports and small series. We present a review of CYC therapy in AIH patients.

MATERIALS AND METHODS

A search for studies with keywords 'autoimmune hepatitis' and 'cyclophosphamide' was performed. Data recorded included gender, age, laboratory parameters and histological findings at the time of AIH diagnosis and before initiation of CYC therapy.

RESULTS

We identified 13 patients across 7 studies who met criteria for study inclusion, of whom around 69.2% (9/13) were primary refractory; 30.8% (4/13) patients used CYC as rescue therapy due to their coexisting autoimmune complications. The main findings of the study were that CYC appears to have an acceptable safety profile in difficult-to-treat AIH patients, with an overall remission rate of 88.9% (8/9). The other four patients with AIH accompanied by extrahepatic autoimmune disorders also achieved remission of transaminase levels and stability of liver function after the addition of CYC. A positive response to CYC treatment was seen in 12(92.3%) patients and none of them relapsed during the follow-up.

CONCLUSIONS

We cautiously recommend that CYC could be a conditioning alternative to starting second-line therapy after unsuccessful intensification of first-line treatment. Pharmacogenetic methods may play a role in guiding cyclophosphamide therapy. Given our small sample size, results should be considered preliminary.

Acute Liver Injury Caused by Cyclophosphamide in a Patient With Factor VIII Deficiency: A Rare Presentation

Because of the variety of drugs, herbal, and dietary supplements used in clinical practice. Drug-induced liver injury (DILI) has become an important and common cause of acute liver injury and failure. Many drugs associated with DILI have been identified, but there remains some uncertainty about others. Cyclophosphamide is a commonly used antineoplastic medication, and its association with DILI has been reported in animals and has been established in humans with the use of high-dose IV. Oral cyclophosphamide has not been clearly shown to cause acute liver injury, thus highlighting many of the unique aspects of this manuscript. Here, we report a case of cyclophosphamide-induced DILI with the aim to alert clinicians regarding this potential association.

Synergistic immunosuppressive effect of hispidulin and nepetin mixtures on human T lymphocytes

BACKGROUND

Clerodendrum petasites S. Moore predominantly contains hispidulin (His) and nepetin (Nep) which are immunosuppressive potentials. Although the effect of individual compounds was previously confirmed, a cumulative suppression of these flavonoid mixtures is unknown. This study thus investigated their inhibitory effects and cytotoxicity on T cells by using His:Nep ratios following a naturally-occurring dose (3:1) and optimized doses (1:1 and 1:3).

MATERIALS AND METHODS

Anti-CD3/28 stimulated peripheral blood mononuclear cells were treated with individual compounds and their mixtures. Changes in early cell activation markers in activated T cells and apoptosis were analyzed by a flow cytometer.

RESULTS

Mixtures at 3:1 suppressed CD69 and CD25 expression in CD4⁺ and CD8⁺ T cells in a dose-dependent manner. At the highest concentration of 200 µM His +66.7 µM Nep, over 90% inhibition was observed for CD25 expression in CD4⁺ and CD8⁺ T cells, whereas a lesser effect was observed for CD69 expression. A dose-dependent inhibition was still observed when using 1:1 and 1:3 ratios. Interestingly, 80-97% inhibition were observed in CD69 and CD25 expression without inducing cell death after treated with the highest doses of each ratio (66.7 µM His +200 µM Nep and 200 µM His +200 µM Nep). These mixtures were also exhibited a better suppression than individual compounds.

CONCLUSIONS

The optimized mixture of His and Nep at 66.7:200 µM is suggested for further study due to a greater suppressive effect than a single compound or a naturally-occurring dose.

Allicin mitigates hepatic injury following cyclophosphamide administration via activation of Nrf2/ARE pathways and through inhibition of inflammatory and apoptotic machinery

Treatment with anti-neoplastic agents, including cyclophosphamide (CP), is associated with several adverse reactions. Here, we distinguished the potential protective effect of allicin against CP-mediated hepatotoxicity in rats. To assess the effect of allicin, four experimental groups were used, with 7 rats per group, including control, allicin (10 mg/kg), CP (200 mg/kg), and allicin + CP-treated groups. All groups were treated for 10 days. Blood and liver samples were collected for biochemical, molecular, and histological analyses. Treatment with CP led to deformations in the liver tissue that were associated with higher liver function markers (alanine transaminase, aspartate transaminase, and alkaline phosphatase). Additionally, a disturbance in the redox balance was observed after CP exposure, as indicated by increased levels of oxidants, including malondialdehyde and nitric oxide, and the decreased levels of endogenous antioxidants, including glutathione, glutathione peroxidase, glutathione reductase, superoxide dismutase, and catalase. At the molecular level, CP treatment resulted in reduced expression of the Nrf2/ARE pathway and other genes related to this pathway, including NAD(P)H quinone dehydrogenase 1 and glutamate-cysteine ligase catalytic subunit. CP also led to a hyper-inflammatory response in hepatic tissue, with increased production of pro-inflammatory cytokines, including tumor necrosis factor-alpha and interlukin-1beta, and upregulation of nitric oxide synthase 2. CP also enhanced the immunoreactivity of the profibrogenic cytokine, transforming growth factor-beta, in liver tissue. Upregulation of caspase 3 and Bcl-2-associated X protein and downregulation of B-cell lymphoma 2 were also observed in response to CP treatment. Treatment with allicin reversed the molecular, biochemical, and histological changes that occurred with CP exposure. These results suggest that allicin can be used in combination with CP to avoid hepatotoxicity.

Leflunomide an immunomodulator with antineoplastic and antiviral potentials but drug-induced liver injury: A comprehensive review

Leflunomide (LF) represents the prototype member of dihydroorotate dehydrogenase (DHODH) enzyme inhibitors. DHODH is a mitochondrial inner membrane enzyme responsible for catalytic conversion of dihydroorotate into orotate, a rate-limiting step in the de novo synthesis of the pyrimidine nucleotides. LF produces cellular depletion of pyrimidine nucleotides required for cell growth and proliferation. Based on the affected cells the outcome can be attainable as immunosuppression, antiproliferative, and/or the recently gained attention of the antiviral potentials of LF and its new congeners. Also, protein tyrosine kinase inhibition is an additional mechanistic benefit of LF, which inhibits immunological events such as cellular expansion and immunoglobulin production with an enhanced release of immunosuppressant cytokines. LF is approved for the treatment of autoimmune arthritis of rheumatoid and psoriatic pathogenesis. Also, LF has been used off-label for the treatment of relapsing-remitting multiple sclerosis. However, LF antiviral activity is repurposed and under investigation with related compounds under a phase-I trial as a SARS CoV-2 antiviral in cases with COVID-19. Despite success in improving patients' mobility and reducing joint destruction, reported events of LF-induced liver injury necessitated regulatory precautions. LF should not be used in patients with hepatic impairment or in combination with drugs elaborating a burden on the liver without regular monitoring of liver enzymes and serum bilirubin as safety biomarkers. This study aims to review the pharmacological and safety profile of LF with a focus on the LF-induced hepatic injury from the perspective of pathophysiology and possible protective agents.

Nerolidol protects the liver against cyclophosphamide-induced hepatic inflammation, apoptosis, and fibrosis via modulation of Nrf2, NF-κB p65, and caspase-3 signaling molecules in Swiss albino mice

Cyclophosphamide (CP)-induced hepatotoxic manifestations are major concern for patients undergoing chemotherapy, which often limit its therapeutic utility. Nerolidol (NER) is a natural bioactive molecule having potent gonadoprotective, neuroprotective, and cardioprotective properties but has not been explored for its hepatoprotective effect and underlying mechanism. Therefore, in the current study hepatoprotective potential of nerolidol was studied in CP-induced hepatic oxidative stress, inflammation, apoptosis, and fibrosis via modulation of Nrf2, NF-κB p65, caspase-3, TGF-β1, and associated biochemical status in Swiss albino mice. NER (200, 400 mg/kg, p.o) and fenofibrate (FF) 80 mg/kg, p.o. were administered from first to fourteenth day and CP was administered at the dose of 200 mg/kg, i.p on seventh day. On fifteenth day, animals were sacrificed and estimation of oxidative stress, inflammation, apoptosis, fibrosis, histopathology (H E and MT staining), and immunohistochemistry was performed in the liver tissue. Administration of NER effectively normalized the elevated level of hepatic injury markers (alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase), marker of oxidative stress that is, malondialdehyde, inflammatory cytokines (TNF-α, IL-6, IL-1β, and IL-10), NF-κB p65, apoptotic marker (cleaved caspase 3) and increased the level of Nrf2 and antioxidant enzymes (superoxide dismutase, CAT, and glutathione). Treatment with NER further reduced the structural damage of hepatocytes and markers of hepatic fibrosis such as TGF-β1, hyaluronic acid, 4-hydroxyproline and collagen-rich stained area, estimated by MT staining. Findings of the current study showed that nerolidol exhibited potent antioxidant, anti-inflammatory, anti-apoptotic, and anti-fibrotic potential and thus acted as hepatoprotective agent. Present study represents novel mechanism of nerolidol against CP-induced hepatotoxicity. However, further studies are needed to use nerolidol as an adjuvant in chemotherapeutically treated patients.

Severe and prolonged cyclophosphamide-induced hepatotoxicity in a breast cancer patient carrying a CYP2B6*7 variant

As a widely used alkylating agent, cyclophosphamide often leads to various toxicities. Severe hepatotoxicity has been rarely reported in breast cancer patients receiving chemotherapy containing cyclophosphamide. Differences in cyclophosphamide metabolism may contribute to variability in adverse events of patients. Here, we report on a case of a 68-year-old Chinese female with breast cancer who experienced severe and prolonged hepatotoxicity induced by cyclophosphamide. Pharmacogenetic tests showed that she was a carrier of CYP2B6*7 allele and this is the first case of a CYP2B6*7 variant in the Han Chinese population so far reported. In addition, the patient was also a carrier of an ALDH3A1*2 variant potentially contributing to the occurrence of hepatotoxicity. CYP2B6 and ALDH3A1 genotyping may play a role in guiding cyclophosphamide therapy.