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Amidžić M, Banović Fuentes J, Banović J, Torović L. Notifications and Health Consequences of Unauthorized Pharmaceuticals in Food Supplements. PHARMACY 2023; 11:154. [PMID: 37888499 PMCID: PMC10609884 DOI: 10.3390/pharmacy11050154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/17/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023] Open
Abstract
Health concerns associated with the consumption of food supplements rise in parallel with the rise in the popularity and market availability of these products. In pursuit of data related to the unauthorized presence of pharmaceuticals in food supplements, the Rapid Alert System for Food and Feed (RASFF) database was searched for the 2011-2022 period. The most "popular" pharmaceuticals for the adulteration of food supplements were phosphodiesterase-5 inhibitors (235 records); anorexics and laxatives (76), including sibutramine and its active metabolite N-didesmethyl sibutramine, phenolphthalein and 2,4-dinitrophenol; stimulants, among which 1,3-dimethylamine (97), and synephrine (53) were the most numerous; nootropic drugs (24); anabolics and prohormones (16); and cannabinoid cannabidiol (14) (pending authorization as a novel food ingredient). Over 65% of notifications of interest were classified as serious risks, and over 80% of these were alert or border rejection notifications, mainly generated as a result of official control on the market. The alarming number of RASFF notifications should be considered a public health issue, demanding clear and targeted recommendation for action for the legislature and authorities. A harmonized nutrivigilance system should be considered as a tool to detect and scrutinize the adverse health effects of food supplements, along with measures to improve their safety, quality, and testing.
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Affiliation(s)
- Maja Amidžić
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (M.A.); (J.B.F.)
| | - Jelena Banović Fuentes
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (M.A.); (J.B.F.)
| | - Jovica Banović
- Department of Internal Medicine, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia;
| | - Ljilja Torović
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (M.A.); (J.B.F.)
- Center for Medical and Pharmaceutical Investigations and Quality Control, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia
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Gurley BJ, McGill MR, Koturbash I. Hepatotoxicity due to herbal dietary supplements: Past, present and the future. Food Chem Toxicol 2022; 169:113445. [PMID: 36183923 DOI: 10.1016/j.fct.2022.113445] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/20/2022] [Accepted: 09/23/2022] [Indexed: 11/26/2022]
Abstract
Dietary supplements (DS) constitute a widely used group of products comprising vitamin, mineral, and botanical extract formulations. DS of botanical or herbal origins (HDS) comprise nearly 30% of all DS and are presented on the market either as single plant extracts or multi-extract-containing products. Despite generally safe toxicological profiles of most products currently present on the market, rising cases of liver injury caused by HDS - mostly by multi-ingredient and adulterated products - are of particular concern. Here we discuss the most prominent historical cases of HDS-induced hepatotoxicty - from Ephedra to Hydroxycut and OxyELITE Pro-NF, as well as products with suspected hepatotoxicity that are either currently on or are entering the market. We further provide discussion on overcoming the existing challenges with HDS-linked hepatotoxicity by introduction of advanced in silico, in vitro, in vivo, and microphysiological system approaches to address the matter of safety of those products before they reach the market.
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Affiliation(s)
- Bill J Gurley
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Mitchell R McGill
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Igor Koturbash
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
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Rao A, Rule JA, Hameed B, Ganger D, Fontana RJ, Lee WM. Secular Trends in Severe Idiosyncratic Drug-Induced Liver Injury in North America: An Update From the Acute Liver Failure Study Group Registry. Am J Gastroenterol 2022; 117:617-626. [PMID: 35081550 PMCID: PMC10668505 DOI: 10.14309/ajg.0000000000001655] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Idiosyncratic drug-induced liver injury (DILI) is the second leading cause of acute liver failure (ALF) in the United States. Our study aims were to characterize secular trends in the implicated agents, clinical features, and outcomes of adults with DILI ALF over a 20-year period. METHODS Among 2,332 patients with ALF enrolled in the ALF Study Group registry, 277 (11.9%) were adjudicated as idiosyncratic DILI ALF (INR ≥ 1.5 and hepatic encephalopathy) through expert opinion. The 155 cases in era 1 (January 20, 1998-January 20, 2008) were compared with the 122 cases in era 2 (January 21, 2008-January 20, 2018). RESULTS Among 277 cases of DILI ALF, 97 different agents, alone or in combination, were implicated: antimicrobials, n = 118 (43%); herbal/dietary supplements (HDS), n = 42 (15%); central nervous system agents/illicit substances, n = 37 (13%); oncologic/biologic agents, n = 29 (10%); and other, n = 51 (18%). Significant trends over time included (i) an increase in HDS DILI ALF (9.7% vs 22%, P < 0.01) and decrease in antimicrobial-induced DILI ALF (45.8% vs. 38.5%, P = 0.03) and (ii) improved overall transplant-free survival (23.5%-38.7%, P < 0.01) while the number of patients transplanted declined (46.4% vs 33.6%, P < 0.03). DISCUSSION DILI ALF in North America is evolving, with HDS cases rising and other categories of suspect drugs declining. The reasons for a significant increase in transplant-free survival and reduced need for liver transplantation over time remain unclear but may be due to improvements in critical care, increased NAC utilization, and improved patient prognostication.
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Affiliation(s)
- Ashwin Rao
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jody A. Rule
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Daniel Ganger
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA
| | - Robert J. Fontana
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - William M. Lee
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Lua PL, Roslim NA, Ahmad A, Mansor M, Aung MMT, Hamzah F. Complementary and Alternative Therapies for Weight Loss: A Narrative Review. J Evid Based Integr Med 2021; 26:2515690X211043738. [PMID: 34496677 PMCID: PMC8436299 DOI: 10.1177/2515690x211043738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Despite various strategies, overweight and obesity problems are still increasingly prevalent worldwide with serious health outcomes. Consequently, the continuous demand for more effective, safe and acceptable therapies for reducing body weight is also escalating—including complementary and alternative therapies (CATs). The aim of this review is to provide a summary of the most commonly- and recently-used CATs, with evaluation of their safety and efficacy for weight loss. Electronic scientific databases such as Scopus, PubMed and EBSCO Host were explored for articles that reported CATs for overweight and obesity treatment from 2015 to December 2019. Only systematic reviews, meta-analysis and randomized controlled trials (RCTs) published in English were included. Studies whereby CATs were not utilized for reducing body weight were excluded. Eight systematic reviews and meta-analyses and 11 additional RCTs with 765 participants (50.2% overweight and 49.8% obese) related to hypnotherapy, acupuncture and dietary supplements met the inclusion criteria. Their results suggested that spirulina, chitosan, probiotic, EPA + DHA, vitamin D, fiber, and herbal extract supplementation may all provide small reductions in body weight (ranging from 1-10 kg). Interestingly, hypnotherapy and acupuncture reported significantly greater reduction in body weight compared with placebo (p < 0.001 and p < 0.0001, respectively). Nonetheless, the evidence is still relatively limited and not encouraging to provide a definitive conclusion due to the methodological shortcomings and the presence of adverse events in chitosan and fiber supplementation. Hence, studies of this nature need to be further replicated and improved to corroborate the efficacy and safety of the CATs to combat weight issues.
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Affiliation(s)
- Pei Lin Lua
- Faculty of Pharmacy, Universiti Sultan Zainal Abidin (UniSZA), Terengganu, Malaysia
| | - Nurul Afiedia Roslim
- Faculty of Pharmacy, Universiti Sultan Zainal Abidin (UniSZA), Terengganu, Malaysia
| | - Aryati Ahmad
- Faculty of Health Sciences, Universiti Sultan Zainal Abidin (UniSZA), Terengganu, Malaysia
| | - Mardiana Mansor
- Faculty of Medicine, Universiti Sultan Zainal Abidin (UniSZA), Terengganu, Malaysia
| | - Myat Moe Thwe Aung
- Faculty of Medicine, Universiti Sultan Zainal Abidin (UniSZA), Terengganu, Malaysia
| | - Farrahdilla Hamzah
- Faculty of Medicine, Universiti Sultan Zainal Abidin (UniSZA), Terengganu, Malaysia
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ACG Clinical Guideline: Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury. Am J Gastroenterol 2021; 116:878-898. [PMID: 33929376 DOI: 10.14309/ajg.0000000000001259] [Citation(s) in RCA: 129] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/25/2021] [Indexed: 12/11/2022]
Abstract
Idiosyncratic drug-induced liver injury (DILI) is common in gastroenterology and hepatology practices, and it can have multiple presentations, ranging from asymptomatic elevations in liver biochemistries to hepatocellular or cholestatic jaundice, liver failure, or chronic hepatitis. Antimicrobials, herbal and dietary supplements, and anticancer therapeutics (e.g., tyrosine kinase inhibitors or immune-checkpoint inhibitors) are the most common classes of agents to cause DILI in the Western world. DILI is a diagnosis of exclusion, and thus, careful assessment for other etiologies of liver disease should be undertaken before establishing a diagnosis of DILI. Model for end-stage liver disease score and comorbidity burden are important determinants of mortality in patients presenting with suspected DILI. DILI carries a mortality rate up to 10% when hepatocellular jaundice is present. Patients with DILI who develop progressive jaundice with or without coagulopathy should be referred to a tertiary care center for specialized care, including consideration for potential liver transplantation. The role of systemic corticosteroids is controversial, but they may be administered when a liver injury event cannot be distinguished between autoimmune hepatitis or DILI or when a DILI event presents with prominent autoimmune hepatitis features.
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Tian M, Zhou S, Li W, Li J, Yang L, Peng Y, Zheng J. Metabolic Activation of Aegeline Mediated by CYP2C19. Xenobiotica 2021; 51:1217-1228. [PMID: 33892609 DOI: 10.1080/00498254.2021.1913666] [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: 10/21/2022]
Abstract
1. Aegeline (AGL) is a natural alkaloidal amide mainly isolated from the leaves and fruits of tropical plant Aegle marmelos, with multiple pharmacological activities.2. As one component of several dietary supplements, AGL caused a series of acute and chronic liver injuries. Nevertheless, the mechanisms of AGL-induced hepatotoxicity remain unclear. This study was conducted to identify reactive metabolite(s), to determine related metabolic pathways, and define the possible association of the bioactivation with AGL cytotoxicity.3. A demethylation metabolite (M1) and a GSH conjugate (M2) were detected in rat liver microsomal incubations containing AGL and GSH. The two metabolites were both found in bile of rats and rat primary hepatocytes after AGL administration.4. Recombinant P450 enzyme incubations showed that CYP2C19 was the principal enzyme catalyzing this metabolic activation.5. Ticlopidine, a selective inhibitor of CYP2C19, decreased the formation of M1 and M2 in hepatocytes and attenuated the susceptibility of hepatocytes to the cytotoxicity of AGL. The results suggest that AGL was metabolized to a p-quinone methide intermediate which could in part participate in AGL-induced cytotoxicity.
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Affiliation(s)
- Min Tian
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P. R. China
| | - Shenzhi Zhou
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P. R. China
| | - Wei Li
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P. R. China
| | - Jiaru Li
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P. R. China
| | - Lan Yang
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P. R. China
| | - Ying Peng
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P. R. China
| | - Jiang Zheng
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P. R. China.,State Key Laboratory of Functions and Applications of Medicinal Plants, Key Laboratory of Pharmaceutics of Guizhou Province, Guizhou Medical University, Guiyang, Guizhou 550025, P. R. China.,Key Laboratory of Environmental Pollution, Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, Guizhou 550025, P. R. China
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Ferreira GDSA, Watanabe ALC, Trevizoli NDC, Jorge FMF, Diaz LGG, Couto CDF, Lima LVD, Raupp DRL, Araujo BED. Acute Liver Failure Caused by Use of Fat Burner: A Case Report. Transplant Proc 2020; 52:1409-1412. [PMID: 32192741 DOI: 10.1016/j.transproceed.2020.01.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 01/10/2020] [Indexed: 02/07/2023]
Abstract
Acute liver failure is a rare condition consisting of abrupt and extensive hepatocyte injury, leading to significant liver dysfunction associated with a high mortality. Liver transplantation is the most effective treatment in severe cases. The most common cause of acute liver failure in Western countries is drug-induced liver injury caused by prescription drugs and herbal and dietary supplements. Thermogenics, or fat burners, are a category of dietary supplements that claim to increase the resting metabolic rate, leading to weight loss. There are previous reports of acute liver failure associated with specific thermogenic formulations. We report the case of a 36-year-old male patient who developed jaundice 7 days after he started taking a thermogenic dietary supplement (Thermo Gun), with progressive deterioration of hepatic function and development of hepatic encephalopathy 19 days after the beginning of the symptoms. He had a Model for End-Stage Liver Disease score of 38 and fulfilled 4 of the King's College Criteria for poor prognosis in patients with acute liver failure. He underwent liver transplantation, receiving a graft from a cadaveric donor, and is alive with good liver graft function 2 years after the transplant. No possible causes for acute liver injury were identified other than the use of the supplement, which contained N-acetyl-L-tyrosine; 1,3,7-trimenthylxanthine; white willow; and 1-hydroxypholedrine. We found no previous reports in the literature of acute liver failure associated with those particular substances. This manuscript is compliant with the Helsinki Congress and the Istanbul Declaration.
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Abstract
PURPOSE OF REVIEW Drug-induced liver injury (DILI) can be induced by a myriad of drugs. Assessing whether the patient has DILI and assessing which drug is the most likely culprit are challenging. There has been too little attention paid to the concept that certain drugs appear to have unique clinical features or 'phenotypes'. RECENT FINDINGS Several case series of DILI because of various drugs have been published, and analysis of these case series points to the fact that individual drugs have characteristic DILI signatures. These clinical phenotypes can be characterized by latency, biochemical features (R-value), as well as clinical symptoms and signs. Several drugs, including isoniazid, amoxicillin-clavulanic acid, anabolic steroids, β-interferon and others, have highly unique clinical features. Such unique properties may be able to be used to improve adjudication processes. SUMMARY Individual drugs have unique clinical DILI phenotypes or signatures. Furthermore, these may be able to be used to improve adjudication.
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Affiliation(s)
- Hans L. Tillmann
- Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition, East Carolina University, Greenville, NC
- Greenville VA Health Care Center, Greenville, NC
| | - Don C. Rockey
- Department of Medicine, Medical University South Carolina, Charleston, SC
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Vilas-Boas V, Gijbels E, Jonckheer J, De Waele E, Vinken M. Cholestatic liver injury induced by food additives, dietary supplements and parenteral nutrition. ENVIRONMENT INTERNATIONAL 2020; 136:105422. [PMID: 31884416 DOI: 10.1016/j.envint.2019.105422] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/05/2019] [Accepted: 12/13/2019] [Indexed: 06/10/2023]
Abstract
Cholestasis refers to the accumulation of toxic levels of bile acids in the liver due to defective bile secretion. This pathological situation can be triggered by drugs, but also by ingredients contained in food, food supplements and parenteral nutrition. This paper provides an overview of the current knowledge on cholestatic injury associated with such ingredients, with particular emphasis on the underlying mechanisms of toxicity.
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Affiliation(s)
- Vânia Vilas-Boas
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Eva Gijbels
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Joop Jonckheer
- Department of Intensive Care, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Elisabeth De Waele
- Department of Intensive Care, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Mathieu Vinken
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium.
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Mosedale M, Watkins PB. Understanding Idiosyncratic Toxicity: Lessons Learned from Drug-Induced Liver Injury. J Med Chem 2020; 63:6436-6461. [PMID: 32037821 DOI: 10.1021/acs.jmedchem.9b01297] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Idiosyncratic adverse drug reactions (IADRs) encompass a diverse group of toxicities that can vary by drug and patient. The complex and unpredictable nature of IADRs combined with the fact that they are rare makes them particularly difficult to predict, diagnose, and treat. Common clinical characteristics, the identification of human leukocyte antigen risk alleles, and drug-induced proliferation of lymphocytes isolated from patients support a role for the adaptive immune system in the pathogenesis of IADRs. Significant evidence also suggests a requirement for direct, drug-induced stress, neoantigen formation, and stimulation of an innate response, which can be influenced by properties intrinsic to both the drug and the patient. This Perspective will provide an overview of the clinical profile, mechanisms, and risk factors underlying IADRs as well as new approaches to study these reactions, focusing on idiosyncratic drug-induced liver injury.
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Affiliation(s)
- Merrie Mosedale
- Institute for Drug Safety Sciences and Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina 27599, United States
| | - Paul B Watkins
- Institute for Drug Safety Sciences and Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina 27599, United States
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Grewal P, Ahmad J. Severe liver injury due to herbal and dietary supplements and the role of liver transplantation. World J Gastroenterol 2019; 25:6704-6712. [PMID: 31857773 PMCID: PMC6920659 DOI: 10.3748/wjg.v25.i46.6704] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/26/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023] Open
Abstract
Herbal and dietary supplements (HDS) are increasingly used worldwide for numerous, mainly unproven health benefits. The HDS industry is poorly regulated compared to prescription medicines and most products are easily obtainable. Drug induced liver injury (DILI) is a well-recognized entity associated with prescription and over the counter medications and many reports have emerged of potential HDS-related DILI. There is considerable geographic variability in the risk and severity of DILI associated with HDS but the presentation of severe liver injury is similar with a hepatocellular pattern accompanied by jaundice. This type of injury can lead to acute liver failure and the need for liver transplantation. Patients will often fail to mention their use of HDS, considering it natural and therefore harmless. Hence physicians should understand that these products can be associated with DILI and explicitly ask about HDS use in any patient with otherwise unexplained acute liver injury.
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Affiliation(s)
- Priya Grewal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Jawad Ahmad
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
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12
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Fontana RJ. Severe Acute Hepatitis Attributed to the Herbal and Dietary Supplement OxyELITE Pro. Clin Liver Dis (Hoboken) 2019; 14:45-48. [PMID: 31508218 PMCID: PMC6726377 DOI: 10.1002/cld.809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/15/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology, Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMI
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Teschke R. Top-ranking drugs out of 3312 drug-induced liver injury cases evaluated by the Roussel Uclaf Causality Assessment Method. Expert Opin Drug Metab Toxicol 2018; 14:1169-1187. [PMID: 30354694 DOI: 10.1080/17425255.2018.1539077] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION A list presenting a valid ranking of drugs most commonly implicated is hardly to be found. Areas covered: Published cases of drug-induced liver injury (DILI) with verified causality using RUCAM (Roussel Uclaf Causality Assessment Method) were used for a ranking of drugs most commonly implicated in causing DILI. Expert opinion: RUCAM-based DILI cases were retrieved from 15 reports published by six international databases of DILI registries and three large medical centers, which provided 3312 cases. Overall 48 drugs with the highest number of DILI cases were listed. Among the top 10 ranking drugs implicated in causing DILI were, in decreasing order: amoxicillin-clavulanate, flucloxacilllin, atorvastatin, disulfiram, diclofenac, simvastatin, carbamazepine, ibuprofen, erythromycin, and anabolic steroids as bodybuilding agents. For these 10 drugs, respective DILI case numbers were highest for Amoxicillin-clavulanate (n=333) and lowest for anabolic steroids (n=26). The author classifies the databases of national DILI registries and large medical centers as best sources of drugs implicated in DILI. Presently discouraged is the use of the LiverTox website because many cases were derived from published cases of poor quality and could previously not be classified as DILI, calling for the inclusion of DILI cases with established causality by the updated RUCAM.
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Affiliation(s)
- Rolf Teschke
- a Department of Internal Medicine II, Division of Gastroenterology and Hepatology , Klinikum Hanau , Hanau , Germany.,b Academic Teaching Hospital of the Medical Faculty , Goethe University Frankfurt/Main , Frankfurt/Main , Germany
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Skinner CM, Miousse IR, Ewing LE, Sridharan V, Cao M, Lin H, Williams DK, Avula B, Haider S, Chittiboyina AG, Khan IA, ElSohly MA, Boerma M, Gurley BJ, Koturbash I. Impact of obesity on the toxicity of a multi-ingredient dietary supplement, OxyELITE Pro™ (New Formula), using the novel NZO/HILtJ obese mouse model: Physiological and mechanistic assessments. Food Chem Toxicol 2018; 122:21-32. [PMID: 30282009 DOI: 10.1016/j.fct.2018.09.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/18/2018] [Accepted: 09/28/2018] [Indexed: 02/07/2023]
Abstract
Herbal dietary supplement (HDS)-induced hepato- and cardiotoxicity is an emerging clinical problem. In this study, we investigated the liver and heart toxicity of HDS OxyELITE-PRO™ New Formula (OEP-NF), a dietary supplement marketed for weight loss and performance enhancement that was recently withdrawn from the market. Using a novel NZO/HlLtJ obese mouse model, we demonstrated that administration of clinically relevant mouse equivalent doses (MED) of OEP-NF produced cardio- and hepatotoxic risks following both short- and long-term administration schedules. Specifically, gavaging female NZO/HlLtJ with up to 2X MED of OEP-NF resulted in 40% mortality within two weeks. Feeding mice with either 1X or 3X MED of OEP-NF for eight weeks, while not exhibiting significant effects on body weights, significantly altered hepatic gene expression, increased the number of apoptotic and mast cells in the heart and affected cardiac function. The degree of toxicity in NZO/HlLtJ mice was higher than that observed previously in non-obese CD-1 and B6C3F1 strains, suggesting that an overweight/obese condition can sensitize mice to OEP-NF. Adverse health effects linked to OEP-NF, together with a number of other hepato- and cardiotoxicity cases associated with HDS ingestion, argue strongly for introduction of quality standards and pre-marketing safety assessments for multi-ingredient HDS.
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Affiliation(s)
- Charles M Skinner
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Isabelle R Miousse
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Laura E Ewing
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Vijayalakshmi Sridharan
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, 72223, USA.
| | - Maohua Cao
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, 72223, USA.
| | - Haixia Lin
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - D Keith Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Bharathi Avula
- National Center for Natural Product Research, School of Pharmacy, University of Mississippi, University, MS, 38677, USA.
| | - Saqlain Haider
- National Center for Natural Product Research, School of Pharmacy, University of Mississippi, University, MS, 38677, USA.
| | - Amar G Chittiboyina
- National Center for Natural Product Research, School of Pharmacy, University of Mississippi, University, MS, 38677, USA.
| | - Ikhlas A Khan
- National Center for Natural Product Research, School of Pharmacy, University of Mississippi, University, MS, 38677, USA.
| | - Mahmoud A ElSohly
- ElSohly Laboratories, Inc. (ELI), Phyto Chemical Services, Inc. (PSI), 5 Industrial Park Drive, Oxford, MS 38655, USA.
| | - Marjan Boerma
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, 72223, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Bill J Gurley
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, 72223, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Igor Koturbash
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
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15
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Gurley BJ, Yates CR, Markowitz JS. “…Not Intended to Diagnose, Treat, Cure or Prevent Any Disease.” 25 Years of Botanical Dietary Supplement Research and the Lessons Learned. Clin Pharmacol Ther 2018; 104:470-483. [DOI: 10.1002/cpt.1131] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/23/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Bill J. Gurley
- Department of Pharmaceutical Sciences; College of Pharmacy; University of Arkansas for Medical Sciences; Little Rock Arkansas USA
| | - Charles R. Yates
- Department of Pharmaceutical Sciences; College of Pharmacy; University of Tennessee Health Science Center; Memphis Tennessee USA
| | - John S. Markowitz
- Department of Pharmacotherapy and Translational Research; College of Pharmacy; University of Florida; Gainesville Florida USA
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16
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Roytman MM, Poerzgen P, Navarro V. Botanicals and Hepatotoxicity. Clin Pharmacol Ther 2018; 104:458-469. [DOI: 10.1002/cpt.1097] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 01/06/2023]
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Abstract
Drug-induced liver injury (DILI) is constantly changing as new drugs are approved and as new herbals and dietary supplements (HDS) reach the market. The pathologist plays a key role in the evaluation of DILI by classifying and interpreting the histologic findings considering patients' medical history and drug exposure. The liver biopsy findings may suggest alternative explanations of the injury and additional testing that should be performed to exclude non-DILI causes. Recent reports of iatrogenic liver injury are reviewed with attention to immunomodulatory and antineoplastic agents as well as reports of injury associated with HDS use.
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Affiliation(s)
- David E Kleiner
- Laboratory of Pathology, National Cancer Institute, 10 Center Drive, Building 10, Room 2S235, MSC1500, Bethesda, MD 20892, USA.
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18
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Dakhoul L, Ghabril M, Gu J, Navarro V, Chalasani N, Serrano J. Heavy Consumption of Alcohol is Not Associated With Worse Outcomes in Patients With Idiosyncratic Drug-induced Liver Injury Compared to Non-Drinkers. Clin Gastroenterol Hepatol 2018; 16:722-729.e2. [PMID: 29306044 PMCID: PMC5911195 DOI: 10.1016/j.cgh.2017.12.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS The relationship between alcohol consumption and idiosyncratic drug-induced liver injury (DILI) is not well understood. We investigated the relationship between heavy consumption of alcohol and characteristics and outcomes of patients with DILI enrolled in the Drug-induced Liver Injury Network (DILIN) prospective study. METHODS We collected data from 1198 individuals with definite, highly likely, or probable DILI enrolled in the DILIN study from September 2004 through April 2016. At enrollment, all participants were asked about alcohol consumption; those with any alcohol consumption during previous 12 months were asked to complete the Skinner questionnaire to assess drinking history. Heavy consumption of alcohol was defined as more than 3 drinks, on average, per day by men or more than 2 drinks, on average, per day by women. RESULTS Of the 601 persons who reported consuming at least 1 alcoholic drink in the preceding 12 months, 348 completed the Skinner questionnaire and 80 reported heavy consumption of alcohol. Heavy drinkers were younger (average age, 42 years) than non-drinkers (average age, 49 years) and a higher proportion were men (63% of heavy drinkers vs 35% of nondrinkers) (P < .01 for each comparison). Anabolic steroids were the most common cause of DILI among heavy drinkers (in 13% vs 2% in non-drinkers) (P < .001). Heavy drinkers had significantly higher peak serum levels of alanine aminotransferase (1323 U/L) than non-drinkers (754 U/L) (P = .02) and higher levels of bilirubin (16.1 mg/dL vs 12.7 mg/dL in non-drinkers) (P = .03) but there was no significant difference in liver-related death or liver transplantation between heavy drinkers (occurred in 10%) vs non-drinkers (occurred in 6%) (P = .18). CONCLUSION In an analysis of data from the DILIN, we found anabolic steroids to be the most common cause of DILI in individuals who are heavy consumers of alcohol. Compared to non-drinkers, DILI was not associated with a greater proportion of liver-related deaths or liver transplantation in heavy drinkers.
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Affiliation(s)
- Lara Dakhoul
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Marwan Ghabril
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Jiezhun Gu
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Naga Chalasani
- Indiana University School of Medicine, Indianapolis, Indiana.
| | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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20
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Tujios SR, Lee WM. Acute liver failure induced by idiosyncratic reaction to drugs: Challenges in diagnosis and therapy. Liver Int 2018; 38:6-14. [PMID: 28771932 PMCID: PMC5741491 DOI: 10.1111/liv.13535] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/27/2017] [Indexed: 12/11/2022]
Abstract
Acute liver failure (ALF) requires urgent attention to identify etiology and determine prognosis, in order to assess likelihood of survival or need for transplantation. Identifying idiosyncratic drug-induced liver injury (iDILI) may be particularly difficult, but the illness generally follows a subacute course, allowing time to assess outcome and find a liver graft if needed. Not all drugs that cause iDILI lead to ALF; the most common are antibiotics including anti-tuberculous medications, non-steroidal anti-inflammatory agents and herbal and dietary supplements (HDS). Determining causality remains challenging particularly if altered mentation is present; identifying the causative agent depends in part on knowing the propensity of the drugs that have been taken in the proper time interval, plus excluding other causes. In general, iDILI that reaches the threshold of ALF will more often than not require transplantation, since survival without transplant is around 25%. Treatment consists of withdrawal of the presumed offending medication, consideration of N-acetylcysteine (NAC), as well as intensive care. Corticosteroids have not proven useful except perhaps in instances of apparent autoimmune hepatitis caused by a limited number of agents. Recently developed prognostic scoring systems may also aid in predicting outcome in this setting.
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Affiliation(s)
- Shannan R Tujios
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
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21
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Abstract
Over 70% of Americans take some form of dietary supplement every day, and the supplement industry is currently big business, with a gross of over $28 billion. However, unlike either foods or drugs, supplements do not need to be registered or approved by the US Food and Drug Administration (FDA) prior to production or sales. Under the Dietary Supplement Health and Education Act of 1994, the FDA is restricted to adverse report monitoring postmarketing. Despite widespread consumption, there is limited evidence of health benefits related to nutraceutical or supplement use in well-nourished adults. In contrast, a small number of these products have the potential to produce significant toxicity. In addition, patients often do not disclose supplement use to their physicians. Therefore, the risk of adverse drug-supplement interactions is significant. An overview of the major supplement and nutraceutical classes is presented here, together with known toxic effects and the potential for drug interactions.
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Affiliation(s)
- Martin J J Ronis
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70112, USA; , ,
| | - Kim B Pedersen
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70112, USA; , ,
| | - James Watt
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70112, USA; , ,
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22
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Shahbaz O, Mahajan S, Lewis JH. Highlights of drug - and herb- induced liver injury in the literature from 2016: how best to translate new information into clinical practice? Expert Opin Drug Metab Toxicol 2017; 13:935-951. [PMID: 28772086 DOI: 10.1080/17425255.2017.1362391] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Over 1500 papers on drug-induced liver injury (DILI) and herb-induced liver injury (HILI) were published in 2016, many of which have the potential to impact clinical practice. Areas covered: Clinical studies and case series that lent themselves to new concepts in diagnosing, and treating DILI were selected for inclusion. Epidemiology of DILI in large prospective registries was highlighted. Causality assessment of drug hepatotoxicity remains challenging, as seen with cases of OxyELITE Pro (OEP). In 2016 updates to the Roussel Uclaf Causality Assessment Method (RUCAM) were published to aid in the accuracy of diagnosing DILI/HILI. New reports of established hepatotoxins were again discussed in 2016, including genetic risk factors for DILI with respect to antituberculous agents. Expert opinion: 2016 marked a turning point in how much credence should be placed in the current causality assessment for DILI/HILI cases. Many recognized hepatotoxins are backed by a relatively few number of literature reports. Danan and Teschke make a strong case that an updated RUCAM should remain the gold standard for diagnosing DILI/HILI going forward, although the role of expert opinion is often still needed in cases where RUCAM falls short. The field of chemoinformatics continues to evolve while we await a truly predictive and diagnostic DILI biomarker.
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Affiliation(s)
- Omar Shahbaz
- a Department of Medicine, Division of Gastroenterology, Hepatology Section , Georgetown University Hospital , Washington , DC , USA
| | - Sandeep Mahajan
- a Department of Medicine, Division of Gastroenterology, Hepatology Section , Georgetown University Hospital , Washington , DC , USA
| | - James H Lewis
- a Department of Medicine, Division of Gastroenterology, Hepatology Section , Georgetown University Hospital , Washington , DC , USA
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23
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Miousse IR, Skinner CM, Lin H, Ewing LE, Kosanke SD, Williams DK, Avula B, Khan IA, ElSohly MA, Gurley BJ, Koturbash I. Safety assessment of the dietary supplement OxyELITE™ Pro (New Formula) in inbred and outbred mouse strains. Food Chem Toxicol 2017; 109:194-209. [PMID: 28843594 DOI: 10.1016/j.fct.2017.08.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/18/2017] [Accepted: 08/20/2017] [Indexed: 12/12/2022]
Abstract
Herbal dietary supplements have gained wide acceptance as alternatives to conventional therapeutic agents despite concerns regarding their efficacy and safety. In 2013, a spate of severe liver injuries across the United States was linked to the dietary supplement OxyELITE Pro-New Formula (OEP-NF), a multi-ingredient product marketed for weight loss and exercise performance enhancement. The principal goal of this study was to assess the hepatotoxic potential of OEP-NF in outbred and inbred mouse models. In an acute toxicity study, significant mortality was observed after administering 10X and 3X mouse-equivalent doses (MED) of OEP-NF, respectively. Increases in liver/body weight ratio, ALT and AST were observed in female B6C3F1 mice after gavaging 2X and 1.5X MED of OEP-NF. Similar findings were observed in a 90-day feeding study. These alterations were paralleled by altered expression of gene- and microRNA-signatures of hepatotoxicity, including Cd36, Nqo1, Aldoa, Txnrd1, Scd1 and Ccng1, as well as miR-192, miR-193a and miR-125b and were most pronounced in female B6C3F1 mice. Body weight loss, observed at week 1, was followed by weight gain throughout the feeding studies. These findings bolster safety and efficacy concerns for OEP-NF, and argue strongly for implementation of pre-market toxicity studies within the dietary supplement industry.
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Affiliation(s)
- Isabelle R Miousse
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Charles M Skinner
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Haixia Lin
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Laura E Ewing
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Stanley D Kosanke
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; Heartland Veterinary Pathology Services, PLLC, Oklahoma City, OK, USA.
| | - D Keith Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Bharathi Avula
- National Center for Natural Product Research, School of Pharmacy, University of Mississippi, University, MS 38677, USA.
| | - Ikhlas A Khan
- National Center for Natural Product Research, School of Pharmacy, University of Mississippi, University, MS 38677, USA.
| | - Mahmoud A ElSohly
- ElSohly Laboratories, Inc. (ELI) and Phyto Chemical Services, Inc. (PSI), 5 Industrial Park Drive, Oxford, MS 38655, USA.
| | - Bill J Gurley
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR 72223, USA.
| | - Igor Koturbash
- Department of Environmental and Occupational Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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Teschke R, Eickhoff A. Suspected Liver Injury and the Dilemma of Causality. Dig Dis Sci 2017; 62:1095-1098. [PMID: 28210906 DOI: 10.1007/s10620-016-4442-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/30/2016] [Indexed: 12/12/2022]
Abstract
For causality assessment in cases of suspected liver injury, RUCAM provides objective and transparent results and should be the preferred tool rather than the DILIN method, which is based on subjective opinion.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Hanau, Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, Leimenstrasse 20, 63450, Hanau, Germany.
| | - Axel Eickhoff
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Hanau, Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, Leimenstrasse 20, 63450, Hanau, Germany
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25
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Navarro VJ, Khan I, Björnsson E, Seeff LB, Serrano J, Hoofnagle JH. Liver injury from herbal and dietary supplements. Hepatology 2017; 65:363-373. [PMID: 27677775 PMCID: PMC5502701 DOI: 10.1002/hep.28813] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/30/2016] [Accepted: 08/02/2016] [Indexed: 12/14/2022]
Abstract
Herbal and dietary supplements (HDS) are used increasingly both in the United States and worldwide, and HDS-induced liver injury in the United States has increased proportionally. Current challenges in the diagnosis and management of HDS-induced liver injury were the focus of a 2-day research symposium sponsored by the American Association for the Study of Liver Disease and the National Institutes of Health. HDS-induced liver injury now accounts for 20% of cases of hepatotoxicity in the United States based on research data. The major implicated agents include anabolic steroids, green tea extract, and multi-ingredient nutritional supplements. Anabolic steroids marketed as bodybuilding supplements typically induce a prolonged cholestatic but ultimately self-limiting liver injury that has a distinctive serum biochemical as well as histological phenotype. Green tea extract and many other products, in contrast, tend to cause an acute hepatitis-like injury. Currently, however, the majority of cases of HDS-associated liver injury are due to multi-ingredient nutritional supplements, and the component responsible for the toxicity is usually unknown or can only be suspected. HDS-induced liver injury presents many clinical and research challenges in diagnosis, identification of the responsible constituents, treatment, and prevention. Also important are improvements in regulatory oversight of nonprescription products to guarantee their constituents and ensure purity and safety. The confident identification of injurious ingredients within HDS will require strategic alignments among clinicians, chemists, and toxicologists. The ultimate goal should be to prohibit or more closely regulate potentially injurious ingredients and thus promote public safety. (Hepatology 2017;65:363-373).
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Affiliation(s)
- Victor J Navarro
- Division of Hepatology, Einstein Healthcare Network, Philadelphia, PA
| | - Ikhlas Khan
- Department of Pharmacognosy, School of Pharmacy, University of Mississippi, Jackson, MS
| | - Einar Björnsson
- National University Hospital of Iceland and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Leonard B Seeff
- Division of Hepatology, Einstein Healthcare Network, Philadelphia, PA
| | - Jose Serrano
- Liver Disease Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Jay H Hoofnagle
- Liver Disease Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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Teschke R, Danan G. Drug-induced liver injury: Is chronic liver disease a risk factor and a clinical issue? Expert Opin Drug Metab Toxicol 2016; 13:425-438. [PMID: 27822971 DOI: 10.1080/17425255.2017.1252749] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Clinicians and practitioners caring for patients with chronic liver disease are often unsure whether drug therapy is a hazard that increases their patient's risk for drug-induced liver injury (DILI). Areas covered: We searched for reports of drug induced liver injury, both idiosyncratic and intrinsic, in patients with chronic liver disease including non-alcoholic and alcoholic liver disease, and cirrhosis. Reports we analyzed include statin treatment in patients with fatty liver, acetaminophen use in alcoholic fatty liver, antituberculous drugs in patients with tuberculosis and viral hepatitis, antiviral medications in hepatitis and antiretroviral medications in HIV/AIDS. The most challenging cases we found are drug therapy in patients with decompensated liver cirrhosis. Expert opinion: We identified many case reports and case series discussing a potential increased risk of DILI in patients with pre-existing liver disease. However, most of these reports were retrospective and ambiguous. With few exceptions, we conclude that drugs seem to be well tolerated by the majority of patients with pre-existing, non-cirrhotic chronic liver diseases. Special care is needed for some therapies, however, including antiviral therapy in chronic hepatitis B and C and in decompensated liver cirrhosis with impaired drug metabolism. Prospective studies are warranted to valid our conclusions.
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Affiliation(s)
- Rolf Teschke
- a Department of Internal Medicine II , Division of Gastroenterology and Hepatology , Klinikum Hanau , Hanau , Germany.,b Academic Teaching Hospital of the Medical Faculty , Goethe University Frankfurt/Main , Frankfurt/Main , Germany
| | - Gaby Danan
- c Pharmacovigilance Consultancy , Paris , France
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27
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Teschke R, Larrey D, Melchart D, Danan G. Traditional Chinese Medicine (TCM) and Herbal Hepatotoxicity: RUCAM and the Role of Novel Diagnostic Biomarkers Such as MicroRNAs. MEDICINES (BASEL, SWITZERLAND) 2016; 3:E18. [PMID: 28930128 PMCID: PMC5456249 DOI: 10.3390/medicines3030018] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 02/08/2023]
Abstract
Background: Traditional Chinese Medicine (TCM) with its focus on herbal use is popular and appreciated worldwide with increased tendency, although its therapeutic efficacy is poorly established for most herbal TCM products. Treatment was perceived as fairly safe but discussions emerged more recently as to whether herb induced liver injury (HILI) from herbal TCM is a major issue; Methods: To analyze clinical and case characteristics of HILI caused by herbal TCM, we undertook a selective literature search in the PubMed database with the search items Traditional Chinese Medicine, TCM, alone and combined with the terms herbal hepatotoxicity or herb induced liver injury; Results: HILI caused by herbal TCM is rare and similarly to drugs can be caused by an unpredictable idiosyncratic or a predictable intrinsic reaction. Clinical features of liver injury from herbal TCM products are variable, and specific diagnostic biomarkers such as microsomal epoxide hydrolase, pyrrole-protein adducts, metabolomics, and microRNAs are available for only a few TCM herbs. The diagnosis is ascertained if alternative causes are validly excluded and causality levels of probable or highly probable are achieved applying the liver specific RUCAM (Roussel Uclaf Causality Assessment Method) as the most commonly used diagnostic tool worldwide. Case evaluation may be confounded by inappropriate or lacking causality assessment, poor herbal product quality, insufficiently documented cases, and failing to exclude alternative causes such as infections by hepatotropic viruses including hepatitis E virus infections; Conclusion: Suspected cases of liver injury from herbal TCM represent major challenges that deserve special clinical and regulatory attention to improve the quality of case evaluations and ascertain patients' safety and benefit.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, D-63450 Hanau, Teaching Hospital of the Medical Faculty of the Goethe University, Frankfurt/Main D-63450, Germany.
| | - Dominique Larrey
- Department of Liver and Transplantation-IRB-INSERM (Institut de Recherche Biologique-INstitut de la Santé Et de la Recherche Médicale) 1183, Saint Eloi Hospital, Montpellier University, 34295 Montpellier, France.
| | - Dieter Melchart
- Competence Centre for Complementary Medicine and Naturopathy (CoCoNat), Klinikum rechts der Isar, Technische Universität München, Munich D-80801, Germany.
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich CH-8091, Switzerland.
| | - Gaby Danan
- Pharmacovigilance Consultancy, Paris 75020, France.
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