Enalapril hepatotoxicity in the rat. Effects of modulators of cytochrome P450 and glutathione

Probable Enalapril Hepatotoxicity in a 13-Year-Old Male Western Lowland Gorilla: Pharmacologic Risks and Vigilance

A 13-year-old male Western lowland gorilla presented acutely with a precipitous decline in health status from liver disease. Through diagnostic assessment, including serum chemistries and advanced imaging, it was diagnosed with probable hepatotoxicity resulting from its prescribed medication, enalapril. As one of several angiotensin converting enzyme inhibitors (ACE-I) available to zoo veterinarians, enalapril had been administered for treatment of mild ventricular hypertrophy diagnosed during routine examination 2.5 years prior to the presentation. The gorilla made a complete recovery with discontinuation of this medication, and provision of hepatoprotectants. Hepatotoxicity has been documented in humans receiving this product as an adverse drug reaction and is considered both rare and unpredictable in occurrence. In this event, an association was suspected with indulgent consumption of mulberry browse (Morus sp.) offered as nutritional enrichment immediately prior to clinical presentation and had potential impact on hepatic cytochrome P450 metabolism of the enalapril. Although ACE-I are important medications in this taxon due to its predisposition to cardiac disease, this event underscores the need for vigilance on the part of veterinarians and managers whenever pharmaceuticals are administered. Most drugs are modeled in a limited number of species but utilized in a wide variety, and unintended results are possible.

Establishment of a mouse model of enalapril-induced liver injury and investigation of the pathogenesis

Drug-induced liver injury (DILI) is a major concern in drug development and clinical drug therapy. Since the underlying mechanisms of DILI have not been fully understood in most cases, elucidation of the hepatotoxic mechanisms of drugs is expected. Although enalapril (ELP), an angiotensin-converting enzyme inhibitor, has been reported to cause liver injuries with a low incidence in humans, the precise mechanisms by which ELP causes liver injury remains unknown. In this study, we established a mouse model of ELP-induced liver injury and analyzed the mechanisms of its hepatotoxicity. Mice that were administered ELP alone did not develop liver injury, and mice that were pretreated with a synthetic glucocorticoid dexamethasone (DEX) and a glutathione synthesis inhibitor l-buthionine-(S,R)-sulfoximine (BSO) exhibited liver steatosis without significant increase in plasma alanine aminotransferase (ALT). In mice pretreated with DEX and BSO, ALT levels were significantly increased after ELP administration, suggesting that hepatic steatosis sensitized the liver to ELP hepatotoxicity. An immunohistochemical analysis showed that the numbers of myeloperoxidase-positive cells that infiltrated the liver were significantly increased in the mice administered DEX/BSO/ELP. The levels of oxidative stress-related factors, including hepatic heme oxygenase-1, serum hydrogen peroxide and hepatic malondialdehyde, were elevated in the mice administered DEX/BSO/ELP. The involvement of oxidative stress in ELP-induced liver injury was further supported by the observation that tempol, an antioxidant agent, ameliorated ELP-induced liver injury. In conclusion, we successfully established a model of ELP-induced liver injury in DEX-treated steatotic mice and demonstrated that oxidative stress and neutrophil infiltration are involved in the pathogenesis of ELP-induced liver injury.

Effect of procysteine on aging-associated changes in hepatic GSH and SMase: evidence for transcriptional regulation of smpd3

In hepatocytes, aging-associated decline in GSH has been linked to activation of neutral SMase (nSMase), accumulation of bioactive ceramide, and inflammation. In this study, we seek to test whether dietary supplementation with the cysteine precursor, L-2-oxothiazolidine-4-carboxylic acid (OTC), would correct the aging-associated differences in hepatic GSH, nSMase, and ceramide. Young and aged mice were placed on a diet that either lacked sulfur-containing amino acids (SAAs) or had 0.5% OTC for 4 weeks. Mice fed standard chow were used as an additional control. SAA-deficient mice exhibited significant aging-associated differences in hepatic GSH, GSH/GSSG, ceramide, and nSMase. C24:1 ceramide, the major ceramide species in liver, was affected the most by aging, followed by the less abundant C16:0 ceramide. OTC supplementation eliminated the aging-associated differences in hepatic GSH and GSH/GSSG ratio. Surprisingly, however, instead of decreasing, the nSMase activity and ceramide increased in the OTC-fed mice irrespective of their age. These effects were due to elevated nSMase-2 mRNA and protein and appeared to be direct. Similar increases were seen in HepG2 cells following treatment with OTC. The OTC-fed aged mice also exhibited hepatic steatosis and triacylglyceride accumulation. These results suggest that OTC is a potent stimulant of nSMase-2 expression and that there may be unanticipated complications of OTC supplementation.

Methapyrilene hepatotoxicity is associated with increased hepatic glutathione, the formation of glucuronide conjugates, and enterohepatic recirculation

The mechanisms by which acute administration of methapyrilene, an H(1)-receptor antihistamine causes periportal necrosis to rats are unknown. This study investigated the role of the hepato-biliary system in methapyrilene hepatotoxicity following daily administration of 150 mg/kg per day over 3 consecutive days. Biliary metabolites of methapyrilene were tentatively identified. In male Han Wistar rats administration of methapyrilene significantly increased hepatic reduced glutathione (GSH) to 140% of control levels 24 h following the last dose. There were no significant changes in the activities of glutathione-related enzymes, glutathione peroxidase (GPx) and reductase (GSH), glutathione S-transferase (GST), and gamma-glutamyl cysteine synthetase (gamma-GCS) over 3 days of methapyrilene administration. Methapyrilene treatment resulted in no significant increase in excretion of biliary oxidized glutathione (GSSG), a sensitive marker of oxidative stress in vivo, following the third dose. [3H]Methapyrilene-derived radioactivity was detected in bile, to a greater extent than in feces, indicating that methapyrilene and/or metabolites underwent enterohepatic recirculation. Cannulation and exteriorization of the bile duct (to interrupt enterohepatic recirculation) afforded some protection against the hepatotoxicity, assessed by clinical chemistry and histopathology. Liquid chromatography-mass spectrometry (LC-MS) analysis of bile indicated the presence of unmetabolized methapyrilene, methapyrilene O-glucuronide and desmethyl methapyrilene O-glucuronide. These data demonstrate that acute methapyrilene hepatotoxicity in vivo is not a consequence of GSH depletion, or oxidative stress, but that enterohepatic recirculation of biliary metabolites may be important. Progressive exposure to non-oxidizing, reactive metabolic intermediates may be responsible for hepatotoxicity.

Serum transaminase elevations as indicators of hepatic injury following the administration of drugs

During the preclinical, early clinical, late-stage clinical, and postmarketing phases of the pharmaceutical discovery and development process, one important aspect of drug safety assessment involves monitoring for possible drug-induced hepatic injury. Hepatic injuries vary in nature from direct, intrinsic effects that are observed in most recipients and more than one species to rare idiosyncratic responses seen only in a few clinical subjects. Histological types of injuries vary from hepatocellular to hepatobiliary with multiple cellular effects characteristic of each type. Of the various clinical laboratory markers for hepatic injury, serum transaminases, especially alanine aminotransferase (ALT), are the most universally important indicators for studies ranging from early preclinical animal testing to postmarketing patient monitoring. This review examines the characteristics of hepatic toxicity that result in serum ALT changes, the differences in the etiology of hepatic responses which govern when liver injury is most likely to be detected during the four phases of the drug discovery and development process, and those modulating factors which affect the utility of ALT as a dependable marker of hepatic injury in clinical populations. The paper concludes with a summary of some ancillary methods for early preclinical screening such as in vitro metabolism and toxicity assays, gene and protein expression analysis, and some strategies for enhancing the probability for the early detection of idiosyncratic hepatotoxic responses which are infrequent but significant factors in the safety assessment process.

Effect of alcohol abuse and glutathione administration on the circulating levels of glutathione and on antipyrine metabolism in patients with alcoholic liver cirrhosis

Glutathione (GSH) is a principal cellular scavenger of free radicals. Chronic alcohol abuse, as well as liver disease, induces a decrease of hepatic GSH. We evaluated the effect of GSH administration (2.4 g day-1 in saline i.v. for 15 days) on the concentration of GSH in plasma and erythrocytes and on liver function tests, including galactose and antipyrine tests. We studied 40 alcoholic cirrhotic patients: 22 treated with GSH (10 persistent alcohol abusers and 12 weaning from alcohol during the study) and 18 treated with saline only (8 persistent alcohol abusers and 10 abstainers). Treatment with GSH improved the concentration of GSH in plasma and erythrocytes only in abstainers from alcohol; it did not affect liver function tests or galactose clearance. Persistent alcohol consumption significantly prolonged antipyrine metabolism; GSH administration counteracted this effect.

Comparative cytotoxicity of angiotensin-converting enzyme inhibitors in cultured rat hepatocytes

Captopril and enalapril, angiotensin-converting enzyme inhibitors (ACEIs), have been associated with idiosyncratic hepatotoxicity. Such drug reactions may be caused by the formation of reactive metabolites by cytochrome P450 isozymes, which can then cause direct or immune-mediated toxicity. Previously, we have demonstrated that enalapril cytotoxicity in primary cultures of rat hepatocytes was due, at least in part, to cytochrome P450-dependent metabolism, and that glutathione was involved in the detoxification process. In the present study, we extended our investigations into mechanisms of cytotoxicity, using rat hepatocyte cultures, to captopril and three recently marketed ACEIs: fosinopril, lisinopril and quinapril. After 24 hr of exposure to lisinopril or enalaprilat (the deesterified metabolite of enalapril), hepatocytes did not show any evidence of cytotoxicity, measured by lactate dehydrogenase leakage, even at 10 mM drug concentrations. The other ACEIs were toxic to the liver cells, with the rank order of toxicity as quinapril (LC50 = 0.28 mM) > fosinopril (LC50 = 0.4 mM) > enalapril (LC50 = 2.0 mM) > captopril (LC50 = 20 mM). In vivo pretreatment of rats with pregnenolone-16 alpha-carbonitrile to induce isozymes of the P450 3A subfamily significantly enhanced the cytotoxicities of quinapril, fosinopril and enalapril but did not affect captopril cytotoxicity. Pretreatment with P450 inducers selective for other isozyme subfamilies (ethanol, beta-naphthoflavone and phenobarbital) did not alter the in vitro toxicity of any of the ACEIs. Co-incubation with SKF525-A (15 microM) or troleandomycin (0.1 mM) reduced the hepatocidal toxicities of quinapril, fosinopril and enalapril. Preincubation with buthionine sulfoximine (2 mM) enhanced the cytotoxicities of quinapril, fosinopril, enalapril and captopril. The results of this study indicate that like enalapril, quinapril and fosinopril can also undergo P450 3A-dependent bioactivation and require maintenance of glutathione status for detoxification, and that captopril causes cytotoxicity independent of cytochrome P450 metabolism.