Acetaminophen hepatotoxicity: studies on the mechanism of cysteamine protection

Acetaminophen (APAP) hepatotoxicity-Isn't it time for APAP to go away?

Acetaminophen (APAP) is the most commonly used drug for the treatment of pain and fever around the world. At the same time, APAP can cause dose-related hepatocellular necrosis, responsible for nearly 500 deaths annually in the United States (US) alone, as well as 100,000 calls to US Poison Control Centers, 50,000 emergency room visits and 10,000 hospitalisations per year. As an over-the-counter and prescription product (with opioids), APAP toxicity dwarfs all other prescription drugs as a cause of acute liver failure in the US and Europe, but it is not regulated in any significant way. In this review the ongoing controversy surrounding the proper role for this ubiquitous pain reliever: its history, pathogenesis, clinical challenges in recognition and management, and current regulatory status are highlighted. A new solution to a 50-year-old problem is proposed.

Repeated preexposure or coexposure to arsenic differentially alters acetaminophen-induced oxidative stress in rat kidney

Acetaminophen (AP) is a widely used, cheap, and over-the-counter nonsteroidal anti-inflammatory drug. Its toxicity depends on the cytochrome P-450 (CYP)-mediated oxidation to the toxic metabolite N-acetyl-p-benzoquinoneimine. On the other hand, arsenic, a global groundwater and environmental contaminant of major public health concern, decreases hepatic CYP content and its dependent monoxygenase activities. We hypothesized that arsenic exposure would reduce the AP toxicity. Our aim was to evaluate the effects of repeated preexposure or coexposure to arsenic on the oxidative stress induced by a single or repeated oral administration of AP in rat kidney and its possible relationship with the effects of arsenic on certain antioxidants. Rats were exposed to arsenic through drinking water at 25 ppm for 28 days. The dosages of AP used for a single administration after arsenic preexposure for 28 days were 420 and 1000 mg kg(-1) , while for daily concurrent administration with arsenic for 28 days were 105 and 420 mg kg(-1) body weight. AP increased lipid peroxidation (LPO) in rat kidney where its acute administration caused more LPO than its subacute dosing. Repeated arsenic exposure differentially altered the AP-induced LPO. Arsenic preexposure antagonized LPO induced by the acute AP administration; in contrast, arsenic coexposure aggravated the repeated dose (AP)-mediated LPO. Arsenic-mediated alterations in renal sensitivity to LPO did not appear to be linked to the antioxidants such as reduced glutathione, superoxide dismutase, catalase, glutathione peroxidase, and glutathione reductase; nor could it be related to glutathione-S-transferase activity. The results indicated that repeated arsenic preexposure decreased susceptibility of rat kidney to acute AP-mediated oxidative stress; on the contrary, its coexposure rendered the rat kidney more vulnerable to oxidative stress induced by the repeated dosing of AP.

Differential gene expression in mouse liver associated with the hepatoprotective effect of clofibrate

Pretreatment of mice with the peroxisome proliferator clofibrate (CFB) protects against acetaminophen (APAP)-induced hepatotoxicity. Previous studies have shown that activation of the nuclear peroxisome proliferator activated receptor-alpha (PPARalpha) is required for this effect. The present study utilizes gene expression profile analysis to identify potential pathways contributing to PPARalpha-mediated hepatoprotection. Gene expression profiles were compared between wild type and PPARalpha-null mice pretreated with vehicle or CFB (500 mg/kg, i.p., daily for 10 days) and then challenged with APAP (400 mg/kg, p.o.). Total hepatic RNA was isolated 4 h after APAP treatment and hybridized to Affymetrix Mouse Genome MGU74 v2.0 GeneChips. Gene expression analysis was performed utilizing GeneSpring software. Our analysis identified 53 genes of interest including vanin-1, cell cycle regulators, lipid-metabolizing enzymes, and aldehyde dehydrogenase 2, an acetaminophen binding protein. Vanin-1 could be important for CFB-mediated hepatoprotection because this protein is involved in the synthesis of cysteamine and cystamine. These are potent antioxidants capable of ameliorating APAP toxicity in rodents and humans. HPLC-ESI/MS/MS analysis of liver extracts indicates that enhanced vanin-1 gene expression results in elevated cystamine levels, which could be mechanistically associated with CFB-mediated hepatoprotection.

Role of NAD(P)H:quinone oxidoreductase 1 in clofibrate-mediated hepatoprotection from acetaminophen

Mice pretreated with the peroxisome proliferator clofibrate (CFB) are resistant to acetaminophen (APAP) hepatotoxicity. Whereas the mechanism of protection is not entirely known, CFB decreases protein adducts formed by the reactive metabolite of APAP, N-acetyl-p-benzoquinone imine (NAPQI). NAD(P)H:quinone oxidoreductase 1 (NQO1) is an enzyme with antioxidant properties that is responsible for the reduction of cellular quinones. We hypothesized that CFB increases NQO1 activity, which in turn enhances the conversion of NAPQI back to the parent APAP. This could explain the decreases in APAP covalent binding and glutathione depletion produced by CFB without affecting APAP bioactivation to NAPQI. Administration of CFB (500mg/kg, i.p.) to male CD-1 mice for 5 or 10 days increased NQO1 protein and activity levels. To evaluate the capacity of NQO1 to reduce NAPQI back to APAP, we utilized a microsomal activating system. Cytochrome P450 enzymes present in microsomes bioactivate APAP to NAPQI, which binds the electrophile trapping agent, N-acetyl cysteine (NAC). We analyzed the formation of APAP-NAC metabolite in the presence of human recombinant NQO1. Results indicate that NQO1 is capable of reducing NAPQI. The capacity of NQO1 to amelioriate APAP toxicity was then evaluated in primary hepatocytes. Primary hepatocytes isolated from mice dosed with CFB are resistant to APAP toxicity. These hepatocytes were also exposed to ES936, a high affinity, and irreversible inhibitor of NQO1 in the presence of APAP. Concentrations of ES936 that resulted in over 94% inhibition of NQO1 activity did not increase the susceptibility of hepatocytes from CFB treated mice to APAP. Whereas NQO1 is mechanistically capable of reducing NAPQI, CFB-mediated hepatoprotection does not appear to be dependent upon enhanced expression of NQO1.

Mechanism of protection of lobenzarit against paracetamol-induced toxicity in rat hepatocytes

The protective effects of lobenzarit, an antioxidative agent and antirheumatic drug, on the cytotoxicity of paracetamol in rat hepatocytes were studied, as well as the inhibitory effects of lobenzarit on cytochrome P-450s and glutathione S-transferases (GSTs) in rat liver. Paracetamol was selected as a model toxin, since it is known to be bioactivated by specific cytochrome P-450s presumably to N-acetyl-p-benzoquinoneimine, a reactive metabolite which upon overdosage of paracetamol causes protein and non-protein thiol depletion, lipid peroxidation and cytotoxicity measurable as LDH leakage. At concentrations of lobenzarit of 0.2 and 0.3 mM, added 30 min before paracetamol, the drug prevented paracetamol-induced leakage of lactate dehydrogenase (LDH) almost completely and lipid peroxidation (LPO) and depletion of glutathione (GSH) substantially and also the formation of the 3-glutathionyl conjugate of paracetamol. However, at a concentration of 0.05 mM Lobenzarit did not protect anymore against the paracetamol toxicity, When added to the hepatocytes 1 h and 2 h before paracetamol, 0.05 and 0.2 and 0.3 mM concentrations of lobenzarit did not protect against the cytotoxicity induced by paracetamol either. Lobenzarit did not inhibit cytochromes P-450 1A1/1A2, 2B1/2B2 and 2E1 which were measured as ethoxyresorufin O-deethylation (EROD) activity in beta-naphthoflavone-induced rat liver microsomes, as pentoxyresorufin de-pentylation (PROD) activity in phenobarbital-induced microsomes and as p-nitrophenol hydroxylation (PNPH) activity in pyrazol-induced microsomes. Lobenzarit did not show inhibition of glutathione S-transferase (GST) activity towards 1-chloro-2,4-dinitrobenzene (CDNB) in cytosol from liver of rats treated with phenobarbital, pyrazol and beta-naphthoflavone either. It is concluded that the cytoprotective effect of lobenzarit is most likely due to its antioxidant effects and/or to its ability to stimulate GSH reductase.

Determination of total cysteamine in urine and plasma samples by gas chromatography with flame photometric detection

A sensitive and selective method for the determination of total cysteamine in urine and plasma samples by gas chromatography (GC) has been developed. After reduction of the sample with sodium borohydride, the liberated cysteamine was converted into its N,S-diisobutoxycarbonyl derivative and measured by GC with flame photometric detection using a DB-210 capillary column. The calibration curve was linear in the range 0.2-5.0 nmol, and the detection limit, at a signal-to-noise ratio of 3, was ca. 0.5 pmol injected. Using this method, total cysteamine in urine and plasma samples could be accurately and precisely determined without any interference from coexisting substances. Analytical results for the determination of total cysteamine in urine and plasma samples from normal subjects are presented.

Determination of cysteamine and cystamine by gas chromatography with flame photometric detection

A gas chromatographic method for the determination of cysteamine and its disulphide cystamine is described. Cysteamine and cystamine are converted into N,S-diisobutoxycarbonyl and N,N-diisobutoxycarbonyl derivatives, respectively. The derivatives are analysed by gas chromatography with flame photometric detection, using a DB-210 capillary column. The calibration curves for cysteamine and cystamine in the range of 0.2-5.0 nmol are linear and sufficiently reproducible for quantitative analysis, and the detection limit is about 0.5 pmol injected. Cysteamine in mouse tissues is found in the free reduced, free oxidized and protein-bound forms. Free oxidized and protein-bound forms are reduced to free cysteamine by the use of sodium borohydride, and then derivatized. Cysteamine and cystamine in mouse tissues can be measured without any interference from coexisting substances by this method. The recoveries of cysteamine and cystamine added to the tissue samples are 91-106%, and their reproducibilities are found to be satisfactory. Analytical results for the determination of various forms of cysteamine in mouse tissues are presented.

An epoxysuccinic acid derivative(loxistatin)-induced hepatic injury in rats and hamsters

Loxistatin is a possible therapeutic agent of muscular dystrophy. A single oral administration of loxistatin to male rats caused focal necrosis of the liver with inflammatory cell infiltration. The severity of the lesions was dose-dependent up to 200 mg/kg and also manifest by an increase in serum alanine aminotransferase and aspartate aminotransferase activities. Hepatic glutathione (GSH) levels decreased with a maximum 20% depletion within 5 hr after the oral administration of loxistatin. Pretreatment with diethyl maleate did not potentiate the loxistatin-induced hepatic injury. On the other hand, the hepatoprotective effect of cysteamine was observed when cysteamine was administered 24 hr before loxistatin dosing, but the effect was not observed when the antidote was administered concomitantly with loxistatin. Pretreatment of rats with phenobarbital or trans-stilbene oxide provided partial protection against the hepatotoxic effect of loxistatin. Pretreatment with SKF-525A resulted in increased hepatic injury, while pretreatment with piperonyl butoxide, cimetidine, or 3-methylcholanthrene had no effect on hepatic damage by loxistatin. Five hours after [14C]loxistatin administration to rats, the covalent binding of the radioactivity to proteins was greatest in the liver, followed by the kidney, then muscle and blood to a lesser extent. [14C]Loxistatin acid, the pharmacologically active form of loxistatin, irreversibly bound to rat liver microsomal proteins; more binding occurred when the NADPH-generating system was omitted and when the microsomes were boiled first. GSH did not alter the extent of irreversible binding, whereas N-ethylmaleimide decreased the binding of [14C]loxistatin acid to rat liver microsomal proteins by 75%. Unlike the rat, administration of loxistatin to hamsters caused neither hepatic injury nor hepatic GSH depletion even at a high dose (500 mg/kg). Both the distribution and covalent binding of radioactivity in the hamster liver were one-third of those in rats following [14C]loxistatin dosing. These results suggest that loxistatin causes species-specific hepatotoxicity and that, at least in part, some of the toxic effects of loxistatin are mediated by the nonenzymatic covalent binding of loxistatin acid to thiol residues on cellular macromolecules.

The role of heme oxygenase and aryl hydrocarbon hydroxylase in the protection by cysteamine from acetaminophen hepatotoxicity

Administration of cysteamine to rats depressed hepatic aryl hydrocarbon hydroxylase (AHH) activity, cytochrome P-450, and total heme at 24 hr. Total heme remained decreased at 48 hr when all other parameters returned to control values. A significant 5-fold increase in heme oxygenase activity occurred in rat liver 5 hr after treatment, when AHH activity and total heme were unchanged. Histological examination of liver biopsies from rats treated with cysteamine revealed normal hepatic architecture. The observed effects of cysteamine on hepatic drug-metabolizing enzymes in vivo were not due to cysteamine-induced hepatotoxicity. Our results indicate that cysteamine increases heme oxygenase activity in rat liver, with a subsequent decrease in total heme, AHH activity, and cytochrome P-450 content. The depression of P-450 by cysteamine is likely to be an important mechanism for its protection in acetaminophen overdose. The protection studies illustrate this mechanism. Centrilobular hepatic necrosis and elevation in transaminase activity following a toxic dose of acetaminophen were prevented by treatment with cysteamine. The hepatoprotective effect of cysteamine was evident when acetaminophen was administered 24 hr after cysteamine but did not occur when acetaminophen was administered 5 hr after cysteamine or simultaneously. All groups of rats receiving cysteamine showed decreased mortality compared to the group receiving acetaminophen alone.

Antidotal effectiveness of N-acetylcysteine in reversing acetaminophen-induced hepatotoxicity. Enhancement of the proteolysis of arylated proteins

The post-arylative mechanisms by which N-acetylcysteine (NAC) reduces the severity of the hepatotoxicity induced by acetaminophen (APAP) were investigated in primary cultures of mouse hepatocytes. When administered at selected times immediately following removal of medium containing 10 mM APAP, 2.0 mM NAC was shown to restore glutathione levels through 16 hr of APAP pretreatment and to minimize the leakage of glutamate-oxaloacetate transaminase resulting from the first 8 hr of drug exposure. This temporal difference defined a critical period in which cells were responsive to NAC and permitted the investigation of potential post-arylative mechanisms of the antidote. In the absence of NAC during the recovery period, the cellular loss of covalently-bound APAP could be accounted for by the appearance of arylated proteins in the medium without any apparent degradation of APAP-bound proteins. By contrast, when NAC was present during the recovery period, there was a decrease in intracellular protein-bound APAP which could not be accounted for by that detected in the medium. Since during the recovery period the low residual intracellular concentration of APAP could not contribute significantly to any additional covalent binding in this system, NAC could not merely be acting as a nucleophilic trap for the reactive electrophile. Furthermore, NAC is not likely to dissociate covalently bound APAP from proteins. Hence, the overall decrease in covalent binding observed in cultures previously exposed to APAP for up to 8 hr must have arisen from an NAC-dependent enhancement of the degradation of the arylated proteins. However, after a more prolonged exposure to APAP, the ineffectiveness of NAC may have resulted from APAP-induced irreparable damage to the intracellular proteolytic system. These data suggest that the post-arylative efficacy of NAC may reside in the ability of the antidote to restore the functional capacity of the proteolytic system to rid the cells of arylated proteins.

Inhibition of acetaminophen hepatotoxicity by chlorpromazine in fed and fasted mice

Acetaminophen hepatotoxicity has been shown previously to be potentiated by fasting, and the mechanism of hepatotoxicity has been correlated with depletion of reduced glutathione and the resulting elevation of cytosolic calcium. Chlorpromazine inhibited the hepatotoxicity of acetaminophen in a dose-dependent manner in fed and fasted mice. A 6 mg/kg dose of chlorpromazine prevented the acetaminophen-promoted increase in SGPT levels and prevented hepatic necrosis. Chlorpromazine did not prevent the depletion of reduced glutathione by acetaminophen in fed or fasted mice, although it did decrease the extent of reduced glutathione depletion caused by acetaminophen in fed mice from 80% depletion to 67% depletion. We propose that chlorpromazine causes a negative sensitivity modulation to calcium in hepatocytes, as evidenced by chlorpromazine preventing the acetaminophen-stimulated rise in phosphorylase a activity. We also propose that fasting potentiates acetaminophen hepatotoxicity by causing a positive sensitivity modulation to calcium in hepatocytes via the actions of glucagon.

Measurement of cyst(e)amine in physiological samples by high performance liquid chromatography

Two methods for measurement of cyst(e)amine in physiological samples are described. One method involves reduction of disulfides present in the sample with tributylphosphine, reversed phase chromatography of thiols, and electrochemical detection of cysteamine and other thiols. The other method involves reduction of disulfides with dithiothreitol, derivatization of thiols with 7-diethylamino-3-(4'-maleimidylphenyl)-4-methylcoumarin, separation of these derivatives by reversed phase chromatography, and fluorometric detection of the thiol adducts. The endogenous concentration of cysteamine in rat liver was estimated to be less than 2.5 nmol/g. Cysteamine is produced in tissues postmortem; rapid sampling/freezing of tissues and rapid inactivation of enzymes during tissue preparation are essential for accurate measurement of endogenous cysteamine concentrations.

Disulfiram prevents acetaminophen hepatotoxicity in rats

Hepatic necrosis due to an oral acetaminophen overdose (4.25 g/kg b.wt.) was prevented by pretreatment with disulfiram 100 mg/kg, given for 3 weeks or as a single dose. Twenty-four hours after acetaminophen the impairment of hepatic function, measured as prothrombin index, and the depletion of hepatic glutathione were prevented. Hepatic cytochrome P-450 levels were unchanged but cytochrome P-450 mediated p-nitroanisole demethylation was reduced by disulfiram pretreatment. Disulfiram pretreatment reduced 24 hour urinary excretion of acetaminophen-mercapturate and- cysteine while excretion of -sulfate and -glucuronide was unchanged. After 72 hours acetaminophen induced hepatic necrosis were prevented. Identical observations were made in animals pretreated with disulfiram for 3 weeks. Five hours after acetaminophen overdose its irreversible binding to hepatic proteins was not changed. After 24 hours, however, it was increased in animals pretreated with a single disulfiram dose and unchanged in animals pretreated for 3 weeks. The protective mechanism of disulfiram after acetaminophen overdose is not mediated via a change in overall irreversible binding of acetaminophen to hepatic protein.

Acetaminophen hepatotoxicity in aging rats

Severity of liver damage 24 hr after i.p. administration of acetaminophen in doses of 0.4 and 0.8 g/kg was evaluated in male Fischer 344 rats at 4, 14 and 25 months of age. Both doses of acetaminophen produced significant elevations of serum alanine aminotransferase (ALT) and sorbitol dehydrogenase (SDH) activities in 4-month-old rats. Enzyme release was somewhat diminished in old age. Hepatic glutathione (GSH) and microsomal cytochrome P-450 concentrations were decreased in rats that received 0.8 g/kg of acetaminophen. The decreases occurred in young-adult and middle-aged rats, but not in old rats. The results demonstrated that old age does not enhance the hepatotoxic effects of acetaminophen in male Fischer 344 rats.