Drug-Induced Rhabdomyolysis Atlas (DIRA) for idiosyncratic adverse drug reaction management

Advancing Adverse Drug Reaction Prediction with Deep Chemical Language Model for Drug Safety Evaluation

The accurate prediction of adverse drug reactions (ADRs) is essential for comprehensive drug safety evaluation. Pre-trained deep chemical language models have emerged as powerful tools capable of automatically learning molecular structural features from large-scale datasets, showing promising capabilities for the downstream prediction of molecular properties. However, the performance of pre-trained chemical language models in predicting ADRs, especially idiosyncratic ADRs induced by marketed drugs, remains largely unexplored. In this study, we propose MoLFormer-XL, a pre-trained model for encoding molecular features from canonical SMILES, in conjunction with a CNN-based model to predict drug-induced QT interval prolongation (DIQT), drug-induced teratogenicity (DIT), and drug-induced rhabdomyolysis (DIR). Our results demonstrate that the proposed model outperforms conventional models applied in previous studies for predicting DIQT, DIT, and DIR. Notably, an analysis of the learned linear attention maps highlights amines, alcohol, ethers, and aromatic halogen compounds as strongly associated with the three types of ADRs. These findings hold promise for enhancing drug discovery pipelines and reducing the drug attrition rate due to safety concerns.

Rhabdomyolysis caused by Botrychium ternatum intoxication: Case report and literature review

RATIONALE

Botrychium ternatum ((Thunb.) Sw.), a traditional Chinese medicine, is known for its therapeutic properties in clearing heat, detoxifying, cough suppression, and phlegm elimination. It has been extensively used in clinics for the treatment of many inflammation-related diseases. Currently, there are no documented cases of rhabdomyolysis resulting from Botrychium ternatum intoxication.

PATIENT CONCERNS

A 57-year-old male presented with a complaint of low back discomfort accompanied by tea-colored urine lasting for 4 days. The patient also exhibited markedly increased creatine phosphate kinase and myoglobin levels. Prior to the onset of symptoms, the patient consumed 50 g of Botrychium ternatum to alleviate pharyngodynia.

DIAGNOSES

The patient was diagnosed with rhabdomyolysis due to Botrychium ternatum intoxication.

INTERVENTIONS

The patient underwent a substantial volume of fluid resuscitation, diuresis, and alkalization of urine, as well as correction of the acid-base balance and electrolyte disruption.

OUTCOMES

Following a 10-day treatment plan involving massive fluid resuscitation, diuresis, and alkalization of urine, the patient showed notable improvement in his lower back pain and reported the absence of any discomfort. Following reexamination, the levels of creatine phosphate kinase and myoglobin were restored to within the normal ranges. Additionally, no abnormalities were detected in liver or renal function. As a result, the patient was considered eligible for discharge and was monitored.

CONCLUSIONS

Botrychium ternatum intoxication was associated with the development of rhabdomyolysis. To manage this condition, it is recommended that patients provide massive fluid resuscitation, diuresis, alkalization of urine, and other appropriate therapeutic interventions.

LESSON

Currently, there are no known cases of rhabdomyolysis resulting from Botrychium ternatum intoxication. However, it is important to consider the potential occurrence of rhabdomyolysis resulting from Botrychium ternatum intoxication when there is a correlation between the administration of Botrychium ternatum and the presence of muscular discomfort in the waist or throughout the body, along with tea-colored urine. Considering the levels of creatine phosphate kinase and myoglobin, the diagnosis or exclusion of rhabdomyolysis caused by Botrychium ternatum intoxication should be made, and suitable treatment should be administered accordingly.

The expanding role of HLA gene tests for predicting drug side effects

Adverse drug reactions can be either dose-dependent (Type A) or idiosyncratic (Type B). Type B adverse drug reactions tend to be extremely rare and difficult to predict. They are usually immune-mediated. Examples include severe skin reactions and drug-induced liver injury. For many commonly prescribed drugs (such as antibiotics), the risk of developing an idiosyncratic adverse drug reaction is influenced by variability in the human leukocyte antigen (HLA) genes. Because these HLA-mediated adverse drug reactions can be lethal, there is growing interest in defining which specific drug-gene relationships might benefit from pre-emptive HLA genotyping and automated clinical decision support. This review summarizes the literature for HLA-mediated adverse reactions linked to common drugs.

DICTrank: The largest reference list of 1318 human drugs ranked by risk of drug-induced cardiotoxicity using FDA labeling

Drug-induced cardiotoxicity (DICT) is a leading cause of drug trial failure and discontinuation. Current drug annotations for cardiotoxicity largely focus on individual outcomes or mechanisms. Considering the broad spectrum of adverse cardiac events, we developed Drug-Induced Cardiotoxicity Rank (DICTrank) using FDA labeling and comprehensively classified 1318 human drugs into four categories: Most-DICT-Concern (n = 341), Less-DICT-Concern (n = 528), No-DICT-Concern (n = 343), and Ambiguous-DICT-Concern (n = 106). Notably, DICTrank covers diverse therapeutic categories, of which several were enriched with Most-DICT-Concern drugs, such as antineoplastic agents, sex hormones, anti-inflammatory drugs, beta-blockers, and cardiac therapy. DICTrank currently presents the largest drug list of DICT annotation, and it could contribute to the development of new approach methods, including AI models for early identification of DICT risk during drug development and beyond.

Levetiracetam-Induced Rhabdomyolysis Reversed by Discontinuation: A Case Report

Rhabdomyolysis has been reported as a rare side effect of levetiracetam, a first-line anti-epileptic medication. We report the case of a 64-year-old man who presented to the medical center after suffering an unwitnessed seizure. Following the initiation of levetiracetam, the patient's serum creatine kinase (CPK) levels rose rapidly and remained elevated for multiple days. However, the patient did not report any symptoms of acute rhabdomyolysis. Following discontinuation of the medication CPK levels normalized, suggesting that this is a reversible adverse effect of levetiracetam. The patient made a complete recovery and did not display any seizure activity after the initial presentation. This seemingly more common side effect could cause further damage, particularly to the kidneys, and should be monitored closely by prescribing clinicians.

Rapid detection of chemical oxygen demand, pH value, total nitrogen, total phosphorus, and ammonia nitrogen in biogas slurry by near infrared spectroscopy

Effective treatment of sewage requires accurate measurement of important water quality parameters, such as chemical oxygen demand (COD), pH value, total nitrogen (TN), total phosphorus (TP), and ammonia nitrogen (NH3-N). Traditional detection techniques can result in secondary contamination and are time- and labor-intensive. Near infrared spectroscopy was used in this study to create a model of these parameters of pig manure anaerobic fermentation sewage. The models' viability for quickly estimating the aforementioned water quality characteristics was reviewed, and the models' performance in predicting the results of several samples (biogas slurry, supernatant, and biogas residue) was contrasted. By analyzing the near infrared spectrograms with a spectral range of 4000 cm-1 and 12 500 cm-1 and using second derivative (SD), Savitzky-Golay smoothing (SG) and standard normal variable (SNV) to preprocess the spectra, partial least squares (PLS) was selected to establish the prediction model. The results showed that the effect of the NIR model constructed from the supernatant was better than that of biogas slurry and biogas residue. The determination coefficients for COD, pH value, NH3-N and TN were 0.69, 0.87, 0.81, and 0.94, respectively. This study could provide reference for on-line monitoring of wastewater in the future.

Mini Review of Biochemical Basis, Diagnosis and Management of Crush Syndrome

Crush syndrome (CS) is a metabolic disorder whose victims are individuals suffered from natural disasters such as earthquake or man-made conflicts. CS complications include acute kidney injury and cardiac arrhythmia that collectively end with death if untreated immediately. These complications are accounted for the liberation of damaged muscle tissues contents, primarily myoglobin and potassium. The present mini review discusses the biochemical basis of the development of CS. In addition, diagnosis and management and the application of novel experimental therapeutics of CS are also highlighted.

Unraveling Structural Alerts in Marketed Drugs for Improving Adverse Outcome Pathway Framework of Drug-Induced QT Prolongation

In pharmaceutical treatment, many non-cardiac drugs carry the risk of prolonging the QT interval, which can lead to fatal cardiac complications such as torsades de points (TdP). Although the unexpected blockade of ion channels has been widely considered to be one of the main reasons for affecting the repolarization phase of the cardiac action potential and leading to QT interval prolongation, the lack of knowledge regarding chemical structures in drugs that may induce the prolongation of the QT interval remains a barrier to further understanding the underlying mechanism and developing an effective prediction strategy. In this study, we thoroughly investigated the differences in chemical structures between QT-prolonging drugs and drugs with no drug-induced QT prolongation (DIQT) concerns, based on the Drug-Induced QT Prolongation Atlas (DIQTA) dataset. Three categories of structural alerts (SAs), namely amines, ethers, and aromatic compounds, appeared in large quantities in QT-prolonging drugs, but rarely in drugs with no DIQT concerns, indicating a close association between SAs and the risk of DIQT. Moreover, using the molecular descriptors associated with these three categories of SAs as features, the structure–activity relationship (SAR) model for predicting the high risk of inducing QT interval prolongation of marketed drugs achieved recall rates of 72.5% and 80.0% for the DIQTA dataset and the FDA Adverse Event Reporting System (FAERS) dataset, respectively. Our findings may promote a better understanding of the mechanism of DIQT and facilitate research on cardiac adverse drug reactions in drug development.

Rhabdomyolysis in Critically Ill Patients With COVID-19: A Retrospective Study

INTRODUCTION

The total number of ICU admissions for COVID-19 patients has increased steadily. Based on the research team's clinical observations, many patients developed rhabdomyolysis, but few cases were reported in the literature. This study explores the incidence of rhabdomyolysis and its outcomes, like mortality, the need for intubation, acute kidney injury, and the need for renal replacement therapy (RRT).

METHODS

We retrospectively reviewed the characteristics and outcomes of patients admitted to the ICU at a COVID-19-designated hospital in Qatar between March and July 2020. Logistic regression analysis was used to determine factors associated with mortality.

RESULTS

1079 patients with COVID-19 were admitted to the ICU, and 146 developed rhabdomyolysis. Overall, 30.1% died (n = 44), and 40.4% developed Acute Kidney Injury (AKI) (n = 59), with only 19 cases (13%) recovering from the AKI. AKI was significantly associated with increased mortality rates among rhabdomyolysis patients. Moreover, significant differences were found between groups regarding the subject's age, calcium level, phosphorus level, and urine output. However, the AKI was the best predictor of mortality for those who got the COVID-19 infection and rhabdomyolysis.

CONCLUSION

Rhabdomyolysis increases the risk of death in COVID-19 patients admitted to the ICU. The strongest predictor of a fatal outcome was acute kidney injury. The findings of this study emphasize the importance of early identification and prompt treatment of rhabdomyolysis in patients with severe COVID-19.

Drug-induced QT Prolongation Atlas (DIQTA) for enhancing cardiotoxicity management

Drug-induced prolongation of the QT interval is common in a variety of pharmaceutical treatments and can lead to serious clinical outcomes. Although substantial efforts have been made to prevent drug-induced QT interval prolongation, the lack of a centralized data source remains the main obstacle to further study of the underlying mechanism and the development of effective prediction strategies. To fill this gap, we propose a schema for stratifying the risk of marketed QT prolonging drugs based on US Food and Drug Administration (FDA)-approved drug labeling and developed a Drug-Induced QT Prolongation Atlas (DIQTA). Potential application of DIQTA was shown by precision dosing in off-label use and therapeutic strategy optimization, as well as the facilitation of artificial intelligence (AI)-based modeling in predictive toxicity.

Quantitative Structure-Activity Relationship (QSAR) Model for the Severity Prediction of Drug-Induced Rhabdomyolysis by Using Random Forest

Drug-induced rhabdomyolysis (DIR) is a rare and potentially life-threatening muscle injury that is characterized by low incidence and high risk. To our best knowledge, the performance of the current predictive models for the early detection of DIR is suboptimal because of the scarcity and dispersion of DIR cases. Therefore, on the basis of the curated drug information from the Drug-Induced Rhabdomyolysis Atlas (DIRA) database, we proposed a random forest (RF) model to predict the DIR severity of the marketed drugs. Compared with the state-of-art methods, our proposed model outperformed extreme gradient boosting, support vector machine, and logistic regression in distinguishing the Most-DIR concern drugs from the No-DIR concern drugs (Matthews correlation coefficient (MCC) and recall rate of our model were 0.46 and 0.81, respectively). Our model was subsequently applied to predicting the potentially serious DIR for 1402 drugs, which were reported to cause DIR by the postmarketing DIR surveillance data in the FDA Spontaneous Adverse Events Reporting System (FAERS). As a result, 62.7% (94) of drugs ranked in the top 150 drugs with the Most-DIR concerns in FAERS can be identified by our model. The top four drugs (odds ratio >30) including acepromazine, rapacuronium, oxyphenbutazone, and naringenin were correctly predicted by our model. In conclusion, the RF model can well predict the Most-DIR concern drug only based on the chemical structure information and can be a facilitated tool for early DIR detection.

Metabolomic profiling for juvenile Chinook salmon exposed to contaminants of emerging concern

Both targeted and non-targeted metabolomic analyses were conducted on juvenile ocean-type fall Chinook salmon (Oncorhynchus tshawytscha) residing in two estuaries receiving wastewater treatment plant (WWTP) effluent and one reference estuary. The data show that the metabolome patterns for fish from the two WWTP-receiving estuaries were more similar to each other compared to that for the reference site fish. Also, a comparison of the metabolome for fish from the reference site and fish from a hatchery upstream of one of the effluent-receiving estuaries indicated no differences, implying that residency for fish in the contaminated estuary resulted in major changes to the metabolome. Based on general health parameters including whole-body lipid content and condition factor, plus the availability of prey for these fish, we conclude that juvenile Chinook salmon in these contaminated estuaries may have been experiencing metabolic disruption without any overt signs of impairment. Additionally, a non-targeted analysis was performed on hatchery summer Chinook salmon from a laboratory study where fish were dosed for 32 days with feed containing 16 of the most common contaminants of emerging concern (CECs) detected in wild fish. In the laboratory experiment a relationship was observed between dose and the number of liver metabolites that were different between control and treatment fish. Laboratory fish were exposed to only 16 CECs, but are generally exposed to hundreds of these compounds in contaminated aquatic environments. These results have implications for the health of juvenile Chinook salmon and the likelihood of a successful life cycle when exposed to effluent-related chemicals.

Incidence of Suspected Serious Adverse Drug Reactions in Corona Virus Disease-19 Patients Detected by a Pharmacovigilance Program by Laboratory Signals in a Tertiary Hospital in Spain: Cautionary Data

BACKGROUND: From March to April 2020, Spain was the center of the SARS-CoV-2 pandemic, particularly Madrid with approximately 30% of the cases in Spain. The aim of this study is to report the suspected serious adverse drug reactions (SADRs) in COVID-19 patients vs. non-COVID-19 patients detected by the prospective pharmacovigilance program based on automatic laboratory signals (ALSs) in the hospital (PPLSH) during that period. We also compared the results with the suspected SADRs detected during the same period for 2019. METHODS: All ALSs that reflected potential SADRs including neutropenia, pancytopenia, thrombocytopenia, anemia, eosinophilia, leukocytes in cerebrospinal fluid, hepatitis, pancreatitis, acute kidney injury, rhabdomyolysis, and hyponatremia were prospectively monitored in hospitalized patients during the study periods. We analyzed the incidence and the distribution of causative drugs for the COVID-19 patients. RESULTS: The incidence rate of SADRs detected in the COVID-19 patients was 760.63 (95% CI 707.89-816.01) per 10,000 patients, 4.75-fold higher than the SADR rate for non-COVID-19 patients (160.15 per 10,000 patients, 95% CI 137.09-186.80), and 5.84-fold higher than the SADR rate detected for the same period in 2019 (130.19 per 10,000 patients, 95% CI 109.53-154.36). The most frequently related drugs were tocilizumab (59.84%), dexketoprofen (13.93%), azithromycin (8.43%), lopinavir-ritonavir (7.35%), dexamethasone (7.62%), and chloroquine/hydroxychloroquine (6.91%). CONCLUSIONS: The incidence rate of SADRs detected by the PPSLH in patients with COVID-19 was 4.75-fold higher than that of the non-COVID-19 patients. Caution is recommended when using medications for COVID-19 patients, especially drugs that are hepatotoxic, myotoxic, and those that induce thromboembolic events.

Case Report: A COVID-19 Patient Presenting with Mild Rhabdomyolysis

The news was reported from the Wuhan region of China about a novel corona virus in the end of 2019. After spreading around the world, a pandemic was declared by the WHO. Depending on the different involvement of the disease, the most common symptoms are fever, cough, and dyspnea. However, some indeterminate symptoms that make diagnosis difficult, such as myalgia and fatigue, can also be seen alone, without the typical clinical picture. We describe a patient with COVID-19 pneumonia, the only complaint of which is myalgia, and the first diagnosis is mild rhabdomyolysis. The patient had no evidence or history other than viral infection that could explain muscle pain and also increased level of muscle enzymes. When mild rhabdomyolysis lack of myoglobinuria and complications was diagnosed, treatment-related rhabdomyolysis was also avoided as no treatment related to COVID-19 was initiated yet. Apart from the typical symptoms leading to the typical diagnosis of COVID-19 at the first admission, SARS-CoV-2 related with rhabdomyolysis should also be kept in mind.

Colchicine-Induced Rhabdomyolysis: Clinical, Biochemical, and Neurophysiological Features and Review of the Literature

We report the case of a 46-years-old man with long-term asymptomatic hyperuricemia who started taking colchicine (0.5 mg/day) and allopurinol (100 mg/d) for normalization of biochemical values. After the third week of starting treatment, acute weakness was present; and by the fifth week, profound weakness in lower extremities and tenderness and cramps on thighs and calves with inability to climb stairs were also observed. Biochemical evaluation showed elevated muscle enzymes (creatinine kinase [CK] raised to five-folds its normal value) and electromyographic features were consistent with myopathy (at rest, fibrillations, positive sharp waves, high-frequency myotonic discharges; motor unit action potentials [MUAPs] of small amplitude, small duration, increased polyphasic Index and occasional satellite potentials; at maximal effort, interferential recruitment pattern with reduced amplitudes were observed). Normal motor and sensitive nerve conduction studies and normal late F-responses and H-reflex discarded neuropathy. Rapid improvement in muscle strength and prompt resolution of abnormal elevated muscle enzymes was observed after withdrawal of both medications. Colchicine is associated with some cases of myotoxicity but very small cases of colchicine-induced rhabdomyolysis are reported on the literature. Colchicine-induced rhabdomyolysis is related to the concomitant use of drugs (statins, steroids, erythromycin, and cyclosporine), renal, and/or hepatic impairment. To the best of our knowledge, this is an uncommon presentation of a case of colchicine-induced rhabdomyolysis reported in a patient without renal or hepatic dysfunction. Therefore, patients receiving colchicine even in the absence of renal insufficiency should be monitored for the development of myopathy and more rarely to rhabdomyolysis.