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Pitaro M, Croce N, Gallo V, Arienzo A, Salvatore G, Antonini G. Coumarin-Induced Hepatotoxicity: A Narrative Review. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27249063. [PMID: 36558195 PMCID: PMC9783661 DOI: 10.3390/molecules27249063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/07/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Abstract
Coumarin is an effective treatment for primary lymphoedema, as well as lymphoedema related to breast cancer radiotherapy or surgery. However, its clinical use is limited in several countries due to the possible occurrence of hepatotoxicity, mainly in the form of mild to moderate transaminase elevation. It is worth noting that only a few cases of severe hepatotoxicity have been described in the literature, with no reported cases of liver failure. Data available on coumarin absorption, distribution, metabolism, and excretion have been reviewed, focusing on hepatotoxicity studies carried out in vitro and in vivo. Finally, safety and tolerability data from clinical trials have been thoroughly discussed. Based on these data, coumarin-induced hepatotoxicity is restricted to a small subset of patients, probably due to the activation in these individuals of alternative metabolic pathways involving specific CYP450s isoforms. The aim of this work is to stimulate research to clearly identify patients at risk of developing hepatotoxicity following coumarin treatment. Early identification of this subset of patients could open the possibility of more safely exploiting the therapeutical properties of coumarin, allowing patients suffering from lymphoedema to benefit from the anti-oedematous activity of the treatment.
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Affiliation(s)
- Michele Pitaro
- INBB—Biostructures and Biosystems National Institute, Viale delle Medaglie d’Oro 305, 00136 Rome, RM, Italy
| | - Nicoletta Croce
- INBB—Biostructures and Biosystems National Institute, Viale delle Medaglie d’Oro 305, 00136 Rome, RM, Italy
| | - Valentina Gallo
- Department of Science, Roma Tre University, Viale Guglielmo Marconi 446, 00146 Rome, RM, Italy
| | - Alyexandra Arienzo
- INBB—Biostructures and Biosystems National Institute, Viale delle Medaglie d’Oro 305, 00136 Rome, RM, Italy
| | - Giulia Salvatore
- INBB—Biostructures and Biosystems National Institute, Viale delle Medaglie d’Oro 305, 00136 Rome, RM, Italy
| | - Giovanni Antonini
- INBB—Biostructures and Biosystems National Institute, Viale delle Medaglie d’Oro 305, 00136 Rome, RM, Italy
- Department of Science, Roma Tre University, Viale Guglielmo Marconi 446, 00146 Rome, RM, Italy
- Correspondence:
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Rafa O, Ostreni I, Basile EJ, Singh A. Potential Role of the Moderna COVID-19 Vaccine in Enoxaparin’s Effects on Liver Functions. Cureus 2022; 14:e24018. [PMID: 35573567 PMCID: PMC9090673 DOI: 10.7759/cureus.24018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 11/05/2022] Open
Abstract
Enoxaparin is commonly used for prophylaxis as an anticoagulant in hospital settings. Although enoxaparin has been known to cause many minor adverse reactions, hepatocellular injury is one of the rare side effects which can impact clinical course, marked by an asymptomatic rise in liver function panel tests. In this paper, we not only delineate the relationship between enoxaparin-induced hepatocellular injury but also associate it with fevers that have not been previously documented. Furthermore, we posit the Moderna COVID19 vaccine as a potential contributor to this outcome. We hypothesize that the link between enoxaparin and hepatic injury is possibly due to the inflammatory state, which may be augmented by the vaccine.
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Reike-Kunze M, Zenouzi R, Hartel J, Krech T, Weidemann S, Sterneck M, Weiler-Normann C, Lohse AW, Schramm C, Sebode M. Drug-induced liver injury at a tertiary care centre in Germany: Model for end-stage liver disease is the best predictor of outcome. Liver Int 2021; 41:2383-2395. [PMID: 34152686 DOI: 10.1111/liv.14985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/24/2021] [Accepted: 06/05/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Agents most frequently inducing idiosyncratic drug-induced liver injury (DILI) differ between countries worldwide. Besides, there is no consistent data on the best model predicting mortality or the need for liver transplantation in DILI. We here analysed the DILI cohort of our centre with regard to causative drugs and clinical outcome. METHODS A retrospective analysis of 157 consecutive severe DILI patients presenting to our tertiary care centre in Hamburg, Germany, from 2008 to 2018, was performed. RESULTS The most frequent putatively causative drugs were phenprocoumon (n = 21), metamizole (n = 17) and flupirtine (n = 6). The mean values of ALT, bilirubin and Model for End-stage Liver Disease (MELD) score at the time of hospitalisation were 1201 U/L (SD: 1169 U/L), 6.8 mg/dL (SD: 7 mg/dL) and 17 (SD: 8). About 71% of all cases were treated with steroids or steroids combined with n-acetylcysteine. About 12.1% of all DILI cases had a poor outcome (liver transplantation and/or death). At the time of admission, MELD score performed better than Hy's law, the ratio (R) or the new ratio (nR) on their own or combined with bilirubin, regarding sensitivity or specificity for poor outcome. MELD score had a c-statistic of 0.847 (95% CI: 0.731-0.964). Furthermore, the cut-off of 18 MELD points had a sensitivity of 88% and a specificity of 72% for poor outcome. CONCLUSION Phenprocoumon and metamizole are frequent causative drugs for DILI in Germany. In comparison to other prognostic scores, MELD score ≥18 at the time of admission performed best in our cohort for the prediction of poor outcome in DILI.
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Affiliation(s)
- Martin Reike-Kunze
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Zenouzi
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Johannes Hartel
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Till Krech
- Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Sören Weidemann
- Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,University Transplant Centre, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Weiler-Normann
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Christoph Schramm
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Marcial Sebode
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
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Apel K, Pütz K, Tolkach Y, Canbay A, Drebber U. [Drug-induced liver injury-significance of pathology]. DER PATHOLOGE 2020; 41:457-470. [PMID: 32813127 DOI: 10.1007/s00292-020-00811-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Many different medical agents, herbal products, and dietary supplements can induce drug-induced liver injury (DILI) as a clinically relevant complication. DILI, which is direct toxic or idiosyncratic, can have a broad spectrum of clinical appearances from elevation of liver enzymes to acute liver failure. DILI is categorized clinically according to the pattern of serum parameters or pathologically according to the pattern of histomorphology. Histopathological patterns can be described as hepatitic, granulomatous, cholestatic, ductopenic, fibrotic, steatotic, steatohepatitic, and vascular. Correlation to the corresponding drug can be carried out with the corresponding databases (US National Library of Medicine, Liver Tox; www.ncbi.nlm.nih.gov/books/NBK547852/ ). Liver biopsy, in contrast to a clinical/serological diagnostic, has the advantage of an exact resolution with evidence of pathophysiology, activity, regeneration, chronification, and prognosis. Co-occurrence of underlying liver disease can be excluded or confirmed. Histological patterns of DILI are described and illustrated. A diagnostic algorithm for the interpretation of liver biopsies is provided.
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Affiliation(s)
- K Apel
- Institut für Pathologie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - K Pütz
- Institut für Pathologie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Y Tolkach
- Institut für Pathologie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - A Canbay
- Universitätklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - U Drebber
- Institut für Pathologie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
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Yasuda K, Asou M, Asakawa T, Araki M. Ascites management by cell-free concentrated ascites reinfusion therapy during recovery from drug-induced acute liver injury: a case report. J Med Case Rep 2020; 14:192. [PMID: 33050943 PMCID: PMC7557035 DOI: 10.1186/s13256-020-02507-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022] Open
Abstract
Background The symptoms of drug-induced hepatic injury are manifold; however, the presence of ascites indicates a severe disease condition. The rapid accumulation of ascites is distressing and requires palliative treatment. Because many cases are addressed by repeated large-volume paracentesis, often resulting in impairment due to protein and electrolyte loss, a different approach is required. Case presentation A 61-year-old Japanese man on maintenance dialysis was admitted to our hospital with acute liver injury. Our patient was diagnosed as having drug-induced liver injury due to warfarin or diltiazem, which started immediately after coronary artery bypass grafting 7 months previously. One month after admission, our patient’s hepatic encephalopathy remained grade 1 and his prothrombin time international normalized ratio was maintained at < 1.5. However, the liver was markedly atrophied with massive ascites. Although liver transplantation was desired, he was considered unfit for transplantation because of his renal and cardiac complications. Therefore, we devised a strategy to manage the massive ascites with cell-free concentrated ascites reinfusion therapy while awaiting liver regeneration. At first, cell-free concentrated ascites reinfusion therapy was required frequently because ascites accumulated rapidly. But the fluid retention interval was gradually extended as intended, and cell-free concentrated ascites reinfusion therapy was withdrawn after 8 months. During that time, the size of his liver increased from 1419 cm3 to 1587 cm3 on computed tomography. Conclusions Cell-free concentrated ascites reinfusion therapy is an apheresis therapy in which ascites are collected aseptically by paracentesis, concentrated, and then reinfused intravenously. This treatment has the advantage of preserving nutrition by reusing the fluid. Previously, cell-free concentrated ascites reinfusion therapy was used only for the management of ascites in patients with cirrhosis or carcinomatous peritonitis. This case suggests that palliation and maintenance of nutritional status with cell-free concentrated ascites reinfusion therapy may be useful as an adjunct to liver regeneration in drug-induced hepatic injury.
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Affiliation(s)
- Koya Yasuda
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan
| | - Mea Asou
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan
| | - Tomohiko Asakawa
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan
| | - Makoto Araki
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan.
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Maura G, Bardou M, Billionnet C, Weill A, Drouin J, Neumann A. Oral anticoagulants and risk of acute liver injury in patients with nonvalvular atrial fibrillation: a propensity-weighted nationwide cohort study. Sci Rep 2020; 10:11624. [PMID: 32669591 PMCID: PMC7363898 DOI: 10.1038/s41598-020-68304-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/15/2020] [Indexed: 11/28/2022] Open
Abstract
Insufficient real-world data on acute liver injury (ALI) risk associated with oral anticoagulants (OACs) exist in patients with nonvalvular atrial fibrillation (NVAF). Using the French national healthcare databases, a propensity-weighted nationwide cohort study was performed in NVAF patients initiating OACs from 2011 to 2016, considering separately those (1) with no prior liver disease (PLD) as main population, (2) with PLD, (3) with a history of chronic alcoholism. A Cox proportional hazards model was used to estimate the hazard ratio with 95% confidence interval (HR [95% CI]) of serious ALI (hospitalised ALI or liver transplantation) during the first year of treatment, for each non-vitamin K antagonist (VKA) oral anticoagulant (NOAC: dabigatran, rivaroxaban, apixaban) versus VKA. In patients with no PLD (N = 434,015), only rivaroxaban new users were at increased risk of serious ALI compared to VKA initiation (adjusted HR: 1.41 [1.05–1.91]). In patients with chronic alcoholism history (N = 13,173), only those initiating dabigatran were at increased risk of serious ALI compared to VKA (2.88 [1.74–4.76]) but an ancillary outcome suggested that differential clinical follow-up between groups might partly explain this association. In conclusion, this study does not suggest an increase of the 1-year risk of ALI in NOAC versus VKA patients with AF.
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Affiliation(s)
- Géric Maura
- French National Health Insurance (Caisse Nationale de L'Assurance Maladie, Cnam), 50 Avenue du Pr. André Lemierre, 75 986, Paris Cedex 20, France.
| | - Marc Bardou
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon-Bourgogne University Hospital, 21 000, Dijon, France.,Division of Gastroenterology, Dijon-Bourgogne University Hospital, 21 000, Dijon, France
| | - Cécile Billionnet
- French National Health Insurance (Caisse Nationale de L'Assurance Maladie, Cnam), 50 Avenue du Pr. André Lemierre, 75 986, Paris Cedex 20, France
| | - Alain Weill
- EPI-PHARE Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM), 93 200, Saint-Denis, France
| | - Jérôme Drouin
- EPI-PHARE Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM), 93 200, Saint-Denis, France
| | - Anke Neumann
- EPI-PHARE Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM), 93 200, Saint-Denis, France
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7
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Orale Antikoagulation mit Vitamin K-Antagonisten – ein Update. Wien Med Wochenschr 2017; 168:121-132. [DOI: 10.1007/s10354-017-0577-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
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8
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Alonso A, MacLehose RF, Chen LY, Bengtson LG, Chamberlain AM, Norby FL, Lutsey PL. Prospective study of oral anticoagulants and risk of liver injury in patients with atrial fibrillation. Heart 2017; 103:834-839. [PMID: 28057799 DOI: 10.1136/heartjnl-2016-310586] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/07/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To assess the risk of liver injury hospitalisation in patients with atrial fibrillation (AF) after initiation of direct oral anticoagulants (DOACs) or warfarin and to determine predictors of liver injury hospitalisation in this population. METHODS We studied 113 717 patients (mean age 70, 39% women) with AF included in the MarketScan Commercial and Medicare Supplemental databases with a first prescription for oral anticoagulation after 4 November 2011, followed through 31 December 2014. Of these, 56 879 initiated warfarin, 17 286 initiated dabigatran, 30 347 initiated rivaroxaban and 9205 initiated apixaban. Liver injury hospitalisation and comorbidities were identified from healthcare claims. RESULTS During a median follow-up of 12 months, 960 hospitalisations with liver injury were identified. Rates of liver injury hospitalisation (per 1000 person-years) by oral anticoagulant were 9.0 (warfarin), 4.0 (dabigatran), 6.6 (rivaroxaban) and 5.6 (apixaban). After multivariable adjustment, liver injury hospitalisation rates were lower in initiators of DOACs compared with warfarin: HR (95% CI) of 0.57 (0.46 to 0.71), 0.88 (0.75 to 1.03) and 0.70 (0.50 to 0.97) for initiators of dabigatran, rivaroxaban, and apixaban, respectively (vs. warfarin). Compared with dabigatran initiators, rivaroxaban initiators had a 56% increased risk of liver injury hospitalisation (HR 1.56, 95% CI 1.22 to 1.99). In addition to type of anticoagulant, prior liver, gallbladder and kidney disease, cancer, anaemia, heart failure and alcoholism significantly predicted liver injury hospitalisation. A predictive model including these variables had adequate discriminative ability (C-statistic 0.67, 95% CI 0.64 to 0.70). CONCLUSIONS Among patients with non-valvular AF, DOACs were associated with lower risk of liver injury hospitalisation compared with warfarin, with dabigatran showing the lowest risk.
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Affiliation(s)
- Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Lindsay Gs Bengtson
- Health Economics and Outcomes Research, Life Sciences, Optum, Eden Prairie, Minnesota, USA
| | | | - Faye L Norby
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Douros A, Bronder E, Andersohn F, Klimpel A, Thomae M, Sarganas G, Kreutz R, Garbe E. Drug-induced liver injury: results from the hospital-based Berlin Case-Control Surveillance Study. Br J Clin Pharmacol 2016; 79:988-99. [PMID: 25444550 DOI: 10.1111/bcp.12565] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/27/2014] [Indexed: 12/15/2022] Open
Abstract
AIM Drug-induced liver injury (DILI) is often responsible for acute liver failure, drug withdrawal, boxed warnings or drug non-approval. Therefore, we conducted a case-control study to determine the hepatotoxic risk of a wide range of drugs. METHODS The Berlin Case-Control Surveillance Study FAKOS included all 51 Berlin hospitals in a hospital network. Between 2002 and 2011, 198 patients with acute idiopathic hepatitis, 377 inpatient controls and 708 outpatient controls were ascertained. Case patients were thoroughly validated using anamnestic, clinical, laboratory and histological data. Drug exposure was obtained in a face-to-face interview. A possible drug aetiology was assessed in individual patients by applying the updated Council for International Organizations of Medical Sciences (CIOMS) scale. Drug risks were further quantified [odds ratios (OR) with 95% confidence intervals (CI)] in a case-control design with unconditional logistic regression analysis. Drug intake in the last 28 days before index date was considered for the analysis. RESULTS The study corroborated hepatotoxic risks for a number of drugs, including phenprocoumon (OR 3.3, 95% CI 1.5, 6.7), amiodarone (OR 5.5, 95% CI 1.3, 21.2), clozapine (OR 34.6, 95% CI 2.8, 824.9) and flupirtine (OR 40.2, 95% CI 5.5, 856.9). Increased risks were also suggested for less commonly reported substances such as angiotensin II receptor blockers, atypical antipsychotics and for biperiden, a drug never before reported to be hepatotoxic. CONCLUSIONS Our study identified a large number of drugs as possible causes of hepatotoxicity. The observed risk for seldom reported substances highlights the need for further post-authorization safety studies not exclusively focusing on drugs already labelled as potentially hepatotoxic.
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Affiliation(s)
- Antonios Douros
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Elisabeth Bronder
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Andersohn
- Institute for Social Medicine, Epidemiology and Health Economy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Klimpel
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Thomae
- Department of Surgery, Maria-Heimsuchung Caritas Klinik Pankow, Berlin, Germany
| | - Giselle Sarganas
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Reinhold Kreutz
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Edeltraut Garbe
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
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10
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Raschi E, Poluzzi E, Koci A, Salvo F, Pariente A, Biselli M, Moretti U, Moore N, De Ponti F. Liver injury with novel oral anticoagulants: assessing post-marketing reports in the US Food and Drug Administration adverse event reporting system. Br J Clin Pharmacol 2015; 80:285-93. [PMID: 25689417 DOI: 10.1111/bcp.12611] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 02/09/2015] [Accepted: 02/10/2015] [Indexed: 12/15/2022] Open
Abstract
AIM We assessed the hepatic safety of novel oral anticoagulants (NOACs) analyzing the publicly available US-FDA adverse event reporting system (FAERS). METHODS We extracted reports of drug-induced liver injury (DILI) associated with NOACs, including acute liver failure (ALF) events. Based on US marketing authorizations, we performed disproportionality analyses, calculating reporting odds ratios (RORs) with 95% confidence interval (CI), also to test for event- and drug-related competition bias, and case-by-case evaluation for concomitant medications. RESULTS DILI reports represented 3.7% (n = 146) and 1.7% (n = 222) of all reports for rivaroxaban and dabigatran, respectively. No statistically significant association was found for dabigatran, in primary and secondary analyses. Disproportionality signals emerged for rivaroxaban in primary analysis (ALF: n = 25, ROR = 2.08, 95% CI 1.34, 3.08). In a large proportion of DILI reports concomitant hepatotoxic and/or interacting drugs were recorded: 42% and 37% (rivaroxaban and dabigatran, respectively), especially statins, paracetamol and amiodarone. Among ALF reports, fatal outcome occurred in 49% of cases (44% and 51%, rivaroxaban and dabigatran, respectively), whereas rapid onset of the event (<1 week) was detected in 46% of patients (47% and 44%, respectively). CONCLUSIONS The disproportionality signal for rivaroxaban calls for further comparative population-based studies to characterize and quantify the actual DILI risk of NOACs, taking into account drug- and patient-related risk factors. As DILI is unpredictable, our findings strengthen the role of (a) timely pharmacovigilance to detect post-marketing signals of DILI through FAERS and other data sources, (b) clinicians to assess early, on a case-by-case basis, the potential responsibility of NOACs when they diagnose a liver injury.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elisabetta Poluzzi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Ariola Koci
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesco Salvo
- University of Bordeaux, U657, F33000, Bordeaux, France.,INSERM U657, F33000, Bordeaux, France
| | - Antoine Pariente
- University of Bordeaux, U657, F33000, Bordeaux, France.,INSERM U657, F33000, Bordeaux, France.,CIC Bordeaux CIC1401, F33000, Bordeaux, France
| | - Maurizio Biselli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Ugo Moretti
- Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Nicholas Moore
- University of Bordeaux, U657, F33000, Bordeaux, France.,INSERM U657, F33000, Bordeaux, France.,CIC Bordeaux CIC1401, F33000, Bordeaux, France
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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11
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Akutes und chronisches Leberversagen. DIE INTENSIVMEDIZIN 2015. [PMCID: PMC7122832 DOI: 10.1007/978-3-642-54953-3_63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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12
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Dietrich CG, Geier A. Effect of drug transporter pharmacogenetics on cholestasis. Expert Opin Drug Metab Toxicol 2014; 10:1533-51. [PMID: 25260651 DOI: 10.1517/17425255.2014.963553] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The liver is the central place for the metabolism of drugs and other xenobiotics. In the liver cell, oxidation and conjugation of compounds take place, and at the same time, bile formation helps in extrusion of these compounds via the biliary route. A large number of transporters are responsible for drug uptake into the liver cell and excretion into bile or efflux to the sinusoidal blood. AREAS COVERED Genetic variants of these transporters and their transactivators contribute to changes in drug handling and are also responsible for cholestatic syndromes of different severity. This review summarizes the current knowledge regarding the influence of these genetic changes. The review covers progressive hereditary cholestatic syndromes as well as recurrent or transient cholestatic syndromes such as drug-induced liver injury, intrahepatic cholestasis of pregnancy, and benign recurrent intrahepatic cholestasis. EXPERT OPINION Polymorphisms in transporter genes are frequent. For clinically relevant cholestatic syndromes, it often requires a combination of genetic variants or acquired triggers such as pregnancy or drug treatment. In combination with other pathogenetic aspects, genetic variants in drug transporters may contribute to our understanding of not only cholestatic diseases such as primary sclerosing cholangitis or primary biliary cirrhosis, but also the natural course of chronic liver disease in general.
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Rohilla R, Garg T, Goyal AK, Rath G. Herbal and polymeric approaches for liver-targeting drug delivery: novel strategies and their significance. Drug Deliv 2014; 23:1645-61. [DOI: 10.3109/10717544.2014.945018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Schmiedl S, Rottenkolber M, Szymanski J, Siegmund W, Hippius M, Farker K, Drewelow B, Hasford J, Thürmann P. Bleeding complications and liver injuries during phenprocoumon treatment: a multicentre prospective observational study in internal medicine departments. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:244-52. [PMID: 23616817 DOI: 10.3238/arztebl.2013.0244] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 12/17/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Even after the recent approval of newer oral anticoagulants for clinical use, the vitamin K antagonist phenprocoumon remains an important treatment option for many patients. In order to quantify the hitherto "accepted" risks of phenprocoumon treatment, we analyzed adverse drug reactions (ADRs) that led to hospitalization on the internal medicine wards of four German pharmacovigilance centers. METHODS We prospectively analyzed ADRs leading to hospitalization on the internal medicine wards of the hospitals belonging to the German Network of Regional Pharmacovigilance Centers (Rostock, Greifswald, Jena, and the Sophien- und Hufeland-Klinikum in Weimar) in the years 2000 to 2008. RESULTS The 851 patients hospitalized for a phenprocoumon-associated ADR accounted for 12.4% of the 6887 ADR-related hospitalizations in the period of the study. 723 (85%) were admitted for a hemorrhage, usually in the gastrointestinal tract (482 patients); 8 patients died as a consequence of hemorrhage associated with phenprocoumon exposure. Using drug utilization data for the catchment areas of the participating hospitals, we calculate a rate of 5 to 7 hemorrhages leading to hospitalization in an internal medicine ward per 1000 patient-years under phenprocoumon treatment. One-third of the patients who had a hemorrhage were taking other interacting drugs, mainly inhibitors of platelet aggregation and non-steroidal anti-inflammatory drugs. Among the patients who were taking phenprocoumon because of a history of thromboembolic events or for atrial fibrillation, 60% to 70% of those who had hemorrhages had an international normalized ratio (INR) that was above the upper limit of the therapeutic range. Phenprocoumon-associated impairment of liver function arose in 23 patients (2.7%). CONCLUSION In this study, about one-eighth of all ADR-related admissions to hospital internal medicine wards were associated with phenprocoumon. There is a need for a comparative risk-benefit assessment of phenprocoumon and the newer oral anticoagulants under real-life conditions.
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Affiliation(s)
- Sven Schmiedl
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University
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15
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Hadem J, Tacke F, Bruns T, Langgartner J, Strnad P, Denk GU, Fikatas P, Manns MP, Hofmann WP, Gerken G, Grünhage F, Umgelter A, Trautwein C, Canbay A. Etiologies and outcomes of acute liver failure in Germany. Clin Gastroenterol Hepatol 2012; 10:664-9.e2. [PMID: 22373724 DOI: 10.1016/j.cgh.2012.02.016] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Revised: 01/24/2012] [Accepted: 02/13/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acute liver failure (ALF) is a severe form of acute liver injury that can progress to multiple organ failure. We investigated causes and outcomes of ALF. METHODS Eleven university medical centers in Germany were asked to report patients with (primary) severe acute liver injury (sALI) (international normalized ratio [INR] >1.5 but no hepatic encephalopathy) and primary ALF (INR >1.5 with overt hepatic encephalopathy) treated from 2008 to 2009. Data were analyzed from 46 patients with sALI and 109 patients with ALF. RESULTS The most frequent etiologies of primary ALF were non-acetaminophen drug-induced (32%), indeterminate (24%), and viral (21%); acetaminophen ingestion was the cause of ALF in only 9% of patients. The support of a ventilator was required by 44% of patients with ALF, vasopressors by 38%, and renal replacement by 36%. Seventy-nine patients with ALF (72%) survived until hospital discharge, 38 (35%) survived without emergency liver transplantation (ELT), and 51 received ELT (47%); 80% of patients who received ELT survived until discharge from the hospital. CONCLUSIONS In Germany, drug toxicity, indeterminate etiology, and viral hepatitis appear to be the major causes of primary ALF, which has high mortality. Patients with ALF are at great risk of progressing to multiple organ failure, but 80% of patients who receive ELT survive until discharge from the hospital.
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Affiliation(s)
- Johannes Hadem
- Department of Gastroenterology, Hepatology & Endocrinology, Hannover Medical School, Hannover, Germany.
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Kneiseler G, Canbay A, Gerken G. Rolle der Vitamin-K-Antagonisten aus Sicht des Hepatologen. Herz 2012; 37:395-401. [DOI: 10.1007/s00059-012-3620-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Winter Y, Dodel R, Korchounov A, Grond M, Oertel WH, Back T. Clinical and pharmacological properties of new oral anticoagulants for the prevention of cerebral thromboembolism: Factor Xa and thrombin inhibitors. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/wjns.2012.21002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Charoin-Pannier A, McIntyre C, Zandt H, Ciorciaro C, Winters K, Pepper T, Schmitt C. Safety, pharmacokinetics and pharmacodynamics of multiple ascending doses of R1663, an oral factor Xa inhibitor, in healthy young subjects coupled with exploration of influence of gender and age. Thromb Haemost 2012; 108:54-64. [DOI: 10.1160/th12-01-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 04/09/2012] [Indexed: 11/05/2022]
Abstract
SummaryThis study investigated the safety, pharmacokinetics and pharmacodynamics of multiple oral doses of R1663, a factor Xa inhibitor, and explored the influence of age and gender on pharmacokinetics and pharmacodynamics of R1663. This was a single-blind, randomised, placebo-controlled, dose escalation study in 48 healthy male volunteers aged 18 to 44 years. R1663 doses up to 300 mg twice daily or 400 mg once daily were administered for seven days. The exploration of gender and age effect was carried out in separate cohorts of eight male and eight female volunteers aged 45 to 65 years. Multiple oral doses of R1663 were safe and well tolerated. Pharmacokinetics was linear and showed moderate variability. Plasma concentrations peaked at 3 hour. Terminal half-life at steady state was 3–5 hours. Accumulation of R1663 was minimal. R1663 prolonged clotting times, inhibited thrombin generation (peak height and endogenous thrombin potential [ETP]) and anti-factor Xa activity in a concentration-dependent manner without increasing bleeding time. Pharmacodynamic parameters were strongly correlated to R1663 plasma concentrations. The inhibition was more pronounced on peak height (IC50 = 194 ng/ml) than on ETP (2790 ng/ml). Pharmacokinetics and pharmacodynamics of R1663 appeared not to be substantially affected by age or gender but remained to be confirmed in larger clinical trials including older patients. Meanwhile, dose adjustments based on age and gender are not anticipated.
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Basanagouda M, Jadhav VB, Kulkarni MV, Rao RN. Computer Aided Prediction of Biological Activity Spectra: Study of Correlation between Predicted and Observed Activities for Coumarin-4-Acetic Acids. Indian J Pharm Sci 2011; 73:88-92. [PMID: 22131629 PMCID: PMC3224418 DOI: 10.4103/0250-474x.89764] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Revised: 10/27/2010] [Accepted: 01/19/2011] [Indexed: 11/05/2022] Open
Abstract
Coumarin-4-acetic acids have been synthesized from various phenols and citric acid under Pechmann cyclisation conditions. All the compounds have been evaluated for antiinflammatory and analgesic activity in acute models. Compounds have also been evaluated for their ulcerogenic potential. Using the computer program, prediction of activity spectra for substances, prediction results and their Pharma Expert software, we have found a correlation between the observed and predicted antiinflammatory activity.
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Affiliation(s)
- M Basanagouda
- P. G. Department of Chemistry, Karnatak University, Dharwad - 580 003, India
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20
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Abstract
Although liver damage is a relatively rare adverse effect of oral anticoagulation with phenprocoumon, acute liver failure can be a serious treatment-associated complication. In this contribution, a patient with drug-induced liver failure during oral anticoagulation with phenprocoumon is presented. This case illustrates the need for close laboratory monitoring and suggests that phenrocoumon-induced liver damage should be considered along with other common complications of this treatment.
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Canbay A, Tacke F, Hadem J, Trautwein C, Gerken G, Manns MP. Acute liver failure: a life-threatening disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011. [PMID: 22114640 DOI: 10.3238/arztebl.2011.0714.epub] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND An estimated 200 to 500 patients develop life-threatening acute liver failure (ALF) in Germany each year. Only sparse data are currently available on the epidemiology and causes of this condition and on potential treatments for it. This article summarizes our current knowledge of the causes, clinical course, and treatment of ALF. METHOD We selectively reviewed the pertinent current literature on ALF from Germany and abroad. RESULTS A shift is currently taking place in Germany with respect to the predominant causes of ALF: The leading cause was formerly acute viral hepatitis, but now more cases of ALF are induced by toxic substances, while there is also a growing incidence of cryptogenic subacute ALF. Precise epidemiological data are still lacking. Scoring -systems for the assessment of ALF should take account of hepatic function, the regenerative capacity of the liver, the extent of existing extrahepatic complications, and the risk that further ones will develop. The mortality from ALF has been reduced through improved specific treatment for certain etiological types of ALF, the introduction of liver transplantation, and progress in intensive care medicine. The optimal treatment of ALF patients requires close collaboration among specialists in all of the involved clinical disciplines, as well as between peripheral hospitals and transplantation centers. CONCLUSION Precise epidemiological data on ALF are still lacking in Germany, as are prospective, randomized trials of treatments for it. It is nonetheless clear that progress has been made in its diagnosis and treatment.
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Affiliation(s)
- Ali Canbay
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen.
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Canbay A, Tacke F, Hadem J, Trautwein C, Gerken G, Manns MP. Acute liver failure: a life-threatening disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:714-20. [PMID: 22114640 DOI: 10.3238/arztebl.2011.0714] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 03/14/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND An estimated 200 to 500 patients develop life-threatening acute liver failure (ALF) in Germany each year. Only sparse data are currently available on the epidemiology and causes of this condition and on potential treatments for it. This article summarizes our current knowledge of the causes, clinical course, and treatment of ALF. METHOD We selectively reviewed the pertinent current literature on ALF from Germany and abroad. RESULTS A shift is currently taking place in Germany with respect to the predominant causes of ALF: The leading cause was formerly acute viral hepatitis, but now more cases of ALF are induced by toxic substances, while there is also a growing incidence of cryptogenic subacute ALF. Precise epidemiological data are still lacking. Scoring -systems for the assessment of ALF should take account of hepatic function, the regenerative capacity of the liver, the extent of existing extrahepatic complications, and the risk that further ones will develop. The mortality from ALF has been reduced through improved specific treatment for certain etiological types of ALF, the introduction of liver transplantation, and progress in intensive care medicine. The optimal treatment of ALF patients requires close collaboration among specialists in all of the involved clinical disciplines, as well as between peripheral hospitals and transplantation centers. CONCLUSION Precise epidemiological data on ALF are still lacking in Germany, as are prospective, randomized trials of treatments for it. It is nonetheless clear that progress has been made in its diagnosis and treatment.
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Affiliation(s)
- Ali Canbay
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen.
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23
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Evidence for immunological (allergic) mechanisms in a subgroup of patients with phenprocoumon-induced liver disease. Eur J Clin Pharmacol 2009; 65:1195-201. [PMID: 19641912 DOI: 10.1007/s00228-009-0705-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 07/09/2009] [Indexed: 10/20/2022]
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Hadem J, Stiefel P, Bahr MJ, Tillmann HL, Rifai K, Klempnauer J, Wedemeyer H, Manns MP, Schneider AS. Prognostic implications of lactate, bilirubin, and etiology in German patients with acute liver failure. Clin Gastroenterol Hepatol 2008; 6:339-45. [PMID: 18328438 DOI: 10.1016/j.cgh.2007.12.039] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Among the potentially helpful indicators of poor prognosis in acute liver failure (ALF) are etiology, encephalopathy grade, blood lactate, and King's College Criteria (KCC). The accuracy of these parameters in predicting transplantation or death shows significant variation in different countries. METHODS We retrospectively analyzed 102 patients with ALF treated at our institution between 1996 and 2005. Baseline parameters, simplified acute physiology score III (SAPS-III), KCC, Model for End-Stage Liver Disease (MELD) score, and a novel score of bilirubin, lactate, and etiology (BiLE score) were compared between transplant-free survivors and patients who required liver transplantation or died, by using multivariate linear regression analysis and receiver operating characteristics (ROC). RESULTS The most common causes of ALF were indeterminate liver failure (21%), acute hepatitis B (18%), acetaminophen ingestion (16%), and Budd-Chiari syndrome (9%). Transplantation-free survival was 38%, 44% of patients underwent liver transplantation, and 18% died without transplantation. Eight-week survival was 77%. The BiLE score was the best predictor of death or need of transplantation, with 79% sensitivity and 84% specificity. ROC analysis revealed a better performance of BiLE score when compared with bilirubin, lactate, MELD score, and SAPS-III (area under the curve: 0.87 +/- 0.04, 0.73 +/- 0.51, 0.73 +/- 0.52, 0.71 +/- 0.05, and 0.68 +/- 0.59, respectively). CONCLUSIONS The simple, combined BiLE score emerged as the best predictor of poor outcome in our patient cohort and should be prospectively evaluated in other populations.
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Affiliation(s)
- Johannes Hadem
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
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Walter T, Lot M, Guillaud O, Vial T, Boillot O, Dumortier J. [Liver toxicity associated with oral anticoagulant treatment: report of two cases]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2007; 31:615-6. [PMID: 17646791 DOI: 10.1016/s0399-8320(07)89441-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Hetzel PG, Glanzmann R, Hasler PW, Ladewick A, Bührer C. Coumarin embryopathy in an extremely low birth weight infant associated with neonatal hepatitis and ocular malformations. Eur J Pediatr 2006; 165:358-60. [PMID: 16411088 DOI: 10.1007/s00431-005-0064-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Revised: 11/19/2005] [Accepted: 11/28/2005] [Indexed: 10/25/2022]
Abstract
Coumarin embryopathy (CE) is a well-documented sequelae of prenatal exposure to vitamin K antagonists. We report on a female premature infant (25 weeks' gestation) born to a mother who had received phenprocoumon during pregnancy following mechanical heart valve replacement. The infant presented with impaired coagulation, intraventricular and minor parenchymal cerebral haemorrhages and midface hypoplasia typical of CE. In addition, there was hepatopathy with conjugated hyperbilirubinemia, elevated liver enzymes and repeated episodes of hypoglycemia upon attempts to discontinue glucose supplementation, all lasting for 4 months. There was corneal opacity with anterior segment dygenesis in the left eye, and persistent pupillary membrane, cataract and persistent hyperplastic primary vitreous in the right eye. While liver disease is an uncommon but serious side effect of vitamin K antagonists, this is the first report describing neonatal hepatopathy as part of CE. In anticoagulation of pregnant women with mechanical heart valves, vitamin K antagonists should be used with utmost restraint.
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Affiliation(s)
- Patrick G Hetzel
- Department of Neonatology, University Children's Hospital, Basel, Switzerland.
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Affiliation(s)
- Nipun Arora
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02115, USA
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Abstract
PURPOSE OF REVIEW To summarize the salient reviews, studies and case reports and series that dealt with clinical, pathological, methodological, and epidemiological descriptions of drug-induced liver disease in the calendar year 2004. RECENT FINDINGS While no new causes of drug-induced liver injury were reported for 2004, several new reports of previously recognized hepatotoxins, including herbal products, were published. These include the antiretroviral drugs for HIV and agents to manage tuberculosis. Acetaminophen (APAP) retained its preeminent position as the leading cause of drug-induced acute liver failure, currently accounting for nearly 50% of cases according to the latest figures from the U.S. Acute Liver Failure Study Group. Not surprisingly, APAP also heads the list of drugs and toxins leading to liver transplantation for acute hepatic failure. Efforts to reduce the number of cases of intentional APAP poisonings by restricting the number of tablets sold at any one time in the UK are ongoing, but the success of the program may be lessening, as was pointed out this year. The use of potentially hepatotoxic medications in patients with underlying liver disease was examined with the statins, and they emerged as a safe class for use in this setting. SUMMARY Given the apparent increasing incidence of acute liver failure attributable to APAP in the US, additional efforts are still needed to better define the risks associated with its use and to further reduce the incidence of severe liver injury from this widely used agent.
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Affiliation(s)
- Susan K Lazerow
- Division of Gastroenterology, Section of Hepatology, Georgetown University Medical Center, Washington, DC 20007, USA
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