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Celsa C, Cabibbo G, Pinato DJ. Reply to: "irLI or not irLI: That is the question". J Hepatol 2024; 81:e33-e34. [PMID: 38484915 DOI: 10.1016/j.jhep.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Ciro Celsa
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, Italy
| | - Giuseppe Cabibbo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, Italy
| | - David James Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy.
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Zhao X, Wang Y, Lai R, Wang X, Yu Y, Li M, Zhao H, Ma Z, Li M, Guo T, Han X, Meng Y, Zhang M, Su Y, Hao K, Deng Y, Kong Y, Li Z, Xie Q, Xie W, Chen C, Jia J. Validation of the revised electronic version of RUCAM for diagnosis of DILI in Chinese patients. Hepatol Commun 2024; 8:e0235. [PMID: 38466883 DOI: 10.1097/hc9.0000000000000235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/24/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND AIMS The Revised Electronic Causality Assessment Method (RECAM), a computerized update of the Roussel Uclaf Causality Assessment Methodology (RUCAM), was recently proposed. In this study, we validated and compared the utility of the RECAM and RUCAM in Chinese patients with a single conventional or herbal agent-induced liver injury. METHODS In this retrospective multicenter cohort of well-established DILI and non-DILI patients from 5 centers in China, the diagnostic performance of the RUCAM and RECAM was compared by AUC analysis. The consistency was evaluated by weighted kappa. The major causes of discrepancy were explored. RESULTS A total of 481 DILI and 100 non-DILI patients were included. In total, 62.6% of the DILI cases were induced by conventional agents, and 37.4% were induced by herbs. The RECAM had relatively higher AUC than RUCAM for overall [0.947 (0.926-0.964) vs. 0.867 (0.836-0.893), p=0.0016], conventional agents [0.923 (0.890-0.949) vs. 0.819 (0.775-0.858), p=0.0185], and herbs [0.972 (0.941-0.989) vs.0.911 (0.866-0.944), p=0.0199]. Latency, scores associated with hepatitis B, and hepatotoxicity information of the insulting drugs were the 3 main causes for the inconsistency between RECAM and RUCAM scores. CONCLUSIONS The RECAM had relatively better diagnostic performance than RUCAM, with a higher AUC for Chinese DILI patients. Timely updates of the LiverTox category and refinement of serum markers to exclude hepatitis B activity would further improve the applicability of RECAM in areas where the use of herbs and resolution of past HBV infections are common.
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Affiliation(s)
- Xinyan Zhao
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yan Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Rongtao Lai
- Department of Infectious Diseases, Ruijing Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaojin Wang
- Liver Disease Research Center, 905th Hospital of PLA Navy, China
| | - Yuecheng Yu
- Liver Disease Center of PLA and Department of Infectious Diseases, General Hospital of Eastern Theater Command, and Bayi Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Min Li
- Department of Clinical Epidemiology and EBM, Beijing Friendship Hospital, Capital Medical University; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Hong Zhao
- Liver Diseases Center, Beijing Ditan Hospital, Capital Medical University, 8 East Jingshun Road, Chaoyang District, Beijing, China
| | - Zikun Ma
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Mengqi Li
- Liver Diseases Center, Beijing Ditan Hospital, Capital Medical University, 8 East Jingshun Road, Chaoyang District, Beijing, China
| | - Tiantian Guo
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xiao Han
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yao Meng
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Mengmeng Zhang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yu Su
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Kunyan Hao
- Liver Disease Center of PLA and Department of Infectious Diseases, General Hospital of Eastern Theater Command, and Bayi Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - You Deng
- Liver Diseases Center, Beijing Ditan Hospital, Capital Medical University, 8 East Jingshun Road, Chaoyang District, Beijing, China
| | - Yuanyuan Kong
- Department of Clinical Epidemiology and EBM, Beijing Friendship Hospital, Capital Medical University; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Zhenyu Li
- Liver Disease Research Center, 905th Hospital of PLA Navy, China
| | - Qing Xie
- Department of Infectious Diseases, Ruijing Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wen Xie
- Liver Diseases Center, Beijing Ditan Hospital, Capital Medical University, 8 East Jingshun Road, Chaoyang District, Beijing, China
| | - Chengwei Chen
- Liver Disease Research Center, 905th Hospital of PLA Navy, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing, China
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Haller K, Doß S, Sauer M. In Vitro Hepatotoxicity of Routinely Used Opioids and Sedative Drugs. Curr Issues Mol Biol 2024; 46:3022-3038. [PMID: 38666919 PMCID: PMC11049542 DOI: 10.3390/cimb46040189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
A hepatocyte cell line was used to determine the hepatotoxicity of sedatives and opioids, as the hepatotoxicity of these drugs has not yet been well characterized. This might pose a threat, especially to critically ill patients, as they often receive high cumulative doses for daily analgosedation and often already have impaired liver function due to an underlying disease or complications during treatment. A well-established biosensor based on HepG2/C3A cells was used for the determination of the hepatotoxicity of commonly used sedatives and opioids in the intensive care setting (midazolam, propofol, s-ketamin, thiopental, fentanyl, remifentanil, and sufentanil). The incubation time was 2 × 3 days with clinically relevant (Cmax) and higher concentrations (C5× and C10×) of each drug in cell culture medium or human plasma. Afterward, we measured the cell count, vitality, lactate dehydrogenase (LDH), mitochondrial dehydrogenase activity, cytochrome P 450 1A2 (CYP1A2), and albumin synthesis. All tested substances reduced the viability of hepatocyte cells, but sufentanil and remifentanil showed more pronounced effects. The cell count was diminished by sufentanil in both the medium and plasma and by remifentanil only in plasma. Sufentanil and remifentanil also led to higher values of LDH in the cell culture supernatant. A reduction of mitochondrial dehydrogenase activity was seen with the use of midazolam and s-ketamine. Microalbumin synthesis was reduced in plasma after its incubation with higher concentrations of sufentanil and remifentanil. Remifentanil and s-ketamine reduced CYP1A2 activity, while propofol and thiopental increased it. Our findings suggest that none of the tested sedatives and opioids have pronounced hepatotoxicity. Sufentanil, remifentanil, and s-ketamine showed moderate hepatotoxic effects in vitro. These drugs should be given with caution to patients vulnerable to hepatotoxic drugs, e.g., patients with pre-existing liver disease or liver impairment as part of their underlying disease (e.g., hypoxic hepatitis or cholestatic liver dysfunction in sepsis). Further studies are indicated for this topic, which may use more complex cell culture models and global pharmacovigilance reports, addressing the limitation of the used cell model: HepG2/C3A cells have a lower metabolic capacity due to their low levels of CYP enzymes compared to primary hepatocytes. However, while the test model is suitable for parental substances, it is not for toxicity testing of metabolites.
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Affiliation(s)
- Katharina Haller
- Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany;
| | - Sandra Doß
- Department Extracorporeal Therapy Systems (EXTHER), Fraunhofer Institute for Cell Therapy and Immunology, Schillingallee 68, 18057 Rostock, Germany;
| | - Martin Sauer
- Department Extracorporeal Therapy Systems (EXTHER), Fraunhofer Institute for Cell Therapy and Immunology, Schillingallee 68, 18057 Rostock, Germany;
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Rostock, Schillingallee 35, 18057 Rostock, Germany
- Center for Anesthesiology and Intensive Care Medicine, Hospital of Magdeburg, Birkenallee 34, 39130 Magdeburg, Germany
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Moreno-Torres M, Quintás G, Martínez-Sena T, Jover R, Castell JV. Exploring Individual Variability in Drug-Induced Liver Injury (DILI) Responses through Metabolomic Analysis. Int J Mol Sci 2024; 25:3003. [PMID: 38474249 DOI: 10.3390/ijms25053003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/24/2024] [Accepted: 02/29/2024] [Indexed: 03/14/2024] Open
Abstract
Drug-induced liver injury (DILI) is a serious adverse hepatic event presenting diagnostic and prognostic challenges. The clinical categorization of DILI into hepatocellular, cholestatic, or mixed phenotype is based on serum alanine aminotransferase (ALT) and alkaline phosphatase (ALP) values; however, this classification may not capture the full spectrum of DILI subtypes. With this aim, we explored the utility of assessing changes in the plasma metabolomic profiles of 79 DILI patients assessed by the RUCAM (Roussel Uclaf Causality Assessment Method) score to better characterize this condition and compare results obtained with the standard clinical characterization. Through the identification of various metabolites in the plasma (including free and conjugated bile acids and glycerophospholipids), and the integration of this information into predictive models, we were able to evaluate the extent of the hepatocellular or cholestatic phenotype and to assign a numeric value with the contribution of each specific DILI sub-phenotype into the patient's general condition. Additionally, our results showed that metabolomic analysis enabled the monitoring of DILI variability responses to the same drug, the transitions between sub-phenotypes during disease progression, and identified a spectrum of residual DILI metabolic features, which can be overlooked using standard clinical diagnosis during patient follow-up.
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Affiliation(s)
- Marta Moreno-Torres
- Unidad Mixta de Hepatología Experimental, Instituto de Investigación Sanitaria del Hospital La Fe (IIS La Fe), 46026 Valencia, Spain
- Departamento de Bioquímica y Biología Molecular, Facultad de Medicina y Odontología, Universidad de Valencia, 46010 Valencia, Spain
- Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas CIBEREHD, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Guillermo Quintás
- Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas CIBEREHD, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Metabolomics and Bioanalysis, Leitat Technological Center (LEITAT,) 46026 Valencia, Spain
| | - Teresa Martínez-Sena
- Unidad Mixta de Hepatología Experimental, Instituto de Investigación Sanitaria del Hospital La Fe (IIS La Fe), 46026 Valencia, Spain
| | - Ramiro Jover
- Unidad Mixta de Hepatología Experimental, Instituto de Investigación Sanitaria del Hospital La Fe (IIS La Fe), 46026 Valencia, Spain
- Departamento de Bioquímica y Biología Molecular, Facultad de Medicina y Odontología, Universidad de Valencia, 46010 Valencia, Spain
- Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas CIBEREHD, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - José V Castell
- Unidad Mixta de Hepatología Experimental, Instituto de Investigación Sanitaria del Hospital La Fe (IIS La Fe), 46026 Valencia, Spain
- Departamento de Bioquímica y Biología Molecular, Facultad de Medicina y Odontología, Universidad de Valencia, 46010 Valencia, Spain
- Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas CIBEREHD, Instituto de Salud Carlos III, 28029 Madrid, Spain
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5
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Jeon JS, Kim H, Jo S, Sim J, Kim SK. Role of microsomal metabolism in bromfenac-induced cytotoxicity. Chem Biol Interact 2024; 391:110903. [PMID: 38331335 DOI: 10.1016/j.cbi.2024.110903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/23/2024] [Accepted: 02/05/2024] [Indexed: 02/10/2024]
Abstract
This study delves into the intricate mechanisms underlying drug-induced liver injury (DILI) with a specific focus on bromfenac, the withdrawn nonsteroidal anti-inflammatory drug. DILI is a pervasive concern in drug development, prompting market withdrawals and posing significant challenges to healthcare. Despite the withdrawal of bromfenac due to DILI, the exact role of its microsomal metabolism in inducing hepatotoxicity remains unclear. Herein, employing HepG2 cells with human liver microsomes and UDP-glucuronic acid (UDPGA), our investigation revealed a substantial increase in bromfenac-induced cytotoxicity in the presence of UDPGA, pointing to the significance of UDP-glucuronosyltransferase (UGT)-dependent metabolism in augmenting toxicity. Notably, among the recombinant UGTs examined, UGT2B7 emerged as a pivotal enzyme in the metabolic activation of bromfenac. Metabolite identification studies disclosed the formation of reactive intermediates, with bromfenac indolinone (lactam) identified as a potential mediator of hepatotoxic effects. Moreover, in cytotoxicity experiments, the toxicity of bromfenac lactam exhibited a 34-fold increase, relative to bromfenac. The toxicity of bromfenac lactam was mitigated by nicotinamide adenine dinucleotide phosphate-dependent metabolism. This finding underscores the role of UGT-dependent metabolism in generating reactive metabolites that contribute to the observed hepatotoxicity associated with bromfenac. Understanding these metabolic pathways and the involvement of specific enzymes, such as UGT2B7, provides crucial insights into the mechanisms of bromfenac-induced liver injury. In conclusion, this research sheds light on the metabolic intricacies leading to cytotoxicity induced by bromfenac, especially emphasizing the role of UGT-dependent metabolism and the formation of reactive intermediates like bromfenac lactam. These findings offer insight into the mechanistic basis of DILI and emphasize the importance of understanding metabolism-mediated toxicity.
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Affiliation(s)
- Jang Su Jeon
- College of Pharmacy, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Hyemin Kim
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon, 34114, Republic of Korea
| | - Seongyea Jo
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon, 34114, Republic of Korea
| | - Jaehoon Sim
- College of Pharmacy, Kyung Hee University, Seoul, 02447, Republic of Korea.
| | - Sang Kyum Kim
- College of Pharmacy, Chungnam National University, Daejeon, 34134, Republic of Korea.
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6
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Lucena MI, Villanueva-Paz M, Alvarez-Alvarez I, Aithal GP, Björnsson ES, Cakan-Akdogan G, Cubero FJ, Esteves F, Falcon-Perez JM, Fromenty B, Garcia-Ruiz C, Grove JI, Konu O, Kranendonk M, Kullak-Ublick GA, Miranda JP, Remesal-Doblado A, Sancho-Bru P, Nelson L, Andrade RJ, Daly AK, Fernandez-Checa JC. Roadmap to DILI research in Europe. A proposal from COST action ProEuroDILINet. Pharmacol Res 2024; 200:107046. [PMID: 38159783 DOI: 10.1016/j.phrs.2023.107046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
In the current article the aims for a constructive way forward in Drug-Induced Liver Injury (DILI) are to highlight the most important priorities in research and clinical science, therefore supporting a more informed, focused, and better funded future for European DILI research. This Roadmap aims to identify key challenges, define a shared vision across all stakeholders for the opportunities to overcome these challenges and propose a high-quality research program to achieve progress on the prediction, prevention, diagnosis and management of this condition and impact on healthcare practice in the field of DILI. This will involve 1. Creation of a database encompassing optimised case report form for prospectively identified DILI cases with well-characterised controls with competing diagnoses, biological samples, and imaging data; 2. Establishing of preclinical models to improve the assessment and prediction of hepatotoxicity in humans to guide future drug safety testing; 3. Emphasis on implementation science and 4. Enhanced collaboration between drug-developers, clinicians and regulatory scientists. This proposed operational framework will advance DILI research and may bring together basic, applied, translational and clinical research in DILI.
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Affiliation(s)
- M I Lucena
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Plataforma de Investigación Clínica y Ensayos Clínicos UICEC-IBIMA, Plataforma ISCIII de Investigación Clínica, Madrid, Spain.
| | - M Villanueva-Paz
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - I Alvarez-Alvarez
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - G P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom; NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - E S Björnsson
- Faculty of Medicine, University of Iceland, Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - G Cakan-Akdogan
- Izmir Biomedicine and Genome Center, Izmir, Turkey. Department of Medical Biology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - F J Cubero
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Department of Immunology, Ophthalmology and ORL, Complutense University School of Medicine, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - F Esteves
- Center for Toxicogenomics and Human Health (ToxOmics), NMS | FCM, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - J M Falcon-Perez
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Exosomes Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Derio, Bizkaia, 48160, Spain. IKERBASQUE, Basque Foundation for Science, Bilbao, Bizkaia 48009, Spain
| | - B Fromenty
- INSERM, Univ Rennes, INRAE, Institut NUMECAN (Nutrition Metabolisms and Cancer) UMR_A 1341, UMR_S 1317, F-35000 Rennes, France
| | - C Garcia-Ruiz
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. University of Barcelona, Barcelona, Spain; Department of Cell Death and Proliferation, Institute of Biomedical Research of Barcelona (IIBB), CSIC, Barcelona, Spain
| | - J I Grove
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom; NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - O Konu
- Department of Molecular Biology and Genetics, Faculty of Science, Bilkent University, Ankara, Turkey; Interdisciplinary Neuroscience Program, Bilkent University, Ankara, Turkey; UNAM-Institute of Materials Science and Nanotechnology, Bilkent University, Ankara, Turkey
| | - M Kranendonk
- Center for Toxicogenomics and Human Health (ToxOmics), NMS | FCM, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - G A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; CMO & Patient Safety, Global Drug Development, Novartis Pharma, Basel, Switzerland
| | - J P Miranda
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - A Remesal-Doblado
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
| | - P Sancho-Bru
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. University of Barcelona, Barcelona, Spain
| | - L Nelson
- Institute for Bioengineering, School of Engineering, Faraday Building, The University of Edinburgh, Scotland, UK
| | - R J Andrade
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - A K Daly
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - J C Fernandez-Checa
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. University of Barcelona, Barcelona, Spain; Department of Cell Death and Proliferation, Institute of Biomedical Research of Barcelona (IIBB), CSIC, Barcelona, Spain; Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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Rogozina O, Ruiz-Fernández C, Martín-López S, Akatbach-Bousaid I, González-Muñoz M, Ramírez E. Organ-specific immune-mediated reactions to polyethylene glycol and polysorbate excipients: three case reports. Front Pharmacol 2024; 14:1293294. [PMID: 38235115 PMCID: PMC10792031 DOI: 10.3389/fphar.2023.1293294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024] Open
Abstract
Drug-related acute pancreatitis (AP), acute interstitial nephritis (AIN) and drug-induced liver injury (DILI) are rare but serious adverse drug reactions (ADRs) that can have life-threatening consequences. Although the diagnosis of these ADRs can be challenging, causality algorithms and the lymphocyte transformation test (LTT) can be employed to help with the diagnosis. In this report, we present 3 cases of drug-related AP, AIN and DILI. The first case involved a patient with AP to lacosamide and to the excipient polysorbate 80 in pantoprazole. The second case involved a patient with DILI secondary to polyethylene glycol (PEG) excipients and amoxicillin-clavulanate. In case 3, AIN was considered to be the result of sensitization to excipients. Diagnoses were made using causality algorithms and the LTT. The LTT is a useful tool for helping diagnose drug-related AP and DILI, and it can be used to identify the specific drug or excipient causing the ADR. These cases highlight the importance of considering PEG and polysorbate excipients in the causality diagnosis of ADRs.
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Affiliation(s)
- Olga Rogozina
- Clinical Pharmacology Department, La Paz University Hospital-IdiPAZ, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | | | - Susana Martín-López
- Clinical Pharmacology Department, La Paz University Hospital-IdiPAZ, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | | | | | - Elena Ramírez
- Clinical Pharmacology Department, La Paz University Hospital-IdiPAZ, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
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8
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Tse J, Natla S, Mekala R, Crumm I, Olken MH. Atorvastatin-Induced Autoimmune Hepatitis: A Case Report. Cureus 2023; 15:e47807. [PMID: 38021877 PMCID: PMC10679798 DOI: 10.7759/cureus.47807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Drug-induced autoimmune hepatitis (DIAIH) is a poorly understood form of drug-induced liver injury that presents with features mimicking autoimmune hepatitis. Statins, commonly prescribed for lowering cholesterol and for cardiovascular disease prevention, have been documented in rare cases as being responsible for DIAIH. In this case report, we detail a case where a patient developed DIAIH due to her atorvastatin. We also highlight the diagnostic approach and management strategies for DIAIH.
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Affiliation(s)
- Jonathan Tse
- Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
| | - Sam Natla
- Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
| | - Rohit Mekala
- Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
| | - Ian Crumm
- Internal Medicine/Pediatrics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
| | - Melissa H Olken
- Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
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Andrade RJ, Aithal GP, de Boer YS, Liberal R, Gerbes A, Regev A, Terziroli Beretta-Piccoli B, Schramm C, Kleiner DE, De Martin E, Kullak-Ublick GA, Stirnimann G, Devarbhavi H, Vierling JM, Manns MP, Sebode M, Londoño MC, Avigan M, Robles-Diaz M, García-Cortes M, Atallah E, Heneghan M, Chalasani N, Trivedi PJ, Hayashi PH, Taubert R, Fontana RJ, Weber S, Oo YH, Zen Y, Licata A, Lucena MI, Mieli-Vergani G, Vergani D, Björnsson ES. Nomenclature, diagnosis and management of drug-induced autoimmune-like hepatitis (DI-ALH): An expert opinion meeting report. J Hepatol 2023; 79:853-866. [PMID: 37164270 PMCID: PMC10735171 DOI: 10.1016/j.jhep.2023.04.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/26/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
Drug-induced liver injury (DILI) can mimic almost all other liver disorders. A phenotype increasingly ascribed to drugs is autoimmune-like hepatitis (ALH). This article summarises the major topics discussed at a joint International Conference held between the Drug-Induced Liver Injury consortium and the International Autoimmune Hepatitis Group. DI-ALH is a liver injury with laboratory and/or histological features that may be indistinguishable from those of autoimmune hepatitis (AIH). Previous studies have revealed that patients with DI-ALH and those with idiopathic AIH have very similar clinical, biochemical, immunological and histological features. Differentiating DI-ALH from AIH is important as patients with DI-ALH rarely require long-term immunosuppression and the condition often resolves spontaneously after withdrawal of the implicated drug, whereas patients with AIH mostly require long-term immunosuppression. Therefore, revision of the diagnosis on long-term follow-up may be necessary in some cases. More than 40 different drugs including nitrofurantoin, methyldopa, hydralazine, minocycline, infliximab, herbal and dietary supplements (such as Khat and Tinospora cordifolia) have been implicated in DI-ALH. Understanding of DI-ALH is limited by the lack of specific markers of the disease that could allow for a precise diagnosis, while there is similarly no single feature which is diagnostic of AIH. We propose a management algorithm for patients with liver injury and an autoimmune phenotype. There is an urgent need to prospectively evaluate patients with DI-ALH systematically to enable definitive characterisation of this condition.
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Affiliation(s)
- Raúl J Andrade
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Ynto S de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, VU University Medical Center, Amsterdam, Netherlands
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar Universitário de São João, Porto, Portugal; Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | - Arie Regev
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Christoph Schramm
- Department of Medicine, University Medical Center Hamburg-Eppendorf. Hamburg Center for Translational Immunology. Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Eleonora De Martin
- APHP, Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, FHU Hepatinov, Villejuif, France
| | - Gerd A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Mechanistic Safety, Global Drug Development, Novartis, Basel, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - John M Vierling
- Departments of Medicine and Surgery, Section of Gastroenterology and Hepatology and Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, United States
| | - Michael P Manns
- Hannover Medical School, Centre of ERN RARE-LIVER, Hannover, Germany
| | - Marcial Sebode
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Maria Carlota Londoño
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Institut d' Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Mark Avigan
- Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Mercedes Robles-Diaz
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Miren García-Cortes
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edmond Atallah
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | | | - Naga Chalasani
- University School of Medicine & Indiana University Health, Indianapolis, Indiana, USA
| | - Palak J Trivedi
- NIHR Birmingham BRC, Institute of Immunology and Immunotherapy, Centre for Liver and Gastrointestinal Research, Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Paul H Hayashi
- Division of Hepatology and Nutrition, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Sabine Weber
- Department of Medicine II, LMU Klinikum Munich, Munich, Germany
| | - Ye Htun Oo
- Center for Liver and Gastro Research & National Institute of Health Research Birmingham Biomedical Research Centre, University of Birmingham, Centre for Rare Disease and ERN Rare Liver Centre, Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, UK
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK
| | - Anna Licata
- Medicina Interna ed Epatologia, Università degli Studi di Palermo, Palermo, Italy
| | - M Isabel Lucena
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Platform ISCiii for Clinical Research and Clinical Trials SCReN UICEC- IBIMA, Málaga, Spain.
| | - Giorgina Mieli-Vergani
- MowatLabs, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, United Kingdom
| | - Diego Vergani
- MowatLabs, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, United Kingdom
| | - Einar S Björnsson
- Faculty of Medicine, University of Iceland, Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
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10
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Sanchez JL, Khiella M, Khoury M, Aryal BB, Verda L. A Fatal Case of Bictegravir-Induced Fulminant Hepatic Failure. Clin Drug Investig 2023; 43:205-208. [PMID: 36856947 DOI: 10.1007/s40261-023-01250-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 03/02/2023]
Affiliation(s)
- Jacob Louis Sanchez
- Department of Internal Medicine, Ross University School of Medicine, Two Mile Hill St. Michael, Barbados
| | - Marco Khiella
- Department of Internal Medicine, Mount Sinai Hospital, 1500 S Fairfield Ave, Chicago, IL, 60608, USA
| | - Mtanis Khoury
- Department of Internal Medicine, Mount Sinai Hospital, 1500 S Fairfield Ave, Chicago, IL, 60608, USA
| | - Barun Babu Aryal
- Department of Internal Medicine, Mount Sinai Hospital, 1500 S Fairfield Ave, Chicago, IL, 60608, USA.
| | - Larissa Verda
- Department of Internal Medicine, Mount Sinai Hospital, 1500 S Fairfield Ave, Chicago, IL, 60608, USA
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11
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Influence of Antibiotics on Functionality and Viability of Liver Cells In Vitro. Curr Issues Mol Biol 2022; 44:4639-4657. [PMID: 36286032 PMCID: PMC9600611 DOI: 10.3390/cimb44100317] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/17/2022] [Accepted: 09/22/2022] [Indexed: 11/22/2022] Open
Abstract
(1) Antibiotics are an important weapon in the fight against serious bacterial infections and are considered a common cause of drug-induced liver injury (DILI). The hepatotoxicity of many drugs, including antibiotics, is poorly analyzed in human in vitro models. (2) A standardized assay with a human hepatoma cell line was used to test the hepatotoxicity of various concentrations (Cmax, 5× Cmax, and 10× Cmax) of antibiotics. In an ICU, the most frequently prescribed antibiotics, ampicillin, cefepime, cefuroxime, levofloxacin, linezolid, meropenem, rifampicin, tigecycline, and vancomycin, were incubated with HepG2/C3A cells for 6 days. Cell viability (XTT assay, LDH release, and vitality), albumin synthesis, and cytochrome 1A2 activity were determined in cells. (3) In vitro, vancomycin, rifampicin, and tigecycline showed moderate hepatotoxic potential. The antibiotics ampicillin, cefepime, cefuroxime, levofloxacin, linezolid, and meropenem were associated with mild hepatotoxic reactions in test cells incubated with the testes Cmax concentration. Rifampicin and cefuroxime showed significantly negative effects on the viability of test cells. (4) Further in vitro studies and global pharmacovigilance reports should be conducted to reveal underlying mechanism of the hepatotoxic action of vancomycin, rifampicin, tigecycline, and cefuroxime, as well as the clinical relevance of these findings.
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12
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RECAM: A New and Improved, Computerized Causality Assessment Tool for DILI Diagnosis. Am J Gastroenterol 2022; 117:1387-1389. [PMID: 35973138 DOI: 10.14309/ajg.0000000000001836] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/06/2022] [Indexed: 12/11/2022]
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13
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Naseralallah LM, Aboujabal BA, Geryo NM, Al Boinin A, Al Hattab F, Akbar R, Umer W, Abdul Jabbar L, Danjuma MI. The determination of causality of drug induced liver injury in patients with COVID-19 clinical syndrome. PLoS One 2022; 17:e0268705. [PMID: 36048762 PMCID: PMC9436150 DOI: 10.1371/journal.pone.0268705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 05/05/2022] [Indexed: 02/06/2023] Open
Abstract
Background
Drug induced liver injury (DILI) is a rising morbidity amongst patients with COVID-19 clinical syndrome. The updated RUCAM causality assessment scale is validated for use in the general population, but its utility for causality determination in cohorts of patients with COVID-19 and DILI remains uncertain.
Methods
This retrospective study was comprised of COVID-19 patients presenting with suspected DILI to the emergency department of Weill Cornell medicine-affiliated Hamad General Hospital, Doha, Qatar. All cases that met the inclusion criteria were comparatively adjudicated by two independent rating pairs (2 clinical pharmacist and 2 physicians) utilizing the updated RUCAM scale to assess the likelihood of DILI.
Results
A total of 72 patients (mean age 48.96 (SD ± 10.21) years) were examined for the determination of DILI causality. The majority had probability likelihood of “possible” or “probable” by the updated RUCAM scale. Azithromycin was the most commonly reported drug as a cause of DILI. The median R-ratio was 4.74 which correspond to a mixed liver injury phenotype. The overall Krippendorf’s kappa was 0.52; with an intraclass correlation coefficient (ICC) of 0.79 (IQR 0.72–0.85). The proportion of exact pairwise agreement and disagreement between the rating pairs were 64.4%, kappa 0.269 (ICC 0.28 [0.18, 0.40]) and kappa 0.45 (ICC 0.43 [0.29–0.57]), respectively.
Conclusion
In a cohort of patients with COVID-19 clinical syndrome, we found the updated RUCAM scale to be useful in establishing “possible” or “probable” DILI likelihood as evident by the respective kappa values; this results if validated by larger sample sized studies will extend the clinical application of this universal tool for adjudication of DILI.
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Affiliation(s)
- Lina Mohammad Naseralallah
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
- School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | - Nejat Mohamed Geryo
- Division of General Internal Medicine, Weill Cornell affiliated-Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Aisha Al Boinin
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | | | - Raza Akbar
- Division of General Internal Medicine, Weill Cornell affiliated-Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Waseem Umer
- Division of General Internal Medicine, Weill Cornell affiliated-Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Layla Abdul Jabbar
- Division of General Internal Medicine, Weill Cornell affiliated-Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed I. Danjuma
- Division of General Internal Medicine, Weill Cornell affiliated-Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, QU Health, Qatar University, Doha, Qatar
- Weill Cornell College of Medicine, New York, Doha, Qatar
- * E-mail:
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14
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A Comprehensive Review on the Use of Herbal Dietary Supplements in the USA, Reasons for Their Use, and Review of Potential Hepatotoxicity. LIVERS 2022. [DOI: 10.3390/livers2030011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Herbal and dietary supplement (HDS) use has grown exponentially in the United States. Unfortunately, the incidence of HDS-related liver injury has proportionally increased. Despite the potential for certain HDSs to cause clinically significant liver injury, they are not regulated by the Food and Drug Administration. Recent efforts have been made to regulate HDSs but are far removed from the scrutiny of prescription medications. Scant literature exists on HDSs and their risks of causing liver injury. In this comprehensive review, we examine trends of HDS use in the United States and the pathophysiologic mechanisms of drug-induced liver injury (DILI) of certain HDSs. Finally, we review usage rates; benefits, if any; purported pathophysiology of DILI; and propensity for progression to fulminant hepatic failure of nine HDSs linked to clinically significant DILI.
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15
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Hayashi PH, Lucena MI, Fontana RJ, Bjornsson ES, Aithal GP, Barnhart H, Jimenez AG, Yang Q, Gu J, Andrade RJ, Hoofnagle JH. A revised electronic version of RUCAM for the diagnosis of DILI. Hepatology 2022; 76:18-31. [PMID: 35014066 PMCID: PMC9233102 DOI: 10.1002/hep.32327] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Roussel Uclaf Causality Assessment Method (RUCAM) for DILI has been hindered by subjectivity and poor reliability. We sought to improve the RUCAM using data from the Drug-Induced Liver Injury Network (DILIN) and the Spanish DILI Registry, published literature, and iterative computer modeling. APPROACH AND RESULTS RUCAM criteria were updated, clarified, and computerized. We removed criteria 3 (risk factors) for lack of added value and criteria 4 because we felt it more useful to assess each drug separately. Criteria 6 (drug-specific risk) was anchored to LiverTox likelihood scores. Iterative testing in subsets of 50-100 single-agent, nonherbal cases from both registries was done to optimize performance. We used classification tree analysis to establish diagnostic cutoffs for this revised electronic causality assessment method (RECAM) and compared RECAM with RUCAM for correlation with expert opinion diagnostic categories in 194 DILI cases (98 DILIN, 96 Spanish DILI). Area under receiver operator curves for identifying at least probable DILI were the same at 0.89 for RECAM and RUCAM. However, RECAM diagnostic categories have better observed overall agreement with expert opinion (0.62 vs. 0.56 weighted kappa, p = 0.14), and had better sensitivity to detect extreme diagnostic categories (73 vs. 54 for highly likely or high probable, p = 0.02; 65 vs. 48 for unlikely/excluded, p = 0.08) than RUCAM diagnostic categories. CONCLUSIONS RECAM is an evidence-based update that is at least as capable as RUCAM in diagnosing DILI compared with expert opinion but is better than RUCAM at the diagnostic extremes. RECAM's increased objectivity and clarity will improve precision, reliability, and standardization of DILI diagnosis, but further refinement and validation in other cohorts are needed.
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Affiliation(s)
| | - M. Isabel Lucena
- Servicio de Aparato Digestivo y de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Facultad de Medicina, Universidad de Málaga, Málaga, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), UICEC-IBIMA, Plataforma Investigación Clínica, Madrid, Spain
| | | | - Einar S Bjornsson
- Landspitali University Hospital, Reykjavik, Iceland,Faculty of Medicine, University of Iceland, Reykjavik Iceland
| | - Guruprasad P. Aithal
- NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust and the University of Nottingham, United Kingdom
| | | | - Andres Gonzalez Jimenez
- Servicio de Aparato Digestivo y de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Facultad de Medicina, Universidad de Málaga, Málaga, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), UICEC-IBIMA, Plataforma Investigación Clínica, Madrid, Spain
| | | | | | - Raul J Andrade
- Servicio de Aparato Digestivo y de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Facultad de Medicina, Universidad de Málaga, Málaga, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), UICEC-IBIMA, Plataforma Investigación Clínica, Madrid, Spain
| | - Jay H. Hoofnagle
- National Institute of Diabetes and Digestive and Kidney Diseases-Bethesda, MD, USA
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16
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Lewis JH. Digitizing DILI: Who can? RUCAM? RECAM? Hepatology 2022; 76:3-5. [PMID: 34990036 DOI: 10.1002/hep.32312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 12/15/2022]
Affiliation(s)
- James H Lewis
- Department of Medicine, Georgetown University Hospital, Washington, District of Columbia, USA
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17
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Weber S, Gerbes AL. Challenges and Future of Drug-Induced Liver Injury Research-Laboratory Tests. Int J Mol Sci 2022; 23:ijms23116049. [PMID: 35682731 PMCID: PMC9181520 DOI: 10.3390/ijms23116049] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/22/2022] [Accepted: 05/24/2022] [Indexed: 02/04/2023] Open
Abstract
Drug-induced liver injury (DILI) is a rare but potentially severe adverse drug event, which is also a major cause of study cessation and market withdrawal during drug development. Since no acknowledged diagnostic tests are available, DILI diagnosis poses a major challenge both in clinical practice as well as in pharmacovigilance. Differentiation from other liver diseases and the identification of the causative agent in the case of polymedication are the main issues that clinicians and drug developers face in this regard. Thus, efforts have been made to establish diagnostic testing methods and biomarkers in order to safely diagnose DILI and ensure a distinguishment from alternative liver pathologies. This review provides an overview of the diagnostic methods used in differential diagnosis, especially with regards to autoimmune hepatitis (AIH) and drug-induced autoimmune hepatitis (DI-AIH), in vitro causality methods using individual blood samples, biomarkers for diagnosis and severity prediction, as well as experimental predictive models utilized in pre-clinical settings during drug development regimes.
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18
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Rao A, Rule JA, Hameed B, Ganger D, Fontana RJ, Lee WM. Secular Trends in Severe Idiosyncratic Drug-Induced Liver Injury in North America: An Update From the Acute Liver Failure Study Group Registry. Am J Gastroenterol 2022; 117:617-626. [PMID: 35081550 PMCID: PMC10668505 DOI: 10.14309/ajg.0000000000001655] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Idiosyncratic drug-induced liver injury (DILI) is the second leading cause of acute liver failure (ALF) in the United States. Our study aims were to characterize secular trends in the implicated agents, clinical features, and outcomes of adults with DILI ALF over a 20-year period. METHODS Among 2,332 patients with ALF enrolled in the ALF Study Group registry, 277 (11.9%) were adjudicated as idiosyncratic DILI ALF (INR ≥ 1.5 and hepatic encephalopathy) through expert opinion. The 155 cases in era 1 (January 20, 1998-January 20, 2008) were compared with the 122 cases in era 2 (January 21, 2008-January 20, 2018). RESULTS Among 277 cases of DILI ALF, 97 different agents, alone or in combination, were implicated: antimicrobials, n = 118 (43%); herbal/dietary supplements (HDS), n = 42 (15%); central nervous system agents/illicit substances, n = 37 (13%); oncologic/biologic agents, n = 29 (10%); and other, n = 51 (18%). Significant trends over time included (i) an increase in HDS DILI ALF (9.7% vs 22%, P < 0.01) and decrease in antimicrobial-induced DILI ALF (45.8% vs. 38.5%, P = 0.03) and (ii) improved overall transplant-free survival (23.5%-38.7%, P < 0.01) while the number of patients transplanted declined (46.4% vs 33.6%, P < 0.03). DISCUSSION DILI ALF in North America is evolving, with HDS cases rising and other categories of suspect drugs declining. The reasons for a significant increase in transplant-free survival and reduced need for liver transplantation over time remain unclear but may be due to improvements in critical care, increased NAC utilization, and improved patient prognostication.
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Affiliation(s)
- Ashwin Rao
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jody A. Rule
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Daniel Ganger
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA
| | - Robert J. Fontana
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - William M. Lee
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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19
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Philips CA, Theruvath AH, Ravindran R. Toxic hepatitis-associated aplastic anaemia after dual homeopathic remedies and Gymnema sylvestre use. BMJ Case Rep 2022; 15:e247867. [PMID: 35318201 PMCID: PMC8943757 DOI: 10.1136/bcr-2021-247867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 01/01/2023] Open
Abstract
Hepatitis-associated aplastic anaemia (HAAA) is a rare condition characterised by onset of acute hepatitis which is followed by development of severe pancytopenia due to bone marrow failure within 6 months. This syndrome can be precipitated by acute viral infections, but the aetiology remains unknown in the majority. Drug-induced HAAA is extremely rare and has been reported with nutritional and dietary supplements in current literature. We report the first cases of ayurvedic herbal and homeopathic remedies-associated HAAA in two patients which proved fatal in both. Evaluation of patients with acute hepatitis and severe pancytopenia must include a detailed evaluation for complementary and alternative medicine use.
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Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology, Rajagiri Hospital, Aluva, Kerala, India
| | | | - Resmi Ravindran
- Department of Clinical Research, Rajagiri Hospital, Aluva, Kerala, India
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20
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Rodríguez A, García-García I, Martínez de Soto L, Gómez López De Las Huertas A, Borobia AM, González-Torbay A, Akatbach-Bousaid I, González-Muñoz M, Ramírez E. Utility of Lymphocyte Transformation Test for Assisting Updated Roussel Uclaf Causality Assessment Method in Drug-Induced Liver Injury: A Case-Control Study. Front Pharmacol 2022; 13:819589. [PMID: 35370653 PMCID: PMC8965575 DOI: 10.3389/fphar.2022.819589] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/02/2022] [Indexed: 11/21/2022] Open
Abstract
Background: The Roussel Uclaf Causality Assessment Method (RUCAM) is a validated tool for assessing causality in cases of suspected drug-induced liver injury (DILI). However, RUCAM cannot discriminate between concomitant hepatotoxic drugs with the same temporal sequence. Objective: To analyse the utility of the lymphocyte transformation test (LTT) for assisting updated RUCAM in 45 patients and 40 controls with a clinical diagnosis of DILI. Methods: Suspected DILI cases were detected through the Prospective Pharmacovigilance Program from Laboratory Signals in Hospital (PPLSH) or by consultations. The controls completed the drug therapy with no adverse reactions during the study period. A receiver operating characteristics (ROC) curve analysis was performed to calculate the optimal cut-off value for the stimulation index (SI), corresponding to the largest sum for the specificity and sensitivity values of LTT for true DILI cases. Results: Out of 45 patients diagnosed with DILI, 42 cases were detected by the PPLSH, two cases by consultation and one case by both methods. Most DILI cases (64.4%) arose during hospitalization. According to the biochemical parameters, 24 cases (53.3%) had the hepatocellular phenotype, 14 (31.1%) had the cholestatic phenotype, and 7 cases (15.6%) had the mixed phenotype. Considering the severity criteria, 7 (15.5%) cases were classified as moderate DILI, and 4 (8.9%) were severe DILI; there were no fatal cases. A total of 149 drugs (median/case, 3; IQR, 2–5) were suspected to be involved in the DILI cases (RUCAM score ≥3). In 8 cases, only one drug was suspected, and polypharmacy (≥5 drugs) was identified in 29% of the cases. Of all DILI cases, 46 (30.9%) of the 149 suspected drugs produced positive LTT results, and the LTT was positive in 34 (75.5%) of the 45 patients. No exposed controls produced positive LTT results. The optimal cut-off of 1.95 for the SI was obtained with a sensitivity of 77% and specificity of 100% (area under the curve, 0.91; 95% asymptotic confidence interval 0.84–0.97; p < 0.001). The sensitivity of the hepatocellular phenotype was 92%. Conclusion: Our results demonstrate that LTT is an add on strengthening causality in cases of suspected idiosyncratic DILI, especially for patients with several suspected drugs and a hepatocellular phenotype.
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Affiliation(s)
- Amelia Rodríguez
- Clinical Pharmacology Department, Faculty of Medicine, La Paz University Hospital-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
| | - Irene García-García
- Clinical Pharmacology Department, Faculty of Medicine, La Paz University Hospital-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
| | - Lucía Martínez de Soto
- Clinical Pharmacology Department, Faculty of Medicine, La Paz University Hospital-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
| | - Arturo Gómez López De Las Huertas
- Clinical Pharmacology Department, Faculty of Medicine, La Paz University Hospital-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alberto M. Borobia
- Clinical Pharmacology Department, Faculty of Medicine, La Paz University Hospital-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
| | | | | | - Miguel González-Muñoz
- Immunology Department, La Paz University Hospital-IdiPAZ, Madrid, Spain
- *Correspondence: Miguel González-Muñoz, ; Elena Ramírez,
| | - Elena Ramírez
- Clinical Pharmacology Department, Faculty of Medicine, La Paz University Hospital-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- *Correspondence: Miguel González-Muñoz, ; Elena Ramírez,
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Bessone F, Hernandez N, Tagle M, Arrese M, Parana R, Méndez-Sánchez N, Ridruejo E, Mendizabal M, Dagher L, Contreras F, Fassio E, Pessoa M, Brahm J, Silva M. Drug-induced liver injury: A management position paper from the Latin American Association for Study of the liver. Ann Hepatol 2022; 24:100321. [PMID: 33609753 DOI: 10.1016/j.aohep.2021.100321] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 02/06/2023]
Abstract
Idiosyncratic drug-induced liver injury (DILI) caused by xenobiotics (drugs, herbals and dietary supplements) is an uncommon cause of liver disease presenting with a wide range of phenotypes and disease severity, acute hepatitis mimicking viral hepatitis to autoimmune hepatitis, steatosis, fibrosis or rare chronic vascular syndromes. Disease severity ranges from asymptomatic liver test abnormalities to acute liver failure. DILI has been traditionally classified in predictable or intrinsic (dose-related) or unpredictable (not dose-related) mechanisms. Few prospective studies are assessing the real prevalence and incidence of hepatotoxicity in the general population. DILI registries represent useful networks used for the study of liver toxicity, aimed at improving the understanding of causes, phenotypes, natural history, and standardized definitions of hepatotoxicity. Although most of the registries do not carry out population-based studies, they may provide important data related to the prevalence of DILI, and also may be useful to compare features from different countries. With the support of the Spanish Registry of Hepatotoxicity, our Latin American Registry (LATINDILI) was created in 2011, and more than 350 DILI patients have been recruited to date. This position paper describes the more frequent drugs and herbs-induced DILI in Latin America, mainly focusing on several features of responsible medicaments. Also, we highlighted the most critical points on the management of hepatotoxicity in general and those based on findings from our Latin American experience in particular.
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Affiliation(s)
- Fernando Bessone
- Hospital Provincial del Centenario, Facultad de Medicina, Universidad Nacional de Rosario, Rosario, Argentina.
| | | | - Martin Tagle
- Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Marco Arrese
- Pontificia Universidad Católica de chile, Santiago de Chile, Chile
| | | | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic & Foundation, Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico; Liver Research Unit, Medica Sur Clinic & Foundation, Mexico City, Mexico
| | - Ezequiel Ridruejo
- Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno "CEMIC", Buenos Aires, Argentina
| | | | - Lucy Dagher
- Policlínica Metropolitana y CMDLT, Caracas, Venezuela
| | | | - Eduardo Fassio
- Hospital Nacional Prof. Alejandro Posadas, Provincia de Buenos Aires, Argentina
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22
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Herb-Induced Liver Injury—A Challenging Diagnosis. Healthcare (Basel) 2022; 10:healthcare10020278. [PMID: 35206892 PMCID: PMC8872293 DOI: 10.3390/healthcare10020278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/23/2022] [Accepted: 01/27/2022] [Indexed: 12/02/2022] Open
Abstract
Herb-induced liver injury (HILI) can be caused by supplements containing herbs, natural products, and products used in traditional medicine. Herbal products’ most common adverse reaction is hepatotoxicity. Almost every plant part can be used to make herbal products, and these products can come in many different forms, such as teas, powders, oils, creams, capsules, and injectables. HILI incidence and prevalence are hard to estimate and vary from study to study because of insufficient large-scale prospective studies. The diagnosis of HILI is a challenging process that requires not only insight but also a high degree of suspicion by the clinician. HILI presents with unspecific symptoms and is a diagnosis of exclusion. For diagnosis, it is necessary to make a causality assessment; the Council for International Organizations of Medical Sciences assessment is the preferred method worldwide. The most effective treatment is the suspension of the use of the suspected herbal product and close monitoring of liver function. The objective of this review is to highlight the necessary steps for the clinician to follow to reach a correct diagnosis of herb-induced liver injury. Further studies of HILI are needed to better understand its complexity and prevent increased morbidity and mortality.
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23
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Choudhary N, Saraf N, Kumar V, Bansal M, Kasliwal R. Drug-induced liver injury: A primer for cardiologists. JOURNAL OF CLINICAL AND PREVENTIVE CARDIOLOGY 2022. [DOI: 10.4103/jcpc.jcpc_8_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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24
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Chen Y, Guan S, Guan Y, Tang S, Zhou Y, Wang X, Bi H, Huang M. Novel clinical biomarkers for drug-induced liver injury. Drug Metab Dispos 2021; 50:671-684. [PMID: 34903588 DOI: 10.1124/dmd.121.000732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/07/2021] [Indexed: 11/22/2022] Open
Abstract
Drug-induced liver injury (DILI) remains a critical clinical issue and has been a treatment challenge nowadays as it was in the past. However, the traditional biomarkers or indicators are insufficient to predict the risks and outcome of patients with DILI due to its poor specificity and sensitivity. Recently, the development of high-throughput technologies, especially omics and multi-omics has sparked growing interests in identification of novel clinical DILI biomarkers, many of which also provide a mechanistic insight. Accordingly, in this mini-review, we summarize recent advances in novel clinical biomarkers for DILI prediction, diagnosis and prognosis and highlight the limitations or challenges involved in biomarker discovery or their clinical translation. Although huge work has been done, most reported biomarkers lack comprehensive information and more specific DILI biomarkers are still needed to complement the traditional biomarkers such as ALT or AST in clinical decision making. Significance Statement The current review outlines an overview of novel clinical biomarkers for DILI identified in clinical retrospective or prospective clinical analysis. Many of these biomarkers provides a mechanistic insight and are promising to complement the traditional DILI biomarkers. This work also highlights the limitations or challenges involved in biomarker discovery or their clinical translation.
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Affiliation(s)
- Youhao Chen
- School of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-Sen University, China
| | - Shaoxing Guan
- School of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-Sen University, China
| | | | - Siyuan Tang
- School of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-Sen University, China
| | - Yanying Zhou
- School of Pharmaceutical Sciences, Sun Yat-sen University, China
| | - Xueding Wang
- School of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-Sen University, China
| | - Huichang Bi
- School of Pharmaceutical Sciences, Sun Yat-sen University, China
| | - Min Huang
- School of Pharmaceutical Sciences, Sun Yat-sen University, China
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25
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Chen Z, Jiang Y, Zhang X, Zheng R, Qiu R, Sun Y, Zhao C, Shang H. ResNet18DNN: prediction approach of drug-induced liver injury by deep neural network with ResNet18. Brief Bioinform 2021; 23:6457162. [PMID: 34882224 DOI: 10.1093/bib/bbab503] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/27/2021] [Accepted: 11/02/2021] [Indexed: 01/22/2023] Open
Abstract
Drug-induced liver injury (DILI) has always been the focus of clinicians and drug researchers. How to improve the performance of the DILI prediction model to accurately predict liver injury was an urgent problem for researchers in the field of medical research. In order to solve this scientific problem, this research collected a comprehensive and accurate dataset of DILI with high recognition and high quality based on clinically confirmed DILI compound datasets, including 1446 chemical compounds. Then, the residual neural network with 18-layer by using more 5-layer blocks (ResNet18) with deep neural network (ResNet18DNN) model was proposed to predict DILI, which was an improved model for DILI prediction through vectorization of compound structure image. In predicting DILI, the ResNet18DNN learned greatly and outperformed the existing state-of-the-art DILI predictors. The results of DILI prediction model based on ResNet18DNN showed that the AUC (area under the curve), accuracy, recall, precision, F1-score and specificity of the training set were 0.973, 0.992, 0.995, 0.994, 0.995 and 0.975; those of test set were, respectively, 0.958, 0.976, 0.935, 0.947, 0.926 and 0.913, which were better than the performance of previously published described DILI prediction models. This method adopted ResNet18 embedding method to vectorize molecular structure images and the evaluation indicators of Resnet18DNN were obtained after 10 000 iterations. This prediction approach will greatly improve the performance of the predictive model of DILI and provide an accurate and precise early warning method for DILI in drug development and clinical medication.
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Affiliation(s)
- Zhao Chen
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Yin Jiang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Xiaoyu Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Rui Zheng
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Ruijin Qiu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Yang Sun
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Chen Zhao
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China.,College of Integrated Traditional Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan 410208, China
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26
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Khan Z, Karataş Y, Kıroğlu O. Evaluation of Adverse Drug Reactions in Paediatric Patients: A Retrospective Study in Turkish Hospital. Front Pharmacol 2021; 12:786182. [PMID: 34867419 PMCID: PMC8638749 DOI: 10.3389/fphar.2021.786182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/25/2021] [Indexed: 12/28/2022] Open
Abstract
Drug safety in paediatric patients is a serious public health concern around the world. The paediatric patients are more prone to adverse drug reactions (ADRs) than adults. Moreover, there is a scarcity of information about ADRs in paediatric patients. This study was conducted to determine the frequency, causality, severity, preventability of paediatric patients’ ADRs reported in a tertiary care hospital in Adana, Turkey. A retrospective study was conducted on all spontaneously reported ADRs between January 01, 2020, to July 30, 2021, in paediatric patients. The ADRs reports were evaluated in terms of gender, age, ADR characteristics, suspected drugs and reporting source. All included ADRs reports were characterized according to the Naranjo Algorithm/World Health Organization (WHO) causality scales, Hartwig/Siegel and Common Terminology Criteria for Adverse Events (CTCAE) severity scales, the modified Schoumock and Thornton preventability scale and hospital pharmacovigilance center criteria for seriousness. Therapeutic groups were also coded using the WHO-Anatomical Therapeutic and Chemical (ATC) classification. During the study period, 8,912 paediatric patients who were admitted had 16 ADRs with 1.7 ADRs/1,000 admissions. The majority of ADRs were found in infants (31.2%) and children (56.2%) as compared to adolescents (12.5%). ADRs were observed more in females (81.2%) than males. Skin (62.5%) was the most affected organ due to the ADRs, and maculopapular rash and erythema multiforme were the most commonly reported symptoms. Most ADRs were probable/likely (93.7%), severe (50%), preventable or probably preventable (43.7%) and serious (37.5%). Antibiotics (93.7%) were found to be the most common cause of ADRs in paediatric patients. The majority of ADRs were associated with vancomycin (68.7%). Most of the ADRs were reported by a medical doctor in this study. This small sample size study highlights significant problems of ADRs in paediatric patients, mainly caused by antibiotics and with a majority of ADRs manifest as skin reactions. Furthermore, a high proportion of the identified ADRs were found to be preventable. More focused efforts are needed at the national level to avoid preventable ADRs in hospitals. Monitoring and management of ADRs and future studies would be beneficial for better patient care and safety.
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Affiliation(s)
- Zakir Khan
- Department of Pharmacology, Institute of Health Sciences, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Yusuf Karataş
- Department of Pharmacology, Institute of Health Sciences, Faculty of Medicine, Cukurova University, Adana, Turkey.,Pharmacovigilance Specialist, Balcali Hospital, Faculty of Medicines, Cukurova University, Adana, Turkey
| | - Olcay Kıroğlu
- Department of Pharmacology, Institute of Health Sciences, Faculty of Medicine, Cukurova University, Adana, Turkey
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27
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Villanueva-Paz M, Niu H, Segovia-Zafra A, Medina-Caliz I, Sanabria-Cabrera J, Lucena MI, Andrade RJ, Alvarez-Alvarez I. Critical Review of Gaps in the Diagnosis and Management of Drug-Induced Liver Injury Associated with Severe Cutaneous Adverse Reactions. J Clin Med 2021; 10:5317. [PMID: 34830594 PMCID: PMC8618381 DOI: 10.3390/jcm10225317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 12/12/2022] Open
Abstract
Drug-induced liver injury (DILI) encompasses the unexpected damage that drugs can cause to the liver. DILI may develop in the context of an immunoallergic syndrome with cutaneous manifestations, which are sometimes severe (SCARs). Nevirapine, allopurinol, anti-epileptics, sulfonamides, and antibiotics are the most frequent culprit drugs for DILI associated with SCARs. Interestingly, alleles HLA-B*58:01 and HLA-A*31:01 are associated with both adverse reactions. However, there is no consensus about the criteria used for the characterization of liver injury in this context, and the different thresholds for DILI definition make it difficult to gain insight into this complex disorder. Moreover, current limitations when evaluating causality in patients with DILI associated with SCARs are related to the plethora of causality assessment methods and the lack of consensual complementary tools. Finally, the management of this condition encompasses the treatment of liver and skin injury. Although the use of immunomodulant agents is accepted for SCARs, their role in treating liver injury remains controversial. Further randomized clinical trials are needed to test their efficacy and safety to address this complex entity. Therefore, this review aims to identify the current gaps in the definition, diagnosis, prognosis, and management of DILI associated with SCARs, proposing different strategies to fill in these gaps.
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Affiliation(s)
- Marina Villanueva-Paz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
| | - Hao Niu
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Antonio Segovia-Zafra
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Inmaculada Medina-Caliz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
| | - Judith Sanabria-Cabrera
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Plataforma ISCIII de Ensayos Clinicos, UICEC-IBIMA, 29071 Malaga, Spain
| | - M. Isabel Lucena
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Plataforma ISCIII de Ensayos Clinicos, UICEC-IBIMA, 29071 Malaga, Spain
| | - Raúl J. Andrade
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Ismael Alvarez-Alvarez
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29071 Malaga, Spain; (M.V.-P.); (H.N.); (A.S.-Z.); (I.M.-C.); (J.S.-C.); (R.J.A.); (I.A.-A.)
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
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28
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Zhu L, Zhang C, Zhang W, Xia Q, Ma J, He X, He Y, Fu PP, Jia W, Zhuge Y, Lin G. Developing urinary pyrrole-amino acid adducts as non-invasive biomarkers for identifying pyrrolizidine alkaloids-induced liver injury in human. Arch Toxicol 2021; 95:3191-3204. [PMID: 34390356 PMCID: PMC8364305 DOI: 10.1007/s00204-021-03129-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/29/2021] [Indexed: 01/24/2023]
Abstract
Pyrrolizidine alkaloids (PAs) have been found in over 6000 plants worldwide and represent the most common hepatotoxic phytotoxins. Currently, a definitive diagnostic method for PA-induced liver injury (PA-ILI) is lacking. In the present study, using a newly developed analytical method, we identified four pyrrole-amino acid adducts (PAAAs), namely pyrrole-7-cysteine, pyrrole-9-cysteine, pyrrole-9-histidine, and pyrrole-7-acetylcysteine, which are generated from reactive pyrrolic metabolites of PAs, in the urine of PA-treated male Sprague Dawley rats and PA-ILI patients. The elimination profiles, abundance, and persistence of PAAAs were systematically investigated first in PA-treated rat models via oral administration of retrorsine at a single dose of 40 mg/kg and multiple doses of 5 mg/kg/day for 14 consecutive days, confirming that these urinary excreted PAAAs were derived specifically from PA exposure. Moreover, we determined that these PAAAs were detected in ~ 82% (129/158) of urine samples collected from ~ 91% (58/64) of PA-ILI patients with pyrrole-7-cysteine and pyrrole-9-histidine detectable in urine samples collected at 3 months or longer times after hospital admission, indicating adequate persistence time for use as a clinical test. As direct evidence of PA exposure, we propose that PAAAs can be used as a biomarker of PA exposure and the measurement of urinary PAAAs could be used as a non-invasive test assisting the definitive diagnosis of PA-ILI in patients.
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Affiliation(s)
- Lin Zhu
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chunyuan Zhang
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wei Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Qingsu Xia
- National Center for Toxicological Research, Food and Drug Administration, Jefferson, AR, 72079, USA
| | - Jiang Ma
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xin He
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yisheng He
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Peter P Fu
- National Center for Toxicological Research, Food and Drug Administration, Jefferson, AR, 72079, USA
| | - Wei Jia
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
| | - Ge Lin
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Kamath P, Kamath A, Ullal SD. Liver injury associated with drug intake during pregnancy. World J Hepatol 2021; 13:747-762. [PMID: 34367496 PMCID: PMC8326163 DOI: 10.4254/wjh.v13.i7.747] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/14/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Drug use during pregnancy is not common. Drug-induced liver injury (DILI) is a potential complication that is rare but can adversely affect both the mother and the fetus. Although many drugs can directly cause hepatotoxicity, idiosyncratic liver injury is common in pregnancy. Underreporting of adverse drug reactions, lack of adequate literature regarding drug safety in pregnancy, and the inherent difficulty in diagnosing DILI during pregnancy make the management of this condition challenging. This review attempts to describe the existing literature regarding DILI in pregnancy, which is mainly in the form of case reports; several studies have looked at the safety of antithyroid drugs, antiretroviral drugs, and paracetamol, which have an indication for use in pregnancy; the relevant data from these studies with regard to DILI has been presented. In addition, the review describes the diagnosis of DILI, grading the disease severity, assessment of causality linking the drug to the adverse event, regulatory guidelines for evaluating the potential of drugs to cause liver injury, efforts to ensure better participation of women in clinical trials and studies in pregnant women population in particular, and the challenges involved in generating adequate research evidence. The establishment of DILI registries in various countries is an encouraging development; however, there is a need for promoting active, spontaneous reporting of adverse events during pregnancy to ensure rapid generation of evidence regarding the safety of a drug in pregnant women.
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Affiliation(s)
- Priyanka Kamath
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
| | - Ashwin Kamath
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
| | - Sheetal D Ullal
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
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Metabolomic analysis to discriminate drug-induced liver injury (DILI) phenotypes. Arch Toxicol 2021; 95:3049-3062. [PMID: 34274980 PMCID: PMC8380240 DOI: 10.1007/s00204-021-03114-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/29/2021] [Indexed: 12/19/2022]
Abstract
Drug-induced liver injury (DILI) is an adverse toxic hepatic clinical reaction associated to the administration of a drug that can occur both at early clinical stages of drug development, as well after normal clinical usage of approved drugs. Because of its unpredictability and clinical relevance, it is of medical concern. Three DILI phenotypes (hepatocellular, cholestatic, and mixed) are currently recognized, based on serum alanine aminotransferase (ALT) and alkaline phosphatase (ALP) values. However, this classification lacks accuracy to distinguish among the many intermediate mixed types, or even to estimate the magnitude and progression of the injury. It was found desirable to have additional elements for better evaluation criteria of DILI. With this aim, we have examined the serum metabolomic changes occurring in 79 DILI patients recruited and monitored using established clinical criteria, along the course of the disease and until recovery. Results revealed that free and conjugated bile acids, and glycerophospholipids were among the most relevant metabolite classes for DILI phenotype characterization. Using an ensemble of PLS-DA models, metabolomic information was integrated into a ternary diagram to display the disease phenotype, the severity of the liver damage, and its progression. The modeling implemented and the use of such compiled information in an easily understandable and visual manner facilitates a straightforward DILI phenotyping and allow to monitor its progression and recovery prediction, usefully complementing the concise information drawn out by the ALT and ALP classification.
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31
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Ariffin SH, A Wahab I, Hassan Y, Abd Wahab MS. Adulterated Traditional-Herbal Medicinal Products and Its Safety Signals in Malaysia. Drug Healthc Patient Saf 2021; 13:133-140. [PMID: 34135639 PMCID: PMC8197568 DOI: 10.2147/dhps.s305953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/24/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Usage of traditional-herbal medicines (THM) for various illnesses has been increased around the world, so does the adulteration of these products with hazardous compounds. There are limited Malaysian data that have been published on the characteristics trend and adverse events associated with adulterated THM products. AIM This study described characteristics of adulterated THM products in Malaysia and aimed to quantify THM products' safety signals of adverse reactions (ARs). METHODS THM products that were seized by Pharmacy Enforcement Division between 2008 and 2014 were extracted and analysed for 59,440 THM products. Of these, only 6452 THM products with complete information were included in the final analyses. Safety signalling tools were used to measure AR signals from AR reports obtained from the National Pharmaceutical Regulatory Agency Adverse Drug Reaction Database. RESULTS More than half of adulterated THM products originated from countries outside of Malaysia, with the majority were from Indonesia. The most common claimed indication of adulterated THM products was for pain and fever relief, while steroids were the most common adulterant. AR signals were generated for cough and cold products for respiratory and thoracic disorders, weight-loss products for cardiac disorders, and women's health products for reproductive and breast disorders. CONCLUSION Health authorities from various fields can work collaboratively by implementing strategic actions that include the use of safety signalling tools to curb the increasing number of adulterated THM products in the Malaysian market.
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Affiliation(s)
- Suriana Hanim Ariffin
- Pharmacy Enforcement Division, National Pharmaceutical Regulatory Agency, Petaling Jaya, 46200, Selangor, Malaysia
| | - Izyan A Wahab
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Malaya, Kuala Lumpur, 50603, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Yahaya Hassan
- Faculty of Pharmacy, Universiti Teknologi MARA (UiTM) Cawangan Selangor, Kampus Puncak Alam, Puncak Alam, 42300, Selangor, Malaysia
| | - Mohd Shahezwan Abd Wahab
- Faculty of Pharmacy, Universiti Teknologi MARA (UiTM) Cawangan Selangor, Kampus Puncak Alam, Puncak Alam, 42300, Selangor, Malaysia
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32
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Hey-Hadavi J, Seekins D, Palmer M, Coffey D, Caminis J, Abdullaev S, Patwardhan M, Tyler H, Raheja R, Stanley AM, Pineda-Salgado L, Bourdet DL, Andrade RJ, Hayashi PH, Dimick-Santos L, Rockey DC, Estilo A. Overview of Causality Assessment for Drug-Induced Liver Injury (DILI) in Clinical Trials. Drug Saf 2021; 44:619-634. [PMID: 33725335 PMCID: PMC8184702 DOI: 10.1007/s40264-021-01051-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 02/08/2023]
Abstract
Causality assessment for suspected drug-induced liver injury (DILI) during drug development and following approval is challenging. The IQ DILI Causality Working Group (CWG), in collaboration with academic and regulatory subject matter experts (SMEs), developed this manuscript with the following objectives: (1) understand and describe current practices; (2) evaluate the utility of new tools/methods/practice guidelines; (3) propose a minimal data set needed to assess causality; (4) define best practices; and (5) promote a more structured and universal approach to DILI causality assessment for clinical development. To better understand current practices, the CWG performed a literature review, took a survey of member companies, and collaborated with SMEs. Areas of focus included best practices for causality assessment during clinical development, utility of adjudication committees, and proposals for potential new avenues to improve causality assessment. The survey and literature review provided renewed understanding of the complexity and challenges of DILI causality assessment as well as the use of non-standardized approaches. Potential areas identified for consistency and standardization included role and membership of adjudication committees, standardized minimum dataset, updated assessment tools, and best practices for liver biopsy and rechallenge in the setting of DILI. Adjudication committees comprised of SMEs (i.e., utilizing expert opinion) remain the standard for DILI causality assessment. A variety of working groups continue to make progress in pursuing new tools to assist with DILI causality assessment. The minimum dataset deemed adequate for causality assessment provides a path forward for standardization of data collection in the setting of DILI. Continued progress is necessary to optimize and advance innovative tools necessary for the scientific, pharmaceutical, and regulatory community.
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Affiliation(s)
| | | | - Melissa Palmer
- Takeda, Cambridge, MA, USA
- Liver Consulting LLC, New York City, USA
| | | | | | | | | | - Haifa Tyler
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center Dr, Princeton, NJ, 08540, USA
| | | | | | - Liliam Pineda-Salgado
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center Dr, Princeton, NJ, 08540, USA
| | | | - Raul J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Málaga, Spain
| | | | | | - Don C Rockey
- Medical University of South Carolina, Charleston, SC, USA
| | - Alvin Estilo
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center Dr, Princeton, NJ, 08540, USA.
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Brar HS, Marathi R. Case of cholestatic drug-induced liver injury (DILI) associated with black cohosh. BMJ Case Rep 2021; 14:e240408. [PMID: 33962922 PMCID: PMC8108679 DOI: 10.1136/bcr-2020-240408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2021] [Indexed: 11/04/2022] Open
Abstract
Drug-induced liver injury is an uncommon yet fatal cause of liver injury. Black cohosh is a herbal supplement that is derived from Actaea racemosa It has been used for vasomotor symptoms in postmenopausal women, but it can cause liver injury. A 50-year-old Afro-American woman presented with a 2-month history of malaise, itching and severe jaundice. The labs showed elevation of bilirubin and alkaline phosphatase. The patient had a history of black cohosh use for postmenopausal symptoms before she developed her current symptoms. The extensive workup for infective and autoimmune pathology was negative. Black cohosh was discontinued. The patient improved clinically, and her liver enzymes normalised 6 months after the discontinuation of black cohosh. This report emphasises the need to recognise black cohosh as a potential hepatotoxic agent and to monitor the liver enzymes for a patient on black cohosh.
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Affiliation(s)
- Himmat Singh Brar
- Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Rachana Marathi
- Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
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34
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Response to Liu et al., and Björnsson and Björnsson. Am J Gastroenterol 2021; 116:1091-1092. [PMID: 33229977 DOI: 10.14309/ajg.0000000000001055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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35
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Cataldi M, Citro V, Resnati C, Manco F, Tarantino G. New Avenues for Treatment and Prevention of Drug-Induced Steatosis and Steatohepatitis: Much More Than Antioxidants. Adv Ther 2021; 38:2094-2113. [PMID: 33761100 PMCID: PMC8107075 DOI: 10.1007/s12325-021-01669-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/11/2021] [Indexed: 12/12/2022]
Abstract
Drug-induced lipid accumulation in the liver may induce two clinically relevant conditions, drug-induced steatosis (DIS) and drug-induced steatohepatitis (DISH). The list of drugs that may cause DIS or DISH is long and heterogeneous and includes therapeutically relevant molecules that cannot be easily replaced by less hepatotoxic medicines, therefore making specific strategies necessary for DIS/DISH prevention or treatment. For years, the only available tools to achieve these goals have been antioxidant drugs and free radical scavengers, which counteract drug-induced mitochondrial dysfunction but, unfortunately, have only limited efficacy. In the present review we illustrate how in vitro preclinical research unraveled new key players in the pathogenesis of specific forms of DISH, and how, in a few cases, proof of concept of the beneficial effects of their pharmacological modulation has been obtained in vivo in animal models of this condition. The key issue emerging from these studies is that, in selected cases, liver toxicity depends on mechanisms unrelated to those responsible for the desired, primary pharmacological effects of the toxic drug and, therefore, specific strategies can be designed to overcome steatogenicity without making the drug ineffective. In particular, the hepatotoxic drug could be given in combination with a second molecule intended to selectively antagonize its liver toxicity whilst, ideally, potentiating its desired pharmacological activity. Although most of the evidence that we discuss is from in vitro or animal models and will need to be further explored and validated in humans, it highlights new avenues to be pursued in order to improve the safety of steatogenic drugs.
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36
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Villanueva-Paz M, Morán L, López-Alcántara N, Freixo C, Andrade RJ, Lucena MI, Cubero FJ. Oxidative Stress in Drug-Induced Liver Injury (DILI): From Mechanisms to Biomarkers for Use in Clinical Practice. Antioxidants (Basel) 2021; 10:390. [PMID: 33807700 PMCID: PMC8000729 DOI: 10.3390/antiox10030390] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/02/2021] [Indexed: 12/11/2022] Open
Abstract
Idiosyncratic drug-induced liver injury (DILI) is a type of hepatic injury caused by an uncommon drug adverse reaction that can develop to conditions spanning from asymptomatic liver laboratory abnormalities to acute liver failure (ALF) and death. The cellular and molecular mechanisms involved in DILI are poorly understood. Hepatocyte damage can be caused by the metabolic activation of chemically active intermediate metabolites that covalently bind to macromolecules (e.g., proteins, DNA), forming protein adducts-neoantigens-that lead to the generation of oxidative stress, mitochondrial dysfunction, and endoplasmic reticulum (ER) stress, which can eventually lead to cell death. In parallel, damage-associated molecular patterns (DAMPs) stimulate the immune response, whereby inflammasomes play a pivotal role, and neoantigen presentation on specific human leukocyte antigen (HLA) molecules trigger the adaptive immune response. A wide array of antioxidant mechanisms exists to counterbalance the effect of oxidants, including glutathione (GSH), superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPX), which are pivotal in detoxification. These get compromised during DILI, triggering an imbalance between oxidants and antioxidants defense systems, generating oxidative stress. As a result of exacerbated oxidative stress, several danger signals, including mitochondrial damage, cell death, and inflammatory markers, and microRNAs (miRNAs) related to extracellular vesicles (EVs) have already been reported as mechanistic biomarkers. Here, the status quo and the future directions in DILI are thoroughly discussed, with a special focus on the role of oxidative stress and the development of new biomarkers.
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Affiliation(s)
- Marina Villanueva-Paz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, 29071 Málaga, Spain; (M.V.-P.); (M.I.L.)
| | - Laura Morán
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (L.M.); (N.L.-A.)
- Health Research Institute Gregorio Marañón (IiSGM), 28009 Madrid, Spain
| | - Nuria López-Alcántara
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (L.M.); (N.L.-A.)
| | - Cristiana Freixo
- CINTESIS, Center for Health Technology and Services Research, do Porto University School of Medicine, 4200-319 Porto, Portugal;
| | - Raúl J. Andrade
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, 29071 Málaga, Spain; (M.V.-P.); (M.I.L.)
| | - M Isabel Lucena
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, 29071 Málaga, Spain; (M.V.-P.); (M.I.L.)
| | - Francisco Javier Cubero
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (L.M.); (N.L.-A.)
- 12 de Octubre Health Research Institute (imas12), 28041 Madrid, Spain
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37
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Prevention and management of idiosyncratic drug-induced liver injury: Systematic review and meta-analysis of randomised clinical trials. Pharmacol Res 2021; 164:105404. [DOI: 10.1016/j.phrs.2020.105404] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023]
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38
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Rathman J, Yang C, Ribeiro JV, Mostrag A, Thakkar S, Tong W, Hobocienski B, Sacher O, Magdziarz T, Bienfait B. Development of a Battery of In Silico Prediction Tools for Drug-Induced Liver Injury from the Vantage Point of Translational Safety Assessment. Chem Res Toxicol 2020; 34:601-615. [PMID: 33356149 DOI: 10.1021/acs.chemrestox.0c00423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Drug-induced liver injury (DILI) remains a challenge when translating knowledge from the preclinical stage to human use cases. Attempts to model human DILI directly based on the information from drug labels have had some success; however, the approach falls short of providing insights or addressing uncertainty due to the difficulty of decoupling the idiosyncratic nature of human DILI outcomes. Our approach in this comparative analysis is to leverage existing preclinical and clinical data as well as information on metabolism to better translate mammalian to human DILI. The human DILI knowledge base from the United States Food and Drug Administration (U.S. FDA) National Center for Toxicology Research contains 1036 pharmaceuticals from diverse therapeutic categories. A human DILI training set of 305 oral marketed drugs was prepared and a binary classification scheme applied. The second knowledge base consists of mammalian repeated dose toxicity with liver toxicity data from various regulatory sources. Within this knowledge base, we identified 278 pharmaceuticals containing 198 marketed or withdrawn oral drugs with data from the U.S. FDA new drug application and 98 active pharmaceutical ingredients from ToxCast. From this collection, a set of 225 oral drugs was prepared as the mammalian hepatotoxicity training set with particular end points of pathology findings in the liver and bile duct. Both human and mammalian data sets were processed using various learning algorithms, including artificial intelligence approaches. The external validations for both models were comparable to the training statistics. These data sets were also used to extract species-differentiating chemotypes that differentiate DILI effects on humans from mammals. A systematic workflow was devised to predict human DILI and provide mechanistic insights. For a given query molecule, both human and mammalian models are run. If the predictions are discordant, both metabolites and parents are investigated for quantitative structure-activity relationship and species-differentiating chemotypes. Their results are combined using the Dempster-Shafer decision theory to yield a final outcome prediction for human DILI with estimated uncertainty. Finally, these tools are implementable within an in silico platform for systematic evaluation.
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Affiliation(s)
- James Rathman
- Molecular Networks GmbH - Computerchemie (MN-AM), 90411 Nurnberg, Germany.,Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio 43210, United States
| | - Chihae Yang
- Molecular Networks GmbH - Computerchemie (MN-AM), 90411 Nurnberg, Germany
| | - J Vinicius Ribeiro
- Molecular Networks GmbH - Computerchemie (MN-AM), 90411 Nurnberg, Germany
| | - Aleksandra Mostrag
- Molecular Networks GmbH - Computerchemie (MN-AM), 90411 Nurnberg, Germany
| | - Shraddha Thakkar
- National Center for Toxicology Research, United States Food and Drug Administration, Jefferson, Arkansas 72079, United States
| | - Weida Tong
- National Center for Toxicology Research, United States Food and Drug Administration, Jefferson, Arkansas 72079, United States
| | - Bryan Hobocienski
- Molecular Networks GmbH - Computerchemie (MN-AM), 90411 Nurnberg, Germany
| | - Oliver Sacher
- Molecular Networks GmbH - Computerchemie (MN-AM), 90411 Nurnberg, Germany
| | - Tomasz Magdziarz
- Molecular Networks GmbH - Computerchemie (MN-AM), 90411 Nurnberg, Germany
| | - Bruno Bienfait
- Molecular Networks GmbH - Computerchemie (MN-AM), 90411 Nurnberg, Germany
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López-Riera M, Conde I, Castell JV, Jover R. A Novel MicroRNA Signature for Cholestatic Drugs in Human Hepatocytes and Its Translation into Novel Circulating Biomarkers for Drug-Induced Liver Injury Patients. Toxicol Sci 2020; 173:229-243. [PMID: 31198949 DOI: 10.1093/toxsci/kfz138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Drug-induced liver injury (DILI) diagnosis and classification (hepatocellular, cholestatic, and mixed) relies on traditional clinical biomarkers (eg ALT and ALP), despite limitations such as extrahepatic interferences, narrow dynamic ranges, and low mechanistic value. microRNAs may be very useful for complementing traditional DILI biomarkers but most studies in this direction have considered only paracetamol poisoning. Thus the value of microRNAs (miRNAs) as biomarkers for idiosyncratic DILI has not yet been demonstrated. In this study, we first examined the effect of model cholestatic drugs on the human hepatocyte miRNome by RNAseq and RT-qPCR. Results demonstrated that chlorpromazine, cyclosporin A, and ANIT induced (miR-21-3p, -21-5p, -22-3p, -27a-5p, -1260b, -34a-5p, and -98-5p) and repressed (-122-5p, -192-5p, -30c-5p, -424-5p, and -16-5p) specific miRNAs in sandwich-cultured upcyte hepatocytes. However, no common signature was found for cholestatic drugs. Next we investigated the levels of these miRNA in human serum and found that most were also significantly altered in cholestatic/mixed DILI patients upon hospital/ambulatory admission. However, miR-122-5p, -192-5p, -34a-5p, and -22-3p demonstrated a much more significant induction in patients with hepatocellular DILI, thus revealing better specificity for hepatocellular damage. Time-course analyses demonstrated that -1260b and -146 had a very similar profile to ALP, but with wider dynamic ranges, while -16-5p and -451a showed a negative correlation. Conversely, -122-5p and -192-5p correlated with ALT but with wider dynamic ranges and faster recoveries. Finally, the 122/451a and 122/16 ratios showed excellent prediction performances in both the study [area under the receiver operating characteristic curve (AUROC) >0.93] and the validation cohort (AUROC > 0.82), and can, therefore, be postulated for the first time as circulating miRNA biomarkers for idiosyncratic DILI.
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Affiliation(s)
- Mireia López-Riera
- *Unidad Mixta en Hepatología Experimental, IIS Hospital La Fe, 46026 Valencia, Spain
| | - Isabel Conde
- *Unidad Mixta en Hepatología Experimental, IIS Hospital La Fe, 46026 Valencia, Spain.,Medicina Digestiva, Sección Hepatología, Hospital La Fe, 46026 Valencia, Spain
| | - José V Castell
- *Unidad Mixta en Hepatología Experimental, IIS Hospital La Fe, 46026 Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain.,Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain
| | - Ramiro Jover
- *Unidad Mixta en Hepatología Experimental, IIS Hospital La Fe, 46026 Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain.,Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain
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40
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Kesenogile B, Godman B, Rwegerera GM. Alanine transaminase and hemoglobin appear to predict the occurrence of antituberculosis medication hepatotoxicity; findings and implications in Botswana. Expert Rev Anti Infect Ther 2020; 19:379-391. [PMID: 32909487 DOI: 10.1080/14787210.2020.1822735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Tuberculosis (TB) remains a global health problem, with medications having adverse effects including drug-induced hepatotoxicity. We determined the prevalence of anti-tuberculosis drug-induced hepatotoxicity and associated risk factors. METHODS Retrospective cross-sectional study in Botswana including TB patients admitted from 1 June 2017 to 30 June 2018. Anti-TB drug-induced hepatotoxicity was categorized according to WHO criteria whereas causality assessment was made according to the updated Roussel Uclaf Causality Assessment Method (RUCAM) scale. The association between hepatotoxicity and included variables was undertaken by binary logistic regression. RESULTS Out of 112 patient files, 15 (13.4%) developed hepatotoxicity after an average of 20.4 days from the start of treatment. Grade 3 and 4 hepatotoxicity was found in 66.7% of the cases. According to the updated RUCAM tool, 86.7% of patients were categorized as having possible anti-TB-associated hepatotoxicity. Patients with elevated baseline alanine transaminase (ALT) were more likely to develop hepatotoxicity (OR = 3.484, 95% CI = 1.02-11.90). Patients with normal hemoglobin (Hb ≥ 12 g/dl) were also more likely to develop hepatotoxicity (OR = 4.413, 95% CI = 1.160-14.8). CONCLUSION Overall, normal hemoglobin and elevated baseline ALT levels were significantly associated with anti-TB drug-induced hepatotoxicity. Additional research is needed to explore this association further.
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Affiliation(s)
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa.,Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Godfrey Mutashambara Rwegerera
- Department of Medicine, Princess Marina Hospital, Gaborone, Botswana.,Department of Internal Medicine, University of Botswana, Gaborone, Botswana
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41
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Liu Y, Li P, Wang F, Liu L, Zhang Y, Liu Y, Shi R. Comparison of diagnostic accuracy of 3 diagnostic criteria combined with refined pathological scoring system for drug-induced liver injury. Medicine (Baltimore) 2020; 99:e22259. [PMID: 33031266 PMCID: PMC10545333 DOI: 10.1097/md.0000000000022259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/18/2020] [Accepted: 08/14/2020] [Indexed: 12/26/2022] Open
Abstract
Drug-induced liver injury (DILI) is difficult in diagnose, criteria used now are mostly based on history review. We tried to evaluate the value of these criteria and histopathology features in DILI to perform a method diagnosing DILI more definitely.We enrolled 458 consecutive hospitalized DILI patients from January 1, 2012 to December 31, 2018, using Roussel-Uclaf Causality Assessment Method (RUCAM), Maria & Victorino scale (M&V), and Digestive Disease Week-Japan criterion (DDW-J) combined with refined pathological scoring system respectively to perform the evaluation.A total of 458 DILI patients were enrolled, the area under receiver operating characteristics (AUROC) of the 3 clinical diagnostic criteria were 0.730 (95% confidence interval [CI]: 0.667-0.793), 0.793 (95% CI: 0.740-0.847), and 0.764 (95% CI: 0.702-0.826) respectively. Three hundred two DILI patients' liver biopsies were included: steatosis in 204 cases (67.5%), cholestasis in 151 cases (50%), cell apoptosis in 139 cases (46%), eosinophil granulocyte infiltration in 131 cases (43.4%), central and/or portal phlebitis in 103 cases (34.1%), iron deposition in 90 cases (29.8%), and pigmented macrophages in 92 cases (30.5%). The AUROC of refined pathological scale combined with 3 criteria were 0.843 (95% CI: 0.747-0.914), 0.907 (95% CI: 0.822-0.960), and 0.881 (95% CI: 0.790-0.942) respectively. In hepatocellular type, the AUROCs were 0.894 (95% CI: 0.787-0.959), 0.960 (95% CI: 0.857-0.994), and 0.940 (95% CI: 0.847-0.985); in cholestatic type, the AUROCs were 0.750 (95% CI: 0.466-0.931), 0.500 (95% CI: 0.239-0.761), and 0.500 (95% CI: 0.239-0.761); in mixed type, the AUROCs were 0.786 (95% CI: 0.524-0.943), 0.869 (95% CI: 0.619-0.981), and 0.762 (95% CI: 0.498 to -0.930).Combined with pathological scale can significantly improve the accuracy of clinical diagnostic criteria, no matter in alone or combined condition, M&V might be more accurate in diagnosing DILI from suspected patients.
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Affiliation(s)
- Yiqi Liu
- School of Graduates, Tianjin Medical University
- Department of Hepatology, Tianjin Second People's Hospital
| | - Ping Li
- Department of Hepatology, Tianjin Second People's Hospital
- Tianjin Research Institute of Liver Diseases, Tianjin
| | - Fangfang Wang
- Department of Infectious Disease, Cangzhou Central Hospital, Cangzhou
| | - Liang Liu
- School of Graduates, Tianjin Medical University
- Department of Hepatology, Tianjin Second People's Hospital
| | - Yilian Zhang
- School of Graduates, Tianjin Medical University
- Department of Hepatology, Tianjin Second People's Hospital
| | - Yonggang Liu
- Tianjin Research Institute of Liver Diseases, Tianjin
- Department of Pathology, Tianjin Second People's Hospital, Tianjin, China
| | - Ruifang Shi
- Tianjin Research Institute of Liver Diseases, Tianjin
- Department of Pathology, Tianjin Second People's Hospital, Tianjin, China
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42
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Abstract
Kratom (Mitragyna speciosa) leaves contain the mu opioid partial agonists mitragynine and 7-hydroxymitragynine. The US Drug Enforcement Agency considers it a 'drug of concern', and the US FDA is reviewing kratom, but there is a paucity of information regarding health effects. Liver injury is often cited as a potential health consequence, however the same few case reports are repeatedly referenced, without a broader context. Furthermore, reports have largely lacked standardized causality assessment methods. The objective is to evaluate causality in kratom liver injury, through a comprehensive scoping review of human cases, and by reviewing epidemiologic, animal, and mechanistic reports that relate to kratom liver injury. Hepatotoxicity causality was systematically examined using the Roussel Uclaf Causality Assessment Method (RUCAM) for case reports. Biopsy findings, potential pathophysiologic mechanisms, and management options are discussed. This review identified 26 case reports and abstracts, in addition to 7 cases reported from the Drug-Induced Liver Injury Network, 25 in FDA databases, and 27 in internet user forums. Latency periods to symptom onset had a median of 20.6 days and mean of 21 days (range 2-49). Common presenting signs and symptoms were abdominal discomfort, jaundice, pruritis, and dark urine. Histologic findings were predominantly cholestatic, although, biochemically, the condition was heterogenous or mixed; the median R ratio was 3.4 and the mean was 4.6 (range 0.24-10.4). Kratom likely causes liver injury based on the totality of low-quality human evidence, and, in the context of epidemiologic, animal, and mechanistic studies. It remains unclear which subgroups of users are at heightened risk.
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Affiliation(s)
- Jonathan Schimmel
- Department of Emergency Medicine, Division of Medical Toxicology, Mount Sinai Hospital Icahn School of Medicine, New York, NY, USA.
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
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43
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Nunes V, Mendez‐Sanchez N. Impact of Herbal and Dietary Supplements Causing Drug-Induced Liver Injury in Latin America. Clin Liver Dis (Hoboken) 2020; 16:83-86. [PMID: 33005386 PMCID: PMC7508779 DOI: 10.1002/cld.905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 11/26/2019] [Indexed: 02/04/2023] Open
Abstract
Watch a video presentation of this article.
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Affiliation(s)
- Vinicius Nunes
- Hospital Universitario Prof. Edgard SantosSalvador de BahiaBrazil
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44
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Jiménez-Pérez M, González-Grande R, García-Cortés M, Andrade RJ. Drug-Induced Liver Injury After Liver Transplantation. Liver Transpl 2020; 26:1167-1176. [PMID: 32445416 DOI: 10.1002/lt.25804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 04/28/2020] [Accepted: 05/17/2020] [Indexed: 02/07/2023]
Abstract
Drug-induced liver injury (DILI) is an adverse reaction to many drugs in common use that in a liver transplantation (LT) recipient may cause graft dysfunction and may even lead to graft loss and the need for retransplantation. However, several potential clinical scenarios, such as graft rejection and infection, can confound the diagnosis of suspected DILI in the setting of LT. This makes causal assessment of a new liver injury more uncertain and has traditionally precluded collection of bona fide cases of DILI affecting LT patients in prospective DILI registries and cohorts. Although no studies have yet determined a greater susceptibility of the transplant patient to DILI, these patients nevertheless present certain risk factors that can theoretically increase the risk of DILI. These include the fact that these patients are polymedicated, use drugs that are potentially hepatotoxic, and can have coexisting hepatitis B or C viruses in addition to other factors found in nontransplant patients, such as genetic variants. Therefore, awareness is crucial of any potential hepatotoxic effect of drugs used in the LT recipient and their possible implication in any case of liver dysfunction. In the present article, we review the most common drugs used in LT recipients from a liver safety perspective and address the main pitfalls in attributing causality in this clinical setting. We also affirm the need for further research and collaboration in this somewhat neglected topic in the field of DILI.
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Affiliation(s)
- Miguel Jiménez-Pérez
- Unidad de Gestión Clínica de Aparato Digestivo, seccion Hepatología-Trasplante Hepático, Hospital Regional, Universidad de Málaga, Malaga, Spain
| | - Rocío González-Grande
- Unidad de Gestión Clínica de Aparato Digestivo, seccion Hepatología-Trasplante Hepático, Hospital Regional, Universidad de Málaga, Malaga, Spain
| | - Miren García-Cortés
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Malaga, Spain
| | - Raúl J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Malaga, Spain
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45
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Lucena MI, Sanabria J, García-Cortes M, Stephens C, Andrade RJ. Drug-induced liver injury in older people. Lancet Gastroenterol Hepatol 2020; 5:862-874. [DOI: 10.1016/s2468-1253(20)30006-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 12/12/2022]
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46
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Abstract
Drug induced liver injury (DILI) is a relatively rare hepatic condition in response to the use of medications, illegal drugs, herbal products or dietary supplements. It occurs in susceptible individuals through a combination of genetic and environmental risk factors believed to modify drug metabolism and/or excretion leading to a cascade of cellular events, including oxidative stress formation, apoptosis/necrosis, haptenization, immune response activation and a failure to adapt. The resultant liver damage can present with an array of phenotypes, which mimic almost every other liver disorder, and varies in severity from asymptomatic elevation of liver tests to fulminant hepatic failure. Despite recent research efforts specific biomarkers are not still available for routine use in clinical practice, which makes the diagnosis of DILI uncertain and relying on a high degree of awareness of this condition and the exclusion of other causes of liver disease. Diagnostic scales such as the CIOMS/RUCAM can support the causality assessment of a DILI suspicion, but need refinement as some criteria are not evidence-based. Prospective collection of well-vetted DILI cases in established DILI registries has allowed the identification and validation of a number of clinical variables, and to predict a more severe DILI outcome. DILI is also in need of properly designed clinical trials to evaluate the efficacy of new DILI treatments as well as older drugs such as ursodeoxycholic acid traditionally used to ameliorate cholestasis or corticosteroids now widely tried in the oncology field to manage the emergent type of hepatotoxicity related to immune checkpoint inhibitors.
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47
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Varghese G, Madi L, Ghannam M, Saad R. A possible increase in liver enzymes due to amlodipine: A case report. SAGE Open Med Case Rep 2020; 8:2050313X20917822. [PMID: 32637107 PMCID: PMC7315662 DOI: 10.1177/2050313x20917822] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 03/02/2020] [Indexed: 12/20/2022] Open
Abstract
Amlodipine is a commonly prescribed antihypertensive drug, well tolerated and has rarely been attributed as a cause for elevated liver enzymes. Here, we present a 47-year-old male patient known to be hypertensive and admitted to our rehabilitation facility after an acute stroke. During his stay, amlodipine was started in addition to other antihypertensive medications to control his blood pressure. His liver transaminases after 4 days (notably alanine aminotransferase) were found to be markedly elevated. After reviewing the medications and investigating probable causes, amlodipine was suspended. After 5 days of suspending amlodipine, the transaminases started to trend downward. The Naranjo Adverse Drug Reaction Probability Scale and the Roussel Uclaf Causality Assessment Method were performed to assess causality in this suspected idiosyncratic drug-induced liver injury case. Both the scores denoted a probable amlodipine-induced liver injury. Previous case reports related to amlodipine-induced liver injury are mentioned and presented in the table below. In conclusion, amlodipine, though not well known to be hepatotoxic, can induce liver enzyme elevations in an idiosyncratic manner.
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Affiliation(s)
| | - Lama Madi
- Qatar Rehabilitation Institute (QRI), Doha, Qatar
| | | | - Rafaat Saad
- Qatar Rehabilitation Institute (QRI), Doha, Qatar
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48
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Abstract
Although levetiracetam is the antiepileptic of choice in patients after hepatic transplantation and patients with hepatic dysfunction, we report a patient in whom levetiracetam was the most probable cause of hepatic dysfunction. Treatment of this hepatic dysfunction is to have a high degree of suspicion and withdraw the drug at the earliest to prevent morbidity and rarely mortality. Though rare, this is an important unwanted side effect of this highly useful medication.
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Affiliation(s)
- Parthasarathi Gayatri
- Department of Neuroanesthesia and Neuro Intensive Care, Sagar Hospitals, Kumaraswamy Layout, Banashankari, Bengaluru, Karnataka, India
| | - Murali Mohan Selvam
- Department of Neurosurgery, Sagar Hospitals, Kumaraswamy Layout, Banashankari, Bengaluru, Karnataka, India
| | - S V Sreeharsha
- Department of Neurosurgery, Sagar Hospitals, Kumaraswamy Layout, Banashankari, Bengaluru, Karnataka, India
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49
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Sanabria-Cabrera J, Medina-Cáliz I, Stankevičiūtė S, Rodríguez-Nicolás A, Almarza-Torres M, Lucena MI, Andrade RJ. Drug-Induced liver Injury Associated with Severe Cutaneous Hypersensitivity Reactions: A Complex Entity in Need of a Multidisciplinary Approach. Curr Pharm Des 2020; 25:3855-3871. [PMID: 31696806 DOI: 10.2174/1381612825666191107161912] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/06/2019] [Indexed: 12/12/2022]
Abstract
Idiosyncratic drug-induced liver injury (DILI) occasionally occurs in the setting of severe cutaneous adverse reactions (SCARs), including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and drug reaction with eosinophilia and systemic symptoms (DRESS). This strengthens the proposed immunologic mechanism associated with this adverse reaction. DRESS exhibits the most common association with DILI. SCARs have a wide spectrum of heterogeneous clinical presentations and severity, and genetic predisposition has been identified. In the context of SCARs, DILI present a different clinical picture, ranging from mild injury to acute liver failure. Elucidating the role of DILI in the clinical presentation and outcome of SCARs represents a challenge due to limited information from published studies and the lack of consensus on definitions. The cholestatic and mixed pattern of liver damage typically predominates in the case of DILI associated with SCARs, which is different from DILI without SCARs where hepatocellular is the most common injury pattern. Only a few drugs have been associated with both DILI and SCARs. Is this article, the criteria used for DILI recognition among SCARS have been revised and discussed, along with the drugs most commonly involved in these syndromes as well as the outcome, prognostic factors and the need for a multidisciplinary approach to improve the management of DILI in the context of SCARs.
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Affiliation(s)
- Judith Sanabria-Cabrera
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain.,UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Madrid, Spain
| | - Inmaculada Medina-Cáliz
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | - Marina Almarza-Torres
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain
| | - M Isabel Lucena
- Servicio de Farmacologia Clinica, Instituto de Investigacion Biomedica de Malaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Malaga, Malaga, Spain.,UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Raúl J Andrade
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
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50
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Santos G, Gasca J, Parana R, Nunes V, Schinnoni M, Medina-Caliz I, Cabello MR, Lucena MI, Andrade RJ. Profile of herbal and dietary supplements induced liver injury in Latin America: A systematic review of published reports. Phytother Res 2020; 35:6-19. [PMID: 32525269 DOI: 10.1002/ptr.6746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023]
Abstract
Hepatotoxicity related to HDS is a growing global health issue. We have undertaken a systematic review of published case reports and case series from LA from 1976 to 2020 to describe the clinical features of HDS related hepatotoxicity in this region. We search in PubMed, Web of Science, Scopus and specific LA databases according to PRISMA guidelines. Only HILI cases published in LA that met criteria for DILI definition were included. Duplicate records or reports that lacked relevant data that precluded establishing causality were excluded. Finally, 17 records (23 cases) were included in this review. Centella asiatica, Carthamus tinctorius, and Herbalife® were the most reported HDS culprit products, the main reason for HDS consumption was weight loss. The clinical characteristics of HDS hepatotoxicity in our study were compared to those of other studies in the USA, Europe and China showing a similar signature with predominance of young females, hepatocellular damage, a high rate of ALF and mortality, more frequent inadvertent re-challenge and chronic damage. This study underscores the challenge in causality assessment when multi-ingredients HDS are taken and the need for consistent publication practice when reporting hepatotoxicity cases due to HDS, to foster HDS liver safety particularly in LA.
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Affiliation(s)
- Genario Santos
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil
| | - Jessica Gasca
- UICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Raymundo Parana
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil
| | - Vinicius Nunes
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil
| | - Maria Schinnoni
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil
| | - Inmaculada Medina-Caliz
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga - IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Spain
| | - Maria Rosario Cabello
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil.,CIBERehd, Madrid, Spain
| | - Maria Isabel Lucena
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil.,UICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,CIBERehd, Madrid, Spain
| | - Raul J Andrade
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga - IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Spain.,CIBERehd, Madrid, Spain
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