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Jagtap YA, Kumar P, Dubey AR, Kinger S, Choudhary A, Karmakar S, Lal G, Kumar A, Kumar A, Prasad A, Mishra A. Acetaminophen induces mitochondrial apoptosis through proteasome dysfunctions. Life Sci 2024; 349:122732. [PMID: 38768775 DOI: 10.1016/j.lfs.2024.122732] [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: 11/15/2023] [Revised: 03/12/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024]
Abstract
Acetaminophen is a known antipyretic and non-opioid analgesic for mild pain and fever. Numerous studies uncover their hidden chemotherapeutics applications, including chronic cancer pain management. Acetaminophen also represents an anti-proliferative effect in some cancer cells. Few studies also suggest that the use of Acetaminophen can trigger apoptosis and impede cellular growth. However, Acetaminophen's molecular potential and precise mechanism against improper cellular proliferation and use as an effective anti-proliferative agent still need to be better understood. Here, our current findings show that Acetaminophen induces proteasomal dysfunctions, resulting in aberrant protein accumulation and mitochondrial abnormalities, and consequently induces cell apoptosis. We observed that the Acetaminophen treatment leads to improper aggregation of ubiquitylated expanded polyglutamine proteins, which may be due to the dysfunctions of proteasome activities. Our in-silico analysis suggests the interaction of Acetaminophen and proteasome. Furthermore, we demonstrated the accumulation of proteasome substrates and the depletion of proteasome activities after treating Acetaminophen in cells. Acetaminophen induces proteasome dysfunctions and mitochondrial abnormalities, leading to pro-apoptotic morphological changes and apoptosis successively. These results suggest that Acetaminophen can induce cell death and may retain a promising anti-proliferative effect. These observations can open new possible molecular strategies in the near future for developing and designing specific and effective proteasome inhibitors, which can be helpful in conjugation with other anti-tumor drugs for their better efficiency.
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Affiliation(s)
- Yuvraj Anandrao Jagtap
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Rajasthan, 342037, India
| | - Prashant Kumar
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Rajasthan, 342037, India
| | - Ankur Rakesh Dubey
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Rajasthan, 342037, India
| | - Sumit Kinger
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Rajasthan, 342037, India
| | - Akash Choudhary
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Rajasthan, 342037, India
| | - Surojit Karmakar
- National Centre for Cell Science (NCCS), Ganeshkhind, Pune, Maharashtra, 411007, India
| | - Girdhari Lal
- National Centre for Cell Science (NCCS), Ganeshkhind, Pune, Maharashtra, 411007, India
| | - Awanish Kumar
- Department of Biotechnology, National Institute of Technology, Raipur, Chhattisgarh, 492010, India
| | - Amit Kumar
- Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Simrol, Indore, Madhya Pradesh, 453552, India
| | - Amit Prasad
- School of Biosciences and Bioengineering, Indian Institute of Technology Mandi, Mandi, Himachal Pradesh, 175005, India
| | - Amit Mishra
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Rajasthan, 342037, India.
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Scullion KM, MacIntyre IM, Sloan-Dennison S, Clark B, Fineran P, Mair J, Creasey D, Rathmell C, Faulds K, Graham D, Webb DJ, Dear JW. Cytokeratin-18 is a sensitive biomarker of alanine transaminase increase in a placebo-controlled, randomized, crossover trial of therapeutic paracetamol dosing (PATH-BP biomarker substudy). Toxicol Sci 2024; 199:203-209. [PMID: 38521541 PMCID: PMC11131027 DOI: 10.1093/toxsci/kfae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024] Open
Abstract
Drug-induced liver injury (DILI) is a challenge in clinical medicine and drug development. Highly sensitive novel biomarkers have been identified for detecting DILI following a paracetamol overdose. The study objective was to evaluate biomarker performance in a 14-day trial of therapeutic dose paracetamol. The PATH-BP trial was a double-blind, placebo-controlled, crossover study. Individuals (n = 110) were randomized to receive 1 g paracetamol 4× daily or matched placebo for 2 weeks followed by a 2-week washout before crossing over to the alternate treatment. Blood was collected on days 0 (baseline), 4, 7, and 14 in both arms. Alanine transaminase (ALT) activity was measured in all patients. MicroRNA-122 (miR-122), cytokeratin-18 (K18), and glutamate dehydrogenase (GLDH) were measured in patients who had an elevated ALT on paracetamol treatment (≥50% from baseline). ALT increased in 49 individuals (45%). All 3 biomarkers were increased at the time of peak ALT (K18 paracetamol arm: 18.9 ± 9.7 ng/ml, placebo arm: 11.1 ± 5.4 ng/ml, ROC-AUC = 0.80, 95% CI 0.71-0.89; miR-122: 15.1 ± 12.9fM V 4.9 ± 4.7fM, ROC-AUC = 0.83, 0.75-0.91; and GLDH: 24.6 ± 31.1U/l V 12.0 ± 11.8U/l, ROC-AUC = 0.66, 0.49-0.83). All biomarkers were correlated with ALT (K18 r = 0.68, miR-122 r = 0.67, GLDH r = 0.60). To assess sensitivity, biomarker performance was analyzed on the visit preceding peak ALT (mean 3 days earlier). K18 identified the subsequent ALT increase (K18 ROC-AUC = 0.70, 0.59-0.80; miR-122 ROC-AUC = 0.60, 0.49-0.72, ALT ROC-AUC = 0.59, 0.48-0.70; GLDH ROC-AUC = 0.70, 0.50-0.90). Variability was lowest for ALT and K18. In conclusion, K18 was more sensitive than ALT, miR-122, or GLDH and has potential significant utility in the early identification of DILI in trials and clinical practice.
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Affiliation(s)
- Kathleen M Scullion
- Centre for Cardiovascular Science, University of Edinburgh, Queen’s Medical Research Institute, Edinburgh EH16 4TJ, UK
| | - Iain M MacIntyre
- Centre for Cardiovascular Science, University of Edinburgh, Queen’s Medical Research Institute, Edinburgh EH16 4TJ, UK
| | - Sian Sloan-Dennison
- Department of Pure and Applied Chemistry, Technology and Innovation Centre, University of Strathclyde, Glasgow G1 1RD, UK
| | - Benjamin Clark
- Department of Pure and Applied Chemistry, Technology and Innovation Centre, University of Strathclyde, Glasgow G1 1RD, UK
| | - Paul Fineran
- Centre for Inflammation Research, University of Edinburgh, Institute for Regeneration and Repair, Edinburgh EH16 4UU, UK
| | - Joanne Mair
- Centre for Inflammation Research, University of Edinburgh, Institute for Regeneration and Repair, Edinburgh EH16 4UU, UK
| | - David Creasey
- Wasatch Photonics, Morrisville, North Carolina 27560, USA
| | | | - Karen Faulds
- Department of Pure and Applied Chemistry, Technology and Innovation Centre, University of Strathclyde, Glasgow G1 1RD, UK
| | - Duncan Graham
- Department of Pure and Applied Chemistry, Technology and Innovation Centre, University of Strathclyde, Glasgow G1 1RD, UK
| | - David J Webb
- Centre for Cardiovascular Science, University of Edinburgh, Queen’s Medical Research Institute, Edinburgh EH16 4TJ, UK
| | - James W Dear
- Centre for Cardiovascular Science, University of Edinburgh, Queen’s Medical Research Institute, Edinburgh EH16 4TJ, UK
- Centre for Precision Cell Therapy for the Liver, Lothian Health Board, Queen’s Medical Research Institute, Edinburgh EH16 4TJ, UK
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Hassan HM, Abdel-Halim NHM, El-Shenbaby I, Helmy MA, Hammad MO, Habotta OA, El Nashar EM, Alghamdi MA, Aldahhan RA, Al-Khater KM, Almohaywi B, Farrag EAE. Phytic acid attenuates acetaminophen-induced hepatotoxicity via modulating iron-mediated oxidative stress and SIRT-1 expression in mice. Front Pharmacol 2024; 15:1384834. [PMID: 38751780 PMCID: PMC11094543 DOI: 10.3389/fphar.2024.1384834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/04/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction: Administration of high doses of acetaminophen (APAP) results in liver injury. Oxidative stress and iron overload play roles in the pathogenesis of APAP-induced hepatotoxicity. The present study assessed the potential hepatoprotective effects of phytic acid (PA), a natural antioxidant and iron chelator, on APAP-induced hepatotoxicity and the possible underlying mechanism through its effects on CYP2E1 gene expression, iron homeostasis, oxidative stress, and SIRT-1 expression levels. Methods: Twenty-four adult male albino mice were used in this study. Mice were divided into four groups (six mice in each group): control, APAP-treated, PA-treated and APAP + PA-treated groups. Liver function tests, serum and liver tissue iron load were evaluated in all the study groups. Hepatic tissue homogenates were used to detect oxidative stress markers, including malondialdehyde (MDA) and reduced glutathione (GSH). Histological hepatic evaluation and immunohistochemistry of SIRT-1 were performed. Quantitative real-time PCR was used for the assessment of CYP2E1 and SIRT-1 gene expressions. APAP-induced biochemical and structural hepatic changes were reported. Results: PA administration showed beneficial effects on APAP-induced hepatotoxicity through improvements in liver functions, decreased CYP2E1 gene expression, decreased serum and liver iron load, decreased MDA, increased GSH, increased SIRT-1 expression level and improvement in hepatic architecture. Conclusion: Conclusively, PA can be considered a potential compound that can attenuate acetaminophen-induced hepatotoxicity through its role as an iron chelator and antioxidant, as well as the up-regulation of SIRT-1 and down-regulation of CYP2E1.
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Affiliation(s)
- Hend M. Hassan
- Human Anatomy and Embryology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Human Anatomy and Embryology Department, New Mansoura University, New Mansoura, Egypt
| | | | - Ibrahim El-Shenbaby
- Clinical Pharmacology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Manar A. Helmy
- Forensic Medicine and Toxicology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Maha O. Hammad
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ola A. Habotta
- Forensic Medicine and Toxicology Department, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
| | - Eman M. El Nashar
- Department of Anatomy, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Mansour A. Alghamdi
- Department of Anatomy, College of Medicine, King Khalid University, Abha, Saudi Arabia
- Genomics and Personalized Medicine Unit, The Center for Medical and Health Research, King Khalid University, Abha, Saudi Arabia
| | - Rashid A. Aldahhan
- Department of Anatomy, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Khulood M. Al-Khater
- Department of Anatomy, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Basmah Almohaywi
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - Eman A. E. Farrag
- Clinical Pharmacology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Ezhilarasan D, Shree Harini K, Karthick M, Selvaraj C. Ethyl gallate concurrent administration protects against acetaminophen-induced acute liver injury in mice: An in vivo and in silico approach. Chem Biol Drug Des 2024; 103:e14369. [PMID: 37817304 DOI: 10.1111/cbdd.14369] [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: 07/31/2023] [Revised: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 10/12/2023]
Abstract
Acetaminophen (APAP) in high doses causes acute liver injury and acute liver failure. Ethyl gallate (EG) is a natural polyphenol, possessing antioxidant, anti-inflammatory, and anti-microbial properties. Therefore, in this study, we evaluated the protective role of EG against APAP-induced acute liver injury in mice. Acute liver injury was induced by a single dose of APAP (400 mg/kg., i.p.). In separate groups, EG (10 mg/kg), EG (20 mg/kg), and N-acetylcysteine (NAC; 1200 mg/kg., i.p.) were administered concurrently with APAP. The mice were sacrificed after 24 h of treatment. Liver marker enzymes of hepatotoxicity, antioxidant markers, inflammatory markers, and histopathological studies were done. APAP administration caused a significant elevation of marker enzymes of hepatotoxicity and lipid peroxidation. APAP administration also decreased enzymic and nonenzymic antioxidants. Acute APAP intoxication induced nuclear factor κ B, tumor necrosis factor-α, interleukin-1, p65, and p52 and downregulated IκB gene expressions. Our histopathological studies have confirmed the presence of centrilobular necrosis, 24 h after APAP intoxication. All the above abnormalities were significantly inhibited in groups of mice that were concurrently administered with APAP + EG and APAP + NAC. Our in silico analysis further confirms that hydroxyl groups of EG interact with the above inflammatory proteins at the 3,4,5-trihydroxybenzoic acid region. These effects of EG against APAP-induced acute liver injury could be attributed to its antioxidative, free radical scavenging, and anti-inflammatory potentials. Therefore, this study suggests that EG can be an efficient therapeutic approach to protect the liver from APAP intoxication.
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Affiliation(s)
- Devaraj Ezhilarasan
- Department of Pharmacology, Hepatology and Molecular Medicine Lab, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, India
| | - Karthik Shree Harini
- Department of Pharmacology, Hepatology and Molecular Medicine Lab, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, India
| | - Munusamy Karthick
- Department of Pharmacology, Hepatology and Molecular Medicine Lab, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, India
| | - Chandrabose Selvaraj
- Department of Pharmacology, Hepatology and Molecular Medicine Lab, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, India
- Laboratory for Artificial Intelligence and Molecular Modelling, Center for Global Health Research, Saveetha Medical College, Saveetha Institute of Medical and Technical Sciences, Chennai, India
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Ferreira GM, Clarindo FA, Ribeiro ÁL, Gomes-de-Pontes L, de Carvalho LD, Martins-Filho OA, da Fonseca FG, Teixeira MM, Sabino ADP, Eapen MS, Morris DL, Valle SJ, Coelho-dos-Reis JGA. Taming the SARS-CoV-2-mediated proinflammatory response with BromAc ®. Front Immunol 2023; 14:1308477. [PMID: 38193087 PMCID: PMC10773902 DOI: 10.3389/fimmu.2023.1308477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/23/2023] [Indexed: 01/10/2024] Open
Abstract
Introduction In the present study, the impact of BromAc®, a specific combination of bromelain and acetylcysteine, on the SARS-CoV-2-specific inflammatory response was evaluated. Methods An in vitro stimulation system was standardized using blood samples from 9 healthy donors, luminex assays and flow cytometry were performed. Results and discussion BromAc® demonstrated robust anti-inflammatory activity in human peripheral blood cells upon SARS-CoV-2 viral stimuli, reducing the cytokine storm, composed of chemokines, growth factors, and proinflammatory and regulatory cytokines produced after short-term in vitro culture with the inactivated virus (iSARS-CoV-2). A combined reduction in vascular endothelial growth factor (VEGF) induced by SARS-CoV-2, in addition to steady-state levels of platelet recruitment-associated growth factor-PDGFbb, was observed, indicating that BromAc® may be important to reduce thromboembolism in COVID-19. The immunophenotypic analysis of the impact of BromAc® on leukocytes upon viral stimuli showed that BromAc® was able to downmodulate the populations of CD16+ neutrophils and CD14+ monocytes observed after stimulation with iSARS-CoV-2. Conversely, BromAc® treatment increased steady-state HLA-DR expression in CD14+ monocytes and preserved this activation marker in this subset upon iSARS-CoV-2 stimuli, indicating improved monocyte activation upon BromAc® treatment. Additionally, BromAc® downmodulated the iSARS-CoV-2-induced production of TNF-a by the CD19+ B-cells. System biology approaches, utilizing comprehensive correlation matrices and networks, showed distinct patterns of connectivity in groups treated with BromAc®, suggesting loss of connections promoted by the compound and by iSARS-CoV-2 stimuli. Negative correlations amongst proinflammatory axis and other soluble and cellular factors were observed in the iSARS-CoV-2 group treated with BromAc® as compared to the untreated group, demonstrating that BromAc® disengages proinflammatory responses and their interactions with other soluble factors and the axis orchestrated by SARS-CoV-2. Conclusion These results give new insights into the mechanisms for the robust anti-inflammatory effect of BromAc® in the steady state and SARS-CoV-2-specific immune leukocyte responses, indicating its potential as a therapeutic strategy for COVID-19.
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Affiliation(s)
- Geovane Marques Ferreira
- Laboratório de Virologia Básica e Aplicada (LVBA), Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Felipe Alves Clarindo
- Laboratório de Virologia Básica e Aplicada (LVBA), Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ágata Lopes Ribeiro
- Laboratório de Virologia Básica e Aplicada (LVBA), Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Letícia Gomes-de-Pontes
- Laboratório de Virologia Básica e Aplicada (LVBA), Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Luciana Debortoli de Carvalho
- Departamento de Biologia e Biotecnologia de Microrganismos, Universidade Estadual de Santa Cruz (UESC), Ilhéus, Brazil
| | - Olindo Assis Martins-Filho
- Grupo Integrado de Pesquisas em Biomarcadores, Rene Rachou Institute, Oswaldo Cruz Foundation, Belo Horizonte, Brazil
| | - Flávio Guimarães da Fonseca
- Laboratório de Virologia Básica e Aplicada (LVBA), Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Centro de Tecnologia em Vacinas (CT-Vacinas), Parque Tecnológico de Belo Horizonte, Belo Horizonte, Brazil
| | - Mauro Martins Teixeira
- CT Terapias Avançadas e Inovadoras (CT-Terapias), Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Adriano de Paula Sabino
- Laboratório de Hematologia Clínica, Experimental e Molecular, Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Mathew Suji Eapen
- Research & Development Department, Mucpharm Pty Ltd, Sydney, NSW, Australia
| | - David L. Morris
- Research & Development Department, Mucpharm Pty Ltd, Sydney, NSW, Australia
- St George and Sutherland Hospital Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Surgery, St George Hospital, Sydney, NSW, Australia
| | - Sarah J. Valle
- Research & Development Department, Mucpharm Pty Ltd, Sydney, NSW, Australia
- St George and Sutherland Hospital Clinical School, University of New South Wales, Sydney, NSW, Australia
- Intensive Care Unit, St George Hospital, Sydney, NSW, Australia
| | - Jordana Grazziela Alves Coelho-dos-Reis
- Laboratório de Virologia Básica e Aplicada (LVBA), Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- CT Terapias Avançadas e Inovadoras (CT-Terapias), Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Bateman DN, Dart RC, Dear JW, Prescott LF, Rumack BH. Fifty years of paracetamol (acetaminophen) poisoning: the development of risk assessment and treatment 1973-2023 with particular focus on contributions published from Edinburgh and Denver. Clin Toxicol (Phila) 2023; 61:1020-1031. [PMID: 38197864 DOI: 10.1080/15563650.2023.2293452] [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: 10/04/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Fifty years ago, basic scientific studies and the availability of assay methods made the assessment of risk in paracetamol (acetaminophen) poisoning possible. The use of the antidote acetylcysteine linked to new methods of risk assessment transformed the treatment of this poisoning. This review will describe the way in which risk assessment and treatments have developed over the last 50 years and highlight the remaining areas of uncertainty. METHODS A search of PubMed and its subsidiary databases revealed 1,166 references published in the period 1963-2023 using the combined terms "paracetamol", "poisoning", and "acetylcysteine". Focused searches then identified 170 papers dealing with risk assessment of paracetamol poisoning, 141 with adverse reactions to acetylcysteine and 114 describing different acetylcysteine regimens. To manage the extensive literature, we focused mainly on contributions made by the authors during their time in Edinburgh and Denver. DOSE AND CONCENTRATION RESPONSE The key relationship between paracetamol dose and toxicity risk was established in 1971 and led to the development of the Rumack-Matthew nomogram from data collected in Edinburgh. MECHANISMS OF TOXICITY A series of papers on the mechanisms of toxicity were published in 1973, and these showed that paracetamol hepatotoxicity was caused by the formation of a toxic intermediate epoxide metabolite normally detoxified by glutathione but which, in excess, was bound covalently to hepatic enzymes and proteins. An understanding of the relationship between the rate of paracetamol metabolism, paracetamol concentration, and toxic hazard in humans soon followed. ANTIDOTE DEVELOPMENT AND EFFICACY IN PATIENTS These discoveries were followed by the testing of a range of sulfhydryl-donors in animals and "at risk" patients. Acetylcysteine was developed as the lead intravenous antidote in the United Kingdom. The license holder in the United States refused to make an intravenous formulation. Thus, oral acetylcysteine became the antidote trialed in the United States National Multicenter Study. Intravenous acetylcysteine regimens used initially in the United Kingdom and subsequently in the United States used loading doses of 150 mg/kg over 15 minutes or one hour, 50 mg/kg over four hours, and 100 mg/kg over 16 hours. These regimens were associated with adverse drug reactions (nausea, vomiting and anaphylactoid reactions) and hence, treatment interruption. Newer dosing regimens now give loading doses more slowly. One, the Scottish and Newcastle Anti-emetic Pretreatment protocol, using an acetylcysteine regimen of 100 mg/kg over two hours followed by 200 mg/kg over 10 hours, has been widely adopted in the United Kingdom. A cohort comparison study suggests this regimen has comparable efficacy to standard regimens and offers opportunities for selective higher acetylcysteine dosing. RISK ASSESSMENT AT PRESENTATION No dose-ranging studies with acetylcysteine were done, and no placebo-controlled studies were performed. Thus, there is uncertainty regarding the optimal dose of acetylcysteine, particularly in patients ingesting very large overdoses of paracetamol. The choice of intervention concentration on the Rumack-Matthew nomogram has important consequences for the proportion of patients treated. The United States National Multicenter Study used a "treatment" line starting at 150 mg/L (992 µmol/L) at 4 hours post overdose, extending to 24 hours with a half-life of 4 hours, now standard there, and subsequently adopted in Australia and New Zealand. In the United Kingdom, the treatment line was initially 200 mg/L (1,323 µmol/L) at 4 hours (the Rumack-Matthew "risk" line). In 2012, the United Kingdom Medicines and Healthcare products Regulatory Agency lowered the treatment line to 100 mg/L (662 µmol/L) at 4 hours for all patients, increasing the number of patients admitted and treated at a high cost. Risk assessment is a key issue for ongoing study, particularly following the development of potential new antidotes that may act in those at greatest risk. The development of biomarkers to assess risk is ongoing but has yet to reach clinical trials. CONCLUSION Even after 50 years, there are still areas of uncertainty. These include appropriate acetylcysteine doses in patients who ingest different paracetamol doses or multiple (staggered) ingestions, early identification of at-risk patients, and optimal treatment of late presenters.
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Affiliation(s)
- D Nicholas Bateman
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Medical Toxicology, University of CO School of Medicine, Aurora, CO, USA
| | - James W Dear
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Laurie F Prescott
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Barry H Rumack
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Marín-Romero A, Pernagallo S. A comprehensive review of Dynamic Chemical Labelling on Luminex xMAP technology: a journey towards Drug-Induced Liver Injury testing. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2023; 15:6139-6149. [PMID: 37965948 DOI: 10.1039/d3ay01481a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Drug-Induced Liver Injury (DILI) is a grave global adverse event that can result in fatal consequences, causing drug failures, market withdrawals, and regulatory warnings, leading to substantial financial losses. The early detection of DILI remains a significant challenge in global healthcare. Although circulating microRNAs (miRs) show promise as clinical biomarkers for DILI, the current analytical methods for their measurement are insufficient. There is a pressing need for rapid and reliable miR detection methods that eliminate the need for nucleic acid extraction and PCR-based amplification. This review highlights recent advancements achieved by integrating Dynamic Chemical Labelling (DCL) with Luminex xMAP technology. This powerful combination has resulted in groundbreaking bead-based assays that allow (1) the direct, multiplex detection of miRs, and (2) the simultaneous testing of miR and protein biomarkers. This triple capability enables a comprehensive assessment that significantly enhances the detection and analysis of crucial biomarkers, thus improving the understanding and diagnosis of DILI. In conclusion, this review offers valuable insights into the capabilities and potential applications of these groundbreaking assays in DILI research, as well as their potential use in other diagnostic and research domains that require direct or multiplex analysis of miRs or analysis of miRs in combination with proteins.
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Affiliation(s)
- Antonio Marín-Romero
- DESTINA Genomica S.L., Parque Tecnológico Ciencias de la Salud (PTS), Avenida de la Innovación 1, Edificio BIC, Armilla, Granada 18100, Spain.
| | - Salvatore Pernagallo
- DESTINA Genomica S.L., Parque Tecnológico Ciencias de la Salud (PTS), Avenida de la Innovación 1, Edificio BIC, Armilla, Granada 18100, Spain.
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Abushanab D, Gasim M, Devi D, Elbdairy M, Elqasass H, Ahmed N, Vincent M, Abdul Rouf PV, Mohammed HR, Hail MA, Thomas B, Elkassem W, Hanssens Y, Elgassim M, Elmoheen A, Azad A, Mohammed S, Salem W. Patterns and outcomes of paracetamol poisoning management in Hamad Medical Corporation, Qatar: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e34872. [PMID: 37746996 PMCID: PMC10519564 DOI: 10.1097/md.0000000000034872] [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: 04/18/2023] [Revised: 06/30/2023] [Accepted: 08/01/2023] [Indexed: 09/26/2023] Open
Abstract
We aimed to investigate the characteristics and clinical outcomes of paracetamol poisoning and paracetamol overdose in Qatar. This retrospective cohort study included patients admitted to the emergency department (ED). We included patients who presented with excessive paracetamol ingestion, between December 2018 and September 2019. The primary outcomes were describing the characteristics and outcomes of paracetamol overdose (from a suicidal overdose or accidental overdose, dose ≤ 150 mg/kg, when serum levels of <60 mmol/L) or dose ingested (≤75 mg/kg) with staggered ingestion poisoning due to suicidal attempt or accidental attempt, defined as the dose ingested (>150 mg/kg), acute ingestion, nomogram level more than the treatment line, or dose ingested (>75 mg/kg) with staggered ingestion, and assessing the management of excessive paracetamol ingestion. Secondary outcomes included evaluation of the time difference between ingestion and time of administration, hospitalization, and adverse drug events. Significant differences were detected between patients who presented with paracetamol overdose and those who presented with paracetamol toxicity. A total of 69 patients were analyzed, of whom 43 received paracetamol overdose (mean age 27.5 ± 11.1 years) and 26 had paracetamol poisoning (mean age 25 ± 6.22 years). Paracetamol poisoning was identified in 26% of the patients with a 24.3% history of psychiatric illness, compared to 18.6% with paracetamol overdose. More patients presented with paracetamol toxicity in the time between ingestion and obtaining serum levels compared to the overdose group. A significantly longer length of hospitalization was observed in the toxicity group. A significantly higher number of patients in the toxicity group received N-acetylcysteine (NAC). More hypotension and rashes were observed among those who received NAC in the toxicity group. Patients presenting to the ED due to paracetamol toxicity are not uncommon, and most cases occur in young adults, and few in patients with a history of psychiatric illness, suggesting that preventive approaches are highly required.
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Affiliation(s)
- Dina Abushanab
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Mahmoud Gasim
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Dyomgy Devi
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Noon Ahmed
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Manna Vincent
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Moza Al Hail
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Binny Thomas
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Wessam Elkassem
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohammed Elgassim
- Department of Accident and Emergency, Hamad Medical Corporation, Doha, Qatar
| | - Amr Elmoheen
- Department of Accident and Emergency, Hamad Medical Corporation, Doha, Qatar
| | - Aftab Azad
- Department of Accident and Emergency, Hamad Medical Corporation, Doha, Qatar
| | - Shaban Mohammed
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Waleed Salem
- Department of Accident and Emergency, Hamad Medical Corporation, Doha, Qatar
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9
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Yao Q, Tang Y, Dai S, Huang L, Jiang Z, Zheng S, Sun M, Xu Y, Lu R, Sun T, Huang H, Jiang X, Yao X, Lin G, Kou L, Chen R. A Biomimetic Nanoparticle Exerting Protection against Acute Liver Failure by Suppressing CYP2E1 Activity and Scavenging Excessive ROS. Adv Healthc Mater 2023; 12:e2300571. [PMID: 37236618 DOI: 10.1002/adhm.202300571] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/19/2023] [Indexed: 05/28/2023]
Abstract
Acute liver failure (ALF) is a severe liver disease caused by many reasons. One of them is the overdosed acetaminophen (APAP), which is metabolized into N-acetyl-p-benzoquinone imine (NAPQI), an excessive toxic metabolite, by CYP2E1, resulting in excessive reactive oxygen species (ROS), exhausted glutathione (GSH), and thereafter hepatocyte necrosis. N-acetylcysteine is the Food and Drug Administration-approved drug for detoxification of APAP, but it has limited clinical application due to the short therapeutic time window and concentration-related adverse effects. In this study, a carrier-free and bilirubin dotted nanoparticle (B/BG@N) is developed, which is formed using bilirubin and 18β-Glycyrrhetinic acid, and bovine serum albumin (BSA) is then adsorbed to mimic the in vivo behavior of the conjugated bilirubin for hitchhiking. The results demonstrate that B/BG@N can effectively reduce the production of NAPQI as well as exhibit antioxidant effects against intracellular oxidative stress via regulating the nuclear factor erythroid 2-related factor 2/heme oxygenase-1 signal axis and reducing the production of inflammatory factors. In vivo study shows that B/BG@N can effectively improve the clinical symptom of the mice model. This study suggests that B/BG@N own increases circulation half-life, improves accumulation in the liver, and dual detoxification, providing a promising strategy for clinical ALF treatment.
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Affiliation(s)
- Qing Yao
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, P. R. China
| | - Yingying Tang
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- Key Laboratory of Structural Malformations in Children of Zhejiang Province, Wenzhou, 325027, P. R. China
| | - Sheng Dai
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- Key Laboratory of Structural Malformations in Children of Zhejiang Province, Wenzhou, 325027, P. R. China
| | - Lihui Huang
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- Key Laboratory of Structural Malformations in Children of Zhejiang Province, Wenzhou, 325027, P. R. China
| | - Zewei Jiang
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- Key Laboratory of Structural Malformations in Children of Zhejiang Province, Wenzhou, 325027, P. R. China
| | - Shiming Zheng
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- Key Laboratory of Structural Malformations in Children of Zhejiang Province, Wenzhou, 325027, P. R. China
| | - Meng Sun
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- Key Laboratory of Structural Malformations in Children of Zhejiang Province, Wenzhou, 325027, P. R. China
| | - Yitianhe Xu
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, P. R. China
| | - Ruijie Lu
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
| | - Tuyue Sun
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
| | - Huirong Huang
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, P. R. China
| | - Xinyu Jiang
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- Key Laboratory of Structural Malformations in Children of Zhejiang Province, Wenzhou, 325027, P. R. China
| | - Xiaomin Yao
- Faculty of Pharmacy, Zhejiang Pharmaceutical University, Ningbo, 315100, P. R. China
| | - Guangyong Lin
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
| | - Longfa Kou
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- Key Laboratory of Structural Malformations in Children of Zhejiang Province, Wenzhou, 325027, P. R. China
- Zhejiang Engineering Research Center for Innovation and Application of Intelligent Radiotherapy Technology, Wenzhou, 325000, P. R. China
- Wenzhou Key Laboratory of Basic Science and Translational Research of Radiation Oncology, Wenzhou, 325027, P. R. China
- Zhejiang-Hong Kong Precision Theranostics of Thoracic Tumors Joint Laboratory, Wenzhou, 325000, P. R. China
| | - Ruijie Chen
- Wenzhou Municipal Key Laboratory of Pediatric Pharmacy, Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, P. R. China
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, P. R. China
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10
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Chiew AL, Isbister GK. Advances in the understanding of acetaminophen toxicity mechanisms: a clinical toxicology perspective. Expert Opin Drug Metab Toxicol 2023; 19:601-616. [PMID: 37714812 DOI: 10.1080/17425255.2023.2259787] [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: 05/15/2023] [Revised: 08/02/2023] [Accepted: 09/13/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Acetaminophen (paracetamol) is a commonly used analgesic and antipyretic agent, which is safe in therapeutic doses. Acetaminophen poisoning due to self-harm or repeated supratherapeutic ingestion is a common cause of acute liver injury. Acetylcysteine has been a mainstay of treatment for acetaminophen poisoning for decades and is efficacious if administered early. However, treatment failures occur if administered late, in 'massive' overdoses or in high-risk patients. AREAS COVERED This review provides an overview of the mechanisms of toxicity of acetaminophen poisoning (metabolic and oxidative phase) and how this relates to the assessment and treatment of the acetaminophen poisoned patient. The review focuses on how these advances offer further insight into the utility of novel biomarkers and the role of proposed adjunct treatments. EXPERT OPINION Advances in our understanding of acetaminophen toxicity have allowed the development of novel biomarkers and a better understanding of how adjunct treatments may prevent acetaminophen toxicity. Newly proposed adjunct treatments like fomepizole are being increasingly used without robust clinical trials. Novel biomarkers (not yet clinically available) may provide better assessment of these newly proposed adjunct treatments, particularly in clinical trials. These advances in our understanding of acetaminophen toxicity and liver injury hold promise for improved diagnosis and treatment.
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Affiliation(s)
- Angela L Chiew
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Geoffrey K Isbister
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Clinical Toxicology Research Group, University of Newcastle, Callaghan, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle, Waratah, NSW, Australia
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11
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Dear JW, Bateman DN. Developing new antidotes for poisons with existing effective treatments: a case study of fomepizole in paracetamol poisoning. Clin Toxicol (Phila) 2023; 61:577-580. [PMID: 37747339 DOI: 10.1080/15563650.2023.2259085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Acetylcysteine is the only effective and licensed therapy for paracetamol poisoning. However, acetylcysteine loses efficacy if treatment is delayed 8-12 hours after paracetamol ingestion, and there is also uncertainty as to whether the dose should be increased in high-risk paracetamol ingestions. Studies have identified potential therapeutic targets, including enzymes that metabolize paracetamol; the pathways causing mitochondrial toxicity via c-Jun N-terminal kinases or superoxide generation; and other specific targets, such as nuclear factor-erythroid factor 2-dependent gene induction and autophagy. With this range of potential additional therapies, how should the speciality of clinical toxicology approach the development of new antidotes for this common poisoning? HISTORICAL BACKGROUND When the first treatments for paracetamol toxicity were developed, the clinical trial and ethical basis of practice were different from today. Acetylcysteine was never subjected to placebo-controlled studies, even by the United States Food and Drug Administration, as it was presumed that the toxicity of high paracetamol concentrations was so evident that placebo-controlled studies were unethical. Thus, the absolute benefit of acetylcysteine remains unknown. In addition, no dose-ranging studies of acetylcysteine in patients were ever done. The weakness of assessing the efficacy of additional antidotes in small groups of patients with moderate poisoning is illustrated by the use of cimetidine in paracetamol poisoning. CURRENT APPROACHES TO DRUG (AND ANTIDOTE) DEVELOPMENT The approach required by regulatory authorities today relies on several important steps. First, a clear target for therapeutic effect is sought, normally in a laboratory model. Next, a 'proof of principle' study is required to demonstrate that the target is 'druggable'. Finally, clinical studies to confirm proof of principle applies in humans, followed by a controlled trial with matched patient groups with sufficient power to demonstrate the clinical outcome being sought. Such patient studies can be expensive to conduct, and non-commercial groups suffer the risk of not being funded. FOMEPIZOLE Fomepizole prevents paracetamol-induced hepatic toxicity in mice by inhibiting cytochrome P4502E1, thereby preventing the conversion of paracetamol to its toxic metabolite. Fomepizole also inhibits c-Jun N-terminal kinases, a key pathway in the downstream toxicity on the mitochondria. The present evidence of efficacy in humans is based on small case series with no control groups. The availability of a licensed indication has facilitated off-label use of fomepizole in an unproven indication. CONCLUSIONS Paracetamol poisoning is common, and randomized, controlled clinical trials are possible. The benefit of fomepizole can only be shown by such a study. As clinical trials using fomepizole as an added therapy to acetylcysteine are recruiting in the United States, these should be supported by all clinical toxicologists. In the interim, the publication of small case series using fomepizole should be discouraged by journals.
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Affiliation(s)
- James W Dear
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - D Nicholas Bateman
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
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12
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Humphries C, Roberts G, Taheem A, Abdel Kader H, Kidd R, Smith J. SNAPTIMED study: does the Scottish and Newcastle Antiemetic Protocol achieve timely intervention and management from the emergency department to discharge for paracetamol poisoning? Emerg Med J 2023; 40:221-223. [PMID: 35981856 DOI: 10.1136/emermed-2021-212180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 08/03/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND This study aimed to establish whether the modified 12-hour Scottish and Newcastle Antiemetic Protocol (SNAP) for paracetamol poisoning is associated with improvement in hospital length of stay (LoS), as well as to validate the performance of the protocol for the prevention of anaphylactoid reactions and total infusion duration. METHODS Retrospective chart review from 25 March 2019 to 25 September 2020. Patients aged 16 or older with a diagnosis of suspected or confirmed paracetamol overdose were included in the analysis if they received treatment for paracetamol poisoning, and the protocol used could be identified. Data were collected for LoS, number of extended treatment infusions used and evidence of anaphylactoid reaction. RESULTS 1167 records were assessed for eligibility, and 294 were included for analysis. Use of the SNAP was associated with a statistically significant reduction in LoS of -8.8 hours (95% CI -12.6 to -2.0), and a reduced risk of anaphylactoid reaction (Number Needed to Treat=10). CONCLUSION In this retrospective study, use of the SNAP reduced the duration of inpatient admissions and rate of anaphylactoid reactions.
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Affiliation(s)
| | | | - Anjeli Taheem
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | | | - Rebecca Kidd
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Jason Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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13
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Luo G, Huang L, Zhang Z. The molecular mechanisms of acetaminophen-induced hepatotoxicity and its potential therapeutic targets. Exp Biol Med (Maywood) 2023; 248:412-424. [PMID: 36670547 DOI: 10.1177/15353702221147563] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Acetaminophen (APAP), a widely used antipyretic and analgesic drug in clinics, is relatively safe at therapeutic doses; however, APAP overdose may lead to fatal acute liver injury. Currently, N-acetylcysteine (NAC) is clinically used as the main antidote for APAP poisoning, but its therapeutic effect remains limited owing to rapid disease progression and the general diagnosis of advanced poisoning. As is well known, APAP-induced hepatotoxicity (AIH) is mainly caused by the toxic metabolite N-acetyl-p-benzoquinone imine (NAPQI), and the toxic mechanisms of AIH are complicated. Several cellular processes are involved in the pathogenesis of AIH, including liver metabolism, mitochondrial oxidative stress and dysfunction, sterile inflammation, endoplasmic reticulum stress, autophagy, and microcirculation dysfunction. Mitochondrial oxidative stress and dysfunction are the major cellular events associated with APAP-induced liver injury. Many biomolecules involved in these biological processes are potential therapeutic targets for AIH. Therefore, there is an urgent need to comprehensively clarify the molecular mechanisms underlying AIH and to explore novel therapeutic strategies. This review summarizes the various cellular events involved in AIH and discusses their potential therapeutic targets, with the aim of providing new ideas for the treatment of AIH.
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Affiliation(s)
- Guangwen Luo
- Jinhua Municipal Central Hospital, Jinhua 321000, China
| | - Lili Huang
- Ningbo Medical Center Lihuili Hospital, Ningbo 315040, China
| | - Zhaowei Zhang
- Jinhua Municipal Central Hospital, Jinhua 321000, China
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14
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Bateman DN. Large paracetamol overdose-Higher dose acetylcysteine is required. Br J Clin Pharmacol 2023; 89:34-38. [PMID: 34957591 DOI: 10.1111/bcp.15201] [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: 07/08/2021] [Revised: 08/04/2021] [Accepted: 08/25/2021] [Indexed: 11/30/2022] Open
Abstract
Paracetamol poisoning continues to be a worldwide problem and, despite the availability of an effective antidote, acetylcysteine (NAC), the optimal way to use this antidote, particularly following very large doses of paracetamol, has not been established. Recent case series have shown an increased toxicity from high doses of paracetamol, even in those receiving prompt NAC therapy, particularly in patients above the 300 mg/L nomogram treatment line. Clinical trial evidence supporting shorter NAC dosing now allows the possibility for intensifying treatment without the risk of very high rates of ADRs. New biomarkers also show the possibility of early identification of patients at risk of liver injury who might also benefit from increased intensity treatment. This article discusses these data and proposes a logical therapy for increasing NAC dosing which now requires clinical trial testing.
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Affiliation(s)
- D Nicholas Bateman
- Clinical Toxicology, Pharmacology and Toxicology, Queen's Medical Research Institute, University of Edinburgh, UK
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15
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Thanacoody HKR. Large paracetamol overdose - Higher dose NAC is NOT required. Br J Clin Pharmacol 2023; 89:39-42. [PMID: 34951044 DOI: 10.1111/bcp.15199] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 11/27/2022] Open
Abstract
Paracetamol overdose is common in developed countries but less than 10% involve large ingestions exceeding 30 g or 500 mg/kg. High dose acetylcysteine (NAC) has been proposed in patients taking large paracetamol overdoses based on reports of hepatotoxicity despite early initiation of NAC treatment with the commonly used 300 mg/kg intravenous acetylcysteine regimen. The evidence from cohorts of patients treated with the standard NAC regimen after large paracetamol overdoses shows that it is effective in most patients. A small study in patients with paracetamol overdoses of 40 g or more and paracetamol concentrations above the 300 mg/L nomogram line showed that modification of the standard NAC regimen to provide a total of 400-500 mg/kg NAC over 21-22 h may reduce the risk of hepatotoxicity (peak ALT > 1000 IU/L) but the impact on development of hepatic failure, liver transplantation and mortality with this approach is presently unknown. Better risk stratification of patients taking paracetamol overdose may allow higher dose NAC and adjunctive treatments such as CYP2E1 inhibition and extracorporeal removal of paracetamol to be targeted to those patients at the highest risk of hepatotoxicity after a large paracetamol overdose.
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Affiliation(s)
- H K Ruben Thanacoody
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,National Poisons Information Service (Newcastle unit), The Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
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16
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Sudanagunta S, Camarena-Michel A, Pennington S, Leonard J, Hoyte C, Wang GS. Comparison of Two-Bag Versus Three-Bag N-Acetylcysteine Regimens for Pediatric Acetaminophen Toxicity. Ann Pharmacother 2023; 57:36-43. [PMID: 35587124 DOI: 10.1177/10600280221097700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Acetaminophen overdose is a leading cause of liver failure, and a leading cause of pediatric poisoning requiring hospital admission. The antidote, N-acetylcysteine (NAC), is traditionally administered as a three-bag intravenous infusion. Despite its efficacy, NAC is associated with high incidence of nonallergic anaphylactoid reactions (NAARs). Adult evidence demonstrates that alternative dosing regimens decrease NAARs and medication errors (MEs). OBJECTIVES To compare NAARs and MEs associated with two- versus three-bag NAC for acetaminophen overdose in a pediatric population. METHODS This is a retrospective observational cohort study comparing pediatric patients who received three- versus two-bag NAC for acetaminophen toxicity. The primary outcome was incidence of NAARs. Secondary outcomes were rates of MEs and relevant hospital outcomes (length of stay [LOS], intensive care unit (ICU) admission, liver transplant, death). RESULTS Two hundred forty-three patients met inclusion criteria (median age of 15 years): 150 (62%) three-bag NAC and 93 (38%) two-bag NAC. There was no difference in overall NAARs (p = 0.54). Fewer cutaneous NAARs were observed in the two-bag group, three-bag: 15 (10%), two-bag: 2 (2%), p = 0.02. MEs were significantly decreased with the two-bag regimen, three-bag: 59 (39%), two-bag: 21 (23%), p = 0.01. No statistical differences were observed in LOS, ICU admissions, transplant, or death. CONCLUSION AND RELEVANCE A significant decrease in cutaneous NAARs and MEs was observed in pediatric patients by combining the first two bags of the traditional three-bag NAC regimen. In pediatric populations, a two-bag NAC regimen for acetaminophen overdose may improve medication tolerance and safety.
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Affiliation(s)
- Sindhu Sudanagunta
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Children's Hospital Colorado, Aurora, CO, USA
| | | | | | - Jan Leonard
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christopher Hoyte
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Rocky Mountain Poison and Drug Safety, Denver, CO, USA
| | - George Sam Wang
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Rocky Mountain Poison and Drug Safety, Denver, CO, USA.,Children's Hospital Colorado, Aurora, CO, USA
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17
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Yau CE, Chen H, Lim BPY, Ng M, Ponampalam R, Lim DYZ, Chin YH, Ho AFW. Performance of the paracetamol-aminotransferase multiplication product in risk stratification after paracetamol (acetaminophen) poisoning: a systematic review and meta-analysis. Clin Toxicol (Phila) 2023; 61:1-11. [PMID: 36444937 DOI: 10.1080/15563650.2022.2152350] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Risk stratification in paracetamol (acetaminophen) poisoning is crucial because hepatotoxicity is common and can be mitigated with treatment. However, current risk stratification tools have limitations. AIMS We evaluated the diagnostic performance of the paracetamol concentration × aminotransferase multiplication product, for predicting hepatotoxicity after paracetamol overdose. METHODS Medline, Cochrane Library and Embase were searched for eligible papers. We used random effects models to obtain pooled estimates of the likelihood ratios and diagnostic odds ratios, from which sensitivity and specificity were computed. We assessed two commonly used cut-off values of paracetamol × aminotransferase, 1500 mg/L × IU/L and 10,000 mg/L × IU/L. Using the confusion matrices of these two cut-offs, area under the summary receiver operator characteristic curve and optimal cut-off values in different clinical scenarios were established. RESULTS Six studies comprising 5036 participants were included. In 4051 patients, using the cut-off of 1500 mg/L × IU/L, a diagnostic odds ratio of 31.90 (95%CI: 9.52-106.90), sensitivity of 0.98 (95%CI: 0.94-1.00) and specificity of 0.66 (95%CI: 0.49-0.89) were obtained. In 3983 patients, using the cut-off of 10,000 mg/L × IU/L, a diagnostic odds ratio of 99.34 (95%CI: 12.26-804.87), sensitivity of 0.65 (95%CI: 0.51-0.82) and specificity of 0.97 (95%CI: 0.95-1.00) were obtained. For staggered ingestions, the 1500 mg/L × IU/L cut-off yielded a diagnostic odds ratio of 69.53 (95%CI: 4.03-1199.75), sensitivity of 1.00 (95%CI: 0.87-1.00) and specificity of 0.74 (95%CI: 0.43-1.00). Next, using the 10,000 mg/L × IU/L cut-off in this scenario yielded a diagnostic odds ratio of 254.58 (95%CI: 11.12-5827.60), sensitivity of 0.79 (95%CI: 0.59-1.00) and specificity of 0.98 (95%CI: 0.94-1.00). The overall summary receiver operator characteristic curve was 0.91 (95%CI: 0.75-0.97), and the optimal cut-off value was 3840 mg/L × IU/L. The summary receiver operator characteristic curve in patients with staggered ingestions was 0.96 (95%CI: 0.85-0.99). The summary receiver operator characteristic curve in patients with staggered ingestions and whose paracetamol concentration was below the detectable limit of 10 mg/L at presentation was 0.97 (95%CI: 0.94-0.99). CONCLUSION In this first meta-analysis, paracetamol × aminotransferase demonstrates its use in prognosticating hepatotoxicity in patients with paracetamol poisoning. It complements the Rumack-Matthew nomogram as it has shown promise in addressing two key limitations of the nomogram: it is usable after more than 24 h between overdose and acetylcysteine treatment, and it is applicable in staggered ingestions.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haoyang Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bryant Po-Yuen Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mingwei Ng
- SingHealth Toxicology Service; Singapore, Singapore
| | - R Ponampalam
- SingHealth Toxicology Service; Singapore, Singapore
| | - Daniel Yan Zheng Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
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Janković SM. Acetaminophen toxicity and overdose: current understanding and future directions for NAC dosing regimens. Expert Opin Drug Metab Toxicol 2022; 18:745-753. [PMID: 36420805 DOI: 10.1080/17425255.2022.2151893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Although N-acetyl-cysteine (NAC) has long been used for the treatment of acetaminophen poisoning/overdose, the optimal NAC dosing regimen for varying patterns or severity of the poisoning/overdose is still unknown. AREAS COVERED Relevant literature was searched for in the MEDLINE (from 1964 until August 31st, 2022), SCOPUS (from 2004 until August 31st, 2022) and GOOGLE SCHOLAR (from 2004 until August 31st, 2022) databases, without restriction in terms of publication date. The inclusion criteria were: original clinical studies reporting results, and studies investigating efficacy and safety of NAC dosing regimens in case(s) of overdose or poisoning with acetaminophen. EXPERT OPINION For a more effective treatment of acetaminophen poisoning in the future, it will be crucial to advance the technology of measuring acetaminophen, its metabolites and NAC in the serum, preferably with the point-of-care technique, so that in real time it can be continuously assessed whether it is necessary to administer NAC, and further to increase the dose of NAC and extend the duration of its administration, or not.
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19
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Zhang L, Zhang F, Xiao Y, Du J, Zhang X, Chen M, Wu B. The nuclear receptor REV-ERBα regulates CYP2E1 expression and acetaminophen hepatotoxicity. Xenobiotica 2022; 52:633-643. [PMID: 36149338 DOI: 10.1080/00498254.2022.2128934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
CYP2E1 plays an important role in drug metabolism and drug-induced hepatotoxicity. Here, we aimed to investigate a potential role for the nuclear receptor REV-ERBα in regulation of CYP2E1 expression and acetaminophen (APAP)-induced hepatotoxicity, and to determine the underlying mechanisms.Regulatory effects of REV-ERBα on CYP2E1 expression were assessed in vivo (using Rev-erbα-/- mice) and in vitro (using AML12 and HepG2 cells). In vitro microsomal CYP2E1 activity was probed using its specific substrate p-nitrophenol. Pharmacokinetic and acute toxicities studies were performed with Rev-erbα-/- and wild-type mice after APAP administration.We found that Rev-erbα ablation led to decreases in hepatic CYP2E1 expression and activity in mice. In line with this, APAP-induced hepatotoxicity was attenuated in Rev-erbα-deficient mice. The attenuated toxicity was due to down-regulation of APAP metabolism mediated by CYP2E1, which was evidenced by a decrease in formation of the toxic intermediate metabolite NAPQI (i.e., reduced APAP-Cysteine and APAP-N-acetylcysteine levels). Furthermore, positive regulation of CYP2E1 expression by REV-ERBα was confirmed in both AML12 and HepG2 cells. Based on luciferase reporter assays, it was found that REV-ERBα regulated Cyp2e1 transcription and expression through repression of DEC2.In conclusion, REV-ERBα positively regulates CYP2E1 expression in mice, thereby affecting APAP metabolism and hepatotoxicity.
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Affiliation(s)
- Li Zhang
- College of Pharmacy, Jinan University, Guangzhou, China
| | - Fugui Zhang
- Institute of Molecular Rhythm and Metabolism, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yifei Xiao
- Institute of Molecular Rhythm and Metabolism, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jianhao Du
- School of Medicine, Jinan University, Guangzhou, China
| | | | - Min Chen
- College of Pharmacy, Jinan University, Guangzhou, China.,Institute of Molecular Rhythm and Metabolism, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Baojian Wu
- Institute of Molecular Rhythm and Metabolism, Guangzhou University of Chinese Medicine, Guangzhou, China
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20
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Liu K, Chen X, Ren Y, Liu C, Yuan A, Zheng L, Li B, Zhang Y. Identification of a novel farnesoid X receptor agonist, kaempferol-7-O-rhamnoside, a compound ameliorating drug-induced liver injury based on virtual screening and in vitro validation. Toxicol Appl Pharmacol 2022; 454:116251. [PMID: 36150480 DOI: 10.1016/j.taap.2022.116251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/11/2022] [Accepted: 09/16/2022] [Indexed: 11/19/2022]
Abstract
Farnesoid X receptor (FXR), a bile acid receptor, plays an essential role in maintaining bile acid and liver homeostasis and has been recognized as an essential target for drug-induced liver injury (DILI). This study aimed to identify potential FXR agonists by virtual screening, molecular dynamics (MD) simulation, and biological assays. First, an in-house Traditional Chinese medicine compound database was screened using a virtual approach based on molecular docking to reveal potential FXR agonists. Secondly, MD was applied to analyze the process of agonist binding. Finally, the acetaminophen (APAP)-induced L02 cells model evaluated the pharmacodynamic activity of agonists treating DILI. Virtual screening results showed that kaempferol-7-O-rhamnoside was confirmed as the FXR agonist. MD results showed that kaempferol-7-O-rhamnoside could stably bind the FXR. In addition, in vitro cell-based assay showed that kaempferol-7-O-rhamnoside could promote the expression of the FXR gene and inhibit the Cyp7a1 gene expression in APAP-induced cells, significantly reducing the activities of AST, AKP and ROS, and enhancing the expression of GSH. The current study confirmed that kaempferol-7-O-rhamnoside might improve liver function by promoting proliferation, ameliorating oxidative stress, and regulating FXR target genes as observed in vitro. Therefore, in this study, discovering the FXR agonist, kaempferol-7-O-rhamnoside, provides valuable guidance for developing novel drugs against DILI.
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Affiliation(s)
- Kaiyang Liu
- Key Laboratory of TCM-information Engineer of State Administration of TCM, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 102488, China
| | - Xi Chen
- Key Laboratory of TCM-information Engineer of State Administration of TCM, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 102488, China
| | - Yue Ren
- Key Laboratory of TCM-information Engineer of State Administration of TCM, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 102488, China
| | - Chaoqun Liu
- Key Laboratory of TCM-information Engineer of State Administration of TCM, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 102488, China
| | - Anlei Yuan
- Key Laboratory of TCM-information Engineer of State Administration of TCM, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 102488, China
| | - Lulu Zheng
- Key Laboratory of TCM-information Engineer of State Administration of TCM, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 102488, China
| | - Beiyan Li
- Key Laboratory of TCM-information Engineer of State Administration of TCM, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 102488, China
| | - Yanling Zhang
- Key Laboratory of TCM-information Engineer of State Administration of TCM, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing 102488, China.
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21
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Motohashi K, Thanacoody RHK. Toxicology in the emergency department: what's new? Br J Hosp Med (Lond) 2022; 83:1-16. [DOI: 10.12968/hmed.2022.0313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intentional and accidental drug overdose, recreational drug use and exposure to toxic substances are common reasons for people presenting to emergency departments. Although the mortality rate associated with these presentations is low in the UK, they can lead to significant morbidity and prolonged hospital admissions. This review discusses new developments in the management of paracetamol overdose. Several new protocols for the infusion of acetylcysteine, the antidote for paracetamol overdose, have been proposed in the past decade and evaluated in clinical studies. The 12-hour Scottish and Newcastle Acetylcysteine Protocol regimen and 20-hour Australian two-infusion bag protocol have been widely adopted into clinical practice and endorsed in national guidelines because of their shorter duration, reduction in adverse effects and efficacy in treating overdose. This article includes a care pathway that can facilitate the implementation of the Scottish and Newcastle Acetylcysteine Protocol. This article also discusses the emergency management of ingested button batteries, describes the emerging threat of novel psychoactive substances, and provides an update on new UK antidote guidelines. Further up-to-date guidance on management of clinical toxicology is available to healthcare professionals on the internet database TOXBASE.
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Affiliation(s)
- Kenzo Motohashi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Ruben HK Thanacoody
- National Poisons Information Service (Newcastle Unit), Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
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22
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Licata A, Minissale MG, Stankevičiūtė S, Sanabria-Cabrera J, Lucena MI, Andrade RJ, Almasio PL. N-Acetylcysteine for Preventing Acetaminophen-Induced Liver Injury: A Comprehensive Review. Front Pharmacol 2022; 13:828565. [PMID: 36034775 PMCID: PMC9399785 DOI: 10.3389/fphar.2022.828565] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 06/03/2022] [Indexed: 12/28/2022] Open
Abstract
Aims: N-Acetylcysteine (NAC) is used as an antidote in acetaminophen (APAP) overdose to prevent and mitigate drug-induced liver injury (DILI). Our objective was to systematically review evidence of the use of NAC as a therapeutic option for APAP overdose and APAP-related DILI in order to define the optimal treatment schedule and timing to start treatment. Methods: Bibliographic databases (PubMed, Web of Science, Embase, and MEDLINE) were searched for retrospective and prospective cohort studies, case series, and clinical trials. The prespecified primary outcomes were DILI-related mortality, hepatotoxicity, and adverse events (AEs). Results: In total, 34 studies of NAC usage in APAP-related DILI cases with 19,580 patients were identified, of which 2,376 patients developed hepatotoxicities. The mortality rate across different studies ranged from 0 to 52%. Large variability of NAC regimens was found, i.e., intravenous (I.V.) (100–150 mg/kg) and oral (70–140 mg/kg), and length of treatment varied—12, 24, or 48 h for I.V. regimen and 72 h for oral administration. The timing of initiation of NAC treatment showed different results in terms of occurrence of hepatotoxicity and mortality; if started within 8 h and no more than 24 h from APAP overdose, either intravenously or orally, NAC administration was efficacious in terms of mortality. The most frequent AEs reported were anaphylactic reactions, followed by cutaneous AEs for the IV route and intestinal AEs for the oral one. Conclusion: NAC improves hepatotoxicity and reduces mortality. Timing of treatment, ranging from 8 to 24 h from APAP overdose, regardless of the regimen or route of administration, is important to prevent or minimize liver damage, particularly in children and in elderly and obese patients.
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Affiliation(s)
- Anna Licata
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
- *Correspondence: Anna Licata,
| | - Maria Giovanna Minissale
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
| | - Simona Stankevičiūtė
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
| | - Judith Sanabria-Cabrera
- UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Malaga, Spain
- Centro de Investigación Biomedica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Maria Isabel Lucena
- UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Malaga, Spain
- Centro de Investigación Biomedica 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
| | - Raul J Andrade
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Piero Luigi Almasio
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
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23
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Sanabria-Cabrera J, Tabbai S, Niu H, Alvarez-Alvarez I, Licata A, Björnsson E, Andrade RJ, Lucena MI. N-Acetylcysteine for the Management of Non-Acetaminophen Drug-Induced Liver Injury in Adults: A Systematic Review. Front Pharmacol 2022; 13:876868. [PMID: 35656297 PMCID: PMC9152180 DOI: 10.3389/fphar.2022.876868] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/14/2022] [Indexed: 12/30/2022] Open
Abstract
Introduction: Idiosyncratic drug-induced liver injury (DILI) is a rare adverse reaction to drugs and other xenobiotics. DILI has different grades of severity and may lead to acute liver failure (ALF), for which there is no effective therapy. N-acetylcysteine (NAC) has been occasionally tested for the treatment of non-acetaminophen drug-induced ALF. However, limited evidence for its efficacy and safety is currently available. Our aim was to elucidate the benefit and safety of NAC in DILI and evaluate its hepatoprotective effect. Methods: We conducted a systematic review to evaluate the management and prevention focused on NAC in idiosyncratic DILI. The main outcomes included mortality due to DILI, time to normalization of liver biochemistry, transplant-free survival, and adverse events. We included clinical trials and observational studies, either prospective or retrospective. Results: A total of 11 studies were included after literature screening. All studies had different methodologies, and some of them had important risk of bias that may lead to interpreting their findings with caution. The majority of the studies proved NAC efficacy in a cohort of patients with ALF due to different etiologies, where DILI represented a subgroup. NAC seemed to improve transplant-free survival; however, its benefit was inconclusive in terms of overall survival. With regard to safety, NAC showed an adequate safety profile. In prevention studies, NAC showed a possible hepatoprotective effect; however, this finding is limited by the lack of studies and presence of bias. Conclusion: NAC treatment seems to have some benefit in non-acetaminophen drug-induced liver failure patients with acceptable safety; however, due to the lack of evidence and limitations detected across studies, its benefit must be corroborated in clinical trials with adequate methodology.
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Affiliation(s)
- Judith Sanabria-Cabrera
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- UCICEC IBIMA, Plataforma ISCIII de soporte para la Investigación Clínica, Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Sara Tabbai
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- UCICEC IBIMA, Plataforma ISCIII de soporte para la Investigación Clínica, Málaga, Spain
| | - Hao Niu
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, 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
| | - Ismael Alvarez-Alvarez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Màlaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Màlaga, Malaga, Spain
| | - Anna Licata
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
| | - Einar Björnsson
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Raul 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 Màlaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Màlaga, Malaga, Spain
| | - M. Isabel Lucena
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- UCICEC IBIMA, Plataforma ISCIII de soporte para la Investigación Clínica, Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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24
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Approach to paracetamol intoxication in intensive care: 2 pregnant cases. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.907301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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25
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Sandilands EA, Rees JM, Raja K, Dhaun N, Morrison EE, Hickson K, Wraight J, Gray T, Briody L, Cameron S, Thompson AP, Johnston NR, Uren N, Goddard J, Treweeke A, Rushworth G, Webb DJ, Bateman DN, Norrie J, Megson IL, Eddleston M. Acetylcysteine has No Mechanistic Effect in Patients at Risk of Contrast-Induced Nephropathy - A Failure of Academic Clinical Science. Clin Pharmacol Ther 2022; 111:1222-1238. [PMID: 35098531 PMCID: PMC9306485 DOI: 10.1002/cpt.2541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/10/2022] [Indexed: 11/25/2022]
Abstract
Contrast‐induced nephropathy (CIN) is a major complication of imaging in patients with chronic kidney disease (CKD). The publication of an academic randomized controlled trial (RCT; n = 83) reporting oral (N)‐acetylcysteine (NAC) to reduce CIN led to > 70 clinical trials, 23 systematic reviews, and 2 large RCTs showing no benefit. However, no mechanistic studies were conducted to determine how NAC might work; proposed mechanisms included renal artery vasodilatation and antioxidant boosting. We evaluated the proposed mechanisms of NAC action in participants with healthy and diseased kidneys. Four substudies were performed. Two randomized, double‐blind, placebo‐controlled, three‐period crossover studies (n = 8) assessed the effect of oral and intravenous (i.v.) NAC in healthy kidneys in the presence/absence of iso‐osmolar contrast (iodixanol). A third crossover study in patients with CKD stage III (CKD3) (n = 8) assessed the effect of oral and i.v. NAC without contrast. A three‐arm randomized, double‐blind, placebo‐controlled parallel‐group study, recruiting patients with CKD3 (n = 66) undergoing coronary angiography, assessed the effect of oral and i.v. NAC in the presence of contrast. We recorded systemic (blood pressure and heart rate) and renal (renal blood flow (RBF) and glomerular filtration rate (GFR)) hemodynamics, and antioxidant status, plus biomarkers of renal injury in patients with CKD3 undergoing angiography. Primary outcome for all studies was RBF over 8 hours after the start of i.v. NAC/placebo. NAC at doses used in previous trials of renal prophylaxis was essentially undetectable in plasma after oral administration. In healthy volunteers, i.v. NAC, but not oral NAC, increased blood pressure (mean area under the curve (AUC) mean arterial pressure (MAP): mean difference 29 h⋅mmHg, P = 0.019 vs. placebo), heart rate (28 h⋅bpm, P < 0.001), and RBF (714 h⋅mL/min, 8.0% increase, P = 0.006). Renal vasodilatation also occurred in the presence of contrast (RBF 917 h⋅mL/min, 12% increase, P = 0.005). In patients with CKD3 without contrast, only a rise in heart rate (34 h⋅bpm, P = 0.010) and RBF (288 h⋅mL/min, 6.0% increase, P = 0.001) occurred with i.v. NAC, with no significant effect on blood pressure (MAP rise 26 h⋅mmHg, P = 0.156). Oral NAC showed no effect. In patients with CKD3 receiving contrast, i.v. NAC increased blood pressure (MAP rise 52 h⋅mmHg, P = 0.008) but had no effect on RBF (151 h⋅mL/min, 3.0% increase, P = 0.470), GFR (29 h⋅mL/min/1.73m², P = 0.122), or markers of renal injury. Neither i.v. nor oral NAC affected plasma antioxidant status. We found oral NAC to be poorly absorbed and have no reno‐protective effects. Intravenous, not oral, NAC caused renal artery vasodilatation in healthy volunteers but offered no protection to patients with CKD3 at risk of CIN. These findings emphasize the importance of mechanistic clinical studies before progressing to RCTs for novel interventions. Thousands were recruited to academic clinical trials without the necessary mechanistic studies being performed to confirm the approach had any chance of working.
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Affiliation(s)
- Euan A Sandilands
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service (Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jessica Mb Rees
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Khuram Raja
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - Neeraj Dhaun
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Emma E Morrison
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service (Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Kirsty Hickson
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - Jonathan Wraight
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service (Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Tanya Gray
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Lesley Briody
- Wellcome Trust Clinical Research Facility, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sharon Cameron
- Wellcome Trust Clinical Research Facility, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Adrian P Thompson
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Neil R Johnston
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Neal Uren
- Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jane Goddard
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andy Treweeke
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - Gordon Rushworth
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - David J Webb
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - D Nicholas Bateman
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Ian L Megson
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - Michael Eddleston
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service (Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
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Drug-Induced Liver Injury: Clinical Evidence of N-Acetyl Cysteine Protective Effects. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:3320325. [PMID: 34912495 PMCID: PMC8668310 DOI: 10.1155/2021/3320325] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/12/2021] [Accepted: 11/22/2021] [Indexed: 12/29/2022]
Abstract
Oxidative stress is a key pathological feature implicated in both acute and chronic liver diseases, including drug-induced liver injury (DILI). The latter describes hepatic injury arising as a direct toxic effect of administered drugs or their metabolites. Although still underreported, DILI remains a significant cause of liver failure, especially in developed nations. Currently, it is understood that mitochondrial-generated oxidative stress and abnormalities in phase I/II metabolism, leading to glutathione (GSH) suppression, drive the onset of DILI. N-Acetyl cysteine (NAC) has attracted a lot of interest as a therapeutic agent against DILI because of its strong antioxidant properties, especially in relation to enhancing endogenous GSH content to counteract oxidative stress. Thus, in addition to updating information on the pathophysiological mechanisms implicated in oxidative-induced hepatic injury, the current review critically discusses clinical evidence on the protective effects of NAC against DILI, including the reduction of patient mortality. Besides injury caused by paracetamol, NAC can also improve liver function in relation to other forms of liver injury such as those induced by excessive alcohol intake. The implicated therapeutic mechanisms of NAC extend from enhancing hepatic GSH levels to reducing biomarkers of paracetamol toxicity such as keratin-18 and circulating caspase-cleaved cytokeratin-18. However, there is still lack of evidence confirming the benefits of using NAC in combination with other therapies in patients with DILI.
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Sattari M, Ostadi A, Hassani S, Mazloumi Z, Noshad H, Mirnia K, Salek Maghsoudi A. Plasma Concentration of Taurine Changes following Acetaminophen Overdose in Male Patients during Hospitalization. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2021; 20:297-306. [PMID: 34567163 PMCID: PMC8457743 DOI: 10.22037/ijpr.2020.113698.14435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Changes in plasma concentration of taurine during hospitalization of acetaminophen poisoned patients have not been studied. Hepatotoxicity is a common consequence of acetaminophen overdose that may lead to acute liver failure. Numerous biomarkers for drug-induced liver injury have been explored. All biomarkers are usually obtainable 48 h following acetaminophen overdose. We have already introduced taurine as a non-specific early biomarker of acetaminophen overdose. This study aimed to follow up changes in plasma concentration of taurine during the first three days of acetaminophen overdose. Sixty-four male patients suffering from acetaminophen overdose were selected for the study. Four blood samples were taken from the patients every 12 h. Sixty blood samples were also taken from sixty healthy humans. The plasma concentration of taurine in both groups was analyzed an already developed HPLC method. Analysis of regression showed a significant correlation between means of plasma concentrations of taurine and acetaminophen, aspartate aminotransferase, Alanine aminotransferase, glutathione peroxidase, and prothrombin time during hospitalization. The high plasma concentration of taurine, 6 h or more after acetaminophen overdose, could be a useful early indicator of liver damage.
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Affiliation(s)
- Mohammadreza Sattari
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Pharmacology and Toxicology, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Ostadi
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Internal Medicine, Sina Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shokoufeh Hassani
- Toxicology and Diseases Group (TDG), Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran.,Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeynab Mazloumi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hamid Noshad
- Department of Nephrology, Sina Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kayvan Mirnia
- Department of Neonatology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Armin Salek Maghsoudi
- Toxicology and Diseases Group (TDG), Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran.,Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Acetaminophen is a common medication taken in deliberate self-poisoning and unintentional overdose. It is the commonest cause of severe acute liver injury in Western countries. The optimal management of most acetaminophen poisonings is usually straightforward. Patients who present early should be offered activated charcoal and those at risk of acute liver injury should receive acetylcysteine. This approach ensures survival in most. The acetaminophen nomogram is used to assess the need for treatment in acute immediate-release overdoses with a known time of ingestion. However, scenarios that require different management pathways include modified-release, large/massive, and repeated supratherapeutic ingestions.
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Affiliation(s)
- Angela L Chiew
- Clinical Toxicology Unit, Prince of Wales Hospital, Barker Street, Randwick, New South Wales 2031, Australia.
| | - Nicholas A Buckley
- Pharmacology and Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales 2050, Australia
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29
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García-Cortés M, Ortega-Alonso A, Andrade RJ. Safety of treating acute liver injury and failure. Expert Opin Drug Saf 2021; 21:191-203. [PMID: 34254839 DOI: 10.1080/14740338.2021.1955854] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Acute liver injury and progression to acute liver failure can be life-threatening conditions that require prompt careful clinical assessment and therapeutic management. AREAS COVERED The aim of this article is to review the safety and side effect profile of pharmacological therapies used in the treatment of acute liver injury with specific focus on hepatic toxicity. We performed an extensive literature search with the terms 'acute liver injury,' 'acute liver failure,' 'therapy,' 'safety,' 'adverse reactions' and 'drug induced liver injury.' A thorough discussion of the main drugs and devices used in patients with acute liver injury and acute liver failure, its safety profile and the management of complications associated to therapy of these conditions is presented. EXPERT OPINION Several pharmacological approaches are used in acute liver injury and acute liver failure in an empirical basis. Whilst steroids are frequently tried in serious drug-induced liver injury there is concern on a potential harmful effect of these agents because of the higher mortality in patients receiving the drug; hence, statistical approaches such as propensity score matching might help resolve this clinical dilemma. Likewise, properly designed clinical trials using old and new drugs for subjects with serious drug-induced liver injury are clearly needed.
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Affiliation(s)
- Miren García-Cortés
- Servicio 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
| | - Aida Ortega-Alonso
- Servicio 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
| | - Raúl J Andrade
- Servicio 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
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30
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Wong KK, Lee SWH, Kua KP. N-Acetylcysteine as Adjuvant Therapy for COVID-19 - A Perspective on the Current State of the Evidence. J Inflamm Res 2021; 14:2993-3013. [PMID: 34262324 PMCID: PMC8274825 DOI: 10.2147/jir.s306849] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/26/2021] [Indexed: 12/15/2022] Open
Abstract
The looming severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a long-lasting pandemic of coronavirus disease 2019 (COVID-19) around the globe with substantial morbidity and mortality. N-acetylcysteine, being a nutraceutical precursor of an important antioxidant glutathione, can perform several biological functions in mammals and microbes. It has consequently garnered a growing interest as a potential adjunctive therapy for coronavirus disease. Here, we review evidence concerning the effects of N-acetylcysteine in respiratory viral infections based on currently available in vitro, in vivo, and human clinical investigations. The repurposing of a known drug such as N-acetylcysteine may significantly hasten the deployment of a novel approach for COVID-19. Since the drug candidate has already been translated into the clinic for several decades, its established pharmacological properties and safety and side-effect profiles expedite preclinical and clinical assessment for the treatment of COVID-19. In vitro data have depicted that N-acetylcysteine increases antioxidant capacity, interferes with virus replication, and suppresses expression of pro-inflammatory cytokines in cells infected with influenza viruses or respiratory syncytial virus. Furthermore, findings from in vivo studies have displayed that, by virtue of immune modulation and anti-inflammatory mechanism, N-acetylcysteine reduces the mortality rate in influenza-infected mice animal models. The promising in vitro and in vivo results have prompted the initiation of human subject research for the treatment of COVID-19, including severe pneumonia and acute respiratory distress syndrome. Albeit some evidence of benefits has been observed in clinical outcomes of patients, precision nanoparticle design of N-acetylcysteine may allow for greater therapeutic efficacy.
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Affiliation(s)
- Kon Ken Wong
- Department of Microbiology and Immunology, Hospital Canselor Tuanku Muhriz UKM, Cheras, Kuala Lumpur, Malaysia.,Faculty of Medicine, The National University of Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia.,Asian Centre for Evidence Synthesis in Population, Implementation, and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University, Bandar Sunway, Selangor, Malaysia.,Gerontechnology Laboratory, Global Asia in the 21st Century (GA21) Platform, Monash University, Bandar Sunway, Selangor, Malaysia.,Faculty of Health and Medical Sciences, Taylor's University, Bandar Sunway, Selangor, Malaysia
| | - Kok Pim Kua
- Puchong Health Clinic, Petaling District Health Office, Ministry of Health Malaysia, Petaling, Selangor, Malaysia
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31
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Dear JW, Ng ML, Bateman DN, Leroy Sivappiragasam P, Choi H, Khoo BBJ, Ibrahim B, Drum CL. A metabolomic analysis of thiol response for standard and modified N-acetyl cysteine treatment regimens in patients with acetaminophen overdose. Clin Transl Sci 2021; 14:1476-1489. [PMID: 33742775 PMCID: PMC8301594 DOI: 10.1111/cts.13009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 12/20/2022] Open
Abstract
N-acetylcysteine (NAC) is an antidote to prevent acetaminophen (paracetamol-APAP)-induced acute liver injury (ALI). The 3-bag licensed 20.25 h standard regimen, and a 12 h modified regimen, are used to treat APAP overdose. This study evaluated the redox thiol response and APAP metabolites, in patients with a single APAP overdose treated with either the 20.25 h standard or 12 h modified regimen. We used liquid chromatography tandem mass spectrometry to quantify clinically important oxidative stress biomarkers and APAP metabolites in plasma samples from 45 patients who participated in a randomized controlled trial (SNAP trial). We investigated the time course response of plasma metabolites at predose, 12 h, and 20.25 h post-start of NAC infusion. The results showed that the 12 h modified regimen resulted in a significant elevation of plasma NAC and cysteine concentrations at 12 h post-infusion. We found no significant alteration in the metabolism of APAP, mitochondrial, amino acids, and other thiol biomarkers with the two regimens. We examined APAP and purine metabolism in overdose patients who developed ALI. We showed the major APAP-metabolites and xanthine were significantly higher in patients with ALI. These biomarkers correlated well with alanine aminotransferase activity at admission. Receiver operating characteristic analysis showed that at admission, plasma APAP-metabolites and xanthine concentrations were predictive for ALI. In conclusion, a significantly higher redox thiol response with the modified NAC regimen at 12 h postdose suggests this regimen may produce greater antioxidant efficacy. At baseline, plasma APAP and purine metabolites may be useful biomarkers for early prediction of APAP-induced ALI.
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Affiliation(s)
- James W Dear
- Pharmacology, Toxicology, and TherapeuticsCentre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | - Mei Li Ng
- Cardiovascular Research InstituteNational University Health SystemSingapore CitySingapore
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore CitySingapore
- Advanced Medical and Dental InstituteUniversiti Sains MalaysiaKepala BatasMalaysia
| | - D. Nicholas Bateman
- Pharmacology, Toxicology, and TherapeuticsCentre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | | | - Hyungwon Choi
- Cardiovascular Research InstituteNational University Health SystemSingapore CitySingapore
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore CitySingapore
- Institute of Molecular and Cell BiologyAgency for Science, Technology, and ResearchSingapore CitySingapore
| | - Benjamin Bing Jie Khoo
- Cardiovascular Research InstituteNational University Health SystemSingapore CitySingapore
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore CitySingapore
| | - Baharudin Ibrahim
- School of Pharmaceutical SciencesUniversiti Sains MalaysiaKepala BatasMalaysia
| | - Chester Lee Drum
- Cardiovascular Research InstituteNational University Health SystemSingapore CitySingapore
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore CitySingapore
- Department of SurgeryYong Loo Lin School of MedicineNational University of SingaporeSingapore CitySingapore
- Department of BiochemistryYong Loo Lin School of MedicineNational University of SingaporeSingapore CitySingapore
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32
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Burnham K, Yang T, Smith H, Knight S. A review of alternative intravenous acetylcysteine regimens for acetaminophen overdose. Expert Rev Clin Pharmacol 2021; 14:1267-1278. [PMID: 34187297 DOI: 10.1080/17512433.2021.1946392] [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: 02/05/2023]
Abstract
INTRODUCTION Acetylcysteine is the standard treatment for preventing hepatotoxicity caused by acetaminophen overdose. Several novel approaches to the management of acetaminophen overdose have been suggested to improve patient safety by reducing adverse drug reactions and dosing errors. This article reviews these alternative treatment regimens and intends to offer a detailed assessment of the available options to assist providers in managing cases of acetaminophen overdose. AREAS COVERED This review article covers observational and experimental studies that assessed the efficacy and safety of alternative intravenous acetylcysteine regimens for acetaminophen overdose. A literature search was conducted using PubMed, ProQuest, and Scopus to identify the studies, which included results through April 2021. The assessment of alternative regimens consists of a discussion on the limitations and benefits, barriers to implementation, and important considerations for each regimen. EXPERT OPINION Several alternative regimens have been studied and implemented in various institutions. Many of these dosing regimens have supporting safety data but most lack robust data. A reduction in infusion-related side effects is an important outcome, but established efficacy, local poison center familiarity with the regimen, institutional resources, and patient-specific factors should be equally considered when deciding on implementing and using an alternative dosing strategy.
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Affiliation(s)
- Kevin Burnham
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Tianrui Yang
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Haleigh Smith
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Steven Knight
- Methodist Mansfield Medical Center, Mansfield, TX, USA
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33
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Acquisto NM, Slocum GW, Bilhimer MH, Awad NI, Justice SB, Kelly GF, Makhoul T, Patanwala AE, Peksa GD, Porter B, Truoccolo DMS, Treu CN, Weant KA, Thomas MC. Key articles and guidelines for the emergency medicine clinical pharmacist: 2011-2018 update. Am J Health Syst Pharm 2021; 77:1284-1335. [PMID: 32766731 DOI: 10.1093/ajhp/zxaa178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy. SUMMARY Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma. CONCLUSION There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Giles W Slocum
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | | | - Nadia I Awad
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | | | - Gregory F Kelly
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Therese Makhoul
- Department of Pharmacy, Santa Rosa Memorial Hospital, Santa Rosa, CA
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | - Blake Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, VT
| | | | - Cierra N Treu
- Department of Pharmacy, NewYork Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY
| | - Kyle A Weant
- Medical University of South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC
| | - Michael C Thomas
- McWhorter School of Pharmacy, Samford University, Birmingham, AL
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34
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[Consensus of Chinese experts on prevention and standardized treatment of drug-induced liver injury in patients with blood diseases (2021)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:185-192. [PMID: 33910302 PMCID: PMC8081943 DOI: 10.3760/cma.j.issn.0253-2727.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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35
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Pingali P, Wu YJ, Boothello R, Sharon C, Li H, Sistla S, Sankaranarayanan NV, Desai UR, Le AT, Doebele RC, Muldoon LL, Patel BB, Neuwelt A. High dose acetaminophen inhibits STAT3 and has free radical independent anti-cancer stem cell activity. Neoplasia 2021; 23:348-359. [PMID: 33640759 PMCID: PMC7920811 DOI: 10.1016/j.neo.2021.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 01/06/2023] Open
Abstract
High-dose acetaminophen (AAP) with delayed rescue using n-acetylcysteine (NAC), the FDA-approved antidote to AAP overdose, has demonstrated promising antitumor efficacy in early phase clinical trials. However, the mechanism of action (MOA) of AAP's anticancer effects remains elusive. Using clinically relevant AAP concentrations, we evaluated cancer stem cell (CSC) phenotype in vitro and in vivo in lung cancer and melanoma cells with diverse driver mutations. Associated mechanisms were also studied. Our results demonstrated that AAP inhibited 3D spheroid formation, self-renewal, and expression of CSC markers when human cancer cells were grown in serum-free CSC media. Similarly, anti-CSC activity was demonstrated in vivo in xenograft models - tumor formation following in vitro treatment and ex-vivo spheroid formation following in vivo treatment. Intriguingly, NAC, used to mitigate AAP's liver toxicity, did not rescue cells from AAP's anti-CSC effects, and AAP failed to reduce glutathione levels in tumor xenograft in contrast to mice liver tissue suggesting nonglutathione-related MOA. In fact, AAP mediates its anti-CSC effect via inhibition of STAT3. AAP directly binds to STAT3 with an affinity in the low micromolar range and a high degree of specificity for STAT3 relative to STAT1. These findings have high immediate translational significance concerning advancing AAP with NAC rescue to selectively rescue hepatotoxicity while inhibiting CSCs. The novel mechanism of selective STAT3 inhibition has implications for developing rational anticancer combinations and better patient selection (predictive biomarkers) for clinical studies and developing novel selective STAT3 inhibitors using AAP's molecular scaffold.
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Affiliation(s)
- Pavani Pingali
- Section of Hematology and Oncology, Medicine Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA
| | | | - Rio Boothello
- Section of Hematology and Oncology, Medicine Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA
| | - Chetna Sharon
- Section of Hematology and Oncology, Medicine Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA
| | - Howard Li
- Department of Pulmonology, Hunter Holmes McGuire VA Medical Center, Richmond, VA; Department of Pulmonology, Virginia Commonwealth University Hospital, Richmond, VA
| | - Srinivas Sistla
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA
| | - Nehru Viji Sankaranarayanan
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA
| | - Umesh R Desai
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA; Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, Richmond, VA
| | - Anh T Le
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Robert C Doebele
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Bhaumik B Patel
- Section of Hematology and Oncology, Medicine Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA; Division of Hematology, Oncology, and Palliative care, Department of Medicine, and Massey Cancer Center, Virginia Commonwealth University. Richmond, VA.
| | - Alexander Neuwelt
- Section of Hematology and Oncology, Medicine Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA; Division of Hematology, Oncology, and Palliative care, Department of Medicine, and Massey Cancer Center, Virginia Commonwealth University. Richmond, VA.
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da Silva Souza B, Sales ACS, da Silva FDS, de Souza TF, de Freitas CDT, Vasconcelos DFP, de Oliveira JS. Latex Proteins from Plumeria pudica with Therapeutic Potential on Acetaminophen-Induced Liver Injury. Mini Rev Med Chem 2020; 20:2011-2018. [DOI: 10.2174/1389557520666200821121903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/29/2020] [Accepted: 06/09/2020] [Indexed: 11/22/2022]
Abstract
Liver disease is global health problem. Paracetamol (APAP) is used as an analgesic drug
and is considered safe at therapeutic doses, but at higher doses, it causes acute liver injury. N-acetyl-p-
Benzoquinone Imine (NAPQI) is a reactive toxic metabolite produced by biotransformation of APAP.
NAPQI damages the liver by oxidative stress and the formation of protein adducts. The glutathione
precursor N-acetylcysteine (NAC) is the only approved antidote against APAP hepatotoxicity, but it
has limited hepatoprotective effects. The search for new drugs and novel therapeutic intervention strategies
increasingly includes testing plant extracts and other natural products. Plumeria pudica (Jacq.,
1760) is a plant that produces latex containing molecules with therapeutic potential. Proteins obtained
from this latex (LPPp), a well-defined mixture of chitinases, proteinases proteinase inhibitors have
shown anti-inflammatory, antinociceptive, antidiarrheal effects as well as a protective effect against
ulcerative colitis. These studies have demonstrated that LPPp acts on parameters such as Glutathione
(GSH) and Malondialdehyde (MDA) concentration, Superoxide Dismutase (SOD) activity, Myeloperoxidase
(MPO) activity, and TNF- α IL1-β levels. Since oxidative stress and inflammation have been
reported to affect the initiation and progression of liver injury caused by APAP, it is suggested that
LPPp can act on aspects related to paracetamol hepatoxicity. This article brings new insights into the
potential of the laticifer proteins extracted from the latex of P. pudica and opens new perspectives for
the treatment of this type of liver disease with LPPp.
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Affiliation(s)
- Bruna da Silva Souza
- Universidade Federal do Delta do Parnaiba - UFDPar, Laboratorio de Bioquimica de Plantas Laticiferas (LABPL), CEP 64.202-020, Parnaiba, Piaui, Brazil
| | - Ana Clara Silva Sales
- Universidade Federal do Delta do Parnaiba - UFDPar, Laboratorio de Bioquimica de Plantas Laticiferas (LABPL), CEP 64.202-020, Parnaiba, Piaui, Brazil
| | - Francisca Dayane Soares da Silva
- Universidade Federal do Delta do Parnaiba - UFDPar, Laboratorio de Bioquimica de Plantas Laticiferas (LABPL), CEP 64.202-020, Parnaiba, Piaui, Brazil
| | - Thalis Ferreira de Souza
- Universidade Federal do Delta do Parnaiba - UFDPar, Laboratorio de Bioquimica de Plantas Laticiferas (LABPL), CEP 64.202-020, Parnaiba, Piaui, Brazil
| | | | - Daniel Fernando Pereira Vasconcelos
- Universidade Federal do Piaui - UFPI, Programa de Doutorado em Biotecnologia - Rede Nordeste de Biotecnologia (RENORBIO), CEP 64049-550, Teresina, PI, Brazil
| | - Jefferson Soares de Oliveira
- Universidade Federal do Delta do Parnaiba - UFDPar, Laboratorio de Bioquimica de Plantas Laticiferas (LABPL), CEP 64.202-020, Parnaiba, Piaui, Brazil
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Mégarbane B, Oberlin M, Alvarez JC, Balen F, Beaune S, Bédry R, Chauvin A, Claudet I, Danel V, Debaty G, Delahaye A, Deye N, Gaulier JM, Grossenbacher F, Hantson P, Jacobs F, Jaffal K, Labadie M, Labat L, Langrand J, Lapostolle F, Le Conte P, Maignan M, Nisse P, Sauder P, Tournoud C, Vodovar D, Voicu S, Claret PG, Cerf C. Management of pharmaceutical and recreational drug poisoning. Ann Intensive Care 2020; 10:157. [PMID: 33226502 PMCID: PMC7683636 DOI: 10.1186/s13613-020-00762-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis. METHODS A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology. RESULTS The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature. CONCLUSIONS The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Mathieu Oberlin
- Emergency Department, HuManiS Laboratory (EA7308), University Hospital, Strasbourg, France
| | - Jean-Claude Alvarez
- Department of Pharmacology and Toxicology, Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, Paris-Saclay University, Garches, France
| | - Frederic Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Sébastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, AP-HP, INSERM UMRS-1144, Paris-Saclay University, Boulogne-Billancourt, France
| | - Régis Bédry
- Hospital Secure Unit, Pellegrin University Hospital, Bordeaux, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, AP-HP, Paris, France
| | - Isabelle Claudet
- Pediatric Emergency Department Children’s Hospital CHU Toulouse, Toulouse, France
| | - Vincent Danel
- Department of Emergency Medicine, University Hospital of Grenoble, Grenoble, France
| | - Guillaume Debaty
- 5525, University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, Grenoble, France
| | | | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM U942, University of Paris, Paris, France
| | - Jean-Michel Gaulier
- Laboratory of Toxicology, EA 4483 - IMPECS - IMPact de L’Environnement Chimique Sur La Santé Humaine, University of Lille, Lille, France
| | | | - Philippe Hantson
- Intensive Care Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Frédéric Jacobs
- Polyvalent Intensive Care Unit, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, Clamart, France
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Magali Labadie
- Poison Control Centre of Bordeaux, University Hospital of Bordeaux, Bordeaux, France
| | - Laurence Labat
- Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, INSERM UMRS-1144, University of Paris, Paris, France
| | - Jérôme Langrand
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Inserm, U942, Avicenne Hospital, AP-HP, Paris-13 University, Bobigny, France
| | - Philippe Le Conte
- Department of Emergency Medicine, University Hospital of Nantes, Nantes, France
| | - Maxime Maignan
- Emergency Department, Grenoble University Hospital, INSERM U1042, Grenoble Alpes University, Grenoble, France
| | - Patrick Nisse
- Poison Control Centre, University Hospital of Lille, Lille, France
| | - Philippe Sauder
- Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France
| | | | - Dominique Vodovar
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Pierre-Géraud Claret
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Charles Cerf
- Intensive Care Unit, Foch Hospital, Suresnes, France
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Meaden CW, Procopio G, Calello DP, Nelson LS, Ruck B, Gupta A, Jacob JE. Carbon tetrachloride poisoning from an antique fire extinguisher. Am J Emerg Med 2020; 38:2139-2141. [PMID: 33071087 DOI: 10.1016/j.ajem.2020.07.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/17/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Christopher W Meaden
- Rutgers New Jersey Medical School, Newark, NJ, United States of America; New Jersey Poison Information and Education System, Newark, NJ, United States of America.
| | - Gabrielle Procopio
- Hackensack University Medical Center, Hackensack, NJ, United States of America
| | - Diane P Calello
- Rutgers New Jersey Medical School, Newark, NJ, United States of America; New Jersey Poison Information and Education System, Newark, NJ, United States of America
| | - Lewis S Nelson
- Rutgers New Jersey Medical School, Newark, NJ, United States of America; New Jersey Poison Information and Education System, Newark, NJ, United States of America
| | - Bruce Ruck
- Rutgers New Jersey Medical School, Newark, NJ, United States of America; New Jersey Poison Information and Education System, Newark, NJ, United States of America
| | - Amit Gupta
- Hackensack University Medical Center, Hackensack, NJ, United States of America
| | - Jeena E Jacob
- Rutgers New Jersey Medical School, Newark, NJ, United States of America; New Jersey Poison Information and Education System, Newark, NJ, United States of America
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Poe FL, Corn J. N-Acetylcysteine: A potential therapeutic agent for SARS-CoV-2. Med Hypotheses 2020; 143:109862. [PMID: 32504923 PMCID: PMC7261085 DOI: 10.1016/j.mehy.2020.109862] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/07/2020] [Accepted: 05/21/2020] [Indexed: 02/08/2023]
Abstract
COVID-19, a respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), continues to spread across the globe. Predisposing factors such as age, diabetes, cardiovascular disease, and lowered immune function increase the risk of disease severity. T cell exhaustion, high viral load, and high levels of TNF-ɑ, IL1β, IL6, IL10 have been associated with severe SARS-CoV-2. Cytokine and antigen overstimulation are potentially responsible for poor humoral response to the virus. Lower cellular redox status, which leads to pro-inflammatory states mediated by TNF-ɑ is also potentially implicated. In vivo, in vitro, and human clinical trials have demonstrated N-acetylcysteine (NAC) as an effective method of improving redox status, especially when under oxidative stress. In human clinical trials, NAC has been used to replenish glutathione stores and increase the proliferative response of T cells. NAC has also been shown to inhibit the NLRP3 inflammasome pathway (IL1β and IL18) in vitro, and decrease plasma TNF-ɑ in human clinical trials. Mediation of the viral load could occur through NAC's ability to increase cellular redox status via maximizing the rate limiting step of glutathione synthesis, and thereby potentially decreasing the effects of virally induced oxidative stress and cell death. We hypothesize that NAC could act as a potential therapeutic agent in the treatment of COVID-19 through a variety of potential mechanisms, including increasing glutathione, improving T cell response, and modulating inflammation. In this article, we present evidence to support the use of NAC as a potential therapeutic agent in the treatment of COVID-19.
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Affiliation(s)
- Francis L Poe
- Whole Systems Research Institute, 1020 SW Taylor St Ste. 340, Portland, OR 97239, United States.
| | - Joshua Corn
- Whole Systems Research Institute, 1020 SW Taylor St Ste. 340, Portland, OR 97239, United States
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Chefirat B, Zergui A, Rahmani C, Belmessabih MN, Rezk-kallah H. Acute paracetamol poisonings received at the Oran University Hospital. Toxicol Rep 2020; 7:1172-1177. [PMID: 32983905 PMCID: PMC7494939 DOI: 10.1016/j.toxrep.2020.08.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/10/2020] [Accepted: 08/21/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Paracetamol is the most commonly used drug worldwide for its analgesic/antipyretic effect and especially a non-prescription access in pharmacies. Acute Paracetamol poisoning remains problematic for clinicians because of its insidious progression to fulminant hepatitis and even death. This work proposes to draw up the epidemiological profile of acute Paracetamol poisonings. Materials and Methods A retrospective descriptive study has been carried out over 8 years on cases of acute Paracetamol poisoning received at the Pharmacology Toxicology department of University Hospital of Oran (UHO). Data were collected using a pre-established fact sheet. Toxicological analysis was carried out by colorimetric and enzyme immunoassay method. Results and Discussion A total of 400 cases were recorded, mainly from emergency departments of UHO (85 %). These are suicide attempts in 82 % of cases, observed especially in adolescents (69 %), and accidental poisoning in 12 % of cases, predominant in small children (89 %). Half of the patients were admitted asymptomatic in the first 24 h of intoxication. Digestive and neurological disorders were the most described (18.75 % and 20.5 %). The quantitative determination of Paracetamol showed that 16 cases had a high risk of developing liver injury and required antidote therapy, based on N-acetylcysteine. The evolution was mostly favorable (84 %) but 8 patients had liver damage and 5 deaths were recorded. Conclusion Although it seems benign, acute Paracetamol poisoning is serious and requires adequate care making clinicians collaborate with toxicologists. The general population must be made aware of the dangers of Paracetamol. The pharmacist must provide the necessary information concerning the recommended doses and the toxicity.
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Affiliation(s)
- Bilel Chefirat
- Department of Pharmacy, Faculty of Medicine, University Oran1 Ahmed Ben Bella, Oran, Algeria
- Department of Pharmacology Toxicology, University Hospital of Oran, Oran, Algeria
- Environmental Health Research Laboratory, University Oran1 Ahmed Ben Bella, Oran, Algeria
- Corresponding author at: Department of Pharmacy, Faculty of Medicine, University Oran1 Ahmed Ben Bella, Oran, Algeria
| | - Anissa Zergui
- Department of Pharmacy, Faculty of Medicine, University Oran1 Ahmed Ben Bella, Oran, Algeria
- Department of Pharmacology Toxicology, University Hospital of Oran, Oran, Algeria
- Environmental Health Research Laboratory, University Oran1 Ahmed Ben Bella, Oran, Algeria
| | - Chaïmaa Rahmani
- Department of Pharmacy, Faculty of Medicine, University Oran1 Ahmed Ben Bella, Oran, Algeria
| | - Meriem Nour Belmessabih
- Department of Pharmacy, Faculty of Medicine, University Oran1 Ahmed Ben Bella, Oran, Algeria
| | - Haciba Rezk-kallah
- Department of Pharmacy, Faculty of Medicine, University Oran1 Ahmed Ben Bella, Oran, Algeria
- Department of Pharmacology Toxicology, University Hospital of Oran, Oran, Algeria
- Environmental Health Research Laboratory, University Oran1 Ahmed Ben Bella, Oran, Algeria
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41
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Isbister GK, Chiew A. The changing face of paracetamol toxicity and new regimens for an old antidote acetylcysteine. Br J Clin Pharmacol 2020; 87:715-716. [PMID: 32748454 DOI: 10.1111/bcp.14495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/24/2020] [Accepted: 07/01/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Waratah, New South Wales, Australia
| | - Angela Chiew
- NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
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Maskell KF, Powell SW, Willis D, Okhomina V, Sima AP, Wills BK. Patterns of transaminase elevation in rhabdomyolysis versus acetaminophen toxicity. Am J Emerg Med 2020; 44:362-365. [PMID: 32507476 DOI: 10.1016/j.ajem.2020.04.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/13/2020] [Accepted: 04/17/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Transaminase elevations can occur from liver injury or in the setting of rhabdomyolysis. The goal of this study is to evaluate indices that could differentiate acetaminophen toxicity from muscle injury in the setting of transaminase elevations. METHODS A retrospective chart review of consecutive cases reported to our regional poison center. Patients with transaminase (AST and ALT) elevation were grouped as those with acetaminophen exposure (AT) and those with elevated creatine phosphokinase (CPK) without evidence of acetaminophen exposure (RHB). RESULTS Of the 345 patients included in the study, elevated AST/ALT levels were attributed to rhabdomyolysis in 168 patients and attributed to acetaminophen toxicity in 177 patients. The median AST: ALT values also differed between groups, with patients in the RHB group had higher median ratios (p < 0.001). Using an AST: ALT value of 2.02 as a diagnostic cutoff produced a specificity of 0.52 (95% CI: 0.37, 0.64) and sensitivity of 0.84 (95% CI: 0.73, 0.94) for acetaminophen detection in the test dataset (N = 104). CONCLUSIONS Elevated transaminases due to liver injury from acetaminophen ingestion had a different pattern than elevated transaminases due to rhabdomyolysis. Lower AST:ALT ratios were found in acetaminophen cases, however, the specificity using a ratio threshold of ≤1 would be 83%.
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Affiliation(s)
- Kevin F Maskell
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Scott W Powell
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Deanna Willis
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Victoria Okhomina
- Department of Biostatistics, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Adam P Sima
- Department of Biostatistics, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Brandon K Wills
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America.
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James J, Stauss M, Ponnusamy A, Myers M. False-positive paracetamol levels in a patient with hyperbilirubinaemia: clinical perspectives. BMJ Case Rep 2020; 13:13/6/e234702. [DOI: 10.1136/bcr-2020-234702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Serum concentrations of paracetamol are measured to investigate the cause of acute hepatitis, monitor the clearance of paracetamol from the body and to determine if supratherapeutic levels warrant treatment with N-acetylcysteine (NAC). A 49-year-old man treated for ischaemic colitis developed worsening renal and liver function tests. As part of the investigation of hepatorenal failure, paracetamol levels were requested, which were elevated at 14 mg/L (normal <4 mg/L) resulting in treatment with NAC. Despite treatment, levels of paracetamol remained elevated and the link between hyperbilirubinemia and false-positive paracetamol levels was identified. Bilirubin and its by-products have intense absorbance in the ultraviolet and visible regions of the electromagnetic spectrum, causing interference in the enzymatic colorimetric assay most commonly used to measure paracetamol concentration, resulting in false-positive paracetamol levels. Laboratories correct for this interference above a predetermined bilirubin concentration, termed the Icteric Index; however, in our case this interference occurred at a lower level of hyperbilirubinaemia than previously identified as significant. This interaction was found to be more significant at lower bilirubin levels when low or no paracetamol levels were present in the serum, resulting in a change to laboratory practice and development of a ‘Sliding Scale’ approach to analysis. Concurrent bilirubin or Icteric Index measurement is recommended for all laboratories that use the enzymatic colorimetric assay for paracetamol measurement. Lower Icteric Index or bilirubin thresholds are required when low or no paracetamol levels are present in the serum to prevent false-positive paracetamol results. We describe a new ‘Sliding Scale’ approach to analysis, and highlight an important interaction for clinicians to be aware of.
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Absolute measurement of the tissue origins of cell-free DNA in the healthy state and following paracetamol overdose. BMC Med Genomics 2020; 13:60. [PMID: 32252771 PMCID: PMC7133021 DOI: 10.1186/s12920-020-0705-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/17/2020] [Indexed: 11/12/2022] Open
Abstract
Background Despite the emergence of cell-free DNA (cfDNA) as a clinical biomarker in cancer, the tissue origins of cfDNA in healthy individuals have to date been inferred only by indirect and relative measurement methods, such as tissue-specific methylation and nucleosomal profiling. Methods We performed the first direct, absolute measurement of the tissue origins of cfDNA, using tissue-specific knockout mouse strains, in both healthy mice and following paracetamol (APAP) overdose. We then investigated the utility of total cfDNA and the percentage of liver-specific cfDNA as clinical biomarkers in patients presenting with APAP overdose. Results Analysis of cfDNA from healthy tissue-specific knockout mice showed that cfDNA originates predominantly from white and red blood cell lineages, with minor contribution from hepatocytes, and no detectable contribution from skeletal and cardiac muscle. Following APAP overdose in mice, total plasma cfDNA and the percentage fraction originating from hepatocytes increased by ~ 100 and ~ 19-fold respectively. Total cfDNA increased by an average of more than 236-fold in clinical samples from APAP overdose patients with biochemical evidence of liver injury, and 18-fold in patients without biochemically apparent liver injury. Measurement of liver-specific cfDNA, using droplet digital PCR and methylation analysis, revealed that the contribution of liver to cfDNA was increased by an average of 175-fold in APAP overdose patients with biochemically apparent liver injury compared to healthy subjects, but was not increased in overdose patients with normal liver function tests. Conclusions We present a novel method for measurement of the tissue origins of cfDNA in healthy and disease states and demonstrate the potential of cfDNA as a clinical biomarker in APAP overdose.
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Wong A, Isbister G, McNulty R, Isoardi K, Harris K, Chiew A, Greene S, Gunja N, Buckley N, Page C, Graudins A. Efficacy of a two bag acetylcysteine regimen to treat paracetamol overdose (2NAC study). EClinicalMedicine 2020; 20:100288. [PMID: 32211597 PMCID: PMC7082646 DOI: 10.1016/j.eclinm.2020.100288] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/06/2020] [Accepted: 02/07/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Previous studies of paracetamol overdose treatment show that a 2-bag, 20-h intravenous (IV) acetylcysteine regimen decreased the incidence of non-allergic anaphylactic reactions compared to the 3-bag, 21 h IV regimen, but have not examined efficacy of the 20-h 2 bag regimen. METHODS This was a multi-centre observational study of paracetamol overdose presentations treated with a 2-bag IV acetylcysteine regimen (200 mg/kg over 4 h, 100 mg/kg over 16 h) compared to a 3-bag regimen, performed from 2009 to 2019. Patients were referred from the emergency department to the inpatient toxicology units for continued management. For the primary non-inferiority analysis: subjects had single, acute ingestions, a serum paracetamol-concentration performed 4 to 8-h post-ingestion. The primary outcome was development of acute liver injury (ALI), defined as peak ALT>150 U/L; and > double admission baseline ALT (for presentations within 24 h post-overdose). Secondary outcomes included adverse reactions to acetylcysteine (cutaneous and systemic). FINDING Out of 6419 paracetamol overdoses, 2763 received acetylcysteine. For the primary analysis, 1003 received the 2-bag and 783 the 3-bag acetylcysteine regimen. When presentation bloods were performed 4 to 8-h post-overdose, 21 (3.1%) developed ALI with the 2-bag regimen vs 16 (2.9%) with the 3-bag regimen (Difference: 0.2%, 95%CI:-1.6 to 2.2). The incidence of hepatotoxicity was: 1.2% (n = 8) with the two-bag regimen and 1.6% (n = 9) with the three-bag regimen (Difference -0.4%, 95%CI -1.75, 0.91). When presentation bloods were performed 8 to 24-h post-overdose, 70 (21%) developed ALI with the 2-bag regimen vs 46 (23%) with the 3-bag regimen (Difference: -2%, 95%CI -9.12 to 5.36). There were significantly less cutaneous and systemic non-allergic anaphylactic reactions recorded after treatment with the two-bag than the three-bag regimen (1.3% [n = 17] and 7.1% [n = 65], Difference: -5.8%, 95%CI -7.6 to -4.0, p < 0.0001), respectively. INTERPRETATION A two-bag intravenous acetylcysteine regimen was found to be non-inferior to the three-bag regimen with regards to efficacy in preventing acute liver injury for early presentations of paracetamol overdose. No important differences were seen for any other presentations. The two-bag regimen also decreased the incidence of both non-allergic anaphylactic reactions and gastrointestinal adverse events from acetylcysteine treatment. FUNDING AW is funded by a National Health and Medical Research Council (NHMRC) Early Career Fellowship ID 1159907. GI is funded by a NHMRC Senior Research Fellowship ID 1061041. The NHMRC had no role in the design, writing of this manuscript. The corresponding author (AW) had full access to all the data in the study and final responsibility for the decision to submit the manuscript for publication.
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Affiliation(s)
- Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Unit, Victoria, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Geoff Isbister
- Clinical Toxicology Research Group, University of Newcastle, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle, NSW, Australia
| | - Richard McNulty
- Department of Emergency Medicine, Blacktown Mount Druitt hospitals, Sydney, Australia
- Western Sydney Toxicology Service, Western Sydney LHD, Sydney, Australia
| | - Katherine Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Keith Harris
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Angela Chiew
- Clinical Toxicology Unit, Princes of Wales Hospital, Randwick, NSW, Australia
- Pharmacology, Faculty of Medicine and Health, University of Sydney, Australia
| | - Shaun Greene
- Victorian Poisons Information Centre and Austin Toxicology Unit, Victoria, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, Victoria, Australia
- Department of Forensic Medicine, Monash University, Victoria, Australia
- Guy's and St Thomas’ NHS Foundation Trust, United Kingdom
| | - Naren Gunja
- Western Sydney Toxicology Service, Western Sydney LHD, Sydney, Australia
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
- Emergency Medicine, Westmead Clinical School, University of Sydney, Australia
| | - Nicholas Buckley
- Department of Pharmacology, Faculty of Medicine and Health, University of Sydney, Australia
- NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Colin Page
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Andis Graudins
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
- Monash Toxicology Unit, Dandenong Hospital, Monash Health, Victoria, Australia
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Hoffman RS. Acetylcysteine for paracetamol: Will one size ever fit all? EClinicalMedicine 2020; 20:100314. [PMID: 32211600 PMCID: PMC7082209 DOI: 10.1016/j.eclinm.2020.100314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 11/22/2022] Open
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Affiliation(s)
- Robin Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, UK
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49
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Bateman DN, Dear JW. Comment on “What is the most appropriate dose of N acetylcysteine after massive acetaminophen overdose?” by Hendrickson et al. Clin Toxicol (Phila) 2020; 58:70-71. [DOI: 10.1080/15563650.2019.1594873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- D Nicholas Bateman
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - James W Dear
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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Tschirdewahn J, Eyer F. [Diagnostics and treatment of selected clinically relevant, acute drug intoxications]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:1313-1323. [PMID: 31578621 DOI: 10.1007/s00103-019-03024-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute drug poisoning due to accidental or self-damaging overdoses is responsible for 5-10% of emergency medical interventions in Germany. The treatment of asymptomatic to life-threatening courses requires extensive expertise. On the basis of a selective literature search, this article gives an overview of selected clinically relevant, acute drug poisonings with regard to epidemiology, symptomatology, diagnostics, and therapy.Intoxications with psychotropic drugs are the most common drug intoxications. Poisoning with tricyclic antidepressants causes anticholinergic, central nervous, and cardiovascular symptoms. Less toxic are selective serotonin reuptake inhibitors (SSRIs); the intoxication may be characterized by serotonin syndrome. Malignant neuroleptic syndrome is a severe complication of neuroleptic poisoning.Poisoning with analgesics is clinically relevant due to its high availability. For paracetamol poisoning, intravenous acetylcysteine is available as an antidote. Hemodialysis may be indicated for severe salicylate intoxication. Poisoning with nonsteroidal anti-inflammatory drugs is usually only associated with mild signs of intoxication.Poisoning with cardiac drugs (β-blockers and calcium antagonists) can cause life-threatening cardiovascular events. In addition to symptomatic therapy, insulin glucose therapy also plays an important role.The majority of acute drug poisonings can be treated adequately by symptomatic and partly intensive care therapy - if necessary with the application of primary and secondary toxin elimination. Depending on the severity of the intoxication, pharmacology-specific therapy must be initiated.
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Affiliation(s)
- Julia Tschirdewahn
- Abteilung für Klinische Toxikologie & Giftnotruf München, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Florian Eyer
- Abteilung für Klinische Toxikologie & Giftnotruf München, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
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