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Elzagallaai AA, Rieder MJ. Pathophysiology of drug hypersensitivity. Br J Clin Pharmacol 2024; 90:1856-1868. [PMID: 36519187 DOI: 10.1111/bcp.15645] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) are type B adverse drug reactions (ADRs) traditionally defined as unpredictable, dose independent and not related to the drug pharmacology. DHRs, also called drug allergy if the immune system involvement is confirmed, represent around one-sixth of all ADRs and can cause major clinical problems due to their vague clinical presentation and irregular time course. Understanding the underlying pathophysiology of DHRs is very important for their diagnosis and management. Multiple layers of evidence exist pointing to the involvement of the immune system in DHRs. Recent data have led to a paradigm shift in our understanding of the exact pathophysiology of these reactions. Numerous hypotheses proposing explanation on how a low molecular weight drug molecule can elicit an immune reaction have been proposed. In addition to the classical "hapten" hypothesis, the reactive metabolite hypothesis, the pharmacological interaction with the immune system (p-i) concept, the danger/injury hypothesis and the altered peptide repertoire hypothesis have been proposed. We here introduce the inflammasome activation hypothesis and the cross-reactivity hypothesis as additional models explaining the pathophysiology of DHRs. Available data supporting these hypotheses are briefly summarized and discussed. We also introduced the cross-reactivity model, which may provide a platform to appreciate the potential role played by other factors leading to the activation of the immune system. We believe that although the drug in question could be the trigger of the reaction, the components of the immune system mediating the reaction do not act in isolation but rather are affected by the proinflammatory milieu occurring at the time of the reaction. This review attempts to summarize the available evidence to further illustrate the pathophysiology of DHRs.
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Affiliation(s)
- Abdelbaset A Elzagallaai
- Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Michael J Rieder
- Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Department of Pediatrics and Physiology, University of Western Ontario, London, Ontario, Canada
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2
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Line J, Saville E, Meng X, Naisbitt D. Why drug exposure is frequently associated with T-cell mediated cutaneous hypersensitivity reactions. FRONTIERS IN TOXICOLOGY 2023; 5:1268107. [PMID: 37795379 PMCID: PMC10546197 DOI: 10.3389/ftox.2023.1268107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
Cutaneous hypersensitivity reactions represent the most common manifestation of drug allergy seen in the clinic, with 25% of all adverse drug reactions appearing in the skin. The severity of cutaneous eruptions can vastly differ depending on the cellular mechanisms involved from a minor, self-resolving maculopapular rash to major, life-threatening pathologies such as the T-cell mediated bullous eruptions, i.e., Stevens Johnson syndrome/toxic epidermal necrolysis. It remains a significant question as to why these reactions are so frequently associated with the skin and what factors polarise these reactions towards more serious disease states. The barrier function which the skin performs means it is constantly subject to a barrage of danger signals, creating an environment that favors elicitation. Therefore, a critical question is what drives the expansion of cutaneous lymphocyte antigen positive, skin homing, T-cell sub-populations in draining lymph nodes. One answer could be the heterologous immunity hypothesis whereby tissue resident memory T-cells that express T-cell receptors (TCRs) for pathogen derived antigens cross-react with drug antigen. A significant amount of research has been conducted on skin immunity in the context of contact allergy and the role of tissue specific antigen presenting cells in presenting drug antigen to T-cells, but it is unclear how this relates to epitopes derived from circulation. Studies have shown that the skin is a metabolically active organ, capable of generating reactive drug metabolites. However, we know that drug antigens are displayed systemically so what factors permit tolerance in one part of the body, but reactivity in the skin. Most adverse drug reactions are mild, and skin eruptions tend to be visible to the patient, whereas minor organ injury such as transient transaminase elevation is often not apparent. Systemic hypersensitivity reactions tend to have early cutaneous manifestations, the progression of which is halted by early diagnosis and treatment. It is apparent that the preference for cutaneous involvement of drug hypersensitivity reactions is multi-faceted, therefore this review aims to abridge the findings from literature on the current state of the field and provide insight into the cellular and metabolic mechanisms which may contribute to severe cutaneous adverse reactions.
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Affiliation(s)
| | | | | | - Dean Naisbitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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3
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The Role of Myeloperoxidase in Clozapine-Induced Inflammation: A Mechanistic Update for Idiosyncratic Drug-Induced Agranulocytosis. Int J Mol Sci 2023; 24:ijms24021243. [PMID: 36674761 PMCID: PMC9862306 DOI: 10.3390/ijms24021243] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/11/2023] Open
Abstract
The risk of idiosyncratic drug-induced agranulocytosis (IDIAG) markedly constrains the use of clozapine, a neuroleptic with unparalleled efficacy. Most clozapine patients experience an early inflammatory response, likely a necessary step in IDIAG onset. However, most patients do not progress to IDIAG, presumably because of the requirement of specific human leukocyte antigen (HLA) haplotypes, T cell receptors, and other unknown factors. We established that clozapine activates inflammasomes and that myeloperoxidase bioactivation of clozapine generates neoantigens, but the connection between these early mechanistic events remained unknown and, thus, was the aim of this work. We found that the myeloperoxidase inhibitor PF-1355 attenuated myeloperoxidase activity in phorbol myristate acetate (PMA)-differentiated THP-1 macrophages, and it also attenuated clozapine-induced release of inflammatory mediators (e.g., IL-1β, CXCL1, and C-reactive protein). In vivo, pretreatment of Sprague Dawley rats with PF-1355 significantly attenuated clozapine-induced increases in neutrophil mobilization from the bone marrow to the blood and spleen, as determined using differential blood counts and flow cytometry. Moreover, the clozapine-triggered release of inflammatory mediators (e.g., IL-1β, calprotectin, CXCL1, and α-1-acid glycoprotein) from the liver, spleen, and bone marrow was dampened by myeloperoxidase inhibition. These data support the working hypothesis that oxidation of clozapine to a reactive metabolite by myeloperoxidase is critical for induction of the inflammatory response to clozapine. Ultimately, a better mechanistic understanding of the early events involved in the immune response to clozapine may elucidate ways to prevent IDIAG, enabling safer, more frequent therapeutic use of this and potentially other highly efficacious drugs.
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Sernoskie SC, Lobach AR, Kato R, Jee A, Weston JK, Uetrecht J. Clozapine induces an acute proinflammatory response that is attenuated by inhibition of inflammasome signaling: implications for idiosyncratic drug-induced agranulocytosis. Toxicol Sci 2021; 186:70-82. [PMID: 34935985 PMCID: PMC8883353 DOI: 10.1093/toxsci/kfab154] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Although clozapine is a highly efficacious schizophrenia treatment, it is under-prescribed due to the risk of idiosyncratic drug-induced agranulocytosis (IDIAG). Clinical data indicate that most patients starting clozapine experience a transient immune response early in treatment and a similar response has been observed in clozapine-treated rats, but the mechanism by which clozapine triggers this transient inflammation remains unclear. Therefore, the aim of this study was to characterize the role of inflammasome activation during the early immune response to clozapine using in vitro and in vivo models. In both differentiated and nondifferentiated human monocytic THP-1 cells, clozapine, but not its structural analogues fluperlapine and olanzapine, caused inflammasome-dependent caspase-1 activation and IL-1β release that was inhibited using the caspase-1 inhibitor yVAD-cmk. In Sprague Dawley rats, a single dose of clozapine caused an increase in circulating neutrophils and a decrease in lymphocytes within hours of drug administration along with transient spikes in the proinflammatory mediators IL-1β, CXCL1, and TNF-α in the blood, spleen, and bone marrow. Blockade of inflammasome signaling using the caspase-1 inhibitor VX-765 or the IL-1 receptor antagonist anakinra attenuated this inflammatory response. These data indicate that caspase-1-dependent IL-1β production is fundamental for the induction of the early immune response to clozapine and, furthermore, support the general hypothesis that inflammasome activation is a common mechanism by which drugs associated with the risk of idiosyncratic reactions trigger early immune system activation. Ultimately, inhibition of inflammasome signaling may reduce the risk of IDIAG, enabling safer, more frequent use of clozapine in patients.
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Affiliation(s)
| | - Alexandra R Lobach
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada
| | - Ryuji Kato
- Department of Cardiovascular Pharmacotherapy and Toxicology, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University, Osaka, 569-1094, Japan
| | - Alison Jee
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - J Kyle Weston
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada
| | - Jack Uetrecht
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada.,Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada
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5
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Rattay B, Benndorf RA. Drug-Induced Idiosyncratic Agranulocytosis - Infrequent but Dangerous. Front Pharmacol 2021; 12:727717. [PMID: 34483939 PMCID: PMC8414253 DOI: 10.3389/fphar.2021.727717] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022] Open
Abstract
Drug-induced agranulocytosis is a life-threatening side effect that usually manifests as a severe form of neutropenia associated with fever or signs of sepsis. It can occur as a problem in the context of therapy with a wide variety of drug classes. Numerous drugs are capable of triggering the rare idiosyncratic form of agranulocytosis, which, unlike agranulocytosis induced by cytotoxic drugs in cancer chemotherapy, is characterised by “bizzare” type B or hypersensitivity reactions, poor predictability and a mainly low incidence. The idiosyncratic reactions are thought to be initiated by chemically reactive drugs or reactive metabolites that react with proteins and may subsequently elicit an immune response, particularly directed against neutrophils and their precursors. Cells or organs that exhibit specific metabolic and biotransformation activity are therefore frequently affected. In this review, we provide an update on the understanding of drug-induced idiosyncratic agranulocytosis. Using important triggering drugs as examples, we will summarise and discuss the chemical, the biotransformation-related, the mechanistic and the therapeutic basis of this clinically relevant and undesirable side effect.
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Affiliation(s)
- Bernd Rattay
- Department of Clinical Pharmacy and Pharmacotherapy, Institute of Pharmacy, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Ralf A Benndorf
- Department of Clinical Pharmacy and Pharmacotherapy, Institute of Pharmacy, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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6
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Wei S, Ma W, Zhang B, Li W. NLRP3 Inflammasome: A Promising Therapeutic Target for Drug-Induced Toxicity. Front Cell Dev Biol 2021; 9:634607. [PMID: 33912556 PMCID: PMC8072389 DOI: 10.3389/fcell.2021.634607] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/18/2021] [Indexed: 12/13/2022] Open
Abstract
Drug-induced toxicity, which impairs human organ function, is a serious problem during drug development that hinders the clinical use of many marketed drugs, and the underlying mechanisms are complicated. As a sensor of infections and external stimuli, nucleotide-binding oligomerization domain (NOD)-like receptor family pyrin domain containing 3 (NLRP3) inflammasome plays a key role in the pathological process of various diseases. In this review, we specifically focused on the role of NLRP3 inflammasome in drug-induced diverse organ toxicities, especially the hepatotoxicity, nephrotoxicity, and cardiotoxicity. NLRP3 inflammasome is involved in the initiation and deterioration of drug-induced toxicity through multiple signaling pathways. Therapeutic strategies via inhibiting NLRP3 inflammasome for drug-induced toxicity have made significant progress, especially in the protective effects of the phytochemicals. Growing evidence collected in this review indicates that NLRP3 is a promising therapeutic target for drug-induced toxicity.
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Affiliation(s)
- Shanshan Wei
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Wanjun Ma
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Bikui Zhang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Wenqun Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
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Mosedale M, Watkins PB. Understanding Idiosyncratic Toxicity: Lessons Learned from Drug-Induced Liver Injury. J Med Chem 2020; 63:6436-6461. [PMID: 32037821 DOI: 10.1021/acs.jmedchem.9b01297] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Idiosyncratic adverse drug reactions (IADRs) encompass a diverse group of toxicities that can vary by drug and patient. The complex and unpredictable nature of IADRs combined with the fact that they are rare makes them particularly difficult to predict, diagnose, and treat. Common clinical characteristics, the identification of human leukocyte antigen risk alleles, and drug-induced proliferation of lymphocytes isolated from patients support a role for the adaptive immune system in the pathogenesis of IADRs. Significant evidence also suggests a requirement for direct, drug-induced stress, neoantigen formation, and stimulation of an innate response, which can be influenced by properties intrinsic to both the drug and the patient. This Perspective will provide an overview of the clinical profile, mechanisms, and risk factors underlying IADRs as well as new approaches to study these reactions, focusing on idiosyncratic drug-induced liver injury.
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Affiliation(s)
- Merrie Mosedale
- Institute for Drug Safety Sciences and Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina 27599, United States
| | - Paul B Watkins
- Institute for Drug Safety Sciences and Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina 27599, United States
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8
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Kato R, Ijiri Y, Hayashi T, Uetrecht J. Reactive metabolite of gefitinib activates inflammasomes: implications for gefitinib-induced idiosyncratic reaction. J Toxicol Sci 2020; 45:673-680. [DOI: 10.2131/jts.45.673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Ryuji Kato
- Department of Cardiovascular Pharmacotherapy and Toxicology, Osaka University of Pharmaceutical Sciences
| | - Yoshio Ijiri
- Department of Cardiovascular Pharmacotherapy and Toxicology, Osaka University of Pharmaceutical Sciences
| | - Tetsuya Hayashi
- Department of Cardiovascular Pharmacotherapy and Toxicology, Osaka University of Pharmaceutical Sciences
| | - Jack Uetrecht
- Department of Pharmaceutical Scinces, Faculty of Pharmacy, University of Toronto, Canada
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Wang Z, Xu G, Zhan X, Liu Y, Gao Y, Chen N, Guo Y, Li R, He T, Song X, Niu M, Wang J, Bai Z, Xiao X. Carbamazepine promotes specific stimuli-induced NLRP3 inflammasome activation and causes idiosyncratic liver injury in mice. Arch Toxicol 2019; 93:3585-3599. [PMID: 31677073 DOI: 10.1007/s00204-019-02606-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023]
Abstract
The occurrence of idiosyncratic drug-induced liver injury (IDILI) is a leading cause of post-marketing safety warnings and withdrawals of drugs. Carbamazepine (CBZ), widely used as an antiepileptic agent, could cause rare but severe idiosyncratic liver injury in humans. Although recent studies have shown that inflammasome is implicated in CBZ-induced hepatocellular injury in vitro, the precise pathogenesis of hepatotoxicity remains largely unexplored. Here we report that CBZ causes idiosyncratic liver injury through promoting specific stimuli-induced NLRP3 inflammasome activation. CBZ (40 μM) enhances NLRP3 inflammasome activation triggered by adenosine triphosphate (ATP) or nigericin, rather than SiO2, monosodium urate crystal or intracellular lipopolysaccharide (LPS). In addition, CBZ has no effect on NLRC4 or AIM2 inflammasome activation. Mechanistically, synergistic induction of mitochondrial reactive oxygen species (mtROS) is a crucial event in the enhancement effect of CBZ on ATP- or nigericin-induced NLRP3 inflammasome activation. Moreover, the "C=C" on the seven-membered ring and "C=O" on the nitrogen of CBZ may be contribute to NLRP3 inflammasome hyperactivation and hepatotoxicity. Notably, in vivo data indicate that CBZ (50 mg/kg) causes liver injury in an LPS (2 mg/kg)-mediated susceptibility mouse model of IDILI, accompanied by an increase in caspase-1 activity and IL-1β production, whereas the combination of CBZ and LPS does not exhibit the effect in NLRP3-knockout mice. In conclusion, CBZ specifically promotes ATP- or nigericin-induced NLRP3 inflammasome activation and causes idiosyncratic liver injury. Our findings also suggest that CBZ may be avoided in patients with NLRP3 inflammasome activation-related diseases that are triggered by ATP or nigericin, which may be risk factors for IDILI.
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Affiliation(s)
- Zhilei Wang
- China Military Institute of Chinese Materia, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Guang Xu
- China Military Institute of Chinese Materia, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China
| | - Xiaoyan Zhan
- China Military Institute of Chinese Materia, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China
| | - Youping Liu
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Yuan Gao
- School of Chinese Materia Medica, Capital Medical University, Beijing, 100029, China
| | - Nian Chen
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Yuming Guo
- China Military Institute of Chinese Materia, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China
| | - Ruisheng Li
- Research Center for Clinical and Translational Medicine, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China
| | - Tingting He
- Integrative Medical Center, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China
| | - Xueai Song
- Integrative Medical Center, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China
| | - Ming Niu
- China Military Institute of Chinese Materia, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China
| | - Jiabo Wang
- China Military Institute of Chinese Materia, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China
| | - Zhaofang Bai
- China Military Institute of Chinese Materia, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China.
- Integrative Medical Center, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China.
| | - Xiaohe Xiao
- China Military Institute of Chinese Materia, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China.
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.
- Integrative Medical Center, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, 100039, China.
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10
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Uetrecht J. Mechanistic Studies of Idiosyncratic DILI: Clinical Implications. Front Pharmacol 2019; 10:837. [PMID: 31402866 PMCID: PMC6676790 DOI: 10.3389/fphar.2019.00837] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/01/2019] [Indexed: 12/18/2022] Open
Abstract
The idiosyncratic nature of idiosyncratic drug-induced liver injury (IDILI) makes mechanistic studies very difficult, and little is known with certainty. However, the fact that the IDILI caused by some drugs is associated with specific HLA genotypes provides strong evidence that it is mediated by the adaptive immune system. This is also consistent with the histology and the general characteristics of IDILI. However, there are other mechanistic hypotheses. Various in vitro and in vivo systems have been used to test hypotheses. Two other hypotheses are mitochondrial injury and inhibition of the bile salt export pump. It is possible that these mechanisms are responsible for some cases of IDILI or that these mechanisms are complementary and are involved in initiating an immune response. In general, it is believed that the initiation of an immune response requires activation of antigen-presenting cells by molecules such as danger-associated molecular pattern molecules (DAMPs). An attractive hypothesis for the mechanism by which DAMPs induce an immune response is through the activation of inflammasomes. The dominant immune response in the liver is immune tolerance, and it is only when immune tolerance fails that significant liver injury occurs. Consistent with this concept, an animal model was developed in which immune checkpoint inhibition unmasked the ability of drugs to cause liver injury. Although it appears that the liver damage is mediated by the adaptive immune system, an innate immune response is required for an adaptive immune response. The innate immune response is not dependent on specific HLA genes or T cell receptors and may occur in most patients and animals treated with a drug that can cause IDILI. Studies of the subclinical innate immune response to drugs may provide important mechanistic clues and provide a method to screen drugs for their potential to cause IDILI.
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Affiliation(s)
- Jack Uetrecht
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, ON, Canada
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11
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Mak A, Kato R, Weston K, Hayes A, Uetrecht J. Editor's Highlight: An Impaired Immune Tolerance Animal Model Distinguishes the Potential of Troglitazone/Pioglitazone and Tolcapone/Entacapone to Cause IDILI. Toxicol Sci 2019; 161:412-420. [PMID: 29087505 DOI: 10.1093/toxsci/kfx219] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We have developed an animal model of amodiaquine-induced liver injury that has characteristics very similar to idiosyncratic drug-induced liver injury (IDILI) in humans by impairing immune tolerance using a PD1-/- mouse and cotreatment with anti-CTLA-4. In order to test the usefulness of this model as a general model for human IDILI risk, pairs of drugs with similar structures were tested, one of which is associated with a relatively high risk of IDILI and the other not. One such pair is troglitazone and pioglitazone; troglitazone has caused fatal cases of IDILI while pioglitazone is quite safe. Another pair is tolcapone and entacapone; tolcapone can cause serious IDILI; in contrast, although entacapone has been reported to cause liver injury, it is relatively safe. PD1-/- mice treated with anti-CTLA-4 and troglitazone or tolcapone displayed liver injury as determined by ALT levels and histology, while pioglitazone and entacapone showed less signs of liver injury. One possible mechanism by which drugs could induce an immune response leading to IDILI is by causing the release of danger-associated molecular pattern molecules that activate inflammasomes. We found that the supernatants from incubations of troglitazone, tolcapone, or entacapone with hepatocytes were also able to activate inflammasomes in macrophages, while the supernatant from pioglitazone incubations did not. These results are consistent with an immune mechanism for troglitazone- and tolcapone-induced IDILI and add to the evidence that this may be a general model for IDILI.
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Affiliation(s)
- Alastair Mak
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S 3M2, Canada
| | - Ryuji Kato
- Laboratory of Cardiovascular Pharmacotherapy and Toxicology, Osaka University of Pharmaceutical Sciences, Osaka 569-1094, Japan
| | - Kyle Weston
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S 3M2, Canada
| | - Anthony Hayes
- Department of Pathology, University of Guelph, Guelph, Ontario, Canada
| | - Jack Uetrecht
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S 3M2, Canada
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12
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Mak A, Uetrecht J. Involvement of CCL2/CCR2 macrophage recruitment in amodiaquine-induced liver injury. J Immunotoxicol 2019; 16:28-33. [PMID: 30663942 DOI: 10.1080/1547691x.2018.1516014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Evidence suggests that macrophages may play a role in the development of idiosyncratic drug-induced liver injury (IDILI). However, there has yet to be a clear link between macrophage activation and the inflammatory infiltrate that is characteristic of IDILI. A major chemokine involved in the recruitment of macrophages into the liver is C-C motif chemokine ligand 2 (CCL2)/monocyte chemoattractant protein 1 (MCP1). Therefore, we tested the effect of this chemokine in an animal model of IDILI. Specifically, amodiaquine (AQ), which is known to cause IDILI in humans, causes mild liver injury in wild-type C57BL/6 mice that resolves despite continued AQ treatment, but it causes more severe liver injury that does not resolve in PD-1-/- mice co-treated with anti-CTLA-4 to impair immune tolerance. CCR2-/- mice treated with AQ were not protected from the expected AQ-induced liver injury seen in wild-type C57BL/6 mice. In contrast, anti-CCL2 antibodies attenuated the liver injury caused by AQ in the impaired immune tolerance model. The difference in response of the two models is likely due to a difference in the IDILI mechanism; the mild injury in wild-type animals is mediated by NK cells, while the more serious injury in the impaired immune tolerance model requires CD8 T-cells. The results from these experiments provide evidence that macrophage infiltration into the liver may not be involved in mild IDILI mediated by the innate immune system, but it does appear necessary in more severe IDILI involving cytotoxic T-cells.
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Affiliation(s)
- Alastair Mak
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Jack Uetrecht
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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13
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Sharma A, Saito Y, Hung SI, Naisbitt D, Uetrecht J, Bussiere J. The skin as a metabolic and immune-competent organ: Implications for drug-induced skin rash. J Immunotoxicol 2018; 16:1-12. [PMID: 30318948 DOI: 10.1080/1547691x.2018.1514444] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Current advances in the study of cutaneous adverse drug reactions can be attributed to the recent understanding that the skin is both a metabolically and immunologically competent organ. The ability of the skin to serve as a protective barrier with limited drug biotransformation ability, yet highly active immune function, has provided insights into its biological capability. While the immune response of the skin to drugs is vastly different from that of the liver due to evolutionary conditioning, it frequently occurs in response to various drug classes and manifests as a spectrum of hypersensitivity reactions. The skin is a common site of adverse and idiosyncratic drug reactions; drug-specific T-cells, as well as involvement of an innate immune response, appear to be key mechanistic drivers in such scenarios. Association of other factors such as human leukocyte antigen (HLA) polymorphisms may play a significant role for particular drugs. This review aims to integrate emerging findings into proposed mechanisms of drug metabolism and immunity in the skin that are likely responsible for rashes and other local allergic responses. These unique biological aspects of the skin, and their translation into implications for drug development and the use of animal models, will be discussed.
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Affiliation(s)
- Amy Sharma
- Amgen Research, Thousand Oaks, CA, USA.,Genentech Inc., South San Francisco, CA, USA
| | - Yoshiro Saito
- Division of Medicinal Safety Science, National Institute of Health Sciences, Tokyo, Japan
| | - Shuen-Iu Hung
- Department and Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | | | - Jack Uetrecht
- Faculty of Pharmacy and Medicine, University of Toronto, Toronto, Canada
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14
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Chaikuad A, Koch P, Laufer SA, Knapp S. The Cysteinome of Protein Kinases as a Target in Drug Development. Angew Chem Int Ed Engl 2018; 57:4372-4385. [DOI: 10.1002/anie.201707875] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/20/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Apirat Chaikuad
- Nuffield Department of Clinical Medicine; Structural Genomics Consortium and Target Discovery Institute; University of Oxford, Old Road Campus Research Building; Roosevelt Drive Oxford OX3 7DQ UK
- Institute for Pharmaceutical Chemistry; Goethe-University; Max-von-Laue-Strasse 9 60438 Frankfurt am Main Germany
| | - Pierre Koch
- Department of Pharmaceutical/Medicinal Chemistry; Eberhard-Karls-University Tübingen; Auf der Morgenstelle 8 72076 Tübingen Germany
| | - Stefan A. Laufer
- Department of Pharmaceutical/Medicinal Chemistry; Eberhard-Karls-University Tübingen; Auf der Morgenstelle 8 72076 Tübingen Germany
- German Cancer Consortium DKTK, Standort Tübingen; Germany
| | - Stefan Knapp
- Nuffield Department of Clinical Medicine; Structural Genomics Consortium and Target Discovery Institute; University of Oxford, Old Road Campus Research Building; Roosevelt Drive Oxford OX3 7DQ UK
- German Cancer Consortium DKTK, Standort Frankfurt/Mainz; Germany
- Institute for Pharmaceutical Chemistry; Goethe-University; Max-von-Laue-Strasse 9 60438 Frankfurt am Main Germany
- Structural Genomics Consortium and Buchmann Institute for Molecular Life Sciences; Johann Wolfgang Goethe-University; Max-von-Laue-Strasse 15 60438 Frankfurt am Main Germany
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15
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Chaikuad A, Koch P, Laufer SA, Knapp S. Das Cysteinom der Proteinkinasen als Zielstruktur in der Arzneistoffentwicklung. Angew Chem Int Ed Engl 2018. [DOI: 10.1002/ange.201707875] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Apirat Chaikuad
- Nuffield Department of Clinical Medicine; Structural Genomics Consortium and Target Discovery Institute; Universität Oxford, Old Road Campus Research Building; Roosevelt Drive Oxford OX3 7DQ Großbritannien
- Institut für pharmazeutische Chemie; Johann Wolfgang Goethe-Universität; Max-von-Laue-Straße 9 60438 Frankfurt am Main Deutschland
| | - Pierre Koch
- Institut für pharmazeutische und medizinische Chemie; Eberhard-Karls-Universität Tübingen; Auf der Morgenstelle 8 72076 Tübingen Deutschland
| | - Stefan A. Laufer
- Institut für pharmazeutische und medizinische Chemie; Eberhard-Karls-Universität Tübingen; Auf der Morgenstelle 8 72076 Tübingen Deutschland
- Deutsches Zentrum für translationale Krebsforschung, Standort; Tübingen Deutschland
| | - Stefan Knapp
- Nuffield Department of Clinical Medicine; Structural Genomics Consortium and Target Discovery Institute; Universität Oxford, Old Road Campus Research Building; Roosevelt Drive Oxford OX3 7DQ Großbritannien
- Deutsches Zentrum für translationale Krebsforschung, Standort Frankfurt/Mainz; Deutschland
- Institut für pharmazeutische Chemie; Johann Wolfgang Goethe-Universität; Max-von-Laue-Straße 9 60438 Frankfurt am Main Deutschland
- Structural Genomics Consortium and Buchmann Institute for Molecular Life Sciences; Johann Wolfgang Goethe-Universität; Max-von-Laue-Straße 15 60438 Frankfurt am Main Deutschland
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16
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Curtis BR. Non-chemotherapy drug-induced neutropenia: key points to manage the challenges. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:187-193. [PMID: 29222255 PMCID: PMC6142577 DOI: 10.1182/asheducation-2017.1.187] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Non-chemotherapy idiosyncratic drug-induced neutropenia (IDIN) is a relatively rare but potentially fatal disorder that occurs in susceptible individuals, with an incidence of 2.4 to 15.4 cases per million population. Affected patients typically experience severe neutropenia within several weeks to several months after first exposure to a drug, and mortality is ∼5%. The drugs most frequently associated with IDIN include metamizole, clozapine, sulfasalazine, thiamazole, carbimazole, amoxicillin, cotrimoxazole, ticlopidine, and valganciclovir. The idiosyncratic nature of IDIN, the lack of mouse models and diagnostic testing, and its low overall incidence make rigorous studies to elucidate possible mechanisms exceptionally difficult. An immune mechanism for IDIN involving neutrophil destruction by hapten (drug)-specific antibodies and drug-induced autoantibodies is frequently suggested, but strong supporting evidence is lacking. Although laboratory testing for neutrophil drug-dependent antibodies is rarely performed because of the complexity and low sensitivity of tests currently in use, these assays could possibly be enhanced by using reactive drug metabolites in place of the parent drug. Patients typically experience acute, severe neutropenia, or agranulocytosis (<0.5 × 109 neutrophils/L) and symptoms of fever, chills, sore throat, and muscle and joint pain. Diagnosis can be difficult, but timely recognition is critical because if left untreated, there is an increase in mortality. Expanded studies of the production and mechanistic role of reactive drug metabolites, genetic associations, and improved animal models of IDIN are essential to further our understanding of this important disorder.
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Affiliation(s)
- Brian R Curtis
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
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17
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Kato R, Uetrecht J. Supernatant from Hepatocyte Cultures with Drugs That Cause Idiosyncratic Liver Injury Activates Macrophage Inflammasomes. Chem Res Toxicol 2017; 30:1327-1332. [PMID: 28525267 DOI: 10.1021/acs.chemrestox.7b00065] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There is increasing evidence that most idiosyncratic drug-induced liver injury (IDILI) is immune mediated, and in most cases, reactive metabolites appear to be responsible for the induction of this immune response. Reactive metabolites can cause cell damage with the release of damage-associated molecular patterns (DAMPs), which is thought to be involved in immune activation. Presumably, the reason that the liver is a common target of idiosyncratic drug reactions is because it is the major site of drug metabolism and reactive metabolite formation. Inflammasomes can be activated by DAMPs, and this may be a common mechanism by which DAMPs initiate an immune response. In this study, we tested the ability of drugs to induce the release of DAMPs that activate inflammasomes. The drugs tested were amodiaquine and nevirapine; both are associated with significant incidences of severe IDILI. The hepatocytes were a human hepatocarcinoma functional liver cell-4 (FLC-4) cell line. For the detection of inflammasome activation, we used the human macrophage cell line, THP-1 cells. We found that the supernatant from the incubation of both drugs with FLC-4 cells for 7 days led to increased caspase-1 activity and production of IL-1β by THP-1 cells. However, amodiaquine alone also directly activated THP-1 cells. This is presumably because the myeloperoxidase in THP-1 cells can bioactivate amodiaquine to a reactive metabolite. In contrast, nevirapine requires cytochromes P450 for reactive metabolite formation and therefore required incubation with hepatocytes. These results support the hypothesis that reactive metabolites of drugs can cause the release of DAMPs, which in turn can activate inflammasomes. Inflammasome activation may be an important step in the activation of the immune system by drugs, which in some patients can lead to IDILI. Our in vitro model is simple and convenient for evaluating inflammasome activation, and this may be a method to screen drugs for IDILI risk.
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Affiliation(s)
- Ryuji Kato
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto , Toronto, Ontario M5S 3M2, Canada.,Laboratory of Cardiovascular Pharmacotherapy and Toxicology, Osaka University of Pharmaceutical Sciences , Osaka 569-1094, Japan
| | - Jack Uetrecht
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto , Toronto, Ontario M5S 3M2, Canada
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18
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Abstract
Inflammasomes are intracellular multiprotein complexes that comprise part of the
innate immune response. Since their definition, inflammasome disorders have been
linked to an increasing number of diseases. Autoinflammatory diseases refer to
disorders in which local factors lead to the activation of innate immune cells,
causing tissue damage when in the absence of autoantigens and autoantibodies.
Skin symptoms include the main features of monogenic inflammasomopathies, such
as Cryopyrin-Associated Periodic Syndromes (CAPS), Familial Mediterranean Fever
(FMF), Schnitzler Syndrome, Hyper-IgD Syndrome (HIDS), PAPA Syndrome, and
Deficiency of IL-1 Receptor Antagonist (DIRA). Concepts from other pathologies
have also been reviewed in recent years, such as psoriasis, after the
recognition of a combined contribution of innate and adaptive immunity in its
pathogenesis. Inflammasomes are also involved in the response to various
infections, malignancies, such as melanoma, autoimmune diseases, including
vitiligo and lupus erythematosus, atopic and contact dermatitis, acne,
hidradenitis suppurativa, among others. Inhibition of the inflammasome pathway
may be a target for future therapies, as already occurs in the handling of CAPS,
through the introduction of IL-1 inhibitors. This study presents a literature
review focusing on the participation of inflammasomes in skin diseases.
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Affiliation(s)
| | - Cyro Festa
- Universidade de São Paulo (USP) - São Paulo (SP), Brazil
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19
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Toksoy A, Sennefelder H, Adam C, Hofmann S, Trautmann A, Goebeler M, Schmidt M. Potent NLRP3 Inflammasome Activation by the HIV Reverse Transcriptase Inhibitor Abacavir. J Biol Chem 2017; 292:2805-2814. [PMID: 28057759 DOI: 10.1074/jbc.m116.749473] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 12/13/2016] [Indexed: 12/22/2022] Open
Abstract
There is experimental and clinical evidence that some exanthematous allergic drug hypersensitivity reactions are mediated by drug-specific T cells. We hypothesized that the capacity of certain drugs to directly stimulate the innate immune system may contribute to generate drug-specific T cells. Here we analyzed whether abacavir, an HIV-1 reverse transcriptase inhibitor often inducing severe delayed-type drug hypersensitivity, can trigger innate immune activation that may contribute to its allergic potential. We show that abacavir fails to generate direct innate immune activation in human monocytes but potently triggers IL-1β release upon pro-inflammatory priming with phorbol ester or Toll-like receptor stimulation. IL-1β processing and secretion were sensitive to Caspase-1 inhibition, NLRP3 knockdown, and K+ efflux inhibition and were not observed with other non-allergenic nucleoside reverse transcriptase inhibitors, identifying abacavir as a specific inflammasome activator. It further correlated with dose-dependent mitochondrial reactive oxygen species production and cytotoxicity, indicating that inflammasome activation resulted from mitochondrial damage. However, both NLRP3 depletion and inhibition of K+ efflux mitigated abacavir-induced mitochondrial reactive oxygen species production and cytotoxicity, suggesting that these processes were secondary to NLRP3 activation. Instead, depletion of cardiolipin synthase 1 abolished abacavir-induced IL-1β secretion, suggesting that mitochondrial cardiolipin release may trigger abacavir-induced inflammasome activation. Our data identify abacavir as a novel inflammasome-stimulating drug allergen. They implicate a potential contribution of innate immune activation to medication-induced delayed-type hypersensitivity, which may stimulate new concepts for treatment and prevention of drug allergies.
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Affiliation(s)
- Atiye Toksoy
- From the Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Helga Sennefelder
- From the Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Christian Adam
- From the Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Sonja Hofmann
- From the Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Axel Trautmann
- From the Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Matthias Goebeler
- From the Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Marc Schmidt
- From the Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, 97080 Würzburg, Germany
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20
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Gan J, Zhang H, Humphreys WG. Drug–Protein Adducts: Chemistry, Mechanisms of Toxicity, and Methods of Characterization. Chem Res Toxicol 2016; 29:2040-2057. [DOI: 10.1021/acs.chemrestox.6b00274] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jinping Gan
- Department of Biotransformation, Bristol-Myers Squibb Pharmaceutical Company, Princeton, New Jersey 08540, United States
| | - Haiying Zhang
- Department of Biotransformation, Bristol-Myers Squibb Pharmaceutical Company, Princeton, New Jersey 08540, United States
| | - W. Griffith Humphreys
- Department of Biotransformation, Bristol-Myers Squibb Pharmaceutical Company, Princeton, New Jersey 08540, United States
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21
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Cho T, Uetrecht J. How Reactive Metabolites Induce an Immune Response That Sometimes Leads to an Idiosyncratic Drug Reaction. Chem Res Toxicol 2016; 30:295-314. [DOI: 10.1021/acs.chemrestox.6b00357] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Tiffany Cho
- Faculty
of Pharmacy, University of Toronto, Toronto, Ontario, Canada M5S 3M2
| | - Jack Uetrecht
- Faculty
of Pharmacy, University of Toronto, Toronto, Ontario, Canada M5S 3M2
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23
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Johnston A, Uetrecht J. Current understanding of the mechanisms of idiosyncratic drug-induced agranulocytosis. Expert Opin Drug Metab Toxicol 2014; 11:243-57. [DOI: 10.1517/17425255.2015.985649] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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