Acute hepatitis induced by bupropion

Rapid bupropion-induced hepatotoxicity: a case report and review of the literature

BACKGROUND

Bupropion is an antidepressant that is also used as a non-nicotine method to aid in smoking cessation. Bupropion-induced hepatotoxicity is quoted to affect between 0.1% and 1% of treated patients with either a hepatocellular and/or cholestatic pattern of damage. The mechanism of damage is considered to be predominantly immune-mediated with the presence of a hypersensitivity syndrome (fever, rash, eosinophilia, autoantibodies) and a short latency period (1-6 weeks). We believe our reporting of this case to the already existing small list of only seven cases in the world literature will help practicing physicians to deal with the diagnostic and management dilemmas that bupropion-induced hepatotoxicity brings.

CASE PRESENTATION

A 50-year-old Caucasian woman presented to our hospital with significant derangement of liver transaminases after 6 days of bupropion treatment for smoking cessation. The patient's other medications were considered unlikely to be the cause of the hepatotoxicity and were therefore continued. The patient's liver function tests normalized on withdrawal of bupropion, confirming that bupropion was the probable cause of the patient's hepatotoxicity.

CONCLUSIONS

We conclude that hepatotoxicity is a rare adverse effect of bupropion use, but physicians should be aware of the possibility of this potentially serious clinical picture of drug-induced hepatotoxicity with varied clinical presentation and prognosis.

Mechanisms of hepatocellular toxicity associated with new psychoactive synthetic cathinones

Synthetic cathinones are a new class of psychostimulant substances. Rarely, they can cause liver injury but associated mechanisms are not completely elucidated. In order to increase our knowledge about mechanisms of hepatotoxicity, we investigated the effect of five frequently used cathinones on two human cell lines. Bupropion was included as structurally related drug used therapeutically. In HepG2 cells, bupropion, MDPV, mephedrone and naphyrone depleted the cellular ATP content at lower concentrations (0.2-1mM) than cytotoxicity occurred (0.5-2mM), suggesting mitochondrial toxicity. In comparison, methedrone and methylone depleted the cellular ATP pool and induced cytotoxicity at similar concentrations (≥2mM). In HepaRG cells, cytotoxicity and ATP depletion could also be demonstrated, but cytochrome P450 induction did not increase the toxicity of the compounds investigated. The mitochondrial membrane potential was decreased in HepG2 cells by bupropion, MDPV and naphyrone, confirming mitochondrial toxicity. Bupropion, but not the other compounds, uncoupled oxidative phosphorylation. Bupropion, MDPV, mephedrone and naphyrone inhibited complex I and II of the electron transport chain, naphyrone also complex III. All four mitochondrial toxicants were associated with increased mitochondrial ROS and increased lactate production, which was accompanied by a decrease in the cellular total GSH pool for naphyrone and MDPV. In conclusion, bupropion, MDPV, mephedrone and naphyrone are mitochondrial toxicants impairing the function of the electron transport chain and depleting cellular ATP stores. Since liver injury is rare in users of these drugs, affected persons must have susceptibility factors rendering them more sensitive for these drugs.

Antidepressant-lnduced Liver Injury

Objective:

To review principles of drug-induced liver injury (DILI), summarize characteristics of antidepressant-mediated liver Injury, and provide recommendations for monitoring and management.

Data Sources:

A search relating to antidepressant-induced liver injury was performed using MEDLINE (1966–March 2007). Search terms included antidepressant, cholestasis, hepatotoxicity, jaundice, liver injury, toxic hepatitis, and transaminases. Reference citations not Identified in the initial database search were also utilized.

Study Selection and Data Extraction:

All English-language case reports, letters, and review articles identified from the data sources were used. Case reports and letters relating to hepatotoxicity from antidepressant overdose were excluded.

Data Synthesis:

Antidepressant-induced liver injury described in published cases were of the idiopathic type and, by definition, cannot be predicted based on dose or specific risk factors. Paroxetine had the largest number of cases within the selective serotonin-reuptake inhibitor class. Nefazodone, a serotonin–norepinephrine reuptake inhibitor, appeared to have the most serious cases and is the only antidepressant agent that carries a Food and Drug Administration Black Box Warning regarding hepatotoxiciiy. The tricyclic antidepressants and monoamine oxidase Inhibitors are capable of producing hepatotoxicity, but fewer cases with these agents have been reported in the past 15 years, possibly due to a decline in their use. Causality has not been well established in all reports due to the concurrent use of other drugs and/or underlying liver disease.

Conclusions:

Most antidepressant agents have the potential to produce idiopathic liver injury. There is no way to prevent idiopathic DILI, but the severity of the reaction may be minimized with prompt recognition and early withdrawal of the agent. The clinician must be careful to provide ongoing therapy of the underlying depressive disorder and be aware of possible drug discontinuation syndromes should potential hepatotoxicity be suspected.

Acute Hepatocellular Drug-Induced Liver Injury From Bupropion and Doxycycline

The management and diagnosis of drug-induced liver injury (DILI) is often challenging, particularly when patients are taking multiple medications. We present a 29-year-old African American man who presented with jaundice and malaise after starting bupropion and doxycycline 2 weeks prior. He was found to have acute hepatocellular drug-induced liver injury with autoimmune features, and made a complete recovery with prednisone. Although bupropion and doxycycline are both known to cause liver toxicity, a closer inspection of the signature of liver injury and a review of prior related DILI cases assigns causality more to bupropion than doxycycline.

Novel Objective Biomarkers of Alcohol Use: Potential Diagnostic and Treatment Management Tools in Dual Diagnosis Care

Alcohol use disorders are highly prevalent conditions that generate a large fraction of the total public health burden. These disorders are concentrated in mentally ill populations, in which reliability of self-reporting of alcohol consumption may be especially compromised. The application of objective biomarkers for alcohol use may therefore play an important role in these patients. This article provides a description and comparative overview of traditional versus novel biomarkers of alcohol consumption. Greater professional familiarity with and use of novel biomarkers as diagnostic and treatment management tools may enhance clinical standards and research on alcohol use in patients with a dual diagnosis.

A fatal case of bupropion (Zyban) hepatotoxicity with autoimmune features: Case report

Background

Bupropion is approved for the treatment of mood disorders and as an adjuvant medication for smoking cessation. Bupropion is generally well tolerated and considered safe. Two randomized controlled trials of bupropion therapy for smoking cessation did not report any hepatic adverse events. However, there are three reports of severe but non-fatal bupropion hepatotoxicity published in the literature.

Case Presentation

We present the case of a 55-year old man who presented with jaundice and severe hepatic injury approximately 6 months after starting bupropion for smoking cessation. Laboratory evaluation demonstrated a mixed picture of hepatocellular injury and cholestasis. Liver biopsy demonstrated findings consistent with severe hepatotoxic injury due to drug induced liver injury. Laboratory testing was also notable for positive autoimmune markers. The patient initially had clinical improvement with steroid therapy but eventually died of infectious complications.

Conclusion

This report represents the first fatal report of bupropion related hepatotoxicity and the second case of bupropion related liver injury demonstrating autoimmune features. The common use of this medication for multiple indications makes it important for physicians to consider this medication as an etiologic agent in patients with otherwise unexplained hepatocellular jaundice.

Drug-induced rash with eosinophilia and systemic symptoms syndrome with bupropion administration

BACKGROUND

Sustained-release bupropion is commonly used for the symptomatic relief of depressive illness and as an adjuvant in smoking cessation therapy.

OBJECTIVE

To report a case of bupropion-induced drug rash with eosinophilia and systemic symptoms syndrome, including acute hepatitis, obstructive lung disease, and myositis.

METHODS

After the patient discontinued use of bupropion, serologic tests, muscle biopsies, pulmonary function tests, a chest x-ray examination, venous Doppler ultrasounds, and an electrocardiogram were performed.

RESULTS

On discontinuation of bupropion and prolonged systemic corticosteroid therapy, there was complete resolution of symptoms.

CONCLUSIONS

To our knowledge, this is the first reported case of drug rash with eosinophilia and systemic symptoms syndrome induced by bupropion therapy. We report this case to notify clinicians of the potential serious multisystem complications that can occur with sustained-release bupropion therapy.

Antidepressant-induced hepatotoxicity

Depression is a chronic, severe and increasingly prevalent illness associated with substantial morbidity, mortality and healthcare costs. Antidepressant drugs, the cornerstone of depression treatment, are not devoid of adverse effects, including hepatotoxicity. To review the risk of liver toxicity related to major antidepressants, the authors have followed structural criteria focusing on the underlying mechanism presumably involved and the role of particular chemical structures. The clinicopathological expression goes from transient increases in liver enzymes to fulminant liver failure. Classical antidepressants such as monoamine oxidase inhibitors (MAOIs) or tricyclic antidepressants (TCAs) seem to have the highest potential to induce liver damage compared with the newer drugs such as selective serotonin re-uptake inhibitors (SSRIs). The potential for severe hepatotoxicity associated with nefazodone is stressed. Guidelines for therapy and prevention of antidepressant-induced hepatotoxicity are also discussed.

Acute liver failure with concurrent bupropion and carbimazole therapy

OBJECTIVE

To report a case of fatal liver failure possibly associated with concurrent use of bupropion and carbimazole.

CASE SUMMARY

A 41-year-old Chinese man with a history of hyperthyroidism had been treated with carbimazole and propranolol for the past 5 years. He received a 10-day course of bupropion as an aid for smoking cessation 10 weeks prior to presentation. He developed acute liver failure with rapid deterioration of renal function. Liver biopsy showed evidence of nonspecific drug-induced acute liver injury. His condition was further complicated by sepsis and coagulopathy. Death resulted 19 days after the onset of symptoms. The likelihood that bupropion induced hepatotoxicity in our patient was possible, based on the Naranjo probability scale.

DISCUSSION

Although there is increasing evidence of hepatotoxicity induced by bupropion, this is the first case of fatality that could have resulted from acute liver failure in a patient receiving bupropion while on concomitant treatment with carbimazole.

CONCLUSIONS

Clinicians should be aware of the possibility of acute liver insult induced by bupropion given concurrently with other hepatotoxic drugs.

Acute cholestatic hepatitis induced by bupropion prescribed as pharmacological support to stop smoking. A case report

We report the first case of acute cholestatic hepatitis induced by bupropion. This antidepressant was taken by a 49-year-old female as adjuvant treatment to stop smoking. After 20 days of bupropion, the patient presented a symptomatology characterized by asthenia, nausea and scleral icterus and biochemical analyses showed a dramatic increase in direct bilirubin (up to 28 mg/dl) and transaminases (up to 68-fold normal limits). Antinuclear antibodies were positive (title = 1:80; speckled pattern). Biochemical analyses and antinuclear antibodies were normal two years earlier. The histology showed a pattern of acute hepatitis with involvement of bile ducts and with features of centrolobular cholestasis. Treatment with methylprednisolone was commenced and continued for 20 days. Liver enzymes and bilirubin returned to normal within two months of withdrawal of bupropion and remained normal during the 4-month follow-up. Antinuclear antibodies also became negative. Other causes of liver damage were excluded. Considering the clinical diagnostic scale for hepatotoxic adverse drug reaction, our patient showed a score compatible with the final diagnosis of bupropion-related cholestatic hepatitis.

Drug-induced liver disease

This year's review is divided into several sections: the first describes drug withdrawals and new general reviews of drug-induced liver disease (DILD), including a review of a classification of drug injury. We review agents newly described as causing DILD, and new reports of DILD from established agents appearing in the year 2000. New aspects regarding the treatment of acetaminophen toxicity are included, and in the final section we deal with prevention of DILD as well as issues surrounding the use of potentially hepatotoxic medications in patients with underlying chronic disease.

• Childhood Poisonings and Harmful Effects of otc Drugs in the Unborn /• Vancomycin-Induced Neutropenia/ • Two Cases of Drug-Induced Hepatitis: Lamotrigine and Bupropion are the Culprits/ • Impotence Caused by Haloperidol

The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), to discuss methods of prevention, and to promote reporting of ADRs to the FDA's medWatch program (1-800-FDA-1088). If you have reported an interesting preventable ADR to medWatch, please consider sharing the account with our readers