Acute hepatitis after lamotrigine administration

Strain and interindividual differences in lamotrigine-induced liver injury in mice

Lamotrigine (LTG) has been widely prescribed as an antipsychotic drug, although it causes idiosyncratic drug-induced liver injury in humans. LTG is mainly metabolized by UDP-glucuronosyltransferase, while LTG undergoes bioactivation by cytochrome P450 to a reactive metabolite; it is subsequently conjugated with glutathione, suggesting that reactive metabolite would be one of the causes for LTG-induced liver injury. However, there is little information regarding the mechanism of LTG-induced liver injury in both humans and rodents. In this study, we established an LTG-induced liver injury mouse model through co-administration with LTG and a glutathione synthesis inhibitor, l-buthionine-(S,R)-sulfoximine. We found an increase in alanine aminotransferase (ALT) levels (>10 000 U/L) in C57BL/6J mice, with apparent interindividual differences. On the other hand, a drastic increase in ALT was not noted in BALB/c mice, suggesting that the initiation mechanism would be different between the two strains. To examine the cause of interindividual differences, C57BL/6J mice that were co-administered LTG and l-buthionine-(S,R)-sulfoximine were categorized into three groups based on ALT values: no-responder (ALT <100 U/L), low-responder (100 U/L < ALT < 1000 U/L) and high-responder (ALT >1000 U/L). In the high-responder group, induction of hepatic oxidative stress, inflammation and damage-associated molecular pattern molecules in mRNA was associated with vacuolation and karyorrhexis in hepatocytes. In conclusion, we demonstrated that LTG showed apparent strain and interindividual differences in liver injuries from the aspects of initiation and exacerbation mechanisms. These results would support interpretation of the mechanism of LTG-induced liver injury observed in humans.

Liver dysfunction induced by systemic hypersensitivity reaction to lamotrigine: case report

Lamotrigine is an anticonvulsant drug used to treat partial and generalized seizure disorders. Hypersensitivity to lamotrigine usually causes mild symptoms such as fever, rash, and slight invasion of internal organs. However, a 33-year-old male patient who was admitted with Stevens-Johnson syndrome after taking lamotrigine for 15 days experienced hepatic failure and died 5 days after admission. This case demonstrates the importance of realizing that lamotrigine can lead to fatal hepatic failure, and that tests for the normal liver function should be performed when administering lamotrigine.

Lamotrigine and its applications in the treatment of epilepsy and other neurological and psychiatric disorders

Lamotrigine is a broad-spectrum antiepileptic drug, initially approved in 1994 for the adjunctive treatment of partial seizures in adults and for the generalized seizures of Lennox-Gastaut syndrome in pediatric (>2 years old) and adult populations. Its role in the treatment of bipolar disorder type I has also been well established. In addition, lamotrigine has been successfully used for the management of other neurological conditions such as migraines and neuropathic pain, and preliminary data show promising results. It has favorable pharmacokinetic properties and is generally well tolerated. The small risk of serious skin rash can be minimized with slow titration of the drug and dose adjustment with concomitant medications. Lamotrigine has demonstrated particular benefit in the treatment of women and elderly patients with epilepsy.

Drug-induced liver injury from antiepileptic drugs

Drug-induced liver injury is a potential complication of innumerable medications. Most cases do not occur in a predictable, dose-dependent manner, leading to delayed recognition of a drug's hepatotoxic potential until after its release into the market. The estimated occurrence is 1 in 10,000 to 100,000 patients. However, the rates are likely higher because many cases go unrecognized owing to lack of reporting or missed diagnosis. This article reviews the most commonly associated antiepileptic drugs.

Hepatotoxicity associated with antiepileptic drugs

BACKGROUND

Drug-induced liver injury associated with antiepileptic drugs (AED) is well recognized. The frequency of the most common AED is rare but the consequences can be very serious leading to death or liver transplantation due to acute liver failure induced by these drugs.

CLINICAL FEATURES

Hypersensitivity features are found in more than 70% of patients with phenytoin-induced liver injury, whereas this is only observed in 30% of carbamazepine-associated hepatotoxicity and very rarely with valproate (VPA)-induced liver injury.

PATHOPHYSIOLOGY

The underlying mechanisms behind hepatotoxicity induced by AED are not clear. Reactive metabolites from AED can, in some cases, lead to direct cytotoxicity and liver cell necrosis, whereas in other cases this may lead to neoantigen formation inducing immunoallergic mechanisms.

TREATMENT

No specific therapy is of proved value in severe hepatotoxicity due to AED. However, N-acetylcystein is an appropriate treatment in patients with clinically significant liver injury due to phenytoin and carbamazepine. In patients with VPA-associated liver injury, carnitine that is an important co-factor in the mitochondrial beta-oxidation of fatty acids is the recommended treatment. Early referral of patients with severe liver reactions and coagulopathy to liver transplant centers before encephalopathy can be the difference between liver transplantation and death.

Simultaneous toxicities in a child on multiple anticonvulsants

It is rare to develop simultaneous toxicities while on anticonvulsants. This article presents a 3(1/2)-year-old child on valproic acid, lamotrigine, and phenytoin who developed simultaneous hepatotoxicity and bone marrow toxicity during a parainfluenza virus type 3 infection. These toxicities resolved after the cessation of anticonvulsants, and her seizures were managed acutely with scheduled lorazepam. This article discusses the possibility that simultaneous use of valproic acid, lamotrigine, and phenytoin could give this combination of toxicities and that concurrent viral infection may increase this risk.

Does therapeutic use of acetaminophen cause acute liver failure?

STUDY OBJECTIVE

To compare the reported occurrence of liver failure in subjects in prospective trials with that in patients in retrospective reports after repeated use of therapeutic dosages of acetaminophen.

DESIGN

Systematic review of the medical literature.

DATA SOURCE

MEDLINE and EMBASE biomedical and pharmacologic databases.

SUBJECTS

Adults who received repeated dosing of acetaminophen 4 g/day or lower for at least 24 hours.

MEASUREMENTS AND MAIN RESULTS

Articles written in several languages were abstracted by trained personnel using a structured abstraction form. Data were categorized by methodology (prospective vs retrospective), acetaminophen dosage, and type of liver effect. A total of 791 articles were identified, which included 30,865 subjects in prospective studies and 9337 patients in retrospective reports. The prospective studies reported no cases of fulminant hepatic injury, liver transplantation, or death due to acetaminophen. Of the 30,865 subjects in these studies, 129 (0.4%) were identified who had a serum aminotransferase level that exceeded the upper limit of normal, including 61 subjects in randomized trials in which the proportion of serum aminotransferase level increase was the same as or less than that in the placebo group and 68 subjects in trials without a placebo group. In addition, 4263 (13.8%) received the maximum recommended therapeutic dosage (3.9-4 g/day). In the retrospective reports, 96 patients (1.0%) had a serum alanine aminotransferase level that exceeded the upper limit of normal, one (0.01%) underwent liver transplantation, and six (0.06%) died. Causality relationship of acetaminophen for each retrospective case was assessed with the Naranjo adverse drug reaction probability scale. The mean +/- SD Naranjo score for all 103 retrospective cases was 3.2 +/- 1.9, indicating a possible relationship between the increased aminotransferase levels and acetaminophen use. Some retrospective reports contained information suggesting that the patient had ingested an overdose despite a history of therapeutic use.

CONCLUSION

Prospective studies indicated that repeated use of a true therapeutic acetaminophen dosage may slightly increase the level of serum aminotransferase activity, but hepatic failure or death was not reported. Retrospective reports indicated a higher rate of increased serum aminotransferase levels, and several reported associated liver injury and death. The differing results and presence of evidence indicating inaccurate acetaminophen dosage information in some case reports suggests that these cases may be inadvertent overdoses, rather than true therapeutic dosages.

Antiepileptic drugs and liver disease

Antiepileptic drugs (AEDs) are no longer restricted to the treatment of epilepsy. These are widely used in a broad spectrum of psychiatric and neurological disorders. Liver plays a major role in the metabolism of a majority of these drugs. Hepatotoxicity is rare, but a real concern when initiating therapy. Likewise, liver disease can adversely affect the biotransformation of some of these drugs. This manuscript addresses the significance of elevated liver enzymes associated with AED use, the role of therapeutic drug monitoring, pharmacokinetics during liver disease and potential risk of hepatotoxicity.

Lamotrigine in psychiatry: pharmacology and therapeutics

Following the introduction of lamotrigine in 1994 as a treatment for epilepsy in the United States, the drug has seen progressively greater application in psychiatry, particularly as a treatment for bipolar disorder. This review critically evaluates the support for lamotrigine use across a broad range of psychiatric disorders as well as discuss its pharmacology, side-effect profile, and interactions with other medications.

Fulminant hepatitis after grand mal seizures: mechanisms and role of liver transplantation

Fulminant liver failure is a rare complication of grand mal seizures with a high mortality, the prognosis being largely determined by the combination of the hepatic and neurologic insults. The mechanisms of acute liver failure secondary to grand mal epilepsy and the place of liver transplantation in this context are poorly defined and are the subject of this report. A series of 6 such patients is presented. All had a history of chronic primary or post-traumatic epilepsy and presented with acute liver failure shortly after a grand mal fit. Detailed accounts of background, presentation, and management are given and integrated with blood, radiologic, and histologic investigations. Two of the 6 patients survived, 1 making a full recovery and the other with neurologic sequelae. Two patients underwent liver transplantation but died with severe neurologic sequelae despite improving liver function. The remaining 2 patients were considered too ill to undergo liver transplantation and died in multiple organ failure. Liver histology from needle biopsy and/or native liver explants identified lesions compatible with a combination of steatosis and necrosis. Factor V and transaminase levels may allow early identification of patients in whom liver function is likely to improve spontaneously. In conclusion, the mechanisms of liver failure occurring after grand mal seizures appear multifactorial, including hypoxia, steatosis, and drug-induced components. The neurological prognosis and overall survival of these patients remains poor.

Lamotrigine update and its use in mood disorders

OBJECTIVE

To provide a qualitative, systematic update and review of the pharmacology, pharmacokinetics, efficacy in mood disorders, adverse effects, and costs of lamotrigine.

DATA SOURCES

Citations obtained from MEDLINE searches (1985-September 2001) using lamotrigine as a text word, articles identified in reference lists of pertinent articles, abstracts presented at conferences, and research data from GlaxoSmithKline.

DATA EXTRACTION

English-language articles were considered for possible inclusion. Each title and abstract was examined to determine whether the publication contained up-to-date information relevant to the objective. Twenty clinical trials that provided data on response rates in mood disorders were tabulated.

DATA SYNTHESIS

Lamotrigine's primary action is to modulate voltage-gated sodium channels. Evidence suggests that it decreases glutamate transmission, directly reduces calcium influx, mildly blocks transmitter reuptake, and alters intracellular mechanisms of resting transmitter release. The average half-life of lamotrigine is approximately 24 hours, but decreases to approximately 7.4 hours when used concurrently with phenytoin, and increases to approximately 59 hours with valproic acid. Seven of the 20 clinical trials were randomized, double-blind, and controlled. Existing data are inadequate to evaluate lamotrigine use in major depression. The pooled response rates for patients with depressed, manic, mixed, and rapid cycling bipolar disorder were similar, ranging from 52% to 63%. Adverse effects are infrequent when the drug is used alone, but become more frequent when lamotrigine is combined with other anticonvulsants. While most rashes are mild, approximately 1 in 500 patients develops exfoliative dermatitis. A slow upward dose titration is recommended to reduce the incidence of serious rash, but this may delay the attainment of adequate dosage for 6 weeks. Lamotrigine has positive effects on cognitive function, but occasionally produces insomnia. Lamotrigine costs 2-4 times more than lithium, carbamazepine, and generic valproic acid.

CONCLUSIONS

When efficacy, adverse effects, and cost are considered, lamotrigine should probably be reserved as a second-line agent for bipolar depression.

Lamotrigine

Lamotrigine is a newly available antiepileptic drug with a broad spectrum of efficacy and a tolerability profile that is favorable for use in many patients. Problems with rash are related to rate of dose ascension and drug interactions with valproate. Efficacy in treatment of mood disorder and some pain syndromes will broaden the use of this unique compound.

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