1
|
Contreras-Omaña R, Velarde-Ruiz Velasco JA, Castro-Narro GE, Trujillo-Benavides O, Zamarripa-Dorsey F, Reyes-Dorantes AA, Muñoz-Espinosa L, Aiza-Haddad I, Castillo-Barradas M, Cerda-Reyes E, Cisneros-Garza LE, Flores-Calderón J, García-Jiménez ES, Higuera-de-la-Tijera MF, Lira-Pedrín MA, Marquez-Guillén E, Moctezuma-Velázquez C, Moreno-Alcántar R, Noyola-Cedillo SG, Pérez-Hernández JL, Ramos-Gómez MV, Remes-Troche JM, Rizo-Robles MT, Rodríguez-Hernández H. Approach to the patient with cholestasis and jaundice syndrome. Joint AMH, AMG, and AMEG scientific position statement. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 87:80-88. [PMID: 34866042 DOI: 10.1016/j.rgmxen.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 04/14/2021] [Indexed: 11/17/2022]
Abstract
The term cholestasis refers to bile acid retention, whether within the hepatocyte or in the bile ducts of any caliber. Biochemically, it is defined by a level of alkaline phosphatase that is 1.67-times higher than the upper limit of normal. Cholestatic diseases can be associated with an inflammatory process of the liver that destroys hepatocytes (hepatitis), withjaundice (yellowing of the skin and mucus membranes, associated with elevated serum bilirubin levels), or with both, albeit the three concepts should not be considered synonymous. Cholestatic diseases can be classified as intrahepatic or extrahepatic, depending on their etiology. Knowing the cause of the condition is important for choosing the adequate diagnostic studies and appropriate treatment in each case. A complete medical history, together with a thorough physical examination and basic initial studies, such as liver ultrasound and liver function tests, aid the clinician in deciding which path to follow, when managing the patient with cholestasis. In a joint effort, the Asociación Mexicana de Hepatología (AMH), the Asociación Mexicana de Gastroenterología (AMG) and the Asociación Mexicana de Endoscopia Gastrointestinal (AMEG) developed the first Mexican scientific position statement on said theme.
Collapse
Affiliation(s)
- R Contreras-Omaña
- Centro de Estudio e Investigación en Enfermedades Hepáticas (CEIHE), Pachuca, Hidalgo, Mexico.
| | | | | | | | | | | | - L Muñoz-Espinosa
- Centro de Hepatología, Departamento de Medicina Interna, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - I Aiza-Haddad
- Clínica de Enfermedades Hepáticas, Hospital Ángeles Lomas, Mexico City, Mexico
| | - M Castillo-Barradas
- Hospital de Especialidades CMN La Raza, IMSS Hospital Ángeles Lindavista, Mexico City, Mexico
| | | | | | - J Flores-Calderón
- Servicio de Gastropediatría, UMAE Hospital de Pediatría CMN Siglo XXI IMSS, Mexico City, Mexico
| | - E S García-Jiménez
- Hospital Civil de Guadalajara "Fray Antonio Alcalde", Guadalajara, Jalisco, Mexico
| | - M F Higuera-de-la-Tijera
- Servicio de Gastroenterología, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - M A Lira-Pedrín
- Hospital Centro Médico del Prado, Tijuana, Baja California, Mexico
| | | | | | | | - S G Noyola-Cedillo
- Centro Médico del Noreste, Clínica 25 IMSS, Monterrey, Nuevo León, Hospital Ángeles Torreón, Coahuila, Mexico
| | - J L Pérez-Hernández
- Hospital Central Sur de Alta Especialidad Petróleos Mexicanos, Mexico City, Mexico
| | - M V Ramos-Gómez
- Servicio de Gastroenterología, CMN 20 de Noviembre, ISSSTE Mexico City, Mexico
| | - J M Remes-Troche
- Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - M T Rizo-Robles
- UMAE Hospital de Especialidades CMN La Raza IMSS, Mexico City, Mexico
| | - H Rodríguez-Hernández
- Facultad de Medicina y Nutrición, Universidad Juárez del Estado de Durango, Durango, Mexico
| |
Collapse
|
2
|
Sanjel B, Shim WS. Recent advances in understanding the molecular mechanisms of cholestatic pruritus: A review. Biochim Biophys Acta Mol Basis Dis 2020; 1866:165958. [PMID: 32896605 DOI: 10.1016/j.bbadis.2020.165958] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023]
Abstract
Cholestasis, a condition characterized by an abnormal decrease in bile flow, is accompanied by various symptoms such as pruritus. Although cholestatic pruritus is a prominent condition, its precise mechanisms have largely been elusive. Recently, advancements have been made for understanding the etiology and pathogenesis of cholestatic pruritus. The current review therefore focuses on summarizing the overall progress made in the elucidation of its molecular mechanisms. We have reviewed the available animal models on cholestasis to compare the differences between them, characterized potential pruritogens involved in cholestatic pruritus, and have summarized the receptor and ion channels implicated in the condition. Finally, we have discussed the available treatment options for alleviation of cholestatic pruritus. As our understanding of the mechanisms of cholestatic pruritus deepens, novel strategies to cure this condition are awaited.
Collapse
Affiliation(s)
- Babina Sanjel
- College of Pharmacy, Gachon University, Hambakmoero 191, Yeonsu-gu, Incheon 21936, Republic of Korea; Gachon Institute of Pharmaceutical Sciences, Hambakmoero 191, Yeonsu-gu, Incheon 21936, Republic of Korea
| | - Won-Sik Shim
- College of Pharmacy, Gachon University, Hambakmoero 191, Yeonsu-gu, Incheon 21936, Republic of Korea; Gachon Institute of Pharmaceutical Sciences, Hambakmoero 191, Yeonsu-gu, Incheon 21936, Republic of Korea.
| |
Collapse
|
3
|
Van Vaisberg V, Tannuri ACA, Lima FR, Tannuri U. Ileal exclusion for pruritus treatment in children with progressive familial intrahepatic cholestasis and other cholestatic diseases. J Pediatr Surg 2020; 55:1385-1391. [PMID: 31708211 DOI: 10.1016/j.jpedsurg.2019.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/02/2019] [Accepted: 09/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pruritus is a major health-related quality-of-life burden in progressive familial intrahepatic cholestasis (PFIC) and other childhood cholestatic liver diseases. Several nontransplant surgical techniques were developed in an attempt to ameliorate symptoms and slow disease progression. Very few case-series have been published on a particular intervention, ileal exclusion (IE), which has been considered to be inferior to the other approaches. METHODS We conducted a single-center retrospective chart-review case-series of patients submitted to IE as the first-line surgical treatment at our institution from 1995 to 2018. The primary goal was pruritus relief, followed by survival with the native liver and improvement in biochemical parameters. RESULTS Eleven patients were submitted to IE, with a mean follow-up of 60 months. Complete resolution or significant reduction of pruritus was obtained in 72.7% (n = 8) of patients. One patient (9.1%) had a major postoperative complication that required surgery. No other morbidities were reported. Two cases progressed to end-stage liver disease (ESLD) within the short-term and one year after surgery. CONCLUSIONS This case series study shows that IE provided excellent results in pruritus control and permitted survival with the native liver. We believe IE is a safe procedure, with few associated morbidities, and should be considered more often as primary surgical treatment for PFIC and other cholestasis. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Victor Van Vaisberg
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Fabiana Roberto Lima
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
| |
Collapse
|
4
|
de Vries E, Beuers U. Ursodeoxycholic acid in pregnancy? J Hepatol 2019; 71:1237-1245. [PMID: 31479696 DOI: 10.1016/j.jhep.2019.08.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/19/2019] [Accepted: 08/26/2019] [Indexed: 02/08/2023]
Abstract
The case of a 34-year-old woman with primary biliary cholangitis (PBC) before, during and after pregnancy is described. The use of ursodeoxycholic acid (UDCA) during and after pregnancy is discussed. UDCA has not been approved by the drug regulatory authorities as a pregnancy-safe drug; therefore, the reluctance of clinicians to prescribe UDCA during pregnancy is understandable. This Grand Round aims to provide a detailed analysis of the current evidence, safety data and clinical experience with UDCA (and alternative drugs) during pregnancy and lactation. Based on this analysis, advice for clinicians regarding the use of UDCA during pregnancy and lactation is given.
Collapse
Affiliation(s)
- Elsemieke de Vries
- Department of Gastroenterology and Hepatology and Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology and Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.
| |
Collapse
|
5
|
BAM8-22 and its receptor MRGPRX1 may attribute to cholestatic pruritus. Sci Rep 2019; 9:10888. [PMID: 31350433 PMCID: PMC6659683 DOI: 10.1038/s41598-019-47267-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/11/2019] [Indexed: 12/16/2022] Open
Abstract
Pruritus is an unexpected symptom observed in cholestasis and its mechanism is still unclear. Here, we show that bovine adrenal medulla (BAM) 8-22, an endogenous itch-inducing peptide, could be involved in cholestatic pruritus. It was found that bile duct ligation (BDL) mice, an obstructive cholestasis model, showed increased spontaneous scratching behaviour. Importantly, the mRNA level of proenkephalin, a precursor polypeptide of BAM8-22, was significantly increased in the skin of BDL mice. Furthermore, the mRNA level of Mrgprx1, which encodes a receptor for BAM8-22, was significantly increased in the dorsal root ganglia (DRG) of BDL mice. This was further confirmed by elevation of intracellular calcium levels upon BAM8-22 treatment in primarily-cultured DRG neurons. In addition, BDL mice showed augmented scratching behaviour by BAM8-22, indicating enhanced activity of MRGPRX1. Moreover, the skin homogenate of BDL mice induced elevation of intracellular calcium levels through MRGPRX1. Finally, among the various bile acids, chenodeoxycholic acid significantly increased proenkephalin transcription in a human keratinocyte cell line (HaCaT). In conclusion, cholestatic pruritus could be attributed in part to enhanced action of both BAM8-22 in the skin and its receptor MRGPRX1 in sensory neurons.
Collapse
|
6
|
Abstract
Intractable itching is a symptom of cholestatic liver disease of various causes that is bothersome and difficult to manage. Although treatment of the primary cause of cholestasis is paramount in resolving the issue, given the debilitating consequences of pruritus, symptomatic treatment is frequently necessary. Although many medications including cholestyramine, rifampin, opioid antagonists (i.e., naloxone, naltrexone), phenobarbital, and antihistamines have been used to treat cholestatic-induced pruritus, none has resulted in uniform success. We report anecdotal success with the use of ondansetron to treat pruritus associated with cholestasis following prolonged intensive care unit course of a 16-year-old. The theories accounting for pruritus with cholestasis are presented, treatment options are reviewed, and the role of ondansetron in the treatment of pruritus is discussed.
Collapse
Affiliation(s)
- Sarah Dillon
- School of Medicine, Upstate Medical University, Syracuse, New York
| | | |
Collapse
|
7
|
Belghiti M, Estévez-Herrera J, Giménez-Garzó C, González-Usano A, Montoliu C, Ferrer-Montiel A, Felipo V, Planells-Cases R. Potentiation of the transient receptor potential vanilloid 1 channel contributes to pruritogenesis in a rat model of liver disease. J Biol Chem 2013; 288:9675-9685. [PMID: 23408423 DOI: 10.1074/jbc.m113.455162] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Persistent pruritus is a common disabling dermatologic symptom associated with different etiologic factors. These include primary skin conditions, as well as neuropathic, psychogenic, or systemic disorders like chronic liver disease. Defective clearance of potential pruritogenic substances that activate itch-specific neurons innervating the skin is thought to contribute to cholestatic pruritus. However, because the underlying disease-specific pruritogens and itch-specific neuronal pathways and mechanism(s) are unknown, symptomatic therapeutic intervention often leads to no or only limited success. In the current study, we aimed to first validate rats with bile duct ligation (BDL) as a model for hepatic pruritus and then to evaluate the contribution of inflammation, peripheral neuronal sensitization, and specific signaling pathways and subpopulations of itch-responsive neurons to scratching behavior and thermal hypersensitivity. Chronic BDL rats displayed enhanced scratching behavior and thermal hyperalgesia indicative of peripheral neuroinflammation. BDL-induced itch and hypersensitivity involved a minor contribution of histaminergic/serotonergic receptors, but significant activation of protein-activated receptor 2 (PAR2) receptors, prostaglandin PGE2 formation, and potentiation of transient receptor potential vanilloid 1 (TRPV1) channel activity. The sensitization of dorsal root ganglion nociceptors in BDL rats was associated with increased surface expression of PAR2 and TRPV1 proteins and an increase in the number of PAR2- and TRPV1-expressing peptidergic neurons together with a shift of TRPV1 receptor expression to medium sized dorsal root ganglion neurons. These results suggest that pruritus and hyperalgesia in chronic cholestatic BDL rats are associated with neuroinflammation and involve PAR2-induced TRPV1 sensitization. Thus, pharmacological modulation of PAR2 and/or TRPV1 may be a valuable therapeutic approach for patients with chronic liver pruritus refractory to conventional treatments.
Collapse
Affiliation(s)
| | | | | | | | - Carmina Montoliu
- Fundación Investigación Hospital Clínico de Valencia, INCLIVA, 46010 Valencia, Spain
| | - Antonio Ferrer-Montiel
- Instituto de Biología Molecular y Celular, Universidad Miguel Hernández, 03202 Elche, Spain
| | - Vicente Felipo
- Centro de Investigación Príncipe Felipe, 46012 Valencia, Spain
| | - Rosa Planells-Cases
- Centro de Investigación Príncipe Felipe, 46012 Valencia, Spain; Leibniz-Institut für Molekulare Pharmakologie (FMP) and Max-Delbrück-Centrum für Molekulare Medizin (MDC), 13125 Berlin, Germany.
| |
Collapse
|
8
|
Schaefer B, Schaefer F, Wittmer D, Engelmann G, Wenning D, Schmitt CP. Molecular Adsorbents Recirculating System dialysis in children with cholestatic pruritus. Pediatr Nephrol 2012; 27:829-34. [PMID: 22083365 DOI: 10.1007/s00467-011-2058-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/28/2011] [Accepted: 08/30/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cholestatic pruritus may severely compromise quality of life. The Molecular Adsorbents Recirculating System (MARS) allows removal of pruritogenic substances without exposure to foreign proteins. Pediatric data, however, are scant. METHODS We retrospectively analyzed the efficacy of MARS in three boys with severe cholestatic pruritus. They received a total of 135 MARS sessions during 8, 4, and 13 months prior to liver transplantation. Total serum bilirubin and bile acids were monitored, and pruritus was assessed by a numerical rating scale (NRS 0 = no pruritus, 10 = maximal pruritus). RESULTS MARS sessions were initially performed three times weekly at a mean duration of 6.3 ± 1.4 h. Sessions could be reduced to once weekly and once every other week in two patients. Pre-MARS plasma bile acid concentrations averaged 207 ± 67 μmol/l. They declined to 67 ± 9%, 48 ± 3%, 38 ± 14%, and 37 ± 5% of baseline within 2, 4, 6 and 8 h of therapy, respectively (all p < 0.05). The average interdialytic increase of plasma bile acids was 34 ± 33 μmol/l per day. Mean NRS score decreased from 6.5 ± 2.3 to 3.3 ± 2.9 (p < 0.01). Skin lesions from itching disappeared. All MARS treatments were well tolerated. CONCLUSION MARS dialysis substantially reduces cholestatic pruritus in children refractory to pharmacological treatment.
Collapse
Affiliation(s)
- Betti Schaefer
- Center for Pediatric and Adolescent Medicine Heidelberg, University of Heidelberg, INF 430, 69120 Heidelberg, Germany
| | | | | | | | | | | |
Collapse
|
9
|
Eisendle K, Müller H, Ortner E, Talasz H, Graziadei I, Vogel W, Höpfl R. Pruritus of unknown origin and elevated total serum bile acid levels in patients without clinically apparent liver disease. J Gastroenterol Hepatol 2011; 26:716-21. [PMID: 21155876 DOI: 10.1111/j.1440-1746.2010.06522.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Generalized pruritus of unknown origin (PUO) is a highly distressing condition that is unrelated to any underlying dermatologic or systemic disorder (e.g. cholestasis). Little is known about the potential contribution of elevated total serum bile acid (TSBA) levels to PUO. Our aim in the present study was to investigate the role of elevated TSBA levels in patients with PUO and the efficacy of ursodeoxycholic acid (UDCA) and cholestyramine therapy. METHODS Retrospective study comprising 117 patients with chronic pruritic conditions (PUO, atopic disease, asteatotic eczema, latent cholestasis, etc.); 99 patients with available TSBA levels were included and compared with healthy controls. RESULTS Elevated TSBA levels were detected more frequently in patients with chronic pruritic diseases than in the control population (28.28% vs 6%; P<0.001) with significantly higher pathological absolute levels (mean 17.45±34.46 µmol/L vs 6.02±4.73 µmol/L; P=0.001). Patients with PUO (n=18) showed the second-highest prevalence of pathological bile acid level elevation (83.3%; control population 6%; P<0.001), after patients with subclinical cholestasis and presented with particularly high TSBA serum values (mean 37.79±53.38 µmol/L; P<0.001). Cholestyramine (n=9) and UDCA (n=8) therapy were both effective in lowering TSBA levels and lead to substantial improvement of pruritus in patients with elevated TSBA levels. CONCLUSIONS Total serum bile acid levels are elevated in a high proportion of patients with PUO. These results provide evidence of a potential involvement of subclinical cholestasis in the pathogenesis of PUO. We suggest that evaluation of TSBA levels should be included in the diagnostic work-up of patients with chronic unexplained pruritus.
Collapse
Affiliation(s)
- Klaus Eisendle
- Department of Dermatology and Venerology, Medical University Innsbruck, Innsbruck, Austria
| | | | | | | | | | | | | |
Collapse
|
10
|
Generali JA, Cada DJ. Cholestatic Pruritus: Sertraline (Adults). Hosp Pharm 2010. [DOI: 10.1310/hpj4510-768] [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
This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a quarterly publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@kumc.edu .
Collapse
Affiliation(s)
- Joyce A. Generali
- Drug Information Center, Kansas University Medical Center, 3901 Rainbow Boulevard, Kansas City, Kansas 66160
| | | |
Collapse
|
11
|
Generali JA, Cada DJ. Gabapentin: Cholestatic Pruritis. Hosp Pharm 2009. [DOI: 10.1310/hpj4412-1086] [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
This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a quarterly publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. A summary of the most relevant data is provided, including background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to hospital pharmacy@drugfacts.com .
Collapse
Affiliation(s)
- Joyce A. Generali
- Drug Information Center, Kansas University Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160
| | | |
Collapse
|
12
|
Chronic Upregulation of the Endogenous Opioid System Impairs the Skin Flap Survival in Rats. Ann Plast Surg 2009; 63:558-63. [DOI: 10.1097/sap.0b013e31818d458e] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
13
|
Generali JA, Cada DJ. Ondansetron: Cholestatic Pruritus (Adults). Hosp Pharm 2009. [DOI: 10.1310/hpj4410-868] [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
This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a quarterly publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. A summary of the most relevant data is provided, including background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to hospital pharmacy@drugfacts.com .
Collapse
Affiliation(s)
- Joyce A. Generali
- Drug Information Center, Kansas University Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160
| | | |
Collapse
|
14
|
Shafaroodi H, Ghasemi M, Dehpour AR. Elevation of pentylenetetrazole-induced seizure threshold in cholestatic mice: interaction between opioid and cannabinoid systems. J Gastroenterol Hepatol 2008; 23:e251-7. [PMID: 17764531 DOI: 10.1111/j.1440-1746.2007.05101.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Several studies have reported that endogenous opioid and cannabinoid systems may be involved in some pathophysiological changes occurring in cholestatic liver disease. It is well known that endogenous opioids and cannabinoids alter the susceptibility of experimental animals to different models of seizure. METHODS The alterations in pentylenetetrazole-induced clonic seizure thresholds were evaluated from 1 to 6 days after bile duct ligation in mice. Whether the pretreatment of cholestatic mice with different doses of opioid receptor antagonist naltrexone or cannabinoid CB(1) receptor antagonist AM251 (AM251) would have changed the clonic seizure threshold was also examined. RESULTS Although the clonic seizure threshold was similar between sham-operated and unoperated mice, there was a time-dependent increase in the threshold in cholestatic mice, reaching a peak on day 3 after bile duct ligation and declining partially after day 4. Chronic pretreatment with naltrexone (2, 5, and 10 mg/kg) reversed the increased threshold in cholestatic mice on day 3 after operation in a dose-dependent manner with the highest doses used restoring the threshold to that of the control animals. A similar reversal of the increased threshold was observed after acute (0.5, 0.75, and 1 mg/kg) or chronic (0.5 mg/kg for 4 days) pretreatment with AM251. Moreover, concurrent administration of doses of AM251 and naltrexone that each separately induced a partial reversal of increased seizure threshold in cholestasis caused a complete restoring of the threshold to the control level. CONCLUSIONS Both opioid and cannabinoid CB(1) receptors may be involved in the dramatic increase in pentylenetetrazole-induced seizure threshold in cholestasis.
Collapse
Affiliation(s)
- Hamed Shafaroodi
- Department of Pharmacology, Tehran Medical Unit, Islamic Azad University of Medical Sciences, Tehran, Iran
| | | | | |
Collapse
|
15
|
|
16
|
Prevalence of osteoporosis in community-dwelling individuals with intellectual and/or developmental disabilities. J Am Med Dir Assoc 2008; 9:109-13. [PMID: 18261703 DOI: 10.1016/j.jamda.2007.09.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Revised: 09/21/2007] [Accepted: 09/24/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Measure central bone mineral density (BMD) in community-dwelling individuals with intellectual and/or developmental disabilities. DESIGN A cross-sectional study. SETTING A regional center providing outpatient medical, residential, and day activity services for individuals with intellectual and/or developmental disabilities. PARTICIPANTS Documented BMD results were obtained for 298 community-dwelling individuals with intellectual and/or developmental disabilities. MEASUREMENTS BMD by central dual-energy x-ray absorptiometry (DXA) on the participant's spine, converted into T-scores categories using CDC guidelines (T < or = -2.5 [osteoporotic]; -2.5 > T < -1.0 [osteopenic]; > or = -1.0 [normal]). Comparisons were made using multiple regression to determine significant independent risk factors for low BMD. RESULTS Significant predictors were noted in the rates of osteoporosis attributable to subject age, race, and level of ambulation. No gender differences were noted for the rate of osteoporosis in this community sample of individuals with intellectual and/or developmental disabilities, nor were any differences noted for varying levels of mental retardation. Diagnostic differences were significant only for those individuals with a diagnosis of metabolic error, who had a significantly lower rate of osteoporosis than the rest of the study population. CONCLUSION This study's findings regarding age, race, and level of ambulation are consistent with those of previous studies using an intellectually and/or developmentally disabled population as well as the general population at large. Our finding that the rate of osteoporosis among disabled males is higher than for males in the general population suggests a possible case-finding deficit for asymptomatic males in the general population. It is also interesting that the only diagnostic category observed to be statistically different from the group in general was metabolic error, a finding that warrants further investigation.
Collapse
|
17
|
Masmoudi A, Hadj-Taieb I, Kammon T, Mseddi M, Boudaya S, Chaabouni M, Hachicha M, Turki H. Forme anictérique d’une cholestase intrahépatique familiale et progressive (syndrome de Byler). Ann Dermatol Venereol 2008; 135:228-30. [DOI: 10.1016/j.annder.2007.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Accepted: 07/12/2007] [Indexed: 10/22/2022]
|
18
|
Aydogdu S, Cakir M, Arikan C, Tumgor G, Yuksekkaya HA, Yilmaz F, Kilic M. Liver transplantation for progressive familial intrahepatic cholestasis: clinical and histopathological findings, outcome and impact on growth. Pediatr Transplant 2007; 11:634-40. [PMID: 17663686 DOI: 10.1111/j.1399-3046.2007.00722.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In this study, we analyze the demographic features, clinical and histopathological findings in patients who underwent liver transplantation for progressive familial intrahepatic cholestasis. We also analyze outcome and impact of liver transplantation on growth and bone mineral content. Most of the patients were presented with jaundice mainly beginning within the first six months. At the time of initial admission; eight patients had short stature (height SD score<2), and four patients had weight SD score<2. Liver transplantation were performed at the age of 43.2+/-27 months (range 9 to 96 months), 6.5+/-3.5 months later after the first admission. Infection, surgical complications and osmotic diarrhea associated with severe metabolic acidosis were noted in 41.4%, 16.6% and 33.3%, respectively. One patient developed posttransplant lymphoproliferative disorder. Overall; 1 year graft and patient survival was 69.2% and 75%, respectively. At the end of the 1st year only 2 patients had height SD score<2. Linear regression of height gain against increase in total body BMD measured at the time of transplantation and 1 year after liver transplantation gave a coefficient r=0.588 (p=0.074). No correlation was found between the height gain and age and PELD score at time of transplantation, and no difference was noted between the sexes and donor type. Liver transplantation is effective treatment modality with good outcome and little morbidity, and increases the growth acceleration in patients with PFIC associated with cirrhosis.
Collapse
Affiliation(s)
- Sema Aydogdu
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Ege University, Faculty of Medicine, Bornova, Izmir, Turkey
| | | | | | | | | | | | | |
Collapse
|
19
|
Pusl T, Beuers U. Extrahepatic manifestations of cholestatic liver diseases: pathogenesis and therapy. Clin Rev Allergy Immunol 2006. [PMID: 15879620 DOI: 10.1385/criai:] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pruritus, fatigue, and metabolic bone disease are frequent complications of cholestatic liver diseases, which can be quite distressing for the patient and can considerably reduce the quality of life. The molecular pathogenesis of these extrahepatic manifestations of cholestasis is poorly understood, and hypotheses to explain these symptoms are being discussed. This article provides treatment recommendations for the complications of cholestasis based on putative pathomechanisms and summarizes recent experimental and clinical data involving management options.
Collapse
Affiliation(s)
- Thomas Pusl
- Department of Medicine II, Klinikum of the University of Munich-Grosshadern, Munich, Germany
| | | |
Collapse
|
20
|
Pusl T, Beuers U. Extrahepatic manifestations of cholestatic liver diseases: pathogenesis and therapy. Clin Rev Allergy Immunol 2006; 28:147-57. [PMID: 15879620 DOI: 10.1385/criai:28:2:147] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pruritus, fatigue, and metabolic bone disease are frequent complications of cholestatic liver diseases, which can be quite distressing for the patient and can considerably reduce the quality of life. The molecular pathogenesis of these extrahepatic manifestations of cholestasis is poorly understood, and hypotheses to explain these symptoms are being discussed. This article provides treatment recommendations for the complications of cholestasis based on putative pathomechanisms and summarizes recent experimental and clinical data involving management options.
Collapse
Affiliation(s)
- Thomas Pusl
- Department of Medicine II, Klinikum of the University of Munich-Grosshadern, Munich, Germany
| | | |
Collapse
|
21
|
Dilger K, Denk A, Heeg MHJ, Beuers U. No relevant effect of ursodeoxycholic acid on cytochrome P450 3A metabolism in primary biliary cirrhosis. Hepatology 2005; 41:595-602. [PMID: 15726657 DOI: 10.1002/hep.20568] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Induction of cytochrome P450 3A (CYP3A) has been suggested as a mechanism of action of ursodeoxycholic acid (UDCA) in cholestasis. CYP3A is of key importance in human drug metabolism, being involved in presystemic extraction of more than 50% of all drugs currently available and of various endogenous compounds. Therefore, we compared the induction potential of UDCA with that of the prototypical inducer rifampicin in a human model study with the CYP3A substrates budesonide and cortisol. Twelve patients with early-stage primary biliary cirrhosis and eight healthy volunteers were treated with UDCA (15 mg/kg daily) for 3 weeks and subsequently with rifampicin (600 mg/d) for 1 week. Extensive pharmacokinetic profiling of oral budesonide (3 mg) was performed by determination of budesonide and phase I metabolites (6beta-hydroxybudesonide, 16alpha-hydroxyprednisolone) in plasma and urine at baseline and at the end of each treatment. In parallel, urinary 6beta-hydroxycortisol, a validated marker of CYP3A induction, was determined. UDCA did not affect biotransformation of budesonide and urinary excretion of 6beta-hydroxycortisol either in patients or in healthy volunteers. Ratios of areas under plasma concentration-time curves (AUC(0-12 h) during UDCA/AUC(0-12 h) before UDCA) of both metabolites were not higher than those of budesonide itself. In contrast, administration of rifampicin markedly induced CYP3A metabolism, resulting in abolished budesonide plasma levels and high urinary excretion of 6beta-hydroxycortisol. Metabolite formation was enhanced by rifampicin, but not by UDCA (e.g., AUC(16alpha-hydroxyprednisolone)/AUC(budesonide) in patients: baseline, 8.6 +/- 3.9; UDCA, 10.7 +/- 7.1; rifampicin, 527.0 +/- 248.7). In conclusion, UDCA is not a relevant inducer of CYP3A enzymes in humans.
Collapse
|
22
|
Mahé E, Lacaille F, Hadj-Rabia S, Bodemer C, De Prost Y, Hamel-Teillac D. [Hereditary cholestasis, an unusual etiology of pruritus in the infant]. Ann Dermatol Venereol 2005; 131:1092-4. [PMID: 15692445 DOI: 10.1016/s0151-9638(04)93847-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Pruritus in the infant is predominantly related to common dermatosis. General causes remain exceptional. We report two cases of pruritus in infants revealing anicteric cholestasis. OBSERVATIONS Case no 1. A thirteen month-old boy had exhibited pruritus since the age of 2 months. The clinical examination was non-specific. Biological explorations revealed an isolated and moderate rise in total bilary acids. The search for mutations in the genes of a familial fibrogenic cholestasis was negative. The diagnosis retained was hypercholanemia. Treatment combined ursodesoxycholic acid and rifampicine, which controlled the pruritus and normalized the bilary acid levels. Case no 2. A twenty-one month-old boy had exhibited pruritus since the age of 2 months and delayed growth. The clinical examination was unspecific. The biological explorations revealed cholestasis with normal delta GT, moderate cytolysis and liposoluble vitamin deficiency. The hepatic biopsy was normal. The diagnosis retained was familial fibrogenic cholestasis. Treatment combined ursodesoxycholic acid and rifampicine, which controlled the pruritus and normalized the hepatic parameters. DISCUSSION Non-dermatological isolated pruritus is rare in infants. These two observations illustrate two abnormalities in bilary acid transport. Hypercholanemia is a faulty canalization of bilary acids by the hepatocyte. Familial fibrogenic cholestasis is a default in the elimination of these bilary acids. Such pathologies must be evoked because specific treatment will treat the symptoms and avoid the evolution of familial fibrogenic cholestasis towards cirrhosis.
Collapse
Affiliation(s)
- E Mahé
- Service de Dermatologie, Groupe Hospitalier Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, 75015 Paris.
| | | | | | | | | | | |
Collapse
|
23
|
Chen HL, Chang MH. Growth failure and metabolic bone disease in progressive familial intrahepatic cholestasis. J Pediatr Gastroenterol Nutr 2004; 39:328-30. [PMID: 15448419 DOI: 10.1097/00005176-200410000-00005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
|
24
|
Bellmann R, Feistritzer C, Zoller H, Graziadei IW, Schwaighofer H, Propst A, Wiedermann CJ, Joannidis M. Treatment of Intractable Pruritus in Drug Induced Cholestasis with Albumin Dialysis: A Report of Two Cases. ASAIO J 2004; 50:387-91. [PMID: 15307554 DOI: 10.1097/01.mat.0000132552.58214.00] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cholestatic liver injury can be caused by a variety of drugs and is difficult to treat. We report two patients, a 22 year old male and a 55 year old female, with drug induced cholestasis caused by anabolic-androgenic steroids (silabolin and nandrolone) and by fluoxetine, respectively. Both patients presented with massive jaundice and severe pruritus resulting in sleep deprivation and suicide ideation. Laboratory examination revealed signs of cholestasis. Medical treatment was ineffective; therefore, extracorporeal albumin dialysis using the molecular adsorbent recirculating system (MARS) was started. Three treatments with a mean duration of 16 hours were performed in each patient. The procedure was well tolerated by the patients and resulted in a sustained relief of pruritus as well as in a decline of plasma bilirubin and serum 3alpha-hydroxy bile acid levels. The mean plasma bilirubin concentration decreased from 25.27 mg/dl to 10.7 mg/dl; the mean serum 3alpha-hydroxy bile acid concentration decreased from 299 micromol/L to 88 micromol/L. After 2 months, the pruritus had nearly vanished in both patients, and there was a further decline of bilirubin levels after discharge from hospital. In conclusion, extracorporeal albumin dialysis appears to be a therapeutic option in severe drug induced cholestasis refractory to medical treatment.
Collapse
Affiliation(s)
- Romuald Bellmann
- Division of General Internal Medicine, Department of Internal Medicine, University of Innsbruck, Anichstrasse, Innsbruck, Austria
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Bellmann R, Graziadei IW, Feistritzer C, Schwaighofer H, Stellaard F, Sturm E, Wiedermann CJ, Joannidis M. Treatment of refractory cholestatic pruritus after liver transplantation with albumin dialysis. Liver Transpl 2004; 10:107-14. [PMID: 14755786 DOI: 10.1002/lt.20001] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Albumin dialysis has been shown to improve the outcome in patients with cholestatic liver failure caused by chronic liver disease. This study reports 7 liver transplant recipients who were treated with albumin dialysis for intractable pruritus of different origin (ductopenic graft rejection, non-anastomotic strictures, and recurrence of hepatitis C). Treatment with histamine (H1) blockers, opioid antagonists, and cholestyramine had not been effective. The Molecular Adsorbent Recirculating System (MARS; Teraklin, Rostock, Germany) was used for albumin dialysis. All patients presented with numerous scratch marks, 6 of whom had a pronounced icterus. Six patients (86%) responded to 3 consecutive treatments with significant reduction of pruritus. The mean pruritus score, which was quantified by a visual analog scale (VAS), decreased from 9.7 +/- 0.5 to 3.7 +/- 0.8 (SD). The mean duration of 1 treatment was 15.6 hours. The procedure was well tolerated by all patients. The mean total serum bilirubin in patients who responded to therapy declined from 19.11 +/- 16.96 mg/dL (SD) before MARS therapy to 9.24 +/- 3.52 mg/dL after treatment. The mean serum concentration of 3 alpha-hydroxy bile acids decreased from 192.67 +/- 58.12 micromol/L (SD) to 42.33 +/- 31.58 micromol/L (SD). Follow-up in 3 cases showed sustained improvement of pruritus lasting for more than 3 months. In 3 patients, however, pruritus relapsed. One patient, who showed severe pruritus, without relevant elevation of serum bile acids before treatment, did not respond to albumin dialysis. Our data indicate that MARS is an effective therapeutic option for patients with intractable cholestatic pruritus.
Collapse
Affiliation(s)
- Romuald Bellmann
- Division of General Internal Medicine, Department of Internal Medicine, University of Innsbruck, Austria
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Hempfling W, Dilger K, Beuers U. Systematic review: ursodeoxycholic acid--adverse effects and drug interactions. Aliment Pharmacol Ther 2003; 18:963-72. [PMID: 14616161 DOI: 10.1046/j.1365-2036.2003.01792.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ursodeoxycholic acid is increasingly being used for the treatment of chronic cholestatic liver diseases. It appears to be generally well tolerated, but a systematic review on drug safety is lacking. AIM As experimental data suggest a role of bile acids in the regulation of hepatic drug metabolism at both the transcriptional and post-transcriptional level, the literature was screened for adverse drug reactions and drug interactions related to ursodeoxycholic acid. METHODS A systematic review of the literature was performed using a refined search strategy to evaluate the adverse effects of ursodeoxycholic acid and its interactions with other drugs. RESULTS Ursodeoxycholic acid caused diarrhoea in a small proportion of patients. Rare skin reactions were due to drug adjuvants rather than the active substance. Decompensation of liver cirrhosis was reported after the administration of ursodeoxycholic acid in single cases of end-stage primary biliary cirrhosis. Recurrent right upper quadrant abdominal pain was incidentally observed. The absorption of ursodeoxycholic acid was impaired by colestyramine, colestimide, colestipol, aluminium hydroxide and smectite. Metabolic drug interactions were reported for the cytochrome P4503A substrates, ciclosporin, nitrendipine and dapsone. CONCLUSIONS Ursodeoxycholic acid is generally well tolerated. Drug absorption interactions with anion exchange resins deserve consideration. Metabolic interactions with compounds metabolized by cytochrome P4503A are to be expected.
Collapse
Affiliation(s)
- W Hempfling
- Department of Medicine II, Klinikum Grosshadern, University of Munich, Munich, Germany
| | | | | |
Collapse
|
27
|
Affiliation(s)
- James Neuberger
- Liver Unit, Queen Elizabeth Hospital, 3rd Floor, Nuffield House, Edgbaston, Birmingham B15 2TH, UK.
| |
Collapse
|
28
|
Abstract
Further insights into the cellular and molecular mechanisms underlying hepatobiliary transport function and its regulation now permit a better understanding of the pathogenesis and treatment options of cholestatic liver diseases. Identification of the molecular basis of hereditary cholestatic syndromes will result in an improved diagnosis and management of these conditions. New insights into the pathogenesis of extrahepatic manifestations of cholestasis (eg, pruritus) have facilitated new treatment strategies. Important new studies have been published about the pathogenesis, clinical features, diagnosis, and treatment of primary biliary cirrhosis, primary sclerosing cholangitis, cholestasis of pregnancy, total parenteral nutrition-induced cholestasis, drug-induced cholestasis, and viral cholestatic syndromes.
Collapse
Affiliation(s)
- Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Karl-Franzens University, School of Medicine, Graz, Austria
| | | |
Collapse
|