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Merz M, Fettiplace A, Marcinak J, Tillmann HL, Rockey DC, Kullak-Ublick GA. Liver toxicity in oncology trials and beyond: a simplified concept for management of hepatocellular drug-induced liver injury in patients with abnormal baseline liver tests. Expert Opin Drug Saf 2024; 23:527-537. [PMID: 38482670 DOI: 10.1080/14740338.2024.2327509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/26/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Management of side effects in clinical trials has to balance generation of meaningful data with risk for patients. A toxicity area requiring detailed management guidelines is drug-induced liver injury (DILI). In oncology trials, patients are often included despite baseline liver test abnormalities, for whom there is no consensus yet on levels of liver test changes that should trigger action, such as drug interruption or discontinuation. METHODS We provide an innovative approach to manage hepatocellular DILI in oncology trials for patients with abnormal baseline alanine aminotransferase (ALT) levels. The algorithm proposed is based on mathematical derivation of action thresholds from those generally accepted for patients with normal baselines. RESULTS The resulting algorithm is grouped by level of baseline abnormality and avoids calculation of baseline multiples. Suggested layered action levels are 4, 6, and 11 × Upper Limit of Normal (ULN) for patients with baseline ALT between 1.5 and 3 × ULN, and 6, 8, and 12 × ULN for patients with baseline ALT between 3 and 5 × ULN, respectively. CONCLUSIONS Our concept and resulting algorithm are consistent, transparent, and easy to follow, and the method for derivation from consensus-based thresholds may also be applicable to other drug toxicity areas.
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Affiliation(s)
- Michael Merz
- Michael Merz Consulting, Freiburg, Germany
- Mechanistic Safety, Patient Safety and Pharmacovigilance, Global Drug Development, Novartis, Basel, Switzerland
| | | | - John Marcinak
- Medical Safety Evaluation, Pharmacovigilance and Patient Safety, AbbVie, North Chicago, IL, USA
| | - Hans L Tillmann
- Division Gastroenterology, Hepatology & Nutrition, Department of Medicine, East Carolina University, Greenville, NC, USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, SC, USA
| | - Gerd A Kullak-Ublick
- Mechanistic Safety, Patient Safety and Pharmacovigilance, Global Drug Development, Novartis, Basel, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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2
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Newsome PN, Sanyal AJ, Neff G, Schattenberg JM, Ratziu V, Ertle J, Link J, Mackie A, Schoelch C, Lawitz E. A randomised Phase IIa trial of amine oxidase copper-containing 3 (AOC3) inhibitor BI 1467335 in adults with non-alcoholic steatohepatitis. Nat Commun 2023; 14:7151. [PMID: 37932258 PMCID: PMC10628239 DOI: 10.1038/s41467-023-42398-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 10/10/2023] [Indexed: 11/08/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH) is a progressive, inflammatory liver disease with no approved pharmacological treatment. This Phase IIa, double-blind, placebo-controlled, multicentre trial (ClinicalTrials.gov: NCT03166735) investigated pharmacodynamics and safety of BI 1467335, an amine oxidase copper-containing 3 (AOC3) inhibitor, in adults with NASH from Europe and North America. Participants from 44 centres across the US, Germany, Spain, Belgium, the UK, Netherlands, Canada, France and Ireland were randomised (2:1:1:1:2; 27 July 2017 to 14 June 2019) to daily oral BI 1467335 1 mg (n = 16), 3 mg (n = 16), 6 mg (n = 17), 10 mg (n = 32) or placebo (n = 32) for 12 weeks, with follow-up to Week 16. Primary endpoint was AOC3 activity relative to baseline (%), 24 hours post-dose after 12 weeks' treatment. Secondary biomarker endpoints included changes from baseline at Week 12 in alanine aminotransferase (ALT) and caspase-cleaved cytokeratin 18 (CK-18 caspase). Mean AOC3 activities relative to baseline at Week 12: 90.4% (placebo; n = 32), 26.5% (1 mg; n = 16), 10.4% (3 mg; n = 16), 5.0% (6 mg; n = 16), 3.3% (10 mg; n = 32). These changes indicated that BI 1467335 dose-dependently inhibited AOC3 activity; ≥3 mg doses achieved >80% inhibition ( < 20% activity) at Week 4. At Week 12 following doses of BI 1467335 ≥ 3 mg, ALT and CK-18 caspase decreased dose-dependently. All tested BI 1467335 doses were well tolerated, with no clinically relevant treatment-emergent safety signals. BI 1467335 strongly inhibited AOC3 in participants with NASH, with doses ≥3 mg dose-dependently reducing the levels of liver injury biomarkers, ALT and CK-18. This trial was registered with ClinicalTrials.gov (NCT03166735) and the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT 2016-000499-83).
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Affiliation(s)
- Philip N Newsome
- National Institute for Health Research, Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- Centre for Liver & Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | | | - Guy Neff
- Covenant Research, Sarasota, FL, USA
| | | | - Vlad Ratziu
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Hospital Pitié-Salpêtrière, Paris, France
| | - Judith Ertle
- Boehringer Ingelheim, Ingelheim am Rhein, Germany
| | | | | | | | - Eric Lawitz
- Texas Liver Institute, University of Texas Health, San Antonio, TX, USA
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3
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Philips CA, Theruvath AH. Homeopathic formulations and liver injury: Authors' reply to national homoeopathy research institute in mental health. Hepatol Commun 2023; 7:02009842-202306010-00029. [PMID: 37267203 DOI: 10.1097/hc9.0000000000000176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/23/2023] [Indexed: 06/04/2023] Open
Affiliation(s)
- Cyriac A Philips
- Clinical and Translational Hepatology & Monarch Liver Laboratory, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Arif H Theruvath
- Department of Clinical Research, Division of Complementary and Alternative Medicine (Homoeopathy), Center for Excellence in Gastrointestinal Sciences, The Liver Institute, Rajagiri Hospital, Aluva, Kerala, India
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4
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Izawa T, Travlos GS, Cortes RA, Clayton NP, Sills RC, Pandiri AR. Absence of Increased Susceptibility to Acetaminophen-Induced Liver Injury in a Diet-Induced NAFLD Mouse Model. Toxicol Pathol 2023; 51:112-125. [PMID: 37158481 PMCID: PMC10523943 DOI: 10.1177/01926233231171101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a common chronic liver disease and its influence on drug-induced liver injury (DILI) is not fully understood. We investigated whether NAFLD can influence acetaminophen (APAP [N-acetyl-p-aminophenol])-induced hepatotoxicity in a diet-induced obese (DIO) mouse model of NAFLD. The male C57BL/6NTac DIO mice, fed a high-fat diet for more than 12 weeks, developed obesity, hyperinsulinemia, impaired glucose tolerance, and hepatomegaly with hepatic steatosis, similar to human NAFLD. In the acute toxicity study after a single dose of APAP (150 mg/kg), compared with control lean mice, the DIO mice had decreased serum transaminase levels and less severe hepatocellular injury. The DIO mice also had altered expression of genes related to APAP metabolism. Chronic APAP exposure for 26 weeks did not predispose the DIO mice with NAFLD to more severe hepatotoxicity compared with the lean mice. These results suggested that the C57BL/6NTac DIO mouse model appears to be more tolerant to APAP-induced hepatotoxicity than lean mice, potentially related to altered xenobiotic metabolizing capacity in the fatty liver. Further mechanistic studies with APAP and other drugs in NAFLD animal models are necessary to investigate the mechanism of altered susceptibility to intrinsic DILI in some human NAFLD patients.
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Affiliation(s)
- Takeshi Izawa
- Comparative and Molecular Pathogenesis Branch, Division of Translational Toxicology, NIEHS, Research Triangle Park, NC, USA
- Laboratory of Veterinary Pathology, Osaka Metropolitan University, Izumisano, Osaka, Japan
| | - Gregory S. Travlos
- Comparative and Molecular Pathogenesis Branch, Division of Translational Toxicology, NIEHS, Research Triangle Park, NC, USA
| | - Ricardo A. Cortes
- Comparative and Molecular Pathogenesis Branch, Division of Translational Toxicology, NIEHS, Research Triangle Park, NC, USA
- Experimental Pathology Laboratories, Inc., Research Triangle Park, NC, USA
| | - Natasha P. Clayton
- Comparative and Molecular Pathogenesis Branch, Division of Translational Toxicology, NIEHS, Research Triangle Park, NC, USA
| | - Robert C. Sills
- Comparative and Molecular Pathogenesis Branch, Division of Translational Toxicology, NIEHS, Research Triangle Park, NC, USA
| | - Arun R. Pandiri
- Comparative and Molecular Pathogenesis Branch, Division of Translational Toxicology, NIEHS, Research Triangle Park, NC, USA
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5
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Lewis JH, Khaldoyanidi SK, Britten CD, Wei AH, Subklewe M. Clinical Significance of Transient Asymptomatic Elevations in Aminotransferase (TAEAT) in Oncology. Am J Clin Oncol 2022; 45:352-365. [PMID: 35848749 PMCID: PMC9311471 DOI: 10.1097/coc.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Monitoring for liver injury remains an important aspect of drug safety assessment, including for oncotherapeutics. When present, drug-induced liver injury may limit the use or result in the discontinuation of these agents. Drug-induced liver injury can exhibit with a wide spectrum of clinical and biochemical manifestations, ranging from transient asymptomatic elevations in aminotransferases (TAEAT) to acute liver failure. Numerous oncotherapeutics have been associated with TAEAT, with published reports indicating a phenomenon in which patients may be asymptomatic without overt liver injury despite the presence of grade ≥3 aminotransferase elevations. In this review, we discuss the occurrence of TAEAT in the context of oncology clinical trials and clinical practice, as well as the clinical relevance of this phenomenon as an adverse event in response to oncotherapeutics and the related cellular and molecular mechanisms that may underlie its occurrence. We also identify several gaps in knowledge relevant to the diagnosis and the management of TAEAT in patients receiving oncotherapeutics, and identify areas warranting further study to enable the future development of consensus guidelines to support clinical decision-making.
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Affiliation(s)
| | | | | | - Andrew H. Wei
- The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Marion Subklewe
- University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
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6
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Shneider BL, Spino CA, Kamath BM, Magee JC, Ignacio RV, Huang S, Horslen SP, Molleston JP, Miethke AG, Kohli R, Leung DH, Jensen MK, Loomes KM, Karpen SJ, Mack C, Rosenthal P, Squires RH, Baker A, Rajwal S, Kelly D, Sokol RJ, Thompson RJ. Impact of long-term administration of maralixibat on children with cholestasis secondary to Alagille syndrome. Hepatol Commun 2022; 6:1922-1933. [PMID: 35672955 PMCID: PMC9315125 DOI: 10.1002/hep4.1992] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/03/2022] [Indexed: 11/10/2022] Open
Abstract
There is growing interest in, but limited data about, intestinal bile acid transport inhibitors as treatment for cholestatic liver disease. The current analyses combine two similar randomized placebo-controlled trials with subsequent extension phases investigating the impact of maralixibat in children with severe cholestasis secondary to Alagille Syndrome (n = 57). The primary outcomes were measures of pruritus (ItchRO[Obs]) and clinician scratch scale (CSS), both increasing in severity from 0 to 4) and quality of life (QoL) (Parent PedsQL and Multidimensional Fatigue Scale module [MFS] scaled 0-100 with increased QoL) at week 48 of the extension phase relative to the baseline of the placebo-controlled trials (week 13). Secondary assessments included other clinical and biochemical parameters assessed in participants at week 72 or end of treatment (after week 48). At week 48, statistically and clinically significant least square mean (95% CI) improvements in pruritus and QoL were observed (ItchRO[Obs] -1.59 [-1.81, -1.36], CSS -1.36 [-1.67, -1.05], PedsQL +10.17 [4.48, 15.86], and multidimension fatigue [MFS] +13.97 [7.85, 20.08]). At week 48, serum bile acids, platelet count, and cholesterol decreased, whereas alanine aminotransferase (ALT) increased and total bilirubin (TB) and albumin were stable. Changes were durable at week 72 and end of treatment. There were no deaths; 2 participants underwent liver transplantation. Study drug was discontinued in 9 participants after treatment-emergent adverse events, 6 of which were events of increased ALT or TB. Conclusion: Maralixibat administration was associated with marked improvement in pruritus and QoL. Interpretation of these findings is complicated by the complex natural history of severe cholestasis in Alagille syndrome.
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Affiliation(s)
- Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsBaylor College of Medicine and Texas Children's HospitalHoustonTexasUSA
| | | | | | | | | | | | - Simon P Horslen
- Department of PediatricsSeattle Children's HospitalUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsRiley Hospital for ChildrenIndiana UniversityIndianapolisIndianaUSA
| | - Alexander G Miethke
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of CincinnatiCincinnatiOhioUSA
| | - Rohit Kohli
- Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA.,Liver Transplant ProgramChildren's Hospital-Los AngelesLos AngelesCaliforniaUSA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsBaylor College of Medicine and Texas Children's HospitalHoustonTexasUSA
| | - M Kyle Jensen
- Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology, and NutritionThe Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Saul J Karpen
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsChildren's Healthcare of Atlanta and Emory University School of MedicineAtlantaGeorgiaUSA
| | - Cara Mack
- Department of Pediatrics-Gastroenterology, Hepatology, and NutritionUniversity of Colorado School of Medicine and Children's Hospital ColoradoAuroraColoradoUSA
| | - Philip Rosenthal
- Department of PediatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Robert H Squires
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of Pittsburgh, School of Medicine and Children's Hospital of Pittsburgh of University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Alastair Baker
- Department of Child HealthThe Pediatric Liver CenterKing's College HospitalLondonUK
| | | | - Deirdre Kelly
- Liver UnitBirmingham Women's & Children's HospitalBirminghamUK
| | - Ronald J Sokol
- Department of PediatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Richard J Thompson
- Department of Child HealthThe Pediatric Liver CenterKing's College HospitalLondonUK
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7
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Szpakowski JL, Tucker LY, Baer DM, Pauly MP. Hepatotoxicity during legacy cancer chemotherapy in patients infected with hepatitis C virus: A retrospective cohort study. CANADIAN LIVER JOURNAL 2022; 5:43-60. [PMID: 35990784 PMCID: PMC9231429 DOI: 10.3138/canlivj-2021-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 11/04/2023]
Abstract
BACKGROUND The rates and causes of significant hepatotoxicity with cancer chemotherapy (CCT) in patients infected with hepatitis C virus (HCV) are incompletely characterized. METHODS We compared rates of grade 3 or 4 hepatotoxicity, defined as elevated transaminases, during CCT in patients who are mono-infected with HCV compared with rates in controls matched on demographics, diagnosis, and rituximab use. We excluded patients with hepatobiliary cancers, hepatitis B virus or human immunodeficiency virus infection. Hepatotoxicity was attributed to a medical cause, cancer progression, or CCT, including HCV flare. RESULTS Patients with HCV (n = 196) had a higher rate of cirrhosis than the 1,130 matched controls (21.9% versus 4%; P <0.001). Their higher rate of overall hepatotoxicity (8.7% versus 4.5% of controls, P = 0.01) was due to higher rate of CCT-related hepatotoxicity (4.1% versus 1.2%, P = 0.01). On multivariable analysis, the largest risk factor for overall hepatotoxicity was cirrhosis, and the only risk factor for CCT-related hepatotoxicity was HCV infection. Among those with HCV, the only significant risk factor for hepatotoxicity was rituximab use. Hepatotoxicity caused by CCT delayed or altered treatment in only 3 HCV patients and 1 control (1.5% versus 0.1%, P = 0.01). CONCLUSIONS Most patients with HCV can safely be treated with cancer chemotherapy. Cirrhosis and HCV infection contributed to increased hepatotoxicity in subjects on CCT. Among HCV patients, rituximab use was the major risk factor for increased hepatotoxicity. Hepatotoxicity due to CCT itself rarely altered or delayed CCT. Nonetheless, HCV-positive patients should be monitored carefully during CCT.
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Affiliation(s)
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - David M Baer
- Kaiser Permanente Medical Center, Oakland, California, USA
| | - Mary Pat Pauly
- Kaiser Permanente Medical Center, Sacramento, California, USA
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8
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Ghabril M, Ma J, Patidar KR, Nephew L, Desai AP, Orman ES, Vuppalanchi R, Kubal S, Chalasani N. Eight-Fold Increase in Dietary Supplement-Related Liver Failure Leading to Transplant Waitlisting Over the Last Quarter Century in the United States. Liver Transpl 2022; 28:169-179. [PMID: 34331346 DOI: 10.1002/lt.26246] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/01/2021] [Accepted: 07/20/2021] [Indexed: 01/13/2023]
Abstract
We investigated the trends in listing and outcomes of drug-induced acute liver failure (DIALF) over the last quarter century in the United States using the United Network for Organ Sharing (UNOS) database. We examined waitlisted patients in the UNOS database between 1995 and 2020 with a diagnosis of DIALF and assessed trends in etiologies, demographic and clinical characteristics, and outcomes over 3 periods: 1995-2003, 2004-2012, and 2013-2020. Patients with DIALF and cirrhosis were classified as drug-induced acute-on-chronic liver failure. Implicated agents including acetaminophen (APAP) and herbal or dietary supplements (HDSs) were ascertained. There were 2146 individuals with DIALF during the study period. The observed demographic trends between the earliest and latest period included fewer pediatric patients (18.8% to 13.5%) but with an increasing number of males in non-APAP DIALF (31.8% to 41.4%) and increased racial diversity in APAP DIALF. Antimicrobials remained the most common non-APAP agents across all periods, but antiepileptics, propylthiouracil, and mushroom poisoning decreased, while HDSs markedly increased from 2.9% to 24.1% of all non-APAP DIALF patients. The overall 5-year post-liver transplantation (LT) patient survival improved significantly over the 3 periods (69.9% to 77.4% to 83.3%) and was evident for both APAP and non-APAP DIALF. Over the last quarter century, there has been an 8-fold increase in HDS-related liver failure necessitating waitlisting for liver transplantation in the United States. There are other important temporal trends during the study period, including improved survival following LT among both APAP and non-APAP DIALF patients.
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Affiliation(s)
- Marwan Ghabril
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Jiayi Ma
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Kavish R Patidar
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Lauren Nephew
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Archita P Desai
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Eric S Orman
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Raj Vuppalanchi
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Shekhar Kubal
- Department of Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Naga Chalasani
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
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9
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da Silva JA, Falcão D, Cardoso C, Pires AL, Araújo A, Castro-Poças F. Hepatic immune-mediatedadverseeffects of immune checkpoint inhibitors: analysis of real-life experience. Ann Hepatol 2021; 26:100561. [PMID: 34653687 DOI: 10.1016/j.aohep.2021.100561] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/12/2021] [Accepted: 04/30/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Immune Checkpoint Inhibitors (ICI) have shifted the paradigm of cancer therapy treatment. Despite their efficacy, ICIs may induce immune-related adverse events (irAE), which can affect various organs, namely the liver. This study intends to perform a comprehensive clinical description of the hepatic irAEs associated with ICI in a Portuguese population of a tertiary hospital centre. MATERIALS AND METHODS A retrospective analysis of patients who developed immune-mediated liver injury (IMLI), among a cohort of patients treated with ICIs between March 15th of 2015 and December 15th of 2019 in a tertiary hospital. We used both Common Terminology Criteria for Adverse Events (CTCAE) and Drug-Induced Liver Injury Network (DILIN) criteria to define liver injury. RESULTS Among 151 patients, eight (5.3%) patients developed liver injury grade ≥3, of which five had hepatic metastasis. As such, only 3 cases were classified as IMLI. All IMLI presented with cholestasis pattern; the median duration from ICI initiation to IMLI was 84 days and/or 4 ICI cycles; one patient registered IMLI one month after nivolumab suspension; all were treated with steroids and one was successfully submitted to ICI re-challenge; a favourable outcome was seen in all patients; the median time to hepatic biochemistries normalization was 150 days. Among 10 patients with previous hepatic conditions, only one developed liver injury grade 2. CONCLUSIONS Clinically significant ICI-related hepatotoxicity was uncommon; Immune-mediated liver injury may present a cholestatic pattern predominance. There was a low rate of liver injury of any kind in patients with previous hepatic disease while on ICI.
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Affiliation(s)
| | - Daniela Falcão
- Gastroenterology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Cláudia Cardoso
- Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal
| | - Ana Luísa Pires
- Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal
| | - António Araújo
- Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal; Oncology Service, Pathology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Fernando Castro-Poças
- Gastroenterology, Centro Hospitalar Universitário do Porto, Porto, Portugal; Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal
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10
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Wu Y, Xiao W, Tong W, Borlak J, Chen M. A systematic comparison of hepatobiliary adverse drug reactions in FDA and EMA drug labeling reveals discrepancies. Drug Discov Today 2021; 27:337-346. [PMID: 34607018 DOI: 10.1016/j.drudis.2021.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/20/2021] [Accepted: 09/20/2021] [Indexed: 01/23/2023]
Abstract
Drug labeling informs physicians and patients on the safe and effective use of medication. However, recent studies suggested discrepancies in labeling of the same drug between different regulatory agencies. Here, we evaluated the hepatic safety information in labeling for 549 medications approved by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA). Limited discrepancies were found regarding risk for hepatic adverse drug reactions (ADRs) (8.7% in hepatic ADR warnings and 21.3% in contraindication for liver disease), while caution should be exercised over drugs with inconsistencies in contraindications for liver disease and evidence for hepatotoxicity (4.9%). Most discrepancies were attributable to less-severe hepatic events and low-frequency hepatic ADR reports and had limited implication on clinical outcomes.
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Affiliation(s)
- Yue Wu
- Division of Bioinformatics and Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, AR, USA
| | - Wenzhong Xiao
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA
| | - Weida Tong
- Division of Bioinformatics and Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, AR, USA
| | - Jürgen Borlak
- Center of Pharmacology and Toxicology, Hannover Medical School, 30625 Hannover, Germany.
| | - Minjun Chen
- Division of Bioinformatics and Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, AR, USA.
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11
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Suh Y, Ah YM, Chun HJ, Lee SM, Kim HS, Gu HJ, Kim AJ, Chung JE, Cho Y, Lee YH, Hwangbo SY, Kim J, Kim ES, Kim HB, Lee E, Lee JY. Potential Impact of the Involvement of Clinical Pharmacists in Antimicrobial Stewardship Programs on the Incidence of Antimicrobial-Related Adverse Events in Hospitalized Patients: A Multicenter Retrospective Study. Antibiotics (Basel) 2021; 10:853. [PMID: 34356774 PMCID: PMC8300750 DOI: 10.3390/antibiotics10070853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/23/2021] [Accepted: 07/09/2021] [Indexed: 01/14/2023] Open
Abstract
Although specialized pharmacists have been suggested to be essential members of antimicrobial stewardship programs (ASPs), not all hospitals in Korea operate ASPs with pharmacists involved. We aimed to evaluate the association of involvement of clinical pharmacists as team members of multidisciplinary ASPs with the incidence of antimicrobial-related adverse drug events (ADEs). Five tertiary teaching hospitals participated in this retrospective cohort study. At each participating hospital, we randomly selected 1000 participants among patients who had received systemic antimicrobial agents for more than one day during the first quarter of 2017. We investigated five categories of antimicrobial-related ADEs: allergic reactions, hematologic toxicity, nephrotoxicity, hepatotoxicity, and antimicrobial-related diarrhea. Multivariate logistic regression analysis was used to evaluate the potential impact of pharmacist involvement in ASPs on the incidence of ADEs. A total of 1195 antimicrobial-related ADEs occurred in 618 (12.4%) of the 4995 patients included in the analysis. The overall rate of ADE occurrence was 17.4 per 1000 patient days. Hospitals operating ASPs with pharmacists showed significantly lower AE incidence proportions than other hospitals (8.9% vs. 14.7%; p < 0.001). Multidisciplinary ASPs that included clinical pharmacists reduced the risk of antimicrobial-related ADEs by 38% (adjusted odds ratio 0.62; 95% confidence interval 0.50-0.77). Our results suggest that the active involvement of clinical pharmacists in multidisciplinary ASPs may contribute to reduce the incidence of antimicrobial-related ADEs in hospitalized patients.
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Affiliation(s)
- Yewon Suh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Korea;
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (H.-s.K.); (E.L.)
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsan 38541, Korea;
| | - Ha-Jin Chun
- Department of Pharmacy, Ajou University Medical Center, Suwon 16499, Korea; (H.-J.C.); (Y.-H.L.)
| | - Su-Mi Lee
- Department of Pharmacy, Samsung Medical Center, Seoul 06351, Korea; (S.-M.L.); (J.K.)
| | - Hyung-sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (H.-s.K.); (E.L.)
| | - Hyun-Jun Gu
- Department of Pharmacy, The Catholic University of Korea Seoul ST. Mary’s Hospital, Seoul 06591, Korea; (H.-J.G.); (S.-Y.H.)
| | - A-Jeong Kim
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea; (A.-J.K.); (Y.C.)
| | - Jee-Eun Chung
- College of Pharmacy and Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan 15588, Korea;
| | - Yoonsook Cho
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea; (A.-J.K.); (Y.C.)
| | - Young-Hee Lee
- Department of Pharmacy, Ajou University Medical Center, Suwon 16499, Korea; (H.-J.C.); (Y.-H.L.)
| | - Shin-Yi Hwangbo
- Department of Pharmacy, The Catholic University of Korea Seoul ST. Mary’s Hospital, Seoul 06591, Korea; (H.-J.G.); (S.-Y.H.)
| | - Jeongmee Kim
- Department of Pharmacy, Samsung Medical Center, Seoul 06351, Korea; (S.-M.L.); (J.K.)
| | - Eu-Suk Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (E.-S.K.); (H.-B.K.)
| | - Hong-Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (E.-S.K.); (H.-B.K.)
| | - Eunsook Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (H.-s.K.); (E.L.)
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Korea;
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (H.-s.K.); (E.L.)
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12
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SACRED: Effect of simvastatin on hepatic decompensation and death in subjects with high-risk compensated cirrhosis: Statins and Cirrhosis: Reducing Events of Decompensation. Contemp Clin Trials 2021; 104:106367. [PMID: 33771685 PMCID: PMC8422958 DOI: 10.1016/j.cct.2021.106367] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/21/2021] [Accepted: 03/20/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS The development of decompensation in cirrhosis demarcates a marked change in the natural history of chronic liver disease. HMG-CoA reductase inhibitors (statins) exert pleiotropic effects that reduce inflammation and fibrosis as well as improve vascular reactivity. Retrospective studies uniformly have associated statin utilization with improved outcomes for patients with cirrhosis. Prospective human studies have shown that statins reduce portal hypertension and reduce death in patients with decompensated cirrhosis after variceal hemorrhage when added to standard therapy with an acceptable safety profile. This proposal aims to extend these findings to demonstrate that simvastatin reduces incident hepatic decompensation events among cirrhotic patients at high risk for hepatic decompensation. METHODS We will perform the SACRED Trial (NCT03654053), a phase III, prospective, multi-center, double-blind, randomized clinical trial at 11 VA Medical Centers. Patients with compensated cirrhosis with clinically significant portal hypertension will be stratified based upon the concomitant use of nonselective beta-blockers and randomized to simvastatin 40 mg/day versus placebo for up to 24 months. Patients will be observed for the development of hepatic decompensation (variceal hemorrhage, ascites, encephalopathy), hepatocellular carcinoma, liver-related death, death from any cause, and/or complications of statin therapy. Ancillary studies will evaluate patient-reported outcomes and pharmacogenetic corollaries of safety and/or efficacy. CONCLUSION Statins have a long track-record of safety and tolerability. This class of medications is generic and inexpensive, and thus, if the hypothesis is proven, there will be few barriers to widespread acceptance of the role of statins to prevent decompensation in patients with compensated cirrhosis. ClinicalTrials.gov Identifier: NCT03654053.
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13
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Treem WR, Palmer M, Lonjon-Domanec I, Seekins D, Dimick-Santos L, Avigan MI, Marcinak JF, Dash A, Regev A, Maller E, Patwardhan M, Lewis JH, Rockey DC, Di Bisceglie AM, Freston JW, Andrade RJ, Chalasani N. Consensus Guidelines: Best Practices for Detection, Assessment and Management of Suspected Acute Drug-Induced Liver Injury During Clinical Trials in Adults with Chronic Viral Hepatitis and Adults with Cirrhosis Secondary to Hepatitis B, C and Nonalcoholic Steatohepatitis. Drug Saf 2021; 44:133-165. [PMID: 33141341 PMCID: PMC7847464 DOI: 10.1007/s40264-020-01014-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 02/07/2023]
Abstract
With the widespread development of new drugs to treat chronic liver diseases (CLDs), including viral hepatitis and nonalcoholic steatohepatitis (NASH), more patients are entering trials with abnormal baseline liver tests and with advanced liver injury, including cirrhosis. The current regulatory guidelines addressing the monitoring, diagnosis, and management of suspected drug-induced liver injury (DILI) during clinical trials primarily address individuals entering with normal baseline liver tests. Using the same laboratory criteria cited as signals of potential DILI in studies involving patients with no underlying liver disease and normal baseline liver tests may result in premature and unnecessary cessation of a study drug in a clinical trial population whose abnormal and fluctuating liver tests are actually due to their underlying CLD. This position paper focuses on defining best practices for the detection, monitoring, diagnosis, and management of suspected acute DILI during clinical trials in patients with CLD, including hepatitis C virus (HCV) and hepatitis B virus (HBV), both with and without cirrhosis and NASH with cirrhosis. This is one of several position papers developed by the IQ DILI Initiative, comprising members from 16 pharmaceutical companies in collaboration with DILI experts from academia and regulatory agencies. It is based on an extensive literature review and discussions between industry members and experts from outside industry to achieve consensus regarding the recommendations. Key conclusions and recommendations include (1) the importance of establishing laboratory criteria that signal potential DILI events and that fit the disease indication being studied in the clinical trial based on knowledge of the natural history of test fluctuations in that disease; (2) establishing a pretreatment value that is based on more than one screening determination, and revising that baseline during the trial if a new nadir is achieved during treatment; (3) basing rules for increased monitoring and for stopping drug for potential DILI on multiples of baseline liver test values and/or a threshold value rather than multiples of the upper limit of normal (ULN) for that test; (4) making use of more sensitive tests of liver function, including direct bilirubin (DB) or combined parameters such as aspartate transaminase:alanine transaminase (AST:ALT) ratio or model for end-stage liver disease (MELD) to signal potential DILI, especially in studies of patients with cirrhosis; and (5) being aware of potential confounders related to complications of the disease being studied that may masquerade as DILI events.
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Affiliation(s)
| | - Melissa Palmer
- Takeda, Cambridge, MA, USA
- Liver Consulting LLC, New York, NY, USA
| | | | | | | | - Mark I Avigan
- US Food and Drug Administration, Silver Spring, MD, USA
| | | | - Ajit Dash
- , Genentech, South San Francisco, CA, USA
| | - Arie Regev
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Eric Maller
- Pfizer, Collegeville, PA, USA
- MEMS Biopharma Consulting, LLC, Wynnewood, PA, USA
| | | | | | - Don C Rockey
- Medical University of South Carolina, Charleston, SC, USA
| | | | - James W Freston
- University of Connecticut Health Center, Farmington, CT, USA
| | - Raul J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Universidad de Málaga, Málaga, Spain
| | - Naga Chalasani
- Indiana University School of Medicine, Indianapolis, IN, USA.
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14
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Spontaneous Fluctuations in Liver Biochemistries in Patients with Compensated NASH Cirrhosis: Implications for Drug Hepatotoxicity Monitoring. Drug Saf 2020; 43:281-290. [PMID: 31907854 DOI: 10.1007/s40264-019-00896-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Patients with cirrhosis may have spontaneous fluctuations in liver enzymes, which may confound detection of drug-induced liver injury (DILI), but these fluctuations have not been described. OBJECTIVE We sought to quantify spontaneous liver enzyme abnormalities in patients with cirrhosis due to nonalcoholic steatohepatitis (NASH) enrolled in clinical trials. METHODS We examined the laboratory values of patients with compensated cirrhosis randomized to placebo in two clinical trials for NASH. Patients in one study were followed every 13 weeks up to week 57; patients in the other study were followed every 4 weeks up to week 120. RESULTS In total, 53 and 85 patients were randomized to placebo in the trials. Baseline alanine aminotransferase (ALT) was greater than the laboratory upper limit of normal (ULN) in 53% and 49% of participants, aspartate aminotransferase (AST) was > ULN in 49% and 59%, alkaline phosphatase was > ULN in 36% and 27%, and bilirubin was >ULN in 13% and 19%. During follow-up, ALT increased to 2× baseline in 8% and 15%, AST increased to 2× baseline in 6% and 21%, and bilirubin increased to 2× baseline in 9% and 18%. Alkaline phosphatase did not increase to 2× baseline for any patient. The maximum ALT was 3× ULN in 9% and 12%. ALT increased to 3× baseline in three patients and to 5× ULN in two patients. No patients had elevations consistent with Hy's law. The maximum ALT for patients with abnormal baseline values was higher [median 48 U/L (range 34-299) and 56 U/L (47-85)] than for those with normal baseline values [median 26.5 U/L (range 18-33) and 29 U/L (25.5-30.5)] in both studies, respectively, with p < 0.001. CONCLUSION Spontaneous liver enzyme abnormalities are common in patients with NASH cirrhosis in clinical trials, and these abnormalities rarely met criteria for DILI suspicion. Further work to better define these abnormalities and continued vigilance to detect DILI in this population is needed.
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15
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Regev A, Avigan MI, Kiazand A, Vierling JM, Lewis JH, Omokaro SO, Di Bisceglie AM, Fontana RJ, Bonkovsky HL, Freston JW, Uetrecht JP, Miller ED, Pehlivanov ND, Haque SA, Harrison MJ, Kullak-Ublick GA, Li H, Patel NN, Patwardhan M, Price KD, Watkins PB, Chalasani NP. Best practices for detection, assessment and management of suspected immune-mediated liver injury caused by immune checkpoint inhibitors during drug development. J Autoimmun 2020; 114:102514. [DOI: 10.1016/j.jaut.2020.102514] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
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16
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Worland T, Chin KL, Rodrigues B, Nicoll A. A retrospective case-controlled cohort study of inpatient drug induced liver injury: the RIDDLE study. Transl Gastroenterol Hepatol 2020; 5:33. [PMID: 32632384 DOI: 10.21037/tgh.2019.10.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/23/2019] [Indexed: 12/22/2022] Open
Abstract
Background Identification of risk factors for drug-induced liver injury (DILI) has been hindered by the unpredictable incidence and idiosyncratic nature of DILI. The aim of this study was to identify characteristic host risk factors for DILI. Methods A retrospective cohort study was performed examining all patients admitted with a diagnosis of DILI over a 5.5-year period. Cases were compared to a control group non-exposed to DILI using propensity score-derived inverse probability weights. Patients with DILI due to alcohol or paracetamol were excluded from analysis. Results Seventy-two cases of DILI admitted to hospital were identified. Antimicrobials caused 56.9% of cases, with amoxicillin-clavulanate the single most common agent, responsible for 13.9% of cases. DILI cohort median age (50.2±36 years) was significantly younger than controls (65.0±38 years) (P<0.001). Pre-existing chronic liver disease (OR, 3.44; 95% CI, 1.38-8.59; P=0.008), length of stay (P<0.001) and in-hospital death (P=0.009) were more likely to be associated with DILI cases. There was no correlation with sex (OR male, 0.92; 95% CI, 0.50-1.67; P=0.78), presence of comorbid autoimmune disease (OR, 1.44; 95% CI, 0.68-3.05; P=0.35), past drug allergies (OR, 1.71; 95% CI, 0.92-3.16; P=0.09), or atopy (OR, 0.87; 95% CI, 0.42-1.82; P=0.72). Conclusions Younger age and presence of chronic liver disease were associated with an admission with DILI; however, it remains difficult to predict the population at risk of DILI on clinical grounds and putative risk factors such as female gender, and history of other drug allergies and autoimmunity, were not demonstrated in this study.
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Affiliation(s)
- Thomas Worland
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia
| | - Ken Lee Chin
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Beverley Rodrigues
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia
| | - Amanda Nicoll
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia.,Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
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17
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Xiang C, Cao M, Miao A, Gao F, Li X, Pan G, Zhang W, Zhang Y, Yu P, Teng Y. Antioxidant activities of anastatin A & B derivatives and compound 38c's protective effect in a mouse model of CCl 4-induced acute liver injury. RSC Adv 2020; 10:14337-14346. [PMID: 35498475 PMCID: PMC9051925 DOI: 10.1039/d0ra00822b] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/26/2020] [Indexed: 12/15/2022] Open
Abstract
Anastatins A and B, two flavonoid compounds isolated from desert plant Anastatica hierochuntica, have protective activities for primary rat hepatocytes. Anastatins A and B, and their derivatives, were synthesized by our group previously. In this study, the antioxidant activity and cytotoxicity of these compounds were studied using chemical assessment methods, cell proliferation inhibition experiments, and cell oxidative damage models. The best compound, 38c, was used to study the hepatoprotection activity and mechanism by using a CCl4-induced liver injury model in mice. The results show that most of these flavonoid compounds have good antioxidant activity and low cytotoxicity in vitro. Among them, the most potent compound was 38c, which exhibited a protective effect on CCl4-induced hepatic injury by suppressing the amount of CYP2E1. These findings indicate that anastatin flavonoid derivatives have potential therapeutic utility against oxidative hepatic injury.
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Affiliation(s)
- Cen Xiang
- China International Science and Technology Cooperation Base of Food Nutrition/Safety and Medicinal Chemistry, Tianjin University of Science and Technology Tianjin 300457 China
| | - Menglin Cao
- China International Science and Technology Cooperation Base of Food Nutrition/Safety and Medicinal Chemistry, Tianjin University of Science and Technology Tianjin 300457 China
| | - Ai Miao
- China International Science and Technology Cooperation Base of Food Nutrition/Safety and Medicinal Chemistry, Tianjin University of Science and Technology Tianjin 300457 China
| | - Feng Gao
- China International Science and Technology Cooperation Base of Food Nutrition/Safety and Medicinal Chemistry, Tianjin University of Science and Technology Tianjin 300457 China
| | - Xuzhe Li
- China International Science and Technology Cooperation Base of Food Nutrition/Safety and Medicinal Chemistry, Tianjin University of Science and Technology Tianjin 300457 China
| | - Guojun Pan
- School of Life Sciences, Shandong First Medical University, Shandong Academy of Medical Sciences Changcheng Road 619 Tai'an City 271000 Shandong province China
| | - Wenqiang Zhang
- China International Science and Technology Cooperation Base of Food Nutrition/Safety and Medicinal Chemistry, Tianjin University of Science and Technology Tianjin 300457 China
| | - Yongmin Zhang
- China International Science and Technology Cooperation Base of Food Nutrition/Safety and Medicinal Chemistry, Tianjin University of Science and Technology Tianjin 300457 China
- Sorbonne Université, Institut Parisien de Chimie Moléculaire, UMR8232 CNRS 4 Place Jussieu 75005 Paris France
| | - Peng Yu
- China International Science and Technology Cooperation Base of Food Nutrition/Safety and Medicinal Chemistry, Tianjin University of Science and Technology Tianjin 300457 China
| | - Yuou Teng
- China International Science and Technology Cooperation Base of Food Nutrition/Safety and Medicinal Chemistry, Tianjin University of Science and Technology Tianjin 300457 China
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18
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Worland T, Chin KL, van Langenberg D, Garg M, Nicoll A. Retrospective study of idiosyncratic drug-induced liver injury from infliximab in an inflammatory bowel disease cohort: the IDLE study. Ann Gastroenterol 2020; 33:162-169. [PMID: 32127737 PMCID: PMC7049241 DOI: 10.20524/aog.2020.0453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 11/24/2019] [Indexed: 12/12/2022] Open
Abstract
Background Infliximab therapy may be associated with drug-induced liver injury (DILI), often resembling a drug-induced autoimmune hepatitis. However, the prevalence of DILI in patients receiving infliximab is unclear. Abnormal liver biochemistry is common in patients with inflammatory bowel disease (IBD) and definitive diagnosis may be difficult. The aim of this study was to describe the patterns of abnormal liver biochemistry in an IBD cohort. Methods In a retrospective cohort study of adult patients with IBD treated with infliximab through a single institution we used the Roussel Uclaf Causality Assessment Method (RUCAM) to evaluate liver biochemistry and possible DILI. All cases of abnormal liver biochemistry were ascribed a presumptive diagnosis from the electronic medical record. Results Fifty-seven of the 175 patients (149 Crohn's disease, 26 ulcerative colitis) had abnormal liver biochemistry. Of the 57 cases, one had highly probable, and 10 possible DILI due to infliximab. There were no significant differences regarding demographics, concomitant therapy/disease, indication for infliximab or outcomes between patients with normal and abnormal liver biochemistry, except for higher baseline alanine transaminase and alkaline phosphatase in the abnormal biochemistry group (P<0.001). Multivariate logistic regression showed male sex (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.22-5.09; P=0.01) and background liver disease (OR 15.09, 95%CI 4.09-55.69; P<0.001) to be associated with the abnormal liver biochemistry group. Conclusions Abnormal liver biochemistry is common in IBD patients on infliximab. Patients who are male, or have abnormal pre-therapy liver biochemistry or background liver disease, are more likely to develop worsening liver biochemistry during infliximab therapy. RUCAM scoring may help identify true cases of DILI.
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Affiliation(s)
- Thomas Worland
- Department of Gastroenterology, Eastern Health (Thomas Worland, Daniel van Langenberg, Muyur Garg, Amanda Nicoll)
| | - Ken Lee Chin
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University (Ken Lee Chin)
| | - Daniel van Langenberg
- Department of Gastroenterology, Eastern Health (Thomas Worland, Daniel van Langenberg, Muyur Garg, Amanda Nicoll).,Eastern Health Clinical School, Monash University, Eastern Health Clinical School (Daniel van Langenberg, Mayur Garg, Amanda Nicoll), Australia
| | - Mayur Garg
- Department of Gastroenterology, Eastern Health (Thomas Worland, Daniel van Langenberg, Muyur Garg, Amanda Nicoll).,Eastern Health Clinical School, Monash University, Eastern Health Clinical School (Daniel van Langenberg, Mayur Garg, Amanda Nicoll), Australia
| | - Amanda Nicoll
- Department of Gastroenterology, Eastern Health (Thomas Worland, Daniel van Langenberg, Muyur Garg, Amanda Nicoll).,Eastern Health Clinical School, Monash University, Eastern Health Clinical School (Daniel van Langenberg, Mayur Garg, Amanda Nicoll), Australia
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19
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Fontana RJ, Avigan MI, Janssen HLA, Regev A, Mishra P, Gaggar A, Brown N, Wat C, Mendez P, Anderson RT, Given B, Miller V, Beumont M. Liver safety assessment in clinical trials of new agents for chronic hepatitis B. J Viral Hepat 2020; 27:96-109. [PMID: 31828894 DOI: 10.1111/jvh.13223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/17/2019] [Accepted: 09/26/2019] [Indexed: 12/17/2022]
Abstract
Investigational agents that reduce or eliminate covalently closed circular DNA (cccDNA) or enhance host immunity against hepatitis B virus (HBV)-infected hepatocytes are intended to induce a durable off-treatment clearance of hepatitis B surface antigen (HBsAg) (referred to as functional cure). The aim of this paper was to highlight challenges in interpreting liver safety data in clinical trials of these agents when given alone or in combination regimens. The incidence, grading and management of spontaneous serum ALT flares in untreated chronic HBV patients are reviewed along with a summary of serum ALT flares observed during the registration trials for peginterferon and nucleos(t)ide reverse transcriptase inhibitors. Recommendations regarding the detection, management and interpretation of liver safety biomarker data in future clinical trials as well as suggested inclusion and exclusion criteria for phase 1/2 vs phase 3 studies are provided. Criteria to help classify liver safety signals as being due to the intended therapeutic response, emergence of drug-resistant HBV virions, or idiosyncratic drug-induced liver injury are provided along with a review of the role of an expert hepatic adjudication panel in assessing a compound's hepatotoxicity profile. Finally, an algorithmic approach to the differential diagnosis and recommended medical evaluation and management of individual clinical trial patients that develop a liver safety signal is provided along with the rationale to collect and test research blood samples for future mechanistic studies.
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Affiliation(s)
- Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Mark I Avigan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Arie Regev
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Poonam Mishra
- Division of Antiviral Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | - Ryan T Anderson
- Forum for Collaborative Research, University of California, Berkeley
| | - Bruce Given
- Arrowhead Pharmaceuticals, Inc, Pasadena, CA, USA
| | - Veronica Miller
- Forum for Collaborative Research, University of California, Berkeley
| | - Maria Beumont
- Janssen Research & Development, Janssen Pharmaceutica NV, Beerse, Belgium
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Abstract
INTRODUCTION We conducted this study to characterize the incidence, clinical features, treatment, and outcomes of immune checkpoint inhibitor (ICI) hepatotoxicity. METHODS Patients who received ICIs (with either single-agent or combination regimens) from January 1, 2010, to March 31, 2018, were identified. Hepatotoxicity was defined as alanine aminotransferase (ALT) >5 times the upper limit of normal (ULN), in the absence of an alternate cause, and categorized as grade 3 (ALT 5-20× ULN) or grade 4 (ALT >20× ULN), according to Common Terminology Criteria for Adverse Events 4.03. RESULTS Among 5,762 patients, 100 (2%) developed hepatotoxicity, occurring in a higher proportion of recipients of combination therapy (9.2%) compared with monotherapy (up to 1.7%, P < 0.001). ICIs were discontinued permanently in 69 and temporarily in 31 patients. Sixty-seven patients received steroids, 10 of whom (14%) had recurrent hepatotoxicity after the steroid taper. Thirty-one patients resumed ICIs after ALT improvement, 8 of whom (26%) developed recurrent hepatotoxicity. Characteristics of liver injury, response to steroids, and outcomes were similar between 38 individuals with and 62 without possible pre-existing liver disease. The severity and outcome of hepatotoxicity due to combination therapy were not significantly different from monotherapy. There were 36 deaths. Two had liver failure at the time of death, both with progression of liver metastases and grade 3 hepatotoxicity. DISCUSSION Clinically significant ICI-related hepatotoxicity was uncommon but led to permanent ICI discontinuation in the majority. ICIs were restarted in a sizable proportion of patients, most of whom did not experience recurrent hepatotoxicity.
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21
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Abstract
Drug-induced liver injury (DILI) is the most common cause of acute liver failure (ALF) in Western countries. Without liver transplantation, the mortality rate for ALF approaches greater than 80%. Acetaminophen-related ALF may be associated with a rapid progression but fortunately has a high chance for spontaneous survival compared with idiosyncratic DILI-related ALF. Several prognostic scoring systems for severe DILI have been developed to aid clinicians in selecting patients who require urgent liver transplantation. Patients who undergo liver transplantation for ALF are at risk for early graft loss and death and should be closely followed.
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Affiliation(s)
- Maneerat Chayanupatkul
- Department of Physiology, Chulalongkorn University, Pattayapat Building, 10th Floor, 1873 Rama IV Road, Pathumwan, Bangkok 10330, Thailand; Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Pattayapat Building, 10th Floor, 1873 Rama IV Road, Pathumwan, Bangkok 10330, Thailand.
| | - Thomas D Schiano
- Division of Liver Diseases, Department of Medicine, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, Icahn Building, 3rd Floor, 1425 Madison Avenue, New York, NY 10029, USA
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Palmer M, Regev A, Lindor K, Avigan MI, Dimick‐Santos L, Treem W, Marcinak JF, Lewis JH, Anania FA, Seekins D, Shneider BL, Chalasani N. Consensus guidelines: best practices for detection, assessment and management of suspected acute drug-induced liver injury occurring during clinical trials in adults with chronic cholestatic liver disease. Aliment Pharmacol Ther 2020; 51:90-109. [PMID: 31762074 PMCID: PMC6972572 DOI: 10.1111/apt.15579] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/03/2019] [Accepted: 10/19/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Improved knowledge of the molecular pathophysiology and immunopathogenesis of cholestatic liver diseases in recent years has led to an increased interest in developing novel therapies. Patients with cholestatic liver disease often require different approaches to assessment and management of suspected drug-induced liver injury (DILI) compared to those with healthy livers and those with parenchymal liver diseases. At present, there are no regulatory guidelines or society position papers, that systematically address best practices pertaining to detection of DILI in these patients. AIMS To outline best practices for detection, assessment and management of suspected acute DILI during clinical trials in adults with the cholestatic liver diseases - Primary Biliary Cholangitis (PBC) and Primary Sclerosing Cholangitis (PSC). METHODS This is one of the several papers developed by the IQ DILI Initiative, which is comprised of members from 16 pharmaceutical companies, in collaboration with DILI experts from academia and regulatory agencies. The contents are the result of an extensive literature review, as well as in-depth discussions among industry, regulatory and academic DILI experts, to achieve consensus recommendations on DILI-related issues occurring during clinical trials for cholestatic liver diseases. RESULTS Recommended best practices are outlined pertaining to hepatic eligibility criteria, monitoring of liver tests, approach to a suspected DILI signal, and hepatic discontinuation rules. CONCLUSIONS This paper provides a framework for the approach to detection, assessment and management of suspected acute DILI occurring during clinical trials in adults with cholestatic liver disease.
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23
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Kang Y, Kim SH, Park SY, Park BY, Lee JH, An J, Won HK, Song WJ, Kwon HS, Cho YS, Moon HB, Shim JH, Yang MS, Kim TB. Evaluation of Drug-Induced Liver Injury Developed During Hospitalization Using Electronic Health Record (EHR)-Based Algorithm. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2020; 12:430-442. [PMID: 32141257 PMCID: PMC7061161 DOI: 10.4168/aair.2020.12.3.430] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/14/2019] [Accepted: 11/27/2019] [Indexed: 01/11/2023]
Abstract
Purpose The incidence of drug-induced liver injury (DILI) has been increasing; however, few algorithms are available to identify DILI in electronic health records (EHRs). We aimed to identify and evaluate DILI with an appropriate screening algorithm. Methods We collected data from 3 university hospitals between June 2015 and May 2016 using our newly developed algorithm for identifying DILI. Among patients with alanine transferase (ALT) ≤ 120 IU/L and total bilirubin (TB) ≤ 2.4 mg/dL in blood test results within 48 hours of admission, those who either had 1) ALT > 120 IU/L and TB > 2.4 mg/dL or 2) ALT > 200 IU/L at least once during hospitalization were identified. After excluding patients with liver disease-related diagnosis at discharge, medical records were retrospectively reviewed to evaluate epidemiological characteristics of DILI. Results The total number of inpatients was 256,598, of whom 1,100 (0.43%) were selected by the algorithm as suspected DILI. Subsequently, 365 cases (0.14% of total inpatients, 95% confidence interval, 0.13–0.16) were identified as DILI, yielding a positive predictive value of 33.1%. Antibiotics (n = 214, 47.2%) were the major class of causative drug followed by chemotherapeutic agents (n = 87, 19.2%). The most common causative drug was piperacillin-tazobactam (n = 38, 8.4%); the incidence of DILI by individual agent was highest for methotrexate (19.4 cases/1,000 patients administered the drug). Common reasons for excluding suspected DILI cases were ischemic hepatitis and postoperative liver dysfunction. Conclusions Using our EHR-based algorithm, we identified that approximately 0.14% of patients developed DILI during hospitalization. Further studies are needed to modify criteria for more accurate identification of DILI.
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Affiliation(s)
- Yewon Kang
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Sae Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - So Young Park
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Allergy and Respiratory Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Bo Young Park
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyang Lee
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin An
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ha Kyeong Won
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Internal Medicine, VHS Medical Center, Seoul, Korea
| | - Woo Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyouk Soo Kwon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - You Sook Cho
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Bom Moon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyun Shim
- Department of Gastroenterology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea.
| | - Tae Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Pharmacovigilance Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Raschi E, De Ponti F. Strategies for Early Prediction and Timely Recognition of Drug-Induced Liver Injury: The Case of Cyclin-Dependent Kinase 4/6 Inhibitors. Front Pharmacol 2019; 10:1235. [PMID: 31708776 PMCID: PMC6821876 DOI: 10.3389/fphar.2019.01235] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022] Open
Abstract
The idiosyncratic nature of drug-induced liver injury (DILI) represents a current challenge for drug developers, regulators and clinicians. The myriad of agents (including medications, herbals, and dietary supplements) with recognized DILI potential not only strengthens the importance of the post-marketing phase, when urgent withdrawal sometimes occurs for rare unanticipated liver toxicity, but also shows the imperfect predictivity of pre-clinical models and the lack of validated biomarkers beyond traditional, non-specific liver function tests. After briefly reviewing proposed key mechanisms of DILI, we will focus on drug-related risk factors (physiochemical and pharmacokinetic properties) recently proposed as predictors of DILI and use cyclin-dependent kinase 4/6 inhibitors, relatively novel oral anticancer medications approved for breast cancer, as a case study to discuss the feasibility of early detection of DILI signals during drug development: published data from pivotal clinical trials, unpublished post-marketing reports of liver adverse events, and pharmacokinetic properties will be used to provide a comparative evaluation of their liver safety and gain insight into drug-related risk factors likely to explain the observed differences.
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Affiliation(s)
- Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Fabrizio De Ponti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Abstract
Drug-induced liver injury (DILI), including herbal and dietary supplement hepatotoxicity, is often passed lightly; however, it can lead to the requirement of a liver transplant or may even cause death because of liver failure. Recently, the American College of Gastroenterology, Chinese Society of Hepatology and European Association for the Study of the Liver guidelines for the diagnosis and treatment of DILI have been established, and they will be helpful for guiding clinical treatment decisions. Roussel Uclaf Causality Assessment Method scoring is the most commonly used method to diagnose DILI; however, it has some limitations, such as poor validity and reproducibility. Recently, studies on new biomarkers have been actively carried out, which will help diagnose DILI and predict the prognosis of DILI. It is expected that the development of new therapies such as autophagy inducers and various other technologies of the fourth industrial revolution will be applicable to DILI research.
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Affiliation(s)
- Jeong Ill Suh
- Department of Internal Medicine, College of Medicine, Dongguk Unversity, Gyeongju, Korea
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26
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Timmer A, de Sordi D, Kappen S, Kohse KP, Schink T, Perez-Gutthann S, Jacquot E, Deltour N, Pladevall M. Validity of hospital ICD-10-GM codes to identify acute liver injury in Germany. Pharmacoepidemiol Drug Saf 2019; 28:1344-1352. [PMID: 31373108 DOI: 10.1002/pds.4855] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE Acute liver injury (ALI) is an important adverse drug reaction. We estimated the positive predictive values (PPVs) of ICD-10-GM codes of ALI used in an international postauthorisation safety study (PASS). METHODS Analyses used routine data (2007 to 2016, adults) from a German academic hospital in a cross-sectional design. Two algorithms from the PASS were applied to extract potential cases from the hospital information system: specific end point (A) (discharge diagnosis of liver disease-specific codes) and less specific end point (B) (discharge and outpatient-specific and nonspecific codes suggestive of liver injury). ALI cases were confirmed on the basis of plasma liver enzyme activity elevation. Secondary analysis was performed following exclusion of cases with known cancer, chronic liver, biliary and pancreatic disease, heart failure, and alcohol-related disorders, as applied in the PASS. RESULTS On the basis of ICD codes: outcome A, 154 cases (143 with case notes and lab data for case verification); outcome B, 485 cases (357 with case notes and lab data). ALI was confirmed in 71 outcome A cases, PPV of 49.7% (95% confidence interval [CI], 41.2%-58.1%), and 100 outcome B cases, PPV of 28.0% (95% CI, 23.4%-33.0%). Applying exclusion criteria increased PPV (95% CI) to 62.7% (50.0%-74.2%) for outcome A and 45.7% (37.2%-54.3%) for outcome B. CONCLUSIONS In safety studies on hepatotoxicity based on routine data using ICD-10-GM discharge codes and when validation of potential cases is not feasible, only the more specific codes should be used to describe ALI, and competing diagnoses for liver injury should be excluded to avoid substantial misclassification.
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Affiliation(s)
- Antje Timmer
- Division of Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Dominik de Sordi
- Division of Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Sanny Kappen
- Division of Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Klaus Peter Kohse
- Institute for Laboratory Medicine and Microbiology, Klinikum Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Tania Schink
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | | | | | | | - Manel Pladevall
- Epidemiology, RTI Health Solutions, Barcelona, Spain.,The Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
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Abstract
Idiosyncratic (unpredictable) drug-induced liver injury is one of the most challenging liver disorders faced by hepatologists, because of the myriad of drugs used in clinical practice, available herbs and dietary supplements with hepatotoxic potential, the ability of the condition to present with a variety of clinical and pathological phenotypes and the current absence of specific biomarkers. This makes the diagnosis of drug-induced liver injury an uncertain process, requiring a high degree of awareness of the condition and the careful exclusion of alternative aetiologies of liver disease. Idiosyncratic hepatotoxicity can be severe, leading to a particularly serious variety of acute liver failure for which no effective therapy has yet been developed. These Clinical Practice Guidelines summarize the available evidence on risk factors, diagnosis, management and risk minimization strategies for drug-induced liver jury.
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28
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Abstract
OBJECTIVES Acute insults from viruses, infections, or alcohol are established causes of decompensation leading to acute-on-chronic liver failure (ACLF). Information regarding drugs as triggers of ACLF is lacking. We examined data regarding drugs producing ACLF and analyzed clinical features, laboratory characteristics, outcome, and predictors of mortality in patients with drug-induced ACLF. METHODS We identified drugs as precipitants of ACLF among prospective cohort of patients with ACLF from the Asian Pacific Association of Study of Liver (APASL) ACLF Research Consortium (AARC) database. Drugs were considered precipitants after exclusion of known causes together with a temporal association between exposure and decompensation. Outcome was defined as death from decompensation. RESULTS Of the 3,132 patients with ACLF, drugs were implicated as a cause in 329 (10.5%, mean age 47 years, 65% men) and other nondrug causes in 2,803 (89.5%) (group B). Complementary and alternative medications (71.7%) were the commonest insult, followed by combination antituberculosis therapy drugs (27.3%). Alcoholic liver disease (28.6%), cryptogenic liver disease (25.5%), and non-alcoholic steatohepatitis (NASH) (16.7%) were common causes of underlying liver diseases. Patients with drug-induced ACLF had jaundice (100%), ascites (88%), encephalopathy (46.5%), high Model for End-Stage Liver Disease (MELD) (30.2), and Child-Turcotte-Pugh score (12.1). The overall 90-day mortality was higher in drug-induced (46.5%) than in non-drug-induced ACLF (38.8%) (P = 0.007). The Cox regression model identified arterial lactate (P < 0.001) and total bilirubin (P = 0.008) as predictors of mortality. DISCUSSION Drugs are important identifiable causes of ACLF in Asia-Pacific countries, predominantly from complementary and alternative medications, followed by antituberculosis drugs. Encephalopathy, bilirubin, blood urea, lactate, and international normalized ratio (INR) predict mortality in drug-induced ACLF.
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Xiao X, Tang J, Mao Y, Li X, Wang J, Liu C, Sun K, Ye Y, Zou Z, Peng C, Yang L, Guo Y, Bai Z, He T, Jing J, Li F, An N. Guidance for the clinical evaluation of traditional Chinese medicine-induced liver injuryIssued by China Food and Drug Administration. Acta Pharm Sin B 2019; 9:648-658. [PMID: 31193760 PMCID: PMC6543019 DOI: 10.1016/j.apsb.2018.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Xiaohe Xiao
- China Military Institute of Chinese Medicine, Beijing 302 Hospital of China, Beijing 100039, China
| | - Jianyuan Tang
- Center for Drug Evaluation, China Food and Drug Administration, Beijing 100022, China
| | - Yimin Mao
- Renji Hospital of Shanghai Jiaotong University, Shanghai 200127, China
| | - Xiuhui Li
- Beijing Youan Hospital of Capital Medical University, Beijing 100069, China
| | - Jiabo Wang
- China Military Institute of Chinese Medicine, Beijing 302 Hospital of China, Beijing 100039, China
| | - Chenghai Liu
- Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai 200127, China
| | - Kewei Sun
- First Affiliated Hospital of Hunan University of Traditional Chinese Medicine, Changsha 410007, China
| | - Yong'an Ye
- Dongzhimen Hospital of Beijing University of Traditional Chinese Medicine, Beijing 100700, China
| | - Zhengsheng Zou
- Center for Non-infectious Liver Diseases, Beijing 302 Hospital of China, Beijing 100039, China
| | - Cheng Peng
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 610075, China
| | - Ling Yang
- College of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Yuming Guo
- China Military Institute of Chinese Medicine, Beijing 302 Hospital of China, Beijing 100039, China
| | - Zhaofang Bai
- China Military Institute of Chinese Medicine, Beijing 302 Hospital of China, Beijing 100039, China
| | - Tingting He
- China Military Institute of Chinese Medicine, Beijing 302 Hospital of China, Beijing 100039, China
| | - Jing Jing
- China Military Institute of Chinese Medicine, Beijing 302 Hospital of China, Beijing 100039, China
| | - Fengyi Li
- Center for Infectious Liver Diseases, Beijing 302 Hospital of China, Beijing 100039, China
| | - Na An
- Center for Drug Evaluation, China Food and Drug Administration, Beijing 100022, China
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30
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Abraldes JG, Trebicka J, Chalasani N, D’Amico G, Rockey DC, Shah VH, Bosch J, Garcia-Tsao G. Prioritization of Therapeutic Targets and Trial Design in Cirrhotic Portal Hypertension. Hepatology 2019; 69:1287-1299. [PMID: 30318607 PMCID: PMC11090176 DOI: 10.1002/hep.30314] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/10/2018] [Indexed: 12/12/2022]
Abstract
Portal hypertension (PH) is the main driver of cirrhosis decompensation, the main determinant of death in patients with cirrhosis. PH results initially from increased intrahepatic vascular resistance. Subsequently, increased inflow from splanchnic vasodilation and increased cardiac output lead to a further increase in portal pressure (PP). Reducing PP in cirrhosis results in better outcomes. Removing the cause of cirrhosis might improve PP. However, this is a slow process and patients may continue to be at risk of decompensation. Additionally, for some chronic liver diseases, such as nonalcoholic fatty liver disease (NAFLD), etiological treatments are not yet available. Therefore, there is a need to develop better therapies specifically aimed at reducing PP. For over 35 years, the mainstay of such therapy has been the use of nonselective beta-blockers (NSBBs) that act by reducing portal venous inflow. Recently, many drugs (mainly targeting intrahepatic mechanisms) have shown promise in preclinical and early clinical studies and may act alone or synergistically with NSBBs in reducing PP in cirrhosis. The objective of this position paper is to propose a novel framework for the design of clinical trials (phase 1, 2, and 3) in patients with cirrhosis and PH and to prioritize targets and pharmacological therapies in this setting. We have focused the discussion on patients with compensated cirrhosis. The paper summarizes discussions held at The American Association for the Study of Liver Diseases (AASLD) Industry Colloquium in January 2018, with the participation of clinical and translational investigators, regulatory professionals, and industry partners.
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Affiliation(s)
- Juan G. Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Department of Medicine, CEGIIR, University of Alberta, Edmonton, Canada
| | - Jonel Trebicka
- Translational Hepatology, Department of Internal Medicine I, University Clinic Frankfurt, Frankfurt, Germany
- European Foundation for the Study of Chronic Liver Failure, Institute for Bioengineering of Catalonia, Barcelona, Spain
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | | | - Don C. Rockey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Jaime Bosch
- Swiss Liver Group, University Clinic for Visceral Medicine and Surgery (UVCM), Inselspital, University of Bern, Bern, Switzerland
- Hospital Clinic-IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Digestive Diseases Section, Yale University School of Medicine; VA-CT Healthcare System, New Haven/West Haven, CT
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Regev A, Palmer M, Avigan MI, Dimick‐Santos L, Treem WR, Marcinak JF, Seekins D, Krishna G, Anania FA, Freston JW, Lewis JH, Sanyal AJ, Chalasani N. Consensus: guidelines: best practices for detection, assessment and management of suspected acute drug-induced liver injury during clinical trials in patients with nonalcoholic steatohepatitis. Aliment Pharmacol Ther 2019; 49:702-713. [PMID: 30761572 PMCID: PMC6593464 DOI: 10.1111/apt.15153] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 10/22/2018] [Accepted: 01/02/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The last decade has seen a rapid growth in the number of clinical trials enrolling patients with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis (NASH). Due to the underlying chronic liver disease, patients with NASH often require different approaches to the assessment and management of suspected drug-induced liver injury (DILI) compared to patients with healthy livers. However, currently no regulatory guidelines or position papers systematically address best practices pertaining to DILI in NASH clinical trials. AIMS This publication focuses on best practices concerning the detection, monitoring, diagnosis and management of suspected acute DILI during clinical trials in patients with NASH. METHODS This is one of several papers developed by the IQ DILI Initiative, comprised of members from 15 pharmaceutical companies, in collaboration with DILI experts from academia and regulatory agencies. This paper is based on extensive literature review, and discussions between industry members with expertise in drug safety and DILI experts from outside industry to achieve consensus on common questions related to this topic. RESULTS Recommended best practices are outlined pertaining to hepatic inclusion and exclusion criteria, monitoring of liver tests, DILI detection, approach to a suspected DILI signal, causality assessment and hepatic discontinuation rules. CONCLUSIONS This paper provides a framework for the approach to assessment and management of suspected acute DILI during clinical trials in patients with NASH.
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Jing J, Wang RL, Zhao XY, Zhu Y, Niu M, Wang LF, Song XA, He TT, Sun YQ, Xu WT, Yu SM, Wang LP, Guo YM, Bai ZF, Xiao XH, Wang JB. Association between the concurrence of pre-existing chronic liver disease and worse prognosis in patients with an herb- Polygonum multiflorum thunb. induced liver injury: a case-control study from a specialised liver disease center in China. BMJ Open 2019; 9:e023567. [PMID: 30782709 PMCID: PMC6340630 DOI: 10.1136/bmjopen-2018-023567] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/17/2018] [Accepted: 11/26/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The present study aimed to evaluate the association between the concurrence of pre-existing chronic liver diseases (CLD) and worse prognosis in patients with HILI. DESIGN A case-control study. SETTING Tertiary hospital specialising in liver diseases in China. PARTICIPANTS 145 hospitalised HILI patients were assessed with respect to prognosis by comparing HILI with or without pre-existing CLD from February 2007 to January 2017. Twenty-five HILI cases with pre-existing alcoholic liver disease (ALD) or non-alcoholic fatty liver disease (NAFLD) and 200 ALD or NAFLD controls matched 1:8 for sex, age (±4 years old), body mass index (±2 kg/m2), the type of CLD, alcohol intake (±5 g/d) and the presence or absence of cirrhosis. PRIMARY OUTCOME MEASURES Mortality and chronicity in HILI patients with or without pre-existing CLD, and matched CLD patients. RESULTS Of the 193 714 hospitalised patients with liver diseases, 5703 patients met the diagnostic criteria for drug-induced liver injury (DILI), which was attributed to Polygonum multiflorum Thunb. (PMT) in 145 patients. Among these HILI patients, 22.8% (33 of 145) had pre-existing CLD, including 17 (51.5%) with ALD, 8 (24.2%) with NAFLD, 5 (15.2%) with chronic viral hepatitis and 3 (9.1%) with autoimmune liver disease. Compared with HILI patients without CLD, HILI patients with pre-existing CLD showed higher mortality (0.9% vs 9.1%, p=0.037) and higher chronicity (12.5% vs 30.3%, p=0.016). Compared with matched ALD (136 patients) or NAFLD (64 patients) patients, HILI patients with pre-existing ALD showed higher chronicity (35.3% vs 11.8%, p=0.019). Multivariate logistic regression analysis found that concurrence of pre-existing CLD was an independent risk factor for both of chronicity and mortality (OR 3.966, 95% CI 1.501 to 10.477, p=0.005), especially the chronicity (OR 3.035, 95% CI 1.115 to 8.259, p=0.030). CONCLUSIONS Concurrence of pre-existing CLD could be an independent risk factor for worse prognosis, especially chronicity, in PMT-related HILI.
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Affiliation(s)
- Jing Jing
- Department of Integrative Medicine, Medical School of Chinese PLA, Beijing, China
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Rui-lin Wang
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Xin-yan Zhao
- Liver Research Center, Beijing Friendship Hospital, Capital Medial University, Beijing, China
| | - Yun Zhu
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Ming Niu
- Institute of Chinese Herbal Medicine, Beijing 302 Hospital, Beijing, China
| | - Li-fu Wang
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Xue-ai Song
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Ting-ting He
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Yong-qiang Sun
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Wen-tao Xu
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Si-miao Yu
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Li-ping Wang
- Division of Integrative Medicine, Beijing 302 Hospital, Beijing, China
| | - Yu-ming Guo
- Institute of Chinese Herbal Medicine, Beijing 302 Hospital, Beijing, China
| | - Zhao-fang Bai
- Institute of Chinese Herbal Medicine, Beijing 302 Hospital, Beijing, China
| | - Xiao-he Xiao
- Department of Integrative Medicine, Medical School of Chinese PLA, Beijing, China
- Institute of Chinese Herbal Medicine, Beijing 302 Hospital, Beijing, China
| | - Jia-bo Wang
- Institute of Chinese Herbal Medicine, Beijing 302 Hospital, Beijing, China
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33
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Shneider BL, Spino C, Kamath BM, Magee JC, Bass LM, Setchell KD, Miethke A, Molleston JP, Mack CL, Squires RH, Murray KF, Loomes KM, Rosenthal P, Karpen SJ, Leung DH, Guthery SL, Thomas D, Sherker AH, Sokol RJ. Placebo-Controlled Randomized Trial of an Intestinal Bile Salt Transport Inhibitor for Pruritus in Alagille Syndrome. Hepatol Commun 2018; 2:1184-1198. [PMID: 30288474 PMCID: PMC6167076 DOI: 10.1002/hep4.1244] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/13/2018] [Indexed: 01/06/2023] Open
Abstract
Medically refractory, severe, cholestasis-induced pruritus in Alagille syndrome may be improved by surgical interruption of the enterohepatic circulation. This multicenter trial (NCT02057692) tested the hypothesis that the intestinal bile acid transport inhibitor maralixibat would similarly reduce pruritus in Alagille syndrome. Thirty-seven children with Alagille syndrome were randomly assigned to double-blinded administration of placebo, 70, 140, or 280 µg/kg/day of maralixibat for 13 weeks. Pruritus was assessed by caregiver (itch-reported outcome instrument [ItchRO]) and clinician report (range, 0-4 [severe]). Liver chemistries and serum bile acids were measured. The primary outcome was the change from baseline to week 13 in ItchRO relative to placebo. In the a priori first analysis of the primary efficacy endpoint, the mean adjusted difference between participants receiving 140 or 280 µg/kg/day and placebo was -0.47 (95% confidence interval [CI], -1.14, 0.20; P = 0.16). Statistically significant decreases were observed with doses of 70 and 140 µg/kg/day (mean adjusted difference, -0.89; 95% CI, -1.70, -0.08; P = 0.032; and mean adjusted difference, -0.91; 95% CI, -1.62, -0.19; P = 0.014) but not 280 µg/kg/day (mean adjusted difference, -0.04; 95% CI, -0.94, 0.86; P = 0.44) or all doses combined (mean adjusted difference, -0.61; 95% CI, -1.24, 0.20; P = 0.055). A 1-point reduction in pruritus was more common in maralixibat-treated versus placebo-treated participants (caregiver ItchRO, 65% versus 25%; P = 0.06; clinician score, 76% versus 25%; P = 0.01). There were no significant changes in liver chemistries or bile acids relative to placebo. Adverse and serious adverse events were similar between maralixibat and placebo. Conclusion: Although the prespecified primary analyses of ItchRO were not all statistically significant, the data suggest that maralixibat is safe and may reduce pruritus in Alagille syndrome.
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Affiliation(s)
- Benjamin L. Shneider
- Section of Pediatric Gastroenterology, Hepatology, and NutritionBaylor College of MedicineHoustonTX
| | - Cathie Spino
- School of Public HealthUniversity of MichiganAnn ArborMI
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
| | | | - Lee M. Bass
- Pediatrics Division of Gastroenterology, Hepatology, and NutritionAnn and Robert H. Lurie Children’s Hospital of ChicagoChicagoIL
| | - Kenneth D. Setchell
- Department of Pediatrics‐PathologyCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Alexander Miethke
- Division of Pediatric Gastroenterology, Hepatology, and NutritionCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Jean P. Molleston
- Division of Pediatric Gastroenterology, Hepatology, and NutritionIndiana University School of Medicine/Riley Hospital for ChildrenIndianapolisIN
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology, and NutritionChildren's Hospital ColoradoAuroraCO
| | | | - Karen F. Murray
- Division of Gastroenterology and HepatologyUniversity of Washington School of Medicine, Seattle Children’s HospitalSeattleWA
| | - Kathleen M. Loomes
- Pediatric Gastroenterology, Hepatology, and NutritionChildren’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
| | - Saul J. Karpen
- Pediatric Gastroenterology, Hepatology, and NutritionEmory University School of Medicine/Children’s Healthcare of AtlantaAtlantaGA
| | - Daniel H. Leung
- Section of Pediatric Gastroenterology, Hepatology, and NutritionBaylor College of MedicineHoustonTX
| | - Stephen L. Guthery
- Pediatric Gastroenterology, Hepatology, and NutritionUniversity of UtahSalt Lake CityUT
| | - Danny Thomas
- Department of GastroenterologyChildren's Hospital Los AngelesLos AngelesCA
| | - Averell H. Sherker
- Liver Diseases Research Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of PediatricsUniversity of Colorado School of MedicineAuroraCO
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Avigan MI, Muñoz MA. Perspectives on the Regulatory and Clinical Science of Drug-Induced Liver Injury (DILI). METHODS IN PHARMACOLOGY AND TOXICOLOGY 2018. [DOI: 10.1007/978-1-4939-7677-5_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Gastroenterologists and hepatologists will encounter oncology patients who develop abnormal liver tests, patients with hepatic malignancies, and patients with acute and chronic liver disease who require chemotherapy or immediate evaluation. Chemotherapy can cause liver injury owing to toxic effects or idiosyncratic reactions. Immune checkpoint inhibitors may be associated with autoimmune-mediated liver toxicities. Venoocclusive disease requires immediate evaluation. Nodular regenerative hyperplasia is a chronic progressive disorder. Screening and prophylaxis for reactivation of hepatitis B is important to minimize complications in patients receiving chemotherapy. Patients with metastatic lesions can undergo resection or ablation. Hepatic injury may occur in those receiving radiation-based therapies.
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Affiliation(s)
- Renu Dhanasekaran
- Department of Medicine, Stanford University School of Medicine, 750 Welch Road #210, Palo Alto, CA 94304-1507, USA
| | - Paul Y Kwo
- Department of Medicine, Stanford University School of Medicine, 750 Welch Road #210, Palo Alto, CA 94304-1507, USA.
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Shahbaz O, Mahajan S, Lewis JH. Highlights of drug - and herb- induced liver injury in the literature from 2016: how best to translate new information into clinical practice? Expert Opin Drug Metab Toxicol 2017; 13:935-951. [PMID: 28772086 DOI: 10.1080/17425255.2017.1362391] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Over 1500 papers on drug-induced liver injury (DILI) and herb-induced liver injury (HILI) were published in 2016, many of which have the potential to impact clinical practice. Areas covered: Clinical studies and case series that lent themselves to new concepts in diagnosing, and treating DILI were selected for inclusion. Epidemiology of DILI in large prospective registries was highlighted. Causality assessment of drug hepatotoxicity remains challenging, as seen with cases of OxyELITE Pro (OEP). In 2016 updates to the Roussel Uclaf Causality Assessment Method (RUCAM) were published to aid in the accuracy of diagnosing DILI/HILI. New reports of established hepatotoxins were again discussed in 2016, including genetic risk factors for DILI with respect to antituberculous agents. Expert opinion: 2016 marked a turning point in how much credence should be placed in the current causality assessment for DILI/HILI cases. Many recognized hepatotoxins are backed by a relatively few number of literature reports. Danan and Teschke make a strong case that an updated RUCAM should remain the gold standard for diagnosing DILI/HILI going forward, although the role of expert opinion is often still needed in cases where RUCAM falls short. The field of chemoinformatics continues to evolve while we await a truly predictive and diagnostic DILI biomarker.
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Affiliation(s)
- Omar Shahbaz
- a Department of Medicine, Division of Gastroenterology, Hepatology Section , Georgetown University Hospital , Washington , DC , USA
| | - Sandeep Mahajan
- a Department of Medicine, Division of Gastroenterology, Hepatology Section , Georgetown University Hospital , Washington , DC , USA
| | - James H Lewis
- a Department of Medicine, Division of Gastroenterology, Hepatology Section , Georgetown University Hospital , Washington , DC , USA
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