Economic Evaluation of Screening Interventions for Drug-induced Liver Injury

Epidemiology, risk factors, and strategies to prevent and manage poisonings due to pharmaceuticals in children in low income and low-middle income countries: A systematic review

Background

There are significant disparities in the burden of disease due to poisoning between children in low- and high-income countries (HICs). However, there is limited data on the impact of increasing pharmaceutical access in low income countries (LICs) and low-middle income countries (LMICs) on the epidemiology of and risk factors associated with poisoning in children in these settings. Furthermore, while strategies in HICs have effectively reduced the burden of disease due to poisonings in children, there is limited information regarding the efficacy of these interventions in LICs/LMICs.

Methods

We conducted a systematic review in eight databases for literature published between January 2000 to April 2022 to evaluate the epidemiology and risk factors associated with poisonings due to pharmaceuticals and effective strategies to prevent and manage them in children in LICs/LMICs. From 16 061 retrieved articles, 41 were included in the final analysis.

Results

Pharmaceuticals were a common cause of poisoning in children in LICs/LMICs, occurring in between 12.4% and 72.36% of cases. Major risk factors were unsafe medication storage and inadequate caregiver knowledge. Delayed access to care and younger age were associated with increased mortality. Prevention strategies that included education demonstrated improvements in knowledge; however, their impact on incidence and mortality was unclear. Management strategies detailed individual patient care interventions, most commonly gastric lavage and activated charcoal. Meanwhile, delayed presentation, limited provider knowledge, and inadequate laboratory resources to support therapeutic monitoring hindered optimal management.

Conclusions

The combination of educational interventions for prevention, along with regulatory processes to maximise medication storage and formulation safety, could be effective in reducing the burden of poisoning in LICs/LMICs. The development of national or regional protocols for the management of common medication poisonings, augmented by the development of poison control centers and expansion of laboratory access in facilities may help reduce the morbidity and mortality associated with pharmaceutical poisonings in children in LICs/LMICs. Further evidence regarding contextual factors, risk and benefit profiles, the pattern of poisoning, and the impact of preventive and treatment interventions specific to LICs/LMICs is needed to better refine recommendations in these settings.

Registration

PROSPERO: CRD42022315686.

Drug-Induced Liver Injury: Highlights and Controversies in the Recent Literature

Drug-induced liver injury (DILI) remains an important, yet challenging diagnosis for physicians. Each year, additional drugs are implicated in DILI and this year was no different, with more than 1400 articles published on the subject. This review examines some of the most significant highlights and controversies in DILI-related research over the past year and their implications for clinical practice. Several new drugs were approved by the US Food and Drug Administration including a number of drugs implicated in causing DILI, particularly among the chemotherapeutic classes. The COVID-19 pandemic was also a major focus of attention in 2020 and we discuss some of the notable aspects of COVID-19-related liver injury and its implications for diagnosing DILI. Updates in diagnostic and causality assessments related to DILI such as the Roussel Uclaf Causality Assessment Method are included, mindful that there is still no single biomarker or diagnostic tool to unequivocally diagnose DILI. Glutamate dehydrogenase received renewed attention as being more specific than alanine aminotransferase. There were a few new reports of previously unrecognized hepatotoxins, including immune modulators and novel gene therapy drugs that we highlight. Updates and new developments of previously described hepatotoxins, such as immune checkpoint inhibitors and anti-tuberculosis drugs are reviewed. Finally, novel technologies such as organoid culture systems to better predict DILI preclinically may be coming of age and determinants of hepatocyte loss, such as calculating P_ALT are poised to improve our current means of estimating DILI severity and the risk of acute liver failure.