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Tun MM, Pandey S, Adhikari S, Mainali A, Thapa A, Bisural R, Bista PB, Htet SY, Chhetri B, Panigrahi K. Amiodarone-Induced Liver Attenuation on CT Scan: Alarming Signal for Toxicity and Prompt Discontinuation. Cureus 2023; 15:e39844. [PMID: 37397675 PMCID: PMC10314806 DOI: 10.7759/cureus.39844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Amiodarone, a class III antiarrhythmic drug, is commonly used for the management of life-threatening ventricular arrhythmias, atrial fibrillation, and other refractory supra-ventricular arrhythmias. Factors like a large volume of distribution, lipophilic property, deposition in tissues in large amounts, etc. have led to the development of amiodarone-induced multisystem adverse events. We report a case of amiodarone-induced hepatic attenuation on computed tomography (CT) of the abdomen in an elderly female patient. Amiodarone with a composition of 40% iodine by weight deposits in the liver, leading to characteristically increased radiodensity reported as increased attenuation on CT scan. Surprisingly, the severity and extent of hepatic attenuation on CT scans do not necessarily correlate with the total exposure to amiodarone over time. Individual factors may influence the liver's response to the drug, leading to varying degrees of hepatic changes. To minimize the risk of adverse events associated with amiodarone, clinicians should carefully adjust the dosage to the lowest effective level and regularly monitor liver function tests in patients. This proactive approach enables early detection of liver dysfunction and facilitates timely adjustments or discontinuation of amiodarone, thereby reducing potential harm.
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Affiliation(s)
- Myo Myint Tun
- Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
| | - Sagar Pandey
- Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
| | - Samaj Adhikari
- Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
| | - Arjun Mainali
- Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
| | - Ashish Thapa
- Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
| | - Roshan Bisural
- Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
| | - Puspa B Bista
- Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
| | - Shwe Yee Htet
- Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
| | - Bhawana Chhetri
- Internal Medicine, Nepal Medical College Teaching Hospital, Kathmandu, NPL
| | - Kalpana Panigrahi
- Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
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Waguespack T, Cutshall BT, Brooks C. The aftermath of amiodarone therapy: Hyperammonemia and encephalopathy. Nurse Pract 2022; 47:5-9. [PMID: 35604291 DOI: 10.1097/01.npr.0000822600.59447.c7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Hepatocyte Thorns, A Novel Drug-Induced Stress Response in Human and Mouse Liver Spheroids. Cells 2022; 11:cells11101597. [PMID: 35626634 PMCID: PMC9139950 DOI: 10.3390/cells11101597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/03/2022] [Accepted: 05/07/2022] [Indexed: 02/01/2023] Open
Abstract
The in vivo-relevant phenotype of 3D liver spheroids allows for long-term studies of, e.g., novel mechanisms of chronic drug-induced liver toxicity. Using this system, we present a novel drug-induced stress response in human and murine hepatocyte spheroids, wherein long slender filaments form after chronic treatment with four different drugs, of which three are PPARα antagonists. The morphology of the thorns varies between donors and the compounds used. They are mainly composed of diverse protein fibres, which are glycosylated. Their formation is inhibited by treatment with fatty acids or antioxidants. Treatment of mice with GW6471 revealed changes in gene and protein expression, such as those in the spheroids. In addition, similar changes in keratin expression were seen following the treatment of hepatotoxic drugs, including aflatoxin B1, paracetamol, chlorpromazine, cyclosporine, and ketoconazole. We suggest that thorn formation may be indicative of hepatocyte metaplasia in response to toxicity and that more focus should be placed on alterations of ECM-derived protein expression as biomarkers of liver disease and chronic drug-induced hepatotoxicity, changes that can be studied in stable in vivo-like hepatic cell systems, such as the spheroids.
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Lv HJ, Zhao HW. Amiodarone-induced hepatotoxicity — quantitative measurement of iodine density in the liver using dual-energy computed tomography: Three case reports. World J Clin Cases 2020; 8:4958-4965. [PMID: 33195667 PMCID: PMC7642530 DOI: 10.12998/wjcc.v8.i20.4958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/29/2020] [Accepted: 09/09/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Amiodarone is the drug most commonly used to manage arrhythmias. Long-term amiodarone administration causes hepatotoxicity due to iodine accumulation in the liver. Here, we present three cases of amiodarone-induced hepatotoxicity in patients on long-term oral amiodarone therapy who underwent dual-energy computed tomography (DECT).
CASE SUMMARY We report the clinical and iodine density in the liver using DECT in three patients with amiodarone-induced hepatotoxicity. Liver enzymes were increased in these three patients, and abdominal DECT without contrast medium showed highly increased attenuation in the liver. Furthermore, the iodine concentration in the liver was increased. The first patient with amiodarone-induced reversible hepatotoxicity, showed a reversible course of liver function and a decrease in CT values after discontinuation of amiodarone. The second patient on long-term oral amiodarone had increased iodine concentration in the liver and liver damage, the patient eventually developed rapidly progressive pneumonia and died of multiple organ failure. The third patient, showed an increased iodine concentration in the liver and elevated liver enzymes. However, the patient refused radiofrequency ablation for atrial fibrillation and continued oral amiodarone to control atrial fibrillation, and routine liver function tests were required every 3-6 mo in this patient.
CONCLUSION DECT is a potentially noninvasive diagnostic tool for quantifying iodine concentration in the liver and monitoring adverse reactions due to amiodarone.
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Affiliation(s)
- Hai-Juan Lv
- Department of Radiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Hong-Wei Zhao
- Department of Radiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
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Allen LB, Genaro-Mattos TC, Anderson A, Porter NA, Mirnics K, Korade Z. Amiodarone Alters Cholesterol Biosynthesis through Tissue-Dependent Inhibition of Emopamil Binding Protein and Dehydrocholesterol Reductase 24. ACS Chem Neurosci 2020; 11:1413-1423. [PMID: 32286791 DOI: 10.1021/acschemneuro.0c00042] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Amiodarone is prescribed for the treatment and prevention of irregular heartbeats. Although effective in clinical practice, the long-term use of amiodarone has many unwanted side effects, including cardiac, pulmonary, hepatic, and neurological toxicities. Our objective was to elucidate effects of amiodarone exposure on the cholesterol metabolism in cultured neuronal and non-neuronal cells and in individuals taking amiodarone. We observed that amiodarone increases distinct cholesterol precursors in different cell types in a dose-dependent manner. In liver and kidney cell lines, amiodarone causes increase in desmosterol levels, and in primary cortical neurons and astrocytes, amiodarone increases zymosterol, zymostenol, and 8-dehydrocholesterol (8-DHC). We conclude that amiodarone inhibits two enzymes in the pathway, emopamil binding protein (EBP) and dehydrocholesterol reductase 24 (DHCR24). Cortical neurons and astrocytes are more sensitive to amiodarone than liver and kidney cell lines. We confirmed the inhibition of EBP enzyme by analyzing the sterol intermediates in EBP-deficient Neuro2a cells versus amiodarone-treated control Neuro2a cells. To determine if the cell culture experiments have clinical relevance, we analyzed serum samples from amiodarone users. We found that in patient serum samples containing detectable amount of amiodarone there are elevated levels of the sterol precursors zymosterol, 8-DHC, and desmosterol. This study illustrates the need for close monitoring of blood biochemistry during prolonged amiodarone use to minimize the risk of side effects.
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Affiliation(s)
- Luke B. Allen
- Department of Pediatrics, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198, United States
| | - Thiago C. Genaro-Mattos
- Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska 68105, United States
| | - Allison Anderson
- Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska 68105, United States
| | - Ned A. Porter
- Department of Chemistry, Vanderbilt Institute of Chemical Biology and Vanderbilt Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, Tennessee 37235, United States
| | - Károly Mirnics
- Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska 68105, United States
| | - Zeljka Korade
- Department of Pediatrics, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198, United States
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Huang CH, Lai YY, Kuo YJ, Yang SC, Chang YJ, Chang KK, Chen WK. Amiodarone and risk of liver cirrhosis: a nationwide, population-based study. Ther Clin Risk Manag 2019; 15:103-112. [PMID: 30666120 PMCID: PMC6330968 DOI: 10.2147/tcrm.s174868] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background Liver cirrhosis is an uncommon but not rare side effect of amiodarone-induced hepatotoxicity. Patients with hepatitis B virus and hepatitis C virus infections are at a high risk for developing liver cirrhosis. However, the relationship between this treatment and risk of liver cirrhosis in high-risk chronic hepatitis B and chronic hepatitis C patients is unknown. Patients and methods The present study identified amiodarone users (N=8,081) from the Taiwan National Health Insurance Research Database from 1997 through 2013. A total of 32,324 subjects with age, comorbidities, gender, and index date-matched non-amiodarone users were selected as controls (non-amiodarone cohort). The incidences of cumulative liver cirrhosis were compared between cohorts. Stratified Cox’s regression hazard models were used to assess possible comorbidity-attributable risks for liver cirrhosis. Results The amiodarone cohort had a nonsignificant risk of liver cirrhosis compared with the non-amiodarone cohort, with a HR of 1.17 (95% CI: 0.93–1.47; P=0.1723). Patients with specific comorbid diseases, including type 2 diabetes mellitus, chronic hepatitis B, chronic hepatitis C, and heart failure, were probably at a high risk of developing liver cirrhosis. The use of statins was associated with a significant 42% reduction in the risk of liver cirrhosis. Conclusion Patients in the amiodarone cohort had no excess risk of liver cirrhosis compared with patients in the non-amiodarone cohort. Long-term surveillance for liver toxicity in high-risk patients with amiodarone treatment is suggested.
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Affiliation(s)
- Ching-Hui Huang
- Division of Cardiology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.,Department of Beauty Science, Graduate Institute of Beauty Science Technology, Chienkuo Technology University, Changhua, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ya-Yun Lai
- Department of Applied Cosmetology, National Tainan Junior College of Nursing, Tainan, Taiwan,
| | - Yu-Jui Kuo
- Department of Applied Cosmetology, National Tainan Junior College of Nursing, Tainan, Taiwan, .,Department of Traditional Chinese Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
| | - Su-Ching Yang
- Department of Nursing, National Tainan Junior College of Nursing, Tainan, Taiwan
| | - Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Kuo-Kuan Chang
- Department of Hepatogastroenterology, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan,
| | - Wen-Kang Chen
- Department of Applied Cosmetology, National Tainan Junior College of Nursing, Tainan, Taiwan,
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Matsuda M, Otaka A, Tozawa T, Asano T, Ishiyama K, Hashimoto M. Analysis of computed tomography density of liver before and after amiodarone administration. Jpn J Radiol 2018; 36:340-344. [PMID: 29611039 DOI: 10.1007/s11604-018-0733-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE To evaluate CT density of liver changes between before and after amiodarone administration. MATERIALS AND METHODS Twenty-five patients underwent non-enhanced CT including the liver before and after amiodarone administration. We set regions of interest (ROIs) at liver S8, spleen, paraspinal muscle, and calculated average CT density in these ROIs, then compared CT density between liver and other organs. Statistical differences between CT density of liver and various ratios before and after administration were determined, along with correlations between cumulative dose of amiodarone and liver density after administration, density change of liver, and various ratios after administration. RESULTS Liver density, liver-to-spleen ratio, and liver-to-paraspinal muscle ratio differed significantly between before and after amiodarone administration. No significant correlations were found between cumulative doses of amiodarone and any of liver density after administration, density change of liver, or various ratios after administration. CONCLUSION CT density of liver after amiodarone administration was significantly higher than that before administration. No correlations were identified between cumulative dose of amiodarone and either liver density after administration or density change of liver. Amiodarone usage should be checked when radiologists identify high density of the liver on CT.
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Affiliation(s)
- Masazumi Matsuda
- Department of Radiology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan.
| | - Aoi Otaka
- Department of Radiology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Tomoki Tozawa
- Department of Radiology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Tomoyuki Asano
- Department of Radiology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Koichi Ishiyama
- Department of Radiology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Manabu Hashimoto
- Department of Radiology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
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8
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Pecnik P, Ranftl V, Windpessl M. High liver density on CT imaging due to amiodarone toxicity. Wien Klin Wochenschr 2018; 130:220-221. [PMID: 29396800 DOI: 10.1007/s00508-018-1319-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 01/16/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Philipp Pecnik
- Department of Hematology, Nephrology and Dialysis, Klinikum Wels-Grieskirchen, Grieskirchnerstraße 42, 4600, Wels, Austria.
| | - Verena Ranftl
- Department of Hematology, Nephrology and Dialysis, Klinikum Wels-Grieskirchen, Grieskirchnerstraße 42, 4600, Wels, Austria
| | - Martin Windpessl
- Department of Hematology, Nephrology and Dialysis, Klinikum Wels-Grieskirchen, Grieskirchnerstraße 42, 4600, Wels, Austria
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Drug Induced Steatohepatitis: An Uncommon Culprit of a Common Disease. BIOMED RESEARCH INTERNATIONAL 2015; 2015:168905. [PMID: 26273591 PMCID: PMC4529891 DOI: 10.1155/2015/168905] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/27/2015] [Accepted: 02/04/2015] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a leading cause of liver disease in developed countries. Its frequency is increasing in the general population mostly due to the widespread occurrence of obesity and the metabolic syndrome. Although drugs and dietary supplements are viewed as a major cause of acute liver injury, drug induced steatosis and steatohepatitis are considered a rare form of drug induced liver injury (DILI). The complex mechanism leading to hepatic steatosis caused by commonly used drugs such as amiodarone, methotrexate, tamoxifen, valproic acid, glucocorticoids, and others is not fully understood. It relates not only to induction of the metabolic syndrome by some drugs but also to their impact on important molecular pathways including increased hepatocytes lipogenesis, decreased secretion of fatty acids, and interruption of mitochondrial β-oxidation as well as altered expression of genes responsible for drug metabolism. Better familiarity with this type of liver injury is important for early recognition of drug hepatotoxicity and crucial for preventing severe forms of liver injury and cirrhosis. Moreover, understanding the mechanisms leading to drug induced hepatic steatosis may provide much needed clues to the mechanism and potential prevention of the more common form of metabolic steatohepatitis.
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Mueller SO, Guillouzo A, Hewitt PG, Richert L. Drug biokinetic and toxicity assessments in rat and human primary hepatocytes and HepaRG cells within the EU-funded Predict-IV project. Toxicol In Vitro 2015; 30:19-26. [PMID: 25952325 DOI: 10.1016/j.tiv.2015.04.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 03/24/2015] [Accepted: 04/15/2015] [Indexed: 12/17/2022]
Abstract
The overall aim of Predict-IV (EU-funded collaborative project #202222) was to develop improved testing strategies for drug safety in the late discovery phase. One major focus was the prediction of hepatotoxicity as liver remains one of the major organ leading to failure in drug development, drug withdrawal and has a poor predictivity from animal experiments. In this overview we describe the use and applicability of the three cell models employed, i.e., primary rat hepatocytes, primary human hepatocytes and the human HepaRG cell line, using four model compounds, chlorpromazine, ibuprofen, cyclosporine A and amiodarone. This overview described the data generated on mode of action of liver toxicity after long-term repeat-dosing. Moreover we have quantified parent compound and its distribution in various in vitro compartments, which allowed us to develop biokinetic models where we could derive real exposure concentrations in vitro. In conclusion, the complex data set enables quantitative measurements that proved the concept that we can define human relevant free and toxic exposure levels in vitro. Further compounds have to be analyzed in a broader concentration range to fully exploit these promising results for improved prediction of hepatotoxicity and hazard assessment for humans.
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Affiliation(s)
- Stefan O Mueller
- Nonclinical Safety, Merck Serono, Merck KGaA, Darmstadt, Germany; Food Chemistry and Toxicology, TU Kaiserslautern, Kaiserslautern, Germany.
| | | | - Philip G Hewitt
- Nonclinical Safety, Merck Serono, Merck KGaA, Darmstadt, Germany
| | - Lysiane Richert
- KaLy-Cell, 20A Rue du Général Leclerc, Plobsheim, France; Université de Franche-Comté, 25030 Besançon, France
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Ramesh Varkhede N, Jhajra S, Suresh Ahire D, Singh S. Metabolite identification studies on amiodarone in in vitro (rat liver microsomes, rat and human liver S9 fractions) and in vivo (rat feces, urine, plasma) matrices by using liquid chromatography with high-resolution mass spectrometry and multiple-stage mass spectrometry: characterization of the diquinone metabolite supposedly responsible for the drug's hepatotoxicity. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2014; 28:311-331. [PMID: 24395499 DOI: 10.1002/rcm.6787] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 11/05/2013] [Accepted: 11/10/2013] [Indexed: 06/03/2023]
Abstract
RATIONALE Several mechanisms have been anticipated for the toxicity of amiodarone, such as oxidative stress, lipid peroxidation, phospholipidosis, free radical generation, etc. Amiodarone is structurally similar to benzbromarone, an uricosuric agent, which was withdrawn from European markets due to its idiosyncratic hepatotoxicity. A proposed reason behind the toxicity of benzbromarone was the production of a reactive ortho-diquinone metabolite, which was found to form adducts with glutathione. Therefore, taking a clue that a similar diquinone metabolite of amiodarone may be the reason for its hepatotoxicity, metabolite identification studies were carried out on the drug using liquid chromatography/mass spectrometry (LC/MS) tools. METHODS The studies involved in vitro (rat liver microsomes, rat liver S9 fraction, human liver S9 fraction) and in vivo (rat feces, urine, plasma) models, wherein the samples were analyzed by employing LC/HRMS, LC/MS(n) and HDE-MS. RESULTS AND CONCLUSIONS A total of 26 metabolites of amiodarone were detected in the investigated in vitro and in vivo matrices. The suspected ortho-diquinone metabolite was one of them. The formation of the same might be an added reason for the hepatotoxicity shown by the drug.
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Affiliation(s)
- Ninad Ramesh Varkhede
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S. Nagar, 160 062, Punjab, India
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Kim BB, Kim DM, Choi DH, Chung JW, Koh YY, Chang KS, Hong SP. Amiodarone toxicity showing high liver density on CT scan with normal liver function and plasma amiodarone levels in a long-term amiodarone user. Int J Cardiol 2014; 172:494-5. [PMID: 24485640 DOI: 10.1016/j.ijcard.2014.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 12/31/2013] [Accepted: 01/07/2014] [Indexed: 02/04/2023]
Affiliation(s)
- Bo-Bae Kim
- Chosun University Hospital, Department of Internal Medicine, Republic of Korea
| | - Dong-Min Kim
- Chosun University Hospital, Department of Internal Medicine, Republic of Korea.
| | - Dong-Hyun Choi
- Chosun University Hospital, Department of Internal Medicine, Republic of Korea
| | - Joong-Wha Chung
- Chosun University Hospital, Department of Internal Medicine, Republic of Korea
| | - Young-Youp Koh
- Chosun University Hospital, Department of Internal Medicine, Republic of Korea
| | - Kyong-Sig Chang
- Chosun University Hospital, Department of Internal Medicine, Republic of Korea
| | - Soon-pyo Hong
- Chosun University Hospital, Department of Internal Medicine, Republic of Korea
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13
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Amiodarone-induced cirrhosis of liver: what predicts mortality? ISRN CARDIOLOGY 2013; 2013:617943. [PMID: 23577267 PMCID: PMC3612472 DOI: 10.1155/2013/617943] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 02/11/2013] [Indexed: 02/07/2023]
Abstract
Introduction. Amiodarone has been used for more than 5 decades for the treatment of various tachyarrhythmias and previously for the treatment of refractory angina. There are multiple well-established side effects of amiodarone. However, amiodarone-induced cirrhosis (AIC) of liver is an underrecognized complication. Methods. A systematic search of Medline from January 1970 to November 2012 by using the following terms, amiodarone and cirrhosis, identified 37 reported cases of which 30 were used in this analysis. Patients were divided into 2 subsets, survivors versus nonsurvivors, at 5 months. Results. Aspartate aminotransferase was significantly lower (P = 0.03) in patients who survived at 5-months (mean 103.33 IU/L) compared to nonsurvivors (mean 216.88 IU/L). There was no statistical difference in the levels of prothrombin time, total bilirubin, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase, cumulative dose, and latency period between the two groups. The prevalence of DM, HTN, HLD, CAD, and CHF was similar in the two groups. None of the above-mentioned variables could be identified as a predictor of survival at 5 months. Conclusion. AIC carries a mortality risk of 60% at 5 months once the diagnosis is established. Further prospective studies are needed to identify predictors of AIC and of mortality or survival in cases of AIC.
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Cho YS, Han JH, Chae HB, Kim JS, Kang KM, Park SM, Lim JC. A Case of Simultaneously Occurred Amiodarone-induced Hepatitis and Hypothyroidism. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2013; 62:59-63. [DOI: 10.4166/kjg.2013.62.1.59] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Young Shim Cho
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hee Bok Chae
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jae Su Kim
- Department of Internal Medicine, Yuseong Sun Hospital, Daejeon, Korea
| | - Ky Man Kang
- Department of Internal Medicine, Yuseong Sun Hospital, Daejeon, Korea
| | - Sang Min Park
- Department of Internal Medicine, Yuseong Sun Hospital, Daejeon, Korea
| | - Jun Cheol Lim
- Department of Internal Medicine, Yuseong Sun Hospital, Daejeon, Korea
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15
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Lahbabi M, Aqodad N, Ibrahimi A, Lahlou M, Aqodad H. Acute hepatitis secondary to parenteral amiodarone does not preclude subsequent oral therapy. World J Hepatol 2012; 4:196-8. [PMID: 22761971 PMCID: PMC3388118 DOI: 10.4254/wjh.v4.i6.196] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 09/04/2011] [Accepted: 06/23/2012] [Indexed: 02/06/2023] Open
Abstract
Amiodarone chlorhydrate is a diiodated benzofuran derivative used to treat cardiac rhythm abnormalities. Hepatotoxicity is a relatively uncommon side effect of amiodarone and symptomatic hepatic dysfunction occurs in less than 1% to 3% of patients taking amiodarone. We report here on an unusual case of amiodarone-induced hepatotoxicity. A 29 year old woman with normal liver function was given amiodarone intravenously to treat her atrial fibrillation. She developed acute toxic hepatitis after 24 h. The intravenous form of amiodarone was immediately avoided and replaced by the oral form, using conventional loading doses as soon as the deranged liver function tests had normalized, without recurrence of the hepatitis. These observations show that the occurrence of acute hepatic impairment with intravenous amiodarone does not necessarily preclude the use of this drug by mouth and the necessity of monitoring the hepatic function of patients treated with amiodarone.
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Affiliation(s)
- Mounia Lahbabi
- Mounia Lahbabi, Nouredine Aqodad, Adil Ibrahimi, Department of Hepato-Gastroenterology, Hassan II University Hospital, Fes 30000, Morocco
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16
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Trigo P, Fischer GW. Managing atrial fibrillation in the elderly: critical appraisal of dronedarone. Clin Interv Aging 2012; 7:1-13. [PMID: 22291468 PMCID: PMC3267401 DOI: 10.2147/cia.s16677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Atrial fibrillation is the most commonly seen arrhythmia in the geriatric population and is associated with increased cardiovascular morbidity and mortality. Treatment of the elderly with atrial fibrillation remains challenging for physicians, because this unique subpopulation is characterized by multiple comorbidities requiring chronic use of numerous medications, which can potentially lead to severe drug interactions. Furthermore, age-related changes in the cardiovascular system as well as other physiological changes result in altered drug pharmacokinetics. Dronedarone is a new drug recently approved for the treatment of arrhythmias, such as atrial fibrillation and/or atrial flutter. Dronedarone is a benzofuran amiodarone analog which lacks the iodine moiety and contains a methane sulfonyl group that decreases its lipophilicity. These differences in chemical structure are responsible for making dronedarone less toxic than amiodarone which, in turn, results in fewer side effects. Adverse events for dronedarone include gastrointestinal side effects and rash. No dosage adjustments are required for patients with renal impairment. However, the use of dronedarone is contraindicated in the presence of severe hepatic dysfunction.
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Affiliation(s)
- Paula Trigo
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY, USA
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Begriche K, Massart J, Robin MA, Borgne-Sanchez A, Fromenty B. Drug-induced toxicity on mitochondria and lipid metabolism: mechanistic diversity and deleterious consequences for the liver. J Hepatol 2011; 54:773-94. [PMID: 21145849 DOI: 10.1016/j.jhep.2010.11.006] [Citation(s) in RCA: 366] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 11/05/2010] [Accepted: 11/09/2010] [Indexed: 02/08/2023]
Abstract
Numerous investigations have shown that mitochondrial dysfunction is a major mechanism of drug-induced liver injury, which involves the parent drug or a reactive metabolite generated through cytochromes P450. Depending of their nature and their severity, the mitochondrial alterations are able to induce mild to fulminant hepatic cytolysis and steatosis (lipid accumulation), which can have different clinical and pathological features. Microvesicular steatosis, a potentially severe liver lesion usually associated with liver failure and profound hypoglycemia, is due to a major inhibition of mitochondrial fatty acid oxidation (FAO). Macrovacuolar steatosis, a relatively benign liver lesion in the short term, can be induced not only by a moderate reduction of mitochondrial FAO but also by an increased hepatic de novo lipid synthesis and a decreased secretion of VLDL-associated triglycerides. Moreover, recent investigations suggest that some drugs could favor lipid deposition in the liver through primary alterations of white adipose tissue (WAT) homeostasis. If the treatment is not interrupted, steatosis can evolve toward steatohepatitis, which is characterized not only by lipid accumulation but also by necroinflammation and fibrosis. Although the mechanisms involved in this aggravation are not fully characterized, it appears that overproduction of reactive oxygen species by the damaged mitochondria could play a salient role. Numerous factors could favor drug-induced mitochondrial and metabolic toxicity, such as the structure of the parent molecule, genetic predispositions (in particular those involving mitochondrial enzymes), alcohol intoxication, hepatitis virus C infection, and obesity. In obese and diabetic patients, some drugs may induce acute liver injury more frequently while others may worsen the pre-existent steatosis (or steatohepatitis).
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Affiliation(s)
- Karima Begriche
- Department of Metabolism and Aging, The Scripps Research Institute, Jupiter, FL 33458, USA
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Amacher DE. Strategies for the early detection of drug-induced hepatic steatosis in preclinical drug safety evaluation studies. Toxicology 2010; 279:10-8. [PMID: 20974209 DOI: 10.1016/j.tox.2010.10.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 09/21/2010] [Accepted: 10/18/2010] [Indexed: 12/14/2022]
Abstract
Hepatic steatosis is characterized by the accumulation of lipid droplets in the liver. Although relatively benign, simple steatosis can eventually lead to the development of steatohepatitis, a more serious condition characterized by fibrosis, cirrhosis, and eventual liver failure if the underlying cause is not eliminated. According to the "two hit" theory of steatohepatitis, the initial hit involves fat accumulation in the liver, and a second hit leads to inflammation and subsequent tissue injury. Because some xenobiotics target liver fatty acid metabolism, especially mitochondrial β-oxidation, it is important to avoid potential drug candidates that can contribute to either the initiation of liver steatosis or progression to the more injurious steatohepatitis. The gold standard for the detection of these types of hepatic effects is histopathological examination of liver tissue. In animal studies, these examinations are slow, restricted to a single sampling time, and limited tissue sections. Recent literature suggests that rapid in vitro screening methods can be used early in the drug R&D process to identify compounds with steatotic potential. Further, progress in the identification of potential serum or plasma protein biomarkers for these liver changes may provide additional in vivo tools to the preclinical study toxicologist. This review summarizes recent developments for in vitro screening and in vivo biomarker detection for steatotic drug candidates.
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Affiliation(s)
- David E Amacher
- Sciadvisor Toxicology Consulting, P.O. Box 254, Hadlyme, CT 06439, USA.
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Taylor CJ, Hodgkinson J, Hobbs FDR. Rhythm control agents and adverse events in patients with atrial fibrillation. Int J Clin Pract 2010; 64:1069-75. [PMID: 20487051 DOI: 10.1111/j.1742-1241.2010.02426.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the commonest rhythm disorder and has major impact on patients. Controversy remains about the best treatment strategy between rate and rhythm control (in addition to adequate thromboprophylaxis). Rhythm control agents are associated with clinically important adverse events. AIM The aim of this study was to assess the risk of adverse events in patients with AF receiving rhythm control agents. DESIGN OF STUDY This is a retrospective case control note review and outcome linkage analysis. SETTING Setting of this study included patients with a diagnosis of AF receiving amiodarone, flecainide or sotalol in practices registered with the General Practice Research Database (GPRD) in the UK. METHOD This is a retrospective case control note review and outcome linkage analysis on the GPRD routine clinical dataset to evaluate the adverse events and predictors of treatment discontinuation in patients using licenced rhythm modifying medication. RESULTS Adverse events are more common in patients currently or previously taking amiodarone, flecainide or sotalol than age- and gender-matched controls. All three antiarrhythmics were associated with increased all-cause mortality. Congestive heart failure was more common in all amiodarone and sotalol users as well as past users of flecainide. Thyroid disease was more common in patients treated with amiodarone and sotalol but only amiodarone had an increased risk of pulmonary toxicity. The number of patients with liver failure was too small in all cases for statistical analysis. CONCLUSION The rhythm control agents amiodarone, flecainide and sotalol have significant adverse effects which can lead to discontinuation of their use. This should be considered when deciding the most appropriate treatment option for patients with AF.
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Affiliation(s)
- C J Taylor
- Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Birmingham, UK.
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Giri S, Nieber K, Bader A. Hepatotoxicity and hepatic metabolism of available drugs: current problems and possible solutions in preclinical stages. Expert Opin Drug Metab Toxicol 2010; 6:895-917. [DOI: 10.1517/17425251003792521] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Arkun A, Van Deusen SK, Grau T, Birkhahn RH. Hepatic Dysfunction and Neurotoxicity in a Patient Receiving Long-Term Low-Dose Amiodarone Therapy. J Emerg Med 2010; 38:337-9. [DOI: 10.1016/j.jemermed.2008.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2007] [Revised: 12/12/2007] [Accepted: 01/09/2008] [Indexed: 12/20/2022]
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Donato MT, Martínez-Romero A, Jiménez N, Negro A, Herrera G, Castell JV, O'Connor JE, Gómez-Lechón MJ. Cytometric analysis for drug-induced steatosis in HepG2 cells. Chem Biol Interact 2009; 181:417-23. [PMID: 19647728 DOI: 10.1016/j.cbi.2009.07.019] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 07/22/2009] [Accepted: 07/23/2009] [Indexed: 12/01/2022]
Abstract
Drugs are capable of inducing hepatic lipid accumulation. When fat accumulates, lipids are primarily stored as triglycerides which results in steatosis and provides substrates for lipid peroxidation. An in vitro multiparametric flow cytometry assay was performed in HepG2 cells by using fluorescent probes to analyze cell viability (propidium iodide, PI), lipid accumulation (BODIPY493/503), mitochondrial membrane potential (tetramethyl rhodamine methyl ester, TMRM) and reactive oxygen species generation (ROS) (2',7'-dihydrochlorofluorescein diacetate, DHCF-DA) as functional markers. All the measurements were restricted to live cells by gating the cells that excluded PI or those that exhibited the typical forward and side scatter features of live cells. The assay was qualified by analyzing a number of selected model drugs with a well documented induction of steatosis in vivo using different mechanisms as positive controls and several non-steatosic compounds as negative controls. For the cytometric screening assay, the concentrations tested were up to the corresponding IC(10) value determined by the MTT assay. Among the parameters analyzed, increased BODIPY fluorescence was the most sensitive and selective marker of drug-induced steatosis. However, a more consistent predictive approach was the combination of two endpoints: lipid accumulation and ROS generation. The assay correctly identified 100% of steatosis-positive and steatosis-negative compounds, and a high steatosis risk was predicted for amiodarone, doxycycline, tetracycline and valproate treatments at therapeutic doses. The results suggest that this cell-based assay may be a useful approach to identify the potential of drug candidates to induce steatosis.
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Affiliation(s)
- M Teresa Donato
- Unidad de Hepatología Experimental, Centro de Investigación, Hospital La Fe, Avda Campanar 21, 46009 Valencia, Spain
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Llanos L, Moreu R, Peiró AM, Pascual S, Francés R, Such J, Horga JF, Pérez-Mateo M, Zapater P. Causality assessment of liver injury after chronic oral amiodarone intake. Pharmacoepidemiol Drug Saf 2009; 18:291-300. [PMID: 19165760 DOI: 10.1002/pds.1709] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM The number of patients receiving amiodarone will increase in future years. As clinically significant hepatotoxicity associated with oral amiodarone is infrequent and difficult to predict, a new Bayesian-developed model is proposed to help in the causality assessment of amiodarone-induced liver injury. METHODS Incidence of abnormal liver enzymes in patients receiving amiodarone was obtained from placebo controlled clinical trials. Published case reports of amiodarone-induced hepatotoxicity were identified through a literature search. Maximum number of expected hepatotoxicity cases in amiodarone and placebo-treated patients was calculated using Poisson distribution. The calculated odds ratio was used as a Prior Odds (PrO) to subsequent quantification, using a Bayesian-approach, of individual amiodarone-induced hepatotoxicity likelihood. RESULTS PrO of amiodarone-induced hepatotoxicity was 0.48. Thirty nine amiodarone-associated hepatotoxicity case reports were retrieved. Half of published case reports developed an irreversible damage. The amiodarone Bayesian model combining information about latency period and period of remission, together with analytical parameters properly defines the toxicity profile shown in published case reports. The analytical pattern defined by this model is different from the one expected if liver injury in published cases was caused by other etiologies. CONCLUSIONS A method based on a Bayesian-approach, which links information from clinical trials with clinical hepatotoxicity profile from published case reports can be a useful tool for amiodarone-induced liver injury causality assessment. At present, this method is limited due to scarcity and quality of available data. Further efforts are needed to improve model ability in order to identify amiodarone-induced liver injury.
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Affiliation(s)
- Lucía Llanos
- Clinical Pharmacology Section, University General Hospital, Alicante, Spain.
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Kim SJ, Koo BW, Bae JH, Lim SW. Amiodarone Induced Toxic Hepatitis - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2007.53.4.528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Seon Jung Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Bon Wook Koo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Jin Ho Bae
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Seung Woon Lim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungbuk National University, Cheongju, Korea
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Abstract
Amiodarone chlorhydrate is a diiodated benzofuran derivative, and it is used to treat cardiac rhythm abnormalities. Hepatotoxicity is a relatively uncommon side effect of amiodarone, and symptomatic hepatic dysfunction occurs in fewer than 1% of the patients taking amiodarone. Cirrhosis is a rare complication that's been confirmed in 12 cases. Peripheral neuropathy occurs in 10% of patients taking aminodarone. We report here on an unusual case of amiodarone-induced hepatotoxicity and peripheral neurotoxicity. A 75 year old man with normal liver function was given amiodarone for treating his atrial fibrillation and heart failure. He developed nausea, vomiting, muscle weakness and wasting after 17.8 months therapy with amiodarone (400 mg orally once per day). Liver biopsy showed the presence of foam cells in the hepatic sinusoids and Mallory bodies in the periportal hepatocytes on light microscopy. Sural nerve biopsy showed demyelination, and nerve conduction studies showed mixed sensorimotor polyneuropathy. These observations show the necessity of monitoring the hepatic function and conducting neurologic examination of the patients treated with amiodarone.
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Affiliation(s)
- Hyun Mo Kang
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yoon Sae Kang
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Seok Hyun Kim
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Kyu Seong
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dae Young Kang
- Department of Pathology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Heon Young Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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