Transient increase of liver enzymes induced by risperidone: two case reports

Systematic management approach to pharmacotherapy for people with learning disabilities

With progressive deinstitutionalisation in many countries, the general psychiatrist is now more frequently requested to provide assistance with behavioural problems in people with learning disabilities. There are a range of challenges in providing quality care for these people. There are challenges in assessment and diagnosis, in coordinating behavioural and social interventions with pharmacotherapy, and in the lack of psychopharmacological research in this population, which results in a diminished evidence base. In addition, there are numerous factors beyond the patient. These include legal consent requirements and the complex system of carers surrounding those with disabilities with whom the practitioner may need to interact.

Psychotropic drugs and liver disease: A critical review of pharmacokinetics and liver toxicity

The liver is the organ by which the majority of substances are metabolized, including psychotropic drugs. There are several pharmacokinetic changes in end-stage liver disease that can interfere with the metabolization of psychotropic drugs. This fact is particularly true in drugs with extensive first-pass metabolism, highly protein bound drugs and drugs depending on phase I hepatic metabolic reactions. Psychopharmacological agents are also associated with a risk of hepatotoxicity. The evidence is insufficient for definite conclusions regarding the prevalence and severity of psychiatric drug-induced liver injury. High-risk psychotropics are not advised when there is pre-existing liver disease, and after starting a psychotropic agent in a patient with hepatic impairment, frequent liver function/lesion monitoring is advised. The authors carefully review the pharmacokinetic disturbances induced by end-stage liver disease and the potential of psychopharmacological agents for liver toxicity.

Risperidone- and Quetiapine-Induced Cholestasis

Objective:

To describe a case of a patient who developed drug-induced cholestasis after being on risperidone maintenance therapy for 8 years.

Case Summary:

A 30-year-old male with schizoaffective disorder, bipolar type, and insulin-dependent diabetes mellitus had been stable on risperidone 6 mg at night for 8 years. His other medications included lithium 900 mg twice daily and enalapril 5 mg daily, as well as regular insulin and NPH insulin as needed. The patient developed cholestasis that resolved once risperidone was discontinued. Over the next 11 months, he tolerated trials of ziprasidone and olanzapine. When quetiapine was initiated, the patient developed signs and symptoms of cholestasis within 3 weeks after starting this medication. The signs and symptoms of cholestasis resolved with removal of quetiapine. The Naranjo probability scale indicated that these atypical antipsychotics (risperidone and quetiapine) were the probable cause of cholestasis in this patient.

Discussion:

It is well known that atypical antipsychotics can cause isolated asymptomatic increases in aminotransferase levels. Liver injury, both the hepatic and cholestatic type, has been described previously, although the incidence with atypical antipsychotics is rare.

Conclusions:

To our knowledge, this is the first case of cholestasis that developed after years of treatment and reappeared with another antipsychotic agent. Given that liver failure, of either the hepatic or cholestatic type, is a relatively rare phenomenon with atypical antipsychotics, it seems that the most reasonable approach to manage this risk is through education. By educating patients on early warning signs of hepatotoxicity, this rare but potentially fatal consequence could be detected early to allow appropriate intervention.

Antipsychotics and abnormal liver function tests: systematic review

OBJECTIVE

Systematic assessment of the prevalence and pattern of liver function test (LFT) abnormalities associated with regular antipsychotics in adult humans and consideration of management of such abnormalities.

DATA SOURCES

Systematic search identifying cohort, cross-sectional or case studies/series, reporting LFT abnormalities in patients receiving regular antipsychotics. EMBASE, PsychINFO, and MEDLINE were searched for studies in English from record onset.

STUDY SELECTION

Abstracts were independently screened for eligibility by 2 researchers. Ineligible studies included those that did not report LFT reference ranges, those that studied fewer than 10 patients on a given antipsychotic, and those studying children.

DATA EXTRACTION

Key variables in group studies were extracted. Case studies/series were examined for patient outcome.

DATA SYNTHESIS

Ten group studies and 91 case studies/series were eligible, although quality was poor. All groups receiving regular antipsychotics had a prevalence of LFT abnormalities greater than chance. The median percentage of patients with any abnormal LFT on any antipsychotic was 32%, with a range of 5% to 78%. The median percentage of patients with clinically significant elevations was 4%, with a range of 0% to 15%. Transaminases were most commonly elevated. Abnormalities were generally asymptomatic, arose within 6 weeks, and were either stably persistent or resolved with continued treatment. Case reports suggested that antipsychotics can be associated with severe hepatitis, fatal in a small minority of cases. Chlorpromazine is most commonly associated with acute liver injury.

CONCLUSIONS

The LFT abnormalities in patients receiving regular antipsychotics are common but generally mild and transient. Very rarely, a severe or fatal hepatic injury can emerge.

Six months of treatment with risperidone may be associated with nonsignificant abnormalities of liver function tests in children and adolescents: a longitudinal, observational study from Turkey

OBJECTIVE

Risperidone is a promising agent for the treatment of schizophrenia, Tourette's disorder, mood disorders, and disruptive behavior disorders in young populations. However, adverse effects of risperidone may take a long time to emerge. The objective of this study was to investigate the changes in the liver function tests (LFTs) associated with more than 6 months of risperidone treatment in children and adolescents.

METHOD

A total of 102 youths treated with risperidone for more than 6 months were eligible for the study. For this study, patients' baseline and follow-up weight and hepatobiliary function tests, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), and serum bilirubin levels, were measured at baseline and at 6 months.

RESULTS

Asymptomatic abnormalities of LFTs, mostly ALP elevation, were found in 38.2% of the cases, and marked elevation of liver enzymes was found in 0.8% of cases treated with risperidone. The mean levels of liver enzymes and bilirubin of the patients were significantly higher than the baseline after first and sixth months of treatment. However, there was no statistically significant change in the liver enzymes and bilirubin levels between the first and sixth months. There was no significant relationship between changes in weight and liver enzymes and bilirubin levels after 6 months of risperidone treatment.

CONCLUSION

These findings suggest that risperidone treatment in the long term commonly leads to liver function changes, although at therapeutic doses in children and adolescents it may rarely induce a serious hepatic toxicity. Concomitant use of antidepressants and methylphenidate and variations in age and pubertal status are limitations of present study. Further studies are needed to assess the importance and role of other variables over LFT abnormalities in youth population.

Risperidone and liver function tests in children and adolescents: a short-term prospective study

OBJECTIVE

Revealing of unknown adverse effects of atypical antipsychotics on pediatric population may take a long period of time. The purpose of this prospective study is to document changes in the liver function tests (LFTs) associated with risperidone usage in a group of children and adolescents.

METHOD

Study subjects consist of 120 youths with ages ranging from 3-17 years. For this study, patients' baseline and follow-up weight and hepatobiliary function tests including alanine aminotransferases(ALT) and aspartat aminotransferases (AST), gamma gluatamyl transerase (GGT), alkaline phosphatase (ALP) and serum bilirubin levels were measured before and after the treatment period of one month.

RESULTS

Only one male patient's ALT levels increased up to three-fold and AST levels increased up to two-fold of the basal levels. First month mean levels of liver enzymes and billuribin of the patients were significantly higher than the baseline. Sixty-three patients (52.5%) showed an asymptomatic increase in the liver enzymes and/or billuribin levels of the first month of this study. Weight gain was observed in 58 patients (57.4%). There was no significant association between changes in weight and liver enzymes and billuribin levels.

CONCLUSION

We found clinically non significant liver function test abnormalities mostly in the form of ALP elevation in 52.5% and marked liver enzymes elevation in 0.8% of risperidone-treated subjects. However use of concomitant medications and variations in age are the limitations of this study. These findings suggest that risperidone treatment in the short term may lead to liver function changes in children and adolescents.

A review of liver function tests during treatment with atypical antipsychotic drugs: a chart review study

OBJECTIVE

Atypical antipsychotic drugs commonly cause asymptomatic increase in the liver enzymes and serum bilirubin levels. However they rarely may induce a serious hepatic toxicity. In this article we aimed to evaluate the effect of atypical antipsychotic drugs namely olanzapine, risperidone and quetiapine on the hepatic enzymes and serum bilirubin levels in psychiatric patients.

METHOD

Chart reviews of 312 patient followed-up at Psychiatry Department of Zonguldak Karaelmas University Hospital were examined in detail. The patients whose baseline and follow-up liver function tests including alanine aminotransfeaminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alkaline phosphotase (ALP) and serum bilirubin that were measured before and within the treatment period of first and sixth months were enrolled. Forty eight males and 62 females whose ages ranging from 12 to 65 years were eligible for this study (no pregnant case was present).

RESULTS

The repartition according to treatment is as follows: olanzapine (n=33), risperidone (n=29), and quetiapine (n=48). Two of the 110 patients (1.8%) presented with increased AST levels of up to 4 fold and ALT of thrice the basal level and needed to stop treatment (AST increase in one female with olanzapine 20 mg/day; ALT increase in one male with olanzapine 30 mg/day). Thirty of the 110 patients (27.2%) showed asymptomatic increases in ALT, AST, GGT and serum bilirubin levels in the first month of the study. After 6 months of the treatment, abnormalities in the liver function tests were observed in 25 patients (22.7%).

CONCLUSION

These results were in accordance with previous studies that asymptomatic increase of liver enzymes are common but significant liver enzyme elevations are rare during atypical antipsychotic treatment. We suggest that obtaining baseline liver enzyme tests before atypical antipsychotic therapy and monitoring regularly specifically in patients with risk factors for liver damage during therapy.

Association between antipsychotic-induced elevation of liver enzymes and weight gain: a prospective study

We conducted a prospective, open study in schizophrenia patients treated with second-generation antipsychotics in order to investigate the risk for elevation of liver enzymes and its correlation to antipsychotic-induced weight gain. Body mass index, serum transaminases, plasma serum levels of the antipsychotic used, and blood cell counts were measured weekly during the first 6 weeks of treatment and monthly thereafter. A considerable proportion of subjects showed an increase beyond normal levels of at least one of the measured transaminases. In all but one case, the elevation of liver enzymes was transient. We found a statistically significant correlation between weight gain and liver enzyme elevation. The group of patients that had gained at least 7% of the baseline body weight showed significantly higher increases of transaminases as compared with those who had gained less than 7% weight. We conclude that antipsychotic-induced elevation of liver enzymes is mostly transient and could be associated with weight gain.

Liver function tests during treatment with antipsychotic drugs: a case series of 23 patients

Atypical antipsychotics represent a new class of medication for the treatment of schizophrenia and their use is associated with a reduction of neurological side effects. This article reports the result of the systematic clinical and biological supervision of hepatic enzymes on 23 schizophrenic inpatients treated by atypical antipsychotic during 2 weeks at Days 1 (D1), 7 (D7), and 14 (D14) in a naturalistic study during 6 months. The drug administrated was limited to four medications--risperidone, amisulpride, olanzapine, and clozapine--but other psychotropic agents were prescribed. Six cases of biological cytolytic hepatitis were observed. Due to the numerous risk factors and the frequency of "routine" conditions, careful supervision of the hepatic function is needed to prevent this kind of side effect.

The pharmacology and toxicology of atypical antipsychotic agents

Recently, atypical antipsychotic agents have largely replaced traditional agents as first-line drugs for the treatment of schizophrenia. It is likely that atypical agents will soon account for the majority of poisonings from antipsychotic agents that present to health care facilities in the US. This article reviews the pharmacodynamics, pharmacokinetics, and toxicology of atypical antipsychotic drugs, chiefly clozapine, risperidone, olanzapine, and quetiapine. A descriptive summary of the human overdose experience with these agents is provided. Adverse effect and drug interaction data are reviewed. Based on the available pharmacodynamic, pharmacokinetic, and human overdose data, recommendations on management are provided.