Atrium and paroxetine-related severe hepatitis

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.

Antidepressant-lnduced Liver Injury

Objective:

To review principles of drug-induced liver injury (DILI), summarize characteristics of antidepressant-mediated liver Injury, and provide recommendations for monitoring and management.

Data Sources:

A search relating to antidepressant-induced liver injury was performed using MEDLINE (1966–March 2007). Search terms included antidepressant, cholestasis, hepatotoxicity, jaundice, liver injury, toxic hepatitis, and transaminases. Reference citations not Identified in the initial database search were also utilized.

Study Selection and Data Extraction:

All English-language case reports, letters, and review articles identified from the data sources were used. Case reports and letters relating to hepatotoxicity from antidepressant overdose were excluded.

Data Synthesis:

Antidepressant-induced liver injury described in published cases were of the idiopathic type and, by definition, cannot be predicted based on dose or specific risk factors. Paroxetine had the largest number of cases within the selective serotonin-reuptake inhibitor class. Nefazodone, a serotonin–norepinephrine reuptake inhibitor, appeared to have the most serious cases and is the only antidepressant agent that carries a Food and Drug Administration Black Box Warning regarding hepatotoxiciiy. The tricyclic antidepressants and monoamine oxidase Inhibitors are capable of producing hepatotoxicity, but fewer cases with these agents have been reported in the past 15 years, possibly due to a decline in their use. Causality has not been well established in all reports due to the concurrent use of other drugs and/or underlying liver disease.

Conclusions:

Most antidepressant agents have the potential to produce idiopathic liver injury. There is no way to prevent idiopathic DILI, but the severity of the reaction may be minimized with prompt recognition and early withdrawal of the agent. The clinician must be careful to provide ongoing therapy of the underlying depressive disorder and be aware of possible drug discontinuation syndromes should potential hepatotoxicity be suspected.

Toxic hepatitis associated with paroxetine

Hepatotoxicity is a rare complication of paroxetine, a selective serotonin reuptake inhibitor. Regarded as safe in therapeutic use, there have been reports of cases of severe hepatic dysfunction with gross elevations of transaminase levels that may be related to this drug. We report here severe adverse cholestatic and hepatocellular injury in a patient taking paroxetine probably due to an immune-mediated hypersensitivity reaction.

Hepatic injury and pancreatitis during treatment with serotonin reuptake inhibitors: data from the World Health Organization (WHO) database of adverse drug reactions

Severe hepatic adverse drug reactions have been occasionally reported in the literature for the selective serotonin reuptake inhibitors (SSRIs), venlafaxine and nefazodone. In addition, a few case reports have suggested a possible association between SSRI treatment and pancreatitis. To further investigate this issue, a Bayesian confidence propagation neural network (BCPNN) method was applied on the World Health Organization database of adverse drug reactions. This method identifies whether a drug/adverse drug reaction combination is reported more frequently to the database than expected on the basis of chance alone compared to general reporting in the database. A statistically significant unexpected high number of reports were found for nefazodone and hepatic injury, relative to the generality of the dataset but, for the other drug/adverse drug reaction combinations, no such association was found. The nefazodone finding is in accordance with data from other publications, suggesting that the risk of hepatic injury is increased. However, because of the nature of the BCPNN, the negative findings do not necessarily prove that there is no excess risk for hepatic injury/pancreatitis during treatment with drugs other than nefazodone. Further studies are required using alternative methodologies to demonstrate whether the selective serotonin reuptake inhibitors or venlafaxine may cause hepatic injury or pancreatitis.

Severe hepatotoxicity with jaundice associated with paroxetine

Hepatotoxicity due to paroxetine, a selective serotonin reuptake inhibitor, is very rare, and to the best of our knowledge, only five cases of liver injury in association with paroxetine have previously been reported in the medical literature. We describe the clinical, biochemical, and pathological findings in a patient with paroxetine hepatotoxicity, which was reversed after withdrawal of the drug. The present case and the others previously reported suggest that hepatotoxicity should be taken into account as a rare complication, sometimes severe, that may occur with paroxetine.

Fulminant chemical hepatitis possibly associated with donepezil and sertraline therapy

OBJECTIVE

To describe a case of fulminant hepatitis possibly related to concomitant donepezil and seratriline therapy.

PATIENT AND SETTING

An 83-year-old woman treated in a dementia care facility and later in a tertiary medical center.

INTERVENTION AND MANAGEMENT

Discontinuation of donepezil and sertraline therapy with subsequent improvement evidenced by liver biopsy and liver function tests.

RESULTS

An older woman with Alzheimer's disease was admitted to a dementia care facility because of aggressive behavior. Treatment with sertraline was initiated in February 1998. Sertraline doses were increased gradually to 200 mg daily by May 1998, and some improvement in behavior was seen. Concomitant therapy with donepezil 5 mg qhs was initiated June 26, 1998. Ten days later, confusion and jaundice were noted. Total bilirubin was 5.6 mg/dL, GGTP was 1,208 IU/L, and alkaline phosphatase was 369 IU/L. Computed tomography revealed cholelithiasis without ductal dilation. Liver, spleen, and pancreas seemed normal. Donepezil and sertraline were discontinued. The patient was admitted to our institution and treated for dehydration. A liver biopsy revealed scattered portal eosinophils and prominent cholestasis consistent with acute chemical hepatitis. The GGTP and total bilirubin of this patient peaked at 2,235 IU/L and 22.6 mg/dL, respectively. The patient improved, and her liver function tests normalized over the next 2 months.