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Lewis JH, Korkmaz SY, Rizk CA, Copeland MJ. Diagnosis, prevention and risk-management of drug-induced liver injury due to medications used to treat mycobacterium tuberculosis. Expert Opin Drug Saf 2024:1-15. [PMID: 39212296 DOI: 10.1080/14740338.2024.2399074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/19/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Many of the first line medications for the treatment of active and latent M. tuberculosis are hepatoxic and cause a spectrum of anti-tuberculosis drug induced liver injury (ATLI), including acute liver failure (ALF). Despite advances in recognition of and prevention of ATLI, isoniazid remains one of the leading causes of DILI as well as drug-induced ALF. AREAS COVERED A literature search of the incidence, risk factors, current societal guidelines, monitoring, and prophylactic medication usage in ATLI was performed using PubMed and institutional websites. Relevant articles from 1972 to 2024 were included in this review. EXPERT OPINION Current societal guidelines regarding ATLI monitoring are mixed, but many recommend liver enzyme testing of high-risk populations. We recommend liver test monitoring for all patients on multi-drug therapy as well as those on isoniazid therapy. Precision medicine practices, such as N-acetyltransferase-2 polymorphism genotyping, are thought to be beneficial in reducing the incidence of ATLI in high-risk populations. However, broader implementation is currently cost prohibitive. Hepatoprotective drugs are not currently recommended, although we do recognize their potential. In patients who develop ATLI but require ongoing anti-TB treatment, strategies to restart the same or less hepatotoxic regimens are currently being followed.
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Affiliation(s)
- James H Lewis
- Department of Medicine, Division of Gastroenterology-Hepatology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Serena Y Korkmaz
- Department of Medicine, General Internal Medicine, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Courtney A Rizk
- Department of Medicine, General Internal Medicine, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Matthew J Copeland
- Department of Medicine, Division of Infectious Diseases, Washington, DC, USA
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Thomas L, Raju AP, Mallayasamy S, Rao M. Precision Medicine Strategies to Improve Isoniazid Therapy in Patients with Tuberculosis. Eur J Drug Metab Pharmacokinet 2024; 49:541-557. [PMID: 39153028 PMCID: PMC11365851 DOI: 10.1007/s13318-024-00910-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 08/19/2024]
Abstract
Due to interindividual variability in drug metabolism and pharmacokinetics, traditional isoniazid fixed-dose regimens may lead to suboptimal or toxic isoniazid concentrations in the plasma of patients with tuberculosis, contributing to adverse drug reactions, therapeutic failure, or the development of drug resistance. Achieving precision therapy for isoniazid requires a multifaceted approach that could integrate various clinical and genomic factors to tailor the isoniazid dose to individual patient characteristics. This includes leveraging molecular diagnostics to perform the comprehensive profiling of host pharmacogenomics to determine how it affects isoniazid metabolism, such as its metabolism by N-acetyltransferase 2 (NAT2), and studying drug-resistant mutations in the Mycobacterium tuberculosis genome for enabling targeted therapy selection. Several other molecular signatures identified from the host pharmacogenomics as well as other omics-based approaches such as gut microbiome, epigenomic, proteomic, metabolomic, and lipidomic approaches have provided mechanistic explanations for isoniazid pharmacokinetic variability and/or adverse drug reactions and thereby may facilitate precision therapy of isoniazid, though further validations in larger and diverse populations with tuberculosis are required for clinical applications. Therapeutic drug monitoring and population pharmacokinetic approaches allow for the adjustment of isoniazid dosages based on patient-specific pharmacokinetic profiles, optimizing drug exposure while minimizing toxicity and the risk of resistance. Current evidence has shown that with the integration of the host pharmacogenomics-particularly NAT2 and Mycobacterium tuberculosis genomics data along with isoniazid pharmacokinetic concentrations in the blood and patient factors such as anthropometric measurements, comorbidities, and type and timing of food administered-precision therapy approaches in isoniazid therapy can be tailored to the specific characteristics of both the host and the pathogen for improving tuberculosis treatment outcomes.
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Affiliation(s)
- Levin Thomas
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576104, India
| | - Arun Prasath Raju
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576104, India
| | - Surulivelrajan Mallayasamy
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576104, India
| | - Mahadev Rao
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576104, India.
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Yoon JG, Jang DG, Cho SG, Lee C, Noh SH, Seo SK, Yu JW, Chung HW, Han K, Kwon SS, Han DH, Oh J, Jang IJ, Kim SH, Jee YK, Lee H, Park DW, Sohn JW, Yoon HJ, Kim CH, Lee JM, Kim SH, Lee MG. Synergistic toxicity with copper contributes to NAT2-associated isoniazid toxicity. Exp Mol Med 2024; 56:570-582. [PMID: 38424191 PMCID: PMC10984958 DOI: 10.1038/s12276-024-01172-8] [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] [Received: 06/21/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 03/02/2024] Open
Abstract
Anti-tuberculosis (AT) medications, including isoniazid (INH), can cause drug-induced liver injury (DILI), but the underlying mechanism remains unclear. In this study, we aimed to identify genetic factors that may increase the susceptibility of individuals to AT-DILI and to examine genetic interactions that may lead to isoniazid (INH)-induced hepatotoxicity. We performed a targeted sequencing analysis of 380 pharmacogenes in a discovery cohort of 112 patients (35 AT-DILI patients and 77 controls) receiving AT treatment for active tuberculosis. Pharmacogenome-wide association analysis was also conducted using 1048 population controls (Korea1K). NAT2 and ATP7B genotypes were analyzed in a replication cohort of 165 patients (37 AT-DILI patients and 128 controls) to validate the effects of both risk genotypes. NAT2 ultraslow acetylators (UAs) were found to have a greater risk of AT-DILI than other genotypes (odds ratio [OR] 5.6 [95% confidence interval; 2.5-13.2], P = 7.2 × 10-6). The presence of ATP7B gene 832R/R homozygosity (rs1061472) was found to co-occur with NAT2 UA in AT-DILI patients (P = 0.017) and to amplify the risk in NAT2 UA (OR 32.5 [4.5-1423], P = 7.5 × 10-6). In vitro experiments using human liver-derived cell lines (HepG2 and SNU387 cells) revealed toxic synergism between INH and Cu, which were strongly augmented in cells with defective NAT2 and ATP7B activity, leading to increased mitochondrial reactive oxygen species generation, mitochondrial dysfunction, DNA damage, and apoptosis. These findings link the co-occurrence of ATP7B and NAT2 genotypes to the risk of INH-induced hepatotoxicity, providing novel mechanistic insight into individual AT-DILI susceptibility. Yoon et al. showed that individuals who carry NAT2 UAs and ATP7B 832R/R genotypes are at increased risk of developing isoniazid hepatotoxicity, primarily due to the increased synergistic toxicity between isoniazid and copper, which exacerbates mitochondrial dysfunction-related apoptosis.
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Affiliation(s)
- Jihoon G Yoon
- Department of Pharmacology, BK21 Project of Yonsei Advanced Medical Science, Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Genomic Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Geon Jang
- Department of Pharmacology, BK21 Project of Yonsei Advanced Medical Science, Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Gyu Cho
- Department of Microbiology and Immunology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chaeyoung Lee
- Department of Pharmacology, BK21 Project of Yonsei Advanced Medical Science, Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Shin Hye Noh
- Department of Pharmacology, BK21 Project of Yonsei Advanced Medical Science, Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul, Republic of Korea
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soo Kyung Seo
- Department of Pharmacology, BK21 Project of Yonsei Advanced Medical Science, Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Woo Yu
- Department of Pharmacology, BK21 Project of Yonsei Advanced Medical Science, Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyeon Woo Chung
- Department of Microbiology and Immunology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - KyeoRe Han
- Department of Microbiology and Immunology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon Sung Kwon
- Department of Pharmacology, BK21 Project of Yonsei Advanced Medical Science, Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dai Hoon Han
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - In-Jin Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Sang-Hoon Kim
- Department of Internal Medicine, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Young-Koo Jee
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Hyun Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Dong Won Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jang Won Sohn
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Ho Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Chul Hoon Kim
- Department of Pharmacology, BK21 Project of Yonsei Advanced Medical Science, Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Myun Lee
- Department of Microbiology and Immunology, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea.
| | - Min Goo Lee
- Department of Pharmacology, BK21 Project of Yonsei Advanced Medical Science, Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Amaeze OU, Isoherranen N. Application of a physiologically based pharmacokinetic model to predict isoniazid disposition during pregnancy. Clin Transl Sci 2023; 16:2163-2176. [PMID: 37712488 PMCID: PMC10651660 DOI: 10.1111/cts.13614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/08/2023] [Accepted: 08/02/2023] [Indexed: 09/16/2023] Open
Abstract
Pregnancy can increase the risk of latent tuberculosis infection (LTBI) progression to tuberculosis (TB) disease. Isoniazid (INH) is the preferred preventative treatment for LTBI in pregnancy. INH is mainly cleared by N-acetyltransferase 2 (NAT2) but the pharmacokinetics (PK) of INH in different NAT2 phenotypes during pregnancy is not well characterized. To address this knowledge gap, we used physiologically based pharmacokinetic (PBPK) modeling to evaluate NAT2 phenotype-specific effects of pregnancy on INH disposition. A whole-body PBPK model for INH was developed and verified for non-pregnant NAT2 fast (FA), intermediate (IA), and slow (SA) acetylators. Model predictive performance was assessed using a drug-specific model acceptance criterion for mean plasma area under the curve (AUC) and peak plasma concentration (Cmax ), and the absolute average fold error (AAFE) for individual plasma concentrations. The verified model was extended to simulate INH disposition during pregnancy in NAT2 SA, IA, and FA populations. A sensitivity analysis was conducted using the verified PBPK model and known changes in INH disposition during pregnancy to determine whether NAT2 activity changes during pregnancy or other INH clearance pathways are altered. This analysis suggested that NAT2 activity is unchanged while other INH clearance pathways increase by ~80% during pregnancy. The model was applied to explore the effect of pregnancy on INH disposition in two ethnic populations with different NAT2 phenotype distributions and with high TB burden. Our PBPK model can be used to predict INH disposition during pregnancy in diverse populations and expanded to other drugs cleared by NAT2 during pregnancy.
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Affiliation(s)
- Ogochukwu U. Amaeze
- Department of PharmaceuticsUniversity of Washington, School of PharmacySeattleWashingtonUSA
| | - Nina Isoherranen
- Department of PharmaceuticsUniversity of Washington, School of PharmacySeattleWashingtonUSA
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Chen Y, Guan S, Guan Y, Tang S, Zhou Y, Wang X, Bi H, Huang M. Novel clinical biomarkers for drug-induced liver injury. Drug Metab Dispos 2021; 50:671-684. [PMID: 34903588 DOI: 10.1124/dmd.121.000732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/07/2021] [Indexed: 11/22/2022] Open
Abstract
Drug-induced liver injury (DILI) remains a critical clinical issue and has been a treatment challenge nowadays as it was in the past. However, the traditional biomarkers or indicators are insufficient to predict the risks and outcome of patients with DILI due to its poor specificity and sensitivity. Recently, the development of high-throughput technologies, especially omics and multi-omics has sparked growing interests in identification of novel clinical DILI biomarkers, many of which also provide a mechanistic insight. Accordingly, in this mini-review, we summarize recent advances in novel clinical biomarkers for DILI prediction, diagnosis and prognosis and highlight the limitations or challenges involved in biomarker discovery or their clinical translation. Although huge work has been done, most reported biomarkers lack comprehensive information and more specific DILI biomarkers are still needed to complement the traditional biomarkers such as ALT or AST in clinical decision making. Significance Statement The current review outlines an overview of novel clinical biomarkers for DILI identified in clinical retrospective or prospective clinical analysis. Many of these biomarkers provides a mechanistic insight and are promising to complement the traditional DILI biomarkers. This work also highlights the limitations or challenges involved in biomarker discovery or their clinical translation.
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Affiliation(s)
- Youhao Chen
- School of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-Sen University, China
| | - Shaoxing Guan
- School of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-Sen University, China
| | | | - Siyuan Tang
- School of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-Sen University, China
| | - Yanying Zhou
- School of Pharmaceutical Sciences, Sun Yat-sen University, China
| | - Xueding Wang
- School of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-Sen University, China
| | - Huichang Bi
- School of Pharmaceutical Sciences, Sun Yat-sen University, China
| | - Min Huang
- School of Pharmaceutical Sciences, Sun Yat-sen University, China
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Abstract
Nowadays multiple heterogeneous chemicals affect the human body. They include drugs, household chemicals, dyes, food supplements and others. The human organism can modify, inactivate, and eliminate the chemicals by biotransformation enzymes. But it is well known that biotransformation can lead to toxification phenomenon. Individuals differ from each other by the rate of chemical modification that promotes accumulation of toxins and carcinogens in some patients. An N-acetyltransferase 2 enzyme participates in the aromatic amines second phase metabolism. This work reviews the acetyltransferase gene polymorphism possible role in diseases development including drug-induced organs damage.Gene of acetyltransferase has polymorphisms associated with two haplotypes of fast and slow substrate acetylation. Gene alleles combine in three genotypes: fast, intermediate, and slow acetylators. Acetylation rate plays a significant role in side effects development during tuberculosis treatment and cancer pathogenesis. Recently, new data described the role of enzyme in development of non-infectious diseases in the human. Scientists consider that slow acetylation genotype in combination with high xenobiotic load result in accumulation of toxic substances able to damage cells.Therefore, acetyltransferase genotyping helps to reveal risk groups of cancer and non-infectious disease development and to prescribe more effective and safe doses of drugs.
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Levano KS, Jaramillo-Valverde L, Tarazona DD, Sanchez C, Capristano S, Vásquez-Loarte T, Solari L, Mendoza-Ticona A, Soto A, Rojas C, Zegarra-Chapoñan R, Guio H. Allelic and genotypic frequencies of NAT2, CYP2E1, and AADAC genes in a cohort of Peruvian tuberculosis patients. Mol Genet Genomic Med 2021; 9:e1764. [PMID: 34510815 PMCID: PMC8580101 DOI: 10.1002/mgg3.1764] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/02/2021] [Accepted: 07/03/2021] [Indexed: 11/06/2022] Open
Abstract
Background We determined the frequency of genetic polymorphisms in three anti‐TB drug metabolic proteins previously reported: N‐acetyltransferase 2 (NAT2), cytochrome P450 2E1 (CYP2E1), and arylacetamide deacetylase (AADAC) within a Peruvian population in a cohort of TB patients. Methods We genotyped SNPs rs1041983, rs1801280, rs1799929, rs1799930, rs1208, and rs1799931 for NAT2; rs3813867 and rs2031920 for CYP2E1; and rs1803155 for AADAC in 395 participants completed their antituberculosis treatment. Results Seventy‐four percent of the participants are carriers of slow metabolizer genotypes: NAT2*5, NAT2*6, and NAT2*7, which increase the sensitivity of INH at low doses and increase the risk of drug‐induced liver injuries. Sixty‐four percent are homozygous for the wild‐type CYP2E1*1A allele, which could increase the risk of hepatotoxicity. However, 16% had a NAT2 fast metabolizer phenotype which could increase the risk of acquiring resistance to INH, thereby increasing the risk of multidrug‐resistant (MDR) or treatment failure. The frequency of rs1803155 (AADAC*2 allele) was higher (99.9%) in Peruvians than in European American, African American, Japanese, and Korean populations. Conclusions This high prevalence of slow metabolizers for isoniazid in the Peruvian population should be further studied and considered to help individualize drug regimens, especially in countries with a great genetic diversity like Peru. These data will help the Peruvian National Tuberculosis Control Program develop new strategies for therapies.
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Affiliation(s)
| | | | | | | | | | | | | | - Alberto Mendoza-Ticona
- Estrategia Sanitaria Nacional de Prevención y Control de Tuberculosis en el Perú, MINSA, Lima, Peru
| | - Alonso Soto
- Instituto de investigación en Ciencias Biomédicas (INICIB), Facultad de Medicina, Universidad Ricardo Palma, Lima, Peru.,Departamento de Medicina, Hospital Nacional Hipólito Unanue, Lima, Peru
| | | | | | - Heinner Guio
- Instituto Nacional de Salud, Lima, Peru.,Universidad de Huánuco, Huánuco, Peru.,Universidad Científica del Sur, Lima, Peru
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