Drug-induced liver disease related to citalopram

Escitalopram-induced hepatitis: A case report

BACKGROUND

The antidepressant escitalopram is widely prescribed for the treatment of depression. It is generally well-tolerated, and cholestasis is not mentioned in its summary of product characteristics (SmPC). We present a case of cholestatic and cytolysis liver injury due to escitalopram and a VigiBase^® study.

CASE SUMMARY

A 68-year-old man was admitted to our emergency unit due to clinical jaundice associated with hepatitis, pruritus and dark urine. We tested the patient for the most common etiologies of jaundice, including hemolysis, viral hepatitis, cirrhosis, carcinoma, cholangitis, cholelithiasis and intrahepatic or extrahepatic obstruction. The etiological study was negative, and an adverse drug reaction was the sole possible explanation. The patient was receiving treatment with escitalopram. Two days after its withdrawal, pruritus was resolved. Ten days after withdrawal, clinical jaundice disappeared. It took a month and three weeks after withdrawal for the patient to have normalized liver function tests. To our knowledge, this is the first reported case of cholestasis where treatment with escitalopram was the only possible cause, with a highly probable causality. In addition, we determined whether escitalopram is associated with hepatotoxicity and cholestasis by performing a disproportionality analysis. All cases of hepatobiliary disorders induced by escitalopram and reported in the World Health Organization pharmacovigilance database (VigiBase^®) were analyzed to characterize this toxicity. We found that patients treated with escitalopram had an increased risk of hepatitis [odds ratio (OR) = 1.938^{(1.186-3.166)}] and cholestasis [OR = 1.866^{(1.279-2.724)}] [OR (95% confidence interval)]. The median duration between the introduction of escitalopram and the occurrence of acute hepatitis and/or cholestasis was ten days +/- seven days.

CONCLUSION

Although extremely rare, this case report, the review of the literature and the pharmacovigilance update confirm that escitalopram can cause drug-induced hepatotoxicity and cholestasis, generally within a week after initiation. Thus, escitalopram should be withdrawn immediately if an iatrogenic cause cannot be excluded. If its responsibility is ascertained, escitalopram should be consequently contraindicated. In addition, serotoninergic antidepressants in patients with non-severe depression are ineffective and harmful. Finally, the SmPC of escitalopram should be updated to alert for this risk and give clear clinical guidelines.

Antidepressants- and antipsychotics-induced hepatotoxicity

Drug-induced liver injury (DILI) is a serious health burden. It has diverse clinical presentations that can escalate to acute liver failure. The worldwide increase in the use of psychotropic drugs, their long-term use on a daily basis, common comorbidities of psychiatric and metabolic disorders, and polypharmacy in psychiatric patients increase the incidence of psychotropics-induced DILI. During the last 2 decades, hepatotoxicity of various antidepressants (ADs) and antipsychotics (APs) received much attention. Comprehensive review and discussion of accumulated literature data concerning this issue are performed in this study, as hepatotoxic effects of most commonly prescribed ADs and APs are classified, described, and discussed. The review focuses on ADs and APs characterized by the risk of causing liver damage and highlights the ones found to cause life-threatening or severe DILI cases. In parallel, an overview of hepatic oxidative stress, inflammation, and steatosis underlying DILI is provided, followed by extensive review and discussion of the pathophysiology of AD- and AP-induced DILI revealed in case reports, and animal and in vitro studies. The consequences of some ADs and APs ability to affect drug-metabolizing enzymes and therefore provoke drug–drug interactions are also addressed. Continuous collecting of data on drugs, mechanisms, and risk factors for DILI, as well as critical data reviewing, is crucial for easier DILI diagnosis and more efficient risk assessment of AD- and AP-induced DILI. Higher awareness of ADs and APs hepatotoxicity is the prerequisite for their safe use and optimal dosing.

Autoimmune hepatitis in association with ramelteon

Ramelteon is a nonscheduled insomnia medication that lacks the abuse potential and residual effects common for other sedative-hypnotics. Distinct in its mechanism, the drug is a melatonin agonist with a high affinity for the membrane receptors MT1 and MT2. Although it therapeutically targets the suprachiasmatic nucleus of the hypothalamus, many organ systems have melatonin receptors and thus may be influenced by ramelteon. A growing body of research on melatonin indicates that it modulates the immune system. Indeed, immune cells have been shown to synthesize and to respond to this compound through receptors including MT1 and MT2. Melatonin's effects are generally immunostimulatory, and there is evidence to suggest that the chemical may potentiate autoimmunty. Here, we describe a case of autoimmune hepatitis that developed in a 50-year-old man after starting ramelteon for insomnia. The temporal association between ramelteon initiation and disease development, as well as the immunomodulatory properties of melatonergic compounds, suggest a role for ramelteon in the etiology of his illness.

Which psychotropic medications induce hepatotoxicity?

OBJECTIVE

Safe prescribing practices to minimize pharmaceutically induced liver damage or worsening of preexisting conditions require knowledge about medicines with hepatotoxic potential. This paper reviews psychotropic medications and their effects on the liver.

METHODS

A MEDLINE search was performed utilizing the phrase "drug-induced liver injury" with various categories of psychiatric drugs. Only articles written in English were utilized.

RESULTS

Hepatotoxicity can be acute or chronic in nature. Medication discontinuation is necessary in acute forms, while close monitoring is required in milder forms of medication-induced chronic liver damage. Nefazodone, pemoline and/or tacrine are the highest offenders. Carbamazepine and valproate products (e.g., divalproex) can lead to this adverse event and should be avoided in patients with liver disease, persons with alcohol misuse or those consuming high doses of acetaminophen.

CONCLUSION

Knowing the risk levels associated with various medicines is important; prescribing multiple drugs with hepatotoxic effects should be avoided. One should educate patients about early warning signs of liver injury. Always provide clinical and laboratory monitoring before and during the use of hepatotoxic drugs. Clinical features and laboratory results govern medication prescribing with ongoing risk-to-benefit ratio assessment during pharmacotherapy.