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Mertens JE, Bömmer MTC, Regier MB, Gabriëls G, Pavenstädt H, Grünewald I, Horvath J, Trebicka J, Schmidt H, Schlevogt B. Liver Injury after Selective Androgen Receptor Modulator Intake: A Case Report and Review of the Literature. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:935-943. [PMID: 37871633 DOI: 10.1055/a-2165-6323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Liver injury associated with selective androgen receptor modulators (SARMs) is an issue that has not been reported often. We report a case of a previously healthy 24-year-old male, who was referred to our hospital for severe jaundice with intense pruritus. He had previously taken the SARM Enobosarm (also known as Ostarine) for muscle-building purposes. Blood serum levels of total bilirubin exceeded 30 mg/dL with only a slight elevation of liver enzymes. Liver biopsy revealed isolated hepatocellular cholestasis (bland cholestasis) with limited inflammation or necrosis. Supportive treatment was begun in our hospital with molecular adsorbent recirculation system (MARS) albumin dialysis, as well as cholestyramine for pruritus relief. During therapy, bilirubin levels and symptoms regressed, and after five sessions of dialysis, the patient could be released from our clinic in a markedly improved clinical and laboratory condition. However, bilirubin parameters regressed slowly after this, reaching normal levels as late as six months after first intake of the compound. Exome-based genetic testing brought about no pathogenic variants for cholestatic liver disease in our patient. Nevertheless, three common heterozygous polymorphisms associated with an increased risk for intrahepatic cholestasis could be identified. Our case demonstrates that SARMs can cause severe liver injuries not prominently mentioned in safety data sheets. Therefore, these compounds constitute a potential danger to the user's health. This holds especially true when taking SARMs without supervision by a medical professional, which should consist of a thorough monitoring of liver enzyme and bilirubin levels.
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Affiliation(s)
- Jonas E Mertens
- Department of Medicine B, University Hospital Münster, Münster, Germany
- Department of Biochemistry, University of Oxford, Oxford, United Kingdom of Great Britain and Northern Ireland
| | - M Till C Bömmer
- Department of Medicine B, University Hospital Münster, Münster, Germany
- Department of Neurology and Research Center Neurosensory Sciences, University of Oldenburg, Oldenburg, Germany
| | - Manuel B Regier
- Department of Medicine D, University Hospital Münster, Münster, Germany
| | - Gert Gabriëls
- Department of Medicine D, University Hospital Münster, Münster, Germany
| | | | - Inga Grünewald
- Department of Pathology, University Hospital Münster, Münster, Germany
| | - Judit Horvath
- Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Jonel Trebicka
- Department of Medicine B, University Hospital Münster, Münster, Germany
| | - Hartmut Schmidt
- Department of Medicine B, University Hospital Münster, Münster, Germany
- Department for Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Bernhard Schlevogt
- Department of Medicine B, University Hospital Münster, Münster, Germany
- Department of Gastroenterology, Medical Center Osnabrück, Osnabrück, Germany
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Matusak M, Aljabban J, Wirtz M, Agni R, Spengler E. Cholestasis Linked to Bodybuilding Supplements: Exploring the Risks of Contamination. Case Reports Hepatol 2024; 2024:5112461. [PMID: 38826497 PMCID: PMC11142851 DOI: 10.1155/2024/5112461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 10/26/2023] [Accepted: 04/22/2024] [Indexed: 06/04/2024] Open
Abstract
Drug-induced liver injury resulting from herbal and dietary supplement use is increasingly common and underrecognized. We report a case of a 34-year-old male recreational bodybuilder who presented with muscle cramping, fatigue, and diffuse itching in the setting of bodybuilding supplement use. Labs showed cholestatic liver injury, and liver biopsy revealed bland cholestasis and sinusoidal dilation. He was diagnosed with anabolic-androgenic steroid-induced liver injury. He was symptomatically managed with plasmapheresis for debilitating pruritus. This case highlights drug-induced liver injury as a complication of bodybuilding supplement use containing unlabeled anabolic-androgenic steroids. Sports medicine providers should inquire on herbal and dietary supplement use and be aware of potential contaminants.
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Affiliation(s)
- Mark Matusak
- Department of Family Medicine, University of Wisconsin Hospital and Clinics, Madison, USA
| | - Jihad Aljabban
- Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, USA
| | - Mark Wirtz
- Department of Family Medicine, University of Wisconsin Hospital and Clinics, Madison, USA
| | - Rashmi Agni
- Department of Pathology, University of Wisconsin Hospital and Clinics, Madison, USA
| | - Erin Spengler
- Department of Gastroenterology and Hepatology, University of Wisconsin Hospital and Clinics, Madison, USA
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Stephens C. Editorial: Muscles at the expense of liver injury. Is it worth it? Aliment Pharmacol Ther 2024; 59:1003-1004. [PMID: 38523081 DOI: 10.1111/apt.17929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
LINKED CONTENTThis article is linked to Nash et al paper. To view this article, visit https://doi.org/10.1111/apt.17906
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Affiliation(s)
- C Stephens
- Servicio de Gastroenterología, Instituto de Investigación Biomédica de Málaga-IBIMA Plataforma BIONAND, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Nash E, Nicoll A, Batt N, George J, Perananthan V, Prince D, Wallace M, Gow P, Vaz K, Chitturi S, Flores JE, Braund A, Bonnichsen M, Riordan S, Humphris J, Duong T, McKenzie C, Liu K, Strasser SI. Drug-induced liver injury from selective androgen receptor modulators, anabolic-androgenic steroids and bodybuilding supplements in Australia. Aliment Pharmacol Ther 2024; 59:953-961. [PMID: 38372012 DOI: 10.1111/apt.17906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/11/2023] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Reports of DILI due to herbal and dietary supplements have been increasing over time. AIMS To characterise clinical, laboratory and histopathological phenotypes and outcomes of drug-induced liver injury (DILI) due to anabolic-androgenic steroids (AAS), selective androgen receptor modulators (SARMs), and bodybuilding supplements (BBS) in Australia. METHODS Retrospective case series. Patients presented to nine Australian tertiary hospitals, 2017-2023. DILI was defined biochemically and patients were included if their treating physician attributed DILI to preceding use of AAS, SARMs or BBS. Primary endpoint was time to normalisation of liver biochemistry. Secondary endpoints were hospitalisation for investigation or management of DILI, death attributable to liver injury, and liver transplantation. RESULTS Twenty-three cases of DILI were identified, involving 40 drugs: 18 AAS, 14 SARMs and eight BBS. Patients were predominantly male (22/23), with median age 30 years (IQR 26-42). Most were symptomatic (21/23). Median latency of onset was 58 days (IQR 28-112 days) from drug commencement. Most patients (17/23) were admitted to hospital. Based on updated Roussel Uclaf Causality Assessment Method, DILI was possible in 17/23, probable in 2/23 and unlikely in 4/23. Median time to normalisation of liver biochemistry was 175 days (IQR 70-292 days) from presentation. Three (3/23) were treated with corticosteroids, 14/23 were treated for itch, and one (1/23) underwent liver transplantation. There were no deaths. CONCLUSIONS The prognosis of DILI from AAS, SARMs and BBS is good although liver transplantation may rarely be required. A detailed drug history is important in uncovering DILI due to these supplements.
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Affiliation(s)
- Emily Nash
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | | | | | - Jacob George
- Storr Liver Centre, Westmead Millennium Institute, Westmead Hospital, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Varan Perananthan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - David Prince
- Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael Wallace
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Paul Gow
- Austin Health, Melbourne, Victoria, Australia
| | - Karl Vaz
- Austin Health, Melbourne, Victoria, Australia
| | | | - Joan Ericka Flores
- The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Alicia Braund
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Mark Bonnichsen
- Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Stephen Riordan
- Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Jeremy Humphris
- The Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Tuan Duong
- The Wollongong Hospital, Wollongong, New South Wales, Australia
| | | | - Ken Liu
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Ahmed T, Ahmad J. Recent advances in the diagnosis of drug-induced liver injury. World J Hepatol 2024; 16:186-192. [PMID: 38495272 PMCID: PMC10941738 DOI: 10.4254/wjh.v16.i2.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/03/2024] [Accepted: 02/03/2024] [Indexed: 02/27/2024] Open
Abstract
Drug-induced liver injury (DILI) is a major problem in the United States, commonly leading to hospital admission. Diagnosing DILI is difficult as it is a diagnosis of exclusion requiring a temporal relationship between drug exposure and liver injury and a thorough work up for other causes. In addition, DILI has a very variable clinical and histologic presentation that can mimic many different etiologies of liver disease. Objective scoring systems can assess the probability that a drug caused the liver injury but liver biopsy findings are not part of the criteria used in these systems. This review will address some of the recent updates to the scoring systems and the role of liver biopsy in the diagnosis of DILI.
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Affiliation(s)
- Taqwa Ahmed
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Jawad Ahmad
- Department of Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States.
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Dukewich M, Stolz AA. Anabolic steroid-associated liver injury. Clin Liver Dis (Hoboken) 2024; 23:e0196. [PMID: 38872787 PMCID: PMC11168845 DOI: 10.1097/cld.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/27/2024] [Indexed: 06/15/2024] Open
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Hayashi PH, Hoofnagle JH. Diagnostic challenges in drug-induced liver injury. Clin Liver Dis (Hoboken) 2024; 23:e0206. [PMID: 38831765 PMCID: PMC11146506 DOI: 10.1097/cld.0000000000000206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/09/2024] [Indexed: 06/05/2024] Open
Affiliation(s)
- Paul H. Hayashi
- Division of Hepatology and Nutrition, Office of New Drugs, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jay H. Hoofnagle
- Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Rivero-Pino F, Casanova AG. Hepatotoxicity due to dietary supplements: state-of-the-art, gaps and perspectives. Crit Rev Toxicol 2023; 53:601-610. [PMID: 38062980 DOI: 10.1080/10408444.2023.2282415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/23/2023] [Indexed: 12/22/2023]
Abstract
Food supplements are products intended to complement the normal diet and consist of concentrated sources of nutrients or other substances with a nutritional or physiological effect. Although they are generally considered safe if the manufacturer's recommendations are followed, many of them have shown hepatotoxic properties. This can cause many diseases (e.g. steatohepatitis and cirrhosis) characterized by progressive damage and malfunction of the liver that in the long term can lead to death. A review of the literature was carried out to elucidate which dietary supplements have been associated with cases of hepatotoxicity in recent years, with emphasis on those relevant to the consumer and the new trends (e.g. cannabidiol). It has been reported that the supplements described as hepatotoxic are mainly of botanical origin (e.g. green tea or turmeric) and those used in sports (mainly anabolic androgenic steroids). There is a great variability of compounds described as causing liver damage, although sometimes it is not possible to identify them, because they are contaminants or adulterants of the products. In addition, the prevalence of toxic effects after the administration of supplements is difficult to define due to underreporting and the lack of specific studies. Globally regarding hepatotoxicity of dietary supplements, there is a paucity of well-conducted clinical trials on the efficacy of these compounds and the frequency of related liver damage, as the use of these products is largely uncontrolled.
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Affiliation(s)
- Fernando Rivero-Pino
- Department of Medical Biochemistry, Molecular Biology, and Immunology, School of Medicine, University of Seville, Seville, Spain
| | - Alfredo G Casanova
- Toxicology Unit, Universidad de Salamanca, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
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Fontana RJ, Bjornsson ES, Reddy R, Andrade RJ. The Evolving Profile of Idiosyncratic Drug-Induced Liver Injury. Clin Gastroenterol Hepatol 2023; 21:2088-2099. [PMID: 36868489 DOI: 10.1016/j.cgh.2022.12.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 03/05/2023]
Abstract
Idiosyncratic drug-induced liver injury (DILI) is an infrequent but important cause of liver disease. Newly identified causes of DILI include the COVID vaccines, turmeric, green tea extract, and immune checkpoint inhibitors. DILI is largely a clinical diagnosis of exclusion that requires evaluation for more common causes of liver injury and a compatible temporal association with the suspect drug. Recent progress in DILI causality assessment includes the development of the semi-automated revised electronic causality assessment method (RECAM) instrument. In addition, several drug-specific HLA associations have been identified that can help with the confirmation or exclusion of DILI in individual patients. Various prognostic models can help identify the 5%-10% of patients at highest risk of death. Following suspect drug cessation, 80% of patients with DILI fully recover, whereas 10%-15% have persistently abnormal laboratory studies at 6 months of follow-up. Hospitalized patients with DILI with an elevated international normalized ratio or mental status changes should be considered for N-acetylcysteine therapy and urgent liver transplant evaluation. Selected patients with moderate to severe drug reaction with eosinophilia and systemic symptoms or autoimmune features on liver biopsy may benefit from short-term corticosteroids. However, prospective studies are needed to determine the optimal patients and dose and duration of steroids to use. LiverTox is a comprehensive, freely accessible Web site with important information regarding the hepatotoxicity profile of more than 1000 approved medications and 60 herbal and dietary supplement products. It is hoped that ongoing "omics" studies will lead to additional insight into DILI pathogenesis, improved diagnostic and prognostic biomarkers, and mechanism-based treatments.
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Affiliation(s)
- Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.
| | - Einar S Bjornsson
- Deparment of Internal Medicine, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raul J Andrade
- Division of Gastroenterology and Hepatology, University Hospital-IBIMA Platform BIONAND, University of Malaga, CIBERehd, Spain
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Conway K, Ferstl C, Kumar M. Dietary supplement adulteration - knowledge, attitudes, and practices of California health care professionals: A cross-sectional survey study. PATIENT EDUCATION AND COUNSELING 2023; 114:107824. [PMID: 37290282 DOI: 10.1016/j.pec.2023.107824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/08/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To assess knowledge, attitudes, and practices surrounding dietary supplements (DS) among California health care professionals (HCPs) and assess factors contributing to the frequency with which HCPs discuss DS with patients. METHODS In this cross-sectional study, an online questionnaire was distributed to HCPs in California from December 2021-April 2022 via professional membership email listservs. RESULTS Among 514 HCPs, overall knowledge of DS did not vary significantly by professional group, and 90% had received little to no DS education. Pharmacists (OR = 0.328, p = 0.0001) and those with less reported DS education (OR = 0.58, p = 0.0045; OR = 0.075, p = 0.0097) had a decreased likelihood of initiating conversations about DS more frequently. Females (OR = 2.5, p < 0.0001) and those with a higher knowledge score (OR = 1.2, p = 0.0297) had an increased likelihood of initiating conversations about DS more frequently. CONCLUSIONS HCPs acknowledge the clinical significance of DS adulteration and would benefit from additional informational resources to reduce the adverse effects associated with adulterated supplements. PRACTICE IMPLICATIONS HCPs initiate more conversations about DS use when they are more informed and will gain from staying up to date on DS-related information to encourage more patient communication.
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Affiliation(s)
- Kimberly Conway
- California Department of Public Health, Sacramento, USA; California Epidemiologic Investigation Service (Cal-EIS) Fellowship, Sacramento, USA.
| | - Carrie Ferstl
- California Department of Public Health, Sacramento, USA.
| | - Madhur Kumar
- California Department of Public Health, Sacramento, USA.
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Fontana RJ, Liou I, Reuben A, Suzuki A, Fiel MI, Lee W, Navarro V. AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury. Hepatology 2023; 77:1036-1065. [PMID: 35899384 PMCID: PMC9936988 DOI: 10.1002/hep.32689] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Iris Liou
- University of Washington, Seattle, Washington, USA
| | - Adrian Reuben
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ayako Suzuki
- Division of Gastroenterology, Duke University, Durham, North Carolina, USA
| | - M. Isabel Fiel
- Department of Pathology, Mount Sinai School of Medicine, New York City, New York, USA
| | - William Lee
- Division of Gastroenterology, University of Texas Southwestern, Dallas, Texas, USA
| | - Victor Navarro
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
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12
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Ault TA, Braxton DR, Watson RA, Marcus AO, Fong TL. Mifepristone induced liver injury in a patient with Cushing syndrome: a case report and review of the literature. J Med Case Rep 2023; 17:33. [PMID: 36732814 PMCID: PMC9894739 DOI: 10.1186/s13256-022-03696-x] [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] [Received: 09/07/2022] [Accepted: 11/28/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Mifepristone, also known as RU-486, is an anti-progestational steroid with similar chemical structure to anabolic steroids. Given as a single dose in conjunction with misoprostol, mifepristone is used to induce medical abortion. Mifepristone administered chronically at a higher dose is also approved for the management of hypercortisolism. There have been only 2 reported cases of mifepristone associated liver injury, in both cases, in the setting of Cushing syndrome. We report a third patient with Cushing syndrome with mifepristone induced liver injury with unique histological findings that provide insight to the pathophysiology of liver injury in mifepristone and anabolic steroids. CASE PRESENTATION Patient is a 63-year-old Caucasian female Cushing disease with no prior history of liver disease. She was started on mifepristone and semaglutide. Ninety days after initiating mifepristone, she developed deep jaundice, severe pruritus, fatigue, and nausea. Liver tests revealed a mixed hepatocellular/cholestatic pattern. Viral and autoimmune serologies were negative and there was no biliary dilatation on imaging. Liver biopsy showed severe cholestasis but no bile duct injury. Focal endothelialitis was present within a central venule. Cholestatic symptoms persisted for one month after presentation before slowly subsiding. Four months after stopping mifepristone, the patient's symptoms completely resolved, and liver tests became normal. Compilation of Roussell Uclaf Causality Assessment Method score indicated probable causality. CONCLUSIONS Mifepristone shares a similar chemical structure as synthetic anabolic/androgenic steroids and there are many similarities in the clinical presentation of liver injury. This case and the 2 other reported cases share similar clinical characteristics. The observation of endothelialitis in our patient may provide a mechanistic link between mifepristone, or anabolic steroids in general, and the development of vascular complications such as peliosis.
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Affiliation(s)
- Taylor A. Ault
- grid.414587.b0000 0000 9755 6590Hoag Digestive Health Institute, Hoag Memorial Hospital Presbyterian, One Hoag Drive, Newport Beach, CA 92663 USA
| | - David R. Braxton
- grid.414587.b0000 0000 9755 6590Department of Pathology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA USA
| | - Rebecca A. Watson
- grid.414587.b0000 0000 9755 6590Department of Pathology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA USA
| | | | - Tse-Ling Fong
- grid.414587.b0000 0000 9755 6590Hoag Digestive Health Institute, Hoag Memorial Hospital Presbyterian, One Hoag Drive, Newport Beach, CA 92663 USA
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13
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Smoliga JM, Wilber ZT, Robinson BT. Premature Death in Bodybuilders: What Do We Know? Sports Med 2023; 53:933-948. [PMID: 36715876 PMCID: PMC9885939 DOI: 10.1007/s40279-022-01801-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 01/31/2023]
Abstract
Premature deaths in bodybuilders regularly make headlines and are cited as evidence that bodybuilding is a dangerous activity. A wealth of research has revealed elite athletes typically enjoy lower mortality rates than non-athletes, but research on bodybuilder lifespan is surprisingly limited. Anabolic androgenic steroid (AAS) use is commonly cited as a key contributor to morbidity and premature mortality in bodybuilders, but this area of research is highly nuanced and influenced by numerous confounders unique to bodybuilding. It is quite possible that bodybuilders are at elevated risk and that AAS use is the primary reason for this, but there remains much unknown in this realm. As global participation in bodybuilding increases, and healthcare providers play a more active role in monitoring bodybuilder health, there is a need to identify how numerous factors associated with bodybuilding ultimately influence short- and long-term health and mortality rate. In this Current Opinion, we discuss what is currently known about the bodybuilder lifespan, identify the nuances of the literature regarding bodybuilder health and AAS use, and provide recommendations for future research on this topic.
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Affiliation(s)
- James M. Smoliga
- Department of Physical Therapy, One University Parkway, High Point University, High Point, NC 27268 USA
| | - Z. Taggart Wilber
- Department of Physical Therapy, One University Parkway, High Point University, High Point, NC 27268 USA ,Helix Performance Recovery, Wellington, FL USA
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14
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Pinazo-Bandera JM, García-Cortés M, Segovia-Zafra A, Lucena MI, Andrade RJ. Recreational Drugs and the Risk of Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:5395. [PMID: 36358813 PMCID: PMC9657889 DOI: 10.3390/cancers14215395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/03/2023] Open
Abstract
Recreational or aesthetic drug use is a distinctive behavior of humans, principally attested in the last century. It is known that recreational and illegal drugs are major contributors to the universal morbidity rate worldwide. Many of these substances have a well-established hepatotoxic potential, causing acute or chronic liver injury, liver fibrosis and cirrhosis, but their implications for hepatocellular carcinoma or other varieties of liver tumors are little known. In this article, we perform an extensive literature review, aiming to provide updated information about recreational drug use and the risk of developing liver tumors. Khat use and pyrrolizidine alkaloid consumption (present in some natural plants) have been linked to liver cirrhosis. Kava intake is associated with different liver tumors in animal models but not in humans. Cannabis' potential to accelerate liver fibrosis in chronic hepatitis is controversial according to the existing data. Cigarette smoking is an important contributor to hepatocellular carcinoma, and anabolic androgen steroids are well-defined causes of a variety of liver cancers and other hepatic tumors. Long-term follow-up studies of subjects who have developed injuries in association with the use of recreational drugs are warranted so as to better define the risk of developing hepatocellular carcinoma in association with these substances and, thus, to implement health care policies to combat this preventable cause of cancer.
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Affiliation(s)
- José M. Pinazo-Bandera
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
| | - Miren García-Cortés
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 29010 Madrid, Spain
| | - Antonio Segovia-Zafra
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 29010 Madrid, Spain
- Service of Clinical Pharmacology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
| | - María Isabel Lucena
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 29010 Madrid, Spain
- Service of Clinical Pharmacology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
| | - Raúl J. Andrade
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 29010 Madrid, Spain
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15
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Soares PF, Fernandes MTCF, Souza ADS, Lopes CM, Dos Santos DAC, Oliveira DPR, Pereira MG, Prado NMDBL, Gomes GSDS, Santos G, Paraná R. Causality imputation between herbal products and HILI: An algorithm evaluation in a systematic review. Ann Hepatol 2022; 25:100539. [PMID: 34555512 DOI: 10.1016/j.aohep.2021.100539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 02/04/2023]
Abstract
Algorithms can have several purposes in the clinical practice. There are different scales for causality imputation in DILI (Drug-Induced Liver Injury), but the applicability and validity of these for the HILI (Herb-Induced Liver Injury) evaluation is questionable for some scales. The purpose of the study was to determine the clinical and demographic profile of the patients with HILI, and the main algorithmic scales used in its causality assessment. The methodology was a systematic review of articles in English, Spanish, or Portuguese language, from 1979 to 2019, involving humans, with descriptors related to HILI. Qualitative and quantitative statistical analysis were performed. As a result, from a total of 60 articles, 203 HILI reports were selected: 59.9% were women, similar with other studies, and the average age was 45.8 years. Jaundice was the most frequent symptom and regarding the type of lesion, the hepatocellular was the most frequent. In regard to HILI severity, 3.0% were severe and 7.6% were fatal or required liver transplantation. In 72.3% of the cases, the most used algorithm was RUCAM (Roussel Uclaf Causality Assessment Method). The conclusion of the study is that RUCAM was the most used algorithm for causality assessment in HILI. The patients were predominantly female, jaundice was the main symptom, and HILI is reversible in the majority of cases.
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Affiliation(s)
- Pedro Felipe Soares
- School Medicine of Bahia- University Federal of Bahia, Av. Rector Miguel Calmon, S/N - Vale do Canela, 40110-100, Salvador - BA, Brazil.
| | | | | | - Caio Medina Lopes
- Faculty of Pharmacy - University Federal of Bahia, Salvador, BA, Brazil.
| | | | | | | | | | | | - Genário Santos
- Sciences of Health Post Graduation Program - University Federal of Bahia, Salvador, BA, Brazil.
| | - Raymundo Paraná
- School Medicine of Bahia- University Federal of Bahia, Av. Rector Miguel Calmon, S/N - Vale do Canela, 40110-100, Salvador - BA, Brazil.
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16
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Crawford C, Walter AR, Avula B, Lindsey AT, Hunter AM, Ikhlas AK, Deuster PA. Relative safety and quality of various dietary supplement products U.S. Service Members ask about. Clin Toxicol (Phila) 2022; 60:737-744. [PMID: 35156875 DOI: 10.1080/15563650.2022.2036751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CONTEXT The purpose of this project was to determine types of dietary supplement products U.S. Service Members frequently ask about and identify risks associated with select products that consumers should be aware of when considering their use. METHODS Forty-one dietary supplement products frequently asked about through the Operation Supplement Safety's (OPSS.org) Ask-the-Expert portal were selected. Product analysis was performed to verify whether select products were accurately labeled and to identify any risky ingredients contained in these products. Operation Supplement Safety Risk Assessment Scorecard criteria were additionally used as a screening tool to assess a product's relative safety potential. RESULTS Among the select dietary supplements, 12 (29.3%) were marketed as pre-workout products; 14 (34.1%) for weight loss; four (9.8%) for male enhancement/testosterone boosters; and 11 (26.8%) as body building supplements. Eleven (26.8%) products had accurate labels; only eight of these had accurate labels plus no risky ingredients listed on the labels. Twenty-six (63.4%) products were misbranded; 10 (24.4%) were adulterated, and six (14.6%) were both misbranded and adulterated. Risky ingredients appeared on 23 (56%) of all product labels. Eight of these 23 products also had additional risky ingredients not listed on the labels but detected through analysis. According to the Scorecard based on label claims, 35 (85.4%) received a rating of "no-go/risky". CONCLUSIONS U.S. Service Members and the public at large should be aware that dietary supplements may contain risky ingredients and know how to identify ingredients on the label to evaluate potential risk.
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Affiliation(s)
- Cindy Crawford
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Abraham R Walter
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Bharathi Avula
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Andrea T Lindsey
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Aimee M Hunter
- Department of Laboratory Animal Resources, Uniformed Services University, Bethesda, MD, USA
| | - A Khan Ikhlas
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Patricia A Deuster
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, USA
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17
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Versatility of Anabolic Androgenic Steroid-Induced Hepatotoxicity. J Clin Exp Hepatol 2022; 12:216-221. [PMID: 35068803 PMCID: PMC8766528 DOI: 10.1016/j.jceh.2021.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/03/2021] [Indexed: 01/03/2023] Open
Abstract
The modified derivatives of testosterone, termed as androgenic steroids are indicated in the management of hypogonadism, visceral obesity and metabolic disorders. Anabolic androgenic steroids (AASs) however are surreptitiously used by athletes and body builders for cosmetic purpose owing to their anabolic effects on muscle mass and strength. The unsurveilled use of AASs subjects these users to various side effects involving multiple systems such as the endocrine, genitourinary, hepatobiliary, central nervous, musculoskeletal and psychosocial system. The liver is a hormone-sensitive organ owing to abundance of androgen receptors and is vulnerable to a wide array of hepatotoxicity ranging from asymptomatic liver enzyme elevation to life-threatening subacute liver failure. The type of drug-induced liver injury (DILI) due to AASs can be hepatocellular injury, cholestasis, fatty liver disease, chronic vascular injury and neoplastic disease. Herein, we report three cases of AAS-related DILI associated with AAS abuse.
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Key Words
- AAS, anabolic androgenic steroid
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AR, androgen receptor
- AST, aspartate aminotransferase
- CT, computed tomography
- DILI
- DILI, drug-induced liver injury
- GGT, gamma-glutamyl transferase
- HA, hepatocellular adenoma
- HCC, hepatocellular carcinoma
- HE, hepatic encephalopathy
- HUMP, hepatocellular neoplasm of uncertain malignant potential
- LDLT, living donor liver transplantation
- LFT, liver function test
- RUCAM, Roussel Uclaf Causality Assessment Method
- SALF, subacute liver failure
- TACE, transarterial chemoembolization
- TPE, therapeutic plasma exchange
- anabolic steroids
- cholestasis
- hepatocellular neoplasm
- peliosis hepatis
- steatosis
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18
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Ordway S, Sadowski B, Driggers KE, Kwok R. Severe Drug-Induced Liver Injury in the Military: A Retrospective Review. Mil Med 2021; 188:e991-e996. [PMID: 34697623 DOI: 10.1093/milmed/usab445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/24/2021] [Accepted: 10/15/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Drug-induced liver injury (DILI) is a significant cause of morbidity and mortality. Establishing a diagnosis is challenging due to the broad differential diagnosis of liver injury. We retrospectively reviewed patients with severe idiosyncratic DILI at Walter Reed National Military Medical Center in order to define the scope and patterns of injury in the military population. METHODS Using the military health database, we identified a total of 110 patients who had an International Classification of Disease (ICD)-10 code for toxic liver injury in the electronic medical record at Walter Reed National Military Medical Center between 2016 and 2019. Each patient record was reviewed, and all pertinent data for included patients were recorded into a database for analysis. RESULTS Twenty-seven out of 110 patients with a diagnostic code for toxic liver injury met inclusion criteria for severe idiosyncratic DILI. Nine cases were caused by supplements, including 5 active duty service members using synthetic anabolic steroids or preworkout supplements. The majority of patients were men and one-third were serving on active duty. The ranges of liver enzyme elevation and patterns of liver injury widely varied. CONCLUSION Military service members are at particularly high risk for DILI given the frequent use of over-the-counter and other unregulated strength- and performance-enhancing supplements. These injuries not only have significant medical consequences but can profoundly impact military readiness and mission capability. Diagnosis of DILI among active duty service members requires a strong index of suspicion, and inquiry regarding all ingestions is crucial. Educating physicians, providers, and policy makers on the risks of supplement-induced liver injury among service members is crucial. These data will facilitate additional studies exploring susceptibility to severe idiosyncratic DILI among the military population.
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Affiliation(s)
- Sarah Ordway
- Department of Internal Medicine, Division of Gastroenterology/Hepatology, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Brett Sadowski
- Department of Internal Medicine, Division of Gastroenterology/Hepatology, Portsmouth Naval Medical Center, Portsmouth, VA 23708, USA
| | - Kathryn E Driggers
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Ryan Kwok
- Department of Family Medicine, Division of Gastroenterology/Hepatology, Fort Belvoir Community Hospital, Fort Belvoir, VA 22060, USA
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19
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Mazzilli M, Macaluso F, Zambelli S, Picerno P, Iuliano E. The Use of Dietary Supplements in Fitness Practitioners: A Cross-Sectional Observation Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18095005. [PMID: 34065071 PMCID: PMC8125933 DOI: 10.3390/ijerph18095005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 12/22/2022]
Abstract
This study was aimed at evaluating the prevalence of use of dietary supplements (DSs) among gym users and gym instructors involved in body shaping-oriented fitness training. Furthermore, this study aimed to verify whether differences existed in the prevalence and in the types of DSs used in both gym users and gym instructors involved in body shaping-oriented fitness competitions vs. those not involved in fitness competitions. A survey was distributed to 316 participants, composed of 89 gym instructors and 227 gym users of both genders aged 27.3 ± 7.7. Among these participants, 52 were involved in competitions and 248 were not, while 16 participants did not specify either way. The results showed a high prevalence in the use of DSs in the population considered, with 85.4% of the participants declaring they used DSs, with high heterogeneity in the numbers and in the combinations used. No differences were found between gym instructors and gym users, or between participants involved and those not involved in competitions. The results indicate that DSs are widely used by persons involved in body shaping-oriented fitness training. The results also suggest that the majority of the participants decided individually which DSs to use.
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20
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ACG Clinical Guideline: Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury. Am J Gastroenterol 2021; 116:878-898. [PMID: 33929376 DOI: 10.14309/ajg.0000000000001259] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/25/2021] [Indexed: 12/11/2022]
Abstract
Idiosyncratic drug-induced liver injury (DILI) is common in gastroenterology and hepatology practices, and it can have multiple presentations, ranging from asymptomatic elevations in liver biochemistries to hepatocellular or cholestatic jaundice, liver failure, or chronic hepatitis. Antimicrobials, herbal and dietary supplements, and anticancer therapeutics (e.g., tyrosine kinase inhibitors or immune-checkpoint inhibitors) are the most common classes of agents to cause DILI in the Western world. DILI is a diagnosis of exclusion, and thus, careful assessment for other etiologies of liver disease should be undertaken before establishing a diagnosis of DILI. Model for end-stage liver disease score and comorbidity burden are important determinants of mortality in patients presenting with suspected DILI. DILI carries a mortality rate up to 10% when hepatocellular jaundice is present. Patients with DILI who develop progressive jaundice with or without coagulopathy should be referred to a tertiary care center for specialized care, including consideration for potential liver transplantation. The role of systemic corticosteroids is controversial, but they may be administered when a liver injury event cannot be distinguished between autoimmune hepatitis or DILI or when a DILI event presents with prominent autoimmune hepatitis features.
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21
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Avula B, Parveen I, Zhao J, Wang M, Techen N, Wang YH, Riaz M, Bae JY, Shami AA, Chittiboyina AG, Khan IA, Sharp JS. A Comprehensive Workflow for the Analysis of Bio-Macromolecular Supplements: Case Study of 20 Whey Protein Products. J Diet Suppl 2021; 19:515-533. [PMID: 33764265 DOI: 10.1080/19390211.2021.1897724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The presence of bio-macromolecules as major ingredients is a primary factor in marketing many biologically derived macromolecular supplements. Workflows for analyzing these supplements for quality assurance, adulteration, and other supply-chain difficulties must include a qualitative assessment of small-molecule and macromolecular components; however, no such integrated protocol has been reported for these bio-macromolecular supplements. Twenty whey protein supplements were analyzed using an integrated workflow to identify protein content, protein adulteration, inorganic elemental content, and macromolecular and small-molecule profiles. Orthogonal analytical methods were employed, including NMR profiling, LC-DAD-QToF analysis of small-molecule components, ICP-MS analysis of inorganic elements, determination of total protein content by a Bradford assay, SDS-PAGE protein profiling, and bottom-up shotgun proteomic analysis using LC-MS-MS. All 20 supplements showed a reduced protein content compared to the claimed content but no evidence of adulteration with protein from an unclaimed source. Many supplements included unlabeled small-molecule additives (but nontoxic) and significant deviations in metal content, highlighting the importance of both macromolecular and small-molecule analysis in the comprehensive profiling of macromolecular supplements. An orthogonal, integrated workflow allowed the detection of crucial product characteristics that would have remained unidentified using traditional workflows involving either analysis of small-molecule nutritional supplements or protein analysis.
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Affiliation(s)
- Bharathi Avula
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Iffat Parveen
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Jianping Zhao
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Mei Wang
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Natascha Techen
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Yan-Hong Wang
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Mohammad Riaz
- Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, MS, USA University
| | - Ji-Yeong Bae
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA.,College of Pharmacy, Jeju National University, Jeju, South Korea
| | - Anter A Shami
- Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, MS, USA University
| | - Amar G Chittiboyina
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Ikhlas A Khan
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA.,Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, MS, USA University
| | - Joshua S Sharp
- Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, MS, USA University.,Department of Chemistry and Biochemistry, University of Mississippi, University, MS, USA
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22
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Firman JW, Pestana CB, Rathman JF, Vinken M, Yang C, Cronin MTD. A Robust, Mechanistically Based In Silico Structural Profiler for Hepatic Cholestasis. Chem Res Toxicol 2020; 34:641-655. [PMID: 33314907 DOI: 10.1021/acs.chemrestox.0c00465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Owing to the primary role which it holds within metabolism of xenobiotics, the liver stands at heightened risk of exposure to, and injury from, potentially hazardous substances. A principal manifestation of liver dysfunction is cholestasis-the impairment of physiological bile circulation from its point of origin within the organ to the site of action in the small intestine. The capacity for early identification of compounds liable to exert cholestatic effects is of particular utility within the field of pharmaceutical development, where contribution toward candidate attrition is great. Shortcomings associated with the present in vitro methodologies forecasting cholestasis render their predictivity questionable, permitting scope for the adoption of computational toxicology techniques. As such, the intention of this study has been to construct an in silico profiler, founded upon clinical data, highlighting structural motifs most reliably associated with the end point. Drawing upon a list of >1500 small molecular drugs, compiled and annotated by Kotsampasakou, E. and Ecker, G. F. (J. Chem. Inf. Model. 2017, 57, 608-615), we have formulated a series of 15 structural alerts. These describe fragments intrinsic within distinct pharmaceutical classes including psychoactive tricyclics, β-lactam antimicrobials, and estrogenic/androgenic steroids. Description of the coverage and selectivity of each are provided, alongside consideration of the underlying reactive mechanisms and relevant structure-activity concerns. Provision of mechanistic anchoring ensures that potential exists for framing within the adverse outcome pathway paradigm-the chemistry conveyed through the alert, in particular enabling rationalization at the level of the molecular initiating event.
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Affiliation(s)
- James W Firman
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, United Kingdom
| | - Cynthia B Pestana
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, United Kingdom
| | - James F Rathman
- Molecular Networks GmbH, Neumeyerstraße 28, 90411 Nuremberg, Germany.,Altamira, LLC, Columbus, Ohio 43210, United States.,Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio 43210, United States
| | - Mathieu Vinken
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Chihae Yang
- Molecular Networks GmbH, Neumeyerstraße 28, 90411 Nuremberg, Germany.,Altamira, LLC, Columbus, Ohio 43210, United States
| | - Mark T D Cronin
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, United Kingdom
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23
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Haron MH, Avula PhD B, Gurley PhD BJ, Chittiboyina PhD AG, Khan PhD IA, Khan PhD SI. Possible Herb-Drug Interaction Risk of Some Nutritional and Beauty Supplements on Antiretroviral Therapy in HIV Patients. J Diet Suppl 2020; 19:62-77. [PMID: 33200619 DOI: 10.1080/19390211.2020.1846658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This study was carried out to assess the drug interaction potential of a variety of beauty and sports/nutritional supplements when co-administered with antiviral drug therapy, especially anti-HIV drugs. Ethanolic extracts of seven dietary supplements (two beauty products, three nutritional protein supplement products and two weight loss/body building products) were examined in human liver cells (HepG2 cells and primary hepatocytes) for their influence on the hepatic metabolism of five antiviral drugs (elvitegravir, rilpivirine, tenofovir, dolutegravir, and cobicistat), all of which are substrates for a key drug metabolizing enzyme CYP3A4. Our results showed that six of the seven supplements caused a 1.5 - 2 fold induction in PXR transcriptional activity in HepG2 cells. PXR regulates the expression of key drug metabolizing enzymes including CYP3A4. Follow up studies indicated a 1.5 - 3 fold induction in CYP3A4 enzyme activity in HepG2 cells treated with these supplements. We further investigated the effects of the supplement on the metabolism of above mentioned anti-viral drugs in HepG2 cells and primary hepatocytes. Of the five drugs, rilpivirine and dolutegravir metabolism was increased by up to 2-folds over the no supplement control by some of the supplements. Our findings indicate that concomitant consumption of these products with anti-HIV drugs may compromise the efficacy of antivirals therapy due to supplement-induced metabolism via induction of CYP3A4 activity.
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Affiliation(s)
- Mona H Haron
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Bharathi Avula PhD
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Bill J Gurley PhD
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Amar G Chittiboyina PhD
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Ikhlas A Khan PhD
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA.,Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Shabana I Khan PhD
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA.,Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, University, MS, USA
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24
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Nunes V, Mendez‐Sanchez N. Impact of Herbal and Dietary Supplements Causing Drug-Induced Liver Injury in Latin America. Clin Liver Dis (Hoboken) 2020; 16:83-86. [PMID: 33005386 PMCID: PMC7508779 DOI: 10.1002/cld.905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 11/26/2019] [Indexed: 02/04/2023] Open
Abstract
Watch a video presentation of this article.
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Affiliation(s)
- Vinicius Nunes
- Hospital Universitario Prof. Edgard SantosSalvador de BahiaBrazil
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25
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Villavicencio Kim J, Wu GY. Body Building and Aminotransferase Elevations: A Review. J Clin Transl Hepatol 2020; 8:161-167. [PMID: 32832396 PMCID: PMC7438350 DOI: 10.14218/jcth.2020.00005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/23/2020] [Accepted: 05/08/2020] [Indexed: 12/18/2022] Open
Abstract
In addition to liver injury, elevation of aminotransferases can be caused by strenuous exercise and use of muscle-building and weight-loss supplements. The purpose of this review is to discuss the various mechanisms of elevation of aminotransferases related to body building. A literature review was performed on clinical trials and case reports involving exercise or supplement use and their effects on aminotransferases. Normal aminotransferase levels varied according to gender, age, body mass index, and comorbidities. Strenuous exercise and weight lifting, especially in the unaccustomed, can cause elevated aminotransferases in the absence of liver damage. Supplements such as anabolic steroids, ephedra, and LipoKinetix, amongst others, have also been associated with aminotransferase elevations. The pattern of elevation of aminotransferases is not helpful in distinguishing liver from muscle injury. Other associated muscle enzymes can be useful in making that distinction. To prevent aminotransferase elevations, subjects not accustomed to moderate-high intensity workouts, are recommended to undertake gradual increase in intensity. When causes of liver injury have been ruled out, investigation into bodybuilding, extreme exercise, and supplement use is warranted.
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Affiliation(s)
- Jaimy Villavicencio Kim
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
- Correspondence to: Jaimy Villavicencio Kim, Department of Medicine, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06032, USA. Tel: +1-860-899-8739, E-mail:
| | - George Y. Wu
- Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
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26
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Abstract
PURPOSE OF REVIEW Drug-induced liver injury (DILI) can be induced by a myriad of drugs. Assessing whether the patient has DILI and assessing which drug is the most likely culprit are challenging. There has been too little attention paid to the concept that certain drugs appear to have unique clinical features or 'phenotypes'. RECENT FINDINGS Several case series of DILI because of various drugs have been published, and analysis of these case series points to the fact that individual drugs have characteristic DILI signatures. These clinical phenotypes can be characterized by latency, biochemical features (R-value), as well as clinical symptoms and signs. Several drugs, including isoniazid, amoxicillin-clavulanic acid, anabolic steroids, β-interferon and others, have highly unique clinical features. Such unique properties may be able to be used to improve adjudication processes. SUMMARY Individual drugs have unique clinical DILI phenotypes or signatures. Furthermore, these may be able to be used to improve adjudication.
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Affiliation(s)
- Hans L. Tillmann
- Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition, East Carolina University, Greenville, NC
- Greenville VA Health Care Center, Greenville, NC
| | - Don C. Rockey
- Department of Medicine, Medical University South Carolina, Charleston, SC
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27
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Vilas-Boas V, Gijbels E, Jonckheer J, De Waele E, Vinken M. Cholestatic liver injury induced by food additives, dietary supplements and parenteral nutrition. ENVIRONMENT INTERNATIONAL 2020; 136:105422. [PMID: 31884416 DOI: 10.1016/j.envint.2019.105422] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/05/2019] [Accepted: 12/13/2019] [Indexed: 06/10/2023]
Abstract
Cholestasis refers to the accumulation of toxic levels of bile acids in the liver due to defective bile secretion. This pathological situation can be triggered by drugs, but also by ingredients contained in food, food supplements and parenteral nutrition. This paper provides an overview of the current knowledge on cholestatic injury associated with such ingredients, with particular emphasis on the underlying mechanisms of toxicity.
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Affiliation(s)
- Vânia Vilas-Boas
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Eva Gijbels
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Joop Jonckheer
- Department of Intensive Care, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Elisabeth De Waele
- Department of Intensive Care, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Mathieu Vinken
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium.
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28
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Mosedale M, Watkins PB. Understanding Idiosyncratic Toxicity: Lessons Learned from Drug-Induced Liver Injury. J Med Chem 2020; 63:6436-6461. [PMID: 32037821 DOI: 10.1021/acs.jmedchem.9b01297] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Idiosyncratic adverse drug reactions (IADRs) encompass a diverse group of toxicities that can vary by drug and patient. The complex and unpredictable nature of IADRs combined with the fact that they are rare makes them particularly difficult to predict, diagnose, and treat. Common clinical characteristics, the identification of human leukocyte antigen risk alleles, and drug-induced proliferation of lymphocytes isolated from patients support a role for the adaptive immune system in the pathogenesis of IADRs. Significant evidence also suggests a requirement for direct, drug-induced stress, neoantigen formation, and stimulation of an innate response, which can be influenced by properties intrinsic to both the drug and the patient. This Perspective will provide an overview of the clinical profile, mechanisms, and risk factors underlying IADRs as well as new approaches to study these reactions, focusing on idiosyncratic drug-induced liver injury.
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Affiliation(s)
- Merrie Mosedale
- Institute for Drug Safety Sciences and Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina 27599, United States
| | - Paul B Watkins
- Institute for Drug Safety Sciences and Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina 27599, United States
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Abstract
When patients with suspected drug-induced liver injury (DILI) undergo liver biopsy, the pathologist can provide a wealth of information on the morphologic changes. The most common histologic patterns of DILI include mimics of acute and chronic hepatitis as well as acute cholestasis, chronic cholestasis, and a mixed pattern that combines hepatitis with cholestasis. The pattern may suggest etiologies of injury or correlate with reported patterns of injury for specific agents. Biopsy may exonerate or indict particular drugs as causal agents of injury and provide specific information on severity of injury and specific types of changes related to various outcomes.
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Affiliation(s)
- Billel Gasmi
- Laboratory of Pathology, National Cancer Institute, 10 Center Drive, Building 10, Room 2S235, MSC1500, Bethesda, MD 20892, USA
| | - David E. Kleiner
- Post-Mortem Section, Laboratory of Pathology, National Cancer Institute, 10 Center Drive, Building 10, Room 2S235, MSC1500, Bethesda, MD 20892, USA,Corresponding author,
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30
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Crawford C, Wang YH, Avula B, Bae JY, Khan IA, Deuster PA. The scoop on brain health dietary supplement products containing huperzine A. Clin Toxicol (Phila) 2020; 58:991-996. [DOI: 10.1080/15563650.2020.1713337] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Cindy Crawford
- Consortium for Health and Military Performance, Department of Military & Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Yan-Hong Wang
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Bharathi Avula
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Ji-Yeong Bae
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Ikhlas A. Khan
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA
- Division of Pharmacognosy, Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Patricia A. Deuster
- Consortium for Health and Military Performance, Department of Military & Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, USA
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31
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A Message from the Editors. Aliment Pharmacol Ther 2020; 51:4-5. [PMID: 31850567 DOI: 10.1111/apt.15602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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32
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Philips CA, Rajesh S, George T, Ahamed R, Kumbar S, Augustine P. Outcomes and Toxicology of Herbal Drugs in Alcoholic Hepatitis - A Single Center Experience from India. J Clin Transl Hepatol 2019; 7:329-340. [PMID: 31915602 PMCID: PMC6943206 DOI: 10.14218/jcth.2019.00043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/04/2019] [Accepted: 10/24/2019] [Indexed: 12/23/2022] Open
Abstract
Background and Aims: We aimed to study clinical outcomes and liver biopsy features of alcoholic hepatitis (AH) patients on complementary and alternative medicines (CAMs) and to analyze the retrieved drugs for chemical and toxic components linked to drug-induced liver injury. Methods: We retrospectively assessed clinical, biochemical and liver biopsy features of AH patients on CAM with drug-induced liver injury (AH-CAM, n = 27) and compared them to a control group (classical AH, n = 29) on standard of care. Patients without liver biopsy evaluation and other causes for liver disease were excluded. Samples of the CAMs (n = 42) from patients were retrieved and assessed for chemical and toxins. Results: All were males, and significantly worse clinical presentation, biochemical severity, and liver disease scores were notable in patients with AH-CAM. Traditional Ayurvedic-polyherbal formulations were the most commonly used CAM. On liver histology, varying grades of severe-necrosis, severe hepatocellular, canalicular, cholangiolar cholestasis with predominant lymphocytic-portal-inflammation and varying grades of interface-hepatitis were noted in AH-CAM. Analysis of CAMs revealed presence of heavy metals up to 100,000 times above detectable range and adulterants, such as antibiotics, chemotherapy agents, nonsteroidal anti-inflammatory drugs, alcohols, antidepressants, anxiolytics, and recreational drugs. On follow up, a significantly higher number of patients with AH on CAM died at end of 1, 3- and-6-months compared to controls (37% vs. 83%, 29% vs. 62%, 18% vs. 52% respectively; p < 0.001). Conclusions: Patients with AH and CAM-related drug-induced liver injury have extremely poor short-term survival in the absence of liver transplantation compared to those patients with AH on evidence-based management. Early transplant referral and educating on and curbing of CAM use in severe liver disease through strict monitoring of unregulated traditional health practices can help ease the burden of liver-related death.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
- Correspondence to: Cyriac Abby Philips, The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Symphony, Automobile Road, Palarivattom, Cochin 682025, India. Tel/Fax: +91-484-2907000, E-mail:
| | - Sasidharan Rajesh
- Interventional Radiology, Department of Gastroenterology and Hepatology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
| | - Tom George
- Interventional Radiology, Department of Gastroenterology and Hepatology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I. Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced G.I. Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I. Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India
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33
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Robles-Diaz M, Medina-Cáliz I, Andrade RJ, Lucena MI. Reply letter to "Editorial: bodybuilders beware". Aliment Pharmacol Ther 2019; 50:473. [PMID: 31359466 DOI: 10.1111/apt.15400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Mercedes Robles-Diaz
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Inmaculada Medina-Cáliz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Raúl J Andrade
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - M Isabel Lucena
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Plataforma SCReN (Spanish Clinical Research Network), UCICEC IBIMA, Málaga, Spain
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34
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Affiliation(s)
- Jay H Hoofnagle
- From the Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD (J.H.H.); and the Department of Internal Medicine, National University Hospital of Iceland, and the Faculty of Medicine, University of Iceland - both in Reykjavík (E.S.B.)
| | - Einar S Björnsson
- From the Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD (J.H.H.); and the Department of Internal Medicine, National University Hospital of Iceland, and the Faculty of Medicine, University of Iceland - both in Reykjavík (E.S.B.)
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35
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36
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Feldman DM, Jacobson IM. Editorial: bodybuilders beware. Aliment Pharmacol Ther 2019; 49:1530. [PMID: 31134650 DOI: 10.1111/apt.15270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- David M Feldman
- Division of Gastroenterology and Hepatology, NYU Langone Medical Center, New York City, New York
| | - Ira M Jacobson
- Division of Gastroenterology and Hepatology, NYU Langone Medical Center, New York City, New York
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