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Shi H, Chen D, Si J, Zou Q, Guo Y, Yu J, Li C, Wang F. Efficacy and Safety of Oxymatrine in the Treatment of Patients with Erythrodermic Psoriasis. Dermatol Ther (Heidelb) 2024; 14:1659-1670. [PMID: 38796792 PMCID: PMC11169162 DOI: 10.1007/s13555-024-01181-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION The management of erythrodermic psoriasis (EP), a rare but severe type of psoriasis, is challenging, especially in patients with concomitant chronic hepatitis B (CHB). We previously demonstrated that oxymatrine treatment alleviated severe plaque psoriasis, but its therapeutic potential in treating EP remains unexplored. This study was to assess the efficacy and safety of oxymatrine for the treatment of EP, with attention to concomitant CHB. METHODS In this investigator-initiated clinical trial, four consecutive patients with EP, including two (A and B) with concomitant CHB, were treated with intravenous administration of oxymatrine as monotherapy for 8 weeks, and scheduled to be followed up for a minimum of 24 weeks. The primary outcome was at least 75% improvement in the psoriasis area and severity index (PASI 75) at week 32. Secondary outcomes included the body surface area (BSA) score, dermatology life quality index (DLQI)], and safety. RESULTS Patients A, B, and C achieved PASI 75 at treatment completion and week 32, demonstrating improvements of 77.4%, 97.2%, and 100% in PASI, respectively. Their BSA and DLQI were also improved significantly at week 32 and throughout follow-up of 37, 57, and 105 weeks, respectively. The viral loads in patients A and B with CHB decreased modestly. Patient D discontinued after follow-up for 19 weeks, and the primary outcome could not be analyzed. No adverse events were reported during treatment and follow-up. CONCLUSION Oxymatrine appears to be efficacious and safe for the treatment of patients with EP, including those with concomitant CHB. TRIAL REGISTRATION This study was registered at the Chinese Clinical Trial Registry ( www.chictr.org.cn ; Registration number ChiCTR-TRC-14004301).
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Affiliation(s)
- Huijuan Shi
- Innovation Team for Skin Disease Diagnosis and Treatment Technology and Drug Discovery and Development, Department of Dermatovenereology, General Hospital of Ningxia Medical University, 804 Shengli South Street, Yinchuan, 750004, Ningxia, China.
- Department of Dermatovenereology, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China.
| | - Dongmei Chen
- Innovation Team for Skin Disease Diagnosis and Treatment Technology and Drug Discovery and Development, Department of Dermatovenereology, General Hospital of Ningxia Medical University, 804 Shengli South Street, Yinchuan, 750004, Ningxia, China
- Institute of Human Stem Cell Research, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Jiawei Si
- Clinical Medical School, Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Qian Zou
- Clinical Medical School, Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Yatao Guo
- Clinical Medical School, Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Jiayu Yu
- Clinical Medical School, Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Cheng Li
- Clinical Medical School, Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Fang Wang
- Clinical Medical School, Ningxia Medical University, Yinchuan, 750004, Ningxia, China
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Zhou H, Shi HJ, Yang J, Chen WG, Xia L, Song HB, Bo KP, Ma W. Efficacy of oxymatrine for treatment and relapse suppression of severe plaque psoriasis: results from a single-blinded randomized controlled clinical trial. Br J Dermatol 2017; 176:1446-1455. [PMID: 28112799 DOI: 10.1111/bjd.15316] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Drugs that are currently used in the treatment of psoriasis are associated with drawbacks such as rapid recrudescence, high costs and unwanted side-effects. Oxymatrine has a long history of clinical use in the treatment of hepatitis and cancer in China. OBJECTIVES To explore the efficacy and safety of intravenous oxymatrine in patients with severe plaque psoriasis. METHODS A total of 67 patients were randomly allocated to receive oxymatrine injections (0.6 g per day for 8 weeks) or acitretin capsules (0.75 mg kg-1 per day from week 0 to week 2 and 20-30 mg per day from week 3 to week 8) and followed up for another 24 weeks. The primary end point was the percentage of patients with ≥ 50% reduction of Psoriasis Area and Severity Index (PASI 50) at week 32. The secondary end points included the skin classification grade and the Dermatology Quality of Life Index (DLQI) score. Side-effects were recorded throughout the whole study to assess the safety profile. RESULTS Treatment with oxymatrine or acitretin for 8 weeks significantly decreased PASI score, skin classification grade and DLQI score (P < 0.001), with no significant differences between the oxymatrine and acitretin groups in terms of PASI 50. However, at week 32, the relapse rate in the oxymatrine group was significantly lower than that of the acitretin group (P < 0.001). Moreover, while there was an increase in the number of patients with metabolic abnormalities in the acitretin group, a significant reduction was observed in the oxymatrine group. Furthermore, rates of adverse reactions were significantly decreased in the oxymatrine group compared with that of the acitretin group (P < 0.001). CONCLUSIONS Treatment with oxymatrine effectively ameliorated severe plaque psoriasis, and was accompanied by only minor adverse effects.
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Affiliation(s)
- H Zhou
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - H-J Shi
- Department of Dermatovenereology, Ningxia Medical University General Hospital, Yinchuan, 750004, China
| | - J Yang
- Department of Dermatovenereology, Ningxia Medical University General Hospital, Yinchuan, 750004, China
| | - W-G Chen
- Department of Dermatovenereology, Ningxia Medical University General Hospital, Yinchuan, 750004, China
| | - L Xia
- Department of Dermatovenereology, Ningxia Medical University General Hospital, Yinchuan, 750004, China
| | - H-B Song
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - K-P Bo
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - W Ma
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
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Sauder MB, Cheung L, Beecker J. Acitretin-Induced Hepatitis: When to Monitor Cholestatic Enzymes. J Cutan Med Surg 2015; 19:115-20. [DOI: 10.2310/7750.2014.14051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Importance Acitretin is a systemic retinoid that is used in dermatology for a variety of conditions. A well-recognized potential adverse event from acitretin is elevated transaminases, indicating acute hepatocyte damage. Less well known is the possible cholestatic injury that can occur, signaled by elevated γ-glutamyltransferase (GGT) and alkaline phosphatase (ALP). Observations Our patient presented with an acute acitretin-induced hepatitis with a mixed pattern of elevated transaminases as well as GGT and ALP. A literature review demonstrated that most cases of acitretin-induced hepatitis, outside clinical trials, describe patients with a similar mixed hepatitis pattern. Conclusions This is the first literature review on acitretin-induced hepatitis. Although acitretin-induced hepatoxicity is rare, the seemingly unusual presentation of a mixed pattern of hepatocyte injury and cholestasis may be more common than previously thought. The findings should encourage clinicians not only to monitor transaminases but also to consider measuring cholestatic enzymes (ALP/GGT) in patients with transaminase abnormalities.
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Affiliation(s)
- Maxwell B. Sauder
- From the Division of Dermatology and the Faculty of Medicine, University of Ottawa, Ottawa, ON
| | - Loretta Cheung
- From the Division of Dermatology and the Faculty of Medicine, University of Ottawa, Ottawa, ON
| | - Jennifer Beecker
- From the Division of Dermatology and the Faculty of Medicine, University of Ottawa, Ottawa, ON
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Köck K, Ferslew BC, Netterberg I, Yang K, Urban TJ, Swaan PW, Stewart PW, Brouwer KLR. Risk factors for development of cholestatic drug-induced liver injury: inhibition of hepatic basolateral bile acid transporters multidrug resistance-associated proteins 3 and 4. Drug Metab Dispos 2013; 42:665-74. [PMID: 24154606 DOI: 10.1124/dmd.113.054304] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Impaired hepatic bile acid export may contribute to development of cholestatic drug-induced liver injury (DILI). The multidrug resistance-associated proteins (MRP) 3 and 4 are postulated to be compensatory hepatic basolateral bile acid efflux transporters when biliary excretion by the bile salt export pump (BSEP) is impaired. BSEP inhibition is a risk factor for cholestatic DILI. This study aimed to characterize the relationship between MRP3, MRP4, and BSEP inhibition and cholestatic potential of drugs. The inhibitory effect of 88 drugs (100 μM) on MRP3- and MRP4-mediated substrate transport was measured in membrane vesicles. Drugs selected for investigation included 50 BSEP non-inhibitors (24 non-cholestatic; 26 cholestatic) and 38 BSEP inhibitors (16 non-cholestatic; 22 cholestatic). MRP4 inhibition was associated with an increased risk of cholestatic potential among BSEP non-inhibitors. In this group, for each 1% increase in MRP4 inhibition, the odds of the drug being cholestatic increased by 3.1%. Using an inhibition cutoff of 21%, which predicted a 50% chance of cholestasis, 62% of cholestatic drugs inhibited MRP4 (P < 0.05); in contrast, only 17% of non-cholestatic drugs were MRP4 inhibitors. Among BSEP inhibitors, MRP4 inhibition did not provide additional predictive value of cholestatic potential; almost all BSEP inhibitors were also MRP4 inhibitors. Inclusion of pharmacokinetic predictor variables (e.g., maximal unbound concentration in plasma) in addition to percent MRP4 inhibition in logistic regression models did not improve cholestasis prediction. Association of cholestasis with percent MRP3 inhibition was not statistically significant, regardless of BSEP-inhibition status. Inhibition of MRP4, in addition to BSEP, may be a risk factor for the development of cholestatic DILI.
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Affiliation(s)
- Kathleen Köck
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy (K.K., B.C.F., I.N., K.Y., K.L.R.B.), and Biostatistics Department, School of Public Health (P.W.St.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Pharmacy, Uppsala University, Uppsala, Sweden (I.N.); Center for Human Genome Variation, Duke University Medical Center, Durham, North Carolina (T.J.U.); and Department of Pharmaceutical Sciences, University of Maryland, Baltimore, Maryland (P.W.Sw.)
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Ormerod AD, Campalani E, Goodfield MJD. British Association of Dermatologists guidelines on the efficacy and use of acitretin in dermatology. Br J Dermatol 2010; 162:952-63. [PMID: 20423353 DOI: 10.1111/j.1365-2133.2010.09755.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- A D Ormerod
- Department of Dermatology, University of Aberdeen, Foresterhill, Aberdeen AB9 2ZB, UK.
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BAKULEV AL, KRAVCHENYA SS. Administering hepatoprotectors for psoriasis: a comparative clinical, laboratory and ultrasonic assessment of its efficacy. VESTNIK DERMATOLOGII I VENEROLOGII 2010. [DOI: 10.25208/vdv880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
There was a comparative study of the clinical efficacy of Heptral® and Essentiale® Forte N in 60 patients suffering from psoriasis. Such indices as psoriatic process severity, quality of life, ultrasonic criteria of psoriasis-mediated skin affection and hepatic function biochemistry were assessed. As a result of the treatment with the use of Heptral®, a distinct and statistically reliable reduction of the psoriasis severity, improvement in the quality of life and normalization of hepatic biochemistry indices were observed. In addition, a reduction in the thickness of epidermis and derma, increase in the ultrasonic density of the latter and more even distribution of the echo signal in all derma layers were recorded in the group taking Heptral® as compared to the group of patients receiving Essentiale® Forte N and control group.
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Abstract
Hepatotoxicity associated with the therapeutic ingestion of the vitamin A metabolite acitretin is well recognized. No reported cases of hepatic dysfunction as a consequence of acitretin overdose are, however, present. Here for the first time we report a case of fulminant hepatic failure following an intentional overdose of 600 mg of acitretin. The patient fulfilled the King's College Hospital poor prognostic criteria by 66 h after overdose, but demonstrated a rapid improvement thereafter and did not require liver transplantation. Given the known association between psoriasis and depression, and the possible association of acitretin with psychiatric illness, this is an important potential adverse event.
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Walgren JL, Mitchell MD, Thompson DC. Role of Metabolism in Drug-Induced Idiosyncratic Hepatotoxicity. Crit Rev Toxicol 2008; 35:325-61. [PMID: 15989140 DOI: 10.1080/10408440590935620] [Citation(s) in RCA: 200] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Rare adverse reactions to drugs that are of unknown etiology, or idiosyncratic reactions, can produce severe medical complications or even death in patients. Current hypotheses suggest that metabolic activation of a drug to a reactive intermediate is a necessary, yet insufficient, step in the generation of an idiosyncratic reaction. We review evidence for this hypothesis with drugs that are associated with hepatotoxicity, one of the most common types of idiosyncratic reactions in humans. We identified 21 drugs that have either been withdrawn from the U.S. market due to hepatotoxicity or have a black box warning for hepatotoxicity. Evidence for the formation of reactive metabolites was found for 5 out of 6 drugs that were withdrawn, and 8 out of 15 drugs that have black box warnings. For the other drugs, either evidence was not available or suitable studies have not been carried out. We also review evidence for reactive intermediate formation from a number of additional drugs that have been associated with idiosyncratic hepatotoxicity but do not have black box warnings. Finally, we consider the potential role that high dosages may play in these adverse reactions.
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Affiliation(s)
- Jennie L Walgren
- Pfizer Global Research and Development, Worldwide Safety Sciences, Chesterfield, Missouri 63017, USA
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Abstract
Drug pharmacokinetics and pharmacodynamics may be altered in the elderly. An important contribution is made by decreased renal function, but biotransformation in the liver may also play a role. Commonly prescribed dermatological drugs such as methotrexate and cetirizine are likely to be eliminated more slowly in the elderly and potentially hepatotoxic drugs such as itraconazole and acitretin should be used with caution. Altered drug distribution as a result of body composition changes can lead to prolonged half-life or higher plasma concentrations of many drugs. Higher prevalence of adverse drug reactions and multidrug regimens, and large interindividual variability in drug response make drug dosage and administration in the elderly challenging. New immunobiological agents such as alefacept, efalizumab and etanercept, which are approved for treatment of psoriasis, seem to be as well tolerated in the elderly as in younger patients. A recommended approach when prescribing drugs to the elderly would be to start with a small initial dose and to reduce the number of drugs administered simultaneously. It is crucial to simplify the drug regimen as much as possible in order to enhance drug management in the elderly. To improve pharmacotherapy in the elderly, we review age-related changes in pharmacokinetics that are likely to play a role in dermatological practice.
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Affiliation(s)
- Anna Flammiger
- Department of Dermatology, University of California, San Francisco, California 94143, USA.
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Abstract
With the advent of new biological agents, interest in the treatment of psoriasis has been renewed. Vitamin A and its derivatives (retinoids) have been used successfully in the treatment of psoriasis for over 30 years. In this paper, data on the efficacy and safety of oral retinoids for the treatment of various forms of psoriasis is reviewed. Studies have shown that retinoids are particularly effective in the treatment of pustular and palmoplantar psoriasis. When used in conjunction with ultraviolet therapy, retinoids appear to have a synergistic effect and can be used safely as long-term maintenance therapy. The most common side effects of oral retinoids are usually modest, treatable or reversible, and predominantly affect the liver, musculoskeletal and neurological systems. Potential teratogenicity remains the primary concern with use in women. Oral retinoids appear to be well tolerated in paediatric and HIV-infected patients.
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Affiliation(s)
- JoEllen Van Zander
- New York University, Ronald O. Perelman Department of Dermatology, School of Medicine, 560 First Avenue, New York, NY10016, USA
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Abstract
Dermatologists use a variety of systemic drugs, some of which can cause severe adverse reactions and even fatalities. Ivermectin, a well-tolerated drug, can cause severe neurological side effects, whereas metronidazole, in high cumulative doses, has been associated with convulsions and rarely with hepatotoxicity. Dapsone is associated with frequent hematologic side effects, such as methemoglobinemia, hemolysis, and anemia. Although hepatotoxicity is rare and usually mild and reversible with the new antifungal agents, severe cutaneous reactions (such as toxic epidermal necrolysis, Stevens-Johnson syndrome, and anaphylaxis) have been reported. Even a relatively safe drug such as acyclovir has been reported to be the cause of renal failure and neurotoxicity. Retinoids can cause not so benign "benign" intracranial hypertension. Methotrexate can cause not only liver toxicity, but also myelosuppression and pancytopenia, which may be acute and life threatening. Nephrotoxicity is a well-recognized side effect of cyclosporine, whereas thrombotic thrombocytopenic purpura, which is associated with high morbidity and mortality, is less well known. Dermatologists should be familiar with these and other severe adverse reactions of the most popular and most used systemic medications of our trade.
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Affiliation(s)
- Edith Orion
- The Dermatology Unit, Kaplan Medical Center, Rechovot 76100, Israel.
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Abstract
Cholestasis caused by medicinal and chemical agents is an increasingly well-recognized cause of liver disease. Clinical drug-induced cholestatic syndromes producing jaundice and bile duct injury can mimic extrahepatic biliary obstruction, primary biliary cirrhosis, and sclerosing cholangitis, among others. This article updates the various forms of drug-induced cholestasis, focusing on the clinicopathologic features of this form of hepatic injury and on the known or putative mechanisms by which drugs and chemicals lead to cholestasis.
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Affiliation(s)
- Raja Mohi-ud-din
- Section of Hepatology, Division of Gastroenterology, Georgetown University Medical Center, 3800 Reservoir Road, Washington, DC 20007, USA
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Abstract
Further insights into the cellular and molecular mechanisms underlying hepatobiliary transport function and its regulation now permit a better understanding of the pathogenesis and treatment options of cholestatic liver diseases. Identification of the molecular basis of hereditary cholestatic syndromes will result in an improved diagnosis and management of these conditions. New insights into the pathogenesis of extrahepatic manifestations of cholestasis (eg, pruritus) have facilitated new treatment strategies. Important new studies have been published about the pathogenesis, clinical features, diagnosis, and treatment of primary biliary cirrhosis, primary sclerosing cholangitis, cholestasis of pregnancy, total parenteral nutrition-induced cholestasis, drug-induced cholestasis, and viral cholestatic syndromes.
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Affiliation(s)
- Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Karl-Franzens University, School of Medicine, Graz, Austria
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