Serum transaminases during salicylate therapy

Challenge of liver disease in systemic lupus erythematosus: Clues for diagnosis and hints for pathogenesis

Systemic lupus erythematosus (SLE) encompass a broad spectrum of liver diseases. We propose here to classify them as follows: (1) immunological comorbilities (overlap syndromes); (2) non-immunological comorbilities associated to SLE; and (3) a putative liver damage induced by SLE itself, referred to as "lupus hepatitis". In the first group, liver injury can be ascribed to overlapping hepatopathies triggered by autoimmune mechanisms other than SLE occurring with higher incidence in the context of lupus (e.g., autoimmune hepatitis, primary biliary cirrhosis). The second group includes non-autoimmune liver diseases, such as esteatosis, hepatitis C, hypercoagulation state-related liver lesions, hyperplasic parenchymal and vascular lesions, porphyria cutanea tarda, and drug-induced hepatotoxicity. Finally, the data in the literature to support the existence of a hepatic disease produced by SLE itself, or the occurrence of a SLE-associated prone condition that increases susceptibility to acquire other liver diseases, is critically discussed. The pathological mechanisms underlying each of these liver disorders are also reviewed. Despite the high heterogeneity in the literature regarding the prevalence of SLE-associated liver diseases and, in most cases, lack of histopathological evidence or clinical studies large enough to support their existence, it is becoming increasingly apparent that liver is an important target of SLE. Consequently, biochemical liver tests should be routinely carried out in SLE patients to discard liver disorders, particularly in those patients chronically exposed to potentially hepatotoxic drugs. Diagnosing liver disease in SLE patients is always challenging, and the systematization of the current information carried out in this review is expected to be of help both to attain a better understanding of pathogenesis and to build an appropriate work-up for diagnosis.

Non-steroidal anti-inflammatory drugs: What is the actual risk of liver damage?

Non-steroidal anti-inflammatory drugs (NSAIDs) constitute a family of drugs, which taken as a group, represents one of the most frequently prescribed around the world. Thus, not surprisingly NSAIDs, along with anti-infectious agents, list on the top for causes of Drug-Induced Liver Injury (DILI). The incidence of liver disease induced by NSAIDs reported in clinical studies is fairly uniform ranging from 0.29/100 000 [95% confidence interval (CI): 0.17-051] to 9/100 000 (95% CI: 6-15). However, compared with these results, a higher risk of liver-related hospitalizations was reported (3-23 per 100 000 patients). NSAIDs exhibit a broad spectrum of liver damage ranging from asymptomatic, transient, hyper-transaminasemia to fulminant hepatic failure. However, under-reporting of asymptomatic, mild cases, as well as of those with transient liver-tests alteration, in conjunction with reports non-compliant with pharmacovigilance criteria to ascertain DILI and flawed epidemiological studies, jeopardize the chance to ascertain the actual risk of NSAIDs hepatotoxicity. Several NSAIDs, namely bromfenac, ibufenac and benoxaprofen, have been withdrawn from the market due to hepatotoxicity; others like nimesulide were never marketed in some countries and withdrawn in others. Indeed, the controversy concerning the actual risk of severe liver disease persists within NSAIDs research. The present work intends (1) to provide a critical analysis of the dissimilar results currently available in the literature concerning the epidemiology of NSAIDS hepatotoxicity; and (2) to review the risk of hepatotoxicity for each one of the most commonly employed compounds of the NSAIDs family, based on past and recently published data.

Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it

Aspirin (acetylsalicylic acid) and its salicylate derivatives are effective antipyretic, analgesic, and anti-inflammatory agents that are still very widely used by the elderly despite the advent of newer, potentially safer nonsteroidal anti-inflammatory drugs (NSAIDs). However, none of the new NSAIDs have been proven to be more effective than aspirin or salicylic acid. Chronic salicylate intoxication which is most common in the elderly, may occur with therapeutic doses. Increased toxicity in older patients often appears due to inadvertent overdosage. Dual prescribing or additional use of nonprescription salicylates are some causes of unwitting long term toxicity. According to some studies, systemic clearance of salicylate (mainly by hepatic metabolism) is reduced with age, as is renal elimination. These changes are of increased importance in the elderly using high therapeutic doses of salicylates when metabolism is saturated and more unchanged drug is available for renal excretion. In the face of renal impairment, the risk of toxicity is increased. The diagnosis of acute salicylate intoxication generally does not pose diagnostic problems. Patients often present with a history of intentional overdose, with hyperventilation, fever, and nausea. The diagnosis can be confirmed by measuring serum salicylate concentrations. Chronic intoxication often poses a diagnostic dilemma with atypical presentations mimicking other disease states such as diabetic ketoacidosis, delirium, cerebrovascular accident, myocardial infarction or cardiac failure. The diagnosis of salicylate intoxication should be borne in mind when an older patient presents with recent deterioration in activities of daily living with no known cause. Plasma salicylate concentrations should be measured if salicylate intoxication is suspected, even if there is no documented history of salicylate ingestion. The risk of salicylate nephrotoxicity is also increased with age, and upper gastrointestinal haemorrhage is associated with increased mortality in older age groups. Treatment of acute toxicity consists of prompt recognition of salicylate intoxication, use of activated charcoal, correction of acid-base abnormalities, general supportive measures, and if concentrations are extremely high, dialysis can be effectively used. Chronic toxicity, which can occur even with marginally high salicylate concentrations, is treated with drug withdrawal and supportive therapy. Chronic salicylate toxicity can be averted by prescription of conservative doses of drug, avoidance of concomitant use of different salicylate preparations, and therapeutic monitoring to guide dosage. Renal function should be monitored to detect nephrotoxicity from chronic salicylate therapy. Patients should be regularly screened for evidence of gastrointestinal bleeding.(ABSTRACT TRUNCATED AT 400 WORDS)

Hepatotoxicity of high dose salicylate therapy in acute rheumatic fever

Liver function tests, including serum alanine aminotransferase (ALT) activity, serum bilirubin, alkaline phosphatase, serum proteins, blood ammonia levels and intravenous glucose utilization, were monitored in 50 children with acute rheumatic fever receiving anti-rheumatic doses of aspirin. There was a significant increase in blood ammonia levels and serum ALT after aspirin therapy. A significant fall in glucose utilization coefficient was also recorded. Serum alkaline phosphatase, bilirubin and total proteins did not change significantly. Twenty-two of the 50 children recorded a rise in serum ALT; in 12, the rise was five- to tenfold. These 12 children developed adverse symptoms to aspirin. Also, all had a marked rise in blood ammonia levels. The children improved clinically and biochemically on withdrawal of aspirin. There was no constant relationship between hepatocellular function and serum salicylate levels.

Adult onset Still's disease

Three patients with adult onset of Still's disease are presented. Common early findings were: septic fever, polyarthralgia, leukocytosis, neutrophilia and elevated sedimentation rate. All of them had abnormal liver function tests which returned to normal values following corticosteroid therapy. It is proposed that hepatic abnormalities in adult onset of Still's disease reflect the basic disease process.

Validation of a morphometric analysis procedure using indomethacin-induced alterations in cultured hepatocytes

Morphometric analysis was used to quantitate indomethacin-induced morphological changes in primary cultures of neonatal rat hepatocytes by comparison with standard assessments of functional integrity (i.e. enzyme release, urea levels, and dye exclusion). For this procedural validation, indomethacin concentrations were selected to correspond to the therapeutic plasma levels of rheumatoid arthritic or systemic lupus erythematosus patients having liver cell injury secondary to prolonged, high-dose administration of this nonsteroidal antiinflammatory agent. Primary cultures of neonatal rat hepatocytes were exposed for 12 h to 0, 100, 500 or 1000 microM indomethacin and subjected to a double-blind morphometric analysis procedure modified for use on cultured cells. This procedure systematically converted two-dimensional morphologic information into three-dimensional numerical data for statistical analysis. These optical measurements provided an accurate analysis following 4 h of measurements. When the concentration of indomethacin was increased from 0 to 1000 microM, the relative volume percent of Type I cells decreased. Therefore these cells, which were indistinguishable from healthy, untreated control cells, become less numerous as toxicant level increased. In contrast, the relative volume percent values of other progressively more damaged cell types (i.e. Types II, III, and IV cells) increased with elevation of indomethacin levels. Morphometric assessments paralleled functional assessments of indomethacin-induced cytotoxicity (r2: 0.88-0.99). Therefore, the present study validated this morphometric analysis procedure using a rigorous cellular exposure which caused substantial cell injury and subsequent lifting of 23% cells from the substrate. Combined with previous validation studies involving cadmium, erythromycin and benoxaprofen, the present study showed that morphometric analysis is a rapid, accurate method for the measurement of cell injury in cultured parenchymal hepatocytes.

Aspirin, paracetamol and non-steroidal anti-inflammatory drugs. A comparative review of side effects

Non-steroidal anti-inflammatory drugs (NSAIDs) effectively control the symptoms of many of the rheumatic diseases although they have little effect on the underlying causes. Their effect is mainly on the mediators of the inflammatory process. Unfortunately, these mediators have important physiological roles in the maintenance of health, particularly in the gastrointestinal tract and the kidney, so that their inhibition results in many unwanted reactions of varying severity. The mechanisms underlying these reactions are described. Their occurrence varies, both qualitatively and quantitatively, and an attempt is made to assess these differences, although it may be that they are related directly to differences in dosage and therapeutic efficacy. In addition, immunologically mediated adverse reactions occur. These mechanisms are outlined and related to the clinical picture. There are considerable differences in frequency of reactions between the compounds: in particular there is a wide variation in the rate of dermatological reactions of this type. Agranulocytosis has been particularly associated with the pyrazolone compounds, although it has been reported with most others. Aplastic anaemia, which may not be an immune-mediated reaction, is also thought of as a pyrazolone reaction, but the incidence with indomethacin approaches a similar level. Although all drugs analysed may cause hepatic reactions, these are rare except with the now withdrawn benoxaprofen. Several types of immunologically mediated renal reactions occur and these rarities are also described. Paracetamol does not have any effect on the inflammatory mediators. Anxieties about this substance relates to the parent compound phenacetin and its necrotic effect on the renal papillae. There is extensive literature on this subject concerning not only paracetamol, but also aspirin and other NSAIDs. This is also assessed and summarised. The danger of paracetamol as a direct hepatic toxin in self-poisoning is discussed. Novel NSAIDs are introduced and others withdrawn with frequent and monotonous regularity. Sometimes the reasons have some medical or scientific plausibility, but often they are over-reactions by registration authorities or pharmaceutical companies in response to uninformed media publicity. The problems of the numerically and scientifically accurate collection and assessment of adverse reaction data are legion and as a result useful agents have been lost. Some of these difficulties are described, and some non-drug 'adverse reactions' are described.(ABSTRACT TRUNCATED AT 400 WORDS)

Hepatotoxicity associated with choline magnesium trisalicylate: case report and review of salicylate-induced hepatotoxicity

A case of a 21-year-old woman who had developed mild hepatotoxicity while receiving choline magnesium trisalicylate therapy is described. She presented with fever and mild hepatic enzyme elevations before salicylate therapy was instituted. Liver function tests (LFT) returned to normal within five days of hospitalization but she continued to develop daily fevers. Blood, urine, and throat cultures were negative. An acute viral illness or reactivation of systemic lupus erythematosus were the suspected diagnoses. Choline magnesium trisalicylate was then administered in an effort to control her fever, and was successful. After three days of salicylate therapy her LFT values began to rise. They continued to rise for five more days before salicylate hepatotoxicity was suspected. Choline magnesium trisalicylate was discontinued after eight days and the patient's LFT quickly returned to normal. The source of fever was never identified, although infection with cytomegalovirus was considered the most likely cause. Salicylate-induced hepatotoxicity is reviewed.

Morphometric analysis of cultured hepatocytes exposed to benoxaprofen

This study was undertaken to quantitate morphological changes in primary cultures of liver cells exposed to benoxaprofen and to compare morphological assessments with standard assessments of functional integrity. Rat hepatocytes were exposed for 12 h to 0, 100, 500, or 1000 microM concentrations of benoxaprofen and subjected to double-blind morphometric analysis. As benoxaprofen concentration was increased from 0 to 1000 microM, the relative percentage of morphologically normal cells was reduced, whereas the percentages of damaged cell types increased. These results paralleled those obtained from functional assessments. Therefore, the use of morphometric techniques provided a good assessment of benoxaprofen-induced cytotoxicity and demonstrated the value of quantitative estimates in the evaluation of cellular injury.

Adverse reactions to nonsteroidal anti-inflammatory drugs. Diclofenac compared with other nonsteroidal anti-inflammatory drugs

The most common adverse effects of nonsteroidal anti-inflammatory drugs are gastritis, peptic ulceration, and depression of renal function, all of which result primarily from prostaglandin inhibition. The types of side effects observed with diclofenac are similar to those of other nonsteroidal anti-inflammatory drugs and are unavoidable given that the drugs are prostaglandin inhibitors. However, the incidences of such side effects may be lower with diclofenac than with some of the other nonsteroidal anti-inflammatory drugs. Worldwide experience with diclofenac exceeds 7.6 million patient-years, which should provide estimates of the frequency of very rare adverse reactions. The latter include blood dyscrasias, erythema multiforme, hepatitis, and others, such as aseptic meningitis, anaphylaxis, and urticaria. Moreover, some nonsteroidal anti-inflammatory drugs appear to have unique side-effect profiles. Examples include a higher incidence of ulceration and erythema multiforme with piroxicam, and acute pancreatitis, in rare instances, with sulindac. From a careful survey of the world's accumulated literature and reports to CIBA-GEIGY, diclofenac does not appear to have any unusual adverse reactions.

Effects of non-narcotic analgesics on the liver

Serious hepatotoxicity is uncommon with the proper therapeutic use of non-narcotic analgesics but experience with new non-steroidal anti-inflammatory drugs (NSAIDs) is limited. Drugs such as ibufenac, fenclofenac and benoxaprofen were withdrawn from the market because of hepatotoxicity, and liver damage has been reported on occasion with virtually all non-narcotic analgesics. However, a clear pattern of toxicity with characteristic clinical, biochemical and histopathological abnormalities has emerged with relatively few. With the exception of acute hepatic necrosis following overdosage of paracetamol, little is known of the mechanisms of liver injury induced by non-narcotic analgesics. Involvement of the liver in a generalised drug reaction does not imply specific hepatotoxicity. About 50% of patients given aspirin regularly in anti-inflammatory doses develop mild, dose-dependent reversible liver damage as shown by elevation of the plasma aminotransferase activity. Liver damage is more severe in a small minority and it may rarely be complicated by disseminated intravascular coagulation and encephalopathy with a fatal outcome. There have also been isolated reports of chronic active hepatitis associated with the use of salicylates. Salicylate hepatitis has been reported most often in young females with connective tissue diseases. Many patients with Reye's syndrome have been given aspirin during the prodromal phase, and this serious condition closely resembles subacute salicylate intoxication in children. Salicylate probably has a causal or contributory role in Reye's syndrome, but many refuse to accept this and the issue is the subject of heated debate. Paracetamol in overdosage causes acute hepatic necrosis, and liver damage has been attributed to its therapeutic use. However, most reports have involved chronic alcoholics who took excessive doses and in these patients the clinical, biochemical and pathological findings were typical of paracetamol overdosage. Many authors have failed to make the distinction between therapeutic use and a therapeutic dose. In other cases liver damage could have been caused by exposure to other agents, viral infection or naturally occurring liver disease. If these cases are excluded, there are very few reports of liver damage associated with the proper therapeutic use of paracetamol. In some cases, the picture resembled chronic active hepatitis but no causal relationship has been established between this condition and paracetamol use. Paracetamol does not cause deterioration in liver function in patients with chronic liver disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Sulindac hepatotoxicity: a case report and review

A 44 year old female, previously on propranolol, phenytoin and phenobarbital, developed hepatotoxicity while on sulindac and acetaminophen containing analgesic. A limited review of hepatotoxicity and drug interactions of sulindac is presented. The possible mechanism of hepatotoxicity and its treatment is suggested.

Relative toxicities of several nonsteroidal antiinflammatory compounds in primary cultures of rat hepatocytes

Primary cultures of intact, functional heptocytes were used to compare the relative toxicity of four nonsteroid antiinflammatory agents (NSAID)--benoxaprofen, orpanoxin, aspirin, and ibuprofen--with that of indomethacin. The relative toxicity of these compounds was evaluated on the basis of the release of lactate dehydrogenase, levels of urea (an indicator of a liver specific function), viability (based on dye exclusion), and morphology after a 12-h exposure to concentrations ranging from 0 to 1000 microM. Evaluation of the data obtained from these three parameters enabled us to rank these compounds from toxic to nontoxic, in decreasing order to toxicity: indomethacin greater than benoxaprofen greater than ibuprofen greater than or equal to aspirin greater than or equal to orpanoxin. Morphological evaluations of hepatocytes exposed to these agents under the same conditions supported the order of ranking for these compounds. Ultrastructurally, cells exposed to the two highest concentrations of indomethacin were severely damaged, as evidenced by marked cellular necrosis, nuclear pleomorphism, margination, swollen mitochondria, reductions in the number of microvilli, smooth endoplasmic reticulum proliferation, and cytoplasmic vacuolation. In comparison, exposure of hepatocytes to the highest dose of orpanoxin resulted only in increased vacuolation, a slight increase in cellular debris, and increased electron density of the cytoplasm of hepatocytes.

Measurement of aminotransferases: Part 1. Aspartate aminotransferase

Aminotransferases are ubiquitous enzymes of mammalian cells and several are of important diagnostic use. The application of aspartate aminotransferase activity measurements in serum from individuals suffering from myocardial infarction brought about a new dimension in clinical laboratory testing in the 1950s. This review focuses on measurement techniques for aspartate aminotransferase and their application (a subsequent article will review other aminotransferases). Assay techniques measuring enzyme activity are direct spectrophotometric measurements, manometric techniques, assays using dye substances, coupled enzyme techniques, and radiometric procedures. Of these procedures, the one employing malate dehydrogenase and NADH is the most important and is covered in particular detail. The estimation of the mitochondrial isoenzyme of aspartate aminotransferase is also of clinical interest, in particular for estimating severity of disease or in specific applications (e.g., chronic alcoholism). Methods reviewed for estimation of this enzyme are electrophoresis, chromatography, differential kinetic behavior, and immunochemical separation. Determination of the enzyme protein by techniques independent of its catalytic activity are also reviewed.

Hepatotoxicity following the therapeutic use of antipyretic analgesics

The potential for hepatic injury associated with the therapeutic use of salicylates and acetaminophen has recently attracted considerable attention. About 300 cases have been reported in which elevated transaminase levels or other evidence of hepatic injury developed following treatment with salicylates. Review of the spectrum of abnormalities reveals a group of patients (4 percent) with symptomatic liver damage in whom progressive or chronic liver disease is a possibility with continued use of the drug. In a few patients in this group, jaundice developed; several had abnormal prothrombin times; 11 (70 percent) had transaminase values in excess of 500 units; and five patients (30 percent) had encephalopathy and/or Reye's syndrome. In several reports liver damage has also been associated with the use of acetaminophen in therapeutic or near-therapeutic dosages. Of 18 patients, nine appeared to have ingested acetaminophen in amounts approaching overdose. Of the remaining nine patients, six were alcoholics. In the entire group, only five patients did not have a history of alcohol abuse; in three, glutathione depletion was suggested as a possible explanation for hepatotoxicity. The association with alcoholism or glutathione depletion suggests that host susceptibility may play a critical role. In two patients, long-term use of acetaminophen resulted in liver injury suggestive of chronic active hepatitis, possibly on the basis of an idiosyncratic reaction. In a study of chronic liver disease, acetaminophen half-life was prolonged (168 percent) without accumulation at 4 g a day over five days. In a double-blind, two-week, cross-over study, no clinical or laboratory evidence of adverse effects was found. There is, therefore, no evidence that chronic liver disease increases the risk of hepatotoxicity following the administration of acetaminophen in therapeutic doses. Thus, acetaminophen is the preferred antipyretic analgesic in patients with liver disease. Salicylates should be avoided since many of the adverse effects associated with these drugs are similar to the complications of chronic liver disease.

Treatment of fever in 1982: a review

While there is room for questioning the need, or even advisability, of routine antipyretic therapy, the available data do not yet constitute any sort of a contraindication. There are reasons for individualizing the decision. However, having once decided, there is no compelling reason for selecting one antipyretic over any other, and aspirin remains the most satisfactory in light of the available evidence. Some serious theoretic questions persist about the safety of acetaminophen use in sick persons, and clearly there are some precautions that should be taken with regard to the doses of flavored preparations of this and any future products whose attractiveness to children is thus enhanced.

Age-associated changes of responses to acetylsalicylic acid

Aspirin can be an effective antipyretic, analgesic and anti-inflammatory agent, but unfortunately, its use in the elderly is often excessive [43]. In a survey by Gillies and Skyring, the overall prevalence of daily aspirin intake was greater in middle-age and older-age groups than for those of less than 40 years of age [16]. The elderly are susceptible to the advertising of non-prescription drugs and aspirin is frequently self-prescribed [8,31]. Age-related physiological changes modify the response to aspirin in the elderly. A higher incidence of drug reactions and interactions has been evidenced in this age group. The cases cited throughout this report substantiate the need for caution on the part of the geriatric patient and the physician in regard to aspirin therapy for the elderly.

Pharmacotherapy of juvenile rheumatoid arthritis

Salicylate is the drug of first choice in the initial treatment of juvenile rheumatoid arthritis. In therapeutic dosage it will adequately control joint symptoms in the majority of patients. For children who do not respond to or are intolerant of salicylate, a change to one of the other nonsteroidal anti-inflammatory agents is appropriate. In progressive polyarthritis unresponsive to the above agents, the addition of gold, antimalarials, or penicillamine is indicated, preferably in that order. Corticosteroid therapy should be reserved for selected patients meeting specific criteria. Pharmacotherapy of juvenile rheumatoid arthritis should always be individualized. For optimal treatment of the whole child it must be combined with both physical and educational measures.

Salicylate hepatotoxicity in systemic lupus erythematosus: a common occurrence?

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Hepatoxicity with encephalopathy associated with aspirin therapy in rheumatoid arthritis

Encephalopathy secondary to aspirin-induced hepatoxicity developed in three patients with JRA. In each patient clinical and biochemical resolution occurred after discontinuing the drug, but toxicity appeared on rechallenge. Liver biopsies in two patients showed mild nonspecific changes. Acute hepatic decompensation and encephalopathy may occur as a consequence of aspirin hepatoxicity in JRA and justify sequential observations of liver function tests and salicylate levels in such patients.

Costovertebral and costotransverse joint involvement in rheumatoid arthritis

Lesions of the costovertebral (CV) and costotransverse (CT) joints are distinctly unusual in rheumatoid arthritis. The patient presented had dramatic changes in these joints with destruction, ankylosis, and bony overgrowth. This led to a moderate respiratory impairment and a distinctive radiological presentation.

Cholestatic jaundice caused by D-penicillamine

D-penicillamine is not generally considered to cause hepatic damage. Cholestatic jaundice developed in a patient with rheumatoid arthritis 4 weeks after penicillamine was added to his regimen, and he died in acute renal failure. The probability that penicillamine caused the cholestasis is discussed.

Aspirin-induced hepatic dysfunction in a patient with adult rheumatoid arthritis

A patient with classical rheumatoid arthritis receiving high doses of aspirin developed significant elevation of serum glutamic oxaloacetic transaminase. This patient had recently been on phenylbutazone and an initial liver biopsy, at the time of elevation of the transaminase revealed nonspecific mild fatty infiltration of the liver compatible with the pathology seen with rheumatoid disease. Because of the severity and activity of her rheumatoid arthritis, and thus the need to know whether aspirin was the etiologic factor in liver dysfunction, the patient was challenged with aspirin. SGOT elevation occurred after a 4-6 day lag period, which promptly remitted when salicylates were discontinued. A liver biopsy at this time revealed evidence for degeneration, regeneration, and mild focal mononuclear infiltration. Although previous reports note salicylate-related hepatocellular dysfunction in patients with systemic lupus erythematosus and juvenile rheumatoid arthritis, these data clearly demonstrate the relationship of ASA to liver dysfunction in a patient with adult onset rheumatoid arthritis. This histologic picture as well as the clinical course of this patient's hepatic abnormality suggest a toxic rather than hypersensitivity etiology for this syndrome.

Effect of aspirin on liver tests in patients with RA or SLE and in normal volunteers

Aspirin was given to 20 patients with RA, 16 patients with SLE, and 3 normal volunteers. Four of the RA patients, 7 of the SLE patients, and 1 normal volunteer developed abnormal liver tests, during the study. The abnormalities (elevated transaminases) were most frequent and of rapid onset in patients with cliniclaly active SLE. Increases in BUN and creatinine related to aspirin were observed in several subjects. In a retrospective survey of 80 patients with SLE, aspirin appeared responsible for two-thirds of episodes of liver test abnormalities in 19 patients.

Correlations between transaminase concentrations and serum salicylate concentration in juvenile rheumatoid arthritis

Simultaneous measurements of serum salicylate, SGPT, and SGOT concentrations were made on 92 children receiving salicylates for arthritis during a 13-month period. Statistical correlations were found between salicylate and transaminase concentrations in patients with juvenile rheumatoid arthritis when in active stages. However elevated transaminase levels occurred with low salicylate levels and during inactive stages, and were inconstant in individual patients. Marked transaminase abnormalities were transient and appeared unpredictably in individual patients. Some factor in addition to salicylate concentration must be involved in raising serum transaminase levels. No evidence of chronic hepatotoxicity was noted.

Aspirin-induced hepatotoxicity in juvenile rheumatoid arthritis. A prospective study

Recent reports of and our own experience with biochemical alterations of liver function secondary to salicylate therapy stimulated this prospective study. Thirty-four children with juvenile rheumatoid arthritis, 6 children with acute cartilagenous necrosis of the hipfollowing slipped capital femoral epiphysis, and 2 children with ulcerative colitis and hip disease who were on salicylates were followed over a period of 1-27 months with serial determinations of serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), lactic dehydrogenase (LDH), alkaline phosphatase (AP), bilirubin, and serum salicylate. Prothrombin time was measured in 14 children. Twenty-two of 34 children with rheumatoid arthritis and none of the 8 controls demonstrated abnormalities of various liver functions at serum salicylate levels between 7.0 and mg%. Three children demonstrated severe abnormalities characterized by marked elevation of SGOT, SGPT, LDH, and AP, prolongation of prothrombin time, and epistaxis. This type of reaction occurred within 5-14 days of initiation of aspirin therapy and occurred at serum salicylate levels between 18 and 43 mg%. Moderate changes in various liver function tests were observed in 19 other children. None of those children who were tested showed prolongation of prothrombin time. The serum salicylate level in this group varied between 7.0 and 38.2 mg%. The abnormal liver function tests returned to normal in 6 children upon withdrawal of aspirin and in 12 others even when salicylates were continued. Therefore, despite the occurrence of biochemical abnormalities following chronic salicylate therapy, it does not appear to be necessary to discontinue their use except in those children who develop bleeding.

Liver disease in rheumatoid arthritis and Sjøgren's syndrome. Prospective study using biochemical and serological markers of hepatic dysfunction

Inter-relationships of biochemical and immunological tests of liver function have been studied in a prospective study of 216 patients with rheumatoid arthritis (RA), 32 patients with Sjogren's syndrome, and 27 patients with the sicca syndrome, and these results have been compared with those obtained 289 patients with osteoarthrosis or with a form of seronegative polyarthropathy. In general the prevalence of abnormalities in serum alkaline phosphatase, bromsulphthalein excretion, smooth muscle antibody, and mitochondrial antibody in the former three groups was higher than in patients with osteoarthrosis. Patients with Sjogren's syndrome with RA had a higher prevalence of abnormalities of bromsulphthalein excretion, salivary duct antibody than patients with the sicca syndrome. Patients with RA had a higher pervalence of rheumatoid factor than those with the sicca syndrome. Patients with a positive smooth muscle or mitochondrial antibody were found to have a higher prevalence of hepatomegaly and splenomegaly, of abnormal liver function tests, of other autoantibodies, and of histological abnromalitis of liver than those in whom these tests were negative.

Liver disease in patients with joint symptoms

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