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Petrović S, Kovačević M, Kovačević SV, Miljković B. Hepatotoxicity of newer antiseizure medications in children: an overview and disproportionality analysis of VigiBase. Expert Opin Drug Metab Toxicol 2024; 20:165-173. [PMID: 38380611 DOI: 10.1080/17425255.2024.2322114] [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: 01/04/2024] [Accepted: 02/16/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND We aimed to characterize newer antiseizure medications (ASMs)-induced hepatotoxicity in children and identify signals of disproportionate reporting of hepatotoxicity-related adverse drug events (ADEs). RESEARCH DESIGN AND METHODS Case reports reported to VigiBase were accessed using Empirica™ Signal software. To summarize characteristics of the retrieved cases, descriptive statistics were used. A disproportionality analysis was conducted using the Multi-item Gamma Poisson Shrinker algorithm, which calculates Empirical Bayesian Geometric Mean value and its lower and upper 95% confidence limits (EB05 and EB95, respectively). EB05 > 2, N > 0 was considered a signal. RESULTS Based on 870 analyzed cases, a higher proportion of cases was reported in girls than in boys and in patients aged 2-11 years than in other age groups. Most cases were serious. In 25 cases, hepatotoxicity resulted in death. A high proportion of patients (n = 275, 31.61%) experienced hypersensitivity reactions, mostly due to lamotrigine. The disproportionality analysis yielded 17 signals concerning felbamate, lamotrigine, levetiracetam, oxcarbazepine, stiripentol, and topiramate. Four signals were for severe liver injury and concerned felbamate, lamotrigine, levetiracetam, and topiramate. Gender-biased reporting frequency was detected for four ASM-ADE combinations. CONCLUSION Our results should serve to raise clinicians' awareness about the potential association between several newer ASMs and drug-induced liver injury in children.
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Affiliation(s)
| | - Milena Kovačević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Pharmacy, Belgrade, Serbia
| | - Sandra Vezmar Kovačević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Pharmacy, Belgrade, Serbia
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Pharmacy, Belgrade, Serbia
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Andújar-Vera F, Alés-Palmer ML, Muñoz-de-Rueda P, Iglesias-Baena I, Ocete-Hita E. Metabolomic Analysis of Pediatric Patients with Idiosyncratic Drug-Induced Liver Injury According to the Updated RUCAM. Int J Mol Sci 2023; 24:13562. [PMID: 37686369 PMCID: PMC10487599 DOI: 10.3390/ijms241713562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Hepatotoxicity, a common adverse drug effect, has been extensively studied in adult patients. However, it is equally important to investigate this condition in pediatric patients to develop personalized treatment strategies for children. This study aimed to identify plasma biomarkers that characterize hepatotoxicity in pediatric patients through an observational case-control study. Metabolomic analysis was conducted on 55 pediatric patients with xenobiotic liver toxicity and 88 healthy controls. The results revealed clear differences between the two groups. Several metabolites, including hydroxydecanoylcarnitine, octanoylcarnitine, lysophosphatidylcholine, glycocholic acid, and taurocholic acid, were identified as potential biomarkers (area under the curve: 0.817; 95% confidence interval: 0.696-0.913). Pathway analysis indicated involvement of primary bile acid biosynthesis and the metabolism of taurine and hypotaurine (p < 0.05). The findings from untargeted metabolomic analysis demonstrated an increase in bile acids in children with hepatotoxicity. The accumulation of cytotoxic bile acids should be further investigated to elucidate the role of these metabolites in drug-induced liver injury.
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Affiliation(s)
| | - María Luisa Alés-Palmer
- Department of Pediatrics, University of Granada, 18016 Granada, Spain;
- Department of Pediatrics, “Virgen de las Nieves” University Hospital, 18014 Granada, Spain
| | - Paloma Muñoz-de-Rueda
- Research Support Unit, Biosanitary Research Institute ibs.GRANADA, 18012 Granada, Spain;
| | | | - Esther Ocete-Hita
- Department of Pediatrics, University of Granada, 18016 Granada, Spain;
- Department of Pediatrics, “Virgen de las Nieves” University Hospital, 18014 Granada, Spain
- Biosanitary Research Institute ibs.GRANADA, 18012 Granada, Spain
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Lv B, Liu L, Liu X, Huang M, Chen X, Tang K, Wang C, Chen P. Incidence, clinical features and risk factors of tacrolimus induced idiosyncratic liver injury in renal transplant recipients: A nested case-control study. Front Pharmacol 2023; 14:1126765. [PMID: 36992828 PMCID: PMC10040645 DOI: 10.3389/fphar.2023.1126765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/03/2023] [Indexed: 03/15/2023] Open
Abstract
Rare data reported tacrolimus-induced liver injury (tac-DILI) in real world. We performed a nested case-control analysis of 1,010 renal transplant recipients. Recipients with tac-DILI were randomly matched at a ratio of 1:4 by the year of admission to the remaining recipients without tac-DILI to explore risk factors. The incidence of tac-DILI was 8.9% (95% CI = 7.2–10.7%). The most common type was cholestatic pattern (6.7%, 95% CI = 5.2–8.3%), followed by hepatocellular (1.6%, 95% CI = 0.8–2.4%) and mixed patterns (0.6%, 95% CI = 0.1–1.1%). 98.9% of recipients with tac-DILI have mild severity. The latency period were 42.0 (range, 21.5–99.8 days), 14.0 (range, 9.0–80.3 days), 16.0 (range, 11.5–24.5 days), and 49.0 days (range, 28.0–105.6 days) for total, hepatocellular, mixed, and cholestatic patterns, respectively. Baseline ALP level (OR = 1.015, 95% CI = 1.006–1.025, p = 0.002), age (OR = 0.971, 95% CI = 0.949–0.994, p = 0.006), and body weight (OR = 0.960, 95% CI = 0.940–0.982, p < 0.001) were independent risk factors. In conclusion, cholestatic pattern represents the most frequent type of tac-DILI. Young age, low body weight and abnormal baseline ALP level were risk factors.
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Affiliation(s)
- Binbin Lv
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Longshan Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoman Liu
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Min Huang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Kejing Tang
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Changxi Wang, ; Pan Chen,
| | - Pan Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Changxi Wang, ; Pan Chen,
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Amos K, Garcia-Bournissen F, Zhao L, Taheri S. Carbamazepine-induced liver injury in an 11-year-old female: Case report and review of the literature. J Paediatr Child Health 2023; 59:165-168. [PMID: 36069405 DOI: 10.1111/jpc.16200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Kiersten Amos
- Department of Paediatrics, Western University, London, Ontario, Canada
| | | | - Liena Zhao
- Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada
| | - Sepideh Taheri
- Department of Paediatrics, Western University, London, Ontario, Canada
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5
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Drug-induced Liver Injury in Pediatrics. J Pediatr Gastroenterol Nutr 2022; 75:391-395. [PMID: 35727646 DOI: 10.1097/mpg.0000000000003535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Drug-induced liver injury (DILI) is a rare, underdiagnosed cause of liver disease in children. The incidence of DILI in the pediatric population is unknown but it represents around 10% of all DILI cases. The most common hepatotoxic drugs in children are antibiotics and antiepileptics. DILI is classified as intrinsic or idiosyncratic and it presents mostly with 2 patterns of injury: hepatocellular or cholestatic. Diagnosis can be done with help of the Roussel Uclaf Causality Assessment Method (RUCAM) casualty assessment. The mainstay of treatment is prompt withdrawal of the suspect drug.
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Huang L, Li H, Zhong J, Yang L, Chen G, Wang D, Zheng G, Han H, Han X, Long Y, Wang X, Liang J, Yu M, Shen X, Fan M, Fang F, Liao J, Sun D. Efficacy and Safety of the Ketogenic Diet for Mitochondrial Disease With Epilepsy: A Prospective, Open-labeled, Controlled Study. Front Neurol 2022; 13:880944. [PMID: 35979062 PMCID: PMC9377015 DOI: 10.3389/fneur.2022.880944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/13/2022] [Indexed: 11/14/2022] Open
Abstract
Background The ketogenic diet (KD) is increasingly used to treat drug-resistant epilepsy because of its favorable effect on seizure reduction. Patients with mitochondrial diseases tend to experience seizures. Therefore, this study aimed to test the efficacy of the KD on participants with mitochondrial diseases in a controlled trial. Methods Participants from fourteen clinical centers who were diagnosed with mitochondrial disease were semi-randomized to either the intervention (KD) or control group. The KD group followed a 3-month KD intervention, while the control group received a 1-month normal diet initially and then a 3-month KD intervention. The primary outcome measure was seizure reduction. Biomarker changes, cognitive impairments, and side effects were also recorded, if available. Result A total of 33 participants were assigned to the KD (n = 22) and control groups (n = 11). In the KD group, 31.8% (7/22) of participants achieved ≥50% seizure reduction after 1 month of diet intervention, which increased to 40.9% (9/22) at 3 months. In the control group, only 18.2% (2/11) of the participants had ≥50% seizure reduction during the normal diet period. After the control group was transferred to the KD, 63.6% (7/11) of participants had >50% seizure reduction, and this rate increased to 72.7% (8/11) at 3 months. The KD also showed high efficacy in participants with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) or pathogenic variants in mitochondrial DNA (mtDNA) (90% and 93.3% response rates, respectively). The most frequent side effects reported at the 3-month review were vomiting, cold, hyperlipidemia, and bloating. Conclusion The KD is a safe and effective therapy for seizure control in mitochondrial diseases, especially MELAS and pathogenic variants of mtDNA. KD intervention can be considered in the management of these patients.
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Affiliation(s)
- Lijuan Huang
- Department of Neurology, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Hua Li
- Department of Epilepsy Center, Guangdong 999 Brain Hospital, Guangzhou, China
| | - Jianmin Zhong
- Department of Neurology, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Liming Yang
- Department of Neurology, Hunan Provincial Children's Hospital, Changsha, China
| | - Guohong Chen
- Department of Neurology, Henan Provincial Children's Hospital, Zhengzhou, China
| | - Dong Wang
- Department of Neurology, Xi'an Children's Hospital, Xi'an, China
| | - Guo Zheng
- Department of Neurology, Nanjing Children's Hospital, Nanjing, China
| | - Hong Han
- Department of Neurology, Children's Hospital of Shanxi, Taiyuan, China
| | - Xiong Han
- Department of Neurology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Yiqin Long
- Department of Neurology, Liuzhou Maternal and Child Healthcare Hospital, Liuzhou, China
| | - Xu Wang
- Department of Neurology, Changchun Children's Hospital, Changchun, China
| | - Jianmin Liang
- Department of Neurology, The First Bethune Hospital of Jilin University, Changchun, China
| | - Mei Yu
- Department of Neurology, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyun Shen
- Department of Neurology, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Mengke Fan
- Department of Neurology, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Fang Fang
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, Beijing, China
- *Correspondence: Fang Fang
| | - Jianxiang Liao
- Department of Neurology, Shenzhen Children's Hospital, Shenzhen, China
- Jianxiang Liao
| | - Dan Sun
- Department of Neurology, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science and Technology, Wuhan, China
- Dan Sun
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Tian M, Peng Y, Zheng J. Metabolic Activation and Hepatotoxicity of Furan-containing Compounds. Drug Metab Dispos 2022; 50:655-670. [DOI: 10.1124/dmd.121.000458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 01/18/2022] [Indexed: 11/22/2022] Open
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Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Khan Z, Karataş Y, Kıroğlu O. Evaluation of Adverse Drug Reactions in Paediatric Patients: A Retrospective Study in Turkish Hospital. Front Pharmacol 2021; 12:786182. [PMID: 34867419 PMCID: PMC8638749 DOI: 10.3389/fphar.2021.786182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/25/2021] [Indexed: 12/28/2022] Open
Abstract
Drug safety in paediatric patients is a serious public health concern around the world. The paediatric patients are more prone to adverse drug reactions (ADRs) than adults. Moreover, there is a scarcity of information about ADRs in paediatric patients. This study was conducted to determine the frequency, causality, severity, preventability of paediatric patients’ ADRs reported in a tertiary care hospital in Adana, Turkey. A retrospective study was conducted on all spontaneously reported ADRs between January 01, 2020, to July 30, 2021, in paediatric patients. The ADRs reports were evaluated in terms of gender, age, ADR characteristics, suspected drugs and reporting source. All included ADRs reports were characterized according to the Naranjo Algorithm/World Health Organization (WHO) causality scales, Hartwig/Siegel and Common Terminology Criteria for Adverse Events (CTCAE) severity scales, the modified Schoumock and Thornton preventability scale and hospital pharmacovigilance center criteria for seriousness. Therapeutic groups were also coded using the WHO-Anatomical Therapeutic and Chemical (ATC) classification. During the study period, 8,912 paediatric patients who were admitted had 16 ADRs with 1.7 ADRs/1,000 admissions. The majority of ADRs were found in infants (31.2%) and children (56.2%) as compared to adolescents (12.5%). ADRs were observed more in females (81.2%) than males. Skin (62.5%) was the most affected organ due to the ADRs, and maculopapular rash and erythema multiforme were the most commonly reported symptoms. Most ADRs were probable/likely (93.7%), severe (50%), preventable or probably preventable (43.7%) and serious (37.5%). Antibiotics (93.7%) were found to be the most common cause of ADRs in paediatric patients. The majority of ADRs were associated with vancomycin (68.7%). Most of the ADRs were reported by a medical doctor in this study. This small sample size study highlights significant problems of ADRs in paediatric patients, mainly caused by antibiotics and with a majority of ADRs manifest as skin reactions. Furthermore, a high proportion of the identified ADRs were found to be preventable. More focused efforts are needed at the national level to avoid preventable ADRs in hospitals. Monitoring and management of ADRs and future studies would be beneficial for better patient care and safety.
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Affiliation(s)
- Zakir Khan
- Department of Pharmacology, Institute of Health Sciences, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Yusuf Karataş
- Department of Pharmacology, Institute of Health Sciences, Faculty of Medicine, Cukurova University, Adana, Turkey.,Pharmacovigilance Specialist, Balcali Hospital, Faculty of Medicines, Cukurova University, Adana, Turkey
| | - Olcay Kıroğlu
- Department of Pharmacology, Institute of Health Sciences, Faculty of Medicine, Cukurova University, Adana, Turkey
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Evaluation of Pharmacokinetics and Pharmacodynamics of Deferasirox in Pediatric Patients. Pharmaceutics 2021; 13:pharmaceutics13081238. [PMID: 34452199 PMCID: PMC8401444 DOI: 10.3390/pharmaceutics13081238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/28/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Deferasirox (DFX) is commonly used to reduce the chronic iron overload (IO) in pediatric patients. However, the drug is characterized by a large pharmacokinetic variability and approximately 10% of patients may discontinue the treatment due to toxicities. Therefore, the present retrospective study investigated possible correlations between DFX pharmacokinetics and drug-associated toxicities in 39 children (26 males), aged 2–17 years, who underwent an allogeneic hematopoietic stem cell transplantation. Methods: IO was diagnosed by an abdominal magnetic resonance imaging and DFX was started at a median dose of 500 mg/day. DFX plasma concentrations were measured by a high performance liquid chromatographic method with UV detection and they were analysed by nonlinear mixed-effects modeling. Results: The pharmacometric analysis demonstrated that DFX pharmacokinetics were significantly influenced by lean body mass (bioavailability and absorption constant), body weight (volume of distribution), alanine and aspartate transaminases, direct bilirubin, and serum creatinine (clearance). Predicted DFX minimum plasma concentrations (Ctrough) accounted for 32.4 ± 23.2 mg/L (mean ± SD), and they were significantly correlated with hepatic/renal and hematological toxicities (p-value < 0.0001, T-test and Fisher’s exact tests) when Ctrough threshold values of 7.0 and 11.5 mg/L were chosen, respectively. Conclusions: The population pharmacokinetic model described the interindividual variability and identified Ctrough threshold values that were predictive of hepatic/renal and hematological toxicities associated with DFX.
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Relative Risk Analysis of Liver-related Adverse Drug Reactions in Children Based on China's National Spontaneous Reporting System. J Pediatr 2021; 234:85-91. [PMID: 33794217 DOI: 10.1016/j.jpeds.2021.03.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To compare the risk of liver-related adverse drug reactions (ADRs) in children and adults. STUDY DESIGN A case/non-case analysis on spontaneous reports based on the China National Adverse Drug Reactions Monitoring System database were conducted, focusing on events of liver-related ADRs in children younger than 14 years of age. Both the relative risk of liver-related ADRs in children vs entire population and the risk stratification in children were expressed as a measure of disproportionality using the reporting odds ratio (ROR). RESULTS There were 1206 cases of pediatric liver-related ADRs identified from 2012 to 2016, accounting for 2.82% of the entire population. The greatest ROR values in children from 0 to 14 years vs the entire population were observed for analgesics (3.97, 95% CI 3.27-4.81), respiratory (2.60, 95% CI 1.04-6.43), antineoplastic (2.29, 95% CI 2.02-2.58), immunomodulatory (1.91, 95% CI 1.44-2.53), and antimicrobial agents (1.47, 95% CI 1.33-1.63). Notably, infants aged 0-1 years showed significantly greater risk (3.14, 95% CI 2.85-3.48) of liver-related ADRs than the other age groups of children. For infants, analgesics (3.21, 95% CI 2.20-4.66) and antimicrobials (3.15, 95% CI 2.50-3.97) agents were found to have the greatest adjusted RORs than other drug categories. The highest RORs were found for meropenem, amoxicillin, fluconazole, vancomycin, cefaclor, and ceftazidime in the antimicrobial agents for infants. CONCLUSIONS Children are sensitive to liver-related ADRs caused by several specific drug categories, and infants are the most sensitive.
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Allegaert K, van den Anker J. Dose-Related Adverse Drug Events in Neonates: Recognition and Assessment. J Clin Pharmacol 2021; 61 Suppl 1:S152-S160. [PMID: 34185907 PMCID: PMC8361661 DOI: 10.1002/jcph.1827] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/04/2021] [Indexed: 12/23/2022]
Abstract
The efficacy and safety of a drug is dose or exposure related, and both are used to assess the benefit-risk balance of a given drug and ultimately to decide on the specific drug license, including its dose and indication(s). Unfortunately, both efficacy and safety are much more difficult to establish in neonates, resulting in very few drugs licensed for use in this vulnerable population. This review will focus on dose-related adverse events in neonates. Besides the regulatory classification on seriousness, adverse event assessment includes aspects related to signal detection, causality, and severity. Disentangling confounders from truly dose-related adverse drug events remains a major challenge, as illustrated for drug-induced renal impairment, drug-induced liver injury, and neurodevelopmental outcome. Causality assessment, using either routine tools (Naranjo algorithm, World Health Organization's Uppsala Monitoring Center causality tool) or a Naranjo algorithm tailored to neonates, still does not sufficiently and reliably document causality in neonates. Finally, very recently, a first neonatal severity-grading tool for neonates has been developed. Following the development of advanced pharmacokinetic approaches and techniques to predict and assess drug exposure, additional efforts are needed to truly and fully assess dose adverse drug events. To further operationalize the recently developed tools on causality and severity, reference databases on a palette of biomarkers and outcome variables and their covariates are an obvious next step. These databases should subsequently be integrated in modeling efforts to truly explore safety outcome, including aspects associated with or caused by drug dose or exposure.
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Affiliation(s)
- Karel Allegaert
- Department of Development and RegenerationKU LeuvenLeuvenBelgium
- Department of Pharmaceutical and Pharmacological SciencesKU LeuvenLeuvenBelgium
- Department of Hospital PharmacyErasmus MC University Medical CenterRotterdamthe Netherlands
| | - John van den Anker
- Division of Clinical PharmacologyChildren's National Health HospitalWashingtonDCUSA
- Pediatric Pharmacology and PharmacometricsUniversity Children's Hospital Basel (UKBB)University of BaselBaselSwitzerland
- Intensive Care and Department of Pediatric SurgeryErasmus MC Sophia Children's HospitalRotterdamThe Netherlands
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13
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Zhang C, Wu Y, Yuan S, Dou X, Sheng Q, Wang J, Tian W, Yao L, Ding Y. Characteristics of Drug-Induced Liver Injury in Northeast China: Disease Spectrum and Drug Types. Dig Dis Sci 2020; 65:3360-3368. [PMID: 31907771 DOI: 10.1007/s10620-019-06030-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/22/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of this study was to determine the disease spectrum and drug types causing drug-induced liver injury (DILI) in northeast China, so that the affected population can be reminded of the need to increase their post-medication monitoring. METHODS A total of 470 DILI patients hospitalized at Shengjing Hospital between 2013 and 2016 were involved in this retrospective study. RESULTS There were significant differences in the disease spectrum of the different age groups (P < 0.001) and genders (P = 0.009). Drugs used to treat osteopathies, dermatitis and infections, as well as health care supplements, each accounted for > 10% of all drugs that caused DILI. The percentage of DILIs related to Chinese herbal medicines (CHMs) gradually increased with patient age (P = 0.002). The percentage of males taking health supplements or CHMs was significantly lower compared with females. Total bilirubin (β = 0.01, OR = 1.01, P < 0.001) and INR (β = 0.74, OR = 2.11, P < 0.001) were found to be independent predictors of liver damage. CONCLUSIONS The main type of drug that causes DILI in northeast China is a CHM. There are differences in the disease spectrum found in DILI patients of different ages and gender. Making appropriate changes in the drug-taking habits of high-risk groups and the drugs used to treat high-risk underlying diseases, as well as increasing patient monitoring, may help to reduce the incidence of DILIs.
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Affiliation(s)
- Chong Zhang
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang City, 110022, Liaoning Province, China
| | - Yuyu Wu
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang City, 110022, Liaoning Province, China
| | - Suyu Yuan
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang City, 110022, Liaoning Province, China
| | - Xiaoguang Dou
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang City, 110022, Liaoning Province, China
| | - Qiuju Sheng
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang City, 110022, Liaoning Province, China
| | - Jingyan Wang
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang City, 110022, Liaoning Province, China
| | - Wenyue Tian
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang City, 110022, Liaoning Province, China
| | - Lan Yao
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang City, 110022, Liaoning Province, China
| | - Yang Ding
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang City, 110022, Liaoning Province, China.
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(+)-Clausenamide protects against drug-induced liver injury by inhibiting hepatocyte ferroptosis. Cell Death Dis 2020; 11:781. [PMID: 32951003 PMCID: PMC7502081 DOI: 10.1038/s41419-020-02961-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 08/13/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023]
Abstract
Drug-induced liver injury is the major cause of acute liver failure. However, the underlying mechanisms seem to be multifaceted and remain poorly understood, resulting in few effective therapies. Here, we report a novel mechanism that contributes to acetaminophen-induced hepatotoxicity through the induction of ferroptosis, a distinctive form of programmed cell death. We subsequently identified therapies protective against acetaminophen-induced liver damage and found that (+)-clausenamide ((+)-CLA), an active alkaloid isolated from the leaves of Clausena lansium (Lour.) Skeels, inhibited acetaminophen-induced hepatocyte ferroptosis both in vivo and in vitro. Consistently, (+)-CLA significantly alleviated acetaminophen-induced or erastin-induced hepatic pathological damages, hepatic dysfunctions and excessive production of lipid peroxidation both in cultured hepatic cell lines and mouse liver. Furthermore, treatment with (+)-CLA reduced the mRNA level of prostaglandin endoperoxide synthase 2 while it increased the protein level of glutathione peroxidase 4 in hepatocytes and mouse liver, confirming that the inhibition of ferroptosis contributes to the protective effect of (+)-CLA on drug-induced liver damage. We further revealed that (+)-CLA specifically reacted with the Cys-151 residue of Keap1, which blocked Nrf2 ubiquitylation and resulted in an increased Nrf2 stability, thereby leading to the activation of the Keap1–Nrf2 pathway to prevent drug-induced hepatocyte ferroptosis. Our studies illustrate the innovative mechanisms of acetaminophen-induced liver damage and present a novel intervention strategy to treat drug overdose by using (+)-CLA.
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Drug-Induced Liver Injury in Critically Ill Children Taking Antiepileptic Drugs: A Retrospective Study. Curr Ther Res Clin Exp 2020; 92:100580. [PMID: 32280391 PMCID: PMC7138958 DOI: 10.1016/j.curtheres.2020.100580] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/02/2020] [Indexed: 12/19/2022] Open
Abstract
Critically ill children on anti-epileptic drugs often receive multiple concomitant drugs with potential to result in liver injury. Antimicrobial drugs followed by drugs for stress ulcer prophylaxis form the major drug classes with the risk of DILI that are concomitantly administered with anti-epileptic drugs in critically ill children.
Background Antiepileptic drugs are among the leading causes of drug-induced liver injury (DILI). Due to critical illness, children admitted to intensive care units are more prone to DILI. Objective We attempted to elucidate the association between antiepileptic drug use and the associated factors resulting in DILI in a pediatric intensive care unit of a tertiary care hospital. Methods We carried out an observational retrospective study on children receiving antiepileptic drugs. Details on their demographic characteristics, drugs, serum levels of antiepileptic drugs and liver function tests, and hospital stay were recorded. Council for International Organizations of Medical Sciences definitions were adhered to when defining DILI. LiverTox (https://livertox.nih.gov) and DILIrank were used to assess the risks of hepatotoxicity of the concomitant drugs. Regression models were developed for predicting DILI. Results Five out of 9 patients taking phenobarbitone (55.6%), 9 out of 12 taking phenytoin monotherapy (75%), 7 out of 10 taking phenytoin/phenobarbitone (70%), all 3 receiving phenytoin/phenobarbitone/valproate sodium, and 1 with phenytoin/carbamazepine developed DILI either in the form of hepatocellular injury or liver biochemical test abnormalities. None of the patients had cholestatic or mixed type of liver injury. All the critically ill children received at least 2 concomitant drugs with hepatotoxic potential. Concomitant category B hepatotoxic drugs and toxic drug levels were significantly associated with increased risk of DILI. Similarly, a trend was observed for less-DILI-concern concomitant drug class and toxic drug levels when the drugs were analyzed by DILIrank classification. Conclusions A significant proportion of critically ill children taking antiepileptic drugs experience DILI. Guidelines recommending use of drugs with reduced risk of potential hepatotoxicity for various concomitant disease states in such children admitted to intensive care units receiving antiepileptic drugs are urgently needed.
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Weaning Mice and Adult Mice Exhibit Differential Carbon Tetrachloride-Induced Acute Hepatotoxicity. Antioxidants (Basel) 2020; 9:antiox9030201. [PMID: 32121508 PMCID: PMC7139353 DOI: 10.3390/antiox9030201] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/13/2020] [Accepted: 02/16/2020] [Indexed: 02/06/2023] Open
Abstract
Age is a risk factor for drug-induced liver injury (DILI). However, there is a limited understanding of pediatric DILI. Here, 2-week-old weaning and 8-week-old adult male ICR mice were intraperitoneally injected with CCl4 (0.1 mmol/kg equal to 15.4 mg/kg) to comparatively evaluate the time-dependent liver damage and cellular events. CCl4 significantly enhanced the serum alanine aminotransferase/aspartate aminotransferase levels and hepatic centrilobular necrosis in the weaning mice, whereas it induced mild liver injury in the adult mice. CCl4-treated weaning mice exhibited higher hepatic levels of pro-apoptotic proteins (Bax, cleaved caspase-3, -7, and -9), activated MAPKs (p-JNK and p-Erk), and endoplasmic reticulum stress indicators (ATF6 and CHOP) and lower hepatic anti-apoptotic Bcl-2 levels than the adult mice. The weaning mice exhibited enhanced basal hepatic glutathione (GSH) levels due to high glutamate cysteine ligase (GCL) and low anti-cysteine dioxygenase (CDO) enzyme levels. However, CCl4 markedly reduced the hepatic GSH levels only in the weaning mice. Furthermore, higher hepatic levels of oxidative stress-induced malondialdehyde, 4-hydroxynonenal, nitrotyrosine-protein adducts, and oxidized proteins were observed in CCl4-treated weaning mice than in CCl4-treated adult mice. The enhanced levels of hepatic cytochrome P450 (CYP) 2E1 and CYP3A, and decreased hepatic GSH S-transferase (GST)-π and GSH reductase (GR) levels in the weaning mice may contribute to their enhanced susceptibility to liver damage.
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Abstract
Neonatal acute liver failure (NALF) is a rare disease with a few known primary causes: gestational alloimmune liver disease (GALD), viral infections, metabolic diseases, and ischemic injury. Many cases still do not have a known cause. Laboratory evaluation may suggest a diagnosis. Most of the known causes have disease-specific treatments that improve outcomes. Survival is improving with better knowledge about and treatment options for GALD; however, overall mortality for NALF is still 24%. Liver transplant remains an important option for neonates with an indeterminate cause of NALF and those who do not respond to established treatments.
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Affiliation(s)
- Catherine Larson-Nath
- Pediatric Gastroenterology, Hepatology & Nutrition, University of Minnesota, 2450 Riverside Avenue, Minneapolis, MN 55454, USA
| | - Bernadette E Vitola
- Pediatric Gastroenterology, Hepatology & Nutrition, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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Rieder M. Adverse Drug Reactions Across the Age Continuum: Epidemiology, Diagnostic Challenges, Prevention, and Treatments. J Clin Pharmacol 2019; 58 Suppl 10:S36-S47. [PMID: 30248196 DOI: 10.1002/jcph.1115] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 02/11/2018] [Indexed: 12/15/2022]
Abstract
Adverse drug reactions (ADRs) are common and important complications of drug therapy for children. The risk for ADRs changes over childhood, as do the nature and types of ADRs. Importantly, the risk and nature of ADRs in children are markedly different from those of adults, and adult data cannot be relied on to guide safe drug therapy in children. There are groups of children, notably those with complex and chronic diseases, who are at substantial risk for ADRs. The evaluation of an undesired effect during therapy is ideally accomplished by an organized approach that is a skill that clinicians who care for children-especially those children at high risk for ADRs must have. Additionally, clinicians as well as drug regulatory agencies and industry need to be both vigilant and astute as well as aware that ADRs in children are often different in nature and frequency from those in adults. The increasing use of pharmacogenomics to guide drug dosing and the increasing number of biological agents will provide new sets of challenges to clinicians over the next decade.
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Affiliation(s)
- Michael Rieder
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada
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Abstract
Purpose of Review Drug induced liver injury (DILI) is a complex diagnosis dominantly based of exclusion. Recent Findings Currently available causality assessment instruments are considered to be suboptimal. Expert opinion appears to be best method to adjudicate causality, but is impractical to implement on a wide scale basis. Thus, new approaches are needed, for example improving the specificity of current scoring systems. A further option would be to develop a system that utilizes computer-based scoring - which would reduce human error. Additionally, it would be ideal to have available drug specific scoring systems, based on drugs' characteristic "phenotypes" (presentation and pattern of injury). Eventually, a validated system could be integrated within the electronic health information system. Summary This review highlights an avenue to an improved Causality Assessment Tool.
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