Acute cholestatic hepatitis associated with celecoxib

Research progress on rat model of drug-induced liver injury established by nonsteroidal anti-inflammatory drug (celecoxib) and royal jelly ameliorative effect

OBJECTIVES

NSAIDs, like celecoxib, are widely used to treat pain, fever, and inflammation, with celecoxib being particularly effective in managing arthritis symptoms and acute or chronic pain especially with its favorable gastrointestinal tolerability. The study aimed at exploring the effect of chronic administration of celecoxib on hepatic tissues in male albino rats. It also examined the royal jelly celecoxib interplay.

METHODS

50 male albino rats in 5 equal groups; Group 1: received no drug. Group 2: received celecoxib (50 mg/kg/day, orally), for 30 successive days. Group 3: received celecoxib plus royal jelly (300 mg/kg/day, orally) for 30 successive days. Group 4: received celecoxib, for 30 days, then were left untreated for another 30 days. Group 5: received celecoxib plus royal jelly for 30 days, then were left untreated for another 30 days.

RESULTS

Chronic celecoxib administration caused hepatotoxicity in male albino rats, with ameliorative effect of royal jelly. Celecoxib discontinuation significantly diminished the celecoxib-induced toxicity, and normal liver enzymes and serum protein levels were regained in the case of dual medications (celecoxib+RJ) discontinuation.

CONCLUSIONS

Long-term celecoxib administration caused hepatotoxicity, with ameliorative effects of royal jelly against celecoxib-induced oxidative and apoptotic stress. In addition, it could be concluded that royal jelly may prove a useful adjunct in patients being prescribed celecoxib.

Transplantation of adipose-derived mesenchymal stem cells ameliorates acute hepatic injury caused by nonsteroidal anti-inflammatory drug diclofenac sodium in female rats

BACKGROUND

Although the beneficial role of adipose-derived mesenchymal stem cells (AD-MSCs) in acute liver injury has been addressed by numerous studies employing different liver injury inducers, the role of rat AD-MSCs (rAD-MSCs) in diclofenac sodium (DIC) - induced acute liver injury has not yet been clarified.

OBJECTIVE

This study aimed to investigate whether rat adipose- rAD-MSCs injected intraperitoneal could restore the DIC-induced hepatoxicity.

METHODS

Hepatotoxicity was induced by DIC in a dose-based manner, after which intraperitoneal injection of rAD-MSCs was performed.

RESULTS

Here, the transplanted cells migrated to the injured liver, and this was evidenced by detecting the specific SRY in the liver samples. After administering DIC, a significant decrease in body weight, survival rate, serum proteins, antioxidants, anti-apoptotic gene expression, and certain growth factors, whereas hepatic-specific markers, pro-inflammatory mediators, and oxidative, pro-apoptotic, and ER-stress markers were elevated. These adverse effects were significantly recovered after engraftment with rAD-MSCs. This was evidenced by enhanced survival and body weight, improved globulin and albumin values, increased expression of SOD, GPx, BCL-2, VEGF, and FGF-basic expression, and decreased serum ALT, AST, ALP, and total bilirubin. rAD-MSCs also reduced liver cell damage by suppressing the expression of MDA, IL-1B, IL-6, BAX, JNK, GRP78/BiP, CHOP, XBP-1, and cleaved caspase 3/7. Degenerative hepatic changes and multifocal areas of fatty change within liver cells were observed in DIC-received groups. These changes were improved with the transplantation of rAD-MSCs.

CONCLUSIONS

We could conclude that targeted AD-MSCs could be applied to reduce hepatic toxicity caused by NSAIDs (DIC).

Celecoxib-induced Liver Injury: Analysis of Published Case Reports and Cases Reported to the Food and Drug Administration

BACKGROUND

Celecoxib is a widely prescribed nonsteroidal anti-inflammatory drug, and has been associated with rare instances of idiosyncratic drug-induced liver injury (DILI). The aim of this study is to describe and analyze the salient features of published cases of celecoxib DILI.

MATERIALS AND METHODS

A literature search using common terms for liver injury cross-referenced with celecoxib was undertaken from the year 2000 through June 2016. Identified cases were analyzed with respect to reported demographic and clinical data with descriptive.

RESULTS

Celecoxib DILI was reported in 18 patients with a median age of 54 years (range, 29 to 84) and 15 (88%) were female. The median daily dose was 200 mg (range, 200 to 533), and median duration and latency were 13 days (1 to 730) and 17 days (2 to 730), respectively. In 15 (83%) cases, DILI occurred after relatively short treatment duration, median of 12 days (1 to 42). Rash and immunoallergic features were noted in these patients, with peripheral or histologic findings of eosinophilia in 6 (40%). In 3 cases, DILI occurred after prolonged exposure (range, 152 to 730 d), none with immunoallergic features. The pattern of liver injury included hepatocellular (6), mixed (5), and cholestatic (4), and was unknown in 3 cases. Clinical outcomes included 2 (11%) requiring liver transplantation, 4 (22%) with chronic liver injury and recovery in 12 (67%) cases.

CONCLUSIONS

Women are overrepresented in published reports of celecoxib DILI. Latency was short (<3 mo) in most patients but some subjects may present with DILI following prolonged celecoxib use. Although rare, celecoxib-DILI can have potentially life threatening consequences.

Hepatotoxicity of Nonsteroidal Anti-Inflammatory Drugs: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most widely used medication in several countries, including Thailand. NSAIDs have been associated with hepatic side effects; however, the frequency of these side effects is uncertain.

AIM OF THE REVIEW

To systematically review published literature on randomized, controlled trials that assessed the risk of clinically significant hepatotoxicity associated with NSAIDs.

METHODS

Searches of bibliographic databases EMBASE, PubMed, and the Cochrane Library were conducted up to July 30, 2016, to identify randomized controlled trials of ibuprofen, naproxen, diclofenac, piroxicam, meloxicam, mefenamic acid, indomethacin, celecoxib, and etoricoxib in adults with any disease that provide information on hepatotoxicity outcomes.

RESULTS

Among the 698 studies, 18 studies met the selection criteria. However, only 8 studies regarding three NSAIDs (celecoxib, etoricoxib, and diclofenac) demonstrated clinically significant hepatotoxic evidence based on hepatotoxicity justification criteria. Of all the hepatotoxicity events found from the above-mentioned three NSAIDs, diclofenac had the highest proportion, which ranged from 0.015 to 4.3 (×10^-2), followed by celecoxib, which ranged from 0.13 to 0.38 (×10^-2), and etoricoxib, which ranged from 0.005 to 0.930 (×10^-2).

CONCLUSION

Diclofenac had higher rates of hepatotoxic evidence compared to other NSAIDs. Hepatotoxic evidence is mostly demonstrated as aminotransferase elevation, while liver-related hospitalization or discontinuation was very low.

Cholestatic hepatitis with small duct injury associated with celecoxib

Drug-induced liver injury (DILI) is a common clinical entity but is underreported due to various reasons. Cyclooxygenase-2 inhibitors like Celecoxib have been proven to be associated with lesser incidence of adverse drug reactions compared to other nonsteroidal anti-inflammatory drugs (NSAID). However, Celecoxib has been rarely reported to be associated with cholestasis and hepatitis. We present a young Hispanic female presented with cholestatic liver chemistries who has been taking Celecoxib for 3 weeks. Extensive workup did not support diagnosis of viral, autoimmune, or metabolic liver diseases. Liver biopsy revealed findings suggestive of secondary sclerosing cholangitis. Imaging studies were negative for large duct involvement, and endoscopy ruled out inflammatory bowel disease. Liver chemistries normalized after cessation of medication. We recommend that physician should be aware of this rare complication when prescribing Celecoxib.

Celecoxib in arthritis: relative risk management profile and implications for patients

Celecoxib is a selective cyclo-oxygenase 2 inhibitor licensed for use in musculoskeletal symptoms as well as in primary dysmenorrhea and acute pain. One advantage celecoxib has over traditional nonsteroidal anti-inflammatory drugs is that of significantly fewer gastrointestinal side-effects associated with its use. Much has been published on the potential cardiovascular and cerebrovascular complications of its administration. This review details the available evidence to allow prescribers to make informed decisions in the light of potentially conflicting evidence. The overall cardiovascular risk is increased with higher doses of celecoxib but is comparable with nonselective nonsteroidal anti-inflammatory use. As with all of these drugs, the potential cardiovascular and gastrointestinal risks of prescription need to be weighed up against possible benefits for each individual patient and discussed with the patients themselves.

Celecoxib-induced cholestatic liver failure requiring orthotopic liver transplantation

Selective cyclooxygenase-2 (COX-2) inhibitors are widely used due to their efficacy and good safety profile. However, recent case reports have described varying degrees of liver injuries associated with the use of COX-2 inhibitors. We report the case of a patient who developed acute cholestatic hepatitis progressing to hepatic failure requiring liver transplantation, following a 3-d course of celecoxib for treatment of generalized muscle aches and pains. The clinical presentation, the laboratory data, as well as the liver histopathology were supportive of the putative diagnosis of drug induced liver injury.

Rofecoxib-induced hepatotoxicity: a forgotten complication of the coxibs

Rofecoxib is a member of the coxib family of nonsteroidal anti-inflammatory drugs that selectively inhibit cyclooxygenase-2. Although the coxibs are generally well-tolerated, rofecoxib was recently withdrawn from the market due to concerns regarding cardiovascular safety. Rare cases of hepatic injury attributable to the coxibs have been reported. In the present study, two additional cases of severe hepatotoxicity are described in patients with cholestatic symptoms and abnormal liver biochemistry, shortly following the initiation of rofecoxib for arthritic complaints. In both cases, liver histology was compatible with drug-induced hepatotoxicity, and rapid clinical and biochemical improvements were observed following rofecoxib discontinuation. With new coxibs and expanding indications on the horizon, physicians in all areas of practice must be aware of this disorder and consider it in any patient who develops hepatic dysfunction after taking a coxib.

[Acute colitis closely following the beginning of celecoxib treatment]

Selective inhibitors of cyclooxygenase-2 have less gastroduodenal toxicity than non selective anti-inflammatory drugs. However, there is little information on their effect on the distal gut. A 91 year old woman presented with acute diarrhoea 5 weeks after beginning celecoxib treatment. Laboratory results showed an inflammatory syndrome and increased alanine aminotransferase (ALT) to 13 N. Endoscopic examination of the colon showed diffuse erythematous lesions of the sigmoid and of part of the right colon. No aetiology has been found for colitis or hepatitis. Diarrhea and blood test anomalies disappeared one week after celecoxib was stopped. The role of celecoxib in the etiology of colitis was considered plausible but not for liver damage. This report and a few other cases in the literature suggest that cyclooxygenase-2 selective non-steroidal anti-inflammatory drug inhibitor toxicity should be investigated in case of unexplained acute colitis.

Prolonged cholestasis associated with short-term use of celecoxib

Drug-induced liver injury due to celecoxib, a first generation Cox-2 inhibitor, has been rarely reported. We describe one case of severe and prolonged cholestasis after treatment with celecoxib for 12 days in a young woman with no evidence of other causes of liver disease or allergy. Jaundice lasted for 3 months, pruritus and abnormal liver biochemistry persisted for 18 months after stopping the drug. Liver biopsy specimens showed a cholestatic pattern of liver injury with only minimal mononuclear infiltrate in the portal tracts. This case report supports the notion that celecoxib may cause bland, long term cholestasis.

Sulfonamide Cross-Reactivity: Fact or Fiction?

OBJECTIVE:

To provide a critical and comprehensive review of the literature, specifically case reports and observational studies used to support the concept of cross-reactivity between sulfonylarylamines and non-sulfonylarylamines.

DATA SOURCES:

A list of medications was formulated from several different review articles. A MEDLINE/PubMed search was conducted (1966–March 2004) using the individual medications and the MeSH terms of drug hypersensitivity/etiology, sulfonamides/adverse effects, and/or cross-reaction.

STUDY SELECTION AND DATA EXTRACTION:

A critical review of the methodology and conclusions for each article found in the search was conducted. The manufacturer's package insert (MPI) for each drug was examined for a statement concerning possible cross-reactivity in patients with a sulfonamide allergy. If indicated, the manufacturers were contacted to obtain any clinical data supporting the statement.

DATA SYNTHESIS:

A total of 33 medications were identified. Seventeen (51.5%) of the MPIs contained statements of varying degrees concerning use in patients with a “sulfonamide” allergy; 21 case series, case reports, and other articles were found.

CONCLUSIONS:

After a thorough critique of the literature, it appears that the dogma of sulfonylarylamine cross-reactivity with non-sulfonylarylamines is not supported by the data. While many of the case reports on the surface support the concept of cross-reactivity, on closer examination the level of evidence in many of the cases does not conclusively support either a connection or an association between the observed cause and effect.

Cholangiocarcinoma: molecular targeting strategies for chemoprevention and therapy

Cholangiocarcinomas are devastating cancers that are increasing in both their worldwide incidence and mortality rates. The challenges posed by these often lethal biliary tract cancers are daunting, with conventional treatment options being limited and the only hope for long-term survival being that of complete surgical resection of the tumor. Unfortunately, the vast majority of patients with cholangiocarcinoma typically seek treatment with advanced disease, and often these patients are deemed poor candidates for curative surgery. Moreover, conventional chemotherapy and radiation therapy have not been shown to be effective in prolonging long-term survival, and although photodynamic therapy combined with stenting has been reported to be effective as a palliative treatment, it is not curative. Thus, there is a real need to develop novel chemopreventive and adjuvant therapeutic strategies for cholangiocarcinoma based on exploiting select molecular targets that would impact in a significant way on clinical outcome. This review focuses on potential preventive targets in cholangiocarcinogenesis, such as inducible nitric oxide synthase, cyclooxygenase-2, and altered bile acid signaling pathways. In addition, molecular alterations related to dysregulation of cholangiocarcinoma cell growth and survival, aberrant gene expression, invasion and metastasis, and tumor microenvironment are described in the context of various clinical and pathological presentations. Moreover, an emphasis is placed on the importance of critical signaling pathways and postulated interactions, including those of ErbB-2, hepatocyte growth factor/Met, interleukin-6/glycoprotein130, cyclooxygenase-2, vascular endothelial growth factor, transforming growth factor-beta, MUC1 and MUC4, beta-catenin, telomerase, and Fas pathways as potential molecular therapeutic targets in cholangiocarcinoma.

Drug-induced liver disease

The year 2002 saw a warning from the US Food and Drug Administration not to use the diet agent, Lipokinetix, and brought to light a few new agents as potential hepatotoxins. Numerous other reports confirmed the hepatotoxicity of several previously described agents. Refinements in causality assessment remain an important aspect in defining drug-induced liver disease and proposed new upper limits of normal for alanine aminotransferase that are lower than most laboratories currently report may require rethinking our definition of "normal liver function tests." Chronic viral hepatitis B and C remain important risk factors for antiretroviral-induced liver injury in patients co-infected with the human immunodeficiency virus and in patients receiving antituberculosis therapy. Acetaminophen retains its status as the most common cause of acute drug-induced liver failure in the United States and in many other countries. Several papers addressed the issue of accidental versus intentional overdoses, the role of alcohol consumption as a risk factor, and newer aspects of treating and preventing acetaminophen injury to the liver. Finally, the use of potentially hepatotoxic medications in patients with underlying liver disease continues to be a controversial topic and a rational approach to the use of such drugs in this setting is provided.

Cholestatic syndromes

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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