Risperidone- and Quetiapine-Induced Cholestasis

The regulatory effects of second-generation antipsychotics on lipid metabolism: Potential mechanisms mediated by the gut microbiota and therapeutic implications

Second-generation antipsychotics (SGAs) are the mainstay of treatment for schizophrenia and other neuropsychiatric diseases but cause a high risk of disruption to lipid metabolism, which is an intractable therapeutic challenge worldwide. Although the exact mechanisms underlying this lipid disturbance are complex, an increasing body of evidence has suggested the involvement of the gut microbiota in SGA-induced lipid dysregulation since SGA treatment may alter the abundance and composition of the intestinal microflora. The subsequent effects involve the generation of different categories of signaling molecules by gut microbes such as endogenous cannabinoids, cholesterol, short-chain fatty acids (SCFAs), bile acids (BAs), and gut hormones that regulate lipid metabolism. On the one hand, these signaling molecules can directly activate the vagus nerve or be transported into the brain to influence appetite via the gut-brain axis. On the other hand, these molecules can also regulate related lipid metabolism via peripheral signaling pathways. Interestingly, therapeutic strategies directly targeting the gut microbiota and related metabolites seem to have promising efficacy in the treatment of SGA-induced lipid disturbances. Thus, this review provides a comprehensive understanding of how SGAs can induce disturbances in lipid metabolism by altering the gut microbiota.

An in vivo toxicity assessment of piezoelectric sodium potassium niobate [NaxK1-xNbO3 (x = 0.2-0.8)] nanoparticulates towards bone tissue engineering approach

One of the recent challenges in the design/development of prosthetic orthopedic implants is to address the concern of local/systemic toxicity of debris particles, released due to wear or degradation. Such debris particles often lead to inflammation at the implanted site or aseptic loosening of the prosthesis which results in failure of the implant during long run. Several in vitro studies demonstrated the potentiality of piezoelectric sodium potassium niobate [Na_xK_1-xNbO₃ (x = 0.2, 0.5, 0.8), NKN] as an emerging next-generation polarizable orthopedic implant. In this perspective, we performed an in vivo study to examine the local and systemic toxicity of NKN nanoparticulates, as a first report. In the present study, male Wistar rats were intra-articularly injected to the knee joint with 100 μl of NKN nanoparticulates (25 mg/ml in normal saline). After 7 days of exposure, the histopathological analyses demonstrate the absence of any inflammation or dissemination of nanoparticulates in vital organs such as heart, liver, kidney and spleen. The anti-inflammatory cytokines (IL-4 and IL-10) profile analyses suggest the increased anti-inflammatory response in the treated rats as compared to non-injected (control) rats, preferably for the sodium and potassium rich NKN i.e., Na_0.8K_0.2NbO₃ and Na_0.2K_0.8NbO₃. The biochemical analyses revealed no pathological changes in the liver and kidney of particulate treated rats. The present study is the first proof to confirm the non-toxic nature of NKN nanoparticulates which provides a step forward towards the development of prosthetic orthopedic implants using biocompatible piezoelectric NKN ceramics.

The protective effects of the Ganoderma atrum polysaccharide against acrylamide-induced inflammation and oxidative damage in rats

In this study, the protective effects of the Ganoderma atrum polysaccharide (PSG-1) on selected tissue (liver, spleen, kidneys and intestine) toxicity induced by acrylamide (AA) in SD rats were investigated. The results showed that pretreatment with PSG-1 could prevent AA-induced damage to liver and kidney functions by increasing the activities of ALT, AST and ALP and the levels of TG, BUN and CR in the serum of AA-treated rats. PSG-1 could also maintain the intestinal barrier function and permeability by preventing the reduction of the serum d-Lac and ET-1 levels in the intestine of AA-treated rats. In addition, AA-induced DNA damage, as indicated by an increase of the 8-OHdG level, was alleviated by pretreatment with PSG-1. Histological observations of the tissues confirmed the protective effects of different doses of PSG-1. Moreover, PSG-1 supplementation reduced oxidative stress and inflammation in rats by upregulating the superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GSH-Px) activities and IL-10 levels, and preventing the overproduction of malondialdehyde (MDA), IL-1β, IL-6, and TNF-α. Thus, these findings suggest that PSG-1 effectively prevents AA-induced damage in the liver, spleen, kidneys, and intestine of rats, partially by alleviating the inflammatory response and oxidative stress and protecting the intestinal integrity and barrier function.

Antidepressants- and antipsychotics-induced hepatotoxicity

Drug-induced liver injury (DILI) is a serious health burden. It has diverse clinical presentations that can escalate to acute liver failure. The worldwide increase in the use of psychotropic drugs, their long-term use on a daily basis, common comorbidities of psychiatric and metabolic disorders, and polypharmacy in psychiatric patients increase the incidence of psychotropics-induced DILI. During the last 2 decades, hepatotoxicity of various antidepressants (ADs) and antipsychotics (APs) received much attention. Comprehensive review and discussion of accumulated literature data concerning this issue are performed in this study, as hepatotoxic effects of most commonly prescribed ADs and APs are classified, described, and discussed. The review focuses on ADs and APs characterized by the risk of causing liver damage and highlights the ones found to cause life-threatening or severe DILI cases. In parallel, an overview of hepatic oxidative stress, inflammation, and steatosis underlying DILI is provided, followed by extensive review and discussion of the pathophysiology of AD- and AP-induced DILI revealed in case reports, and animal and in vitro studies. The consequences of some ADs and APs ability to affect drug-metabolizing enzymes and therefore provoke drug–drug interactions are also addressed. Continuous collecting of data on drugs, mechanisms, and risk factors for DILI, as well as critical data reviewing, is crucial for easier DILI diagnosis and more efficient risk assessment of AD- and AP-induced DILI. Higher awareness of ADs and APs hepatotoxicity is the prerequisite for their safe use and optimal dosing.

Risperidone- and paliperidone-induced hepatotoxicity: Case report and review of literature

Purpose

A case of hepatotoxicity likely due to use of risperidone and paliperidone is reported.

Summary

A 23-year-old man with schizophrenia was admitted to an inpatient psychiatric unit after an exacerbation of mental illness secondary to medication nonadherence. During 13 days of treatment with risperidone, the patient’s liver enzyme levels rose sharply, so antipsychotic therapy was switched to oral paliperidone. After a 5-day downward trend in liver enzyme levels, a dose of intramuscular paliperidone was administered to augment oral paliperidone therapy. After 10 days of paliperidone use, abnormally high liver enzyme levels were again noted; both oral and intramuscular paliperidone therapy were discontinued and haloperidol was initiated, with complete resolution of liver enzyme abnormalities within approximately 4 weeks. Scoring of this case using the algorithm of Naranjo et al indicated probable associations between risperidone use and hepatotoxicity (a score of 7) and paliperidone use and hepatotoxicity (a score of 8). To our knowledge, this is the first case report describing a patient who developed hepatotoxicity during risperidone use that did not remit with a switch to paliperidone therapy.

Conclusion

Findings of this case suggest that patients who develop hepatotoxicity with use of risperidone may also do so with paliperidone use; this, in turn, suggests that both risperidone and its metabolite are capable of causing hepatotoxicity. Patients who develop hepatotoxicity in response to risperidone or paliperidone therapy may benefit from treatment with an alternative antipsychotic with a different chemical structure.

In vivo study of silver nanomaterials' toxicity with respect to size

Silver nanoparticles (Ag NPs) are widely used in nanomedicine, pharmaceutical products, industry and other consumer products owing to their unique physiochemical properties with probable potential risk to human health and the ecosystems. The aim of this work was to investigate the in-life morphological effects, biochemical, histological and histochemical alterations that might be induced by variable sizes of Ag NPs in hepatic, renal and testicular tissues with the hypothesis that variable sizes of nano-Ag could induce variable effects in the vital organs. Five groups of adult healthy male mice (BALB/C) were exposed to 35 intraperitoneal injections of Ag NPs (1 mg/kg bw) using five different particle sizes (10, 20, 40, 60 and 100 nm). All mice were subjected to in-life morphometric, biochemical, histological and histochemical analysis. The findings demonstrated that Ag NPs could induce alterations in the average body weight gain, food consumption, water intake and organ indices. In addition, these NPs significantly altered hepatic and renal biomarkers. Moreover, Ag NPs produced ground glass hepatocyte cytoplasm, with mitotic activity, nuclear alterations, degeneration, glycogen depletion and inflammatory cells infiltration in the liver. The kidneys of treated mice exhibited proximal renal tubules degeneration, distal renal tubules regeneration, glomerular shrinkage, Bowman's capsule thickening and interstitial inflammation. The testicular tissues demonstrated spermatocyte sloughing and spermatid giant cell formation. The findings together indicated that Ag NPs could interact with the anatomical structures of the liver, kidney and testis in ways that could induce injury. In addition, the results indicated that smaller Ag NPs posed a greater potential risk than the larger ones, which might be associated with their behaviour, dissolution rate, bioavailability and their probable variable toxicokinetics.

Hepatic Safety of Atypical Antipsychotics: Current Evidence and Future Directions

The newer atypical antipsychotic agents (AAPs) represent an attractive therapeutic option for a wide range of psychotic disorders, including schizophrenia and bipolar mania, because of the reduced risk of disabling extrapyramidal symptoms. However, their growing use has raised questions about their tolerability over the endocrine, metabolic, and cardiovascular axes. Indeed, atypical antipsychotic drugs are associated, to differing extents, with mild elevation of aminotransferases related to weight gain, AAP-induced metabolic syndrome, and nonalcoholic fatty liver disease. Although the hepatic safety of new AAPs seems improved over that of chlorpromazine, they can occasionally cause idiosyncratic liver injury with varying phenotypes and, rarely, lead to acute liver failure. However, AAPs are a group of heterogeneous, chemically unrelated compounds with distinct pharmacological and pharmacokinetic properties and substantially different safety profiles, which precludes the notion of a class effect for hepatotoxicity risk and highlights the need for an individualized therapeutic approach. We discuss the current evidence on the hepatotoxicity potential of AAPs, the emerging underlying mechanisms, and the limitations inherent to this group of drugs for both establishing a proper causality assessment and developing strategies for risk management.

Short-Term and Sub-Chronic Dietary Exposure to Aspalathin-Enriched Green Rooibos (Aspalathus linearis) Extract Affects Rat Liver Function and Antioxidant Status

An aspalathin-enriched green rooibos (Aspalathus linearis) extract (GRE) was fed to male Fischer rats in two independent studies for 28 and 90 days. The average dietary total polyphenol (TP) intake was 75.6 and 62.7 mg Gallic acid equivalents (GAE)/kg body weight (bw)/day over 28 and 90 days, respectively, equaling human equivalent doses (HEDs) of 12.3 and 10.2 GAE mg/kg bw/day. Aspalathin intake of 29.5 mg/kg bw/day represents a HED of 4.8 mg/kg bw/day (90 day study). Consumption of GRE increased feed intake significantly (p < 0.05) compared to the control after 90 days, but no effect on body and organ weight parameters was observed. GRE significantly (p < 0.05) reduced serum total cholesterol and iron levels, whilst significantly (p < 0.05) increasing alkaline phosphatase enzyme activity after 90 days. Endogenous antioxidant enzyme activity in the liver, i.e., catalase and superoxide dismutase activity, was not adversely affected. Glutathione reductase activity significantly (p < 0.05) increased after 28 days, while glutathione (GSH) content was decreased after 90 days, suggesting an altered glutathione redox cycle. Quantitative Real Time polymerase chain reaction (PCR) analysis showed altered expression of certain antioxidant defense and oxidative stress related genes, indicative, among others, of an underlying oxidative stress related to changes in the GSH redox pathway and possible biliary dysfunction.

Long-lasting morphofunctional remodelling of liver parenchyma and stroma after a single exposure to low and moderate doses of cadmium in rats

Frequent exposure to cadmium (Cd) in low doses is common; however, the long-lasting effects of this exposure are still poorly understood. Therefore in this study we have evaluated long-lasting hepatic morphofunctional adaptations in rats exposed to low and moderate doses of Cd. Five experimental groups were tested: control (0.9% saline) and other four receiving single intraperitoneal doses of 0.67, 0.74, 0.86 and 1.1 mg of Cd/kg. The animals were killed after eight weeks and the following parameters were analysed: biometrics, oedema, Cd bio-accumulation, collagen, glycogen, lipid droplets, superoxide dismutase (SOD) and catalase (CAT), serum transaminases, liver histopathology and stereology. In all groups exposed to Cd there was significant increase in SOD and CAT activities, ALP levels, proportion of binucleated hepatocytes, nuclei/cytoplasm ratio, macrophages (Kupffer cells) and collagen fibres. In these groups, glycogen accumulation by hepatocytes and the proportion of sinusoidal capillaries were significantly reduced compared with controls. The liver somatic index was increased, and liver oedema was evident in animals exposed to higher dose of Cd. Areas of necrosis were found in animals exposed to the three highest doses. These results indicate that Cd is an extremely toxic bioactive heavy metal, which even at low doses is able to disrupt liver homeostasis. At low and moderate doses, Cd exposure induces morphofunctional pathological remodelling of the hepatic stroma and parenchyma, which remain active after eight weeks. In response to injury, the liver tissue triggers a reactive process by enhancing activation of antioxidant enzymes and collagenogenesis.

Antipsychotics and abnormal liver function tests: systematic review

OBJECTIVE

Systematic assessment of the prevalence and pattern of liver function test (LFT) abnormalities associated with regular antipsychotics in adult humans and consideration of management of such abnormalities.

DATA SOURCES

Systematic search identifying cohort, cross-sectional or case studies/series, reporting LFT abnormalities in patients receiving regular antipsychotics. EMBASE, PsychINFO, and MEDLINE were searched for studies in English from record onset.

STUDY SELECTION

Abstracts were independently screened for eligibility by 2 researchers. Ineligible studies included those that did not report LFT reference ranges, those that studied fewer than 10 patients on a given antipsychotic, and those studying children.

DATA EXTRACTION

Key variables in group studies were extracted. Case studies/series were examined for patient outcome.

DATA SYNTHESIS

Ten group studies and 91 case studies/series were eligible, although quality was poor. All groups receiving regular antipsychotics had a prevalence of LFT abnormalities greater than chance. The median percentage of patients with any abnormal LFT on any antipsychotic was 32%, with a range of 5% to 78%. The median percentage of patients with clinically significant elevations was 4%, with a range of 0% to 15%. Transaminases were most commonly elevated. Abnormalities were generally asymptomatic, arose within 6 weeks, and were either stably persistent or resolved with continued treatment. Case reports suggested that antipsychotics can be associated with severe hepatitis, fatal in a small minority of cases. Chlorpromazine is most commonly associated with acute liver injury.

CONCLUSIONS

The LFT abnormalities in patients receiving regular antipsychotics are common but generally mild and transient. Very rarely, a severe or fatal hepatic injury can emerge.

Drug-induced cholestasis

Cholestasis caused by drugs is an important differential diagnosis in patients presenting with a biochemical cholestatic pattern. The extent of serologic tests and radiological imaging depends on the clinical context. The underlying condition of the patient and detailed information on drug use, results of rechallenge, and the documented hepatotoxicity of the drug are important to establish a diagnosis of drug-induced liver injury (DILI). Most cases of cholestatic DILI are mild, but in rare cases, ductopenia and cholestatic cirrhosis can develop. Approximately 10% of patients with cholestatic jaundice caused by drugs develop liver failure.

Extraction optimization of Angelica sinensis polysaccharides and its antioxidant activity in vivo

Extraction of Angelica sinensis polysaccharides (ASP) was optimized by the utilization of response surface methodology, RSM. Through the analysis, extraction time and water/solid were found to be the most significant factors. Based on contour plots and variance analysis, optimum operational conditions for maximizing polysaccharides yield (5.6%) were found to be extraction time 130 min, water/solid 5, and extraction number 5. A. sinensis polysaccharides (150 and 300 mg/kg) were administered for 15 days. The hepatoprotective activity was assessed using various biochemical parameters. Serum aspartate aminotransferase (AST), alanine aminotransfere (ALT) and alkaline phosphatase (ALP) levels were significantly restored toward normalization by the extracts (150 and 300 mg/kg body weight). ASP (150 and 300 mg/kg body weight) significantly increased the levels of antioxidant enzymes. It can be concluded that ASP possesses significant protective effect against hepatotoxicity induced by carbon tetrachloride (CCl4). This protective effect appears due to ASP antioxidant properties.

Which psychotropic medications induce hepatotoxicity?

OBJECTIVE

Safe prescribing practices to minimize pharmaceutically induced liver damage or worsening of preexisting conditions require knowledge about medicines with hepatotoxic potential. This paper reviews psychotropic medications and their effects on the liver.

METHODS

A MEDLINE search was performed utilizing the phrase "drug-induced liver injury" with various categories of psychiatric drugs. Only articles written in English were utilized.

RESULTS

Hepatotoxicity can be acute or chronic in nature. Medication discontinuation is necessary in acute forms, while close monitoring is required in milder forms of medication-induced chronic liver damage. Nefazodone, pemoline and/or tacrine are the highest offenders. Carbamazepine and valproate products (e.g., divalproex) can lead to this adverse event and should be avoided in patients with liver disease, persons with alcohol misuse or those consuming high doses of acetaminophen.

CONCLUSION

Knowing the risk levels associated with various medicines is important; prescribing multiple drugs with hepatotoxic effects should be avoided. One should educate patients about early warning signs of liver injury. Always provide clinical and laboratory monitoring before and during the use of hepatotoxic drugs. Clinical features and laboratory results govern medication prescribing with ongoing risk-to-benefit ratio assessment during pharmacotherapy.

Hepatoxicity of major constituents and extractions of Radix Polygoni Multiflori and Radix Polygoni Multiflori Praeparata

ETHNOPHARMACOLOGICAL RELEVANCE

Radix Polygoni Multiflori (RPM) and Radix Polygoni Multiflori Praeparata (RPMP) were traditionally widely used as Chinese herbal medicine. However, liver adverse reactions caused by RPM or RPMP were frequently reported all around the world recent years. The aim of this study was to study the cytotoxicities of RPM, RPMP and their major constituents on human liver cell L-02 simultaneously.

MATERIALS AND METHODS

Multi-assays, including MTT assay, neutral red uptake (NRU) assay, LDH leakage percentage and liver enzyme secretion (AST, ALT and ALP) were used. Cytotoxicities of major chemical constituents of RPM, 2, 3, 5, 4'-tetrahydroxy-stilbene-2-O-β-D-glucoside (TSG), physcion and emodin, were tested. The cytotoxicities of water, 50% ethanol and 95% ethanol extractions of RPM and RPMP were tested. HPLC-DAD analysis was carried to reveal the content change of TSG, physcion and emodin after the processing procedure.

RESULTS

The TD(50) of TSG, physcion and emodin in MTT assay were >10,000 μM, 2853.61 μM and 520.37 μM. In the NRU assay, the TD(50) of TSG, physcion and emodin were much smaller (1401.53 μM, 1140.00 μM, and 3.80 μM). Emodin induced much severe liver enzyme secretion than TSG and physcion. Cell proliferation and LDH leakage rate showed no difference between RPM and RPMP extractions, but ALP, AST and ALT secretions in RPMP extractions were significant lower than that of PMR groups. Water extractions of RPM and RPMP were less toxic than any other solvent in most of the assays. Positive correlation was found between the TSG/emodin ratio and MTT survival rate. The emodin/physcion ratio also showed positive correlation with the LDH leakage percentage.

CONCLUSIONS

In conclusion, Radix Polygonum multiflorum and Radix Polygonum multiflorum Praeparata were not liver injure inducing in our in vitro assays. However, the processing produce of RPM could reduce its effect on both cell proliferation and enzyme secretion of liver cell. Judging from cell proliferation, integrity of cell membrane and enzyme secretion, three major chemical constituents of RPM: TSG, physcion and emodin showed no, moderate and severe cytotoxicity against human liver cell line L-02 respectively. Chemical constituents-cytotoxicity relationship investigation revealed that TSG and physcion probably had attenuating effect to emodin. The attenuating mechanisms were still under investigation.

Quetiapine-associated cholestasis causing lipoprotein-X and pseudohyponatraemia

A case of intrahepatic cholestasis secondary to treatment with quetiapine in combination with lamotrigine and zopiclone, resulting in severe hypercholesterolaemia without overt lactescence of the plasma, is presented. Abundant lipoprotein-X was seen on lipoprotein electrophoresis. The patient was diagnosed and treated for hyponatraemia which was likely factitious and caused by hypercholesterolaemia. Cholestasis and hypercholesterolaemia resolved over a period of several months after the discontinuation of quetiapine.

Practical guidelines for diagnosis and early management of drug-induced liver injury

The spectrum of drug-induced liver injury (DILI) is both diverse and complex. The first step in diagnosis is a suspicion of DILI based on careful consideration of recent comprehensive reports on the disease. There are some situations in which the suspicion of DILI is particularly strong. Exclusion of other possible etiologies according to the pattern of liver injury is essential for the diagnosis. In patients with suspected DILI, diagnostic scales, such as the Councils for International Organizations of Medical Sciences/Roussel Uclaf Causality Assessment Method (CIOMS/RUCAM) scale, may be helpful for the final diagnosis. Early management of DILI involves prompt withdrawal of the drug suspected of being responsible, according to serum levels of alanine aminotransferase (ALT), alkaline phosphatase (ALP), and total bilirubin (T-Bil). However, as DILI patients may show resolution of liver injury without discontinuation of the drug, it should be carefully evaluated whether the suspected drug should be discontinued immediately with adequate consideration of the importance of the medication.

Practical guidelines for diagnosis and early management of drug-induced liver injury

The spectrum of drug-induced liver injury (DILI) is both diverse and complex. The first step in diagnosis is a suspicion of DILI based on careful consideration of recent comprehensive reports on the disease. There are some situations in which the suspicion of DILI is particularly strong. Exclusion of other possible etiologies according to the pattern of liver injury is essential for the diagnosis. In patients with suspected DILI, diagnostic scales, such as the Councils for International Organizations of Medical Sciences/Roussel Uclaf Causality Assessment Method (CIOMS/RUCAM) scale, may be helpful for the final diagnosis. Early management of DILI involves prompt withdrawal of the drug suspected of being responsible, according to serum levels of alanine aminotransferase (ALT), alkaline phosphatase (ALP), and total bilirubin (T-Bil). However, as DILI patients may show resolution of liver injury without discontinuation of the drug, it should be carefully evaluated whether the suspected drug should be discontinued immediately with adequate consideration of the importance of the medication.

Practical guidelines for diagnosis and early management of drug-induced liver injury

The spectrum of drug-induced liver injury (DILI) is both diverse and complex. The first step in diagnosis is a suspicion of DILI based on careful consideration of recent comprehensive reports on the disease. There are some situations in which the suspicion of DILI is particularly strong. Exclusion of other possible etiologies according to the pattern of liver injury is essential for the diagnosis. In patients with suspected DILI, diagnostic scales, such as the Councils for International Organizations of Medical Sciences/Roussel Uclaf Causality Assessment Method (CIOMS/RUCAM) scale, may be helpful for the final diagnosis. Early management of DILI involves prompt withdrawal of the drug suspected of being responsible, according to serum levels of alanine aminotransferase (ALT), alkaline phosphatase (ALP), and total bilirubin (T-Bil). However, as DILI patients may show resolution of liver injury without discontinuation of the drug, it should be carefully evaluated whether the suspected drug should be discontinued immediately with adequate consideration of the importance of the medication.

The current state of serum biomarkers of hepatotoxicity

The level of serum alanine aminotransferase (ALT) activity reflects damage to hepatocytes and is considered to be a highly sensitive and fairly specific preclinical and clinical biomarker of hepatotoxicity. However, an increase in serum ALT activity level has also been associated with other organ toxicities, thus, indicating that the enzyme has specificity beyond liver in the absence of correlative histomorphologic alteration in liver. Thus, unidentified non-hepatic sources of serum ALT activity may inadvertently influence the decision of whether to continue development of a novel pharmaceutical compound. To assess the risk of false positives due to extraneous sources of serum ALT activity, additional biomarkers are sought with improved specificity for liver function compared to serum ALT activity alone. Current published biomarker candidates are reviewed herein and compared with ALT performance in preclinical and on occasion, clinical studies. An examination of the current state of hepatotoxic biomarkers indicates that serum F protein, arginase I, and glutathione-S-transferase alpha (GSTalpha) levels, all measured by ELISA, may show utility, however, antibody availability and high cost per run may present limitations to widespread applicability in preclinical safety studies. In contrast, the enzymatic markers sorbitol dehydrogenase, glutamate dehydrogenase, paraxonase, malate dehydrogenase, and purine nucleoside phosphorylase are all readily measured by photometric methods and use reagents that work across preclinical species and humans and are commercially available. The published literature suggests that these markers, once examined collectively in a large qualification study, could provide additional information relative to serum ALT and aspartate aminotransferase (AST) values. Since these biomarkers are found in the serum/plasma of treated humans and rats, they have potential to be utilized as bridging markers to monitor acute drug-induced liver injury in early clinical trials.