Limited Knowledge of Acetaminophen in Patients with Liver Disease

Mifepristone protects acetaminophen induced liver injury through NRF2/GSH/GST mediated ferroptosis suppression

Ferroptosis is a form of iron-dependent cell death that has attracted significant attention for its potential role in numerous diseases. Targeted inhibition of ferroptosis could be of potential use in treating diseases: such as drug induced liver injury (DILI). Ferroptosis can be antagonized by the xCT/GSH/GPX4, FSP1/CoQ10, DHODH/CoQ10, GCH1/BH4, and NRF2 pathways. Identifying novel anti-ferroptosis pathways will further promote our understanding of the biological nature of ferroptosis and help discover new drugs targeting ferroptosis related human diseases. In this study, we identified the clinically used drug mifepristone (RU486) as a novel ferroptosis inhibitor. Mechanistically, RU486 inhibits ferroptosis by inducing GSH synthesis pathway, which supplies GSH for glutathione-S-transferase (GST) mediated 4-HNE detoxification. Furthermore, RU486 induced RLIP76 and MRP1 export 4-HNE conjugate contributes to its anti-ferroptosis activity. Interestingly, RU486 induced GSH/GSTs/RLIP76&MRP1 anti-ferroptosis pathway acts independent of classic anti-ferroptosis systems: including xCT/GSH/GPX4, FSP1, DHODH, GCH1, SCD1 and FTH1. Moreover, NRF2 was identified to be important for RU486's anti-ferroptosis activity by inducing downstream gene expression. Importantly, in mouse model, RU486 showed strong protection effect on acetaminophen (APAP)-induced acute liver injury, evidenced by decreased ALT, AST level and histological recovery after APAP treatment. Interestingly, RU486 also decreased oxidative markers, including 4-HNE and MDA, and induced NRF2 activation as well as GSTs, MRP1 expression. Together, these data suggest NRF2/GSH/GST/RLIP76&MRP1 mediated detoxification pathway as an important independent anti-ferroptosis pathway act both in vitro and in vivo.

Acetaminophen: A Liver Killer or Thriller

Acetaminophen, or paracetamol, ranks among the most extensively utilized analgesic and antipyretic medications globally. The administration of acetaminophen to individuals with underlying liver disease has long sparked concerns regarding the potential risk of hepatotoxicity. However, the available literature and recommendations consider it a safe option in all forms of liver diseases and is deemed safe when used at recommended doses. This article aims to offer a concise review of the pharmacokinetics, toxicity profile, and the intricate considerations surrounding the safety of acetaminophen in patients with liver disease. By delving into the liver-acetaminophen interactions, we seek to provide a nuanced perspective on the use of acetaminophen in this critical patient population.

Assessing the performance of ChatGPT in answering questions regarding cirrhosis and hepatocellular carcinoma

BACKGROUND/AIMS

Patients with cirrhosis and hepatocellular carcinoma (HCC) require extensive and personalized care to improve outcomes. ChatGPT (Generative Pre-trained Transformer), a large language model, holds the potential to provide professional yet patient-friendly support. We aimed to examine the accuracy and reproducibility of ChatGPT in answering questions regarding knowledge, management, and emotional support for cirrhosis and HCC.

METHODS

ChatGPT's responses to 164 questions were independently graded by two transplant hepatologists and resolved by a third reviewer. The performance of ChatGPT was also assessed using two published questionnaires and 26 questions formulated from the quality measures of cirrhosis management. Finally, its emotional support capacity was tested.

RESULTS

We showed that ChatGPT regurgitated extensive knowledge of cirrhosis (79.1% correct) and HCC (74.0% correct), but only small proportions (47.3% in cirrhosis, 41.1% in HCC) were labeled as comprehensive. The performance was better in basic knowledge, lifestyle, and treatment than in the domains of diagnosis and preventive medicine. For the quality measures, the model answered 76.9% of questions correctly but failed to specify decision-making cut-offs and treatment durations. ChatGPT lacked knowledge of regional guidelines variations, such as HCC screening criteria. However, it provided practical and multifaceted advice to patients and caregivers regarding the next steps and adjusting to a new diagnosis.

CONCLUSION

We analyzed the areas of robustness and limitations of ChatGPT's responses on the management of cirrhosis and HCC and relevant emotional support. ChatGPT may have a role as an adjunct informational tool for patients and physicians to improve outcomes.

Water extract from Herpetospermum pedunculosum attenuates oxidative stress and ferroptosis induced by acetaminophen via regulating Nrf2 and NF-κB pathways

ETHNOPHARMACOLOGICAL RELEVANCE

The seeds of Herpetospermum pedunculosum seeds is a traditional Tibetan medicine possessing hepatoprotective effect, but their protective effect on APAP-induced liver injury has not yet been explored.

AIM OF THE STUDY

This study aimed at exploring the protective effect and mechanism of the water extract from the seeds of Herpetospermum pedunculosum (HPWE) on APAP-induced liver injury in vitro and in vivo.

MATERIALS AND METHODS

In vitro and in vivo models of liver injury were established by APAP treatment of BRL-3A cells or mice. The effect and mechanism of action of HPWE were explored by using cell viability assay, ELISA, immunofluorescence assay, RT-qPCR, histological observation and immunohistochemistry staining, western blotting and high-content imaging system.

RESULTS

In vitro experiments showed that HPWE treatment significantly promoted the cell viability, decreased ALT/AST level, and inhibited the ROS accumulation induced by APAP. Furthermore, HPWE and Fer-1 alleviated erastin-induced cell ferroptosis, upregulated GPX4 and SLC7A11 expression, and reduced lipid peroxides production. Further study showed that APAP could also downregulate the expression of GPX4 and SLC7A11, causing cell ferroptosis, and HPWE and Fer-1 counteracted this process. Our in vivo experiments showed that pretreatment with HPWE in APAP-treated mice significantly alleviated the serum ALT/AST level, decreased necrotic cells and inflammatory cell infiltration, upregulated the expression of GPX4 and SLC7A11. Further, it was demonstrated that HPWE treatment downregulated Nrf2 and its downstream target genes, i.e. HO-1 and NQO1 expression at the mRNA and protein levels. HPWE treatment also inhibited the activation of NF-κB p65 and downregulated its target genes, i.e. TNF-α and IL-1β, expression.

CONCLUSION

The present study showed that HPWE could relieve oxidative stress and ferroptosis via activating Nrf2 signaling pathway and inhibiting NF-κB mediated pathway.

Acetaminophen induced hepatotoxicity: An overview of the promising protective effects of natural products and herbal formulations

BACKGROUND

The liver plays an important role in regulating the metabolic processes and is the most frequently targeted organ by toxic chemicals. Acetaminophen (APAP) is a well-known anti-allergic, anti-pyretic, non-steroidal anti-inflammatory drug (NSAID), which upon overdose leads to hepatotoxicity, the major adverse event of this over-the-counter drug.

PURPOSE

APAP overdose induced acute liver injury is the second most common cause that often requires liver transplantation worldwide, for which N-acetyl cysteine is the only synthetic drug clinically approved as an antidote. So, it was felt that there is a need for the novel therapeutic approach for the treatment of liver diseases with less adverse effects. This review provides detailed analysis of the different plant extracts; phytochemicals and herbal formulations for the amelioration of APAP-induced liver injury.

METHOD

The data was collected using different online resources including PubMed, ScienceDirect, Google Scholar, Springer, and Web of Science using keywords given below.

RESULTS

Over the past decades various reports have revealed that plant-based approaches may be a better treatment choice for the APAP-induced hepatotoxicity in pre-clinical experimental conditions. Moreover, herbal compounds provide several advantages over the synthetic drugs with fewer side effects, easy availability and less cost for the treatment of life-threatening diseases.

CONCLUSION

The current review summarizes the hepatoprotective effects and therapeutic mechanisms of various plant extracts, active phytoconstituents and herbal formulations with potential application against APAP induced hepatotoxicity as the numbers of hepatoprotective natural products are more without clinical relativity. Further, pre-clinical pharmacological research will contribute to the designing of natural products as medicines with encouraging prospects for clinical application.

Why paracetamol (acetaminophen) is a suitable first choice for treating mild to moderate acute pain in adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, or who are older

Acute pain is among the most common reasons that people consult primary care physicians, who must weigh benefits versus risks of analgesics use for each patient. Paracetamol (acetaminophen) is a first-choice analgesic for many adults with mild to moderate acute pain, is generally well tolerated at recommended doses (≤4 g/day) in healthy adults and may be preferable to non-steroidal anti-inflammatory drugs that are associated with undesirable gastrointestinal, renal, and cardiovascular effects. Although paracetamol is widely used, many patients and physicians still have questions about its suitability and dosing, especially for older people or adults with underlying comorbidities, for whom there are limited clinical data or evidence-based guidelines. Inappropriate use may increase the risks of both overdosing and inadequate analgesia. To address knowledge deficits and augment existing guidance in salient areas of uncertainty, we have researched, reviewed, and collated published evidence and expert opinion relevant to the acute use of paracetamol by adults with liver, kidney, or cardiovascular diseases, gastrointestinal disorders, asthma, or/and who are older. A concern is hepatotoxicity, but this is rare among adults who use paracetamol as directed, including people with cirrhotic liver disease. Putative epidemiologic associations of paracetamol use with kidney or cardiovascular disease, hypertension, gastrointestinal disorders, and asthma largely reflect confounding biases and are of doubtful relevance to short-term use (<14 days). Paracetamol is a suitable first-line analgesic for mild to moderate acute pain in many adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, and/or who are older. No evidence supports routine dose reduction for older people. Rather, dosing for adults who are older and/or have decompensated cirrhosis, advanced kidney failure, or analgesic-induced asthma that is known to be cross-sensitive to paracetamol, should be individualized in consultation with their physician, who may recommend a lower effective dose appropriate to the circumstances.

Intentional or Inadvertent Acetaminophen Overdose-How Lethal It Really Is?

BACKGROUND

Acetaminophen, the ubiquitous over-the-counter analgesic and antipyretic, is the most common drug used in intentional overdoses in the United States. Inadvertent self-poisoning is also a surprisingly common unintended consequence of acetaminophen misuse for pain management.

OBJECTIVE

The primary goal of this naturalistic study was to substantiate outcomes that were previously described in other large cohorts of patients with acetaminophen overdoses.

METHODS

The Rochester Epidemiology Project yielded a cohort of 207 patients of age 18 years or older treated at the Mayo Clinic between January 1, 2004 and December 31, 2010 for excessive acetaminophen exposure. Patients with a diagnosis of acetaminophen overdose, acetaminophen ingestion, and/or acetaminophen toxicity were characterized according to demographics, treatment location, overdose intentionality, identities of the drugs and amounts taken, mental health and addiction history, previous suicide attempts, and current alcohol intake. Outcomes included N-acetylcysteine treatment, emergence of serious clinical syndromes, and admission to the liver transplant unit (LTU), liver transplant, and death. Data were analyzed using the JMP statistical program.

RESULTS

Of 140 females and 67 males treated in the emergency department (ED), 184 (89%) were admitted, including 116 (56%) to the intensive care unit, 26 (13%) to medicine services, 18 (9%) directly to LTU, 23 (11%) directly to psychiatry services, and 1 (0.5%) to off-campus detox. The consultation-liaison (C-L) psychiatry service evaluated 175 patients (85%). Eighteen intensive care unit/medicine patients were eventually transferred to the LTU, and 104 of the 184 patients not immediately admitted to psychiatry were ultimately transferred there. Of all, 158 (76.3%) overdoses were intentional, but in the chronic pain subset of 14 patients, only 4 (29%) were. One hundred twenty-seven (61%) patients had no previous suicide attempt history. Twenty-one percent of the intentional overdose group versus 12.5% of the unintentional overdose group was intoxicated at the time of overdose. One hundred thirty-five (65%) patients received N-acetylcysteine, but barely a third (33%) were treated within the recommended 8 hours of overdose. Nonetheless, most outcomes were benign: only 36 (17.6%) required LTU admission because of serious medical complications. Only 12 received consideration for transplant, and only 5 (2.7%) were listed for transplant. Three (1.5%) ultimately received new livers. Two (1.0%) died awaiting transplant. Two of the 3 transplanted patients had unintentionally overdosed while treating chronic pain.

CONCLUSIONS

A vast majority of patients survived and recovered without lasting medical sequelae, including liver transplant. Half of the patients received N-acetylcysteine, and only a third received it within the recommended 8-hour window after ingestion. Serious medical consequences were concentrated in the 17% of patients requiring LTU admission. With a transplant rate of 1.5% and a death rate of less than 1%, we conclude that the risk of serious medical outcomes from this frequent overdose modality is rare, even as the majority of both intentional and unintentional overdose patients received both inpatient medical and psychiatric treatment.

Medicine use and medicine-related problems in patients with liver cirrhosis: a systematic review of quantitative and qualitative studies

PURPOSE

This review aimed to determine the prevalence, causes and risk factors of medicine-related problems (MRPs) in patients with liver cirrhosis.

METHODS

Eight online databases were searched up to 30 September 2018 with no start date. Appropriate Critical Appraisal Skills Programme tools were used to assess the quality of included studies.

RESULTS

An overall 16 quantitative and 11 qualitative studies were included in the review. Methodological quality of the included studies was variable. Mean frequency of MRPs reported in the quantitative studies ranged from 14 to 23.4%. The most frequent causes of MRPs included drug interactions, inappropriate dosing and use of contraindicated drugs. The qualitative analysis identified three themes: patient-related factors, healthcare professionals' related factors and stigma associated with liver cirrhosis.

CONCLUSION

MRPs were found to be prevalent in patients with liver cirrhosis. Factors contributing to MRPs in liver cirrhosis were not limited to medicines' effects and interactions but included healthcare systems and patients. Therefore, management of liver cirrhosis should not be limited to providing an effective medicine therapy and should take into account the patients' behaviour towards the condition.

Knowledge of appropriate acetaminophen use: A survey of college-age women

OBJECTIVES

To evaluate college-age women's knowledge of appropriate doses and potential toxicities of acetaminophen, competency in interpreting Drug Facts label dosing information, and ability to recognize products containing acetaminophen.

METHODS

In this cross-sectional prospective study, a 20-item written survey was provided to female college students at a University of Michigan fundraising event in March 2015.

RESULTS

A total of 203 female college students, 18-24 years of age, participated in the study. Pain was experienced on a daily or weekly basis by 22% of the subjects over the previous 6 months, and 83% reported taking acetaminophen. The maximum 3-gram daily dose of extra-strength acetaminophen was correctly identified by 64 participants; an additional 51 subjects indicated the generally accepted 4 grams daily as the maximum dose. When provided with the Tylenol Drug Facts label, 68.5% correctly identified the maximum amount of regular-strength acetaminophen recommended for a healthy adult. Hepatotoxicity was associated with high acetaminophen doses by 63.6% of participants, significantly more than those who selected distracter responses (P < 0.001). Knowledge of liver damage as a potential toxicity was correlated with age 20 years and older (P < 0.001) but was independent from race and ethnicity and level of alcohol consumption. Although more than one-half of the subjects (58.6%) recognized that Tylenol contained acetaminophen, fewer than one-fourth correctly identified other acetaminophen-containing products.

CONCLUSION

Despite ongoing educational campaigns, a large proportion of the college-age women who participated in our study did not know and could not interpret the maximum recommended daily dose from Drug Facts labeling, did not know that liver damage was a potential toxicity of acetaminophen, and could not recognize acetaminophen-containing products. These data suggest a continued role for pharmacists in educational efforts targeted to college-age women.