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Malnick S, Abdullah A, Maor Y, Neuman MG. Phytotherapy-Induced Hepatocytotoxicity: A Case Report. Curr Issues Mol Biol 2024; 46:7548-7557. [PMID: 39057089 PMCID: PMC11275310 DOI: 10.3390/cimb46070448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 07/03/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Herbal and complementary medicine are frequently integrated with conventional medicine. We aim to report a case of severe herbal-induced liver injury (HILI) due to chronic use of green tea and protein shake. We present both clinical and laboratory evidence implicating mitochondrial toxicity and an immune response leading to a hypersensitivity reaction to the products. We have recently treated a 39-year-old man with hepatotoxicity resulting from a combination of a green tea-containing powder and a branched-chain amino acid supplement that was commenced 2 months previously. The hepatotoxicity resolved by stopping the consumption of these products and no other cause was detected. We decided to perform a lymphocyte toxicity assay (LTA) to determine if there was laboratory support for this diagnosis. LTA (% toxicity) represents the response of the mitochondria to toxic injury. To determine the role of the proinflammatory and anti-inflammatory cytokines and chemokines in the patient's reaction, we measured the level of cytokines and chemokine in the media of growing cells, exposed to each product or to a combination of products. The increased cytokines and chemokines are presented as the x-fold elevations from the upper limit of normal (ULN) for matrix metalloproteinase (MMP) (pg/mL × 1.5 ULN) and interleukin (IL)-1β (pg/mL × 1.8 ULN). Higher elevations were found for interferon (IFN)-β, IFN-γ, IL-8, IL 13, IL-15 (pg/mL × 2 ULN), regulated upon activation, normal T cell expressed and presumably secreted (RANTES) (pg/mL × 2 ULN), and nuclear factor (NFκB) (pg/mL × 3 ULN). The highest increases were for vascular endothelial factor (VEGF) (pg/mL × 10 ULN), tumor necrosis factor (TNF)-α, and tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) (pg/mL × 13 ULN). An examination of cellular markers showed the difference between programmed cell death (apoptosis) and cell death due to necrosis. In our case, cytokeratin-ccK18 (M-30) U/L was within the normal limits, suggesting that apoptosis was normal, while ccK8(M65) U/L was elevated at 1.5 × ULN. This result implies that upon the treatment of the patient's lymphocytes with the products, the mechanism of toxicity is necrosis. In susceptible individuals, the combination of protein and herbal tea produces mitochondrial toxicity and a strong T-lymphocyte-1 response, leading to HILI. There is a need of international reporting of adverse drug reactions by clinicians, laboratories, and pharmaceutical manufacturers to drug regulatory authorities. This requires internationally accepted standard definitions of reactions, as well as criteria for assessment.
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Affiliation(s)
- Stephen Malnick
- Department of Internal Medicine C, Kaplan Medical Center, Hebrew University, Rehovot 76100, Israel; (S.M.); (A.A.)
- Institute of Gastroenterology and Liver Disease, Kaplan Medical Center, Rehovot 76100, Israel;
| | - Ali Abdullah
- Department of Internal Medicine C, Kaplan Medical Center, Hebrew University, Rehovot 76100, Israel; (S.M.); (A.A.)
- Institute of Gastroenterology and Liver Disease, Kaplan Medical Center, Rehovot 76100, Israel;
| | - Yaacov Maor
- Institute of Gastroenterology and Liver Disease, Kaplan Medical Center, Rehovot 76100, Israel;
| | - Manuela G. Neuman
- In Vitro Drug Safety and Biotechnology and Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON M5G OA3, Canada
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Pinazo-Bandera JM, Niu H, Alvarez-Alvarez I, Medina-Cáliz I, Del Campo-Herrera E, Ortega-Alonso A, Robles-Díaz M, Hernández N, Paraná R, Nunes V, Girala M, Bessone F, Lucena MI, Andrade RJ, García Cortés M. Rechallenge in idiosyncratic drug-induced liver injury: An analysis of cases in two large prospective registries according to existing definitions. Pharmacol Res 2024; 203:107183. [PMID: 38631619 DOI: 10.1016/j.phrs.2024.107183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Data on positive rechallenge in idiosyncratic drug-induced liver injury (DILI) are scarce. We aim to analyse the clinical presentation, outcome and drugs associated with positive rechallenge in two DILI registries. METHODS Cases from the Spanish and Latin American DILI registries were included. Demographics, clinical characteristics and outcome of cases with positive rechallenge according to CIOMS/RUCAM and current definitions were analysed. RESULTS Of 1418 patients with idiosyncratic DILI, 58 cases had positive rechallenge (4.1%). Patients with positive rechallenge had shorter duration of therapy (p=0.001) and latency (p=0.003). In patients with rechallenge, aspartate transaminase levels were increased (p=0.026) and showed a prolonged time to recovery (p=0.020), albeit no differences were seen in terms of fatal outcomes. The main drug implicated in rechallenge was amoxicillin-clavulanate (17%). The majority of re-exposure events were unintentional (71%). Using both existing definitions of positive rechallenge, there were four cases which exclusively fulfilled the current criteria and five which only meet the historical definition. All cases of positive rechallenge, irrespective of the pattern of damage, fulfilled the criteria of either alanine transaminase (ALT) ≥3 times the upper limit of normal (ULN) and/or alkaline phosphatase (ALP) ≥2 times ULN. CONCLUSIONS Episodes of rechallenge were characterised by shorter duration of therapy and latency, and longer time to resolution, but did not show an increased incidence of fatal outcome. Based on our findings, ALT ≥3 times ULN and/or ALP ≥2 times ULN, regardless of the pattern of damage, is proposed as a new definition of rechallenge in DILI.
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Affiliation(s)
- J M Pinazo-Bandera
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - H Niu
- Service of Clinical Farmacology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain
| | - I Alvarez-Alvarez
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain
| | - I Medina-Cáliz
- Service of Clinical Farmacology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain
| | - E Del Campo-Herrera
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain
| | - A Ortega-Alonso
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - M Robles-Díaz
- Service of Clinical Farmacology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - R Paraná
- University Hospital Prof. Edgard Santos-UFBA, Salvador, Brasil
| | - V Nunes
- University Hospital Prof. Edgard Santos-UFBA, Salvador, Brasil
| | - M Girala
- Clínicas Hospital, Asunción, Paraguay
| | - F Bessone
- Centenario Hospital, Rosario National University, Rosario, Argentina
| | - M I Lucena
- Service of Clinical Farmacology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - R J Andrade
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
| | - M García Cortés
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Zeng X, Jiang J, Liu S, Hu Q, Hu S, Zeng J, Ma X, Zhang X. Bidirectional effects of geniposide in liver injury: Preclinical evidence construction based on meta-analysis. JOURNAL OF ETHNOPHARMACOLOGY 2024; 319:117061. [PMID: 37598771 DOI: 10.1016/j.jep.2023.117061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/24/2023] [Accepted: 08/16/2023] [Indexed: 08/22/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Gardenia jasminoides J.Ellis is widely used to treat liver diseases in traditional Chinese medicine. Geniposide, a major active constituent of Gardenia jasminoides J.Ellis, exerts therapeutic effects against liver injury, however, it also induces hepatotoxicity. AIM OF THE STUDY This meta-analysis was designed to determine the mechanisms of both the hepatoprotective and hepatotoxic effects of geniposide. MATERIALS AND METHODS The articles analysed in this meta-analysis were primarily obtained from five databases. The 10-item SYRCLE risk-of-bias tool was used to evaluate the quality of the included articles. STATA (version 15.1) was used to evaluate the total effect or toxicity sizes. In addition, three-dimensional (3D) dose/time-effect and mechanistic analyses were performed to assess the therapeutic and toxic effects of geniposide. RESULTS A total of 25 studies involving 479 animals were included. Meta-analysis revealed that geniposide not only significantly (P < 0.001) increased liver injury indices including ALT and AST levels but also improved liver function by decreasing the levels of ALT, AST and inflammatory factors in animal models of liver injury. The 3D dose/time-effect analysis revealed that geniposide administered at a dose of 20-150 mg/kg for 5-28 days effectively protected the liver without inducing toxicity. Mechanistically, geniposide exerts protective or toxic effects by regulating the TNF-α/NF-κB pathway to control oxidative stress and inflammatory responses. CONCLUSION Geniposide exhibits dual pharmacological activity in liver injury. It exerts potent hepatoprotective effects when administered at a dose of 20-150 mg/kg for 5-28 days.
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Affiliation(s)
- Xinyu Zeng
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China; School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.
| | - Jiajie Jiang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China; TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China.
| | - Simiao Liu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China; School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.
| | - Qichao Hu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China; School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.
| | - Sihan Hu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China; Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
| | - Jinhao Zeng
- TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China; Department of Gastroenterology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China.
| | - Xiao Ma
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China; School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.
| | - Xiaomei Zhang
- Institute of Medicinal Chemistry of Chinese Medicine, Chongqing Academy of Chinese Materia Medica, Chongqing, 400065, China.
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Andrade RJ, Aithal GP, de Boer YS, Liberal R, Gerbes A, Regev A, Terziroli Beretta-Piccoli B, Schramm C, Kleiner DE, De Martin E, Kullak-Ublick GA, Stirnimann G, Devarbhavi H, Vierling JM, Manns MP, Sebode M, Londoño MC, Avigan M, Robles-Diaz M, García-Cortes M, Atallah E, Heneghan M, Chalasani N, Trivedi PJ, Hayashi PH, Taubert R, Fontana RJ, Weber S, Oo YH, Zen Y, Licata A, Lucena MI, Mieli-Vergani G, Vergani D, Björnsson ES. Nomenclature, diagnosis and management of drug-induced autoimmune-like hepatitis (DI-ALH): An expert opinion meeting report. J Hepatol 2023; 79:853-866. [PMID: 37164270 PMCID: PMC10735171 DOI: 10.1016/j.jhep.2023.04.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/26/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
Drug-induced liver injury (DILI) can mimic almost all other liver disorders. A phenotype increasingly ascribed to drugs is autoimmune-like hepatitis (ALH). This article summarises the major topics discussed at a joint International Conference held between the Drug-Induced Liver Injury consortium and the International Autoimmune Hepatitis Group. DI-ALH is a liver injury with laboratory and/or histological features that may be indistinguishable from those of autoimmune hepatitis (AIH). Previous studies have revealed that patients with DI-ALH and those with idiopathic AIH have very similar clinical, biochemical, immunological and histological features. Differentiating DI-ALH from AIH is important as patients with DI-ALH rarely require long-term immunosuppression and the condition often resolves spontaneously after withdrawal of the implicated drug, whereas patients with AIH mostly require long-term immunosuppression. Therefore, revision of the diagnosis on long-term follow-up may be necessary in some cases. More than 40 different drugs including nitrofurantoin, methyldopa, hydralazine, minocycline, infliximab, herbal and dietary supplements (such as Khat and Tinospora cordifolia) have been implicated in DI-ALH. Understanding of DI-ALH is limited by the lack of specific markers of the disease that could allow for a precise diagnosis, while there is similarly no single feature which is diagnostic of AIH. We propose a management algorithm for patients with liver injury and an autoimmune phenotype. There is an urgent need to prospectively evaluate patients with DI-ALH systematically to enable definitive characterisation of this condition.
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Affiliation(s)
- Raúl J Andrade
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Ynto S de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, VU University Medical Center, Amsterdam, Netherlands
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar Universitário de São João, Porto, Portugal; Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | - Arie Regev
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Christoph Schramm
- Department of Medicine, University Medical Center Hamburg-Eppendorf. Hamburg Center for Translational Immunology. Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Eleonora De Martin
- APHP, Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, FHU Hepatinov, Villejuif, France
| | - Gerd A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Mechanistic Safety, Global Drug Development, Novartis, Basel, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - John M Vierling
- Departments of Medicine and Surgery, Section of Gastroenterology and Hepatology and Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, United States
| | - Michael P Manns
- Hannover Medical School, Centre of ERN RARE-LIVER, Hannover, Germany
| | - Marcial Sebode
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Maria Carlota Londoño
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Institut d' Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Mark Avigan
- Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Mercedes Robles-Diaz
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Miren García-Cortes
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edmond Atallah
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | | | - Naga Chalasani
- University School of Medicine & Indiana University Health, Indianapolis, Indiana, USA
| | - Palak J Trivedi
- NIHR Birmingham BRC, Institute of Immunology and Immunotherapy, Centre for Liver and Gastrointestinal Research, Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Paul H Hayashi
- Division of Hepatology and Nutrition, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Sabine Weber
- Department of Medicine II, LMU Klinikum Munich, Munich, Germany
| | - Ye Htun Oo
- Center for Liver and Gastro Research & National Institute of Health Research Birmingham Biomedical Research Centre, University of Birmingham, Centre for Rare Disease and ERN Rare Liver Centre, Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, UK
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK
| | - Anna Licata
- Medicina Interna ed Epatologia, Università degli Studi di Palermo, Palermo, Italy
| | - M Isabel Lucena
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Platform ISCiii for Clinical Research and Clinical Trials SCReN UICEC- IBIMA, Málaga, Spain.
| | - Giorgina Mieli-Vergani
- MowatLabs, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, United Kingdom
| | - Diego Vergani
- MowatLabs, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, United Kingdom
| | - Einar S Björnsson
- Faculty of Medicine, University of Iceland, Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
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Lin J, Li M, Mak W, Shi Y, Zhu X, Tang Z, He Q, Xiang X. Applications of In Silico Models to Predict Drug-Induced Liver Injury. TOXICS 2022; 10:788. [PMID: 36548621 PMCID: PMC9785299 DOI: 10.3390/toxics10120788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/09/2022] [Accepted: 12/13/2022] [Indexed: 06/17/2023]
Abstract
Drug-induced liver injury (DILI) is a major cause of the withdrawal of pre-marketed drugs, typically attributed to oxidative stress, mitochondrial damage, disrupted bile acid homeostasis, and innate immune-related inflammation. DILI can be divided into intrinsic and idiosyncratic DILI with cholestatic liver injury as an important manifestation. The diagnosis of DILI remains a challenge today and relies on clinical judgment and knowledge of the insulting agent. Early prediction of hepatotoxicity is an important but still unfulfilled component of drug development. In response, in silico modeling has shown good potential to fill the missing puzzle. Computer algorithms, with machine learning and artificial intelligence as a representative, can be established to initiate a reaction on the given condition to predict DILI. DILIsym is a mechanistic approach that integrates physiologically based pharmacokinetic modeling with the mechanisms of hepatoxicity and has gained increasing popularity for DILI prediction. This article reviews existing in silico approaches utilized to predict DILI risks in clinical medication and provides an overview of the underlying principles and related practical applications.
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Affiliation(s)
| | | | | | | | | | | | - Qingfeng He
- Correspondence: (Q.H.); (X.X.); Tel.: +86-21-51980024 (X.X.)
| | - Xiaoqiang Xiang
- Correspondence: (Q.H.); (X.X.); Tel.: +86-21-51980024 (X.X.)
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Yeboah-Korang A, Memon A, Patel N, Portocarrero-Castillo A, Osman A, Kleesattel D, Lopez C, Louissaint J, Sherman K, Fontana R. Impact of Prior Drug Allergies on the Risk, Clinical Features, and Outcomes of Idiosyncratic Drug-Induced Liver Injury in Adults. Dig Dis Sci 2022; 67:5262-5271. [PMID: 35122190 DOI: 10.1007/s10620-022-07403-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/13/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Prior drug allergies are common and may increase susceptibility to adverse medication effects. The aim of this study was to compare the frequency, clinical features, and outcomes of DILI among patients with and without a history of prior drug allergy. METHODS The EMR at a large liver referral center was searched for all DILI encounters using ICD-10 T-codes for drug poisoning/toxicity and K-71 codes for toxic liver injury between 10/1/2015 and 9/30/2019. Clinically significant liver injury was identified using predefined laboratory criteria, and cases were adjudicated using a 5-point expert opinion scale: 1/2/3 = probable DILI and 4/5 = non-DILI. Drug allergy was defined as a history of anaphylaxis, hives, rash, or pruritus after drug exposure. RESULTS Among 766,930 patient encounters, 127 unique patients met inclusion criteria with 72 (56.7%) cases adjudicated as probable DILI and 55 (43.3%) as non-DILI. In the probable DILI group, the most frequent suspect drug classes were: antimicrobials (41.9%), herbal and dietary supplements (9.5%), and antineoplastics (8.1%). Twenty-three of the 72 DILI patients (31.9%) had a history of drug allergy before the DILI episode compared to 16 (29.1%) of the 55 non-DILI cases (p = 0.89). However, none of the allergy drugs and suspect DILI drugs were the same although many were in the same drug class. DILI patients with a prior drug allergy were more likely to be female (73.9% vs. 44.9%, p = 0.04) and have lower serum bilirubin (4.0 vs. 7.8, p = 0.08) and INR (1.1 vs. 1.6, p = 0.043) levels at presentation. The likelihood of death or liver transplantation among probable DILI cases with prior drug allergy was lower than those without prior drug allergy (0% vs. 8.2%, p = 0.35). The suspect drug was subsequently documented in the "Drug Allergy" section of the EMR in only 23 (31.9%) of the 72 probable DILI patients, and these patients were more likely to present with a rash (7% vs. 2%, p = 0.006) and higher serum bilirubin levels (10.5 vs. 4.7, p = 0.008) compared to those in whom the suspect drug was not listed as "drug allergy." CONCLUSION A prior drug allergy history was not associated with a greater likelihood of developing DILI compared to other causes of acute liver injury. However, the probable DILI patients with a history of prior drug allergy tended to have less severe liver injury and clinical outcomes. The low rate of suspect drug documentation in the "Drug Allergy" section of EMR after a DILI episode is of concern and could lead to avoidable harm from inadvertent suspect drug re-challenge.
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Affiliation(s)
- Amoah Yeboah-Korang
- Division of Digestive Diseases, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0595, Cincinnati, OH, 45267-0595, USA.
| | - Ahmed Memon
- Division of Digestive Diseases, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0595, Cincinnati, OH, 45267-0595, USA
| | - Neil Patel
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, 44109, USA
| | - Andrea Portocarrero-Castillo
- Division of Digestive Diseases, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0595, Cincinnati, OH, 45267-0595, USA
| | - Askanda Osman
- Division of Digestive Diseases, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0595, Cincinnati, OH, 45267-0595, USA
| | - David Kleesattel
- Division of Digestive Diseases, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0595, Cincinnati, OH, 45267-0595, USA
| | - Carmen Lopez
- Division of Digestive Diseases, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0595, Cincinnati, OH, 45267-0595, USA
| | - Jeremy Louissaint
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, 10032, USA
| | - Kenneth Sherman
- Division of Digestive Diseases, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0595, Cincinnati, OH, 45267-0595, USA
| | - Robert Fontana
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, 48103, USA
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Acute liver injury following methylprednisolone pulse therapy: 13 cases from a prospectively collected cohort. Eur J Gastroenterol Hepatol 2022; 34:457-461. [PMID: 35230981 DOI: 10.1097/meg.0000000000002334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM Drug-induced liver injury (DILI) remains a challenging diagnosis requiring exclusion of other causes of liver injury, concise medical history taking to identify potential causative medication and creation of a plausible temporal relation to attribute said liver injury to a potentially hepatotoxic agent. In spite of corticosteroids being considered an effective treatment for DILI in some patients, methylprednisolone (MPS) has been associated with liver injury of varying severity. METHODS We analyzed data of our prospective study on potentially hepatotoxic drugs (NCT02353455), identified 13 cases of MPS-associated liver injury and performed an analysis of clinical, laboratory and histopathological characteristics. For all available liver biopsy specimens, expert histopathological analysis was performed. RESULTS Thirteen patients with a variety of primarily neurologic autoimmune diseases treated with MPS developed subsequent liver injury with a median latency of 5 weeks. Liver injury was severe or required transplantation in six patients. Injury typically occurred after repeated pulsing was hepatocellular and responded swiftly to prednisolone administration. For those patients who received in house-follow up, relapse after discontinuation of immunosuppression was not observed. Histopathological features of MPS-DILI comprised both interface and periportal hepatitis with mixed inflammatory infiltrates, similar to autoimmune hepatitis (AIH) features. DISCUSSION MPS-related liver injury can be life-threatening, occurs with considerable latency and after repeat dosing. Regular surveillance of hepatic biochemistry should therefore be routinely performed also after discharge to avoid further MPS-related liver injury during repeat application. Swift response to prednisolone but not histologic features can be helpful to discriminate MPS-DILI from AIH.
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8
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Brennan PN, Cartlidge P, Manship T, Dillon JF. Guideline review: EASL clinical practice guidelines: drug-induced liver injury (DILI). Frontline Gastroenterol 2021; 13:332-336. [PMID: 35722609 PMCID: PMC9186030 DOI: 10.1136/flgastro-2021-101886] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/19/2021] [Indexed: 02/04/2023] Open
Abstract
The European Association for the Study of the Liver has produced extensive guidelines for the investigation and management of drug-induced liver injury. Here, we provide a commentary and overview of some of the principle disease investigations and management that arise from these guideline recommendations.
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Affiliation(s)
- Paul N Brennan
- Centre for Regenerative Medicine, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK,Molecular and Clinical Medicine, University of Dundee School of Medicine, Dundee, UK
| | - Peter Cartlidge
- Department of Gastroenterology, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK
| | - Thomas Manship
- Centre for Liver and Digestive Disorders, NHS Lothian, Edinburgh, UK
| | - John F Dillon
- Department of Gastroenterology, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK,Molecular and Clinical Medicine, University of Dundee College of Medicine Dentistry and Nursing, Dundee, UK
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9
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Hey-Hadavi J, Seekins D, Palmer M, Coffey D, Caminis J, Abdullaev S, Patwardhan M, Tyler H, Raheja R, Stanley AM, Pineda-Salgado L, Bourdet DL, Andrade RJ, Hayashi PH, Dimick-Santos L, Rockey DC, Estilo A. Overview of Causality Assessment for Drug-Induced Liver Injury (DILI) in Clinical Trials. Drug Saf 2021; 44:619-634. [PMID: 33725335 PMCID: PMC8184702 DOI: 10.1007/s40264-021-01051-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 02/08/2023]
Abstract
Causality assessment for suspected drug-induced liver injury (DILI) during drug development and following approval is challenging. The IQ DILI Causality Working Group (CWG), in collaboration with academic and regulatory subject matter experts (SMEs), developed this manuscript with the following objectives: (1) understand and describe current practices; (2) evaluate the utility of new tools/methods/practice guidelines; (3) propose a minimal data set needed to assess causality; (4) define best practices; and (5) promote a more structured and universal approach to DILI causality assessment for clinical development. To better understand current practices, the CWG performed a literature review, took a survey of member companies, and collaborated with SMEs. Areas of focus included best practices for causality assessment during clinical development, utility of adjudication committees, and proposals for potential new avenues to improve causality assessment. The survey and literature review provided renewed understanding of the complexity and challenges of DILI causality assessment as well as the use of non-standardized approaches. Potential areas identified for consistency and standardization included role and membership of adjudication committees, standardized minimum dataset, updated assessment tools, and best practices for liver biopsy and rechallenge in the setting of DILI. Adjudication committees comprised of SMEs (i.e., utilizing expert opinion) remain the standard for DILI causality assessment. A variety of working groups continue to make progress in pursuing new tools to assist with DILI causality assessment. The minimum dataset deemed adequate for causality assessment provides a path forward for standardization of data collection in the setting of DILI. Continued progress is necessary to optimize and advance innovative tools necessary for the scientific, pharmaceutical, and regulatory community.
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Affiliation(s)
| | | | - Melissa Palmer
- Takeda, Cambridge, MA, USA
- Liver Consulting LLC, New York City, USA
| | | | | | | | | | - Haifa Tyler
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center Dr, Princeton, NJ, 08540, USA
| | | | | | - Liliam Pineda-Salgado
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center Dr, Princeton, NJ, 08540, USA
| | | | - Raul J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Málaga, Spain
| | | | | | - Don C Rockey
- Medical University of South Carolina, Charleston, SC, USA
| | - Alvin Estilo
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center Dr, Princeton, NJ, 08540, USA.
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10
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Hammond S, Thomson P, Meng X, Naisbitt D. In-Vitro Approaches to Predict and Study T-Cell Mediated Hypersensitivity to Drugs. Front Immunol 2021; 12:630530. [PMID: 33927714 PMCID: PMC8076677 DOI: 10.3389/fimmu.2021.630530] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/17/2021] [Indexed: 01/11/2023] Open
Abstract
Mitigating the risk of drug hypersensitivity reactions is an important facet of a given pharmaceutical, with poor performance in this area of safety often leading to warnings, restrictions and withdrawals. In the last 50 years, efforts to diagnose, manage, and circumvent these obscure, iatrogenic diseases have resulted in the development of assays at all stages of a drugs lifespan. Indeed, this begins with intelligent lead compound selection/design to minimize the existence of deleterious chemical reactivity through exclusion of ominous structural moieties. Preclinical studies then investigate how compounds interact with biological systems, with emphasis placed on modeling immunological/toxicological liabilities. During clinical use, competent and accurate diagnoses are sought to effectively manage patients with such ailments, and pharmacovigilance datasets can be used for stratification of patient populations in order to optimise safety profiles. Herein, an overview of some of the in-vitro approaches to predict intrinsic immunogenicity of drugs and diagnose culprit drugs in allergic patients after exposure is detailed, with current perspectives and opportunities provided.
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Affiliation(s)
- Sean Hammond
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
- ApconiX, Alderley Park, Alderley Edge, United Kingdom
| | - Paul Thomson
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Xiaoli Meng
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Dean Naisbitt
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
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11
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Lee BT, Odin JA, Grewal P. An Approach to Drug-Induced Liver Injury from the Geriatric Perspective. Curr Gastroenterol Rep 2021; 23:6. [PMID: 33846832 DOI: 10.1007/s11894-021-00804-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW With its high variability in both presentation and severity, drug-induced liver injury (DILI) is a complex condition increasingly confronting all providers. DILI has an even more muddled presentation among the geriatric population due to age-related changes in liver physiology and biochemistry as well as polypharmacy common in the geriatric population. RECENT FINDINGS Most cases of DILI are idiosyncratic and unpredictable. DILI, especially related to herbal and dietary supplement (HDS) use, is increasingly recognized as a leading cause of acute liver failure and need for liver transplantation. Unfortunately, liver transplantation is a limited option for the elderly, a population that exhibits significant HDS use. One recent study suggests that early use of N-acetylcysteine may be useful in preventing progression to acute liver failure in non-acetaminophen DILI. In the future, a personalized medicine approach using genomic signatures may be feasible to prevent DILI. This review serves to raise recognition of the unique aspects of DILI in the geriatric population to promote rapid diagnosis and early intervention to prevent progression to liver failure and death. For now, DILI remains a diagnosis of exclusion, and care providers for the elderly must focus on obtaining a thorough history that includes HDS use and intervening early in suspected DILI cases.
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Affiliation(s)
- Brian T Lee
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Joseph A Odin
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA. .,Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, NY, USA.
| | - Priya Grewal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.,Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, NY, USA
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12
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13
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Lee FY, Wong HS, Chan HK, Mohamed Ali N, Abu Hassan MR, Omar H, Abdul Mutalib NA. Hepatic adverse drug reactions in Malaysia: An 18-year review of the national centralized reporting system. Pharmacoepidemiol Drug Saf 2020; 29:1669-1679. [PMID: 33064335 DOI: 10.1002/pds.5153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE To determine the incidence, demographic profile, background of reporters, causative agents, severity and clinical outcomes of hepatic adverse drug reaction (ADR) reports in Malaysia using the national ADR reporting database. METHODS The ADR reports recorded between 2000 and 2017 were retrospectively analysed to identify hepatic ADR reports. The trend and characteristics of hepatic ADR cases were described. Multivariate disproportionality analysis of the causative agents was performed to generate signals of hepatic ADRs. RESULTS A total of 2090 hepatic ADRs (1.77% of all ADRs) were reported with mortality rate of 12.7% among cases with known clinical outcomes. The incidence of hepatic ADR reporting in Malaysia increased significantly over 18 years from 0.26 to 9.45 per million population (P < .001). Antituberculosis drugs (n = 268, 12.82%) was the most common suspected class of causative agents with a reporting odds ratio (ROR) and 95% CI of 8.39 (7.26-9.70), followed by traditional/complementary medicines or herbal/dietary supplements (TCM/HDS) (n = 235, 11.24%, ROR 3.26 [2.84-3.75]), systemic antibacterials (n = 159, 7.61%, ROR 2.65 [2.25-3.13]), lipid modifying agents (n = 142, 6.79%, ROR 2.21 [1.86-2.63]) and amiodarone (n = 137, 6.56%, ROR 35.25 [28.40-43.75]). Most (72.9%) of the TCM/HDS were not registered with the authorities. CONCLUSIONS Hepatic ADR cases have increased significantly in Malaysia, with antituberculosis drugs, systemic antibacterials, and TCM/HDS being the most common causative agents reported. Most TCM/HDS reported to be associated with hepatic ADR were not registered with the authorities.
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Affiliation(s)
- Fei Yee Lee
- Clinical Research Centre, Selayang Hospital, Ministry of Health Malaysia, Batu Caves, Selangor, Malaysia
| | - Hin-Seng Wong
- Clinical Research Centre, Selayang Hospital, Ministry of Health Malaysia, Batu Caves, Selangor, Malaysia
| | - Huan-Keat Chan
- Clinical Research Centre, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah, Malaysia
| | - Norleen Mohamed Ali
- Pharmacovigilance Section, Center For Post-Registration and Cosmetic Control, National Pharmaceutical Regulatory Agency (NPRA), Petaling Jaya, Selangor, Malaysia
| | - Muhammad Radzi Abu Hassan
- Clinical Research Centre, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah, Malaysia.,Gastroenterology Unit, Department of Medicine, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah, Malaysia
| | - Haniza Omar
- Hepatology Department, Selayang Hospital, Ministry of Health Malaysia, Batu Caves, Selangor, Malaysia
| | - Noor Aliza Abdul Mutalib
- Hepatology Department, Selayang Hospital, Ministry of Health Malaysia, Batu Caves, Selangor, Malaysia
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14
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Jiménez-Pérez M, González-Grande R, García-Cortés M, Andrade RJ. Drug-Induced Liver Injury After Liver Transplantation. Liver Transpl 2020; 26:1167-1176. [PMID: 32445416 DOI: 10.1002/lt.25804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 04/28/2020] [Accepted: 05/17/2020] [Indexed: 02/07/2023]
Abstract
Drug-induced liver injury (DILI) is an adverse reaction to many drugs in common use that in a liver transplantation (LT) recipient may cause graft dysfunction and may even lead to graft loss and the need for retransplantation. However, several potential clinical scenarios, such as graft rejection and infection, can confound the diagnosis of suspected DILI in the setting of LT. This makes causal assessment of a new liver injury more uncertain and has traditionally precluded collection of bona fide cases of DILI affecting LT patients in prospective DILI registries and cohorts. Although no studies have yet determined a greater susceptibility of the transplant patient to DILI, these patients nevertheless present certain risk factors that can theoretically increase the risk of DILI. These include the fact that these patients are polymedicated, use drugs that are potentially hepatotoxic, and can have coexisting hepatitis B or C viruses in addition to other factors found in nontransplant patients, such as genetic variants. Therefore, awareness is crucial of any potential hepatotoxic effect of drugs used in the LT recipient and their possible implication in any case of liver dysfunction. In the present article, we review the most common drugs used in LT recipients from a liver safety perspective and address the main pitfalls in attributing causality in this clinical setting. We also affirm the need for further research and collaboration in this somewhat neglected topic in the field of DILI.
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Affiliation(s)
- Miguel Jiménez-Pérez
- Unidad de Gestión Clínica de Aparato Digestivo, seccion Hepatología-Trasplante Hepático, Hospital Regional, Universidad de Málaga, Malaga, Spain
| | - Rocío González-Grande
- Unidad de Gestión Clínica de Aparato Digestivo, seccion Hepatología-Trasplante Hepático, Hospital Regional, Universidad de Málaga, Malaga, Spain
| | - Miren García-Cortés
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Malaga, Spain
| | - Raúl J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Malaga, Spain
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15
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Abstract
Drug induced liver injury (DILI) is a relatively rare hepatic condition in response to the use of medications, illegal drugs, herbal products or dietary supplements. It occurs in susceptible individuals through a combination of genetic and environmental risk factors believed to modify drug metabolism and/or excretion leading to a cascade of cellular events, including oxidative stress formation, apoptosis/necrosis, haptenization, immune response activation and a failure to adapt. The resultant liver damage can present with an array of phenotypes, which mimic almost every other liver disorder, and varies in severity from asymptomatic elevation of liver tests to fulminant hepatic failure. Despite recent research efforts specific biomarkers are not still available for routine use in clinical practice, which makes the diagnosis of DILI uncertain and relying on a high degree of awareness of this condition and the exclusion of other causes of liver disease. Diagnostic scales such as the CIOMS/RUCAM can support the causality assessment of a DILI suspicion, but need refinement as some criteria are not evidence-based. Prospective collection of well-vetted DILI cases in established DILI registries has allowed the identification and validation of a number of clinical variables, and to predict a more severe DILI outcome. DILI is also in need of properly designed clinical trials to evaluate the efficacy of new DILI treatments as well as older drugs such as ursodeoxycholic acid traditionally used to ameliorate cholestasis or corticosteroids now widely tried in the oncology field to manage the emergent type of hepatotoxicity related to immune checkpoint inhibitors.
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16
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Andrade RJ, Chalasani N, Björnsson ES, Suzuki A, Kullak-Ublick GA, Watkins PB, Devarbhavi H, Merz M, Lucena MI, Kaplowitz N, Aithal GP. Drug-induced liver injury. Nat Rev Dis Primers 2019; 5:58. [PMID: 31439850 DOI: 10.1038/s41572-019-0105-0] [Citation(s) in RCA: 323] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 02/06/2023]
Abstract
Drug-induced liver injury (DILI) is an adverse reaction to drugs or other xenobiotics that occurs either as a predictable event when an individual is exposed to toxic doses of some compounds or as an unpredictable event with many drugs in common use. Drugs can be harmful to the liver in susceptible individuals owing to genetic and environmental risk factors. These risk factors modify hepatic metabolism and excretion of the DILI-causative agent leading to cellular stress, cell death, activation of an adaptive immune response and a failure to adapt, with progression to overt liver injury. Idiosyncratic DILI is a relative rare hepatic disorder but can be severe and, in some cases, fatal, presenting with a variety of phenotypes, which mimic other hepatic diseases. The diagnosis of DILI relies on the exclusion of other aetiologies of liver disease as specific biomarkers are still lacking. Clinical scales such as CIOMS/RUCAM can support the diagnostic process but need refinement. A number of clinical variables, validated in prospective cohorts, can be used to predict a more severe DILI outcome. Although no pharmacological therapy has been adequately tested in randomized clinical trials, corticosteroids can be useful, particularly in the emergent form of DILI related to immune-checkpoint inhibitors in patients with cancer.
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Affiliation(s)
- Raul J Andrade
- Unidad de Gestión Clínica de Enfermedades Digestivas, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Malaga, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
| | - Naga Chalasani
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Einar S Björnsson
- Department of Gastroenterology, Landspitali University Hospital Reykjavik, University of Iceland, Reykjavík, Iceland.,Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Ayako Suzuki
- Gastroenterology, Duke University, Durham, NC, USA.,Gastroenterology, Durham VA Medical Centre, Durham, NC, USA
| | - Gerd A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Mechanistic Safety, CMO & Patient Safety, Global Drug Development, Novartis Pharma, Basel, Switzerland
| | - Paul B Watkins
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA.,University of North Carolina Institute for Drug Safety Sciences, Research Triangle Park, Chapel Hill, NC, USA
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Michael Merz
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Patient Safety, AstraZeneca, Gaithersburg, MD, USA
| | - M Isabel Lucena
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain. .,Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, UICEC SCReN, Universidad de Málaga, Málaga, Spain.
| | - Neil Kaplowitz
- Division of Gastroenterology and Liver Diseases, Department of Medicine, Keck School of Medicine, Los Angeles, CA, USA
| | - Guruprasad P Aithal
- National Institute for Health Research (NIHR) Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
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17
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Abstract
Drug-induced liver injury (DILI) is a comprehensive phenomenon. The injury to the liver may occur as an unexpected and undesired reaction to a therapeutic dose of a drug (idiosyncratic reaction) or as an expected therapeutic effect of the direct (intrinsic) toxicity of a drug taken in a large enough dose to cause liver injury. The direct toxicity (type A) reactions represent an extension of the drug's therapeutic effect; they occur relatively frequently and are typically dose-related and frequency-of-exposure-related. By contrast, idiosyncratic reactions, or type B reactions, are unpredictable, occurring only in susceptible individuals, and are unrelated to the dose or frequency of exposure. DILI encompasses both acute and/or chronic hepatic lesions. The liver injury may be the only clinical manifestation of the adverse drug effect. Otherwise, it may be accompanied by injury to other organs, or by systemic manifestations. The liver injury may be observed in 1-8 days from taking the drug. DILI cases may result in the disapproval of a new drug or in the removal of a useful drug from the market by regulatory agencies. The purpose of this review is to provide guidance to facilitate the detection and assessment of hepatotoxicity induced by therapeutics that received market authorization. This review supports the safe and effective use of drugs by patients and guides laboratory medicine professional in determining the possible drug-induced liver damage.
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18
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Abstract
Idiosyncratic (unpredictable) drug-induced liver injury is one of the most challenging liver disorders faced by hepatologists, because of the myriad of drugs used in clinical practice, available herbs and dietary supplements with hepatotoxic potential, the ability of the condition to present with a variety of clinical and pathological phenotypes and the current absence of specific biomarkers. This makes the diagnosis of drug-induced liver injury an uncertain process, requiring a high degree of awareness of the condition and the careful exclusion of alternative aetiologies of liver disease. Idiosyncratic hepatotoxicity can be severe, leading to a particularly serious variety of acute liver failure for which no effective therapy has yet been developed. These Clinical Practice Guidelines summarize the available evidence on risk factors, diagnosis, management and risk minimization strategies for drug-induced liver jury.
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19
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Zoubek ME, Pinazo-Bandera J, Ortega-Alonso A, Hernández N, Crespo J, Contreras F, Medina-Cáliz I, Sanabria-Cabrera J, Sanjuan-Jiménez R, González-Jiménez A, García-Cortés M, Lucena MI, Andrade RJ, Robles-Díaz M. Liver injury after methylprednisolone pulses: A disputable cause of hepatotoxicity. A case series and literature review. United European Gastroenterol J 2019; 7:825-837. [PMID: 31316787 DOI: 10.1177/2050640619840147] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 02/17/2019] [Indexed: 01/29/2023] Open
Abstract
Background and Objectives Corticosteroids are often empirically used to treat idiosyncratic hepatotoxicity with severe features. Interestingly, intravenous methylprednisolone (MP) is increasingly being recognized as being responsible for liver injury. We aimed to characterize MP-induced liver injury by analyzing demographical, clinical, laboratory and outcome data of three MP-induced hepatotoxicity cases and compared this information with that of previously published cases. Case series Three females with multiple sclerosis (MS) were treated intravenously with MP, mean daily dose 767 mg. Liver damage occurred 2 to 6 weeks after exposure. Severity was mild to moderate. Two patients suffered positive rechallenge. Literature review We identified 50 published cases of MP hepatotoxicity. Most of these cases were female (86%) and main treatment indications were MS (29 cases) and Graves' ophthalmopathy (13 cases). Hepatocellular damage predominated and mean time to onset was 6 weeks. Four patients died and rechallenge occurred in 19 cases. Conclusion MP pulses can induce severe liver injury, often with an autoimmune phenotype, particularly in patients with MS and Graves' ophthalmopathy. Consequently, these patient groups should have liver tests monitored when treated with MP to provide safer patient care.
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Affiliation(s)
- Miguel Eugenio Zoubek
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Department of Toxicology, School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - José Pinazo-Bandera
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - Aida Ortega-Alonso
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - Nelia Hernández
- Hospital de Clínicas, Clínica Gastroenterología, F Medicina, Montevideo, Uruguay
| | - Javier Crespo
- Unidad de Gestión Clínica de Enfermedades Digestivas, Hospital Marqués de Valdecilla, Instituto de Investigación Biomédica Marques de Valdecilla (IDIVAL), Santander, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Fernando Contreras
- Departamento de Gastroenterología, National University Pedro Henríquez Ureña, Santo Domingo, Dominican Republic
| | - Inmaculada Medina-Cáliz
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - Judith Sanabria-Cabrera
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Unidad Investigación Clínica y Ensayos ClÚcos (UICEC)-Instituto de Investigacióe Biomedicina de Málaga (IBIMA), Plataforma Spanish Clinical Research Network (SCReN), Málaga Spain
| | - Rocío Sanjuan-Jiménez
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Unidad Investigación Clínica y Ensayos ClÚcos (UICEC)-Instituto de Investigacióe Biomedicina de Málaga (IBIMA), Plataforma Spanish Clinical Research Network (SCReN), Málaga Spain
| | - Andrés González-Jiménez
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - Miren García-Cortés
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - M Isabel Lucena
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Unidad Investigación Clínica y Ensayos ClÚcos (UICEC)-Instituto de Investigacióe Biomedicina de Málaga (IBIMA), Plataforma Spanish Clinical Research Network (SCReN), Málaga Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Raúl J Andrade
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Mercedes Robles-Díaz
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
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20
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Danan G, Teschke R. Drug-Induced Liver Injury: Why is the Roussel Uclaf Causality Assessment Method (RUCAM) Still Used 25 Years After Its Launch? Drug Saf 2018; 41:735-743. [PMID: 29502198 DOI: 10.1007/s40264-018-0654-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Launched in 1993 and partially based on the results of an international consensus meeting organized under the auspices of the Council of International Organizations of Medical Sciences (CIOMS), the Roussel Uclaf Causality Assessment Method (RUCAM) is the most used causality assessment tool worldwide for the diagnosis of drug-induced liver injury (DILI) and herb-induced liver injury (HILI) in a large number of epidemiological studies, case reports, and case series. The 25-year experience of RUCAM use confirmed that the success was due to its objective, standardized, and liver-injury-specific approach structured with defined key elements derived from a series of DILI cases with positive rechallenge. Using this series, the validation procedure avoided arbitrary definitions and confirmed scores to key items. The algorithm provides a quantitative causality grading of highly probable, probable, possible, unlikely, or excluded relationship between the liver injury and the suspected product(s). Despite challenges, prospective use of RUCAM fosters case data completeness and transparent causality adjudication in real time, as opposed to subjective opinion resulting from several rounds by experts lacking defined key elements and scores. In 2016, RUCAM was updated with specification of alcohol use and Hepatitis E Virus (HEV) biomarkers and simplified item handling to further reduce inter-observer variability. RUCAM-based probable and highly probable DILI and HILI cases are essential for the detection of new hepatotoxins, confirmation of new biomarkers, description of clinical features and risk factors, and determination of incidence in pharmacoepidemiological studies. This article is intended to encourage systematic use of sophisticated causality assessment methods such as RUCAM to improve DILI and HILI case evaluation and to increase confidence in published cases.
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Affiliation(s)
- Gaby Danan
- Pharmacovigilance Consultancy, 18, rue des ormeaux, 75020, Paris, France.
| | - Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Hanau, Germany
- Teaching Hospital of the Medical Faculty, Goethe University, Frankfurt/Main, Germany
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21
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Kaliyaperumal K, Grove JI, Delahay RM, Griffiths WJH, Duckworth A, Aithal GP. Pharmacogenomics of drug-induced liver injury (DILI): Molecular biology to clinical applications. J Hepatol 2018; 69:948-957. [PMID: 29792895 DOI: 10.1016/j.jhep.2018.05.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 12/14/2022]
Abstract
A 21-year old woman was admitted to hospital with a two-week history of painless jaundice, fatigue and anorexia having previously been fit and well. One month prior to presentation, the patient had taken a five-day course of amoxicillin-clavulanic acid for an infected skin cyst. Otherwise, she was only on the oral contraceptive pill and reported minimal alcohol intake. On examination, she was deeply jaundiced, but alert and oriented with no asterixis. She had no stigmata of chronic liver disease, but hepatomegaly extending 3 cm from below the right subcostal margin was evident. Investigations showed: white cell count 13.4 × 109/L (normal 3.6-9.3), haemoglobin 11.8 g/dl (normal 11-15), platelet count 356 × 109/L (normal 170-420), sodium 138 mmol/L (normal 134-144), potassium 3.5 mmol/L (normal 3.5-5.0), creatinine 32 µmol/L (normal 40-75), albumin 30 g/L (normal 35-48), alanine aminotransferase 707 IU/L (normal 15-54), alkaline phosphatase 151 IU/L (normal 30-130), bilirubin 384 µmol/L (normal 7-31) and prothrombin time 27.2 s (normal 11.7-14). Screening for hepatitis A, B, C, E, Epstein-Barr virus, cytomegalovirus and autoimmune hepatitis was negative. Tests for anti-smooth muscle, antinuclear, and anti-liver-kidney microsomal-1 antibodies were negative; immunoglobulin levels and ceruloplasmin levels were normal. Liver ultrasonography demonstrated a liver of normal contour with no biliary dilatation, a normal spleen size and patent vessels. Liver biopsy revealed severe portal interface hepatitis with lobular inflammation and scant plasma cells. Her clinical condition deteriorated in the following days with prothrombin time and bilirubin rising to 56.6 s and 470 µmol/L, respectively. At follow-up after 11 days, her alanine aminotransferase level was 1,931 IU/L. She developed grade 2 hepatic encephalopathy 14 days after presentation, and was listed for a super-urgent liver transplant. Human leucocyte antigen (HLA) typing was performed as a part of preparatory investigations and showed the patient carried the HLA haplotype HLA-DRB1∗15:02-DQB1∗06:01. Following orthotopic transplantation of a deceased donor graft her explant histology revealed severe ongoing hepatitis with multi-acinar necrosis (Fig. 1A and B). This case raised a number of important questions about the diagnosis of drug-induced liver injury and tools available for clinicians to make the best decisions for patient care: In this Grand Rounds article, we will explore these questions, describing the pathophysiology, diagnostic and prognostic biomarkers, and clinical management of drug-induced liver injury. We will also discuss ongoing areas of uncertainty.
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Affiliation(s)
- Kalaiyarasi Kaliyaperumal
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Jane I Grove
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK; Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Robin M Delahay
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK; Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | | | - Adam Duckworth
- Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK; Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK.
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22
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Benesic A, Rotter I, Dragoi D, Weber S, Leitl A, Buchholtz ML, Gerbes AL. Development and Validation of a Test to Identify Drugs That Cause Idiosyncratic Drug-Induced Liver Injury. Clin Gastroenterol Hepatol 2018; 16:1488-1494.e5. [PMID: 29723689 DOI: 10.1016/j.cgh.2018.04.049] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 04/08/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Idiosyncratic drug-induced liver injury (iDILI) is one of the most challenging diagnoses in hepatology. It is frequently impossible to identify the agent that has caused iDILI in patients who take multiple medicines. We developed an in vitro method to identify drugs that cause liver injury in patients, based on drug toxicity to monocyte-derived hepatocyte-like (MH) cells from patient blood samples. We then collected data on patients who were re-exposed to drugs found to be toxic in the MH test to validate test performance. METHODS We performed a prospective study of patients referred to the University Hospital in Munich, Germany, with acute liver injury believed to be caused by medications (300 patients were enrolled in the study and we present data from 40 patients with iDILI and re-exposure to implicated drugs). We collected data from patients on medical history, laboratory test and imaging results, findings from biopsy analyses, and medications taken. Blood samples were collected from all patients and MH cells were isolated and cultured for 10 days. MH cells were then incubated with drugs to which each patient had been exposed, and toxicity was measured based on release of lactate dehydrogenase. Agents found to be toxic to MH cells were considered as candidates for the cause of liver injury. Patients were followed up for up to 6 months after liver injury and data on drug re-exposures and subsequent liver damage within the following 3 to 24 months were associated with findings from MH tests. RESULTS Our test identified 10 drugs that were toxic to MH cells from 13 patients (amoxicillin/clavulanate to cells from 2 patients; diclofenac to cells from 2 patients; methylprednisolone to cells from 2 patients; and atorvastatin, metamizole, pembrolizumab, piperacillin/tazobactam, moxifloxacin, duloxetine, or sertraline each to cells from 1 patient). Thirteen patients had a recurrence of liver injury after inadvertent re-exposure to a single drug, and the MH test correctly identified 12 of the 13 drugs that caused these liver re-injury events. All 86 drugs that were not toxic to MH cells in our assay were safely resumed by patients and were not associated with liver re-injury in 27 patients. Therefore, the MH test identifies drugs that cause liver injury with 92.3% sensitivity and 100% specificity (1 false-negative and 12 true-positive results). CONCLUSIONS We developed a test to identify drugs that cause liver injury in patients based on their toxicity to MH cells isolated from patients with DILI. We validated results from the assay and found it to identify drugs that cause DILI with 92.3% sensitivity and 100% specificity. The MH cell test could be a tool to identify causes of iDILI, even in patients taking multiple medications. ClinicalTrials.gov no: NCT 02353455.
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Affiliation(s)
- Andreas Benesic
- Department of Internal Medicine 2, Liver Centre Munich, University Hospital Munich (Klinikum der Universität München), Campus Großhadern, Ludwig-Maximilians-Universität Munich, Germany; MetaHeps GmbH, Martinsried, Germany.
| | - Isabelle Rotter
- Department of Internal Medicine 2, Liver Centre Munich, University Hospital Munich (Klinikum der Universität München), Campus Großhadern, Ludwig-Maximilians-Universität Munich, Germany
| | - Diana Dragoi
- Department of Internal Medicine 2, Liver Centre Munich, University Hospital Munich (Klinikum der Universität München), Campus Großhadern, Ludwig-Maximilians-Universität Munich, Germany; MetaHeps GmbH, Martinsried, Germany
| | - Sabine Weber
- Department of Internal Medicine 2, Liver Centre Munich, University Hospital Munich (Klinikum der Universität München), Campus Großhadern, Ludwig-Maximilians-Universität Munich, Germany
| | | | - Marie-Luise Buchholtz
- Department of Internal Medicine 2, Liver Centre Munich, University Hospital Munich (Klinikum der Universität München), Campus Großhadern, Ludwig-Maximilians-Universität Munich, Germany; Institute of Laboratory Medicine, University Hospital, Ludwig-Maximilians-Universität Munich, Germany
| | - Alexander L Gerbes
- Department of Internal Medicine 2, Liver Centre Munich, University Hospital Munich (Klinikum der Universität München), Campus Großhadern, Ludwig-Maximilians-Universität Munich, Germany
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23
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García-Cortés M, Ortega-Alonso A, Lucena MI, Andrade RJ. Drug-induced liver injury: a safety review. Expert Opin Drug Saf 2018; 17:795-804. [PMID: 30059261 DOI: 10.1080/14740338.2018.1505861] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Idiosyncratic drug-induced liver injury (DILI) remains one of the most important causes of drug attrition both in the early phases of clinical drug development and in the postmarketing scenario. This is because, in spite of emerging data on genetic susceptibility variants associated to the risk of hepatotoxicity, the precise identification of the individual who will develop DILI when exposed to a given drug remains elusive. AREAS COVERED In this review, we have addressed recent progress made and initiatives taken in the field of DILI from a safety perspective through a comprehensive search of the literature. EXPERT OPINION Despite the substantial progress made over this century, new approaches using big data analysis to characterize the true incidence of DILI are needed and to categorize the drugs' hepatotoxic potential. Genetic studies have highlighted the role of the adaptive immune system yet the mechanisms leading adaptation versus progression remain to be elucidated. There is a compelling need for development and qualification of sensitive, specific, and affordable biomarkers in DILI to foster drug development, patient treatment stratification and, improvement of causality assessment methods. Gaining mechanistic insights in DILI is essential to uncover therapeutic targets and design prospective clinical trials with appropriate endpoints.
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Affiliation(s)
- Miren García-Cortés
- a Instituto de Investigación Biomédica-IBIMA , Hospital Universitario Virgen de la Victoria, Universidad de Málaga , Málaga , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd , Málaga , Spain
| | - Aida Ortega-Alonso
- a Instituto de Investigación Biomédica-IBIMA , Hospital Universitario Virgen de la Victoria, Universidad de Málaga , Málaga , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd , Málaga , Spain
| | - M Isabel Lucena
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd , Málaga , Spain.,c Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria , Universidad de Málaga , Málaga , Spain
| | - Raúl J Andrade
- a Instituto de Investigación Biomédica-IBIMA , Hospital Universitario Virgen de la Victoria, Universidad de Málaga , Málaga , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd , Málaga , Spain
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24
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Dragoi D, Benesic A, Pichler G, Kulak NA, Bartsch HS, Gerbes AL. Proteomics Analysis of Monocyte-Derived Hepatocyte-Like Cells Identifies Integrin Beta 3 as a Specific Biomarker for Drug-Induced Liver Injury by Diclofenac. Front Pharmacol 2018; 9:699. [PMID: 30022949 PMCID: PMC6039575 DOI: 10.3389/fphar.2018.00699] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/08/2018] [Indexed: 12/12/2022] Open
Abstract
Idiosyncratic drug-induced liver injury (iDILI) is a major cause of acute liver failure resulting in liver transplantation or death. Prediction and diagnosis of iDILI remain a great challenge, as current models provide unsatisfying results in terms of sensitivity, specificity, and prognostic value. The absence of appropriate tools for iDILI detection also impairs the development of reliable biomarkers. Here, we report on a new method for identification of drug-specific biomarkers. We combined the advantages of monocyte-derived hepatocyte-like (MH) cells, able to mimic individual characteristics, with those of a novel mass spectrometry-based proteomics technology to assess potential biomarkers for Diclofenac-induced DILI. We found over 2,700 proteins differentially regulated in MH cells derived from individual patients. Herefrom, we identified integrin beta 3 (ITGB3) to be specifically upregulated in Diclofenac-treated MH cells from Diclofenac-DILI patients compared to control groups. Finally, we validated ITGB3 by flow cytometry analysis of whole blood and histological staining of liver biopsies derived from patients diagnosed with Diclofenac-DILI. In summary, our results show that biomarker candidates can be identified by proteomics analysis of MH cells. Application of this method to a broader range of drugs in the future will exploit its full potential for the development of drug-specific biomarkers. Data are available via ProteomeXchange with identifier PXD008918.
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Affiliation(s)
- Diana Dragoi
- Department of Medicine 2, Liver Centre Munich, University Hospital Munich, Munich, Germany.,MetaHeps GmbH, Martinsried, Germany
| | - Andreas Benesic
- Department of Medicine 2, Liver Centre Munich, University Hospital Munich, Munich, Germany.,MetaHeps GmbH, Martinsried, Germany
| | - Garwin Pichler
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, Martinsried, Germany.,PreOmics GmbH, Martinsried, Germany
| | - Nils A Kulak
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, Martinsried, Germany.,PreOmics GmbH, Martinsried, Germany
| | - Harald S Bartsch
- Institute of Pathology, Medical School, Ludwig Maximilian University, Munich, Germany
| | - Alexander L Gerbes
- Department of Medicine 2, Liver Centre Munich, University Hospital Munich, Munich, Germany
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25
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Philips CA, Paramaguru R, Augustine P. Reply to: Safety in Ayurveda-Need to bring the house in order by Dr. Sanjeev Rastogi. Indian J Gastroenterol 2018; 37:376-377. [PMID: 30121888 DOI: 10.1007/s12664-018-0872-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, 682 028, India. .,Philip Augustine Associates, Symphony, Automobile Road, Palarivattom, Kochi, 682 025, India.
| | | | - Philip Augustine
- Department of Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, 682 028, India
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26
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Hunt CM. Expanding our toolkit to better identify drug-induced liver injury in electronic medical records. Liver Int 2018; 38:585-587. [PMID: 29575769 DOI: 10.1111/liv.13710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Christine M Hunt
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Cooperative Studies Program Epidemiology Center, Durham Veterans Affairs Health Care System, Durham, NC, USA
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27
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Hunt CM, Papay JI, Stanulovic V, Regev A. Drug rechallenge following drug-induced liver injury. Hepatology 2017; 66:646-654. [PMID: 28295448 DOI: 10.1002/hep.29152] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/29/2017] [Accepted: 03/02/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED Drug-induced hepatocellular injury is identified internationally by alanine aminotransferase (ALT) levels equal to or exceeding 5× the upper limit of normal (ULN) appearing within 3 months of drug initiation, after alternative causes are excluded. Upon withdrawing the suspect drug, ALT generally decrease by 50% or more. With drug readministration, a positive rechallenge has recently been defined by an ALT level of 3-5× ULN or greater. Nearly 50 drugs are associated with positive rechallenge after drug-induced liver injury (DILI): antimicrobials; and central nervous system, cardiovascular and oncology therapeutics. Drugs associated with high rates of positive rechallenge exhibit multiple risk factors: daily dose >50 mg, an increased incidence of ALT elevations in clinical trials, immunoallergic clinical injury, and mitochondrial impairment in vitro. These drug factors interact with personal genetic, immune, and metabolic factors to influence positive rechallenge rates and outcomes. Drug rechallenge following drug-induced liver injury is associated with up to 13% mortality in prospective series of all prescribed drugs. In recent oncology trials, standardized systems have enabled safer drug rechallenge with weekly liver chemistry monitoring during the high-risk period and exclusion of patients with hypersensitivity. However, high positive rechallenge rates with other innovative therapeutics suggest that caution should be taken with rechallenge of high-risk drugs. CONCLUSION For critical medicines, drug rechallenge may be appropriate when 1) no safer alternatives are available, 2) the objective benefit exceeds the risk, and 3) patients are fully informed and consent, can adhere to follow-up, and alert providers to hepatitis symptoms. To better understand rechallenge outcomes and identify key risk factors for positive rechallenge, additional data are needed from controlled clinical trials, prospective registries, and large health care databases. (Hepatology 2017;66:646-654).
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Affiliation(s)
- Christine M Hunt
- Department of Medicine, Duke University Medical Center, Durham, NC.,Durham Veterans Administration Medical Center, Durham, NC
| | - Julie I Papay
- Global Patient Safety, UCB BioSciences, Research Triangle Park, NC
| | - Vid Stanulovic
- Accelsiors Clinical Research Organization and Consultancy, Budapest, Hungary.,Semmelweis University School of Pharmacy, Budapest, Hungary
| | - Arie Regev
- Global Patient Safety, Eli Lilly and Company, Indianapolis, IN
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28
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Kullak-Ublick GA, Andrade RJ, Merz M, End P, Benesic A, Gerbes AL, Aithal GP. Drug-induced liver injury: recent advances in diagnosis and risk assessment. Gut 2017; 66:1154-1164. [PMID: 28341748 PMCID: PMC5532458 DOI: 10.1136/gutjnl-2016-313369] [Citation(s) in RCA: 302] [Impact Index Per Article: 43.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/24/2017] [Accepted: 02/28/2017] [Indexed: 12/12/2022]
Abstract
Idiosyncratic drug-induced liver injury (IDILI) is a rare but potentially severe adverse drug reaction that should be considered in patients who develop laboratory criteria for liver injury secondary to the administration of a potentially hepatotoxic drug. Although currently used liver parameters are sensitive in detecting DILI, they are neither specific nor able to predict the patient's subsequent clinical course. Genetic risk assessment is useful mainly due to its high negative predictive value, with several human leucocyte antigen alleles being associated with DILI. New emerging biomarkers which could be useful in assessing DILI include total keratin18 (K18) and caspase-cleaved keratin18 (ccK18), macrophage colony-stimulating factor receptor 1, high mobility group box 1 and microRNA-122. From the numerous in vitro test systems that are available, monocyte-derived hepatocytes generated from patients with DILI show promise in identifying the DILI-causing agent from among a panel of coprescribed drugs. Several computer-based algorithms are available that rely on cumulative scores of known risk factors such as the administered dose or potential liabilities such as mitochondrial toxicity, inhibition of the bile salt export pump or the formation of reactive metabolites. A novel DILI cluster score is being developed which predicts DILI from multiple complimentary cluster and classification models using absorption-distribution-metabolism-elimination-related as well as physicochemical properties, diverse substructural descriptors and known structural liabilities. The provision of more advanced scientific and regulatory guidance for liver safety assessment will depend on validating the new diagnostic markers in the ongoing DILI registries, biobanks and public-private partnerships.
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Affiliation(s)
- Gerd A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich and University of Zurich, Zurich, Switzerland,Drug Safety and Epidemiology, Novartis Pharma, Basel, Switzerland
| | - Raul J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Málaga, Spain
| | - Michael Merz
- Novartis Institutes for BioMedical Research, Novartis Campus, Basel, Switzerland
| | - Peter End
- Novartis Institutes for BioMedical Research, Novartis Campus, Basel, Switzerland
| | - Andreas Benesic
- Department of Medicine II, Klinikum Grosshadern of the University of Munich (KUM), University of Munich, Munich, Germany,MetaHeps GmbH, Planegg/Martinsried, Germany
| | - Alexander L Gerbes
- Department of Medicine II, Klinikum Grosshadern of the University of Munich (KUM), University of Munich, Munich, Germany
| | - Guruprasad P Aithal
- National Institute for Health Research (NIHR), Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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29
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Terziroli Beretta-Piccoli B, Mieli-Vergani G, Bertoli R, Mazzucchelli L, Nofziger C, Paulmichl M, Vergani D. Atovaquone/proguanil-induced autoimmune-like hepatitis. Hepatol Commun 2017; 1:293-298. [PMID: 29404460 PMCID: PMC5721398 DOI: 10.1002/hep4.1039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 04/04/2017] [Accepted: 04/08/2017] [Indexed: 01/18/2023] Open
Abstract
We report a novel association between the commonly used antimalarial medication atovaquone/proguanil and drug‐induced autoimmune‐like hepatitis. The patient developed severe liver disease fulfilling biochemical, immunologic, and histologic criteria for the diagnosis of autoimmune hepatitis after the inadvertent rechallenge with the offending drug, which had caused self‐limited hepatitic symptoms a year previously. Over a period of 18 months, the patient underwent two follow‐up liver biopsies showing progressive resolution of the liver inflammation and achieved complete biochemical and immunologic remission on steroids. This remission persisted for 20 months following treatment withdrawal. Conclusion: This well documented case raises awareness of the potential hepatotoxicity of atovaquone/proguanil. (Hepatology Communications 2017;1:293–298)
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Affiliation(s)
| | | | - Raffaela Bertoli
- Regional Pharmacovigilance Center, Division of Clinical Pharmacology and Toxicology Ente Ospedaliero Cantonale Lugano Switzerland
| | | | - Charity Nofziger
- Institute of Pharmacology and Toxicology Paracelsus Medical University Salzburg Austria
| | - Markus Paulmichl
- Center for Health and Bioresources Austrian Institute of Technology Vienna Austria
| | - Diego Vergani
- Institute of Liver Studies King's College Hospital London United Kingdom
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30
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A Time to Pause and Reflect: When a Patient with Autoimmune Hepatitis Stops Responding to Corticosteroids. Case Rep Gastrointest Med 2017; 2016:7092434. [PMID: 28116182 PMCID: PMC5220420 DOI: 10.1155/2016/7092434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 11/30/2016] [Indexed: 11/18/2022] Open
Abstract
Drug-induced liver injury (DILI) with features of autoimmunity (AI) is a challenging diagnosis to make particularly due to its apparent corticosteroid responsiveness. We present the case of a 74-year-old woman who presented with a 2-week history of jaundice and fatigue. She was initially diagnosed with autoimmune hepatitis (AIH) based on biochemical and histological characteristics and prompt response with budesonide but a biochemical relapse occurred soon after inadvertent rechallenge with irbesartan, a drug that she had discontinued prior to her presentation but was not initially considered to be a cause of her symptoms.
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31
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Björnsson ES. Hepatotoxicity by Drugs: The Most Common Implicated Agents. Int J Mol Sci 2016; 17:224. [PMID: 26861310 PMCID: PMC4783956 DOI: 10.3390/ijms17020224] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 02/01/2016] [Indexed: 02/07/2023] Open
Abstract
Idiosyncratic drug-induced liver injury (DILI) is an underreported and underestimated adverse drug reaction. Information on the documented hepatotoxicity of drugs has recently been made available by a website that can be accessed in the public domain: LiverTox (http://livertox.nlm.nih.gov). According to critical analysis of the hepatotoxicity of drugs in LiverTox, 53% of drugs had at least one case report of convincing reports of liver injury. Only 48 drugs had more than 50 case reports of DILI. Amoxicillin-clavulanate is the most commonly implicated agent leading to DILI in the prospective series. In a recent prospective study, liver injury due to amoxicillin-clavulanate was found to occur in approximately one out of 2300 users. Drugs with the highest risk of DILI in this study were azathioprine and infliximab.
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Affiliation(s)
- Einar S Björnsson
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, The National University Hospital of Iceland and The Faculty of Medicine, The University of Iceland, 108 Reykjavik, Iceland.
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Björnsson ES, Hoofnagle JH. Categorization of drugs implicated in causing liver injury: Critical assessment based on published case reports. Hepatology 2016; 63:590-603. [PMID: 26517184 DOI: 10.1002/hep.28323] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 10/29/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED An important element in assessing causality in drug-induced liver injury is whether the implicated agent is known to cause hepatotoxicity. We classified drugs into categories based on the number of published reports of convincingly documented, clinically apparent, idiosyncratic liver injury. Drugs described in the website LiverTox (http://livertox.nih.gov) were classified into five categories based on the number of published cases (category A, ≥50; category B, 12-49; category C, 4-11; category D, 1-3; category E, none). Case reports in categories C and D were individually reanalyzed using the Roussel Uclaf Causality Assessment Method. Drugs with fatal cases or with rechallenge were noted. Among 671 individual drugs or closely related agents, 353 (53%) were considered convincingly linked to liver injury in published case reports; 48 (13%) were assigned to category A, 76 (22%) were assigned to category B, 96 (27%) were assigned to category C, and 126 (36%) were assigned to category D. Another 7 (2%) were direct hepatotoxins but only in high doses and placed in a separate category (T). The remaining 318 (47%) drugs had no convincing case report of hepatoxicity in the literature (category E). All except one in category A have been available since 1999, 98% had at least one fatal case and 89% a positive rechallenge. In category B, 54% had a fatal case and 41% a rechallenge. Drugs in categories C and D less frequently had instances of fatal (23% and 7%) or rechallenge cases (26% and 11%). CONCLUSION Documentation of hepatoxicity in the medical literature is variable, and many published instances do not stand up to critical review. A standardized system for categorizing drugs for hepatotoxicity potential will help develop objective and reliable, computer-based instruments for assessing causality in drug-induced liver injury.
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Affiliation(s)
- Einar S Björnsson
- The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Jay H Hoofnagle
- Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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Stine JG, Lewis JH. Current and future directions in the treatment and prevention of drug-induced liver injury: a systematic review. Expert Rev Gastroenterol Hepatol 2015; 10:517-36. [PMID: 26633044 PMCID: PMC5074808 DOI: 10.1586/17474124.2016.1127756] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While the pace of discovery of new agents, mechanisms and risk factors involved in drug-induced liver injury (DILI) remains brisk, advances in the treatment of acute DILI seems slow by comparison. In general, the key to treating suspected DILI is to stop using the drug prior to developing irreversible liver failure. However, predicting when to stop is an inexact science, and commonly used ALT monitoring is an ineffective strategy outside of clinical trials. The only specific antidote for acute DILI remains N-acetylcysteine (NAC) for acetaminophen poisoning, although NAC is proving to be beneficial in some cases of non-acetaminophen DILI in adults. Corticosteroids can be effective for DILI associated with autoimmune or systemic hypersensitivity features. Ursodeoxycholic acid, silymarin and glycyrrhizin have been used to treat DILI for decades, but success remains anecdotal. Bile acid washout regimens using cholestyramine appear to be more evidenced based, in particular for leflunomide toxicity. For drug-induced acute liver failure, the use of liver support systems is still investigational in the United States and emergency liver transplant remains limited by its availability. Primary prevention appears to be the key to avoiding DILI and the need for acute treatment. Pharmacogenomics, including human leukocyte antigen genotyping and the discovery of specific DILI biomarkers offers significant promise for the future. This article describes and summarizes the numerous and diverse treatment and prevention modalities that are currently available to manage DILI.
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Affiliation(s)
- Jonathan G. Stine
- University of Virginia Health System, Department of Medicine, Division of Gastroenterology and Hepatology, JPA and Lee Street, MSB 2145, PO Box 800708, Charlottesville VA 22908
| | - James H. Lewis
- Georgetown University Medical Center, Department of Medicine, Division of Gastroenterology and Hepatology, 3800 Reservoir Rd NW, Washington, DC 20007
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Lewis JH. The Art and Science of Diagnosing and Managing Drug-induced Liver Injury in 2015 and Beyond. Clin Gastroenterol Hepatol 2015; 13:2173-89.e8. [PMID: 26116527 DOI: 10.1016/j.cgh.2015.06.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/15/2015] [Accepted: 06/15/2015] [Indexed: 12/13/2022]
Abstract
Drug-induced liver injury (DILI) remains a leading reason why new compounds are dropped from further study or are the subject of product warnings and regulatory actions. Hy's Law of drug-induced hepatocellular jaundice causing a case-fatality rate or need for transplant of 10% or higher has been validated in several large national registries, including the ongoing, prospective U.S. Drug-Induced Liver Injury Network. It serves as the basis for stopping rules in clinical trials and in clinical practice. Because DILI can mimic all known causes of acute and chronic liver disease, establishing causality can be difficult. Histopathologic findings are often nonspecific and rarely, if ever, considered pathognomonic. A daily drug dose >50-100 mg is more likely to be hepatotoxic than does <10 mg, especially if the compound is highly lipophilic or undergoes extensive hepatic metabolism. The quest for a predictive biomarker to replace alanine aminotransferase is ongoing. Markers of necrosis and apoptosis such as microRNA-122 and keratin 18 may prove useful in identifying patients at risk for severe injury when they initially present with a suspected acetaminophen overdose. Although a number of drugs causing idiosyncratic DILI have HLA associations that may allow for pre-prescription testing to prevent hepatotoxicity, the cost and relatively low frequency of injury among affected patients limit the current usefulness of such genome-wide association studies. Alanine aminotransferase monitoring is often recommended but has rarely been shown to be an effective method to prevent serious DILI. Guidelines on the diagnosis and management of DILI have recently been published, although specific therapies remain limited. The LiverTox Web site has been introduced as an interactive online virtual textbook that makes the latest information on more than 650 agents available to clinicians, regulators, and drug developers alike.
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Affiliation(s)
- James H Lewis
- Hepatology Section, Division of Gastroenterology, Georgetown University Hospital, Washington, District of Columbia.
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Spraggs CF, Xu CF, Hunt CM. Genetic characterization to improve interpretation and clinical management of hepatotoxicity caused by tyrosine kinase inhibitors. Pharmacogenomics 2013; 14:541-54. [DOI: 10.2217/pgs.13.24] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tyrosine kinase inhibitors (TKIs) represent important therapeutic alternatives to, or combinations with, traditional cytotoxic chemotherapy. Despite their selective molecular targeting and demonstrated clinical benefit, TKIs produce a range of serious adverse events, including drug-induced liver injury, that require careful patient management to maintain treatment benefit without harm. Genetic characterization of serious adverse events can identify mechanisms of injury and improve safety risk management. This review presents pharmacogenetic comparisons of two approved TKIs, lapatinib and pazopanib, which reveal different mechanisms of injury and inform the characteristics and risk of serious liver injury in treated patients. The data presented demonstrate the utility of genetic studies to investigate drug-induced liver injury and potentially support its management in patients.
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Affiliation(s)
- Colin F Spraggs
- Genetics, Quantitative Sciences, GlaxoSmithKline Research & Development, Medicines Research Centre, Gunnels Wood Road, Stevenage, SG1 2NY, UK.
| | - Chun-Fang Xu
- Genetics, Quantitative Sciences, GlaxoSmithKline Research & Development, Medicines Research Centre, Gunnels Wood Road, Stevenage, SG1 2NY, UK
| | - Christine M Hunt
- Clinical Safety Systems, GlaxoSmithKline Research & Development, Research Triangle Park, NC, USA
- Duke University, Durham, NC, USA
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Corsini A, Bortolini M. Drug-induced liver injury: the role of drug metabolism and transport. J Clin Pharmacol 2013; 53:463-74. [PMID: 23436293 DOI: 10.1002/jcph.23] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 07/17/2012] [Indexed: 12/11/2022]
Abstract
Many studies have pinpointed the significant contribution of liver-mediated drug metabolism and transport to the complexity of drug-induced liver injury (DILI). Phase I cytochrome P450 (CYP450) enzymes can lead to altered drug metabolism and formation of toxic metabolites, whilst Phase II enzymes are also associated with DILI. The emerging role of hepatic transporters in regulating the movement of endogenous and exogenous chemicals (e.g., bile acids and drugs) across cellular and tissue membranes is critical in determining the pathophysiology of liver disease as well as drug toxicity and efficacy. Genetic and environmental factors can have a significant impact on drug metabolism and transporter proteins, consequently increasing the risk of DILI in susceptible individuals. The assessment of these factors therefore represents an important approach for predicting and preventing DILI, by better understanding the pharmacological profile of a specific drug. This review focuses on the mechanisms of DILI associated with drug metabolism and hepatic transport, and how they can be influenced by underlying factors.
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Affiliation(s)
- Alberto Corsini
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy.
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Shin J, Hunt CM, Suzuki A, Papay JI, Beach KJ, Cheetham TC. Characterizing phenotypes and outcomes of drug-associated liver injury using electronic medical record data. Pharmacoepidemiol Drug Saf 2012; 22:190-8. [DOI: 10.1002/pds.3388] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 11/01/2012] [Accepted: 11/18/2012] [Indexed: 01/09/2023]
Affiliation(s)
- Janet Shin
- Pharmacy Analytical Services; Kaiser Permanente Southern California; Downey California USA
| | | | - Ayako Suzuki
- Duke University Medical Center; Durham North Carolina USA
| | - Julie I. Papay
- GlaxoSmithKline; Research Triangle Park North Carolina USA
| | | | - T. Craig Cheetham
- Pharmacy Analytical Services; Kaiser Permanente Southern California; Downey California USA
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Abstract
Idiosyncratic drug-induced liver injury (DILI) is an important cause of morbidity and mortality following drugs taken in therapeutic doses. Hepatotoxicity is a leading cause of attrition in drug development, or withdrawal or restricted use after marketing. No age is exempt although adults and the elderly are at increased risk. DILI spans the entire spectrum ranging from asymptomatic elevation in transaminases to severe disease such as acute hepatitis leading to acute liver failure. The liver specific Roussel Uclaf Causality Assessment Method is the most validated and extensively used for determining the likelihood that an implicated drug caused DILI. Asymptomatic elevation in liver tests must be differentiated from adaptation. Drugs producing DILI have a signature pattern although no single pattern is characteristic. Antimicrobial and central nervous system agents including antiepileptic drugs are the leading causes of DILI worldwide. In the absence of a diagnostic test or a biomarker, the diagnosis rests on the evidence of absence of competing causes such as acute viral hepatitis, autoimmune hepatitis and others. Recent studies show that antituberculosis drugs given for active or latent disease are still a major cause of drug-induced liver injury in India and the West respectively. Presence of jaundice signifies a severe disease and entails a worse outcome. The pathogenesis is unclear and is due to a mix of host, drug metabolite and environmental factors. Research has evolved from incriminating candidate genes to genome wide analysis studies. Immediate cessation of the drug is key to prevent or minimize progressive damage. Treatment is largely supportive. N-acetylcysteine is the antidote for paracetamol toxicity. Carnitine has been tried in valproate injury whereas steroids and ursodeoxycholic acid may be used in DILI associated with hypersensitivity or cholestatic features respectively. This article provides an overview of the epidemiology, the patterns of hepatotoxicity, the pathogenesis and associated risk factors besides its clinical management.
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Key Words
- ADR, adverse drug reaction
- AED, antiepileptic drugs
- BSEP, bile salt export pump
- CDS, clinical diagnostic scale
- CIOMS, Council for International Organization of Medical Sciences
- CXR, constitutive androstane receptor
- DIAIH, drug-induced autoimmune hepatitis
- DIALF, drug-induced acute liver failure
- DILI
- DILI, idiosyncratic drug-induced liver injury
- FXR, farnesoid X receptor
- GWAS, genome wide association studies
- HBV, hepatitis B virus
- HIV, human immunodeficiency virus
- INH, isoniazid
- LPS, lipopolysaccharide
- MHC, major histocompatibility complex
- MRP, multi-drug resistance proteins
- NAC, N-acetylcysteine
- NAPQI, N-acetyl-p-benzoquinone imine
- NRH, nodular regenerative hyperplasia
- PXR, pregnane X receptor
- PZA, pyrazinamide
- RIF, rifampicin
- RUCAM, Roussel Uclaf Causality Assessment Method
- TEN, toxic epidermal necrolysis
- UDCA, ursodeoxycholic acid
- causality
- drug-induced
- hepatotoxicity
- liver injury
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Yes! Statins can be given to liver patients. J Hepatol 2012; 56:305-7. [PMID: 21963520 DOI: 10.1016/j.jhep.2011.08.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 08/16/2011] [Accepted: 08/19/2011] [Indexed: 12/16/2022]
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Devarbhavi H, Karanth D, Prasanna KS, Adarsh CK, Patil M. Drug-Induced liver injury with hypersensitivity features has a better outcome: a single-center experience of 39 children and adolescents. Hepatology 2011; 54:1344-50. [PMID: 21735470 DOI: 10.1002/hep.24527] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 06/17/2011] [Indexed: 12/22/2022]
Abstract
UNLABELLED Drug-induced liver injury (DILI) is rare in children and adolescents, and, consequently, data are remarkably limited. We analyzed the causes, clinical and biochemical features, natural history, and outcomes of children with DILI. Consecutive children with DILI from 1997 to 2004 (retrospective) and 2005 to 2010 (prospective) were studied based on standard criteria for DILI. Thirty-nine children constituted 8.7% of 450 cases of DILI. There were 22 boys and 17 girls. Median age was 16 years (range, 2.6-17). Combination antituberculous drugs were the most common cause (n = 22), followed by the anticonvulsants, phenytoin (n = 10) and carbamazepine (n = 6). All of the 16 children (41%) who developed hypersensitivity features, such as skin rashes, fever, lymphadenopathy, and/or eosinophilia, including the 3 with Stevens-Johnson syndrome, survived. Those with hypersensitivity presented earlier (24.5 versus 35 days; P = 0.24) had less severe disease (MELD, 16 versus 29; P = 0.01) and had no mortality (0/16 versus 12/23; P < 0.001), compared to those without hypersensitivity. The 12 fatalities were largely the result of antituberculous DILI (n = 11). The presence of encephalopathy and ascites were associated with mortality, along with hyperbilirubinemia, high international normalized ratio, and serum creatinine. According to the Roussel Uclaf Causality Assessment Method, 18 were highly probable, 14 probable, and 7 possible. Thirty-two children were hospitalized. CONCLUSION DILI is not uncommon in children and accounts for 8.7% of all patients with DILI. Antituberculous drugs and anticonvulsants are the leading causes of DILI in India. Overall mortality is high (30.7%), largely accounted by antituberculous drugs. Children with DILI and hypersensitivity features present early, have less severe disease, and, consequently, a better prognosis, compared to those without, and are often associated with anticonvulsants or sulfonamides.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India.
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Causality assessment methods in drug induced liver injury: strengths and weaknesses. J Hepatol 2011; 55:683-691. [PMID: 21349301 DOI: 10.1016/j.jhep.2011.02.007] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 02/11/2011] [Accepted: 02/14/2011] [Indexed: 12/12/2022]
Abstract
Diagnosis of drug-induced liver injury (DILI) remains a challenge and eagerly awaits the development of reliable hepatotoxicity biomarkers. Several methods have been developed in order to facilitate hepatotoxicity causality assessments. These methods can be divided into three categories: (1) expert judgement, (2) probabilistic approaches, and (3) algorithms or scales. The last category is further divided into general and liver-specific scales. The Council for International Organizations of Medical Sciences (CIOMS) scale, also referred to as the Roussel Uclaf Causality Assessment Method (RUCAM), although cumbersome and difficult to apply by physicians not acquainted with DILI, is used by many expert hepatologists, researchers, and regulatory authorities to assess the probability of suspected causal agents. However, several limitations of this scale have been brought to light, indicating that a number of adjustments are needed. This review is a detailed timely criticism to alert the readers of the limitations and give insight into what would be needed to improve the scale. Instructions on how to approach DILI diagnosis in practice are provided, using CIOMS as an aid to emphasize the topics to be addressed when assessing DILI cases. Amendments of the CIOMS scale in the form of applying authoritative evidence-based criteria, a simplified scoring system and appropriate weighting given to individual parameters based on statistical evaluations with large databases will provide wider applicability in the clinical setting.
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Hunt CM. Mitochondrial and immunoallergic injury increase risk of positive drug rechallenge after drug-induced liver injury: a systematic review. Hepatology 2010; 52:2216-22. [PMID: 21105110 DOI: 10.1002/hep.24022] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Hunt CM, Papay JI, Rich DS, Abissi CJ, Russo MW. The evaluation of drug rechallenge: the casopitant Phase III program. Regul Toxicol Pharmacol 2010; 58:539-43. [PMID: 20932869 DOI: 10.1016/j.yrtph.2010.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 09/26/2010] [Accepted: 09/27/2010] [Indexed: 10/19/2022]
Abstract
Drug rechallenge (or reinitiation), following an event of drug-induced liver injury, is associated with 13% mortality in prospective series. Rechallenge generally results in much more rapid injury than the initial liver event. The neurokinin-1 antagonist casopitant or its placebo was administered cyclically with ondansetron and dexamethasone in two randomized chemotherapy-induced nausea and vomiting clinical trials in nearly 3000 subjects. Grade 3 ALT elevations were observed in up to 2% of subjects receiving casopitant or placebo treatment. Similar rates of positive rechallenge were observed in the casopitant 8/29 (28%) and placebo groups 2/8 (25%), with no Grade 4 ALT elevations, hypersensitivity or liver-related serious adverse events. Publishing available rechallenge data (positive and negative) will advance our clinical understanding. Rechallenge should only be considered when the potential drug benefit exceeds the risk.
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