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McGill MR, Curry SC. The Evolution of Circulating Biomarkers for Use in Acetaminophen/Paracetamol-Induced Liver Injury in Humans: A Scoping Review. LIVERS 2023; 3:569-596. [PMID: 38434489 PMCID: PMC10906739 DOI: 10.3390/livers3040039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Acetaminophen (APAP) is a widely used drug, but overdose can cause severe acute liver injury. The first reports of APAP hepatotoxicity in humans were published in 1966, shortly after the development of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) as the first biomarkers of liver injury as opposed to liver function. Thus, the field of liver injury biomarkers has evolved alongside the growth in APAP hepatotoxicity incidence. Numerous biomarkers have been proposed for use in the management of APAP overdose patients in the intervening years. Here, we comprehensively review the development of these markers from the 1960s to the present day and briefly discuss possible future directions.
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Affiliation(s)
- Mitchell R McGill
- Dept. of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72212, USA
- Dept. of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72212, USA
- Dept. of Pathology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72212, USA
| | - Steven C Curry
- Division of Clinical Data Analytics and Decision Support, University of Arizona College of Medicine-Phoenix, Phoenix, AZ 85006, USA
- Department of Medical Toxicology, Banner-University Medical Center Phoenix, Phoenix, AZ 85006, USA
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2
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Chiew AL, Isbister GK. Advances in the understanding of acetaminophen toxicity mechanisms: a clinical toxicology perspective. Expert Opin Drug Metab Toxicol 2023; 19:601-616. [PMID: 37714812 DOI: 10.1080/17425255.2023.2259787] [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: 05/15/2023] [Revised: 08/02/2023] [Accepted: 09/13/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Acetaminophen (paracetamol) is a commonly used analgesic and antipyretic agent, which is safe in therapeutic doses. Acetaminophen poisoning due to self-harm or repeated supratherapeutic ingestion is a common cause of acute liver injury. Acetylcysteine has been a mainstay of treatment for acetaminophen poisoning for decades and is efficacious if administered early. However, treatment failures occur if administered late, in 'massive' overdoses or in high-risk patients. AREAS COVERED This review provides an overview of the mechanisms of toxicity of acetaminophen poisoning (metabolic and oxidative phase) and how this relates to the assessment and treatment of the acetaminophen poisoned patient. The review focuses on how these advances offer further insight into the utility of novel biomarkers and the role of proposed adjunct treatments. EXPERT OPINION Advances in our understanding of acetaminophen toxicity have allowed the development of novel biomarkers and a better understanding of how adjunct treatments may prevent acetaminophen toxicity. Newly proposed adjunct treatments like fomepizole are being increasingly used without robust clinical trials. Novel biomarkers (not yet clinically available) may provide better assessment of these newly proposed adjunct treatments, particularly in clinical trials. These advances in our understanding of acetaminophen toxicity and liver injury hold promise for improved diagnosis and treatment.
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Affiliation(s)
- Angela L Chiew
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Geoffrey K Isbister
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Clinical Toxicology Research Group, University of Newcastle, Callaghan, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle, Waratah, NSW, Australia
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3
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Yau CE, Chen H, Lim BPY, Ng M, Ponampalam R, Lim DYZ, Chin YH, Ho AFW. Performance of the paracetamol-aminotransferase multiplication product in risk stratification after paracetamol (acetaminophen) poisoning: a systematic review and meta-analysis. Clin Toxicol (Phila) 2023; 61:1-11. [PMID: 36444937 DOI: 10.1080/15563650.2022.2152350] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Risk stratification in paracetamol (acetaminophen) poisoning is crucial because hepatotoxicity is common and can be mitigated with treatment. However, current risk stratification tools have limitations. AIMS We evaluated the diagnostic performance of the paracetamol concentration × aminotransferase multiplication product, for predicting hepatotoxicity after paracetamol overdose. METHODS Medline, Cochrane Library and Embase were searched for eligible papers. We used random effects models to obtain pooled estimates of the likelihood ratios and diagnostic odds ratios, from which sensitivity and specificity were computed. We assessed two commonly used cut-off values of paracetamol × aminotransferase, 1500 mg/L × IU/L and 10,000 mg/L × IU/L. Using the confusion matrices of these two cut-offs, area under the summary receiver operator characteristic curve and optimal cut-off values in different clinical scenarios were established. RESULTS Six studies comprising 5036 participants were included. In 4051 patients, using the cut-off of 1500 mg/L × IU/L, a diagnostic odds ratio of 31.90 (95%CI: 9.52-106.90), sensitivity of 0.98 (95%CI: 0.94-1.00) and specificity of 0.66 (95%CI: 0.49-0.89) were obtained. In 3983 patients, using the cut-off of 10,000 mg/L × IU/L, a diagnostic odds ratio of 99.34 (95%CI: 12.26-804.87), sensitivity of 0.65 (95%CI: 0.51-0.82) and specificity of 0.97 (95%CI: 0.95-1.00) were obtained. For staggered ingestions, the 1500 mg/L × IU/L cut-off yielded a diagnostic odds ratio of 69.53 (95%CI: 4.03-1199.75), sensitivity of 1.00 (95%CI: 0.87-1.00) and specificity of 0.74 (95%CI: 0.43-1.00). Next, using the 10,000 mg/L × IU/L cut-off in this scenario yielded a diagnostic odds ratio of 254.58 (95%CI: 11.12-5827.60), sensitivity of 0.79 (95%CI: 0.59-1.00) and specificity of 0.98 (95%CI: 0.94-1.00). The overall summary receiver operator characteristic curve was 0.91 (95%CI: 0.75-0.97), and the optimal cut-off value was 3840 mg/L × IU/L. The summary receiver operator characteristic curve in patients with staggered ingestions was 0.96 (95%CI: 0.85-0.99). The summary receiver operator characteristic curve in patients with staggered ingestions and whose paracetamol concentration was below the detectable limit of 10 mg/L at presentation was 0.97 (95%CI: 0.94-0.99). CONCLUSION In this first meta-analysis, paracetamol × aminotransferase demonstrates its use in prognosticating hepatotoxicity in patients with paracetamol poisoning. It complements the Rumack-Matthew nomogram as it has shown promise in addressing two key limitations of the nomogram: it is usable after more than 24 h between overdose and acetylcysteine treatment, and it is applicable in staggered ingestions.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haoyang Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bryant Po-Yuen Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mingwei Ng
- SingHealth Toxicology Service; Singapore, Singapore
| | - R Ponampalam
- SingHealth Toxicology Service; Singapore, Singapore
| | - Daniel Yan Zheng Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
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4
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Mehrpour O, Saeedi F, Hoyte C. Decision tree outcome prediction of acute acetaminophen exposure in the United States: A study of 30,000 cases from the National Poison Data System. Basic Clin Pharmacol Toxicol 2021; 130:191-199. [PMID: 34649297 DOI: 10.1111/bcpt.13674] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 12/25/2022]
Abstract
Acetaminophen is one of the most commonly used analgesic drugs in the United States. However, the outcomes of acute acetaminophen overdose might be very serious in some cases. Therefore, prediction of the outcomes of acute acetaminophen exposure is crucial. This study is a 6-year retrospective cohort study using National Poison Data System (NPDS) data. A decision tree algorithm was used to determine the risk predictors of acetaminophen exposure. The decision tree model had an accuracy of 0.839, an accuracy of 0.836, a recall of 0.72, a specificity of 0.86 and an F1_score of 0.76 for the test group and an accuracy of 0.848, a recall of 0.85, a recall of 0.74, a specificity of 0.87 and an F1_score of 0.78 for the training group. Our results showed that elevated serum levels of liver enzymes, other liver function test abnormality, anorexia, acidosis, electrolyte abnormality, increased bilirubin, coagulopathy, abdominal pain, coma, increased anion gap, tachycardia and hypotension were the most important factors in determining the outcome of acute acetaminophen exposure. Therefore, the decision tree model is a reliable approach in determining the prognosis of acetaminophen exposure cases and can be used in an emergency room or during hospitalization.
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Affiliation(s)
- Omid Mehrpour
- Data Science Institute, Southern Methodist University, Dallas, Texas, USA.,Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Farhad Saeedi
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran.,Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Christopher Hoyte
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,University of Colorado Hospital, Aurora, Colorado, USA
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Shah KR, Beuhler MC. Single bag high dose intravenous N-acetylcysteine associated with decreased hepatotoxicity compared to triple bag intravenous N-acetylcysteine in high-risk acetaminophen ingestions. Clin Toxicol (Phila) 2021; 60:493-498. [PMID: 34549670 DOI: 10.1080/15563650.2021.1979231] [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] [Indexed: 01/08/2023]
Abstract
INTRODUCTION There is controversy that the triple bag intravenous (IV) N-acetylcysteine (NAC) regimen may be underdosing the sickest patients in its current, common usage. We hypothesize that a higher dose IV NAC regimen improves some outcomes. METHODS We conducted a poison center based retrospective observational study from January 1, 2016 to December 31, 2017 comparing a single bag higher dose IV NAC regimen (150 mg/kg over 1 h, 15 mg/kg/hour) to the triple bag IV NAC regimen (150 mg/kg over 1 h, 12.5 mg/kg/hour for 4 h, 6.25 mg/kg/hour). In a high-risk population of patients with acetaminophen ingestion (defined as multiplication product ≥ 10,000 mg/L IU/L, not acute ingestions receiving NAC within 8 h, and not hepatotoxic on first contact), we evaluated the rate of hepatotoxicity, peak transaminase, and rate of laboratory coagulopathy. RESULTS 89 patients met the inclusion criteria. 12 of the 23 patients (52%) who received triple bag NAC became hepatotoxic and 10 (43%) became coagulopathic, while only 19 of 66 patients (29%) who received single bag NAC became hepatotoxic and 15 (23%) became coagulopathic; p = .043 and .057, resp. Mean peak transaminase was 4481 IU/L vs 2143 IU/L in those receiving triple bag NAC vs single bag NAC, difference of means 2338 IU/L; p = .026. CONCLUSION In this exploratory study of a high-risk population of patients with acetaminophen ingestions, the single bag IV NAC regimen was associated with lower peak transaminase and fewer patients becoming hepatotoxic as compared to the triple bag IV NAC regimen.
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Affiliation(s)
- Kartik R Shah
- Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
| | - Michael C Beuhler
- North Carolina Poison Control, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
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Abstract
Acetaminophen is a common medication taken in deliberate self-poisoning and unintentional overdose. It is the commonest cause of severe acute liver injury in Western countries. The optimal management of most acetaminophen poisonings is usually straightforward. Patients who present early should be offered activated charcoal and those at risk of acute liver injury should receive acetylcysteine. This approach ensures survival in most. The acetaminophen nomogram is used to assess the need for treatment in acute immediate-release overdoses with a known time of ingestion. However, scenarios that require different management pathways include modified-release, large/massive, and repeated supratherapeutic ingestions.
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Affiliation(s)
- Angela L Chiew
- Clinical Toxicology Unit, Prince of Wales Hospital, Barker Street, Randwick, New South Wales 2031, Australia.
| | - Nicholas A Buckley
- Pharmacology and Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales 2050, Australia
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Popiolek I, Hydzik P, Jagielski P, Zrodlowska M, Mystek K, Porebski G. Risk Factors for Hepatotoxicity Due to Paracetamol Overdose in Adults. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:752. [PMID: 34440958 PMCID: PMC8402128 DOI: 10.3390/medicina57080752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 12/26/2022]
Abstract
Background and Objectives: Over-the-counter availability and a good safety profile make paracetamol one of the most common analgesics in developed countries but also the leading cause of liver failure due to overdose. The objectives of the study were to identify modifiable risk factors for severe hepatotoxicity following paracetamol overdose in adults. Materials and Methods: A retrospective cohort study involved the consecutive adult patients hospitalized in a toxicological center over a period of seven years due to paracetamol overdose. Complete medical datasets of laboratory and anamnestic variables were analyzed and validated by means of logistic regression model. Results: A total of 185 patients entered the study, including 25 individuals who developed severe hepatotoxicity (plasma aminotransferases levels above 1000 UI/L) and 31 individuals with mild to moderate liver injury (plasma aminotransferases levels above upper normal range, but below 1000 UI/L). In the univariable analysis, significant hepatotoxicity risk factors were male gender, alcohol abuse, an ingested paracetamol dose, and a timespan from ingestion to hospital admission. The later one was the only significant risk factor in the multivariable model (adjusted odds ratio 1.08; 95% CI: 1.03-1.12). Conclusions: A delay in hospital admission, resulting in a delayed administration of disease-specific treatment outweighs any other known risk factors of paracetamol-induced hepatotoxicity.
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Affiliation(s)
- Iwona Popiolek
- Toxicology Clinical Department, University Hospital in Krakow, Jakubowskiego 2, 30-688 Krakow, Poland; (I.P.); (P.H.)
- Department of Toxicology, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Piotr Hydzik
- Toxicology Clinical Department, University Hospital in Krakow, Jakubowskiego 2, 30-688 Krakow, Poland; (I.P.); (P.H.)
- Department of Toxicology, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Pawel Jagielski
- Department of Nutrition and Drug Research, Faculty of Health Science, Jagiellonian University Medical College, Skawińska 8, 31-066 Krakow, Poland;
| | - Monika Zrodlowska
- Faculty of Medicine, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland; (M.Z.); (K.M.)
| | - Karol Mystek
- Faculty of Medicine, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland; (M.Z.); (K.M.)
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
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8
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Yen JS, Hu CC, Huang WH, Hsu CW, Yen TH, Weng CH. An artificial intelligence algorithm for analyzing acetaminophen-associated toxic hepatitis. Hum Exp Toxicol 2021; 40:1947-1954. [PMID: 33955253 DOI: 10.1177/09603271211014587] [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] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Very little artificial intelligence (AI) work has been performed to investigate acetaminophen-associated hepatotoxicity. The objective of this study was to develop an AI algorithm for analyzing weighted features for toxic hepatitis after acetaminophen poisoning. METHODS The medical records of 187 patients with acetaminophen poisoning treated at Chang Gung Memorial Hospital were reviewed. Patients were sorted into two groups according to their status of toxic hepatitis. A total of 40 clinical and laboratory features recorded on the first day of admission were selected for algorithm development. The random forest classifier (RFC) and logistic regression (LR) were used for artificial intelligence algorithm development. RESULTS The RFC-based AI model achieved the following results: accuracy = 92.5 ± 2.6%; sensitivity = 100%; specificity = 60%; precision = 92.3 ± 3.4%; and F1 = 96.0 ± 1.8%. The area under the receiver operating characteristic curve (AUROC) was approximately 0.98. The LR-based AI model achieved the following results: accuracy = 92.00 ± 2.9%; sensitivity = 100%; specificity = 20%; precision = 92.8 ± 3.4%; recall = 98.8 ± 3.4%; and F1 = 95.6 ± 1.5%. The AUROC was approximately 0.68. The weighted features were calculated, and the 10 most important weighted features for toxic hepatitis were aspartate aminotransferase (ALT), prothrombin time, alanine aminotransferase (AST), time to hospital, platelet count, lymphocyte count, albumin, total bilirubin, body temperature and acetaminophen level. CONCLUSION The top five weighted features for acetaminophen-associated toxic hepatitis were ALT, prothrombin time, AST, time to hospital and platelet count.
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Affiliation(s)
- J-S Yen
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou
| | - C-C Hu
- College of Medicine, Chang Gung University, Taoyuan.,Department of Hepatogastroenterology and Liver Research Unit, Chang Gung Memorial Hospital, Keelung
| | - W-H Huang
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
| | - C-W Hsu
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
| | - T-H Yen
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou
| | - C-H Weng
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
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Real M, Barnhill MS, Higley C, Rosenberg J, Lewis JH. Drug-Induced Liver Injury: Highlights of the Recent Literature. Drug Saf 2020; 42:365-387. [PMID: 30343418 DOI: 10.1007/s40264-018-0743-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Drug-induced liver injury (DILI), herbal-induced liver injury, and herbal and dietary supplement (HDS)-induced liver injury are an important aspect of drug safety. Knowledge regarding responsible drugs, mechanisms, risk factors, and the diagnostic tools to detect liver injury have continued to grow in the past year. This review highlights what we considered the most significant publications from among more than 1800 articles relating to liver injury from medications, herbal products, and dietary supplements in 2017 and 2018. The US Drug-Induced Liver Injury Network (DILIN) prospective study highlighted several areas of ongoing study, including the potential utility of human leukocyte antigens and microRNAs as DILI risk factors and new data on racial differences, the role of alcohol consumption, factors associated with prognosis, and updates on the clinical signatures of autoimmune DILI, thiopurines, and HDS agents. Novel data were also generated from the Spanish and Latin American DILI registries as well as from Chinese and Korean case series. A few new agents causing DILI were added to the growing list in the past 2 years, including sodium-glucose co-transporter-2 inhibitors, as were new aspects of chemotherapy-associated liver injury. A number of cases reported previously described hepatotoxins confirmed via the Roussel Uclaf Causality Assessment Method (RUCAM; e.g., norethisterone, methylprednisolone, glatiramer acetate) and/or the DILIN method (e.g., celecoxib, dimethyl fumarate). Additionally, much work centered on elucidating the pathophysiology of DILI, including the importance of bile salt export pumps and immune-mediated mechanisms. Finally, it must be noted that, while hundreds of new studies described DILI in 2017-2018, the quality of such reports must always be addressed. Björnsson reminds us to remain very critical of the data when addressing the future utility of a study, which is why it is so important to adhere to a standardized method such as RUCAM when determining DILI causality. While drug-induced hepatotoxicity remains a diagnosis of exclusion, the diverse array of publications that appeared in 2017 and 2018 provided important advances in our understanding of DILI, paving the way for our improved ability to make a more definitive diagnosis and risk assessment.
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Affiliation(s)
- Mark Real
- Division of Gastroenterology and Hepatology, Georgetown University Hospital, Washington, DC, USA
| | - Michele S Barnhill
- Department of Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Cory Higley
- Department of Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Jessica Rosenberg
- Department of Medicine, Georgetown University Hospital, Washington, DC, USA
| | - James H Lewis
- Division of Gastroenterology and Hepatology, Georgetown University Hospital, Washington, DC, USA.
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Gade C, Dalhoff K, Petersen TS, Riis T, Schmeltz C, Chabanova E, Christensen HR, Mikus G, Burhenne J, Holm JC, Holst H. Higher chlorzoxazone clearance in obese children compared with nonobese peers. Br J Clin Pharmacol 2018; 84:1738-1747. [PMID: 29618168 DOI: 10.1111/bcp.13602] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 12/21/2022] Open
Abstract
AIMS To test the in vivo activity of Cytochrome P450 (CYP) 2E1 in obese children vs. nonobese children, aged 11-18 years. Secondly, whether the activity of CYP2E1 in these patients is associated with NALFD, diabetes or hyperlipidaemia. METHODS Seventy children were divided into groups by body mass index (BMI) standard deviation score (SDS). All children received 250 mg oral chlorzoxazone (CLZ) as probe for CYP2E1 activity. Thirteen blood samples and 20-h urine samples were collected per participant. RESULTS Obese children had an increased oral clearance and distribution of CLZ, indicating increased CYP2E1 activity, similar to obese adults. The mean AUC0-∞ value of CLZ was decreased by 46% in obese children compared to nonobese children. The F was was increased twofold in obese children compared to nonobese children, P < 0.0001. Diabetic biomarkers were significantly increased in obese children, while fasting blood glucose and Hba1c levels were nonsignificant between groups. Liver fat content was not associated with CLZ Cl. CONCLUSION Oral clearance of CLZ was increased two-fold in obese children vs. nonobese children aged 11-18 years. This indicates an increased CYP2E1 activity of clinical importance, and dose adjustment should be considered for CLZ.
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Affiliation(s)
- C Gade
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - K Dalhoff
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - T S Petersen
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - T Riis
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - C Schmeltz
- Children's Obesity Clinic, European Center of Management (EASO). Department of Pediatrics, Zealand University Hospital, Holbaek, Denmark
| | - E Chabanova
- Faculty of Health and Medical Sciences, Copenhagen University, Department of Radiology, Herlev and Gentofte Hospital, Denmark
| | - H R Christensen
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - G Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Germany
| | - J Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Germany
| | - J C Holm
- The Children's Obesity Clinic, Department of Paediatrics, Copenhagen University Hospital Holbaek, Denmark.,Novo Nordisk Foundation Centre for Basic Metabolic Research, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - H Holst
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
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11
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Chomchai S, Chomchai C. Being overweight or obese as a risk factor for acute liver injury secondary to acute acetaminophen overdose. Pharmacoepidemiol Drug Saf 2017; 27:19-24. [DOI: 10.1002/pds.4339] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/26/2017] [Accepted: 09/26/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Summon Chomchai
- Faculty of Medicine Siriraj Hospital; Mahidol University; Bangkok Thailand
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12
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Wong A, Sivilotti MLA, Gunja N, McNulty R, Graudins A. Accuracy of the paracetamol-aminotransferase product to predict hepatotoxicity in paracetamol overdose treated with a 2-bag acetylcysteine regimen. Clin Toxicol (Phila) 2017; 56:182-188. [PMID: 28756679 DOI: 10.1080/15563650.2017.1355058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Paracetamol concentration is a highly accurate risk predictor for hepatotoxicity following overdose with known time of ingestion. However, the paracetamol-aminotransferase multiplication product can be used as a risk predictor independent of timing or ingestion type. Validated in patients treated with the traditional, "three-bag" intravenous acetylcysteine regimen, we evaluated the accuracy of the multiplication product in paracetamol overdose treated with a two-bag acetylcysteine regimen. METHODS We examined consecutive patients treated with the two-bag regimen from five emergency departments over a two-year period. We assessed the predictive accuracy of initial multiplication product for the primary outcome of hepatotoxicity (peak alanine aminotransferase ≥1000IU/L), as well as for acute liver injury (ALI), defined peak alanine aminotransferase ≥2× baseline and above 50IU/L). RESULTS Of 447 paracetamol overdoses treated with the two-bag acetylcysteine regimen, 32 (7%) developed hepatotoxicity and 73 (16%) ALI. The pre-specified cut-off points of 1500 mg/L × IU/L (sensitivity 100% [95% CI 82%, 100%], specificity 62% [56%, 67%]) and 10,000 mg/L × IU/L (sensitivity 70% [47%, 87%], specificity of 97% [95%, 99%]) were highly accurate for predicting hepatotoxicity. There were few cases of hepatotoxicity irrespective of the product when acetylcysteine was administered within eight hours of overdose, when the product was largely determined by a high paracetamol concentration but normal aminotransferase. CONCLUSIONS The multiplication product accurately predicts hepatotoxicity when using a two-bag acetylcysteine regimen, especially in patients treated more than eight hours post-overdose. Further studies are needed to assess the product as a method to adjust for exposure severity when testing efficacy of modified acetylcysteine regimens.
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Affiliation(s)
- Anselm Wong
- a Department of Medicine , School of Clinical Sciences, Monash University , Victoria , Australia.,b Austin Toxicology Service and Victorian Poisons Information Centre, Austin Health , Victoria , Australia
| | - Marco L A Sivilotti
- c Departments of Emergency Medicine and Biomedical & Molecular Sciences , Queen's University , Kingston , Canada
| | - Naren Gunja
- d Westmead and Blacktown Hospitals , Western Sydney Toxicology Service , Sydney , Australia
| | - Richard McNulty
- d Westmead and Blacktown Hospitals , Western Sydney Toxicology Service , Sydney , Australia
| | - Andis Graudins
- a Department of Medicine , School of Clinical Sciences, Monash University , Victoria , Australia.,e Monash Toxicology Service, Monash Health , Dandenong , Australia
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Pharmacokinetic modelling of modified acetylcysteine infusion regimens used in the treatment of paracetamol poisoning. Eur J Clin Pharmacol 2017. [DOI: 10.1007/s00228-017-2277-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Wong A, Graudins A. Risk prediction of hepatotoxicity in paracetamol poisoning. Clin Toxicol (Phila) 2017; 55:879-892. [DOI: 10.1080/15563650.2017.1317349] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
- Monash Emergency Research Collaborative, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Clinical Toxicology Service, Program of Emergency Medicine, Monash Health, Clayton, Australia
| | - Andis Graudins
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
- Monash Emergency Research Collaborative, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Clinical Toxicology Service, Program of Emergency Medicine, Monash Health, Clayton, Australia
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Wong A, Sivilotti MLA, Graudins A. Accuracy of the paracetamol-aminotransferase multiplication product to predict hepatotoxicity in modified-release paracetamol overdose. Clin Toxicol (Phila) 2017; 55:346-351. [DOI: 10.1080/15563650.2017.1290253] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Service, Heidelberg, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - Marco L. A. Sivilotti
- Departments of Emergency Medicine and of Biomedical & Molecular Sciences, Queen’s University, Kingston, Canada
| | - Andis Graudins
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Emergency Medicine and Toxicology Research, Monash Health, Victoria, Australia
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Outcomes of Patients With Premature Discontinuation of the 21-h Intravenous N-Acetylcysteine Protocol After Acute Acetaminophen Overdose. J Emerg Med 2016; 50:629-37. [PMID: 26899513 DOI: 10.1016/j.jemermed.2015.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 11/20/2015] [Accepted: 12/13/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND The minimum recommended treatment duration for i.v. N-acetylcysteine (NAC) after an acute, single acetaminophen (APAP) overdose is 21 h. Some have questioned whether shorter courses may be sufficient in carefully selected cases. OBJECTIVE We sought to describe the incidence of hepatotoxicity in a cohort of acute APAP overdose patients who received <21 h of i.v. NAC for any reason. METHODS We performed a secondary analysis of a large multicenter retrospective cohort of patients hospitalized for APAP poisoning. We selected patients with a potentially toxic serum APAP concentration measured between 4 and 24 h post ingestion, in whom i.v. NAC was initiated but discontinued before completing the full 21-h course. We further characterized outcomes in these patients as a function of two novel risk-prediction tools, the psi (ψ) parameter and APAP × aminotransferase (AT) product. The ψ parameter is an estimate of the cellular burden of injury based on the area under the concentration-time curve before treatment, and calculated with respect to the APAP concentration and time to initiation of NAC. RESULTS Fifty-nine patients met inclusion criteria. Intravenous NAC was initiated a median of 11.3 h post ingestion and administered for a median of 11.0 h. Hepatotoxicity (aspartate aminotransferase [AST] or alanine aminotransferase [ALT] > 1,000 IU/L) occurred in one patient (1.7%; 95% confidence interval 0.04-9.1), and eight additional patients developed hepatic injury (AST or ALT > 100 IU/L). No fatalities occurred. A multiplication product of APAP and AT (APAP × AT) that falls below 10,000 μmol/L/IU-L, or pretreatment ψ < 5 mmol/L-h suggested a low risk of hepatic injury. CONCLUSIONS In this retrospective analysis of patients treated with < 21 h of i.v. NAC for acute APAP overdose, the incidence of hepatotoxicity and coagulopathy was low, despite delays to NAC treatment.
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Curtis RM, Sivilotti MLA. A descriptive analysis of aspartate and alanine aminotransferase rise and fall following acetaminophen overdose. Clin Toxicol (Phila) 2015; 53:849-55. [PMID: 26294195 DOI: 10.3109/15563650.2015.1077968] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONTEXT Risk prediction following acetaminophen (paracetamol, APAP) overdose is based on serum APAP, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels. One recently proposed risk stratification tool, the APAPxAT multiplication product, uses either AST or ALT, whichever is higher, yet their interrelation is not well known following APAP-induced hepatic injury. OBJECTIVE To describe the kinetics of AST and ALT release into and disappearance from the circulation following APAP overdose. MATERIALS AND METHODS An observational case series of adult patients with peak AST or ALT > 100 IU/L attributable to APAP toxicity. Cases were identified by electronic search of hospital laboratory database and by discharge diagnosis corroborated by structured explicit medical record review. RESULTS Of 68 cases identified (mean age (SD): 39 (18) years, 63% female, and 21% ethanol co-ingested), 28 (41%) developed hepatotoxicity (peak AST or ALT > 1000 IU/L), 28 (41%) coagulopathy (international normalized ratio or INR > 2), and 21 (31%) both. Three patients (4%) were transferred for liver transplantation and ultimately six (8.8%) died. Serum AST and ALT activity rose in a closely aligned 1:1 AST:ALT ratio, but fell at distinctly different rates: AST activity fell with a half-life (interquartile range [IQR]) of 15.1 (12.2, 19.4) hours, and ALT 39.6 (32.9, 47.6) hours. Using an aminotransferase falling to below 50% of peak as the basis for discontinuing acetylcysteine would have resulted in antidotal treatment being stopped 24 (IQR: 9.6, 40) hours earlier (and in no cases later) using AST rather than ALT. Only six patients had an AST:ALT ratio greater than 2:1 at the time of acetylcysteine administration; of these six, four died and one survivor developed coagulopathy. DISCUSSION AST and ALT release into the circulation appears tightly linked and numerically similar, except in the sickest patients. Once the aminotransferases peak, AST returns to baseline more quickly. CONCLUSION Either AST or ALT can be used for early risk stratification tools when only one is known. Any criterion for N-AC discontinuation should be based on the decline of AST rather than ALT, with a potential benefit measured in days.
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Affiliation(s)
- R Mason Curtis
- a Departments of Emergency Medicine and of Biomedical & Molecular Sciences , Queen's University , Kingston, Ontario , Canada
| | - Marco L A Sivilotti
- a Departments of Emergency Medicine and of Biomedical & Molecular Sciences , Queen's University , Kingston, Ontario , Canada
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Wong A, Sivilotti MLA, Dargan PI, Wood DM, Greene SL. External validation of the paracetamol-aminotransferase multiplication product to predict hepatotoxicity from paracetamol overdose. Clin Toxicol (Phila) 2015; 53:807-14. [DOI: 10.3109/15563650.2015.1066507] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Hodgman MJ. Seeking a role, Psi and APAP×AT as acetaminophen risk assessment tools. Clin Toxicol (Phila) 2014; 52:451-3. [PMID: 24842249 DOI: 10.3109/15563650.2014.917182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- M J Hodgman
- Department of Emergency Medicine, Upstate New York Poison Center, SUNY Upstate Medical University , Syracuse, NY , USA
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