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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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Lamanilao GG, Dogan M, Patel PS, Azim S, Patel DS, Bhattacharya SK, Eason JD, Kuscu C, Kuscu C, Bajwa A. Key hepatoprotective roles of mitochondria in liver regeneration. Am J Physiol Gastrointest Liver Physiol 2023; 324:G207-G218. [PMID: 36648139 PMCID: PMC9988520 DOI: 10.1152/ajpgi.00220.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/28/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023]
Abstract
Treatment of advanced liver disease using surgical modalities is possible due to the liver's innate ability to regenerate following resection. Several key cellular events in the regenerative process converge at the mitochondria, implicating their crucial roles in liver regeneration. Mitochondria enable the regenerating liver to meet massive metabolic demands by coordinating energy production to drive cellular proliferative processes and vital homeostatic functions. Mitochondria are also involved in terminating the regenerative process by mediating apoptosis. Studies have shown that attenuation of mitochondrial activity results in delayed liver regeneration, and liver failure following resection is associated with mitochondrial dysfunction. Emerging mitochondria therapy (i.e., mitotherapy) strategies involve isolating healthy donor mitochondria for transplantation into diseased organs to promote regeneration. This review highlights mitochondria's inherent role in liver regeneration.
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Affiliation(s)
- Gene G Lamanilao
- Department of Surgery, Transplant Research Institute, James D. Eason Transplant Institute, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Murat Dogan
- Department of Surgery, Transplant Research Institute, James D. Eason Transplant Institute, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Prisha S Patel
- Department of Surgery, Transplant Research Institute, James D. Eason Transplant Institute, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Shafquat Azim
- Department of Surgery, Transplant Research Institute, James D. Eason Transplant Institute, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Disha S Patel
- Department of Legal Studies, Belmont University, Nashville, Tennessee, United States
| | - Syamal K Bhattacharya
- Division of Cardiovascular Diseases, Department of Medicine, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - James D Eason
- Department of Surgery, Transplant Research Institute, James D. Eason Transplant Institute, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Canan Kuscu
- Department of Surgery, Transplant Research Institute, James D. Eason Transplant Institute, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Cem Kuscu
- Department of Surgery, Transplant Research Institute, James D. Eason Transplant Institute, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Amandeep Bajwa
- Department of Surgery, Transplant Research Institute, James D. Eason Transplant Institute, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
- Department of Genetics, Genomics, and Informatics, The University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, United States
- Department of Microbiology, Immunology, and Biochemistry, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
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Alves V, Araújo GR, Frases S. Off-label treatments as potential accelerators in the search for the ideal antifungal treatment of cryptococcosis. Future Microbiol 2023; 18:127-135. [PMID: 36688321 DOI: 10.2217/fmb-2022-0122] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Cryptococcosis is an opportunistic mycosis that mainly affects immunosuppressed patients. The treatment is a combination of three antifungal agents: amphotericin B, 5-flucytosine and fluconazole. However, these drugs have many disadvantages, such as high nephrotoxicity, marketing bans in some countries and fungal resistance. One of the solutions to find possible new drugs is pharmacological repositioning. This work presents repositioned drugs as an alternative for new antifungal therapies for cryptococcosis. All the studies here were performed in vitro or in animal models, except for sertraline, which reached phase III in humans. There is still no pharmacological repositioning approval for cryptococcosis in humans, though this review shows the potential of repurposing as a rapid approach to finding new agents to treat cryptococcosis.
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Affiliation(s)
- Vinicius Alves
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, 21941902, Brazil
| | - Glauber Rs Araújo
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, 21941902, Brazil
| | - Susana Frases
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, 21941902, Brazil
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Afful EY, Frimpong-Manso S, Bekoe SO, Barfi CO, Opuni KFM, Oppong MB. The Unethical Use of Paracetamol As a Food Tenderizer in Four Selected African Countries: A Major Public Health Concern? DRUG METABOLISM AND BIOANALYSIS LETTERS 2022; 15:159-165. [PMID: 35950247 DOI: 10.2174/2949681015666220810125820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/23/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
Paracetamol poisoning is the commonest cause of acute liver injury. Therefore, the unethical use of paracetamol as a food tenderizer poses a threat to human health. Although this is a common practice in Ghana, Uganda, Nigeria, and Kenya, there are few or no scientific records on the use of paracetamol as a food tenderizer and its deleterious effects, thus making it difficult to regulate this practice. This review aims to fully collate and present a systematic overview of the literature on the use of paracetamol as a food tenderizer in these countries, the potentially harmful effects posed by the practice, and measures in place to curb the situation. Additionally, this review aims to reveal the scientific gaps and areas requiring more research, thus providing a reference for further research to regulate this unscrupulous practice. From our extensive review of the literature, the high cost of fuel used in cooking and longer cooking times are the main reasons for the inappropriate use of paracetamol as a food tenderizer. Also, this review concludes that little has been done to create public awareness of this unethical practice. Furthermore, few ways to monitor, control and regulate this practice have been proposed.
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Affiliation(s)
- Ewurabena Y Afful
- Department of Pharmaceutical Chemistry, School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Ghana
| | - Samuel Frimpong-Manso
- Department of Pharmaceutical Chemistry, School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Ghana
| | - Samuel O Bekoe
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, PMB, Kumasi, Ghana
| | - Chris O Barfi
- Department of Pharmaceutical Chemistry, School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Ghana
| | - Kwabena F M Opuni
- Department of Pharmaceutical Chemistry, School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Ghana
| | - Mahmood B Oppong
- Department of Pharmaceutical Chemistry, School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Ghana
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Delayed Acetaminophen Absorption Resulting in Acute Liver Failure. Case Rep Crit Care 2022; 2022:3672248. [PMID: 35578608 PMCID: PMC9107358 DOI: 10.1155/2022/3672248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/11/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction. Acetaminophen is a common medication involved in deliberate and accidental self-poisoning. The acetaminophen treatment nomogram is used to guide acetylcysteine treatment. It is rare to develop hepatotoxicity with an initial acetaminophen concentration below the nomogram line. We present a case of acetaminophen ingestion with an initial concentration below the nomogram line that developed hepatic failure, due to a delayed peak acetaminophen concentration secondary to coingesting medications that slow gastric emptying. Case Report. A 43-year-old (55 kg) female presented after ingesting an unknown quantity of acetaminophen, clonidine, and alcohol. Her acetaminophen level was 41 mg/L (256 μmol/L) at 4.5 h post-ingestion, well below the nomogram line, and ALT was 25 U/L. Hence, acetylcysteine was not commenced. She was intubated for decreased level of conscious. A repeat acetaminophen level 4 h later was 39 mg/L (242 μmol/L), still below the nomogram line. She was extubated 24 h later.At 38 h post-ingestion she developed abdominal pain, the repeat acetaminophen level was 85 mg/L (560 μmol/L), ALT was 489 U/L, and acetylcysteine was commenced. The patient developed hepatic failure with a peak ALT of 7009 U/L and INR of 7.5 but made a full recovery. It was discovered that she had ingested a combination acetaminophen product containing dextromethorphan and chlorphenamine. Acetaminophen metabolites were measured, including nontoxic glucuronide and sulfate conjugates and toxic cytochrome P450 (CYP) metabolites. The metabolite data demonstrated increasing CYP metabolites in occurrence with the delayed acetaminophen peak concentration. Discussion. Opioids and antimuscarinic agents are known to delay gastric emptying and clonidine may also have contributed. These coingested medications resulted in delayed acetaminophen absorption. This case highlights the issue of altered pharmacokinetics when patients coingest gut slowing agents.
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Rotundo L, Pyrsopoulos N. Liver injury induced by paracetamol and challenges associated with intentional and unintentional use. World J Hepatol 2020; 12:125-136. [PMID: 32685105 PMCID: PMC7336293 DOI: 10.4254/wjh.v12.i4.125] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/26/2019] [Accepted: 02/18/2020] [Indexed: 02/06/2023] Open
Abstract
Drug induced liver injury (DILI) is a common cause of acute liver injury. Paracetamol, also known as acetaminophen, is a widely used anti-pyretic that has long been established to cause liver toxicity once above therapeutic levels. Hepatotoxicity from paracetamol overdose, whether intentional or non-intentional, is the most common cause of DILI in the United States and remains a global issue. Given the increased prevalence of combination medications in the form of pain relievers and antihistamines, paracetamol can be difficult to identify and remains a significant cause of acute hepatotoxicity, as evidenced by its contribution to over half of all acute liver failure cases in the United States. This is especially concerning given that, when co-ingested with other medications, the rise in serum paracetamol levels may be delayed past the 4-hour post-ingestion mark that is currently used to determine patients that require medical therapy. This review serves to describe the clinical and pathophysiologic features of hepatotoxicity secondary to paracetamol and provide an update on current available knowledge and treatment options.
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Affiliation(s)
- Laura Rotundo
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Nikolaos Pyrsopoulos
- Department of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
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KhabazianZadeh F, Kazemi T, Nakhaee S, Ng PC, Mehrpour O. Acetaminophen poisoning-induced heart injury: a case-based review. Daru 2019; 27:839-851. [PMID: 31713183 PMCID: PMC6895290 DOI: 10.1007/s40199-019-00307-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 10/11/2019] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Acetaminophen (Paracetamol, APAP) poisoning is frequently implicated in self-harm. Cases of acetaminophen-associated cardiotoxicity are rare in relation to the number of patients with acetaminophen poisoning. A review of acetaminophen cardiotoxicity in 1996 concluded that there was no decisive evidence demonstrating that acetaminophen overdose has a cardiotoxic effect. This review study aimed to determine whether acetaminophen could induce heart injury. METHODS We searched for keywords of acetaminophen, paracetamol, cardiotoxicity, heart injury, heart damage, myocarditis, pericarditis, myocardial infarction, and myocardial ischemia in Web of Science, PubMed, Scopus, Embase, Google Scholar, and Persian databases. The search included articles published from January 1950 to October 2018 with no language restrictions. RESULTS The search yielded 64 citations in English; 36 of the articles were excluded as they were not relevant; 5 articles were excluded since they were duplicates, leaving 23 articles. Full-text articles of the 23 citations were obtained and reviewed. Myocardial infarction, heart dysfunction and failure, cardiac arrhythmias, pericarditis, heart cell necrosis, and sudden cardiac death were reported in acetaminophen overdose. CONCLUSIONS Ddysrhythmias, heart failure, and various other cardiac effects could occur following acetaminophen induced hepatic failure. However, the evidence for direct injury on cardiac tissue is weak. Graphical abstract Potential mechanisms for cardiotoxicity of acetaminophen.
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Affiliation(s)
- Fatemeh KhabazianZadeh
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Tooba Kazemi
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Patrick C Ng
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran.
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.
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N-acetylcysteine protects hepatocytes from hypoxia-related cell injury. Clin Exp Hepatol 2018; 4:260-266. [PMID: 30603674 PMCID: PMC6311746 DOI: 10.5114/ceh.2018.80128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 06/06/2018] [Indexed: 02/06/2023] Open
Abstract
Aim of the study Hepatocyte transplantation has been discussed as an alternative to liver transplantation in selected cases of acute and chronic liver failure and metabolic diseases. Immediately after infusion of hepatocytes, hypoxia-related cell injury is inevitable. N-acetylcysteine (NAC) has been suggested to attenuate hypoxic damage. This study’s objective was to evaluate NAC’s protective effect in a model of hypoxia-related hepatocyte injury. Material and methods HepG2 cells were used as a model for hepatocytes and were cultured under standardized hypoxia or normoxia for 24 hours with or without NAC. Growth kinetics were monitored using trypan blue staining. The activation of apoptotic pathways was measured using quantitative real-time PCR for Bcl-2/Bax and p53. The proportions of vital, apoptotic and necrotic cells were verified by fluorescence activated cell sorting using annexin V-labelling. The expression of hypoxia inducible factor 1 (HIF-1) was measured indirectly using its downstream target vascular endothelial growth factor A (VEGF-A). Results After NAC, cell proliferation increased under both hypoxia and normoxia by 528% and 320% (p < 0.05), while VEGF-A expression decreased under normoxia by 67% and 37% (p < 0.05). Compared to cells treated without NAC under hypoxia, the Bcl-2/Bax ratio increased significantly in cells treated with NAC. This finding was confirmed by an increased number of vital cells in FACS analysis. Conclusions NAC protects hepatocytes from hypoxic injury and ultimately activates anti-apoptotic pathways.
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Onk D, Özçelik F, Onk OA, Günay M, Akarsu Ayazoğlu T, Ünver E. Assessment of Renal and Hepatic Tissue-Protective Effects of N-Acetylcysteine via Ammonia Metabolism: A Prospective Randomized Study. Med Sci Monit 2018. [PMID: 29540661 PMCID: PMC5866733 DOI: 10.12659/msm.908172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background The present study sought to assess the renal and liver protective effect of N-acetylcysteine through NH3 and urea metabolism in patients with chronic obstructive pulmonary disease who were scheduled for coronary artery bypass grafting surgery. Material/Methods Patients with chronic obstructive pulmonary disease (COPD) who were scheduled for coronary artery bypass grafting were divided into 2 groups so as to receive (Group 1, n=35) or not receive (Group 2, n=35) 900 mg/day of n-acetylcysteine for 7 days before the operation starting from their admission to the service by a pulmonologist with the purpose of treating COPD until the day of surgery. Both groups were subjected to the same anesthesia protocol. Blood samples were taken preoperatively, within the first 15th minute following cessation of the cardiopulmonary bypass, at postoperative 24th hour, and at postoperative 48th hour. Blood tests included ammonia (NH3), lactate, blood urea nitrogen, creatinine, aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP), troponin I (Tn I), and creatinine kinase-muscle brain (CKMB). Results There was a significant difference between the groups’ NH3 and lactate levels after cardiopulmonary bypass, postoperative 24th hour, and postoperative 48th hour (respectively, NH3: 39.0±8.8 vs. 55.4±19.6 and 40.1±8.4 vs. 53.2±20.2 mcg/dl, lactate: 1.7±0.9 vs. 2.1±1.2 and 1.2±0.5 vs. 1.8±1.4 mmol/L; p<0.01). Creatinine and BUN levels in Group 2 were found to be significantly higher at the postoperative 48th hour compared to the levels of Group 1 (P<0.05). Conclusions N-acetylcysteine pretreatment appears to improve renal and hepatic functions through regulation of ammonia and nitrogen metabolism and reduction of lactate in patients with chronic obstructive pulmonary disease who undergo coronary artery bypass grafting surgery. We found that N-acetylcysteine improved kidney and/or liver functions.
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Affiliation(s)
- Didem Onk
- Department of Anesthesiology, Faculty of Medicine, Erzincan University, Erzincan, Turkey
| | - Fatih Özçelik
- Department of Medical Biochemistry, Sultan Abdulhamid Han Training Hospital, University of Health Sciences, Istanbul, Turkey
| | - Oruç Alper Onk
- Department of Cardiovascular Surgery, Faculty of Medicine, Erzincan University, Erzincan, Turkey
| | - Murat Günay
- Department of Biochemistry, Faculty of Medicine, Erzincan University, Erzincan, Turkey
| | - Tülin Akarsu Ayazoğlu
- Department of Anesthesiology, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Ethem Ünver
- Department of Chest Diseases, Faculty of Medicine, Erzincan University, Erzincan, Turkey
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Abstract
BACKGROUND Paracetamol (acetaminophen) is the most widely used non-prescription analgesic in the world. Paracetamol is commonly taken in overdose either deliberately or unintentionally. In high-income countries, paracetamol toxicity is a common cause of acute liver injury. There are various interventions to treat paracetamol poisoning, depending on the clinical status of the person. These interventions include inhibiting the absorption of paracetamol from the gastrointestinal tract (decontamination), removal of paracetamol from the vascular system, and antidotes to prevent the formation of, or to detoxify, metabolites. OBJECTIVES To assess the benefits and harms of interventions for paracetamol overdosage irrespective of the cause of the overdose. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (January 2017), CENTRAL (2016, Issue 11), MEDLINE (1946 to January 2017), Embase (1974 to January 2017), and Science Citation Index Expanded (1900 to January 2017). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov database (US National Institute of Health) for any ongoing or completed trials (January 2017). We examined the reference lists of relevant papers identified by the search and other published reviews. SELECTION CRITERIA Randomised clinical trials assessing benefits and harms of interventions in people who have ingested a paracetamol overdose. The interventions could have been gastric lavage, ipecacuanha, or activated charcoal, or various extracorporeal treatments, or antidotes. The interventions could have been compared with placebo, no intervention, or to each other in differing regimens. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included trials. We used fixed-effect and random-effects Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of the review outcomes. We used the Cochrane 'Risk of bias' tool to assess the risks of bias (i.e. systematic errors leading to overestimation of benefits and underestimation of harms). We used Trial Sequential Analysis to control risks of random errors (i.e. play of chance) and GRADE to assess the quality of the evidence and constructed 'Summary of findings' tables using GRADE software. MAIN RESULTS We identified 11 randomised clinical trials (of which one acetylcysteine trial was abandoned due to low numbers recruited), assessing several different interventions in 700 participants. The variety of interventions studied included decontamination, extracorporeal measures, and antidotes to detoxify paracetamol's toxic metabolite; which included methionine, cysteamine, dimercaprol, or acetylcysteine. There were no randomised clinical trials of agents that inhibit cytochrome P-450 to decrease the activation of the toxic metabolite N-acetyl-p-benzoquinone imine.Of the 11 trials, only two had two common outcomes, and hence, we could only meta-analyse two comparisons. Each of the remaining comparisons included outcome data from one trial only and hence their results are presented as described in the trials. All trial analyses lack power to access efficacy. Furthermore, all the trials were at high risk of bias. Accordingly, the quality of evidence was low or very low for all comparisons. Interventions that prevent absorption, such as gastric lavage, ipecacuanha, or activated charcoal were compared with placebo or no intervention and with each other in one four-armed randomised clinical trial involving 60 participants with an uncertain randomisation procedure and hence very low quality. The trial presented results on lowering plasma paracetamol levels. Activated charcoal seemed to reduce the absorption of paracetamol, but the clinical benefits were unclear. Activated charcoal seemed to have the best risk:benefit ratio among gastric lavage, ipecacuanha, or supportive treatment if given within four hours of ingestion. There seemed to be no difference between gastric lavage and ipecacuanha, but gastric lavage and ipecacuanha seemed more effective than no treatment (very low quality of evidence). Extracorporeal interventions included charcoal haemoperfusion compared with conventional treatment (supportive care including gastric lavage, intravenous fluids, and fresh frozen plasma) in one trial with 16 participants. The mean cumulative amount of paracetamol removed was 1.4 g. One participant from the haemoperfusion group who had ingested 135 g of paracetamol, died. There were no deaths in the conventional treatment group. Accordingly, we found no benefit of charcoal haemoperfusion (very low quality of evidence). Acetylcysteine appeared superior to placebo and had fewer adverse effects when compared with dimercaprol or cysteamine. Acetylcysteine superiority to methionine was unproven. One small trial (low quality evidence) found that acetylcysteine may reduce mortality in people with fulminant hepatic failure (Peto OR 0.29, 95% CI 0.09 to 0.94). The most recent randomised clinical trials studied different acetylcysteine regimens, with the primary outcome being adverse events. It was unclear which acetylcysteine treatment protocol offered the best efficacy, as most trials were underpowered to look at this outcome. One trial showed that a modified 12-hour acetylcysteine regimen with a two-hour acetylcysteine 100 mg/kg bodyweight loading dose was associated with significantly fewer adverse reactions compared with the traditional three-bag 20.25-hour regimen (low quality of evidence). All Trial Sequential Analyses showed lack of sufficient power. Children were not included in the majority of trials. Hence, the evidence pertains only to adults. AUTHORS' CONCLUSIONS These results highlight the paucity of randomised clinical trials comparing different interventions for paracetamol overdose and their routes of administration and the low or very low level quality of the evidence that is available. Evidence from a single trial found activated charcoal seemed the best choice to reduce absorption of paracetamol. Acetylcysteine should be given to people at risk of toxicity including people presenting with liver failure. Further randomised clinical trials with low risk of bias and adequate number of participants are required to determine which regimen results in the fewest adverse effects with the best efficacy. Current management of paracetamol poisoning worldwide involves the administration of intravenous or oral acetylcysteine which is based mainly on observational studies. Results from these observational studies indicate that treatment with acetylcysteine seems to result in a decrease in morbidity and mortality, However, further evidence from randomised clinical trials comparing different treatments are needed.
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Affiliation(s)
- Angela L Chiew
- Prince of Wales HospitalEmergency Department and Clinical Toxicology UnitBarker StreetRandwickNSWAustralia2031
- University of SydneyDepartment of PharmacologyCamperdownNSWAustralia
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Jesper Brok
- RigshospitaletPaediatric Department 4072Blemdagsvej 9CopenhagenDenmark2100 Ø
| | - Nick A Buckley
- University of SydneyDepartment of PharmacologyCamperdownNSWAustralia
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Ahmed Abdel-Reheim M, Messiha BAS, Abo-Saif AA. Quillaja saponaria bark saponin protects Wistar rats against ferrous sulphate-induced oxidative and inflammatory liver damage. PHARMACEUTICAL BIOLOGY 2017; 55:1972-1983. [PMID: 28728456 PMCID: PMC6130630 DOI: 10.1080/13880209.2017.1345950] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 05/09/2017] [Accepted: 06/19/2017] [Indexed: 06/07/2023]
Abstract
CONTEXT Saponins from different sources are historically reported in Chinese medicine to possess many beneficial effects. However, insufficient experimental data are available regarding the hepatoprotective potential of Quillaja bark saponin. OBJECTIVE The protective effect of Quillaja saponaria Molina (Quillajaceae) bark triterpenoid saponin against iron-induced hepatotoxicity is compared to the standard N-acetylcysteine in adult male Wistar rats. MATERIALS AND METHODS Animals were divided into (six) groups, namely a normal control, an N-acetylcysteine control (300 mg/kg/day, p.o., 10 days), a saponin control (100 mg/kg/day, p.o., for 10 days), a hepatotoxicity control (two doses of ferrous sulphate, 30 mg/kg/day each, i.p., on 9th and 10th day), an N-acetylcysteine plus ferrous sulphate (standard treatment) and a saponin plus ferrous sulphate (test treatment) group. Hepatocyte integrity loss markers (serum ALT, AST, ALP, GGT and LDH), oxidative stress markers (hepatic MDA, GSH and NOx), dyslipidaemic markers (serum TC and TG) and hepatocyte functioning markers (serum bilirubin and albumin) were assessed. RESULTS Quillaja bark saponin decreased iron-induced elevation of ALT (reaching 57% of hepatotoxicity control), AST (66%), ALP (76%), GGT (60%), LDH (54%), MDA (65%), NOx (77%), TC (70%), TG (54%), and total (54%), direct (54%) and indirect (54%) bilirubin, coupled with increased GSH (219%) and albumin (159%) levels. Histopathological study strongly supported biochemical estimations, while immunohistochemical study showed marked effect on eNOS and iNOS expression. CONCLUSIONS Quillaja bark saponin has a good hepatoprotective effect. Amelioration of oxidative stress and suppression of NOS expression, with resultant maintenance of hepatocyte integrity and functioning, may explain this beneficial effect.
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Affiliation(s)
| | | | - Ali Ahmed Abo-Saif
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Nahda University, Beni Suef, Egypt
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Siegert M, Kranawetvogl A, Thiermann H, John H. N-Acetylcysteine as a chemical scavenger for sulfur mustard: New insights by mass spectrometry. Drug Test Anal 2017; 10:243-253. [DOI: 10.1002/dta.2299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/14/2017] [Accepted: 09/04/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Markus Siegert
- Department of Chemistry; Humboldt-Universität zu Berlin; Berlin Germany
| | | | - Horst Thiermann
- Bundeswehr Institute of Pharmacology and Toxicology; Munich Germany
| | - Harald John
- Bundeswehr Institute of Pharmacology and Toxicology; Munich Germany
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Effect of N-Acetylcysteine on Mortality and Liver Transplantation Rate in Non-Acetaminophen-Induced Acute Liver Failure: A Multicenter Study. Clin Drug Investig 2017; 37:473-482. [DOI: 10.1007/s40261-017-0505-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Cardoso FS, Marcelino P, Bagulho L, Karvellas CJ. Acute liver failure: An up-to-date approach. J Crit Care 2017; 39:25-30. [PMID: 28131021 DOI: 10.1016/j.jcrc.2017.01.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 01/05/2017] [Accepted: 01/09/2017] [Indexed: 12/14/2022]
Abstract
Acute liver failure is a rare but potentially devastating disease. Throughout the last few decades, acute liver failure outcomes have been improving in the context of the optimized overall management. This positive trend has been associated with the earlier recognition of this condition, the improvement of the intensive care unit management, and the developments in emergent liver transplantation. Accordingly, we aimed to review the current diagnostic and therapeutic approach to this syndrome, especially in the intensive care unit setting.
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Affiliation(s)
- Filipe S Cardoso
- Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal.
| | - Paulo Marcelino
- Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal
| | - Luís Bagulho
- Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal
| | - Constantine J Karvellas
- Divisions of Gastroenterology (Liver Unit) and Critical Care, University of Alberta Hospital, Edmonton, Canada
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Glibenclamide impairs responses of neutrophils against Burkholderia pseudomallei by reduction of intracellular glutathione. Sci Rep 2016; 6:34794. [PMID: 27713554 PMCID: PMC5054430 DOI: 10.1038/srep34794] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/20/2016] [Indexed: 02/02/2023] Open
Abstract
The major risk factor for melioidosis, an infectious disease caused by B. pseudomallei, is diabetes mellitus. More than half of diabetic melioidosis patients in Thailand were prescribed glibenclamide. Recent evidence demonstrates that glibenclamide reduces pro-inflammatory cytokine production by polymorphonuclear neutrophils (PMNs) of diabetic individuals in response to this bacterial infection. However, the mechanisms by which glibenclamide affects cytokine production are unknown. We found that PMNs from glibenclamide-treated diabetic individuals infected with live B. pseudomallei in vitro showed lower free glutathione (GSH) levels compared with those of healthy individuals. Glibenclamide decreased GSH levels and glutathione peroxidase (GPx) of PMNs after exposed to live B. pseudomallei. Moreover, glibenclamide reduced cytokine production and migration capacity of infected PMNs, whereas GSH could restore these functions. Taken together, our data show a link between the effect of glibenclamide on GSH and PMN functions in response to B. pseudomallei that may contribute to the susceptibility of diabetic individuals to B. pseudomallei infection.
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Zyoud SH, Waring WS, Al-Jabi SW, Sweileh WM, Awang R. The 100 most influential publications in paracetamol poisoning treatment: a bibliometric analysis of human studies. SPRINGERPLUS 2016; 5:1534. [PMID: 27652107 PMCID: PMC5019997 DOI: 10.1186/s40064-016-3240-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Analysis of the most influential publications within paracetamol poisoning treatment can be helpful in recognizing main and novel treatment issues within the field of toxicology. The current study was performed to recognize and describe the most highly cited articles related to paracetamol poisoning treatment. METHODS The 100 most highly cited articles in paracetamol poisoning treatment were identified from the Scopus database in November 2015. All eligible articles were read for basic information, including total number of citations, average citations per year, authors' names, journal name, impact factors, document types and countries of authors of publications. RESULTS The median number of citations was 75 (interquartile range 56-137). These publications were published between 1974 and 2013. The average number of years since publication was 17.6 years, and 45 of the publications were from the 2000s. A significant, modest positive correlation was found between years since publication and the number of citations among the top 100 cited articles (r = 0.316; p = 0.001). A total of 55 journals published these 100 most cited articles. Nine documents were published in Clinical Toxicology, whereas eight documents were published in Annals of Emergency Medicine. Citations per year since publication for the top 100 most-cited articles ranged from 1.5 to 42.6 and had a mean of 8.5 citations per year and a median of 5.9 with an interquartile range of 3.75-10.35. In relation to the origin of the research publications, they were from 8 countries. The USA had the largest number of articles, 47, followed by the UK and Australia with 38 and nine articles respectively. CONCLUSIONS This study is the first bibliometric assessment of the top 100 cited articles in toxicology literature. Interest in paracetamol poisoning as a serious clinical problem continues to grow. Research published in high-impact journals and from high income countries is most likely to be cited in published paracetamol research.
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Affiliation(s)
- Sa’ed H. Zyoud
- Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), 11800 Pulau Pinang, Penang Malaysia
| | - W. Stephen Waring
- Acute Medical Unit, York Teaching Hospitals NHS Foundation Trust, Wigginton Road, York, YO31 8HE UK
| | - Samah W. Al-Jabi
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Waleed M. Sweileh
- Department of Pharmacology and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Rahmat Awang
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), 11800 Pulau Pinang, Penang Malaysia
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Betten DP, Vohra RB, Cook MD, Matteucci MJ, Clark RF. Antidote Use in the Critically Ill Poisoned Patient. J Intensive Care Med 2016; 21:255-77. [PMID: 16946442 DOI: 10.1177/0885066606290386] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit ( N-acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.
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Affiliation(s)
- David P Betten
- Department of Emergency Medicine, Sparrow Health System, Michigan State University College of Human Medicine, Lansing, Michigan 48912-1811, USA.
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Chiew AL, Isbister GK, Duffull SB, Buckley NA. Evidence for the changing regimens of acetylcysteine. Br J Clin Pharmacol 2016; 81:471-81. [PMID: 26387650 PMCID: PMC4767192 DOI: 10.1111/bcp.12789] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 01/01/2023] Open
Abstract
Paracetamol overdose prior to the introduction of acetylcysteine was associated with significant morbidity. Acetylcysteine is now the mainstay of treatment for paracetamol poisoning and has effectively reduced rates of hepatotoxicity and death. The current three-bag intravenous regimen with an initial high loading dose was empirically derived four decades ago and has not changed since. This regimen is associated with a high rate of adverse effects due mainly to the high initial peak acetylcysteine concentration. Furthermore, there are concerns that the acetylcysteine concentration is not adequate for 'massive' overdoses and that the dose and duration may need to be altered. Various novel regimens have been proposed, looking to address these issues. Many of these modified regimens aim to decrease the rate of adverse reactions by slowing the loading dose and thereby decrease the peak concentration. We used a published population pharmacokinetic model of acetylcysteine to simulate these modified regimens. We determined mean peak and 20 h acetylcysteine concentrations and area under the under the plasma concentration-time curve to compare these regimens. Those regimens that resulted in a lower peak acetylcysteine concentration have been shown in studies to have a lower rate of adverse events. However, these studies were too small to show whether they are as effective as the traditional regimen. Further research is still needed to determine the optimum dose and duration of acetylcysteine that results in the fewest side-effects and treatment failures. Indeed, a more patient-tailored approach might be required, whereby the dose and duration are altered depending on the paracetamol dose ingested or paracetamol concentrations.
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Affiliation(s)
- Angela L Chiew
- Clinical and Experimental Toxicology Unit, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, NSW, Australia
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
| | - Geoffrey K Isbister
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | | | - Nicholas A Buckley
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
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Kumar A, Shalmanova L, Hammad A, Christmas SE. Induction of IL-8(CXCL8) and MCP-1(CCL2) with oxidative stress and its inhibition with N-acetyl cysteine (NAC) in cell culture model using HK-2 cell. Transpl Immunol 2016; 35:40-6. [DOI: 10.1016/j.trim.2016.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 11/17/2022]
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20
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Sewlall NH, Richards G, Duse A, Swanepoel R, Paweska J, Blumberg L, Dinh TH, Bausch D. Clinical features and patient management of Lujo hemorrhagic fever. PLoS Negl Trop Dis 2014; 8:e3233. [PMID: 25393244 PMCID: PMC4230886 DOI: 10.1371/journal.pntd.0003233] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 09/02/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In 2008 a nosocomial outbreak of five cases of viral hemorrhagic fever due to a novel arenavirus, Lujo virus, occurred in Johannesburg, South Africa. Lujo virus is only the second pathogenic arenavirus, after Lassa virus, to be recognized in Africa and the first in over 40 years. Because of the remote, resource-poor, and often politically unstable regions where Lassa fever and other viral hemorrhagic fevers typically occur, there have been few opportunities to undertake in-depth study of their clinical manifestations, transmission dynamics, pathogenesis, or response to treatment options typically available in industrialized countries. METHODS AND FINDINGS We describe the clinical features of five cases of Lujo hemorrhagic fever and summarize their clinical management, as well as providing additional epidemiologic detail regarding the 2008 outbreak. Illness typically began with the abrupt onset of fever, malaise, headache, and myalgias followed successively by sore throat, chest pain, gastrointestinal symptoms, rash, minor hemorrhage, subconjunctival injection, and neck and facial swelling over the first week of illness. No major hemorrhage was noted. Neurological signs were sometimes seen in the late stages. Shock and multi-organ system failure, often with evidence of disseminated intravascular coagulopathy, ensued in the second week, with death in four of the five cases. Distinctive treatment components of the one surviving patient included rapid commencement of the antiviral drug ribavirin and administration of HMG-CoA reductase inhibitors (statins), N-acetylcysteine, and recombinant factor VIIa. CONCLUSIONS Lujo virus causes a clinical syndrome remarkably similar to Lassa fever. Considering the high case-fatality and significant logistical impediments to controlled treatment efficacy trials for viral hemorrhagic fever, it is both logical and ethical to explore the use of the various compounds used in the treatment of the surviving case reported here in future outbreaks. Clinical observations should be systematically recorded to facilitate objective evaluation of treatment efficacy. Due to the risk of secondary transmission, viral hemorrhagic fever precautions should be implemented for all cases of Lujo virus infection, with specialized precautions to protect against aerosols when performing enhanced-risk procedures such as endotracheal intubation.
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Affiliation(s)
- Nivesh H. Sewlall
- Internal Medicine, Morningside MediClinic, Johannesburg, South Africa
- Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Guy Richards
- Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Adriano Duse
- Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Robert Swanepoel
- Department of Medicine, University of Pretoria, Pretoria, South Africa
| | - Janusz Paweska
- National Institute of Communicable Disease, Sandringham, South Africa
| | - Lucille Blumberg
- National Institute of Communicable Disease, Sandringham, South Africa
| | - Thu Ha Dinh
- Centers for Disease control and Prevention, Atlanta, Georgia, United States of America
| | - Daniel Bausch
- Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
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Navid A, Ng DM, Stewart BJ, Wong SE, Lightstone FC. Quantitative In Silico analysis of transient metabolism of acetaminophen and associated causes of hepatotoxicity in humans. In Silico Pharmacol 2013. [PMCID: PMC4750864 DOI: 10.1186/2193-9616-1-14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Abstract
Paracetamol (acetaminophen) overdose remains the leading cause of death or transplantation due to acute liver failure in many parts of the world. Acetylcysteine has long been recognized as an effective antidote, via oral or intravenous administration, minimizing the risk and severity of acute liver injury if administered sufficiently early after a paracetamol overdose. Despite this, its mechanisms of action remain obscure, and there is uncertainty regarding the optimal dose and duration of treatment. The intravenous infusion protocol was originally developed as a three-step loading regimen; it causes very high early peak plasma concentrations of acetylcysteine whereas the later maintenance infusion is associated with much lower concentrations. This pharmacokinetic profile is associated with two particular concerns: a high rate of occurrence of adverse effects that occur after the initial loading infusion, and the possibility that the maintenance phase of treatment might deliver too low a dose of acetylcysteine for optimum protection against liver injury. Recently described novel administration regimens offer different rates of intravenous acetylcysteine administration in both the loading and maintenance phases. These alternative regimens appear to be well tolerated in small patient groups, but too few clinical data are available to evaluate their comparative efficacy in preventing paracetamol-induced liver injury.
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Affiliation(s)
- W Stephen Waring
- Acute Medical Unit, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York YO31 8HE, UK
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Treweeke AT, Winterburn TJ, Mackenzie I, Barrett F, Barr C, Rushworth GF, Dransfield I, MacRury SM, Megson IL. N-Acetylcysteine inhibits platelet-monocyte conjugation in patients with type 2 diabetes with depleted intraplatelet glutathione: a randomised controlled trial. Diabetologia 2012; 55:2920-8. [PMID: 22935960 PMCID: PMC3464379 DOI: 10.1007/s00125-012-2685-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 07/09/2012] [Indexed: 02/05/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to determine whether oral dosing with N-acetylcysteine (NAC) increases intraplatelet levels of the antioxidant, glutathione (GSH), and reduces platelet-monocyte conjugation in blood from patients with type 2 diabetes. METHODS In this placebo-controlled randomised crossover study, the effect of oral NAC dosing on platelet-monocyte conjugation and intraplatelet GSH was investigated in patients with type 2 diabetes (eligibility criteria: men or post-menopausal women with well-controlled diabetes (HbA(1c) < 10%), not on aspirin or statins). Patients (n = 14; age range 43-79 years, HbA(1c) = 6.9 ± 0.9% [52.3 ± 10.3 mmol/mol]) visited the Highland Clinical Research Facility, Inverness, UK on day 0 and day 7 for each arm of the study. Blood was sampled before and 2 h after oral administration of placebo or NAC (1,200 mg) on day 0 and day 7. Patients received placebo or NAC capsules for once-daily dosing on the intervening days. The order of administration of NAC and placebo was allocated by a central office and all patients and research staff involved in the study were blinded to the allocation until after the study was complete and the data fully analysed. The primary outcome for the study was platelet-monocyte conjugation. RESULTS Oral NAC reduced platelet-monocyte conjugation (from 53.1 ± 4.5% to 42.5 ± 3.9%) at 2 h after administration and the effect was maintained after 7 days of dosing. Intraplatelet GSH was raised in individuals with depleted GSH and there was a negative correlation between baseline intraplatelet GSH and platelet-monocyte conjugation. There were no adverse events. CONCLUSIONS/INTERPRETATION The NAC-induced normalisation of intraplatelet GSH, coupled with a reduction in platelet-monocyte conjugation, suggests that NAC might help to reduce atherothrombotic risk in type 2 diabetes. FUNDING Chief Scientist Office (CZB/4/622), Scottish Funding Council, Highlands & Islands Enterprise and European Regional Development Fund. TRIAL REGISTRATION isrctn.org ISRCTN89304265.
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Affiliation(s)
- A T Treweeke
- Free Radical Research Facility, Department of Diabetes & Cardiovascular Science, University of the Highlands & Islands, Centre for Health Science, Inverness IV2 3JH, UK
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Wu S, Zhang L, Chen J. Paracetamol in the environment and its degradation by microorganisms. Appl Microbiol Biotechnol 2012; 96:875-84. [DOI: 10.1007/s00253-012-4414-4] [Citation(s) in RCA: 153] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 08/29/2012] [Accepted: 09/03/2012] [Indexed: 11/28/2022]
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Woodhead JL, Howell BA, Yang Y, Harrill AH, Clewell HJ, Andersen ME, Siler SQ, Watkins PB. An Analysis of N-Acetylcysteine Treatment for Acetaminophen Overdose Using a Systems Model of Drug-Induced Liver Injury. J Pharmacol Exp Ther 2012; 342:529-40. [DOI: 10.1124/jpet.112.192930] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Assessment of the Clinical Use of Intravenous and Oral N-Acetylcysteine in the Treatment of Acute Acetaminophen Poisoning in Children: A Retrospective Review. Clin Ther 2011; 33:1322-30. [DOI: 10.1016/j.clinthera.2011.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2011] [Indexed: 01/09/2023]
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Shen F, Coulter CV, Isbister GK, Duffull SB. A dosing regimen for immediate N-acetylcysteine treatment for acute paracetamol overdose. Clin Toxicol (Phila) 2011; 49:643-7. [PMID: 21854081 DOI: 10.3109/15563650.2011.604034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT Current treatment of paracetamol (acetaminophen) poisoning involves initiating a 3-phase N-acetylcysteine (NAC) infusion after comparing a plasma concentration, taken ≥ 4 h post-overdose, to a nomogram. This may result in dosing errors, a delay in treatment, or possibly more adverse effects - due to the use of a high dose rate for the first infusion when treatment is initiated. OBJECTIVE Our aim was to investigate a novel dosing regimen for the immediate administration of NAC on admission at a lower infusion rate. METHODS We used a published population pharmacokinetic model of NAC to simulate a scenario where a patient presents to the hospital 2 h post-overdose. The conventional regimen is commenced 6 h post-overdose when the 4-h plasma paracetamol concentration is available. We investigated an NAC infusion using a lower dosing rate initiated immediately on presentation. We determined a dosing rate that gave an area under the curve (AUC) of the concentration-time curve that was the same or greater than that from the conventional regimen on 90% of occasions. RESULTS Lower dosing rates of NAC initiated immediately resulted in a similar exposure to NAC. An infusion of 110 mg/kg over the first 5 h (22 mg/kg/h) followed by the last two phases of the conventional regimen, or 200 mg/kg over 9 h (22.6 mg/kg/h) followed by the last phase of the conventional regimen could be used. CONCLUSION The novel dosing regimen allowed immediate treatment of a patient using a lower dosing rate. This greatly simplifies the current dosing regimen and may reduce NAC adverse effects while ensuring the same amount of NAC is delivered.
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Affiliation(s)
- Finna Shen
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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Klein-Schwartz W, Doyon S. Intravenous acetylcysteine for the treatment of acetaminophen overdose. Expert Opin Pharmacother 2010; 12:119-30. [DOI: 10.1517/14656566.2011.537261] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Sidoryk-Wegrzynowicz M, Wegrzynowicz M, Lee E, Bowman AB, Aschner M. Role of astrocytes in brain function and disease. Toxicol Pathol 2010; 39:115-23. [PMID: 21075920 DOI: 10.1177/0192623310385254] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Astrocytes assume multiple roles in maintaining an optimally suited milieu for neuronal function. Select astrocytic functions include the maintenance of redox potential, the production of trophic factors, the regulation of neurotransmitter and ion concentrations, and the removal of toxins and debris from the cerebrospinal fluid (CSF). Impairments in these and other functions, as well as physiological reactions of astrocytes to injury, can trigger or exacerbate neuronal dysfunction. This review addresses select metabolic interactions between neurons and astrocytes and emphasizes the role of astrocytes in mediating and amplifying the progression of several neurodegenerative disorders, such as Parkinson's disease (PD), hepatic encephalopathy (HE), hyperammonemia (HA), Alzheimer's disease (AD), and ischemia.
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Augustyniak A, Bartosz G, Čipak A, Duburs G, Horáková L, Łuczaj W, Majekova M, Odysseos AD, Rackova L, Skrzydlewska E, Stefek M, Štrosová M, Tirzitis G, Venskutonis PR, Viskupicova J, Vraka PS, Žarković N. Natural and synthetic antioxidants: An updated overview. Free Radic Res 2010; 44:1216-62. [DOI: 10.3109/10715762.2010.508495] [Citation(s) in RCA: 177] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Liang Q, Sheng Y, Ji L, Min Y, Xia Y, Wang Z. Acetaminophen-induced cytotoxicity on human normal liver L-02 cells and the protection of antioxidants. Toxicol Mech Methods 2010; 20:273-8. [PMID: 20465405 DOI: 10.3109/15376516.2010.482963] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In vitro cell models, which can partially mimic in vivo responses, offer potentially sensitive tools for toxicological assessment. The objective of this study was to explore the possible mechanisms of acetaminophen (AP)-induced toxicity in human normal liver L-02 cells. The expression of the CYP2E1 enzyme, which is reported to transform AP to its toxic metabolites, was higher in L-02 than in Hep3B cells. Further cell viability and reduced glutathione (GSH) depletion after AP treatment were examined. After exposure to AP for 24 h, cell viability decreased in a concentration-dependent manner. Concentration-dependent GSH depletion was also observed after AP treatment for 48 h, indicating oxidative stress had occurred in L-02 cells. The effects of D, L-buthionine-(S, R)-sulfoximine (BSO), an inhibitor of GSH biosynthesis, and N-acetylcysteine (NAC), a precursor of GSH synthesis, on the cytotoxicity induced by AP were also investigated. BSO aggravated the cytotoxicity induced by AP while NAC ameliorated such cell death. Further results showed that 10 mM AP caused cell apoptosis after 48 h treatment based on the DNA fragmentation assay and western blot of caspase-3 activation, respectively. In addition, the protective effects of various well-known antioxidants against AP-induced hepatotoxicity were observed. Taken together, these results indicate that oxidative stress and cellular apoptosis are involved in AP-induced toxicity in human normal liver L-02 cells, and this cell line is a suitable in vitro cell model for AP hepatotoxicity study.
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Affiliation(s)
- Qingning Liang
- The MOE Key Laboratory for Standardization of Chinese Medicines and The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, PR China
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Koch A, Trautwein C. Akutes Leberversagen. INTENSIVMEDIZIN UND NOTFALLMEDIZIN 2010; 47:235-242. [PMID: 32287644 PMCID: PMC7101637 DOI: 10.1007/s00390-009-0153-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 02/14/2010] [Indexed: 11/12/2022]
Abstract
Als akutes Leberversagen (ALV) wird der Ausfall der Leberfunktion bei Patienten ohne vorbestehende chronische Lebererkrankung bezeichnet. Die häufigsten Ursachen für ein akutes Leberversagen in Deutschland sind Medikamententoxizität und virale Hepatitiden. Die Regenerationskapazität der Leber und die Gesamtprognose sind abhängig von der zugrunde liegenden Ätiologie. Durch die Transplantationschirurgie und durch die Verbesserung der supportiven intensivmedizinischen Therapie konnte das Überleben bei ALV in den letzten 2 Jahrzehnten signifikant verbessert werden. Die Freisetzung von inflammatorischen Zytokinen aus nekrotischen Leberzellen führt zu einem Krankheitsbild, ähnlich dem SIRS oder der Sepsis, mit katastrophalen Auswirkungen auf das Immunsystem und die Hämodynamik. Im Mittelpunkt der supportiven Therapie bei ALV stehen die Kreislaufstabilisierung, die Infektionskontrolle und die Prävention und Behandlung der zerebralen Hypertonie.
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Mehrpour O, Shadnia S, Sanaei-Zadeh H. Late extensive intravenous administration of N-acetylcysteine can reverse hepatic failure in acetaminophen overdose. Hum Exp Toxicol 2010; 30:51-4. [DOI: 10.1177/0960327110366182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acetaminophen is a commonly used analgesic and has been shown to be a main cause of drug-induced liver failure. N-acetylcysteine (NAC) should be employed as the antidote in case of acetaminophen poisoning within the first 8-10 hours. Oral administration of NAC is universally recommended and due to the adverse effects, the intravenous administration of the agent is reserved for patients with oral intolerance and severe complications. We here report an 18-year-old man with severe liver failure due to a huge ingestion of acetaminophen, who was taken into the Loghman Hakim Hospital Poison Center 72 hours after attempted suicide. Regarding the poor prognostic clues as his level of consciousness and impaired liver functions, an extensive intravenous regimen of NAC was started. The patient survived the condition with an additional intravenous administration of NAC past the first 72 hours of treatment. We discuss that even in late phases of intoxication; high-dose intravenous NAC can serve a substantial improvement.
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Affiliation(s)
- Omid Mehrpour
- Department of Clinical Toxicology and Forensic medicine, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran, omehrpour@ razi.tums.ac.ir
| | - Shahin Shadnia
- Loghman-Hakim Hospital Poison Center, Faculty of Medicine and Toxicological Research Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Sanaei-Zadeh
- Department of Forensic Medicine, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Bemeur C, Desjardins P, Butterworth RF. Evidence for oxidative/nitrosative stress in the pathogenesis of hepatic encephalopathy. Metab Brain Dis 2010; 25:3-9. [PMID: 20195724 DOI: 10.1007/s11011-010-9177-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 09/22/2009] [Indexed: 12/11/2022]
Abstract
Hepatic encephalopathy (HE) is a serious complication of liver failure. HE manifests as a series of neuropsychiatric and neuromuscular symptoms including personality changes, sleep abnormalities, asterixis and muscle rigidity progressing through stupor to coma. The pathophysiologic basis of HE remains unclear. There is general agreement that ammonia plays a key role. In recent years, it has been suggested that oxidative/nitrosative stress constitutes part of the pathophysiologic cascade in HE. Direct evidence for oxidative/nitrosative stress in the pathogenesis of HE has been demonstrated in experimental animal models of acute or chronic liver failure. However, evidence from studies in HE patients is limited. This review summarizes this evidence for a role of oxidative/nitrosative stress in relation to ammonia toxicity and to the pathogenesis of HE.
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Affiliation(s)
- Chantal Bemeur
- Neuroscience Research Unit, Hôpital Saint-Luc (CHUM) University of Montreal, Montreal, QC, Canada
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Koch A, Trautwein C. N-acetylcysteine on its way to a broader application in patients with acute liver failure. Hepatology 2010; 51:338-40. [PMID: 20034036 DOI: 10.1002/hep.23484] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Alexander Koch
- Department of Medicine III, University Hospital RWTH-Aachen, Aachen, Germany
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Levanon D, Manov I, Iancu TC. Qualitative and Quantitative Analysis of the Effects of Acetaminophen and N-Acetylcysteine on the Surface Morphology of Hep3B Hepatoma Cells in V itro. Ultrastruct Pathol 2009. [DOI: 10.1080/01913120490275204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
BACKGROUND Alcoholic hepatitis is a severe, cholestatic liver disease occurring in patients with alcohol abuse. Mortality is substantial; however, therapies may improve clinical outcomes. AIM To provide an updated review of the epidemiology, diagnosis, staging and treatment of alcoholic hepatitis. METHODS A MEDLINE literature search was performed to identify pertinent articles. Relevant clinical abstracts were also reviewed. RESULTS Severe alcoholic hepatitis occurs in a small fraction of patients who abuse alcohol. The 28-day mortality ranges from 30% to 50% in most series. Diagnosis is generally based on clinical features, with a limited role for liver biopsy. Beneficial treatment options include alcohol abstinence and nutritional therapy. Despite variable results in clinical trials, corticosteroids and pentoxifylline appear to provide moderate survival benefit. Anti-tumour necrosis factor agents and antioxidants have not proven beneficial, and should be limited to clinical trials. Liver transplant is not a frequent option given the active or recent alcohol use. CONCLUSIONS Severe alcoholic hepatitis is a clinically-diagnosed condition associated with significant mortality. Alcohol abstinence and nutritional therapy have been associated with improved clinical parameters and should be considered in all patients. Corticosteroid therapy and pentoxifylline therapy appear to show moderate survival benefit and should be considered as first-line therapeutic agents.
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Affiliation(s)
- S M Cohen
- Section of Hepatology, Rush University Medical Center, Chicago, IL 60612, USA.
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Athuraliya TNC, Jones AL. Prolonged N-acetylcysteine therapy in late acetaminophen poisoning associated with acute liver failure--a need to be more cautious? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:144. [PMID: 19490595 PMCID: PMC2717416 DOI: 10.1186/cc7800] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Since the 1970s, N-acetylcysteine (NAC) has shown proven efficacy as an antidote for acetaminophen (APAP) poisoning and APAP-induced liver failure for early presenters. The current evidence of benefits of NAC for late presenters is controversial because of the poor understanding of the mechanism of late toxicity. In the previous issue of Critical Care, Yang and colleagues use a mouse model to demonstrate that NAC in doses similar to those used therapeutically to treat APAP poisoning in humans impairs liver regenerative capacity and that the effect is more pronounced when administered for a longer duration. Studies based on cell cultures support this evidence. Cytokine and growth factor signalling pathways are recognised to be involved in the process of liver regeneration and apoptosis. This research paper generates several issues related to the future management of APAP-induced liver failure and research into the mechanism of toxicity, especially of late toxicity.
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Affiliation(s)
- T Nimmi C Athuraliya
- Department of Clinical Pharmacology and Clinical Toxicology, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, NSW 2308, Australia.
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Suzuki K. Anti-oxidants for therapeutic use: why are only a few drugs in clinical use? Adv Drug Deliv Rev 2009; 61:287-9. [PMID: 19306902 DOI: 10.1016/j.addr.2009.03.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 03/07/2009] [Indexed: 10/21/2022]
Abstract
It is well known that ROS are involved in a wide spectrum of diseases. In spite of this fact, only a few drugs are currently in use in clinical settings: Ebselen for the treatment of cerebral infarctions, N-acetylcysteine for over-doses of acetaminophen. Because ROS production is very common and the human body has an abundant capacity for producing anti-oxidants, it is difficult to obtain statistical differences in trials designed to evaluate an anti-oxidative drug. Additional resources will be needed, if we are to use anti-oxidants in human clinical settings; Drug delivery to a specific region, appropriate setting of evaluation goals in clinical trials, new approaches to understanding the details of anti-oxidative systems. In spite of these drawbacks, the additional use of anti-oxidants in clinical settings is clearly warranted, and could contribute positively to human health. It is generally thought that reactive oxygen species (ROS) are involved in a wide variety of diseases, including ischemia-reperfusion, cancer and various types of inflammation. Because of this, the therapeutic use of antioxidants is now widespread. Some of these have been shown to be successful, but many appear to have no or little benefit, in terms of being beneficial to general health or in disease prevention. In this commentary, the author takes a look back at important anti-oxidative drugs and wonders why only a few such drugs are currently in clinical use.
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Chen YH, Lin FY, Liu PL, Huang YT, Chiu JH, Chang YC, Man KM, Hong CY, Ho YY, Lai MT. Antioxidative and hepatoprotective effects of magnolol on acetaminophen-induced liver damage in rats. Arch Pharm Res 2009; 32:221-8. [PMID: 19280152 DOI: 10.1007/s12272-009-1139-8] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 12/15/2008] [Accepted: 12/15/2008] [Indexed: 12/31/2022]
Abstract
Acute liver failure (ALF), an often fatal condition characterized by massive hepatocyte necrosis, is frequently caused by drug poisoning, particularly with acetaminophen (N-acetyl-p-aminophenol/APAP). Hepatocyte necrosis is consecutive to glutathione (GSH) depletion and mitochondrial damage caused by reactive oxygen species (ROS) overproduction. Magnolol, one major phenolic constituent of Magnolia officinalis, have been known to exhibit potent antioxidative activity. In this study, the anti-hepatotoxic activity of magnolol on APAP-induced toxicity in the Sprague-Dawley rat liver was examined. After evaluating the changes of several biochemical parameters in serum, the levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) were elevated by APAP (500 mg/kg) intraperitoneal administration (8 and 24 h) and reduced by treatment with magnolol (0.5 h after APAP administration; 0.01, 0.1, and 1 mug/kg). Histological changes around the hepatic central vein, lipid peroxidation (thiobarbituric acid-reactive substance/TBARS), and GSH depletion in liver tissue induced by APAP were also recovered by magnolol treatment. The data show that oxidative stress followed by lipid peroxidation may play a very important role in the pathogenesis of APAP-induced hepatic injury; treatment with lipid-soluble antioxidant, magnolol, exerts anti-hepatotoxic activity. Our study points out the potential interest of magnolol in the treatment of toxic ALF.
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Affiliation(s)
- Yung-Hsiang Chen
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan.
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Mortera R, Vivero-Escoto J, Slowing II, Garrone E, Onida B, Lin VSY. Cell-induced intracellular controlled release of membrane impermeable cysteine from a mesoporous silica nanoparticle-based drug delivery system. Chem Commun (Camb) 2009:3219-21. [DOI: 10.1039/b900559e] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Sivilotti MLA, Good AM, Yarema MC, Juurlink DN, Johnson DW. A New Predictor of Toxicity Following Acetaminophen Overdose Based on Pretreatment Exposure. Clin Toxicol (Phila) 2008; 43:229-34. [PMID: 16035198 DOI: 10.1081/clt-66056] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Despite extensive clinical experience, no dose-response curve exists for acetaminophen toxicity in man. The absence of accurate toxicodynamics has hampered efforts to optimize patient therapy and to identify risk modifiers following overdose. We set out to parameterize both the degree and duration of pretreatment exposure into a single, continuous measure of exposure, which will serve as the x-axis of an eventual dose-response curve. METHODS The model was constructed from pharmacokinetic first principles, using as inputs the vertical distance above the Rumack-Matthew nomogram line (expressed as the equivalent serum acetaminophen concentration 4 h after ingestion) and the delay to antidote therapy (tNAC). A no-effect dose ([APAP]threshold) and lag time (ti) were assumed. RESULTS The area under the serum acetaminophen concentration vs. time curve bounded by [APAP]threshold, ti and tNAC represents our proposed time-weighted measure of exposure. We demonstrate that this non-negative area estimates the cellular burden of toxic adducts formed following overdose. This measure is also easily calculated at patient presentation using clinical data and allows for both declining serum acetaminophen concentrations and variable delays to antidote therapy. DISCUSSION We describe a new, pharmacokinetically based measure of exposure following acute acetaminophen overdose treated with N-acetylcysteine. Using this measure should enhance the analysis of nonexperimental clinical data and permit more accurate characterization of acetaminophen toxicodynamics. Ultimately, this approach may facilitate progress on many of the long-standing controversies regarding acetaminophen toxicity in man.
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Affiliation(s)
- Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada.
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Abstract
A 25-year-old man presents to the emergency department with a toothache. During the evaluation, the physician determines that the patient has been taking large doses of over-the-counter acetaminophen along with an acetaminophen–hydrocodone product for the past 5 days. His daily dose of acetaminophen has been 12 g per day (maximum recommended dose, 4 g per day). He has no other medical problems and typically consumes two beers a day. The patient has no symptoms beyond his toothache, is not icteric, and has no hepatomegaly or right-upper-quadrant tenderness. His serum acetaminophen concentration 8 hours after the most recent dose is undetectable. His serum alanine aminotransferase concentration is 75 IU per liter, his serum bilirubin concentration is 1.2 mg per deciliter (20.5 μmol per liter), and his international normalized ratio (INR) is 1.1. The emergency department physician contacts the regional poison-control center, which recommends treatment with acetylcysteine.
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Affiliation(s)
- Kennon J Heard
- Rocky Mountain Poison and Drug Center, Denver Health, Denver 80208, USA.
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Abstract
Acute liver failure (ALF) is a rare but challenging clinical syndrome with multiple causes; a specific etiology cannot be identified in 15% of adult and 50% of pediatric cases. The course of ALF is variable and the mortality rate is high. Liver transplantation is the only therapy of proven benefit, but the rapidity of progression and the variable course of ALF limit its use. Currently in the United States, spontaneous survival occurs in approximately 45%, liver transplantation in 25%, and death without transplantation in 30% of adults with ALF. Higher rates of spontaneous recovery (56%) and transplantation (31%) with lower rates of death (13%) occur in children. The outcome of ALF varies by etiology, favorable prognoses being found with acetaminophen overdose, hepatitis A, and ischemia (approximately 60% spontaneous survival), and poor prognoses with drug-induced ALF, hepatitis B, and indeterminate cases (approximately 25% spontaneous survival). Excellent intensive care is critical in management of patients with ALF. Nonspecific therapies are of unproven benefit. Future possible therapeutic approaches include N-acetylcysteine, hypothermia, liver assist devices, and hepatocyte transplantation. Advances in stem cell research may allow provision of cells for bioartificial liver support. ALF presents many challenging opportunities in both clinical and basic research.
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Affiliation(s)
- William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical School, Dallas, TX 75390-8887, USA.
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Abstract
Acetaminophen is a commonly used antipyretic and analgesic agent. It is safe when taken at therapeutic doses; however, overdose can lead to serious and even fatal hepatotoxicity. The initial metabolic and biochemical events leading to toxicity have been well described, but the precise mechanism of cell injury and death is unknown. Prompt recognition of overdose, aggressive management, and administration of N-acetylcysteine can minimize hepatotoxicity and prevent liver failure and death. Liver transplantation can be lifesaving for those who develop acute liver failure.
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Affiliation(s)
- Anne M Larson
- Division of Gastroenterology, Hepatology Section, University of Washington, 1959 NE Pacific Street, Box 356174, Seattle, WA 98195-6174, USA.
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Heubi JE. Measurement of serum acetaminophen-protein adducts in patients with acute liver failure. J Pediatr Gastroenterol Nutr 2007; 44:513-5. [PMID: 17414155 DOI: 10.1097/mpg.0b013e3180399464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- James E Heubi
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Léophonte P, Guérin JC, Lebas FX, Liard F, Boulanger P. Stress oxydatif et BPCO. Rôle des infections. Prévention. Med Mal Infect 2006; 36:245-52. [PMID: 16584860 DOI: 10.1016/j.medmal.2005.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2005] [Accepted: 12/26/2005] [Indexed: 10/24/2022]
Abstract
For the next decade, COPD will become the third cause of mortality in the world. COPD is mainly due to cigarette smoking and presents different levels of severity according to people, probably linked to environmental and genetic factors, which are not well documented. Recent publications pointed out bacterial bronchial colonization and exacerbations of infectious origin as worsening factors through a pro-inflammatory effect and oxidative stress. This should lead to a comprehensive review of anti-infectious prevention tools and to discuss the role of prophylactic antibiotherapy and antioxidants.
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Affiliation(s)
- P Léophonte
- Service de Pneumologie, Clinique des Voies Respiratoires, Hôpital Larrey de Toulouse, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex 09, France.
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Opiate Addicted Patients: The Misconceptions of Chronic Acetaminophen Ingestion. ADDICTIVE DISORDERS & THEIR TREATMENT 2006. [DOI: 10.1097/01.adt.0000210705.64951.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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