A case of flutamide-induced acute cholestatic hepatitis--a case report

Drug-induced liver injury: Is it somehow foreseeable?

The classic view on the pathogenesis of drug-induced liver injury is that the so-called parent compounds are made hepatotoxic by metabolism (formation of neo-substances that react abnormally), mainly by cytochromes P-450 (CYP), with further pathways, such as mitochondrial dysfunction and apoptosis, also playing a role. Risk factors for drug-induced liver injury include concomitant hepatic diseases, age and genetic polymorphisms of CYP. However, some susceptibility can today be predicted before drug administration, working on the common substrate, by phenotyping and genotyping studies and by taking in consideration patients’ health status. Physicians should always think of this adverse effect in the absence of other clear hepatic disease. Ethical and legal problems towards operators in the health care system are always matters to consider.

Cancer chemotherapy I: hepatocellular injury

Although hepatotoxicity is a frequent concern with all medications, chemotherapeutic agents are more often implicated in causing liver damage than most other drug classes. In many instances, these reactions are considered dose related because cytotoxic therapy directed at rapidly growing cancer cells may readily impact hepatocytes even though they are dividing more slowly. Because the stakes (remission of cancer) are high, so are the risks that the oncologist and the patient are willing to assume. The dose of many chemotherapeutic agents is limited by the toxic effects on the lungs, bone marrow, kidneys, and gastrointestinal system, including the liver. An awareness of the toxic potential of each chemotherapeutic agent is necessary before initiation of new oncologic treatments.

Hepatotoxicidade pela flutamida em paciente sob tratamento para acne: relato de caso

A flutamida é agente antiandrogênico não esteróide usado no tratamento do câncer de próstata, da acne e do hirsutismo. Alguns casos de hepatotoxicidade grave têm sido apresentados na literatura com seu uso. Relata-se o caso de uma paciente com 21 anos de idade, que apresentou significativa elevação das aminotransferases durante o tratamento para acne com flutamida, completamente resolvida após a descontinuação da droga. Discute-se o diagnóstico, a relação risco/benefício e conclui-se que a monitoração com exames que avaliem o fígado é imperativa e que a droga deve ser suspensa se houver elevação de aminotransferases, dada a possibilidade de disfunção hepática grave.

[Toxic hepatitis after flutamide treatment]

Introducción

La flutamida es un antiandrógeno no esteroideo generalmente bien tolerado, usado para el tratamiento del cáncer de próstata1. Los efectos secundarios más frecuentes de la flutamida son náuseas, diarrea y ginecomastia2. La incidencia de hepatotoxicidad asociada a flutamida es muy baja y no excede el 0,18%3. También se han descrito casos de toxicidad hepática por flutamida en mujeres tratadas por hirsutismo4.

Caso clínico

A continuación presentamos el caso de un varón de 68 años con antecedents de carcinoma de próstata, prostatectomizado en 2002 con 30 semanas de radioterapia y en tratamiento con flutamida (Prostacur®), hepatitis B hace 11 años con HBsAg positivo y neumonía, que acude a nuestra consulta por hipertransaminasemia. No hay factores de riesgo cardiovasculares ni hábitos tóxicos. En el momento en el que el paciente acudió a nuestra consulta presentaba unos valores de GOT 1.309 U/l (0-40 U/l), GPT 1.474 U/l (0-40 U/l), GGT 540 U/l (10-50 U/l), ferritina 3.589 ng/ml (15-200 ng/ml) y alfafetoproteína 11,5 U/ml (0-7 U/ml). La ecografía y la tomografía computarizada abdominales fueron normales. Un estudio con PCR del ADN-VHB mostraba unas cifras de 10.100 gen/ml. La serología de la hepatitis presentaba los siguientes resultados: HBsAg positivo, anti-HBc positivo, HBe-Ag negativo y antiHBe positivo. Una semana después de la retirada del fármaco los valores de GOT, GPT y GGT descendieron a 50, 49 y 319 U/l, respectivamente, lo cual, tras descartar hepatotoxicidad por etanol, alteraciones hepatobiliares en ecografía, enfermedades autoinmunes por depósitos de hierro y cobre, infección reciente por virus de hepatitis A, B y C y otras causas etiológicas, apoya el diagnóstico de hepatitis tóxica tras tratamiento con flutamida según las escalas diagnósticas de hepatotoxicidad por fármacos de María y Victorino, 19975 y la CIOMS, 19936. Reafirma también este diagnóstico la prácticamente completa resolución de la alteración analítica al mes de suspender el tratamiento con flutamida, quedando las transaminasas normales.

Discusión y conclusiones

Las manifestaciones clínicas de la hepatitis inducida por flutamida incluyen elevación asintomática de transaminasas, hepatitis tóxica y hepatitis colestásica con gran elevación de la fosfatasa alcalina sérica y r-GGT2. Los pacientes normalmente retornan a la normalidad tras la retirada del fármaco, pero se han descrito casos de mortalidad tras síndrome hepatorrenal2, encefalopatía hepática y hepatitis fulminantes7.

La anatomía patológica de estos pacientes muestra una necrosis difusa severa de los hepatocitos. Se han descrito en numerosas ocasiones casos con patrón de colestasis y necrosis focal, pero sólo unos pocos con inflamación portal y necrosis focal.

El mecanismo por el cual la flutamida produce hepatotoxicidad no es bien conocido, pero podrían estar implicadas disfunciones mitocondriales1.

El riesgo de presentar un fallo hepático, encefalopatía hepática e incluso la muerte debido a la toma de flutamida debería ser tenido en cuenta a la hora de iniciar este tratamiento, por lo que es necesario un control estricto de los valores de enzimas hepáticas durante el tratamiento, sobre todo en pacientes como el nuestro con una hepatopatía previa. Sería recomendable advertir al paciente de que consulte inmediatamente en caso de iniciar un cuadro de náuseas, vómitos, fatiga e ictericia en el transcurso del tratamiento con flutamida para prevenir la posible aparición de estos trastornos.

Hepatotoxicity induced by antiandrogens: a review of the literature

INTRODUCTION

Hepatotoxicity is a serious adverse reaction potentially induced by all antiandrogens. We have reviewed here the published cases of hepatotoxicity induced by steroidal and nonsteroidal antiandrogens, and compared the type and characteristics of liver damage.

METHODS

Using two different databases: MEDLINE and IDIS (Iowa Drug Information Service), we searched for published cases of liver injury induced by antiandrogens. Analysis was made of the type of hepatotoxicity, therapeutic indication, other pharmacological treatments and evolution. Mean values of latency and recovery periods of the adverse reactions and liver function tests were also evaluated.

RESULTS

Hepatitis was the most common type of hepatotoxicity reported, and was associated with all antiandrogens. This adverse reaction does not seem to be dependent on the patients age, therapeutic indication or the dose prescribed. Hepatitis showed a longer latency period for cyproterone acetate than for flutamide. Some transaminase levels were significantly higher for flutamide than for cyproterone acetate, although the evolution was no worse in the cases reported for flutamide. We also found occasional reports of hepatocellular carcinoma and hepatic cirrhosis suspected of being induced by cyproterone acetate.

CONCLUSION

Although there are differences in the clinical features of hepatotoxicity induced by steroidal and nonsteroidal antiandrogens, these do not predict which patients will develop hepatotoxicity during treatment or evolution. Serial liver function tests are required for early detection of liver damage.

Metastatic prostate cancer (with prostate-specific antigen of 9996) presenting as obstructive jaundice

A 78-year-old man admitted with clinical jaundice and pelvic pain had a total bilirubin level of 6.56 mg/dL, an alkaline phosphatase level of 855 U/L, and a prostate specific antigen (PSA) level of 9996 ng/mL. A computed tomogram demonstrated marked retroperitoneal, peripancreatic, periceliac, and periaortic lymphadenopathy. A bone scan revealed increased radiolabeled technetium uptake in the pelvis, vertebral column, parietooccipital region, ribs, and appendiceal skeleton. A biopsy of one pelvic lesion revealed metastatic prostate cancer. This man's obstructive jaundice and bone pain had a dramatic response to treatment with a gonadotropin-releasing hormone analog (leupro lide) and antiandrogen (bicalutamide). All bone pair and clinical signs of jaundice disappeared in 1 week His total bilirubin decreased to 0.84 mg/dL by 2 weeks His PSA values reflected this clinical response, decreasing to 4022 ng/mL in 1 week, 2680 ng/dL after 2 weeks and 1028 ng/mL after 1 month of the above therapy.