The Use and Potential Benefits of N-Acetylcysteine in Non-Acetaminophen Acute Liver Failure: An Etiology-Based Review

Mushroom Poisoning and Acute Liver Injury: A Case-Based Review

Mushrooms have always found their way into our dining plates due to their exotic looks and edibility. It is also one of the food items that can lead to fatal hepatotoxicity if the wrong species is picked up. Mushroom poisoning is frequently seen in forest adventure seekers and presents with variable time frames, mainly with acute gastrointestinal symptoms. Here we discuss a case of mushroom poisoning in a lady in her early sixties who presented with acute liver injury after 6 hours of wild toxic mushroom intake, having severely raised INR (International Normalized Ratio). She was managed with N-acetylcysteine (NAC), vitamin K, and regular benzylpenicillin in the liver-intensive therapy unit (ITU). The data regarding the treatment of mushroom poisoning is not tested in conventional rigorous randomized control trials. However, the role of good supportive care in liver-ITU, the addition of NAC, and benzylpenicillin in some cases, is reassuring. And if that fails, then liver transplant is a viable option. Her case underscores the critical importance of early diagnosis and immediate initiation of supportive care, including the addition of NAC and regular benzylpenicillin in selected cases. For those not responding to these conventional therapies, the possibility of a liver transplant, as a last resort, must be considered.

Efficacy of N-Acetylcysteine as an Adjuvant Therapy for Rheumatoid Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Aims/Background Rheumatoid arthritis (RA) is an inflammatory autoimmune disease and N-acetylcysteine (NAC) is considered a potential therapeutic agent for RA due to strong antioxidant and anti-inflammatory properties. Therefore, this systematic review and meta-analysis aimed to evaluate the efficacy of NAC as an adjuvant therapy for RA. Methods A systematic search was conducted across five databases from inception to 1 August 2024, including CINAHL, Cochrane Library, EMBASE, PubMed, and Web of Science. The Cochrane risk-of-bias tool for randomized trials was used to assess the quality of the included studies. Sensitivity analysis was performed when significant heterogeneity was identified. Results Four studies involving 204 patients were included in our meta-analysis. The results indicated that NAC alleviated disease activity in RA patients (Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR): mean difference (MD) = 0.54). Additionally, NAC reduced inflammatory markers (erythrocyte sedimentation rate (ESR): MD = 3.00). However, the beneficial effects of NAC on oxidative stress in RA patients were not observed. Conclusion This meta-analysis demonstrated the efficacy of NAC in reducing inflammatory markers, improving joint tenderness, and swelling in patients with RA.

Utility of N-acetylcysteine in Non-Acetaminophen-Induced Liver Injury Secondary to Influenza A Infection

Influenza A, which belongs to the Orthomyxoviridae viral family, is a known causative agent of respiratory illness and systemic inflammation. Annual influenza immunizations are crucial in reducing the incidence and severity of the flu. Intravenous (IV) N-acetylcysteine (NAC) is a pharmaceutical agent indicated for hepatic injury, particularly to address oxidative stress and inflammation secondary to acetaminophen toxicity. The authors present a case of a young female with acute liver injury and impending liver failure in the setting of viral influenza A infection, successfully treated with IV-NAC.

Amanita-Induced Hepatitis

The consumption of wild mushrooms can be associated with poisoning, particularly with species containing hepatotoxic toxins such as amatoxin, present in more than 35 species. We present a case of Amanita-induced hepatitis in a 73-year-old man after ingestion of wild mushrooms. He presented to the emergency department (ED) with severe diarrhea, intense abdominal pain, and vomiting, with onset approximately six hours after ingestion of wild mushrooms. He developed acute liver injury but never developed hepatic encephalopathy. His clinical course was favorable, with complete recovery of liver function. The diagnosis of Amanita-induced toxic hepatitis is based on clinical observations. Early diagnosis and treatment are fundamental factors in the prognosis of these patients.

Diagnosis, prevention and risk-management of drug-induced liver injury due to medications used to treat mycobacterium tuberculosis

INTRODUCTION

Many of the first line medications for the treatment of active and latent M. tuberculosis are hepatoxic and cause a spectrum of anti-tuberculosis drug induced liver injury (ATLI), including acute liver failure (ALF). Despite advances in recognition of and prevention of ATLI, isoniazid remains one of the leading causes of DILI as well as drug-induced ALF.

AREAS COVERED

A literature search of the incidence, risk factors, current societal guidelines, monitoring, and prophylactic medication usage in ATLI was performed using PubMed and institutional websites. Relevant articles from 1972 to 2024 were included in this review.

EXPERT OPINION

Current societal guidelines regarding ATLI monitoring are mixed, but many recommend liver enzyme testing of high-risk populations. We recommend liver test monitoring for all patients on multi-drug therapy as well as those on isoniazid therapy. Precision medicine practices, such as N-acetyltransferase-2 polymorphism genotyping, are thought to be beneficial in reducing the incidence of ATLI in high-risk populations. However, broader implementation is currently cost prohibitive. Hepatoprotective drugs are not currently recommended, although we do recognize their potential. In patients who develop ATLI but require ongoing anti-TB treatment, strategies to restart the same or less hepatotoxic regimens are currently being followed.

Dexamethasone and N-acetylcysteine before transarterial chemoembolization in hepatocellular carcinoma: A Western perspective

Post-embolization syndrome (PES) is the most common complication in patients with hepatocellular carcinoma treated with transarterial chemoembolization. Many strategies have been evaluated to reduce the incidence of PES, but no standard prevention guidelines currently exist. In a single-center, placebo-controlled trial, Simasingha et al evaluated the prophylactic administration of a combination of dexamethasone and N-acetylcysteine and documented a significant reduction in the incidence of PES (from 80% to 6%), of post-procedural liver decompensation (from 14% to 0%), and a shorter hospital stay (4 days vs 6 days), alongside an acceptable safety profile. The results of this study raise several controversial points regarding their applicability in the Western world. In the West, there is a greater and increasing prevalence of metabolic and alcoholic etiologies of liver cirrhosis, so a not negligible number of patients with type II diabetes or hypertension would be excluded from high-dosage dexamethasone prophylaxis. Furthermore, in the West, there is a preferred use of drug-eluting beads loaded with doxorubicin, which are associated with a lower incidence of PES. A study on prophylaxis with dexamethasone and/or N-acetylcysteine in a Western population is hopefully awaited.

A Narrative Review of Oxidative Stress and Liver Disease in Pregnancy: The Role of Antioxidants

Pregnancy brings numerous physiological changes to the body of the pregnant woman. Liver diseases in pregnancy contribute to increased oxidative stress, disrupting the delicate balance between reactive oxygen species and antioxidant defence. Antioxidant supplementation may have potential benefits in addressing pregnancy-related liver disorders, such as HELLP (haemolysis, elevated liver enzymes, low platelet count) and preeclampsia-associated liver dysfunction in pregnancy. The purpose of this narrative review is to review the evidence regarding oxidative stress in liver disorders during pregnancy and the role of antioxidants in alleviating oxidative stress and its effect on maternal and foetal outcomes. A narrative review study design involved a comprehensive search across three scientific databases: PubMed, Embase, and MEDLINE, published in the last 20 years. The searches were performed up to January 2024. Thirty-two studies were included in the narrative review. The most studied antioxidants were vitamins (vitamin C and E) for their role in clinical treatment, prophylaxis, and clearing surrogate oxidative stress markers. The majority of studies were on preeclampsia. Though the existing literature is not robust, available evidence suggests that antioxidant supplementation may have potential benefits in addressing pregnancy-related liver disorders, such as HELLP and preeclampsia-associated liver dysfunction in pregnancy. However, there is a need to establish consistent protocols, ethical standards, and well-designed clinical trials to clarify the timing and dosage of antioxidants in pregnancy. Antioxidants may alleviate the oxidative stress in various liver disorders during pregnancy, which still needs to be studied further for their clinical relevance.