Statin associated hepatic adverse effects: a retrospective review from a regional hospital in sultanate of oman

Lessons on Drug Development: A Literature Review of Challenges Faced in Nonalcoholic Fatty Liver Disease (NAFLD) Clinical Trials

NAFLD is the most common chronic liver disease worldwide, occurring in both obese and lean patients. It can lead to life-threatening liver diseases and nonhepatic complications, such as cirrhosis and cardiovascular diseases, that burden public health and the health care system. Current care is weight loss through diet and exercise, which is a challenging goal to achieve. However, there are no FDA-approved pharmacotherapies for NAFLD. This review thoroughly examines the clinical trial findings from 22 drugs (Phase 2 and above) and evaluates the future direction that trials should take for further drug development. These trialed drugs can broadly be categorized into five groups-hypoglycemic, lipid-lowering, bile-pathway, anti-inflammatory, and others, which include nutraceuticals. The multitude of challenges faced in these yet-to-be-approved NAFLD drug trials provided insight into a few areas of improvement worth considering. These include drug repurposing, combinations, noninvasive outcomes, standardization, adverse event alleviation, and the need for precision medicine with more extensive consideration of NAFLD heterogenicity in drug trials. Understandably, every evolution of the drug development landscape lies with its own set of challenges. However, this paper believes in the importance of always learning from lessons of the past, with each potential improvement pushing clinical trials an additional step forward toward discovering appropriate drugs for effective NAFLD management.

Modulatory action of withaferin-A on oxidative damage through regulation of inflammatory mediators and apoptosis via PI3K/AKT signaling pathway in high cholesterol-induced atherosclerosis in experimental rats

Statins are widely used lipid-lowering drugs that cause many side effects. Withaferin-A (WA), popularly known as Ashwagandha, an ancient Indian medicinal herb, is extracted from Withania somnifera. Anti-atherosclerotic effect of WA has been reported. However, the mechanism remains unknown. Hence, we planned this study to investigate the WA mechanism in anti-atherosclerosis in a rat model. High cholesterol diet (HCD) was fed to induce atherosclerosis in Sprague-Dawley male rats. Five groups (N = 6 rats/group) were fed with normal diet, HCD, WA (10 mg/kg bw)+HCD, lovastatin (LS: 10 mg/kg bw)+HCD, WA (10 mg/kg bw) respectively for 90 days. Statistical analysis was done by GraphPad Prism (version 8.0.1) using one-way analysis of variance (ANOVA) followed by post hoc Duncan's test with a significance level (p < 0.05). The groups were compared for lipid profiles, oxidative stress, lipid peroxidation, inflammatory mediators, apoptotic markers, and histopathological changes in the liver and aorta. Treatment with HCD increased lipid profiles, inflammatory mediators, cytokines, and lipid peroxidation. WA as well as LS treatments significantly decreased these parameters restored the antioxidant status, and reduced lipid peroxidation (p < 0.05). Histopathological studies revealed that WA and LS reduced the hepatic fat and aortic plaque. WA reduced apoptosis via augmentation of phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) pathway; increased B-cell lymphoma 2 and inhibited Bcl-2 associated X-protein proapoptotic proteins; TNF receptor superfamily member 6, Bim, caspase-3, and -9; demonstrated significant hypolipidemic and anti-inflammatory properties against HCD induced atherosclerosis in rats through regulation of inflammatory mediators and apoptosis via the PI3K/AKT signaling pathway.

Hepatoprotective Effects of a Novel Trihoney against Nonalcoholic Fatty Liver Disease: A Comparative Study with Atorvastatin

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disorder worldwide with no curative therapy. The aim of this study was to investigate the hepatoprotective effects of a novel Trihoney against biochemical and histological manifestations of NAFLD in hypercholesterolemic rabbits. Methodology. Forty-eight male New Zealand white (NZW) rabbits were grouped into normal diet (C), normal diet with 0.6 g/kg/day of Trihoney (C + H), 1% cholesterol diet (HCD), 1% cholesterol diet with 0.3 g/kg/day of Trihoney (HCD + H₁), 1% cholesterol diet with 0.6 g/kg/day of Trihoney (HCD + H₂), and 1% cholesterol diet with 2 mg/kg/day of atorvastatin (HCD + At.). Animals were sacrificed after 12 weeks of treatment. Serum lipids and liver function test (LFT) were measured prior to and at the endpoint of the experiment for total cholesterol (TC), low-density lipoprotein (LDL-c), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), and total bilirubin (T. Bil.). Liver was processed for histopathology study. Liver homogenate was analysed for oxidative stress parameters: superoxide dismutase (SOD), glutathione peroxidase (GPx), and malondialdehyde (MDA). Results. Lipid analysis approved the induction of hypercholesterolemia. A significant elevation (p < 0.01) of serum AST and ALT levels showed by the HCD group was compared to C and C + H groups. Trihoney exhibited a significant reduction (p < 0.001) of AST and ALT compared to the HCD group. Likewise, AST and ALT reduced significantly in the HCD + At. group (p < 0.001). Trihoney supplementation induced significant (p < 0.05) enhancement of SOD and GPx activities. Atorvastatin treatment was associated with significant (p < 0.05) reduction of SOD and GPx activities in the liver. Trihoney and atorvastatin showed marked (p < 0.001) reduction of hepatic lipid peroxidation. Trihoney showed histological protection against progression of NAFLD to nonalcoholic steatohepatitis (NASH). Atorvastatin exhibited no beneficial impact on hepatic architecture. Conclusion. Trihoney was able to maintain normal liver function and showed hepatoprotection against progression of NAFLD to NASH probably through hypocholesterolaemic and antioxidant functions.

Synergistic anti-atherosclerotic role of combined treatment of omega-3 and co-enzyme Q10 in hypercholesterolemia-induced obese rats

Hypercholesterolemia is a metabolic disorder associated with atherosclerosis. This study aimed to investigate the effects of omega-3 and/or coenzyme Q10 (CoQ10) on hypercholesterolemia-induced atherosclerosis. Rats were divided into five groups; (1): served as the negative control, (2): served as hypercholesterolemic (HC) control, (3): HC-rats administrated omega-3 orally, (4): HC-rats administrated CoQ10 orally, and (5): HC-rats administered the combination treatment of both omega-3 and CoQ10. Lipid profile was assayed and cardiovascular risk indices were calculated. Serum levels of Adiponectin (APN) and creatine kinase (CK-MB) were determined using ELISA. Besides, oxidative stress markers, malondialdehyde (MDA), nitric oxide (NO) and glutathione (GSH) were assayed in the heart homogenate. Histopathological investigation of the aortae and heart tissues were investigated. The results revealed that atherogenic HC-rats demonstrated a significant elevation in lipid profiles, except for HDL-C, along with decreased levels of APN, but increased CK-MB activities. Hypercholesterolemia increased lipid peroxidation, reduced NO production, and decreased GSH content in the cardiac tissue. Treatment of atherogenic HC-rats with omega-3 and/or CoQ10 improved dyslipidemia and ameliorated most of the HC-induced biochemical and histopathological changes. The histological observations of aortae and cardiac tissues validated our biochemical results. We concluded that the combined treatment of nutraceuticals such as omega-3 and CoQ10 demonstrated the best outcome, demonstrating their anti-hyperlipidemic, cardioprotective, and atheroprotective potentials. Together, this study supports a beneficial role of dietary co-administration of omega-3 and CoQ10 in obese patients who are prone to develop cardiovascular disorders.

Comparative impact of systemic delivery of atorvastatin, simvastatin, and lovastatin on bone mineral density of the ovariectomized rats

PURPOSE

In addition to lipid-lowering properties, statins have been suggested to affect bone turnover by increasing the osteoblastic bone formation and blocking the osteoclastogenesis. However, there are many controversial reports regarding the beneficial effect of statins on osteoporosis. In this study, we investigated the therapeutic effects of the most important lipophilic statins administered orally for 60 days to the ovariectomized (OVX) female Sprague-Dawley rats and compared the effects on different harvested trabecular and compact bones.

METHODS

Thirty female rats were divided into five equal groups including the normal rats, untreated OVX rats (negative control), and the OVX rats treated with atorvastatin (20 mg/kg/day), simvastatin (25 mg/kg/day), and lovastatin (20 mg/kg/day). The osteoporotic animals were treated daily for 60 days and euthanized at the end of experiments. The effectiveness of these treatments was evaluated by biomechanical testing, histopathologic, histomorphometric, micro-CT scan, real-time PCR, and serum biochemical analysis. Moreover, the hepatotoxicity and rhabdomyolysis related with these treatments were assessed by biochemistry analysis and histopathological evaluation.

RESULTS

The results and statistical analysis showed that systemic delivery of simvastatin and lovastatin significantly increased serum calcium level, expression of osteogenic genes, bone mineral density (BMD), and biomechanical properties in comparison to the untreated OVX rats, especially in trabecular bones (P < 0.05). The results of different analysis also indicated that there was no statistical difference between the atorvastatin-treated animals and the negative control. Among all treatments, only atorvastatin showed an evident hepatotoxicity and myopathy.

CONCLUSIONS

It was concluded that the lovastatin and simvastatin efficiently ameliorated the OVX-induced osteoporosis. Moreover, the simvastatin-treated animals showed more resemblance to the normal group in terms of BMD, expression of osteogenic genes, serum biochemical parameters, histomorphometric findings, and biomechanical performance with no significant side-effects.

Intervention Effects of Atorvastatin Combined with Panax notoginseng Saponins on Rats with Atherosclerosis Complicated with Hepatic Injury

Background:

Statins cannot be used for some active liver diseases, which limits its application to some extent. The combined use of statins with other drugs may be one of the ways to solve this dilemma.

Objective:

This research aims to evaluate the effects of atorvastatin combined with Panax notoginseng saponins (PNS) on rats with atherosclerosis (AS) complicated with hepatic injury.

Materials and Methods:

Seventy-two male Wistar rats were randomly categorized into control group (without any intervention, Group A) and AS model groups, which were divided into hepatic injury (Groups B–E) and nonhepatic injury (Groups F–I) groups. Hepatic and nonhepatic injury groups were intragastrically treated with 5.5 mg/kg·d atorvastatin (Group B, F), 200 mg/kg·d PNS (Group C, G), 5.5 mg/kg·d atorvastatin + 200 mg/kg·d PNS (Group D, H), and normal saline (Group E, I). After 8 weeks, total cholesterol (TC), triglyceride (TG), high density lipoprotein-cholesterol, low density lipoprotein-cholesterol (LDL-C), and serum calcium were analyzed to evaluate the hypolipidemic effect. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, total bilirubin, and r-glutamyltransferase levels were measured to assess liver function. The thoracic aortas were used for hematoxylin–eosin staining.

Results:

In both hepatic injury and nonhepatic injury groups, TC, TG and LDL-C levels significantly decreased in Groups B, D, F, and H. ALT and AST levels significantly increased in Group B, but significantly decreased in Groups C and D. The aortic intima thickness was significantly lower in Groups B, D, F, and H than that in the normal saline group.

Conclusion:

The combination of atorvastatin and PNS treatment showed a significant hypolipidemic effect and hepatic enzyme stability function.

SUMMARY

The single use of Panax notoginseng saponins (PNS) in the rat model for atherosclerosis significantly reduced Ca²⁺ content in serum, whereas the effect of lowing total cholesterol (TC), triglyceride (TG), and low density lipoprotein-cholesterol (LDL-C) is not apparent, especially as compared with atorvastatin treatment

PNS combined with atorvastatin treatment of the rat model for atherosclerosis displayed a noticeable, synergistic effect that allowed for better reduction of TC, TG, LDL-C and Ca²⁺ in the serum than that with the single use of PNS or atorvastatin

In the rat liver injury combined with atherosclerosis model, the single use of PNS significantly improved liver function, whereas atorvastatin alone only aggravated liver injury in the rat model. The effect of PNS combined with atorvastatin on liver function was significantly better than that of atorvastatin alone

The combined use of PNS and atorvastatin showed good stability of liver function on the liver injury combined with atherosclerosis model.

Abbreviations used: PNS: Panax notoginseng saponins; AS: Atherosclerosis; TC: Total cholesterol; TG: Triglyceride; HDL-C: High density lipoprotein-cholesterol; LDL-C: Low density lipoprotein-cholesterol; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; ALP: Alkaline phosphatase; T-BIL: Total bilirubin; r-GT: R-glutamyltransferase; HE: Hematoxylin–eosin.

Icariin Attenuates High-cholesterol Diet Induced Atherosclerosis in Rats by Inhibition of Inflammatory Response and p38 MAPK Signaling Pathway

Icariin is a flavonoid isolated from the traditional Chinese herbal medicine Epimedium brevicornum Maxim and has been reported to be effective for the treatment of a variety of cardiovascular diseases. The aim of the present study was to investigate the effect and mechanism of icariin on atherosclerosis (AS) using a high-cholesterol diet (HCD)-induced rat model. Seventy male Wistar rats were divided into five groups: 20 in the control group, 20 in the AS group, 10 in the simvastatin group, 10 in the low-dose icariin group, and 10 in the high-dose icariin group. A HCD and vitamin D3 were administered to establish AS rat model. The five groups of rats received daily intragastric administration of normal saline, simvastatin, or icariin (30 mg/kg/d, 60 mg/kg/d) for 4 weeks. The levels of blood lipids, superoxide dismutase (SOD), and malonaldehyde (MDA) were measured. The mRNA levels of interleukin (IL)-6 and tumor necrosis factor (TNF)-α were analyzed by real-time RT-PCR, and the serum levels of IL-6 and TNF-α were measured using ELISA kit. In addition, the expression of phosphorylated p38 (p-p38) MAPK was detected by Western blot analysis. The results indicated that AS rat models were successfully constructed. In the AS group, the levels of blood lipids including total cholesterol (TC), triglyceride (TG), low-density lipoprotein-cholesterol (LDL-C), and MDA were significantly increased, while high-density lipoprotein-cholesterol (HDL-C) and SOD were significantly decreased, compared with those in the control group. However, icariin succeeded in improving these biochemical parameters towards the normal values in the control group. In the simvastatin group and the icariin groups, the serum levels of IL-6 and TNF-α and the related tissue mRNA levels, as well as the expression of p-p38 MAPK, were markedly reduced compared with the AS group. In conclusion, the present study indicated that icariin inhibited the HCD-induced dyslipidemia in rats, the mechanisms may be associated with the anti-inflammation, anti-oxidative stress, and downregulation of p-p38 MAPK by icariin.

Influence of crocetin on high-cholesterol diet induced atherosclerosis in rats via anti-oxidant activity together with inhibition of inflammatory response and p38 MAPK signaling pathway

The present study aimed to investigate the effect and possible mechanism of action of crocetin on the high cholesterol diet (HCD) induced atherosclerosis rat. The Wistar rats were used in the current investigation. The rats were divided into following group, Group I: control, Group II: HCD induced AS, Group III: AS + crocetin (25 mg/kg), Group IV: AS + crocetin (50 mg/kg) and Group V: AS + Simvastatin, respectively. AS was induced in the rats using the vitamin D₃ and HCD. The rats received the pre-determined treatment for the 10 weeks. After the study period, the level of lipid profile, malonaldehyde (MDA) and superoxide dismutase (SOD) were also estimated. The proinflammatory cytokines viz., tumor necrosis factor (TNF)-α and interleukin (IL)-6 were scrutinized using the ELISA kits. We also estimated the expression of phosphorylated p38 (p-p38) MAPK using the Western blot techniques. The results revealed that the AS was successfully induced in the rats. The AS control group rats showed the modulated level of lipid profile, and decreased the level of the SOD and boost the level of the MDA as compared with the normal control. However, crocetin thrived in enhancing the lipid profile toward the standard value in the normal control group rats. The crocetin and simvastatin group rats significantly inhibited the expression of the p-p38 MAPK as compared to the AS group rats. In conclusion, the current investigation revealed that the crocetin reduced the HCD induced dyslipidemia in the Wistar rats, the possible mechanism of action may be connected to the antioxidative, down regulating of p-p38 MAPK and antiinflammatory effect by crocetin.

Statins and its hepatic effects: Newer data, implications, and changing recommendations

Hepatic adverse effects are one of the most commonly known adverse effects reported with statins. Frequently, fear of serious hepatic effects contributes to underutilization of statins as well as unnecessary discontinuation of its use among those indicated. There are changing data on the occurrence of these negative hepatic effects, recommendations on their actual risk, monitoring required, and safety of use in those with preexisting hepatic disorders. Based on reviewed literature, statins appear to be associated with a very low risk of true and serious liver injury. Unprecedented fears regarding hepatic adverse effects of statins among prescribers and patients can deny patients of the significant benefits of these agents. Routine periodic monitoring of liver function does not appear to detect or prevent serious liver injury and hence may not be indicated. But the potential of statins to cause significant and serious hepatic effects should not be overlooked in daily clinical practice. Statin use need not be avoided in patients with preexisting liver dysfunction such as nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, compensated cirrhosis, and compensated chronic liver disease if its use is clearly indicated. Physician's judgment based on the risk and benefit for an individual patient does matter when a strategy is chosen regarding the use of statins and monitoring patients while on statins.

Knowledge, Beliefs and Behaviours Regarding the Adverse Effects of Medicines in an Omani Population: Cross-sectional survey

OBJECTIVES

This study aimed to assess the knowledge, beliefs and behaviours of an Omani population with regards to the adverse effects of medicines.

METHODS

This cross-sectional survey was conducted between February and June 2012. A 17-item questionnaire was designed to assess three aspects: knowledge, beliefs and behaviours related to medicine safety. A total of 740 questionnaires were distributed in three representative governorates of Oman. Median total scores for the three sections were estimated. Associations with participants' demographic variables and medication histories were also assessed.

RESULTS

A total of 618 participants completed the survey (response rate: 83.5%). Many participants (46.4%) believed that side-effects occurred only with high doses of medication and over 30% believed that they did not occur at all with traditional and over-the-counter medicines. The median total score was 19 (interquartile range: 6) out of a maximum of 30. Inadequate knowledge, incorrect beliefs and good behaviours were observed among the participants. There was a significant association between certain demographic parameters (age, educational qualification, history of chronic use of medicines and employment status) and median total scores. Participants reported obtaining additional information on medication safety from various sources, with doctors as the most widely used source.

CONCLUSION

Inadequate knowledge and incorrect beliefs among this Omani population indicate a need for interventions to improve public knowledge and address misconceptions regarding medication safety. These interventions could be initiated on both an individual and public scale, with patient interactions by healthcare professionals and mass education activities targeting the larger population.