Salicylate hepatotoxicity in patients with juvenile rheumatoid arthritis

Human ES and iPS cells display less drug resistance than differentiated cells, and naïve-state induction further decreases drug resistance

Pluripotent stem cells (PSCs) possess unique characteristics that distinguish them from other cell types. Human embryonic stem (ES) cells are recently gaining attention as a powerful tool for human toxicity assessment without the use of experimental animals, and an embryonic stem cell test (EST) was introduced for this purpose. However, human PSCs have not been thoroughly investigated in terms of drug resistance or compared with other cell types or cell states, such as naïve state, to date. Aiming to close this gap in research knowledge, we assessed and compared several human PSC lines for their resistance to drug exposure. Firstly, we report that RIKEN-2A human induced pluripotent stem (iPS) cells possessed approximately the same sensitivity to selected drugs as KhES-3 human ES cells. Secondly, both ES and iPS cells were several times less resistant to drug exposure than other non-pluripotent cell types. Finally, we showed that iPS cells subjected to naïve-state induction procedures exhibited a sharp increase in drug sensitivity. Upon passage of these naïve-like cells in non-naïve PSC culture medium, their sensitivity to drug exposure decreased. We thus revealed differences in sensitivity to drug exposure among different types or states of PSCs and, importantly, indicated that naïve-state induction could increase this sensitivity.

Gastrointestinal and hepatic manifestations of rheumatoid arthritis

Rheumatoid arthritis (RA), characterized by inflammation of the synovium and surrounding structures, has a prevalence of 0.5-1%. Rheumatoid vasculitis (RV) is an inflammatory condition of the small- and medium-sized vessels that affects up to 5% of patients with RA with intestinal involvement in 10-38% of these cases. Clinically apparent RV of the gastrointestinal (GI) tract, while rare, is often catastrophic, resulting in ischemic ulcers and bowel infarction. Vasculitis of the colon may present as pancolitis clinically similar to ulcerative colitis. Rectal biopsies that include submucosal vessels are positive for vasculitis in up to 40% of cases. Abnormal esophageal motility in RA may result in heartburn and dysphagia. Chronic atrophic gastritis may be associated with hypergastrinemia and hypo- or achlorhydria, promoting small bowel bacterial overgrowth. RA is the most common cause of secondary amyloidosis with GI symptoms in 22% of affected patients. Although amyloid is usually found in the liver, it is rarely evident clinically. Felty's syndrome occurs in less than 1% of patients with RA and is characterized by neutropenia and splenomegaly. The liver may be involved with portal fibrosis or nodular regenerative hyperplasia. Liver histology is abnormal in 92% of RA patients at autopsy, although the changes are usually mild without associated hepatomegaly. Drug-induced liver disease may occur with aspirin, sulfasalazine, and methotrexate. Significant liver damage is rare if the drug is discontinued or the patient is properly monitored. RA can affect both the GI tract and the liver; changes are usually mild except with RV.

Preliminary diagnostic guidelines for macrophage activation syndrome complicating systemic juvenile idiopathic arthritis

OBJECTIVE

To develop diagnostic guidelines for macrophage activation syndrome (MAS) complicating systemic juvenile idiopathic arthritis (S-JIA).

STUDY DESIGN

We followed the classification criteria approach that is based on the comparison of patients with the index disease with patients with a "confusable" disease. The former group included 74 patients with S-JIA-associated MAS reported in the literature or seen by the authors; the latter group included 37 patients with S-JIA who had 51 instances of "high disease activity" seen by the authors. The relative power of clinical, laboratory, and histopathologic variables in discriminating patients with MAS from patients with high disease activity was evaluated by calculating the sensitivity rate, specificity rate, area under the receiver operating characteristic curve, and diagnostic odds ratio (DOR). The combinations of variables that led to best separation between patients and control subjects were identified through "the number of criteria present" method.

RESULTS

The strongest clinical discriminators were hemorrhages (DOR = 67) and central nervous system dysfunction (DOR = 63); the strongest laboratory discriminators were decreased platelet count (DOR = 1092), increased aspartate aminotransferase (DOR = 247), leukopenia (DOR = 70), and hypofibrinogenemia (DOR = 165). The best separation between patients and control subjects occurred when any 2 or more laboratory criteria (DOR = 1309) were simultaneously present; the second best performance was provided by the presence of any 2, 3, or more clinical and/or laboratory criteria (DOR = 765 and 743, respectively).

CONCLUSION

We identified preliminary diagnostic guidelines for MAS complicating S-JIA. These guidelines deserve prospective validation.

Management of drug-induced liver disease

The treatment and prevention of drug-induced liver injury starts with the recognition of hepatotoxicity at the earliest possible time so that the suspected drug can be discontinued expeditiously. Both liver enzyme monitoring and vigilance for signs of hypersensitivity involving the liver are useful strategies for many agents known to cause hepatocellular necrosis leading to liver failure. Specific antidotes to prevent or limit hepatic damage exist for only a few drugs, the most important being N-acetylcysteine for the treatment of acetaminophen hepatotoxicity. Corticosteroids are of unproven benefit in the setting of fulminant failure. Ursodiol may be helpful in instances of cholestatic injury. For other agents, supportive measures and the increasing use of liver-assist devices as well as emergency liver transplantation are available when drug injury evolves into irreversible liver failure. It is hoped that a better understanding of hepatotoxicity mechanisms will lead to the development of more specific and effective forms of therapy in the near future.

The long-term effect of methotrexate therapy on the liver in patients with juvenile rheumatoid arthritis

OBJECTIVE

To determine if the long-term use of methotrexate (MTX) in juvenile rheumatoid arthritis (JRA) is associated with the development of significant liver fibrosis, and to describe the presence of risk factors for liver fibrosis in patients with JRA.

METHODS

Needle biopsies of the liver were performed on a cross-section cohort of 14 patients with JRA who had received a total cumulative dose of MTX that was either > 3,000 mg or > 4,000 mg/1.73 m2 of body surface area. Biopsy samples were independently graded according to the Roenigk Classification Scale by 2 pathologists. The presence of risk factors for MTX hepatotoxicity, especially biochemical abnormalities reflective of liver injury and alcohol consumption, were assessed.

RESULTS

Thirteen biopsy samples (93%) were classified as grade I, and 1 (7%) as grade II; none demonstrated significant fibrosis. However, histologic abnormalities were found in 13 biopsy samples (93%). Only 2 patients (14%) consumed more than 1 alcoholic drink per month. Thirteen patients (93%) had biochemical abnormalities while being treated with MTX, but only 5 patients (36%) had at least 1 determination in which the aspartate or alanine aminotransferase elevation was > 3 times the upper limit of normal.

CONCLUSION

Long-term use of MTX for JRA does not appear to be associated with the development of significant liver fibrosis. Although nearly all patients had minor histologic changes, no significant clinical consequences were apparent. A prospective study of a larger population will more accurately define the incidence of MTX-related liver fibrosis and appropriate monitoring guidelines in JRA.

Hepatotoxicity of high dose salicylate therapy in acute rheumatic fever

Liver function tests, including serum alanine aminotransferase (ALT) activity, serum bilirubin, alkaline phosphatase, serum proteins, blood ammonia levels and intravenous glucose utilization, were monitored in 50 children with acute rheumatic fever receiving anti-rheumatic doses of aspirin. There was a significant increase in blood ammonia levels and serum ALT after aspirin therapy. A significant fall in glucose utilization coefficient was also recorded. Serum alkaline phosphatase, bilirubin and total proteins did not change significantly. Twenty-two of the 50 children recorded a rise in serum ALT; in 12, the rise was five- to tenfold. These 12 children developed adverse symptoms to aspirin. Also, all had a marked rise in blood ammonia levels. The children improved clinically and biochemically on withdrawal of aspirin. There was no constant relationship between hepatocellular function and serum salicylate levels.

Adult onset Still's disease

Three patients with adult onset of Still's disease are presented. Common early findings were: septic fever, polyarthralgia, leukocytosis, neutrophilia and elevated sedimentation rate. All of them had abnormal liver function tests which returned to normal values following corticosteroid therapy. It is proposed that hepatic abnormalities in adult onset of Still's disease reflect the basic disease process.

Comparative analgesic and anti-inflammatory properties of sodium salicylate and acetylsalicylic acid (aspirin) in rheumatoid arthritis

1. Enteric coated sodium salicylate 4.8 g daily was compared with the same dose of enteric coated aspirin in 18 patients with rheumatoid arthritis. 2. After an initial washout period lasting 3 days, patients were randomly allocated to treatment with sodium salicylate or aspirin. After 2 weeks the two treatments were crossed over. 3. Pain relief, reduction in articular index of joint tenderness, increase in grip strength, decrease in digital joint circumference and patients' assessment showed significant improvement with both treatments compared with the washout period. No significant differences were found between the two therapies. 4. No correlation was found in the degree of improvement in any of the clinical outcomes and the salicylate concentrations at steady state.

Hepatotoxicity associated with choline magnesium trisalicylate: case report and review of salicylate-induced hepatotoxicity

A case of a 21-year-old woman who had developed mild hepatotoxicity while receiving choline magnesium trisalicylate therapy is described. She presented with fever and mild hepatic enzyme elevations before salicylate therapy was instituted. Liver function tests (LFT) returned to normal within five days of hospitalization but she continued to develop daily fevers. Blood, urine, and throat cultures were negative. An acute viral illness or reactivation of systemic lupus erythematosus were the suspected diagnoses. Choline magnesium trisalicylate was then administered in an effort to control her fever, and was successful. After three days of salicylate therapy her LFT values began to rise. They continued to rise for five more days before salicylate hepatotoxicity was suspected. Choline magnesium trisalicylate was discontinued after eight days and the patient's LFT quickly returned to normal. The source of fever was never identified, although infection with cytomegalovirus was considered the most likely cause. Salicylate-induced hepatotoxicity is reviewed.

Carprofen: a new nonsteroidal antiinflammatory drug. Pharmacology, clinical efficacy and adverse effects

Because a patient with arthritis (especially rheumatoid arthritis) may respond to one NSAID but not another, any addition to the ranks of these agents may be of clinical benefit to at least some of the millions of patients afflicted with rheumatoid arthritis, osteoarthritis and related conditions. In terms of potency both as an antiinflammatory and as an analgesic, carprofen appears to be in the middle of the NSAID range--roughly one-fourth as potent as indomethacin, and five times as potent as ibuprofen, milligram for milligram. The two most obvious potential advantages of carprofen are that it seems to have a low profile of major gastrointestinal adverse reactions (it may cause minor complaints similar to those seen with indomethacin, but thus far has caused no documented gastric or duodenal ulcers at 300 mg/d); and that, like naproxen, it offers the convenience of twice-a-day dosing. In clinical experience thus far, the two most bothersome adverse effects seen with carprofen have been a rare but serious photosensitivity reaction and minor, temporary elevations of liver function tests in approximately 14-20% of patients treated (although as yet there have been no reported cases of jaundice or hepatitis). For some patients with rheumatoid arthritis, osteoarthritis or related conditions, particularly for those who cannot tolerate aspirin or indomethacin or who want or need the convenience of twice-a-day dosing, carprofen may represent a useful therapeutic option to the NSAIDs previously available in this country.

Adverse reactions to nonsteroidal anti-inflammatory drugs. Diclofenac compared with other nonsteroidal anti-inflammatory drugs

The most common adverse effects of nonsteroidal anti-inflammatory drugs are gastritis, peptic ulceration, and depression of renal function, all of which result primarily from prostaglandin inhibition. The types of side effects observed with diclofenac are similar to those of other nonsteroidal anti-inflammatory drugs and are unavoidable given that the drugs are prostaglandin inhibitors. However, the incidences of such side effects may be lower with diclofenac than with some of the other nonsteroidal anti-inflammatory drugs. Worldwide experience with diclofenac exceeds 7.6 million patient-years, which should provide estimates of the frequency of very rare adverse reactions. The latter include blood dyscrasias, erythema multiforme, hepatitis, and others, such as aseptic meningitis, anaphylaxis, and urticaria. Moreover, some nonsteroidal anti-inflammatory drugs appear to have unique side-effect profiles. Examples include a higher incidence of ulceration and erythema multiforme with piroxicam, and acute pancreatitis, in rare instances, with sulindac. From a careful survey of the world's accumulated literature and reports to CIBA-GEIGY, diclofenac does not appear to have any unusual adverse reactions.

Reye syndrome in children receiving salicylate therapy for connective tissue disease

Concern that salicylates may play a role in the pathogenesis of Reye syndrome has raised the question of whether children receiving salicylate therapy for connective tissue disease are at risk for development of Reye syndrome. Of 176 patients with biopsy-confirmed Reye syndrome studied between January 1969 and June 1983, six had connective tissue disease at the time of development of Reye syndrome, and all six were receiving salicylates. Compared with the general population, children receiving salicylate therapy for connective tissue disease may be at increased risk for the development of Reye syndrome.

Acute hemorrhagic, hepatic, and neurologic manifestations in juvenile rheumatoid arthritis: possible relationship to drugs or infection

Seven children with juvenile rheumatoid arthritis had a syndrome characterized by hemorrhage and neurologic, hepatic, hematologic, and metabolic manifestations. The disease did not seem to conform clearly to the characteristics of Reye syndrome or any other well-known entity. This severe complication may be induced by macrophage activation secondary to a drug or intercurrent infection. Our data suggest that a sudden fall in erythrocyte sedimentation rate or in platelet and fibrinogen levels may mark the start of this complication and may be an indication for rapid steroid therapy.

A comparison of liver ultrastructure in salicylate intoxication and Reye's syndrome

All childhood liver biopsy specimens from The Cincinnati Children's Hospital Research Foundation which had been prepared for light and electron microscopy were reviewed to identify biopsies from children with salicylate intoxication. Only two cases of primary salicylate intoxication were identified. The histopathology and ultrastructural pathology were compared to that in two cases of Reye's syndrome which were selected because they had been treated with salicylates and had comparable serum salicylate concentrations at the time of liver biopsy. Liver biopsy specimens from the cases of salicylate intoxication were nearly normal by light microscopy. Lipid accumulation was minimal, and the content of glycogen and succinic acid dehydrogenase activity was normal. Mitochondria and peroxisomes appeared normal. Light and electron microscopy of liver specimens from the two cases of Reye's syndrome revealed swollen hepatocytes with microvesicular fat and central nuclei. Glycogen content and succinic acid dehydrogenase activity were diminished. All hepatocyte mitochondria were enlarged, pleomorphic, and had an expanded matrix and no mitochondrial dense bodies. The histopathology and ultrastructural pathology of liver biopsy specimens in salicylate intoxication were different from those in Reye's syndrome. In children in whom the diagnosis of Reye's syndrome is obscure, liver biopsy with electron microscopic examination is necessary for definitive diagnosis.

Hepatotoxic effects of anti-rheumatic drugs in cultured rat hepatocytes

Drug-induced liver injury has been suggested as a possible mechanism for the liver damage in rheumatic diseases. To evaluate the role of direct toxic action of drugs on hepatocytes, the effects of salicylate, chloroquine, prednisolone and indomethacin on LDH leakage from cultured rat hepatocytes were studied. Exposure for 24 h to the first two drugs induced liver damage, as reflected by LDH release, at concentrations 2-10 times as high as the therapeutic plasma levels in humans. Indomethacin and prednisolone at concentrations approx 50-100-fold higher than the therapeutic plasma levels, were not toxic to cultured hepatocytes. The data suggest that direct a toxic effect on hepatocytes is one possible mechanism of hepatotoxicity for salicylate and chloroquine, especially since the exposure time is much longer in humans than in the experimental model used here.

Hepatotoxicity following the therapeutic use of antipyretic analgesics

The potential for hepatic injury associated with the therapeutic use of salicylates and acetaminophen has recently attracted considerable attention. About 300 cases have been reported in which elevated transaminase levels or other evidence of hepatic injury developed following treatment with salicylates. Review of the spectrum of abnormalities reveals a group of patients (4 percent) with symptomatic liver damage in whom progressive or chronic liver disease is a possibility with continued use of the drug. In a few patients in this group, jaundice developed; several had abnormal prothrombin times; 11 (70 percent) had transaminase values in excess of 500 units; and five patients (30 percent) had encephalopathy and/or Reye's syndrome. In several reports liver damage has also been associated with the use of acetaminophen in therapeutic or near-therapeutic dosages. Of 18 patients, nine appeared to have ingested acetaminophen in amounts approaching overdose. Of the remaining nine patients, six were alcoholics. In the entire group, only five patients did not have a history of alcohol abuse; in three, glutathione depletion was suggested as a possible explanation for hepatotoxicity. The association with alcoholism or glutathione depletion suggests that host susceptibility may play a critical role. In two patients, long-term use of acetaminophen resulted in liver injury suggestive of chronic active hepatitis, possibly on the basis of an idiosyncratic reaction. In a study of chronic liver disease, acetaminophen half-life was prolonged (168 percent) without accumulation at 4 g a day over five days. In a double-blind, two-week, cross-over study, no clinical or laboratory evidence of adverse effects was found. There is, therefore, no evidence that chronic liver disease increases the risk of hepatotoxicity following the administration of acetaminophen in therapeutic doses. Thus, acetaminophen is the preferred antipyretic analgesic in patients with liver disease. Salicylates should be avoided since many of the adverse effects associated with these drugs are similar to the complications of chronic liver disease.

Salicylate hepato toxicity in rheumatic fever

Two children with rheumatic fever developed anicteric hepatitis while on high-dose aspirin therapy. The striking chemical abnormality was an elevation of serum glutamic oxalacetic transaminase (SGOT) [aspartate aminotransferase (AST)]. A percutaneous liver biopsy obtained from one of the patients showed ultrastructural abnormalities consistent with a toxic hepatitis and hepatic congestion. An awareness of this potential complication is important when treating children with aspirin at doses previously considered to be non-toxic.

Hepatic and cerebral pathology findings in children with fatal salicylate intoxication: further evidence for a causal relation between salicylate and Reye's syndrome

Histology or necropsy records of 13 children with accidental or therapeutically induced salicylate intoxication were examined for the presence of hepatic and cerebral pathology findings characteristic of Reye's syndrome. Liver sections stained with haematoxylin and eosin showed intrahepatocytic microvesiculation (10 of 12 children) and absence of significant inflammation or necrosis (10 of 12 children). All 6 specimens of liver tissue stained with oil red O showed intrahepatocytic microvesicular fat with central hepatocytic nuclei distributed either diffusely throughout the lobule or more prominently in the lobular periphery. Liver tissue stained with the periodic-acid/Schiff method showed complete absence of stainable glycogen in 5 of 6 children. 9 of 12 children for whom information was available had cerebral oedema. It is concluded that the light-microscopy hepatic findings and the gross cerebral findings for the majority of these children with salicylate intoxication are the same as those for children with Reye's syndrome.

Juvenile rheumatoid arthritis. Mode of onset as key to early diagnosis and management

Juvenile rheumatoid arthritis, which affects almost a quarter of a million American children, is diagnosed at the patient's first visit to the physician in only about half of all cases. Early diagnosis rests on recognition of three distinct modes of onset and is important in preventing deformities, blindness, and even death.

Pharmacotherapy of juvenile rheumatoid arthritis

Salicylate is the drug of first choice in the initial treatment of juvenile rheumatoid arthritis. In therapeutic dosage it will adequately control joint symptoms in the majority of patients. For children who do not respond to or are intolerant of salicylate, a change to one of the other nonsteroidal anti-inflammatory agents is appropriate. In progressive polyarthritis unresponsive to the above agents, the addition of gold, antimalarials, or penicillamine is indicated, preferably in that order. Corticosteroid therapy should be reserved for selected patients meeting specific criteria. Pharmacotherapy of juvenile rheumatoid arthritis should always be individualized. For optimal treatment of the whole child it must be combined with both physical and educational measures.

Reye's syndrome in a child on long-term salicylate medication

A case of Reye's syndrome in a four-year-old child on long-term salicylate medication for rheumatoid arthritis is reported. Severe fatty changes of the liver, lipid vacuolation in the renal proximal tubules, and severe brain oedema were the prominent postmortem findings. Symptoms of a trivial infection and vomiting just before death added to the resemblance of this case to Reye's syndrome.

Toxic encephalopathy with hyperammonaemia during high-dose salicylate therapy

High-dose, long-term aspirin therapy easily overloads the patient's individual capacity to metabolize salicylates and may lead to complex metabolic disturbances including fulminant hepatic failure, hyperammonemia and toxic metabolic encephalopathy. In the two cases presented there was a severe outbreak of hepatotoxic encephalopathy despite the fact that the dosage of salicylates did not exceed that generally recommended for children with rheumatic diseases. The justification of high-dose salicylate therapy is discussed, taking into account the fact that children with juvenile rheumatoid arthritis and allied conditions may have increased susceptibility to liver damage from drugs. EEG abnormalities in these two cases corresponded to those described in other metabolic encephalopathies including Reye's syndrome. The quality of the EEG changes gives prognostic signs, but is of restricted value in establishing the etiology without the anamnestic data of salicylate ingestion. Active therapeutic measures including exchange transfusions are needed to prevent irreversible metabolic and pressure changes in the brain.

Hepatotoxicity of mild analgesics

1 Hepatotoxicity is rare when mild analgesics are used in normal therapeutic doses. 2 The potential of aspirin and salicylates to cause hepatotoxicity has been only recently recognized. 3 Salicylate hepatitis is often asymptomatic, and may only be revealed by finding elevated levels of aminotransferases. 4 Most cases have occurred in children or young adults with connective tissue diseases, who take high doses of salicylates for long periods. 5 Hepatic injury is not recognized as a complication of acute aspirin poisoning. 6 Following overdosage of paracetamol, a toxic intermediate metabolite causes acute hepatic necrosis which may be fatal. 7 Cysteamine, methionine and N-acetylcysteine confer protection against this severe liver damage, but the time between overdosage and treatment is critical. 8 The chronic therapeutic use of paracetamol should be considered a potential but very rare cause of active chronic hepatitis. 9 There is no clear evidence of phenacetin hepatotoxicity in man. 10 Phenylbutazone may cause liver injury and other analgesics can cause hypersensitivity reactions in which the liver is involved.

Liver function in some common rheumatic disorders

Liver function was studied primarily by determination of serum gamma glutamyl transferase and alkaline phosphatase. In subsamples of patients the investigation was extended by determination of serum amino-transferases, isoenzyme analysis of alkaline phosphatase, 99mtechnetium scintigraphy, and liver biopsy. In 183 in-patients with rheumatoid arthritis, the serum gamma glutamyl transferase level was elevated in 47% and serum alkaline phosphatase (of liver origin) in 24%. A concomitant increase in serum aminotransferases was found in 15% of patients with elevated gamma glutamyl transferase level. A closely similar pattern was found in 45 patients with non-rheumatoid arthritis (ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and undefined arthritis), and in 5 patients with polymyalgia rheumatica. In 23 patients with non-rheumatic inflammation (pneumonia), liver dysfunction was common, though the pattern of serum enzyme changes was different. In rheumatoid arthritis, liver scanning showed irregular or low uptake, but biopsy only indicated reactive hepatitis. Hepatotoxicity could not be traced to any single drug or combination of drugs given. On the contrary, chloroquine appeared to reduce serum gamma glutamyl transferase, and corticosteroids had a similar effect on serum alkaline phosphatase. In patients not treated with corticosteroids, both serum gamma glutamyl transferase and alkaline phosphatase were weakly to moderately correlated with laboratory indices of disease activity (ESR and serum orosomucoid). The frequently occurring isolated increase of serum gamma glutamyl transferase and/or serum alkaline phosphatase in arthritis may be an unspecific reaction to inflammation.

Salicylate hepatotoxicity in systemic lupus erythematosus: a common occurrence?

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Hepatoxicity with encephalopathy associated with aspirin therapy in rheumatoid arthritis

Encephalopathy secondary to aspirin-induced hepatoxicity developed in three patients with JRA. In each patient clinical and biochemical resolution occurred after discontinuing the drug, but toxicity appeared on rechallenge. Liver biopsies in two patients showed mild nonspecific changes. Acute hepatic decompensation and encephalopathy may occur as a consequence of aspirin hepatoxicity in JRA and justify sequential observations of liver function tests and salicylate levels in such patients.

Costovertebral and costotransverse joint involvement in rheumatoid arthritis

Lesions of the costovertebral (CV) and costotransverse (CT) joints are distinctly unusual in rheumatoid arthritis. The patient presented had dramatic changes in these joints with destruction, ankylosis, and bony overgrowth. This led to a moderate respiratory impairment and a distinctive radiological presentation.

Cholestatic jaundice caused by D-penicillamine

D-penicillamine is not generally considered to cause hepatic damage. Cholestatic jaundice developed in a patient with rheumatoid arthritis 4 weeks after penicillamine was added to his regimen, and he died in acute renal failure. The probability that penicillamine caused the cholestasis is discussed.

Fenbufen compared with indomethacin in osteoarthrosis

A double-blind, crossover clinical trial was carried out with a new propionic acid derivative, fenbufen, versus indomethacin and placebo in 20 patients with osteoarthrosis. Active drug dosages of 75 mg indomethacin daily and 600 mg fenbufen daily were used. Fenbufen scored significantly better than placebo with respect to two and indomethacin better than placebo with respect to five of the assessment indices used. Indomethacin was significantly better than fenbufen with respect to two indices and, overall, appeared more effective in the dosages tested. Biochemical abnormalities of liver function (serum alkaline phosphatase and/or SGOT) were noted in 5 patients after fenbufen therapy (in 3 patients after 4-weeks' treatment and in 2 after 6 weeks) but in none after indomethacin therapy. The significance of these findings is discussed. It is concluded that fenbufen should be withdrawn from further clinical use until the true incidence and significance of hepatotoxicity has been evaluated.

Analgesic nephropathy: etiology, clinical syndrome, and clinicopathologic correlations in Australia

Analgesic abuse is a major public health hazard in Australia, and analgesic nephropathy with consequent terminal renal failure is the underlying cause in 20% of the patients requiring dialysis and transplantation. Analgesics are invariably taken in the form of compounds and mixtures. In the aspirin-phenacetin-caffeine (APC) mixture, aspirin appears to be the major nephrotoxic agent and phenacetin appears to play a secondary and synergistic role. The renal disease associated with abuse of analgesics is characteristic and is part of a much wider clinical syndrome, the analgesic syndrome, which includes peptic ulcer disease (35%), anemia (60 to 90%), hypertension (15 to 70%), ischemic heart disease (35%), psychological and psychiatric manifestations, pigmentation, and possible gonadal- and pregnancy-related effects. The primary lesion in analgesic nephropathy is renal papillary necrosis (RPN), and this is a nephrotoxic effect common to all nonsteroid antiinflammatory agents. The most important factor in the management of patients with analgesic nephropathy is the cessation of analgesic abuse, and this leads to improvement and stabilization of renal function. A small proportion of patients will, however, deteriorate in relation to accelerated hypertension, persistent proteinuria, ischemic heart disease, and complications leading to nephrectomy. Patients with analgesic nephropathy are poor risk patients and have a poor prognosis, even after dialysis and transplantation.