Fatal hepatic necrosis associated with parenteral gold therapy

Adverse events with ayurvedic medicines- possible adulteration and some inherent toxicities

Ayurvedic medicine, a traditional system of medicine practiced in the Indian subcontinent is considered to be devoid of adverse events. We report three cases which highlight the possibility of adverse events related with the use of ayurvedic products. A 35 year old woman with hepatitis took ayurvedic powder medicine and swarnabhasma (gold salt) and had her liver injury worsened, possibly due to alkaloids, and developed nephrotic syndrome, possibly due to gold salt. A 57 year old hypertensive man was taking ayurvedic medicine containing reserpine which had long been withdrawn from the allopathic system of medicine due to wide range of side effects. A 47 year old woman with rheumatoid arthritis was taking an unknown tablet containing steroid as an adulterant for 2 years and developed side effects typical of steroid excess. We would like to highlight the fact that ayurvedic medicines do have propensity to cause adverse events due to adulteration or inherent constituents like alkaloids, and hence may not always be completely safe.

Hepatotoxicity related to antirheumatic drugs

Antirheumatic agents are among commonly used drugs associated with adverse hepatic reactions. Sulfasalazine and azathioprine are among the most important causes of acute hepatotoxicity. Because such a large number of people take NSAIDs, even the rare occurrence of hepatotoxicity from these agents might contribute substantially to the total burden of drug-induced liver disease. A wide spectrum of hepatotoxic effects is described with antirheumatic drugs. Studies investigating genetic susceptibility to diclofenac hepatotoxicity have expanded our understanding of the potential drug-specific, class-specific and general factors involved in its pathogenesis, and methotrexate-associated liver disease demonstrates the interaction between drug, host and environmental factors that determines the likelihood and magnitude of liver disease. Infliximab therapy is associated with typical drug-induced autoimmune hepatitis. Although validated causality assessment methods have been used to objectively assess the strength of the association between a drug and a clinical event, in practice the diagnosis of drug-induced liver injury (DILI) involves a clinical index of suspicion, pattern recognition, the establishment of a temporal relationship between drug exposure and the adverse event, and the exclusion of alternative explanations for the clinical presentation. Detailed understanding of genetic and environmental factors underlying an individual's susceptibility would enable risk reduction and potentially primary prevention of hepatotoxicity.

Hepatotoxicity of anti-inflammatory and analgesic drugs: ultrastructural aspects

With the increasing incidence of drug-induced liver disease, attempts are being made to better understand the mechanisms behind these frequently life-endangering reactions. Analgesics and anti-inflammatory drugs are a major group exhibiting hepatotoxicity. We review research relating to these reactions, focusing on ultrastructural findings, which may contribute to the comprehension and possible avoidance of drug-induced liver disease. We also present some original observations on clinical material and cultured cells exposed to acetaminophen alone or in combination with the antioxidant N-acetylcysteine or the P-glycoprotein inhibitor verapamil.

Hepatotoxicity associated with non-steroidal anti-inflammatory drugs

NSAIDs are one of most frequently prescribed agents in clinical practice. Whereas hepatotoxicity is a rare complication of most NSAIDs (typically 1 to 10 per 100,000 persons exposed), the high level of usage means that these drugs cause liver disease. Because of their divergent chemical structures, the mechanisms and clinicopathological manifestations of hepatotoxicity vary widely. The reactive metabolite syndrome, in which serious rash, eosinophilia, and other forms of tissue injury are common, may be incited by several NSAIDs, including newer agents. Women, people aged more than 50 years, and for some drugs, the type of arthritis, may be risk factors for drug-induced liver injury. The spectrum of NSAID-drug related hepatotoxicity continues to expand, with reports of interactive toxicity in adults with hepatitis C and recognition of rare cases of liver disease associated with non-selective, selective, and preferential COX-2 inhibitors. Better outcomes require people taking NSAIDs to be aware of possible drug reactions involving the liver, and prescribers should be vigilant for early symptoms of hepatotoxicity so that incriminated agents are discontinued promptly.

Prolonged cholestasis and ductopenia following gold salt therapy

Hepatotoxicity, predominantly cholestatic, is a rare adverse effect of gold salt therapy, which usually completely resolves within a few months. We report the case of a female patient treated for rheumatoid arthritis, who had gold salt overdose, and in whom acute cholestatic hepatitis occurred three weeks after beginning of therapy. Evolution of gold concentration was followed in plasma and urine, as well as in cutaneous and liver dry tissue. Liver biopsy showed marked inflammatory changes of interlobular bile ducts that evolved towards ductopenia, which was responsible for prolonged cholestasis still present 15 months later. In addition, sialadenitis with sicca syndrome was noted six months after onset of the disease. The mechanism of hepatotoxicity was probably immunoallergic since liver lesions were associated with hypersensitivity syndrome including dermatitis and blood and tissue eosinophilia. This is the first report of gold salt hepatotoxicity with histological demonstration of cholangitis followed by ductopenia.

A 10 year follow up of parenteral gold therapy in patients with rheumatoid arthritis

OBJECTIVES

To study the long term tolerance of parenteral gold and subsequent drug treatment in patients with rheumatoid arthritis, including prediction of outcome and 'survival' of sequential treatments.

METHODS

A retrospective cohort study of 376 patients was made, including a detailed screening of 237 patients treated in 1989. Reasons for discontinuing treatment were analysed in life table analyses, which were used to compare patients receiving parenteral gold treatment in 1985 and 1989, and two groups of patients receiving disease modifying antirheumatic drugs after parenteral gold treatment. The causes of discontinuation were followed in sequential treatments.

RESULTS

The estimated probability of discontinuation of parenteral gold treatment was 29% after six months and 42%, 55%, 74%, and 92% after 1, 2, 5, and 10 years, respectively. Mucocutaneous side effects were the main cause of discontinuation of parenteral gold treatment during the first three years, while the probability of discontinuation because of inefficacy dominated after four years. Side effects also constituted the main cause of discontinuation of treatments given after parenteral gold treatment during the first three years of follow up. No significant differences were found when comparing the termination rates between the first and the second and subsequent treatments after parenteral gold treatment. The main reasons for discontinuing one treatment could not predict the cause of discontinuation of the next treatment.

CONCLUSION

Mucocutaneous side effects dominated initially, while inefficacy was the dominating cause of discontinuation of long term parenteral gold treatment. No serious side effects were registered. The cause of discontinuation of one treatment did not predict the cause of discontinuation of the following drug. Drug 'survival' was the same in both treatments after parenteral gold treatment.

Glucokinase activity in isolated islets from obese fa/fa Zucker rats

Glucokinase (EC 2.7.1.2) activity of B-cells was measured in extracted pancreatic islets isolated from lean and obese fa/fa Zucker rats and maintained in primary culture overnight. Formation of [14C]glucose phosphoric esters from D-[U-14C]glucose was measured in the presence of unlabelled glucose from 0.05 to 0.50 mM for hexokinase (EC 2.7.1.1) activity, and 8.0-16.0 mM unlabelled glucose for glucokinase activity. Eadie-Hofstee analysis revealed that hexokinase kinetic parameters (Vmax and Km) for [14C]glucose phosphoric ester formation were similar in lean- and fa/fa-rat islets. For glucokinase, there was no difference in Vmax. between phenotypes. A non-significant tendency to increased sensitivity to glucose was noted in the fa/fa-rat islets (P = 0.13). In lean-rat islets, the glucokinase inhibitor mannoheptulose (3 mM) decreased Vmax. by 80% and increased the apparent Km from 3.3 +/- 0.7 mM to 12.2 +/- 2.0 mM (P < 0.05). There was no difference in Km or Vmax. in mannoheptulose-treated versus control islets from fa/fa rats. This lack of effect was consistent with reported effects of mannoheptulose on insulin secretion from fa/fa-rat islets [Chan, MacPhail and Mitton (1993) Can. J. Physiol. Pharmacol. 71, 34-39]. The data from glucose and mannoheptulose experiments support the hypothesis that glucokinase function is altered in fa/fa Zucker rats and may contribute to fasting hyperinsulinaemia in vivo in these animals.

Hepatonecrosis resulting from parenteral gold therapy in pemphigus vulgaris

A patient who had pemphigus vulgaris received therapy with gold thiomalate in addition to dexamethasone. Three weeks after the initiation of parenteral gold the patient developed acute hepatitis. Causes other than gold toxicity were ruled out, and the patient recovered completely after discontinuation of gold therapy. This is the first case of acute hepatonecrosis resulting from gold therapy of pemphigus to be reported in the dermatologic literature.