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Stoynova MA, Shinkov AD, Dimitrova ID, Yankova IA, Kovatcheva RD. Comparison of the efficacy of two different glucocorticoid regimens for treatment of active moderate-to-severe Graves' orbitopathy. Int Ophthalmol 2023; 43:4747-4757. [PMID: 37698660 DOI: 10.1007/s10792-023-02875-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/26/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE Intravenous glucocorticoids (GCs) are the mainstay of treatment for severe forms of Graves' orbitopathy (GO). Our aim was to assess the effectiveness and safety of a modified monthly regimen (mMR) and to compare them with those of the established weekly regimen (WR). METHODS This was a prospective non-randomized single-center study involving 62 patients, divided into two therapeutic groups depending on their referral time. Thirty-one subjects, admitted in the period 2017-2018, were treated with mMR, total dose-5.5 g, with intake of oral GCs after completion of intravenous infusions. Thirty subjects, who were referred in the period 2019-2020, were treated with WR, total dose-4.5 g One patient refused to be part of the WR group and was treated with mMR. Eye status and therapeutic response were evaluated on the 1st, 3rd and 6th months, quality of life-at 3rd and 6th month. RESULTS At 1st month and 3rd month, there was no significant difference in the therapeutic response between the two groups. At 3rd month, the proportion of patients with improvement in soft tissue manifestations and subjective complaints was significantly higher in mMR group (65.6% vs. 40% and 81.3% vs. 46.7%, respectively) and the same manifestations were of significantly milder degree. At 3rd month, significant improvement in quality of life was found without significant difference between the two groups. At 6th month, worsening of GO occurred in 3 patients from WR group, while in 5 patients from mMR group further improvement was found. CONCLUSIONS The two GC regimens have comparable efficacy with small differences in the time of onset of the effect and its duration, as well as in the effectiveness on some ocular manifestations. Trial registration number NCT05793359/29.03.2023, retrospectively registered..
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Affiliation(s)
- Mariya Asenova Stoynova
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria.
| | - Alexander Dimitrov Shinkov
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria
| | - Inna Dimitrova Dimitrova
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria
| | - Inna Angelova Yankova
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria
| | - Roussanka Dimitrova Kovatcheva
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria
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Abstract
CONTEXT Thyroid eye disease (TED), a vision-threatening and disfiguring autoimmune process, has thwarted our efforts to understand its pathogenesis and develop effective and safe treatments. Recent scientific advances have facilitated improved treatment options. OBJECTIVE Review historically remote and recent advances in understanding TED. DESIGN/SETTING/PARTICIPANTS PubMed was scanned using search terms including thyroid-associated ophthalmopathy, thyroid eye disease, Graves' orbitopathy, autoimmune thyroid disease, and orbital inflammation. MAIN OUTCOME MEASURES Strength of scientific evidence, size, scope, and controls of clinical trials/observations. RESULTS Glucocorticoid steroids are widely prescribed systemic medical therapy. They can lessen inflammation-related manifestations of TED but fail to reliably reduce proptosis and diplopia, 2 major causes of morbidity. Other current therapies include mycophenolate, rituximab (anti-CD20 B cell-depleting monoclonal antibody), tocilizumab (interleukin-6 receptor antagonist), and teprotumumab (IGF-I receptor inhibitor). Several new therapeutic approaches have been proposed including targeting prostaglandin receptors, vascular endothelial growth factor, mTOR, and cholesterol pathways. Of potentially greater long-term importance are attempts to restore immune tolerance. CONCLUSION Despite their current wide use, steroids may no longer enjoy first-tier status for TED as more effective and better tolerated medical options become available. Multiple current and emerging therapies, the rationales for which are rooted in theoretical and experimental science, promise better options. These include teprotumumab, rituximab, and tocilizumab. Restoration of immune tolerance could ultimately become the most effective and safe medical management for TED.
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Affiliation(s)
- Terry J Smith
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA
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3
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Driggers KE, Sadowski BW, Shagla E, Kwok RM. Care of the Hepatology Patient in the COVID-19 Era. CURRENT HEPATOLOGY REPORTS 2022; 21:9-20. [PMID: 35382426 PMCID: PMC8970972 DOI: 10.1007/s11901-021-00581-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/15/2020] [Accepted: 12/16/2021] [Indexed: 01/08/2023]
Abstract
Background and Purpose of Review The COVID-19 pandemic has resulted in over 800,000 deaths worldwide and resulted in fundamental changes in practice in nearly every aspect of medicine. The majority of symptomatic patients experience liver-associated enzyme (LAE) elevations which appear to be correlated to disease severity. Furthermore, there are unique considerations of COVID-19 on chronic liver disease. Background, including epidemiology, pathophysiologic mechanisms and therapeutics, as well as the impact of COVID-19 on specific chronic liver disease, is discussed. Findings Studies suggest that degree of LAE elevation correlates with illness severity, although it is unclear whether this represents true liver injury. Numerous proposed treatments for COVID-19 have been linked with drug induced liver injury and may have clinically significant drug-drug interactions. Others may have unintended consequences on chronic liver disease treatment including reactivation of hepatitis B. The risk of severe COVID-19 in patients with chronic liver disease is largely unknown; metabolic dysfunction-associated fatty liver disease may be linked to higher risk for severe illness. Implications for cirrhosis of other etiologies, autoimmune hepatitis, and viral hepatitis are less well defined. The treatment of chronic liver disease has been severely impacted by the pandemic. The societal factors created by the pandemic have led to decreased in person visits, evolving access to invasive screening modalities, food and financial insecurity, and likely increased alcohol use. Conclusions The impacts of COVID-19 on the liver range from a potential increased risk of severe infection in chronic liver disease patients, to hepatotoxic effects of proposed treatments, to second and third order impacts on the care of patients with chronic liver disease.
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Affiliation(s)
- Kathryn E. Driggers
- Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Brett W. Sadowski
- Gastroenterology/Hepatology, Portsmouth Naval Medical Center, Portsmouth, VA USA
| | - Eva Shagla
- Gastro-Hepatology Department, Mother Theresa University Hospital Center, Tirana, Albania
| | - Ryan M. Kwok
- Chief Department of Gastroenterology/Hepatology, Madigan Army Medical Center, Tacoma WA, USA
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4
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Längericht J, Mitka KI, Hubalewska-Dydejczyk A, Krämer I, Kahaly GJ. Drug safety in thyroid eye disease - a systematic review. Expert Opin Drug Saf 2022; 21:881-912. [PMID: 35447047 DOI: 10.1080/14740338.2022.2069239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The autoimmune-induced thyroid eye disease (TED) is a frequent extrathyroidal manifestation of Graves' disease and less frequently of Hashimoto's thyroiditis. Pathognomonic clinical signs, i.e. exophthalmos, double vision, and inflammation of the orbital tissue cause physical, ophthalmic, and socio-psychological limitations. AREAS COVERED PubMed and MeSH database were searched for specific guidelines, randomized controlled trials, prospective clinical studies, systematic reviews and meta-analyses pertaining to the safety profile of currently administered immunosuppressive agents for the treatment of TED. Occurred adverse events (AE), severe AE (SAE), side effects (SE), and severe SE (SSE) were classified according to the standardized medical dictionary for regulatory activities (MedDRA). EXPERT OPINION This novel systematic analysis offers an overview of potential AE, SAE and SE for currently recommended immunosuppressive drugs for the treatment of TED. Non-specific, anti-inflammatory drugs and more specific, targeted biologicals are treatment options for active and severe TED. Critical evaluation of the pertinent literature confirms an evidence-based, beneficial efficacy/risk ratio of the current first-line and second-line treatment recommendations endorsed by the European Society of Endocrinology. However, further large, well-conceived trials are mandatory to enhance our knowledge and experience with novel specific small molecules and/or monoclonal antibodies targeting the key autoantigens in TED.
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Affiliation(s)
- Jan Längericht
- Department of Medicine I., Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Kamila I Mitka
- Department of Medicine I., Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.,Department of Endocrinology, Jagiellonian University Medical College, Cracow, Poland
| | | | - Irene Krämer
- Department of Pharmacy, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - George J Kahaly
- Department of Medicine I., Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
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Nedeljkovic Beleslin B, Ciric J, Stojkovic M, Savic S, Lalic T, Stojanovic M, Miletic M, Knezevic M, Stankovic B, Zarkovic M. Comparison of efficacy and safety of parenteral versus parenteral and oral glucocorticoid therapy in Graves' orbitopathy. Int J Clin Pract 2020; 74:e13608. [PMID: 32649036 DOI: 10.1111/ijcp.13608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/06/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND/AIMS The most effective and safe treatment protocol for Graves' orbitopathy (GO) needs to be further assessed. The aim of the present study was to evaluate the efficacy, safety and outcome of parenteral versus parenteral and oral glucocorticoid (GC) protocols in euthyroid patients with untreated and active moderate to severe GO. METHODS This was a retrospective observational study in 140 patients comparing intravenous GC pulses only (IVGC group, 74 patients, 51 ± 11 years) with historical controls of combined oral and intravenous GC therapy (CombGC group, 66 patients, 49 ± 10 years, P = ns). IVGC therapy included infusions of 500 mg of methylprednisolone weekly for the first six weeks, followed by infusions of 250 mg weekly for the remaining six weeks (cumulative dose 4.5 g). CombGC therapy included 500 mg of methylprednisolone in 500 mL of saline solution for two alternative days, followed by oral prednisone tapering dose repeated each month for the next 5 months (cumulative dose 10.2 g). RESULTS The overall success of the treatment was 43/66 (65%) in the CombGC group and 37/73 (51%, P = .071) in the IVGC group. Deterioration of GO developed in four (6%) patients during CombGC therapy and in nine (12%, P = .214) patients during IVGC therapy. After 6 months, relapse of GO was observed in 10/37 (26%) in the IVGC group, whereas none of the patients in CombGC had a relapse (P < .001). There were significantly more side effects in the CombGC versus IVGC group (49/66, 74% vs 28/74, 38%, P < .001). CONCLUSIONS Our data suggest that CombGC therapy was more efficient with significantly less relapse rate, but with more side effects in comparison to IVGC therapy.
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Affiliation(s)
- Biljana Nedeljkovic Beleslin
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Jasmina Ciric
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Mirjana Stojkovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Slavica Savic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center of Serbia, Belgrade, Serbia
| | - Tijana Lalic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center of Serbia, Belgrade, Serbia
| | - Milos Stojanovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Marija Miletic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Miroslav Knezevic
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- Clinic for Ophthalmology, Clinical Center of Serbia, Belgrade, Serbia
| | - Branislav Stankovic
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- Clinic for Ophthalmology, Clinical Center of Serbia, Belgrade, Serbia
| | - Milos Zarkovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
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Cottin J, Pierre S, Pizzoglio V, Simon C, Durrieu G, Bleyzac N, Gouraud A, Dumortier J. Methylprednisolone-related liver injury: A descriptive study using the French pharmacovigilance database. Clin Res Hepatol Gastroenterol 2020; 44:662-673. [PMID: 31948782 DOI: 10.1016/j.clinre.2019.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 12/03/2019] [Accepted: 12/18/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Hepatotoxicity associated with methylprednisolone (MP) is rarely reported in the literature. The aim of the present study was to review the characteristics of acute liver injury associated with intravenous (IV) or oral MP registered in the French pharmacovigilance database (FPD). METHODS All cases with MP coded as suspected, concomitant, or interacting drug associated with liver injury as the adverse effect reported up to May 2016 were extracted from the FPD. Cases were identified using the "Drug related hepatic disorders" Standard Medical Query. RESULTS A total of 97 cases of liver injury associated with MP were analysed; 58.8% were women and the median age was 46 years (range: 1-91). MP was used for an autoimmune disease in 47.6% of cases including 26 cases of multiple sclerosis, and was IV in 79.4% of cases. Nearly three-quarters of patients (73,2%) had a hepatocellular type of injury, the severity of which was mainly mild (45%) or moderate (31%). Most patients (92%) spontaneously and fully recovered within a mean 38.4 days. A rechallenge using the IV route was performed in 13 patients and for 10 (76.9%) this was positive (the initial type of injury was hepatocellular for all these cases). Regarding IV route of administration (n=77), MP was coded as the only suspected drug in 22% of cases. DISCUSSION The results suggest that IV MP causality should be considered in case of acute liver injury while data for oral MP is insufficient; systematic liver monitoring for high-dose IV MP may be recommended.
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Affiliation(s)
- Judith Cottin
- Service Hospitalo-Universitaire de Pharmacotoxicologie, Centre de Pharmacovigilance, Hospices Civils de Lyon, CHU-Lyon, 69003 Lyon, France.
| | - Sabrina Pierre
- Service Hospitalo-Universitaire de Pharmacotoxicologie, Centre de Pharmacovigilance, Hospices Civils de Lyon, CHU-Lyon, 69003 Lyon, France
| | - Véronique Pizzoglio
- Service Hospitalo-Universitaire de Pharmacotoxicologie, Centre de Pharmacovigilance, Hospices Civils de Lyon, CHU-Lyon, 69003 Lyon, France
| | - Corinne Simon
- Service de Pharmacosurveillance, Centre Régional de Pharmacovigilance, CHRU Tours, 37044 Tours, France
| | - Geneviève Durrieu
- Service de Pharmacologie Médicale et Clinique, Centre Régional de PharmacoVigilance, de Pharmaco-épidémiologie et d'Informations sur le Médicament, INSERM U 1027, Faculté de Médecine, Centre Hospitalier Universitaire, 31000 Toulouse, France
| | - Nathalie Bleyzac
- Service Hospitalo-Universitaire de Pharmacotoxicologie, Centre de Pharmacovigilance, Hospices Civils de Lyon, CHU-Lyon, 69003 Lyon, France
| | - Aurore Gouraud
- Service Hospitalo-Universitaire de Pharmacotoxicologie, Centre de Pharmacovigilance, Hospices Civils de Lyon, CHU-Lyon, 69003 Lyon, France
| | - Jérôme Dumortier
- Service d'Hépato-gastro-entérologie, Hôpital Edouard-Herriot, Hospices Civils de Lyon, 69003 Lyon, France
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7
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Hasenmajer V, Sbardella E, Sciarra F, Minnetti M, Isidori AM, Venneri MA. The Immune System in Cushing's Syndrome. Trends Endocrinol Metab 2020; 31:655-669. [PMID: 32387195 DOI: 10.1016/j.tem.2020.04.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/10/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022]
Abstract
Cushing's syndrome (CS), or chronic hypercortisolism, induces a variety of alterations in the immune system, often leading to severe clinical complications such as sepsis and opportunistic infections. Prolonged exposure to high levels of glucocorticoids (GC), changes in the circadian rhythm, and the comorbidities associated therewith all combine to cause profound changes in the immune profile of affected patients. While traditionally associated with generalized immune suppression, such changes actually comprise a much more complex scenario, sharing traits with chronic inflammatory disorders. Persistently increased levels of interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNFα) and adipose tissue infiltration by immune cells lead to a chronic, nonresolving, inflammatory state. The combination of low-grade inflammation and selectively impaired immune response is thought to play a major role in the pathogenesis of clinical complications of CS, including diabetes, lipodystrophy, visceral adiposity, atherosclerosis, osteoporosis, and cognitive impairment. This dysregulation also explains rebound phenomena when CS is treated, involving new clinical complications sustained by an excessive immune response and autoimmunity. The aim of this review is to summarize the available evidence on the immune system in chronic hypercortisolism, while describing the main mechanisms of immune derangement and their role in the increased mortality and morbidity seen in this complex disease. A better understanding of immune system alterations in CS could help improve risk stratification, offer novel biomarkers, and provide the basis for more tailored therapies and post-remission follow-up.
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Affiliation(s)
- Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesca Sciarra
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - Mary Anna Venneri
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
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8
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Zoubek ME, Pinazo-Bandera J, Ortega-Alonso A, Hernández N, Crespo J, Contreras F, Medina-Cáliz I, Sanabria-Cabrera J, Sanjuan-Jiménez R, González-Jiménez A, García-Cortés M, Lucena MI, Andrade RJ, Robles-Díaz M. Liver injury after methylprednisolone pulses: A disputable cause of hepatotoxicity. A case series and literature review. United European Gastroenterol J 2019; 7:825-837. [PMID: 31316787 DOI: 10.1177/2050640619840147] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 02/17/2019] [Indexed: 01/29/2023] Open
Abstract
Background and Objectives Corticosteroids are often empirically used to treat idiosyncratic hepatotoxicity with severe features. Interestingly, intravenous methylprednisolone (MP) is increasingly being recognized as being responsible for liver injury. We aimed to characterize MP-induced liver injury by analyzing demographical, clinical, laboratory and outcome data of three MP-induced hepatotoxicity cases and compared this information with that of previously published cases. Case series Three females with multiple sclerosis (MS) were treated intravenously with MP, mean daily dose 767 mg. Liver damage occurred 2 to 6 weeks after exposure. Severity was mild to moderate. Two patients suffered positive rechallenge. Literature review We identified 50 published cases of MP hepatotoxicity. Most of these cases were female (86%) and main treatment indications were MS (29 cases) and Graves' ophthalmopathy (13 cases). Hepatocellular damage predominated and mean time to onset was 6 weeks. Four patients died and rechallenge occurred in 19 cases. Conclusion MP pulses can induce severe liver injury, often with an autoimmune phenotype, particularly in patients with MS and Graves' ophthalmopathy. Consequently, these patient groups should have liver tests monitored when treated with MP to provide safer patient care.
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Affiliation(s)
- Miguel Eugenio Zoubek
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Department of Toxicology, School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - José Pinazo-Bandera
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - Aida Ortega-Alonso
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - Nelia Hernández
- Hospital de Clínicas, Clínica Gastroenterología, F Medicina, Montevideo, Uruguay
| | - Javier Crespo
- Unidad de Gestión Clínica de Enfermedades Digestivas, Hospital Marqués de Valdecilla, Instituto de Investigación Biomédica Marques de Valdecilla (IDIVAL), Santander, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Fernando Contreras
- Departamento de Gastroenterología, National University Pedro Henríquez Ureña, Santo Domingo, Dominican Republic
| | - Inmaculada Medina-Cáliz
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - Judith Sanabria-Cabrera
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Unidad Investigación Clínica y Ensayos ClÚcos (UICEC)-Instituto de Investigacióe Biomedicina de Málaga (IBIMA), Plataforma Spanish Clinical Research Network (SCReN), Málaga Spain
| | - Rocío Sanjuan-Jiménez
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Unidad Investigación Clínica y Ensayos ClÚcos (UICEC)-Instituto de Investigacióe Biomedicina de Málaga (IBIMA), Plataforma Spanish Clinical Research Network (SCReN), Málaga Spain
| | - Andrés González-Jiménez
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - Miren García-Cortés
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain
| | - M Isabel Lucena
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Unidad Investigación Clínica y Ensayos ClÚcos (UICEC)-Instituto de Investigacióe Biomedicina de Málaga (IBIMA), Plataforma Spanish Clinical Research Network (SCReN), Málaga Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Raúl J Andrade
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Mercedes Robles-Díaz
- UGC Digestivo y Farmacología Clínica, Instituto de Investigación Biomédica de Málaga (IBIMA), H U Virgen de la Victoria, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
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9
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Smith TJ. Challenges in Orphan Drug Development: Identification of Effective Therapy for Thyroid-Associated Ophthalmopathy. Annu Rev Pharmacol Toxicol 2018; 59:129-148. [PMID: 30044728 DOI: 10.1146/annurev-pharmtox-010617-052509] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Thyroid-associated ophthalmopathy (TAO), the ocular manifestation of Graves' disease, is a process in which orbital connective tissues and extraocular muscles undergo inflammation and remodeling. The condition seems to result from autoimmune responses to antigens shared by the thyroid and orbit. The thyrotropin receptor (TSHR), expressed at low levels in orbital tissues, is a leading candidate antigen. Recent evidence suggests that another protein, the insulin-like growth factor-I receptor (IGF-IR), is overexpressed in TAO, and antibodies against IGF-IR have been detected in patients with the disease. Furthermore, TSHR and IGF-IR form a physical and functional complex, and signaling initiated at TSHR requires IGF-IR activity. Identification of therapy for this rare disease has proven challenging and currently relies on nonspecific and inadequate agents, thus representing an important unmet need. A recently completed therapeutic trial suggests that inhibiting IGF-IR activity with a monoclonal antibody may be an effective and safe treatment for active TAO.
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Affiliation(s)
- Terry J Smith
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, and Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48105, USA;
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10
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Abstract
Drug-induced liver injury (DILI) is constantly changing as new drugs are approved and as new herbals and dietary supplements (HDS) reach the market. The pathologist plays a key role in the evaluation of DILI by classifying and interpreting the histologic findings considering patients' medical history and drug exposure. The liver biopsy findings may suggest alternative explanations of the injury and additional testing that should be performed to exclude non-DILI causes. Recent reports of iatrogenic liver injury are reviewed with attention to immunomodulatory and antineoplastic agents as well as reports of injury associated with HDS use.
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Affiliation(s)
- David E Kleiner
- Laboratory of Pathology, National Cancer Institute, 10 Center Drive, Building 10, Room 2S235, MSC1500, Bethesda, MD 20892, USA.
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11
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Miśkiewicz P, Jankowska A, Brodzińska K, Milczarek-Banach J, Ambroziak U. Influence of Methylprednisolone Pulse Therapy on Liver Function in Patients with Graves' Orbitopathy. Int J Endocrinol 2018; 2018:1978590. [PMID: 30420883 PMCID: PMC6215562 DOI: 10.1155/2018/1978590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 08/22/2018] [Accepted: 09/03/2018] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Intravenous methylprednisolone (IVMP) pulse therapy is the first-line treatment in active moderate-to-severe Graves' orbitopathy (GO) and dysthyroid optic neuropathy (DON). One of the adverse effects of this therapy is liver dysfunction that can be mild (ALT < 100 U/L), moderate (ALT: 100-300 U/L), and severe defined as acute liver injury (ALI) (ALT > 300 U/L). ALI can be irreversible and fatal. The aim of the study was to evaluate the influence of two different schemes of therapy with IVMP in moderate-to-severe GO and DON on biochemical liver parameters. MATERIALS AND METHODS 49 patients with moderate-to-severe GO were treated with IVMP in every week schedule (cumulative dose 4.5 g), and 19 patients with DON received 3.0 g IVMP (1.0 g/day for 3 consecutive days). AST, ALT, and total bilirubin were measured before treatment and after IVMP in the following selected pulses: after 0.5 g (A1), 3.0 g (A2), and 4.5 g (A3) in the group with moderate-to-severe GO and after 3.0 g IVMP in the group with DON (B1). RESULTS We observed a statistically higher level of AST and ALT after therapy with 3.0 g of IVMP (B1) than after 0.5 g (A1), 3.0 g (A2), and 4.5 g of IVMP (A3). Mild elevation of ALT was found in 4% and 11% of patients with moderate-to-severe GO and DON, respectively. Moderate elevation of ALT was found in 0% and 21% of patients with moderate-to-severe GO and DON, respectively. There were no cases of ALI. CONCLUSION Therapy of GO with higher doses (1.0 g) of IVMP in consecutive days is associated with higher risk of liver damage than treatment with moderate doses (≤0.5 g) in every week schedule. This trial is registered with NCT03667157.
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Affiliation(s)
- Piotr Miśkiewicz
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Anna Jankowska
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Kinga Brodzińska
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Justyna Milczarek-Banach
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Urszula Ambroziak
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
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12
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Dumortier J, Cottin J, Lavie C, Guillaud O, Hervieu V, Chambon-Augoyard C, Scoazec JY, Vukusic S, Vial T. Methylprednisolone liver toxicity: A new case and a French regional pharmacovigilance survey. Clin Res Hepatol Gastroenterol 2017; 41:497-501. [PMID: 28438569 DOI: 10.1016/j.clinre.2017.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 03/15/2017] [Accepted: 03/27/2017] [Indexed: 02/04/2023]
Abstract
Reported hepatotoxicity induced by corticosteroids is very rare, and the diagnosis is highly challenging in the context of auto-immune disease. We report here a case of high-dose methylprednisolone (MP)-induced acute hepatitis confirmed by liver histology in a patient with multiple sclerosis (MS) and a case series (n=4) notified to the French Pharmacovigilance center of Lyon. In all 5 cases, other common causes of hepatitis were excluded. The causal relationship with MP pulse therapy was supported by the fact that MP was the only culprit drug. In addition, 3 of these 5 patients underwent unintended single or multiple positive MP rechallenge. Our 5 patients scored a RUCAM score from 6 (probable) to 10 (highly probable). MP-induced liver injury is probably very rare, since only less than 30 cases have been reported in the literature. Nevertheless, our cases strongly illustrates that many cases could have been unrecognized; final diagnosis in 3 of 5 of our patients was made after the second or third episode of acute hepatitis. In conclusion, these cases we report here strongly illustrates that high-dose MP-induced liver injury can occur in patients treated for MS or auto-immune disorder. Unintended re-challenge can confirm the diagnosis and can help to distinguish it from autoimmune hepatitis. Performing liver function tests routinely both before and after MP administration would be beneficial, as the timely recognition of this complication and early drug withdrawal may prevent progression of severe necrosis hepatic injury.
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Affiliation(s)
- Jérôme Dumortier
- Service d'Hépato-gastro-entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France.
| | - Judith Cottin
- Centre de Pharmacovigilance, Service Hospitalo-Universitaire de Pharmacotoxicologie, Hospices Civils de Lyon, Lyon, France
| | - Caroline Lavie
- Université Claude Bernard Lyon 1, Lyon, France; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Olivier Guillaud
- Service d'Hépato-gastro-entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Valérie Hervieu
- Université Claude Bernard Lyon 1, Lyon, France; Service d'anatomopathologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | | | - Jean-Yves Scoazec
- Service d'anatomopathologie, Institut Gustave Roussy, Villejuif, France
| | - Sandra Vukusic
- Université Claude Bernard Lyon 1, Lyon, France; Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Thierry Vial
- Centre de Pharmacovigilance, Service Hospitalo-Universitaire de Pharmacotoxicologie, Hospices Civils de Lyon, Lyon, France
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13
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Wiersinga WM. Advances in treatment of active, moderate-to-severe Graves' ophthalmopathy. Lancet Diabetes Endocrinol 2017; 5:134-142. [PMID: 27346786 DOI: 10.1016/s2213-8587(16)30046-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 03/23/2016] [Accepted: 04/13/2016] [Indexed: 01/05/2023]
Abstract
Graves' ophthalmopathy is defined as autoimmune inflammation of extraocular muscles and orbital fat or connective tissue, usually in patients with Graves' disease. About one in 20 patients with Graves' hyperthyroidism has moderate-to-severe Graves' ophthalmopathy. Corticosteroids have been the mainstay of treatment, but new evidence about immune mechanisms has provided a basis to explore other drug classes. Intravenous methylprednisolone pulses are more effective and better tolerated than oral prednisone in the treatment of active, moderate-to-severe Graves' ophthalmopathy. Rituximab has also been suggested as a possible replacement for intravenous corticosteroids. Two randomised controlled trials of rituximab reached seemingly contradictory conclusions-rituximab was not better with respect to the primary outcome (clinical activity score) than placebo in one trial (which, however, was confounded by rather long Graves' ophthalmopathy duration), but was slightly better than intravenous methylprednisolone pulses in the other (disease flare-ups occurred only in the latter group). On the basis of evidence published so far, rituximab cannot replace intravenous methylprednisolone pulses, but could have a role in corticosteroid-resistant cases. Open-label studies of tumour-necrosis-factor-α blockade had limited efficacy, but other studies showed that interleukin-6 receptor antibodies were effective. Results of randomised controlled trials investigating the efficacy of the IGF-1 receptor antibody teprotumumab and the interleukin-6 receptor antibody tocilizumab are expected shortly. Approaches that target the causal mechanism of Graves' ophthalmopathy (antibodies or antagonists that block thyroid-stimulating-hormone receptors) also look promising.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Centre, University of Amsterdam, Netherlands.
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14
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Sabini E, Sisti E, Coco B, Leo M, Ionni I, Menconi F, Profilo MA, Mazzi B, Rocchi R, Latrofa F, Vitti P, Brunetto M, Marcocci C, Marinò M. Statins are not a risk factor for liver damage associated with intravenous glucocorticoid pulse therapy for Graves' orbitopathy. J Endocrinol Invest 2016; 39:1323-1327. [PMID: 27465669 DOI: 10.1007/s40618-016-0518-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/18/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Acute liver damage (ALD) is associated with high-dose intravenous (iv) glucocorticoid (GC) (ivGC) pulse therapy in ~1 % of patients for Graves' orbitopathy (GO). It has been proposed that statins may increase the risk of ALD. Here we investigated the frequency of ALD according to the assumption of statins in a large retrospective cohort study. METHODS We studied 1076 consecutive patients with GO given ivGC. ALD was defined as an increase in alanine aminotransferase ≥300 U/l. RESULTS At the time of ivGC, 62 patients were taking statins and 1014 were not. The frequency of ALD has been reported to be 1.2 cases/100,000 statins users and 1300/100,000 in GO patients given ivGC. Thus, the expected frequency of ALD in patients given both statins and ivGC is 1560/100,000. Transferring these data to our series, one would have expected at least 0.96 cases of ALD (~one case), in the 62 patients given both ivGC and statins. However, no cases of ALD were observed in patients given statins, and the previously reported 14 cases of ALD in this series were seen in patients who were not taking statins. CONCLUSIONS The lack of observation of cases of ALD in patients given ivGC and statins is quite reassuring. Although caution should be applied to any patient candidate to ivGC treatment and this should be particularly accurate in patients given statins, our findings somehow justify the use of ivGC in patients under statins, although further studies in larger cohorts are needed to confirm our conclusions.
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Affiliation(s)
- E Sabini
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - E Sisti
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - B Coco
- Hepatology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - M Leo
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - I Ionni
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - F Menconi
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - M A Profilo
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - B Mazzi
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - R Rocchi
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - F Latrofa
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - P Vitti
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - M Brunetto
- Hepatology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - C Marcocci
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - M Marinò
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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15
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Moleti M, Giuffrida G, Sturniolo G, Squadrito G, Campennì A, Morelli S, Puxeddu E, Sisti E, Trimarchi F, Vermiglio F, Marinò M. Acute liver damage following intravenous glucocorticoid treatment for Graves' ophthalmopathy. Endocrine 2016; 54:259-268. [PMID: 27003434 DOI: 10.1007/s12020-016-0928-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/14/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE Over the last years, there have been several reports on the occurrence of acute liver damage (ALD) in patients affected with Graves' ophthalmopathy (GO) receiving intravenous glucocorticoids (ivGCs). This article is aimed at reviewing the literature on this specific topic and reporting two new cases of ALD occurring in GO patients while on ivGCs. METHODS The terms "glucocorticoid therapy" and "Graves' Ophthalmopathy"/"Graves' Orbitopathy"/"Thyroid eye disease" were used both separately and in conjunction with the terms "liver disease," "liver damage," "hepatotoxicity," "liver failure," to search MEDLINE for articles published since the first report of ALD in 2000 and up to 2015. RESULTS ALD [defined as an increase in alanine aminotransferase (ALT) >300 U/L] during or after completion of ivGCs has been so far reported in 17 fully documented cases. Overall, one-half of those patients were diagnosed as having autoimmune hepatitis (AIH) and in the vast majority of the remaining cases a diagnosis of methylprednisolone(MP)-induced hepatotoxicity was suspected. The clinical course of liver injury varied from asymptomatic hypertransaminasemia in the vast majority of patients to fatal hepatic failure in four patients receiving higher (>8 g) cumulative doses of MP. CONCLUSIONS The overall risk of ALD is relatively low (~1 %), and seems higher using a single dose >0.5 g and a cumulative dose >8.5 g MP. Whenever ivGC treatment is required, serum liver enzymes, viral hepatitis markers, and autoantibodies related to AIH should be obtained prior to ivGC administration. Liver function should be monitored during ivGC and up to 6 months after the end of treatment. Prolonging observation after 6 months is likely unnecessary, since all cases of ALD so far reported always occurred well within this term.
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Affiliation(s)
- Mariacarla Moleti
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy.
| | - Giuseppe Giuffrida
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Giacomo Sturniolo
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Giovanni Squadrito
- Dipartimento di Patologia Umana dell'adulto e dell'età evolutiva, University of Messina, Messina, Italy
| | - Alfredo Campennì
- Dipartimento di Scienze Radiologiche, Sezione di Medicina Nucleare University of Messina, Messina, Italy
| | - Silvia Morelli
- Dipartimento di Medicina, University of Perugia, Perugia, Italy
| | - Efisio Puxeddu
- Dipartimento di Medicina, University of Perugia, Perugia, Italy
| | - Eleonora Sisti
- Dipartimento di Medicina Clinica e Sperimentale, University of Pisa, Pisa, Italy
| | - Francesco Trimarchi
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Francesco Vermiglio
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Michele Marinò
- Dipartimento di Medicina Clinica e Sperimentale, University of Pisa, Pisa, Italy
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16
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Davidov Y, Har-Noy O, Pappo O, Achiron A, Dolev M, Ben-Ari Z. Methylprednisolone-induced liver injury: Case report and literature review. J Dig Dis 2016; 17:55-62. [PMID: 26676833 DOI: 10.1111/1751-2980.12306] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 12/13/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Yana Davidov
- Liver Disease Center.,Institute of Gastroenterology
| | - Ofir Har-Noy
- Liver Disease Center.,Institute of Gastroenterology
| | | | - Anat Achiron
- Multiple Sclerosis Center, Sheba Medical Center, Tel HaShomer, Ramat Gan.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark Dolev
- Multiple Sclerosis Center, Sheba Medical Center, Tel HaShomer, Ramat Gan
| | - Ziv Ben-Ari
- Liver Disease Center.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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17
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Sisti E, Coco B, Menconi F, Leo M, Rocchi R, Latrofa F, Profilo MA, Mazzi B, Vitti P, Marcocci C, Brunetto M, Marinò M. Age and Dose Are Major Risk Factors for Liver Damage Associated with Intravenous Glucocorticoid Pulse Therapy for Graves' Orbitopathy. Thyroid 2015; 25:846-50. [PMID: 26090805 DOI: 10.1089/thy.2015.0061] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND High-dose intravenous glucocorticoid (ivGC) pulse therapy, which is commonly used for Graves' orbitopathy (GO), has been associated with acute liver damage (ALD), resulting in a fatal outcome in a few cases. No certain risk factors for ALD have been established. Consequently, a large retrospective cohort study was performed. METHODS The relationship between ALD and several potential risk factors was assessed in 1076 consecutive patients with GO given ivGC. ALD was defined as an increase of alanine aminotransferase ≥300 IU/L. RESULTS Fourteen cases of ALD were recorded, resulting in a morbidity of 1.3%. Thirteen patients recovered and one died, resulting in a mortality of 0.09%. There was a significant, positive correlation of ALD with age and methylprednisolone acetate (MPA) cumulative dose, and ALD was more common (relative risk [RR]=2.8; p=0.05) in patients aged ≥53 years (9/420; 2.14%) than in those aged <53 years (5/656; 0.76%). In patients aged ≥53 years, there was a significant positive correlation of ALD with MPA cumulative dose, and with MPA dose per infusion. Thus, the frequency of ALD in this age group was greater (RR=3.48; p=0.04) in patients with a MPA dose per infusion ≥0.7 g (5/111, 4.5% vs. 4/308, 1.29%). Regardless of age, no cases of ALD were observed for MPA doses per infusion <0.57 g. CONCLUSIONS Age and MPA dose are significant risk factors for ALD, with the following practical implications. First, the total MPA cumulative dose should not exceed 8.5 g (the average dose in patients without ALD). Second, in patients aged ≥53 years, selection and observation should be quite strict. However, being aged ≥53 years should not be seen as an absolute contraindication to ivGC, especially in patients with severe GO, considering that the risk of ALD, although statistically significant, was relatively low. Third, the MPA dose should not exceed 0.57 g per infusion, a measure to be applied regardless of age.
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Affiliation(s)
- Eleonora Sisti
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
| | - Barbara Coco
- 2 Hepatology Unit, University Hospital of Pisa , Pisa, Italy
| | - Francesca Menconi
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
| | - Marenza Leo
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
| | - Roberto Rocchi
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
| | - Francesco Latrofa
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
| | - Maria Antonietta Profilo
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
| | - Barbara Mazzi
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
| | - Paolo Vitti
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
| | - Claudio Marcocci
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
| | | | - Michele Marinò
- 1 Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa , Pisa, Italy
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18
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Sisti E, Coco B, Menconi F, Leo M, Rocchi R, Latrofa F, Profilo MA, Mazzi B, Albano E, Vitti P, Marcocci C, Brunetto M, Marinò M. Intravenous glucocorticoid therapy for Graves' ophthalmopathy and acute liver damage: an epidemiological study. Eur J Endocrinol 2015; 172:269-76. [PMID: 25661744 DOI: 10.1530/eje-14-0712] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Intravenous glucocorticoid (i.v.GC) pulse therapy for Graves' ophthalmopathy (GO) can be associated with acute liver damage (ALD), which was roughly estimated to occur in ∼1% of patients, with an overall mortality of 0.4%. The aim of this study was to evaluate the frequency of ALD after the introduction of a series of exclusion criteria and preventive measures. DESIGN Retrospective evaluation of all consecutive patients candidate to i.v.GC over a period of 5 years. METHODS The study includes 376 GO patients candidate to i.v.GC. Several liver tests were performed before, during, and after i.v.GC. To prevent ALD morbidity and mortality, the following measures were applied: i) exclusion of patients with active viral hepatitis and/or severe liver steatosis; ii) reduction in the GC dose, frequency, and number of pulses; and iii) administration of oral GC after i.v.GC, and also during i.v.GC in patients positive for nonorgan-specific autoantibodies (to prevent autoimmune hepatitis due to immune rebound). ALD was defined as an increase in alanine aminotransferase ≥ 300 U/l. RESULTS A total of 353 patients were given i.v.GC and 23 were excluded for various conditions. ALD was detected in 4/376 patients candidate to i.v.GC, resulting in a morbidity of 1.06%. One patient recovered spontaneously and three after additional treatment with oral GC, given to re-establish immune suppression in the suspect of an autoimmune hepatitis. CONCLUSIONS ALD related to i.v.GC is a relatively rare adverse event. Provided an accurate selection of patients and a series of preventive measures are applied, i.v.GC is a safe treatment for the liver.
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Affiliation(s)
- Eleonora Sisti
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Barbara Coco
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Francesca Menconi
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Marenza Leo
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Roberto Rocchi
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Francesco Latrofa
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Maria Antonietta Profilo
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Barbara Mazzi
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Eleonora Albano
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Paolo Vitti
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Claudio Marcocci
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Maurizia Brunetto
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Michele Marinò
- Endocrinology Unit IDepartment of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, ItalyHepatology UnitUniversity Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
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Riedl M, Kolbe E, Kampmann E, Krämer I, Kahaly GJ. Prospectively recorded and MedDRA-coded safety data of intravenous methylprednisolone therapy in Graves' orbitopathy. J Endocrinol Invest 2015; 38:177-82. [PMID: 25576458 DOI: 10.1007/s40618-014-0227-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/09/2014] [Indexed: 10/24/2022]
Abstract
CONTEXT Safety of intravenous (IV) steroid pulses in patients with Graves' orbitopathy (GO) is still controversial while steroid dose and treatment application have not been finalized. Frequency, severity and characterization of adverse events (AE) were prospectively analyzed. SETTING Academic referral orbital center with a joint thyroid-eye clinic. PATIENTS Eighty consecutive and unselected patients with active and severe GO. METHODS During an established treatment with IV methylprednisolone (cumulative dose 4.5 g) occurring AE were prospectively coded according to the standardized and recognized medical dictionary for regulatory activities (MedDRA). Outcome and severity of AE were documented. AEs judged as at least possibly related to drug treatment were graded as side effect (SE). AEs matching a seriousness criteria as defined by the ICH guideline E6 (good clinical practice) were graded as serious. RESULTS A total of 38.75% (31/80) of the treated GO patients reported at least one AE while 18 patients (22.5%) reported at least one SE. All SE were within the safety profile of IV methylprednisolone; 31/32 SE (96.87%) were mild-moderate and reversible and only 1/80 patient (1.25%) stopped steroid treatment due to exacerbation of her depression. Most AE were accessory symptoms of the underlying disease and a few only were directly related to IV steroids. Most AEs (90.6%) were graded as mild. Only six patients (7.5%) were hospitalized, three of them due to a dysthyroid optic neuropathy. CONCLUSIONS Prospective and standardized evaluation with MedDRA and the ICH guideline demonstrated the good pharmacological tolerance and low morbidity of this moderate steroid regimen.
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Affiliation(s)
- M Riedl
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
- Interdisciplinary Center for Clinical Trials, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - E Kolbe
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - E Kampmann
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - I Krämer
- Central Pharmacy, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany.
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Eguchi H, Tani J, Hirao S, Tsuruta M, Tokubuchi I, Yamada K, Kasaoka M, Teshima Y, Kakuma T, Hiromatsu Y. Liver Dysfunction Associated with Intravenous Methylprednisolone Pulse Therapy in Patients with Graves' Orbitopathy. Int J Endocrinol 2015; 2015:835979. [PMID: 26221141 PMCID: PMC4499413 DOI: 10.1155/2015/835979] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Intravenous methylprednisolone (IVMP) pulse therapy is the first-line treatment for the active phase of moderate to severe Graves' orbitopathy (GO). However, acute and severe liver damage has been reported during and after IVMP therapy. In this retrospective study, we investigated risk factors for liver dysfunction during and after IVMP therapy based on 175 Japanese patients with moderate to severe GO and treated at our center between 2003 and 2011. The results showed that seven patients developed severe liver dysfunction with elevated serum alanine aminotransferase (ALT > 300 U/L). Mild (40-100 U/L) and moderate (100-300 U/L) increases of ALT occurred in 62 patients (35%) and 10 patients (6%), respectively. Liver dysfunction was more frequently observed in males, in patients receiving high-dose methylprednisolone, and patients aged over 50 years. Preexistent viral hepatitis was significantly associated with liver dysfunction (65% in patients positive for hepatitis B core antibody and patients positive for hepatitis C virus antibodies). Our study confirmed the association of liver dysfunction with IVMP during and after treatment. It suggests that, in patients with GO, evaluation of preexisting risk factors-including viral hepatitis-and careful weekly monitoring of liver function during IVMP therapy and monthly thereafter for 12 months are warranted.
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Affiliation(s)
- Hiroyuki Eguchi
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Junichi Tani
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Saori Hirao
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Munehisa Tsuruta
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Ichiro Tokubuchi
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Kentaro Yamada
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Masataka Kasaoka
- Department of Ophthalmology, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Yasuo Teshima
- Department of Ophthalmology, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Tatsuyuki Kakuma
- Division of Biostatistics Center, Kurume University, Kurume 830-0011, Japan
| | - Yuji Hiromatsu
- Division of Endocrinology and Metabolism, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
- *Yuji Hiromatsu:
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Gao G, Dai J, Qian Y, Ma F. Meta-analysis of methylprednisolone pulse therapy for Graves' ophthalmopathy. Clin Exp Ophthalmol 2014; 42:769-77. [PMID: 24617953 DOI: 10.1111/ceo.12317] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 02/20/2014] [Indexed: 01/23/2023]
Abstract
A meta-analysis was performed to evaluate the efficacy of methylprednisolone pulse therapy for Graves' ophthalmopathy. Eight studies involving 376 patients were included. A higher effective rate was found for patients treated with intravenous glucocorticoids (IVGC) over oral glucocorticoids (OGC) (risk ratio [RR] = 1.48; 95% confidence interval [CI] = 1.18-1.86). The combined IVGC and orbital radiotherapy (OR) was markedly more effective than OGC+OR (RR = 1.40; 95% CI = 1.11-1.77). IVGC resulted in an obvious reduction of clinical activity score (CAS) compared with OGC, with a weighted mean difference (WMD) of 0.86 (95% CI = 0.53-1.18). The WMD for the reduction of the CAS between IVGC+OR and OGC+OR was 0.66 (95% CI = 0.30-1.02). IVGC is an effective treatment and cause fewer adverse events. Limiting the total cumulative dose of methylprednisolone, careful patient selection and monitoring the condition of patients during treatment are necessary.
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Affiliation(s)
- Guohong Gao
- Department of Ophthalmology, Eye and ENT Hospital Affiliated with Fudan University, Shanghai, China; Key Laboratory of Myopia, Ministry of Health PR China, Shanghai, China
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Carrier P, Godet B, Crepin S, Magy L, Debette-Gratien M, Pillegand B, Jacques J, Sautereau D, Vidal E, Labrousse F, Gondran G, Loustaud-Ratti V. Acute liver toxicity due to methylprednisolone: consider this diagnosis in the context of autoimmunity. Clin Res Hepatol Gastroenterol 2013; 37:100-4. [PMID: 23318289 DOI: 10.1016/j.clinre.2012.10.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 10/07/2012] [Accepted: 10/17/2012] [Indexed: 02/04/2023]
Abstract
The occurrence of corticosteroid-induced hepatitis is a rare event that has been recently described in the literature. We report the case of an acute cytolytic hepatitis in a patient treated with methylprednisolone for multiple sclerosis associated with an autoimmune thyroid dysfunction. After ruling out other etiologies, we concluded that the acute liver injury was due to steroids, and we analyzed the specific circumstances in the literature where methylprednisolone may have been responsible for acute hepatitis.
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Affiliation(s)
- P Carrier
- Service d'hépato-gastroentérologie, CHU de Limoges, 2, avenue Martin-Luther-King, 87042 Limoges, France.
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Botta R, Lisi S, Marcocci C, Sellari-Franceschini S, Rocchi R, Latrofa F, Menconi F, Altea MA, Leo M, Sisti E, Casini G, Nardi M, Pinchera A, Vitti P, Marinò M. Enalapril reduces proliferation and hyaluronic acid release in orbital fibroblasts. Thyroid 2013; 23:92-6. [PMID: 23030053 DOI: 10.1089/thy.2012.0373] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Orbital fibroblast proliferation and hyaluronic acid (HA) release are responsible for some of the clinical features of Graves' ophthalmopathy (GO). Thus, inhibition of these processes may be a possible therapeutic approach to this syndrome. Enalapril, a widely used antihypertensive drug, was found to have some inhibitory actions on fibroblast proliferation in cheloid scars in vivo, based on which we investigated its effects in primary cultures of orbital fibroblasts from GO patients and control subjects. METHODS Primary cultures of GO and control fibroblasts were treated with enalapril or with a control compound (lisinopril). Cell proliferation assays, lactate dehydrogenase release assays (as a measure of cell necrosis), apoptosis assays, and measurement of HA in the cell media were performed. RESULTS Enalapril significantly reduced cell proliferation in both GO and control fibroblasts. Because enalapril did not affect cell necrosis and apoptosis, we concluded that its effects on proliferation reflected an inhibition of cell growth and/or a delay in cell cycle. Enalapril significantly reduced HA concentrations in the media from both GO and control fibroblasts. CONCLUSIONS Enalapril has antiproliferative and HA suppressing actions in both GO and control fibroblasts. Clinical studies are needed to investigate whether enalapril has any effects in vivo in patients with GO.
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Marcocci C, Marinò M. Treatment of mild, moderate-to-severe and very severe Graves' orbitopathy. Best Pract Res Clin Endocrinol Metab 2012; 26:325-37. [PMID: 22632369 DOI: 10.1016/j.beem.2011.11.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Treatment of Graves' orbitopathy (GO) is better performed through a multidisciplinary approach. Euthyroidism should be promptly restored. Antithyroid drug and thyroidectomy are not disease-modifying treatments, whereas radioiodine may be associated with worsening of GO. This risk is eliminated by glucocorticoid prophylaxis. Treatments for GO differ depending on its severity and activity. Mild forms should be treated with local measures. In addition a course of selenium may be beneficial. Glucocorticoids (oral or intravenous) represent the main treatment of moderate-to-severe GO, the intravenous route being more effective. Weekly pulses of methylprednisolone are used and the cumulative dose should not exceed 8 g. Severe adverse events have been reported, particularly with higher doses. Orbital radiotherapy can be used either alone or associated with glucocorticoids. In very severe sight-threatening GO high dose intravenous glucocorticoid should be the initial treatment, orbital decompression being considered in nonresponding patients. Rehabilitative surgery should be deferred until GO becomes inactive.
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Affiliation(s)
- Claudio Marcocci
- Department of Endocrinology and Metabolism, University of Pisa, 56127 Pisa, Italy.
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Marcocci C, Watt T, Altea MA, Rasmussen AK, Feldt-Rasmussen U, Orgiazzi J, Bartalena L. Fatal and non-fatal adverse events of glucocorticoid therapy for Graves' orbitopathy: a questionnaire survey among members of the European Thyroid Association. Eur J Endocrinol 2012; 166:247-53. [PMID: 22058081 DOI: 10.1530/eje-11-0779] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the side effects of glucocorticoid (GC) therapy observed by European thyroidologists during the treatment of Graves' orbitopathy (GO). DESIGN A questionnaire-based survey among members of the European Thyroid Association (ETA) who treat GO. RESULTS A response was obtained from 128 ETA members of which 115 used GC therapy for GO. The majority of respondents (83/115, 72%) used intravenous (i.v.) GC, with a relatively wide variety of therapeutic regimens. The cumulative dose of methylprednisolone ranged between 0.5 and 12 g (median 4.5 g) for i.v.GC and between 1.0 and 4.9 g (median 2.4 g) for oral GC. Adverse events were often reported during oral GCs (26/32, 81%); most side effects were non-severe, but ten respondents reported severe adverse events (hepatic, cardiovascular, and cerebrovascular complications), including two fatal cases, both receiving a total of 2.3 g prednisone. Adverse events were less common in i.v.GC (32/83 respondents, 39%), but mostly consisted of severe events, including seven fatal cases. All but one fatal event occurred in cumulative i.v.GC doses (>8 g) higher than those currently recommended. CONCLUSIONS GCs are preferentially administered i.v. for the treatment of GO in Europe. Both oral and i.v.GC may be associated with severe adverse effects, including fatal cases, which are more frequently reported in daily or alternate day i.v.GC. IvGC therapy should be undertaken in centers with appropriate expertise. Patients should be carefully examined for risk factors before treatment and monitored for side effects, which may be asymptomatic, both during and after treatment.
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Affiliation(s)
- Claudio Marcocci
- Department of Endocrinology and Metabolism, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy.
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Abstract
BACKGROUND Immunosuppressive therapy with glucocorticoids alone or in combination with radiotherapy is first-choice treatment for the active phase of Graves' ophthalmopathy (GO). Intravenous methylprednisolone (mPRED) pulse therapy is much more effective, safer, and better tolerated than steroids orally administered. There have been some reports, however, of unfavorable reactions to mPRED pulse therapy on liver function. Here, we report laboratory test results in patients with GO before and after intravenous mPRED therapy. METHODS Thirty patients (24 women and 6 men) whose mean age was ± standard error of the mean 53±1.3 participated in the study. All patients were treated with mPRED for their history of GO. None had received radiotherapy before mPRED. There was no history of liver disease including viral hepatitis in any of the patients. A battery of tests including general serum chemistries and liver function tests as well as those relating to clotting parameters and viral forms of hepatitis were performed a week before and 2 days after mPRED therapy. RESULTS mPRED pulse therapy caused a significant, below reference range, decrease in alkaline phosphatase activity from 119.43±14.98 to 105.53±13.98 IU/L and an increase in gamma-glutamyltranspeptidase activity (above reference range, but not statistically significant) from 23.76±2.93 to 25.3±1.52 IU/L. No significant changes were noted in other liver enzymes activities. We also observed a significant, below reference range, decrease in serum total protein as well as a significant, above reference range, increase of alpha-1 globulins, and low-density lipoproteins cholesterol levels. Pulse therapy also resulted in a significant, but still within reference range, decreases in activated partial thromboplastin time (APTT) from 29.03±0.86 to 26.13±1.16 s, fibrinogen from 3.85±0.2 to 3.05±0.13 g/L, and increase of International Normalized Ratio (INR) from 1.06±1.06 to 1.11±0.06. Despite a lack of a history of viral hepatitis, six patients had positive tests for anti-Hepatitis B e (HBe) antibodies before mPRED administration. In two of these patients, anti-HBe antibody tests became negative after mPRED treatment. In two of the six patients who had positive anti-HBe antibodies, anti-HBc antibodies in the IgG class were also present before and after mPRED treatment. Another patient was found to have anti-HBc IgG both before and after mPRED treatment. Other markers of A and C viral hepatitis were negative in all patients. CONCLUSIONS Patients who are on anticoagulents need careful monitoring of their INR, APTT, and fibrinogen while on mPRED therapy. We recommend at least once a week. In patients without evidence for active viral replicating disease, but with past hepatitis B, as judged by the presence of pertinent markers, mPRED pulse therapy for GO does not appear to reactivate hepatitis B.
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Affiliation(s)
- Hanna Wichary
- Department of Internal Diseases and Oncologic Chemotherapy, Silesian Medical University, Katowice, Poland
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Lisi S, Botta R, Lemmi M, Sellari-Franceschini S, Altea MA, Sisti E, Casini G, Nardi M, Marcocci C, Pinchera A, Marinò M. Quercetin decreases proliferation of orbital fibroblasts and their release of hyaluronic acid. J Endocrinol Invest 2011; 34:521-7. [PMID: 21042042 DOI: 10.3275/7321] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inhibition of fibroblast (FB) proliferation and hyaluronic acid (HA) production may be a therapeutic approach to Graves' ophthalmopathy (GO). The flavonoid quercetin has a wide range of activities, including reduction of FB growth. AIM To investigate the effects of quercetin in orbital FB from GO patients and control subjects. METHODS Primary cultures of orbital FB were treated with quercetin or with its glycosides rutin and quercitrin. Cell proliferation, necrosis, apoptosis, HA production, and cell cycle were measured. RESULTS Beginning at a 30 μM concentration, quercetin, but not rutin and quercitrin, reduced cell proliferation, with no difference between GO and control FB. The effect of quercetin on proliferation was due to necrosis and cell cycle blockade, whereas apoptosis was unaffected. Quercetin reduced HA in the cell media, with no difference between GO and control FB. CONCLUSIONS Quercetin reduces cell proliferation and HA release in orbital FB. Whether these initial findings have any potential for the use of quercetin in the clinical practice remains to be established.
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Affiliation(s)
- S Lisi
- Department of Endocrinology, University of Pisa, Pisa, Italy.
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Bolus de méthylprednisolone révélant une hépatite auto-immune chez une patiente atteinte de sclérose en plaques. ACTA ACUST UNITED AC 2009. [DOI: 10.1007/s12157-009-0116-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Sánchez-Ortiga R, Moreno-Pérez O, González Sánchez V, Arias Mendoza N, Mauri Dot M, Alfayate Guerra R, López Macia A, Picó Alfonso A. Treatment of Graves' ophthalmopathy with high-dose intravenous methylprednisolone: a comparison of two dosing regimens. ACTA ACUST UNITED AC 2009; 56:118-22. [PMID: 19627724 DOI: 10.1016/s1575-0922(09)70841-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 03/03/2009] [Indexed: 11/28/2022]
Abstract
RATIONALE AND OBJECTIVE The treatment of active moderate-severe Graves' ophthalmopathy (GO) is based on the administration of highdose intravenous glucocorticoids. The present study compares the efficacy and safety of 2 different intravenous methylprednisolone (MTPiv) dosing regimens. MATERIAL AND METHODS We carry a retrospective descriptive study with sequential sampling of 24 patients (83% females) presenting moderatesevere GO (EUGOGO criteria) and receiving treatment in our center between January 2006 and June 2008. We use 2 dosing regimens: regimen A (12 weeks): 6 doses of 0.5g/week followed by 6 doses of 0.25 g/week, for a cumulative dose of 4.5 g of MTPiv (n=13); and regimen B (16 weeks): 4 cycles of 15 mg/kg, followed by 4 cycles of 7.5mg/kg, for a cumulative dose of 90 mg/kg (range, 4.9-7.4 g) (n=11). Comparisons were made for safety (fasting glucose, cytolysis-cholestasis enzymes, lipid profile) and efficacy data (clinical improvement and recurrence). RESULTS Mild-moderate liver cytolysis was recorded in four patients, one with associated moderate cholestasis and another with hyperglycemia, leading to treatment suspension - with no differences between the 2 treatment regimens. Percentage clinical improvement with regimen A was 92% (CI, 65-94%) versus 100% with regimen B (CI, 74-100%). The recurrence rate was 43% with regimen A and 63% with regimen B (p>0.05). None of the variables examined in the univariate logistic regression study were associated to a lesser treatment response or increased risk of recurrence of GO. CONCLUSIONS The treatment of GO with MTPiv is safe and effective, with a lower recurrence rate when using dosing regimen A.
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Affiliation(s)
- Ruth Sánchez-Ortiga
- Endocrinology Department, Alicante General Universitary Hospital, Alicante, Spain
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Abstract
The NF-kappaB signaling pathway has particular relevance to several liver diseases including hepatitis (liver infection by Helicobacter, viral hepatitis induced by HBV and HCV), liver fibrosis and cirrhosis and hepatocellular carcinoma. Furthermore, the NF-kappaB signaling pathway is a potential target for development of hepatoprotective agents. Several types of drugs including: selective estrogen receptor modulators (SERMs), antioxidants, proteasome inhibitors, IKK inhibitors and nucleic acid-based decoys have been shown to interfere with NF-kappaB activity at different levels and may be useful for the treatment of liver diseases. However, NF-kappaB also plays an important hepatoprotective function that needs to be taken into consideration during development of new therapeutic regimens.
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Affiliation(s)
- B Sun
- Liver Transplantation Center of the First Affiliated Hospital and Cancer Center, Nanjing Medical University, Nanjing, Jiangsu Province, PR China
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Takahashi A, Kanno Y, Takahashi Y, Sakamoto N, Monoe K, Saito H, Abe K, Yokokawa J, Irisawa A, Ohira H. Development of autoimmune hepatitis type 1 after pulsed methylprednisolone therapy for multiple sclerosis: A case report. World J Gastroenterol 2008; 14:5474-7. [PMID: 18803363 PMCID: PMC2744174 DOI: 10.3748/wjg.14.5474] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A 43-year-old woman with multiple sclerosis (MS) was treated with pulsed methylprednisolone and interferon β at a hospital. Four weeks after initiating treatment, liver dysfunction occurred and she was referred and admitted to our hospital. Clinical and laboratory findings were consistent with and fulfilled the criteria for drug-induced hepatitis, but not for autoimmune hepatitis (AIH). She was successfully treated with corticosteroids. As ataxia developed after 1 year, she was treated with pulsed methylprednisolone for 3 d, then readmitted to our hospital when liver dysfunction occurred. Clinical and laboratory findings led to the diagnosis of AIH. To the best of our knowledge, this is the second case of AIH developed after pulsed methylprednisolone for MS.
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Autoimmune hepatitis after high-dose intravenous methylprednisolone pulse in RR-MS. Open Med (Wars) 2007. [DOI: 10.2478/s11536-007-0025-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractThree weeks after the administration of intravenous methylprednisolone therapy, a 42-year-old female patient suffering from relapsing-remitting multiple sclerosis (RR-MS) presented with a profound elevation of liver transaminases (GOT 485 U/l, GPT 1082 U/l, glutamyl transpeptidase 170 U/l). Liver biopsy revealed a profound, still active hepatitis with portal lymphocytic infiltration and fibrosis. Most likely, existing acute hepatitis was of autoimmune origin and emerged from an immune rebound phenomenon after immunosuppressive therapy.
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Marcocci C, Pinchera A, Marinò M. A treatment strategy for Graves' orbitopathy. ACTA ACUST UNITED AC 2007; 3:430-6. [PMID: 17452970 DOI: 10.1038/ncpendmet0500] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Accepted: 01/12/2007] [Indexed: 11/08/2022]
Abstract
BACKGROUND A 59-year-old woman with a history of nodular goiter developed thyrotoxic symptoms while on levothyroxine therapy. Her thyrotoxicosis persisted after levothyroxine withdrawal, so she was given methimazole and, once euthyroid, underwent near-total thyroidectomy. Histological examination revealed a nodular variant of Graves' disease. Proptosis, eyelid swelling and diplopia appeared 2 months after surgery. These symptoms worsened, and the patient was initially given four intravenous pulses of glucocorticoids, which resulted in a transient amelioration of her eye symptoms. After glucocorticoid withdrawal, however, the patient's eye motility worsened and there was a reduction of visual acuity in the left eye. She was then referred to our hospital for further advice and treatment. INVESTIGATIONS Complete thyroid and ophthalmological evaluation, computerized visual field analysis, CT scan of the orbits, routine blood tests, search for occult fecal blood, blood tests for hepatitis B and C virus markers, measurements of serum non-organ-specific autoantibodies and serum anti-TSH-receptor antibodies, and liver ultrasonography. DIAGNOSIS Nodular Graves' disease with severe, active Graves' orbitopathy complicated by optic neuropathy. MANAGEMENT Intravenous glucocorticoid therapy for 3 consecutive days, followed by once-weekly pulses of intravenous glucocorticoids over a 10-week period, and then by oral prednisone treatment on alternate days for 2 months. During the first 2 weeks of intravenous glucocorticoid therapy the patient received orbital irradiation. Therapy resulted in optimized visual acuity and a moderate improvement of soft-tissue inflammatory signs and symptoms, whereas proptosis and eye motility improved only slightly. The patient is now scheduled for orbital decompression and rehabilitative surgery.
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Affiliation(s)
- Claudio Marcocci
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
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Le Moli R, Baldeschi L, Saeed P, Regensburg N, Mourits MP, Wiersinga WM. Determinants of liver damage associated with intravenous methylprednisolone pulse therapy in Graves' ophthalmopathy. Thyroid 2007; 17:357-62. [PMID: 17465867 DOI: 10.1089/thy.2006.0267] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Intravenous methylprednisolone pulses (IVMP) are more efficacious and better tolerated than oral prednisone in Graves' ophthalmopathy (GO) patients. However, acute and severe liver damage has been reported in sporadic cases during IVMP, resulting in fatal acute liver failure in four patients so far. The mechanism causing the liver damage is incompletely understood. DESIGN We performed a prospective observational study in 13 patients with dysthyroid optic neuropathy (group A) and in 14 patients with moderately severe GO (group B) who were treated with high-dose (group A) or low-dose (group B) IVMP; cumulative steroid doses were 8.45 g in group A and 4.5 g in group B, and follow-up time was 24 weeks. MAIN OUTCOME Slight increases in serum aminotransferases (in alanine aminotransferase [ALAT] more than in aspartate aminotransferase [ASAT]) were observed, in seven patients exceeding the upper normal limit of 40 U/L. These changes were more prominent in group A than in group B as was also evident from a decrease in ASAT/ALAT ratio in group A but not in group B. Changes in serum aminotransferases occurred especially in the first 6 weeks of IVMP, becoming smaller thereafter with the decrease in steroid dosage. Pretreatment liver steatosis or diabetes were not related to liver damage, but preexistent viral hepatitis was. CONCLUSION IVMP in GO patients causes dose-dependent liver damage by a direct toxic effect of glucocorticoids on hepatocytes. Nevertheless, IVMP seems to be pretty safe if cumulative doses exceeding 8 g are avoided and liver function is checked before and at regular intervals during pulse therapy.
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Affiliation(s)
- Rosario Le Moli
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, The Netherlands
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Bartalena L, Marcocci C, Tanda ML, Piantanida E, Lai A, Marinò M, Pinchera A. An update on medical management of Graves' ophthalmopathy. J Endocrinol Invest 2005; 28:469-78. [PMID: 16075933 DOI: 10.1007/bf03347230] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Graves' ophthalmopathy (GO), the most frequent extrathyroidal manifestation of Graves' disease, is a disorder of autoimmune origin, the pathogenic mechanisms of which are still incompletely understood. Although GO is severe in only 3-5% of affected individuals, quality of life is severely impaired even in patients with mild GO. Management of severe GO can be either medical or surgical (orbital decompression, eye muscle or lid surgery). Medical management relies on the use of high-dose systemic glucocorticoids or orbital radiotherapy, either alone or in combination. Studies carried out in the last 5 yr have shown that glucocorticoids are more effective through the i.v. route than through the oral route. However, particular attention should be paid to possible liver toxicity of i.v. glucocorticoids. Recent randomized clinical trials have, with one exception, confirmed that orbital radiotherapy is an effective and safe therapeutic procedure for GO. At variance with previous encouraging data, recent randomized clinical trials have shown that currently available SS analogs are not very effective in the management of GO. Antioxidants might have a role, at least in mild forms of GO. Particular attention should be paid to correction of risk factors (cigarette smoking, thyroid dysfunction, radioiodine therapy) involved in GO progression.
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Affiliation(s)
- L Bartalena
- Department of Clinical Medicine, University of Insubria, Varese, Italy.
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