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Lou S, Cui S. Drug treatment of epilepsy: From serendipitous discovery to evolutionary mechanisms. Curr Med Chem 2021; 29:3366-3391. [PMID: 34514980 DOI: 10.2174/0929867328666210910124727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/17/2021] [Accepted: 07/21/2021] [Indexed: 11/22/2022]
Abstract
Epilepsy is a chronic brain disorder caused by abnormal firing of neurons. Up to now, using antiepileptic drugs is the main method of epilepsy treatment. The development of antiepileptic drugs lasted for centuries. In general, most agents entering clinical practice act on the balance mechanisms of brain "excitability-inhibition". More specifically, they target voltage-gated ion channels, GABAergic transmission and glutamatergic transmission. In recent years, some novel drugs representing new mechanisms of action have been discovered. Although there are about 30 available drugs in the market, it is still in urgent need of discovering more effective and safer drugs. The development of new antiepileptic drugs is into a new era: from serendipitous discovery to evolutionary mechanism-based design. This article presents an overview of drug treatment of epilepsy, including a series of traditional and novel drugs.
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Affiliation(s)
- Shengying Lou
- Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou. China
| | - Sunliang Cui
- Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou. China
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2
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Teschke R, Danan G. Worldwide Use of RUCAM for Causality Assessment in 81,856 Idiosyncratic DILI and 14,029 HILI Cases Published 1993-Mid 2020: A Comprehensive Analysis. MEDICINES (BASEL, SWITZERLAND) 2020; 7:E62. [PMID: 33003400 PMCID: PMC7600114 DOI: 10.3390/medicines7100062] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 04/12/2023]
Abstract
Background: A large number of idiosyncratic drug induced liver injury (iDILI) and herb induced liver injury(HILI) cases of variable quality has been published but some are a matter of concern if the cases were not evaluated for causality using a robust causality assessment method (CAM) such as RUCAM (Roussel Uclaf Causality Assessment Method) as diagnostiinjuryc algorithm. The purpose of this analysis was to evaluate the worldwide use of RUCAM in iDILI and HILI cases. Methods: The PubMed database (1993-30 June 2020) was searched for articles by using the following key terms: Roussel Uclaf Causality Assessment Method; RUCAM; Idiosyncratic drug induced liver injury; iDILI; Herb induced liver injury; HILI. Results: Considering reports published worldwide since 1993, our analysis showed the use of RUCAM for causality assessment in 95,885 cases of liver injury including 81,856 cases of idiosyncratic DILI and 14,029 cases of HILI. Among the top countries providing RUCAM based DILI cases were, in decreasing order, China, the US, Germany, Korea, and Italy, with China, Korea, Germany, India, and the US as the top countries for HILI. Conclusion: Since 1993 RUCAM is certainly the most widely used method to assess causality in IDILI and HILI. This should encourage practitioner, experts, and regulatory agencies to use it in order to reinforce their diagnosis and to take sound decisions.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, D-63450 Hanau, Teaching Hospital of the Medical Faculty of the Goethe University, D-60590 Frankfurt/Main, Germany
| | - Gaby Danan
- Pharmacovigilance Consultancy, F-75020 Paris, France;
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3
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Dondorf F, Croner RS, Tautenhahn HM, Felgendreff P, Ardelt M, Settmacher U, Rauchfuss F. Liver Transplant Due to Flupirtine-Induced Acute Liver Failure. EXP CLIN TRANSPLANT 2020; 18:481-484. [PMID: 32635884 DOI: 10.6002/ect.2019.0297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Acute drug-induced liver failure is a rare indication for liver transplant. There is only one case of flupirtine-induced liver failure requiring transplant in the literature. In February 2018, the European Medicines Agency issued a withdrawal of approval for flupirtine medication in European countries as a result of the risk of acute liver failure. MATERIALS AND METHODS The aim of this study was a German-wide collection of data regarding patients with liver transplant as a result of flupirtine-associated liver failure. RESULTS A total of 9 patients received transplants. All patients were women with a mean age of 43 years. Indication for flupirtine medication was musculoskeletal symptoms and migraine headache. The medication was taken over a period of approximately 3 months. All patients developed progressive acute liver failure, and no patient had previous chronic liver disease or cirrhosis. The mean laboratory Model for End Stage Liver Disease score for the patients was 31 ± 7 at time of transplant. Eight of the 9 patients were listed as "high urgency" for transplant. After transplant, they had an uneventful course with a prolonged mean intensive care unit stay of 13 ± 8.7 days. The whole hospitalization time was 43 ± 21 days. CONCLUSIONS This is the largest published series of patients who received liver transplant after a drug-induced acute liver failure from flupirtine medication.
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Affiliation(s)
- Felix Dondorf
- From the Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
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4
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Abstract
The highly structurally similar drugs flupirtine and retigabine have been regarded as safe and effective for many years but lately they turned out to exert intolerable side effects. While the twin molecules share the mode of action, both stabilize the open state of voltage-gated potassium channels, the form and severity of adverse effects is different. The analgesic flupirtine caused drug-induced liver injury in rare but fatal cases, whereas prolonged use of the antiepileptic retigabine led to blue tissue discoloration. Because the adverse effects seem unrelated to the mode of action, it is likely, that both drugs that occupied important therapeutic niches, could be replaced. Reasons for the clinically relevant toxicity will be clarified and future substitutes for these drugs presented in this review.
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5
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Surur AS, Beirow K, Bock C, Schulig L, Kindermann MK, Bodtke A, Siegmund W, Bednarski PJ, Link A. Flupirtine Analogues: Explorative Synthesis and Influence of Chemical Structure on K V7.2/K V7.3 Channel Opening Activity. ChemistryOpen 2019; 8:41-44. [PMID: 30652063 PMCID: PMC6331712 DOI: 10.1002/open.201800244] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/26/2018] [Indexed: 12/19/2022] Open
Abstract
Neuronal voltage‐gated potassium channels KV7.2/KV7.3 are sensitive to small‐molecule drugs such as flupirtine, even though physiological response occurs in the absence of ligands. Clinically, prolonged use of flupirtine as a pain medication is associated with rare cases of drug‐induced liver injury. Thus, safety concerns prevent a broader use of this non‐opioid and non‐steroidal analgesic in therapeutic areas with unmet medical needs such as hyperactive bladder or neonatal seizures. With the goal of studying influences of chemical structure on activity and toxicity of flupirtine, we explored modifications of the benzylamino bridge and the substitution pattern in both rings of flupirtine. Among twelve derivatives, four novel thioether derivatives showed the desired activity in cellular assays and may serve as leads for safer KV channel openers.
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Affiliation(s)
- Abdrrahman S Surur
- Institute of Pharmacy University of Greifswald Friedrich-Ludwig-Jahn-Str. 17 17489 Greifswald Germany
| | - Kristin Beirow
- Institute of Pharmacy University of Greifswald Friedrich-Ludwig-Jahn-Str. 17 17489 Greifswald Germany
| | - Christian Bock
- Institute of Pharmacy University of Greifswald Friedrich-Ludwig-Jahn-Str. 17 17489 Greifswald Germany
| | - Lukas Schulig
- Institute of Pharmacy University of Greifswald Friedrich-Ludwig-Jahn-Str. 17 17489 Greifswald Germany
| | - Markus K Kindermann
- Institute of Pharmacy University of Greifswald Friedrich-Ludwig-Jahn-Str. 17 17489 Greifswald Germany
| | - Anja Bodtke
- Institute of Pharmacy University of Greifswald Friedrich-Ludwig-Jahn-Str. 17 17489 Greifswald Germany
| | | | - Patrick J Bednarski
- Institute of Pharmacy University of Greifswald Friedrich-Ludwig-Jahn-Str. 17 17489 Greifswald Germany
| | - Andreas Link
- Institute of Pharmacy University of Greifswald Friedrich-Ludwig-Jahn-Str. 17 17489 Greifswald Germany
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6
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Puljak L. Prescribers' compliance is part of benefit-risk assessment of medicines and it can lead to failure of risk minimization measures and withdrawals of medicines. Curr Med Res Opin 2019; 35:5-6. [PMID: 30252554 DOI: 10.1080/03007995.2018.1528217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Livia Puljak
- Cochrane Croatia, University of Split School of Medicine, Split, Croatia
- Agency for Quality and Accreditation in Health Care and Social Welfare, Zagreb, Croatia
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7
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Patil MA, Matter BA, Raol YH, Bourne DWA, Kelley RA, Kompella UB. Brain Distribution and Metabolism of Flupirtine, a Nonopioid Analgesic Drug with Antiseizure Effects, in Neonatal Rats. Pharmaceutics 2018; 10:E281. [PMID: 30558371 PMCID: PMC6320943 DOI: 10.3390/pharmaceutics10040281] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/07/2023] Open
Abstract
Flupirtine, a nonopioid analgesic drug, is effective in treating neonatal seizures. However, its brain delivery and pharmacokinetics are unknown in neonatal mammals. The purpose of this study was to determine the pharmacokinetics of flupirtine and the formation of its active metabolite D-13223 in various tissues such as brain in neonate animals. On postnatal day 7, rat pups received 25 mg/kg of flupirtine intraperitoneally. Liver; heart; kidney; lung; spleen; retina; serum; and brain regions hippocampus, cortex, and the remaining brain (devoid of cerebellum) were harvested up to 24-h postdosing. An LC-MS/MS assay was developed to quantify flupirtine and D-13223. Flupirtine was delivered to all tissues assessed, with the highest area under the concentration vs. time curve (AUC0⁻24h) in liver (488 µg·h/g tissue) and the lowest in spleen (82 µg·h/g tissue). Flupirtine reached the brain, including the hippocampus and cortex, within 1 h of dosing and persisted at 24 h. Flupirtine AUC in various brain regions was approximately 195 µg·h/g tissue. The half-life of flupirtine in various tissues ranged from 3.1 to 5.2 h. D-13223 was formed in vivo and detected in all tissues assessed, with the concentrations being the highest in the liver. Incubation of isolated neonatal rat liver, heart, kidney, lung, spleen, whole eye, serum, or whole brain with flupirtine for 3 h at 37 °C formed D-13223 in all tissues, except serum. D-13223 formation was the highest in isolated liver tissue. Tissue partition coefficients based on isolated tissue uptake correlated well with in vivo tissue:serum drug exposure ratios. Thus, flupirtine reaches the target brain tissues from the systemic route in neonatal rats, and brain tissue forms the active metabolite D-13223.
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Affiliation(s)
- Madhoosudan A Patil
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Brock A Matter
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Yogendra H Raol
- Department of Pediatrics, Division of Neurology, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - David W A Bourne
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Ryan A Kelley
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Uday B Kompella
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
- Colorado Center for Nanomedicine and Nanosafety, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
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8
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Dörr J, Wernecke KD, Würfel J, Bellmann-Strobl J, Siffrin V, Sättler MB, Simons M, Linsa A, Tumani H, Paul F. Disease Modification in Multiple Sclerosis by Flupirtine-Results of a Randomized Placebo Controlled Phase II Trial. Front Neurol 2018; 9:842. [PMID: 30356868 PMCID: PMC6190842 DOI: 10.3389/fneur.2018.00842] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 09/19/2018] [Indexed: 12/31/2022] Open
Abstract
Central nervous system inflammation and neurodegeneration are the pathophysiological hallmarks of multiple sclerosis (MS). While inflammation can readily be targeted by current disease modifying drugs, neurodegeneration is by far less accessible to treatment. Based on suggested additional neuroprotective capacities of the orally available non-opioid and centrally acting analgesic drug flupirtine maleate we hypothesized that treatment with flupirtine maleate might be beneficial in MS patients. The flupirtine as oral treatment in multiple sclerosis (FLORIMS) study was a multi-center, randomized and stratified, placebo-controlled double-blind phase II trial to investigate safety and efficacy in terms of clinical and radiographical activity of flupirtine maleate (300 mg per day) given orally for 12 months, add-on to interferon beta 1b subcutaneously in patients with relapsing remitting MS. Due to a substantial delay in recruitment, enrolment of patients was prematurely terminated after randomization of only 30 of the originally planned 80 patients. Of these, 24 regularly terminated study after 12 months of treatment. Data were analyzed as originally planned. Treatment with flupirtine maleate was overall well tolerated. We observed moderate and asymptomatic elevations of liver enzymes in several cases but no overt hepatotoxicity. Neither the intention to treat nor the per protocol analysis revealed any significant treatment effects of flupirtine maleate with respect to occurrence of MS relapses, disability progression, or development of new lesions on cranial MRI. However, substantial methodological limitations need to be considered when interpreting these results. In conclusion, the results of the FLORIMS study neither add further evidence to nor argue against the hypothesized neuroprotective or disease modifying effects of flupirtine maleate in MS.
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Affiliation(s)
- Jan Dörr
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | | | - Jens Würfel
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,MIAC AG, Department Biomedical Engineering, University Basel, Basel, Switzerland
| | - Judith Bellmann-Strobl
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Volker Siffrin
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | | | - Mikael Simons
- Institute of Neuronal Cell Biology, Technical University Munich, Munich, Germany.,German Center for Neurodegenerative Disease (DZNE), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Andreas Linsa
- Klinik für Neurologie, Carl-Thiem Klinikum Cottbus gGmbH, Cottbus, Germany.,Klinik für Neurologie, Lausitzer Seenland Klinikum GmbH, Hoyerswerda, Germany
| | - Hayrettin Tumani
- Neurologische Uniklinik Ulm im RKU, Ulm, Germany.,Fachklinik für Neurologie Dietenbronn, Schwendi, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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9
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Seefeld MA, Lin H, Holenz J, Downie D, Donovan B, Fu T, Pasikanti K, Zhen W, Cato M, Chaudhary KW, Brady P, Bakshi T, Morrow D, Rajagopal S, Samanta SK, Madhyastha N, Kuppusamy BM, Dougherty RW, Bhamidipati R, Mohd Z, Higgins GA, Chapman M, Rouget C, Lluel P, Matsuoka Y. Novel K V7 ion channel openers for the treatment of epilepsy and implications for detrusor tissue contraction. Bioorg Med Chem Lett 2018; 28:3793-3797. [PMID: 30327146 DOI: 10.1016/j.bmcl.2018.09.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/25/2018] [Accepted: 09/27/2018] [Indexed: 10/28/2022]
Abstract
Neuronal voltage-gated potassium channels, KV7s, are the molecular mediators of the M current and regulate membrane excitability in the central and peripheral neuronal systems. Herein, we report novel small molecule KV7 openers that demonstrate anti-seizure activities in electroshock and pentylenetetrazol-induced seizure models without influencing Rotarod readouts in mice. The anti-seizure activity was determined to be proportional to the unbound concentration in the brain. KV7 channels are also expressed in the bladder smooth muscle (detrusor) and activation of these channels may cause localized undesired effects. Therefore, the impact of individual KV7 isoforms was investigated in human detrusor tissue using a panel of KV7 openers with distinct activity profiles among KV7 isoforms. KCNQ4 and KCNQ5 mRNA were highly expressed in detrusor tissue, yet a compound that has significantly reduced activity on homomeric KV7.4 did not reduce detrusor contraction. This may suggest that the homomeric KV7.4 channel plays a less significant role in bladder contraction and further investigation is needed.
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Affiliation(s)
- Mark A Seefeld
- Neuroscience Virtual-Proof-of-Concept Discovery Performance Unit, GlaxoSmithKline, Collegeville, PA, United States.
| | - Hong Lin
- Neuroscience Virtual-Proof-of-Concept Discovery Performance Unit, GlaxoSmithKline, Collegeville, PA, United States; Regenerative Medicine Discovery Performance Unit, GlaxoSmithKline, Collegeville, PA, United States
| | - Joerg Holenz
- Neuroscience Virtual-Proof-of-Concept Discovery Performance Unit, GlaxoSmithKline, Collegeville, PA, United States
| | - Dave Downie
- Screening Profiling & Mechanistic Biology, Platform Technology Sciences, GlaxoSmithKline, Stevenage, UK
| | - Brian Donovan
- Screening, Profiling and Mechanistic Biology, Platform Technology Sciences, GlaxoSmithKline, Collegeville, PA, United States
| | - Tingting Fu
- Mechanistic Safety & Disposition, Product Development and Supply, Platform Technology Sciences, GlaxoSmithKline, Shanghai, China
| | - Kishore Pasikanti
- Neuroscience Virtual-Proof-of-Concept Discovery Performance Unit, GlaxoSmithKline, Collegeville, PA, United States
| | - Wei Zhen
- Integrated Biological Platform Sciences, Product Development and Supply, Platform Technology Sciences, GlaxoSmithKline, Shanghai, China
| | - Matthew Cato
- In Vitro/In Vivo Translation, Safety Pharmacology, Platform Technology Sciences, GlaxoSmithKline, King of Prussia, PA, United States
| | - Khuram W Chaudhary
- In Vitro/In Vivo Translation, Safety Pharmacology, Platform Technology Sciences, GlaxoSmithKline, King of Prussia, PA, United States
| | - Pat Brady
- Screening, Profiling and Mechanistic Biology, Platform Technology Sciences, GlaxoSmithKline, Collegeville, PA, United States
| | - Tania Bakshi
- Pattern Recognition Receptor Discovery Performance Unit, GlaxoSmithKline, Collegeville, PA, United States
| | - Dwight Morrow
- Regenerative Medicine Discovery Performance Unit, GlaxoSmithKline, Collegeville, PA, United States
| | | | | | | | | | | | | | | | | | | | | | | | - Yasuji Matsuoka
- Neuroscience Virtual-Proof-of-Concept Discovery Performance Unit, GlaxoSmithKline, Collegeville, PA, United States.
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10
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Puljak L. Flupirtine, an Effective Analgesic, but Hepatotoxicity Should Limit Its Use. Anesth Analg 2018; 127:309-310. [PMID: 29596091 DOI: 10.1213/ane.0000000000003355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Livia Puljak
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia, Department of Development, Research, and Health Technology Assessment, Agency for Quality and Accreditation in Health Care and Social Welfare, Zagreb, Croatia,
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11
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Puljak L. Randomized controlled trial about pain medication flupirtine ignores recent pharmacovigilance warnings. J Pain Res 2018; 11:177-180. [PMID: 29560967 PMCID: PMC5769781 DOI: 10.2147/jpr.s154447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Livia Puljak
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia.,Department for Development, Research and Health Technology Assessment, Agency for Quality and Accreditation in Health Care and Social Welfare, Zagreb, Croatia
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12
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Perdigoto DN, Amaro P, Ferreira M, Tomé L. Flupirtine drug-induced liver injury in a patient developing acute liver failure. BMJ Case Rep 2018. [PMID: 29523613 DOI: 10.1136/bcr-2017-223329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A patient is admitted with complaints of recent onset nausea, discomfort, jaundice and blood tests that reveal severe hepatitis. At the time, she had been taking medication with Hypericum perforatum (St John's wort) for 6 months, and 6 weeks before this event, she took flupirtine maleate. A few days after being admitted, she developed encephalopathy progressing to acute liver failure (ALF) requiring unsuccessful liver transplantation. The patient was ultimately diagnosed with drug-induced liver injury (DILI). In this context, while H. perforatum could interfere with other medication or trigger DILI itself, flupirtine appears to have triggered the DILI, given its liver toxicity capacity. DILI is one of the major ALF causes and can jeopardise patient's life. Accordingly, all efforts to reduce medication potentially hazardous to the liver are recommended.
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Affiliation(s)
- David Noiva Perdigoto
- Department of Gastroenterology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Pedro Amaro
- Department of Gastroenterology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Manuela Ferreira
- Department of Gastroenterology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Luis Tomé
- Department of Gastroenterology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
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13
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Teschke R, Danan G. Causality Assessment Methods in Drug-Induced Liver Injury. METHODS IN PHARMACOLOGY AND TOXICOLOGY 2018. [DOI: 10.1007/978-1-4939-7677-5_27] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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14
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Peta V, Tse C, Perazzo H, Munteanu M, Ngo Y, Ngo A, Ramanujam N, Verglas L, Mallet M, Ratziu V, Thabut D, Rudler M, Thibault V, Schuppe-Koistinen I, Bonnefont-Rousselot D, Hainque B, Imbert-Bismut F, Merz M, Kullak-Ublick G, Andrade R, van Boemmel F, Schott E, Poynard T. Serum apolipoprotein A1 and haptoglobin, in patients with suspected drug-induced liver injury (DILI) as biomarkers of recovery. PLoS One 2017; 12:e0189436. [PMID: 29287080 PMCID: PMC5747433 DOI: 10.1371/journal.pone.0189436] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 11/26/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is a clear need for better biomarkers of drug-induced-liver-injury (DILI). AIMS We aimed to evaluate the possible prognostic value of ActiTest and FibroTest proteins apoliprotein-A1, haptoglobin and alpha-2-macroglobulin, in patients with DILI. METHODS We analyzed cases and controls included in the IMI-SAFE-T-DILI European project, from which serum samples had been stored in a dedicated biobank. The analyses of ActiTest and FibroTest had been prospectively scheduled. The primary objective was to analyze the performance (AUROC) of ActiTest components as predictors of recovery outcome defined as an ALT <2x the upper limit of normal (ULN), and BILI <2x ULN. RESULTS After adjudication, 154 patients were considered to have DILI and 22 were considered to have acute liver injury without DILI. A multivariate regression analysis (ActiTest-DILI patent pending) combining the ActiTest components without BILI and ALT (used as references), apolipoprotein-A1, haptoglobin, alpha-2-macroglobulin and GGT, age and gender, resulted in a significant prediction of recovery with 67.0% accuracy (77/115) and an AUROC of 0.724 (P<0.001 vs. no prediction 0.500). Repeated apolipoprotein-A1 and haptoglobin remained significantly higher in the DILI cases that recovered (n = 65) versus those that did not (n = 16), at inclusion, at 4-8 weeks and at 8-12 weeks. The same results were observed after stratification on APAP cases and non-APAP cases. CONCLUSIONS We identified that apolipoprotein-A1 and haptoglobin had significant predictive values for the prediction of recovery at 12 weeks in DILI, enabling the construction of a new prognostic panel, the DILI-ActiTest, which needs to be independently validated.
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Affiliation(s)
| | - Chantal Tse
- Department of Biochemistry, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Hugo Perazzo
- Department of Hepatology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Mona Munteanu
- Department of Research, Biopredictive, Paris, France
| | - Yen Ngo
- Department of Research, Biopredictive, Paris, France
| | - An Ngo
- Department of Research, Biopredictive, Paris, France
| | - Nittia Ramanujam
- Department of Biochemistry, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Lea Verglas
- Department of Biochemistry, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Maxime Mallet
- Department of Hepatology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Vlad Ratziu
- Department of Hepatology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
- University Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale UMR 938, Paris, France
| | - Dominique Thabut
- Department of Hepatology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
- University Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale UMR 938, Paris, France
| | - Marika Rudler
- Department of Hepatology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Vincent Thibault
- Department of Virology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | | | - Dominique Bonnefont-Rousselot
- Department of Biochemistry, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Bernard Hainque
- Department of Biochemistry, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Françoise Imbert-Bismut
- Department of Biochemistry, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Michael Merz
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Mechanistic Safety, Novartis Global Drug Development, Basel, Switzerland
| | - Gerd Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Mechanistic Safety, Novartis Global Drug Development, Basel, Switzerland
| | - Raul Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Málaga, Spain
| | - Florian van Boemmel
- Clinic for Hepatology and Rheumatology, Hepatology Section, University Hospital Leipzig, Leipzig, Germany
| | - Eckart Schott
- Clinic for Hepatology and Rheumatology, Hepatology Section, University Hospital Charité, Berlin, Germany
| | - Thierry Poynard
- Department of Hepatology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
- University Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale UMR 938, Paris, France
- * E-mail:
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15
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Chenot JF, Greitemann B, Kladny B, Petzke F, Pfingsten M, Gabriele Schorr S. Non-Specific Low Back Pain. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:883-890. [PMID: 29321099 PMCID: PMC5769319 DOI: 10.3238/arztebl.2017.0883] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 07/28/2017] [Accepted: 10/26/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition. METHODS The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process. RESULTS If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible. CONCLUSION A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.
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Affiliation(s)
- Jean-François Chenot
- Section Family Medicine, Institute for Community Medicine, University Hospital of Greifswald
| | | | - Bernd Kladny
- Department of Orthopedics, Fachklinik Herzogenaurach
| | - Frank Petzke
- ain Clinic, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Göttingen
| | - Michael Pfingsten
- ain Clinic, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Göttingen
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16
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Adrian D, Papich M, Baynes R, Murrell J, Lascelles BDX. Chronic maladaptive pain in cats: A review of current and future drug treatment options. Vet J 2017; 230:52-61. [PMID: 28887012 DOI: 10.1016/j.tvjl.2017.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/10/2017] [Accepted: 08/17/2017] [Indexed: 11/28/2022]
Abstract
Despite our increasing understanding of the pathophysiology underlying chronic or maladaptive pain, there is a significant gap in our ability to diagnose and treat the condition in domestic cats. Newer techniques being used to identify abnormalities in pain processing in the cat include validated owner questionnaires, measurement of movement and activity, and measurement of sensory thresholds and somatomotor responses. While some data are available evaluating possible therapeutics for the treatment of chronic pain in the cat, most data are limited to normal cats. This review details our current understanding of chronic or maladaptive pain, techniques for the detection and measurement of the condition and the associated central nervous changes, as well as an overview of the data evaluating potential therapeutics in cats.
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Affiliation(s)
- Derek Adrian
- Comparative Pain Research and Education Centre, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - Mark Papich
- Molecular and Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - Ron Baynes
- Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - Jo Murrell
- School of Veterinary Sciences, University of Bristol, Bristol, UK
| | - B Duncan X Lascelles
- Comparative Pain Research and Education Centre, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA; Center for Pain Research and Innovation, UNC School of Dentistry, Chapel Hill, NC, USA; Center for Translational Pain Research, Department of Anesthesiology, Duke University, Durham, NC, USA.
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17
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Sampath D, Valdez R, White AM, Raol YH. Anticonvulsant effect of flupirtine in an animal model of neonatal hypoxic-ischemic encephalopathy. Neuropharmacology 2017; 123:126-135. [PMID: 28587899 DOI: 10.1016/j.neuropharm.2017.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 05/07/2017] [Accepted: 06/02/2017] [Indexed: 12/20/2022]
Abstract
Research studies suggest that neonatal seizures, which are most commonly associated with hypoxic-ischemic injury, may contribute to brain injury and adverse neurologic outcome. Unfortunately, neonatal seizures are often resistant to treatment with current anticonvulsants. In the present study, we evaluated the efficacy of flupirtine, administered at clinically relevant time-points, for the treatment of neonatal seizures in an animal model of hypoxic-ischemic injury that closely replicates features of the human syndrome. We also compared the efficacy of flupirtine to that of phenobarbital, the current first-line drug for neonatal seizures. Flupirtine is a KCNQ potassium channel opener. KCNQ channels play an important role in controlling brain excitability during early development. In this study, hypoxic-ischemic injury was induced in neonatal rats, and synchronized video-EEG records were acquired at various time-points during the experiment to identify seizures. The results revealed that flupirtine, administered either 5 min after the first electroclinical seizure, or following completion of 2 h of hypoxia, i.e., during the immediate reperfusion period, reduced the number of rats with electroclinical seizures, and also the frequency and total duration of electroclinical seizures. Further, daily dosing of flupirtine decreased the seizure burden over 3 days following HI-induction, and modified the natural evolution of acute seizures. Moreover, compared to a therapeutic dose of phenobarbital, which was modestly effective against electroclinical seizures, flupirtine showed greater efficacy. Our results indicate that flupirtine is an extremely effective treatment for neonatal seizures in rats and provide evidence for a trial of this medication in newborn humans.
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Affiliation(s)
- Dayalan Sampath
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Robert Valdez
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Andrew M White
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Yogendra H Raol
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA.
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18
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Flupirtine associated acute liver failure- case from India and review of literature. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2017. [DOI: 10.1016/j.injms.2017.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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HLA-DRB1*16: 01-DQB1*05: 02 is a novel genetic risk factor for flupirtine-induced liver injury. Pharmacogenet Genomics 2016; 26:218-24. [PMID: 26959717 DOI: 10.1097/fpc.0000000000000209] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Flupirtine is a nonopioid analgesic with regulatory approval in a number of European countries. Because of the risk of serious liver injury, its use is now limited to short-term pain management. We aimed to identify genetic risk factors for flupirtine-related drug-induced liver injury (DILI) as these are unknown. MATERIALS AND METHODS Six flupirtine-related DILI patients from Germany were included in a genome-wide association study (GWAS) involving a further 614 European cases of DILI because of other drugs and 10,588 population controls. DILI was diagnosed by causality assessment and expert review. Human leucocyte antigen (HLA) and single nucleotide polymorphism genotypes were imputed from the GWAS data, with direct HLA typing performed on selected cases to validate HLA predictions. Four replication cases that were unavailable for the GWAS were genotyped by direct HLA typing, yielding an overall total of 10 flupirtine DILI cases. RESULTS In the six flupirtine DILI cases included in the GWAS, we found a significant enrichment of the DRB1*16:01-DQB1*05:02 haplotype compared with the controls (minor allele frequency cases 0.25 and minor allele frequency controls 0.013; P=1.4 × 10(-5)). We estimated an odds ratio for haplotype carriers of 18.7 (95% confidence interval 2.5-140.5, P=0.002) using population-specific HLA control data. The result was replicated in four additional cases, also with a haplotype frequency of 0.25. In the combined cohort (six GWAS plus four replication cases), the haplotype was also significant (odds ratio 18.7, 95% confidence interval 4.31-81.42, P=6.7 × 10(-5)). CONCLUSION We identified a novel HLA class II association for DILI, confirming the important contribution of HLA genotype towards the risk of DILI generally.
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20
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Douros A, Bronder E, Andersohn F, Klimpel A, Thomae M, Sarganas G, Kreutz R, Garbe E. Drug-induced liver injury: results from the hospital-based Berlin Case-Control Surveillance Study. Br J Clin Pharmacol 2016; 79:988-99. [PMID: 25444550 DOI: 10.1111/bcp.12565] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/27/2014] [Indexed: 12/15/2022] Open
Abstract
AIM Drug-induced liver injury (DILI) is often responsible for acute liver failure, drug withdrawal, boxed warnings or drug non-approval. Therefore, we conducted a case-control study to determine the hepatotoxic risk of a wide range of drugs. METHODS The Berlin Case-Control Surveillance Study FAKOS included all 51 Berlin hospitals in a hospital network. Between 2002 and 2011, 198 patients with acute idiopathic hepatitis, 377 inpatient controls and 708 outpatient controls were ascertained. Case patients were thoroughly validated using anamnestic, clinical, laboratory and histological data. Drug exposure was obtained in a face-to-face interview. A possible drug aetiology was assessed in individual patients by applying the updated Council for International Organizations of Medical Sciences (CIOMS) scale. Drug risks were further quantified [odds ratios (OR) with 95% confidence intervals (CI)] in a case-control design with unconditional logistic regression analysis. Drug intake in the last 28 days before index date was considered for the analysis. RESULTS The study corroborated hepatotoxic risks for a number of drugs, including phenprocoumon (OR 3.3, 95% CI 1.5, 6.7), amiodarone (OR 5.5, 95% CI 1.3, 21.2), clozapine (OR 34.6, 95% CI 2.8, 824.9) and flupirtine (OR 40.2, 95% CI 5.5, 856.9). Increased risks were also suggested for less commonly reported substances such as angiotensin II receptor blockers, atypical antipsychotics and for biperiden, a drug never before reported to be hepatotoxic. CONCLUSIONS Our study identified a large number of drugs as possible causes of hepatotoxicity. The observed risk for seldom reported substances highlights the need for further post-authorization safety studies not exclusively focusing on drugs already labelled as potentially hepatotoxic.
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Affiliation(s)
- Antonios Douros
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Elisabeth Bronder
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Andersohn
- Institute for Social Medicine, Epidemiology and Health Economy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Klimpel
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Thomae
- Department of Surgery, Maria-Heimsuchung Caritas Klinik Pankow, Berlin, Germany
| | - Giselle Sarganas
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Reinhold Kreutz
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Edeltraut Garbe
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
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Danan G, Teschke R. RUCAM in Drug and Herb Induced Liver Injury: The Update. Int J Mol Sci 2015; 17:E14. [PMID: 26712744 PMCID: PMC4730261 DOI: 10.3390/ijms17010014] [Citation(s) in RCA: 432] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 12/07/2015] [Accepted: 12/09/2015] [Indexed: 12/12/2022] Open
Abstract
RUCAM (Roussel Uclaf Causality Assessment Method) or its previous synonym CIOMS (Council for International Organizations of Medical Sciences) is a well established tool in common use to quantitatively assess causality in cases of suspected drug induced liver injury (DILI) and herb induced liver injury (HILI). Historical background and the original work confirm the use of RUCAM as single term for future cases, dismissing now the term CIOMS for reasons of simplicity and clarity. RUCAM represents a structured, standardized, validated, and hepatotoxicity specific diagnostic approach that attributes scores to individual key items, providing final quantitative gradings of causality for each suspect drug/herb in a case report. Experts from Europe and the United States had previously established in consensus meetings the first criteria of RUCAM to meet the requirements of clinicians and practitioners in care for their patients with suspected DILI and HILI. RUCAM was completed by additional criteria and validated, assisting to establish the timely diagnosis with a high degree of certainty. In many countries and for more than two decades, physicians, regulatory agencies, case report authors, and pharmaceutical companies successfully applied RUCAM for suspected DILI and HILI. Their practical experience, emerging new data on DILI and HILI characteristics, and few ambiguous questions in domains such alcohol use and exclusions of non-drug causes led to the present update of RUCAM. The aim was to reduce interobserver and intraobserver variability, to provide accurately defined, objective core elements, and to simplify the handling of the items. We now present the update of the well accepted original RUCAM scale and recommend its use for clinical, regulatory, publication, and expert purposes to validly establish causality in cases of suspected DILI and HILI, facilitating a straightforward application and an internationally harmonized approach of causality assessment as a common basic tool.
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Affiliation(s)
- Gaby Danan
- Pharmacovigilance Consultancy, rue des Ormeaux, 75020 Paris, France.
| | - Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, Frankfurt am Main, D-63450 Hanau, Germany.
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22
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Sampath D, Shmueli D, White AM, Raol YH. Flupirtine effectively prevents development of acute neonatal seizures in an animal model of global hypoxia. Neurosci Lett 2015; 607:46-51. [PMID: 26365409 DOI: 10.1016/j.neulet.2015.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/18/2015] [Accepted: 09/07/2015] [Indexed: 12/16/2022]
Abstract
Current first-line drugs for the treatment of neonatal seizures have limited efficacy and are associated with side effects. Uncontrolled seizures may exacerbate brain injury and contribute to later-life neurological disability. Therefore, it is critical to develop a treatment for neonatal seizures that is effective and safe. In early-life, when the γ-aminobutyric acid (GABA) inhibitory system is not fully developed, potassium channels play an important role in controlling excitability. An earlier study demonstrated that flupirtine, a KCNQ potassium channel opener, is more efficacious than diazepam and phenobarbital for the treatment of chemoconvulsant-induced neonatal seizures. In newborns, seizures are most commonly associated with hypoxic-ischemic encephalopathy (HIE). Thus, in the present study, we examined the efficacy of flupirtine to treat neonatal seizures in an animal model of global hypoxia. Our results showed that flupirtine dose dependently blocks the occurrence of behavioral seizures in pups during hypoxia. Additionally, flupirtine inhibits the development of hypoxia-induced clinical seizures and associated epileptiform discharges, as well as purely electrographic (subclinical) seizures. These results suggest that flupirtine is an effective anti-seizure drug, and that further studies should be conducted to determine the time window within which it's administration can effectively treat neonatal seizures.
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Affiliation(s)
- Dayalan Sampath
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, School of Medicine, Aurora, CO 80045, United States
| | - Doron Shmueli
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, School of Medicine, Aurora, CO 80045, United States
| | - Andrew M White
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, School of Medicine, Aurora, CO 80045, United States
| | - Yogendra H Raol
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, School of Medicine, Aurora, CO 80045, United States.
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Raschi E, De Ponti F. Drug- and herb-induced liver injury: Progress, current challenges and emerging signals of post-marketing risk. World J Hepatol 2015; 7:1761-1771. [PMID: 26167249 PMCID: PMC4491905 DOI: 10.4254/wjh.v7.i13.1761] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/21/2015] [Accepted: 06/19/2015] [Indexed: 02/06/2023] Open
Abstract
Drug-induced liver injury (DILI) and herb-induced liver injury is a hot topic for clinicians, academia, drug companies and regulators, as shown by the steadily increasing number of publications in the past 15 years. This review will first provide clues for clinicians to suspect idiosyncratic (unpredictable) DILI and succeed in diagnosis. Causality assessment remains challenging and requires careful medical history as well as awareness of multifaceted aspects, especially for herbs. Drug discontinuation and therapy reconciliation remain the mainstay in patent’s management to minimize occurrence of acute liver failure. The second section will address novel agents associated with liver injury in 2014 (referred to as “signals”), especially in terms of clinical, research and drug development implications. Insights will be provided into recent trends by highlighting the contribution of different post-marketing data, especially registries and spontaneous reporting systems. This literature scrutiny suggests: (1) the importance of post-marketing databases as tools of clinical evidence to detect signals of DILI risk; and (2) the need for joining efforts in improving predictivity of pre-clinical assays, continuing post-marketing surveillance and design ad hoc post-authorization safety studies. In this context, ongoing European/United States research consortia and novel pharmaco-epidemiological tools (e.g., specialist prescription event monitoring) will support innovation in this field. Direct oral anticoagulants and herbal/dietary supplements appear as key research priorities.
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Lemmerhirt CJ, Rombach M, Bodtke A, Bednarski PJ, Link A. Oxidation potentials of N-modified derivatives of the analgesic flupirtine linked to potassium KV 7 channel opening activity but not hepatocyte toxicity. ChemMedChem 2014; 10:368-79. [PMID: 25392984 DOI: 10.1002/cmdc.201402442] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Indexed: 12/30/2022]
Abstract
Openers of neuronal voltage-gated potassium channels (KV ) are of interest as therapeutic agents for treating pain (flupirtine) and epilepsy (retigabine). In an effort to better understand the mechanisms of action and toxicity of flupirtine, we synthesized nine novel analogues with varying redox behavior. Flupirtine can be oxidatively metabolized into azaquinone diimines; thus, the oxidation potentials of flupirtine and its analogues were measured by cyclic voltammetry. KV 7.2/3 (KCNQ2/3) opening activity was determined by an established assay with HEK293 cells overexpressing these channels. A link was found between the oxidation potentials of the compounds and their EC50 values for potassium channel opening activity. On the other hand, no correlation was observed between oxidation potentials and cytotoxicity in cultures of transgenic mouse hepatocytes (TAMH). These results support the idea that oxidative metabolites of flupirtine contribute to the mechanism of action, similar to what was recently proposed for acetaminophen (paracetamol), but not to hepatotoxicity.
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Affiliation(s)
- Christian J Lemmerhirt
- Pharmaceutical and Medicinal Chemistry, Institute of Pharmacy, Ernst Moritz Arndt University, Friedrich-Ludwig-Jahn-Str. 17, 17487 Greifswald (Germany)
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