Case report: fulminant hepatic failure involving duloxetine hydrochloride

Epidemiology and Risk Determinants of Drug-Induced Liver Injury: Current Knowledge and Future Research Needs

AIMS

Drug-induced liver injury (DILI) is a major global health concern resulting from adverse reactions to medications, supplements or herbal medicines. The relevance of DILI has grown with an aging population, the rising prevalence of chronic diseases and the increased use of biologics, including checkpoint inhibitors. This article aims to summarise current knowledge on DILI epidemiology and risk factors.

METHODS

This review critically appraises available evidence on DILI frequency, outcomes and risk determinants, focusing on drug properties and non-genetic host factors that may influence susceptibility.

RESULTS

DILI incidence varies across populations, with hospitalised patients experiencing notably higher rates than outpatients or the general population. Increased medication use, particularly among older adults and women, may partly explain age- and sex-based disparities in DILI incidence and reporting. Physiological changes associated with aging likely increase susceptibility to DILI in older adults, though further exposure-based studies are needed for definitive conclusions. Current evidence does not strongly support that women are inherently more susceptible to DILI than men; rather, susceptibility appears to depend on specific drugs. However, once DILI occurs, older age and female sex are associated with greater severity and poorer outcomes. Other less-studied host-related risk factors are also discussed based on available evidence.

CONCLUSIONS

This article summarises existing data on DILI frequency, outcomes, drug properties affecting hepatotoxicity and non-genetic host risk factors while identifying critical knowledge gaps. Addressing these gaps through future research could enhance understanding and support preventive measures.

Metabolism of a Selective Serotonin and Norepinephrine Reuptake Inhibitor Duloxetine in Liver Microsomes and Mice

Duloxetine (DLX) is a dual serotonin and norepinephrine reuptake inhibitor, widely used for the treatment of major depressive disorder. Although DLX has shown good efficacy and safety, serious adverse effects (e.g., liver injury) have been reported. The mechanisms associated with DLX-induced toxicity remain elusive. Drug metabolism plays critical roles in drug safety and efficacy. However, the metabolic profile of DLX in mice is not available, although mice serve as commonly used animal models for mechanistic studies of drug-induced adverse effects. Our study revealed 39 DLX metabolites in human/mouse liver microsomes and mice. Of note, 13 metabolites are novel, including five N-acetyl cysteine adducts and one reduced glutathione (GSH) adduct associated with DLX. Additionally, the species differences of certain metabolites were observed between human and mouse liver microsomes. CYP1A2 and CYP2D6 are primary enzymes responsible for the formation of DLX metabolites in liver microsomes, including DLX-GSH adducts. In summary, a total of 39 DLX metabolites were identified, and species differences were noticed in vitro. The roles of CYP450s in DLX metabolite formation were also verified using human recombinant cytochrome P450 (P450) enzymes and corresponding chemical inhibitors. Further studies are warranted to address the exact role of DLX metabolism in its adverse effects in vitro (e.g., human primary hepatocytes) and in vivo (e.g., Cyp1a2-null mice). SIGNIFICANCE STATEMENT: This current study systematically investigated Duloxetine (DLX) metabolism and bioactivation in liver microsomes and mice. This study provided a global view of DLX metabolism and bioactivation in liver microsomes and mice, which are very valuable to further elucidate the mechanistic study of DLX-related adverse effects and drug-drug interaction from metabolic aspects.

Duloxetine-Induced Liver Injury: A Case Report

We present a case of a young (43-year-old), otherwise healthy, female patient who developed drug-induced liver injury (DILI) secondary to routine use of duloxetine. Our case aims to raise awareness amongst physicians about the possibility of duloxetine-induced liver injury. We recommend monitoring liver function tests (LFTs) when initiating or adjusting the dose of duloxetine, and intermittently thereafter, to facilitate early identification and management of potential DILI.

Antidepressants- and antipsychotics-induced hepatotoxicity

Drug-induced liver injury (DILI) is a serious health burden. It has diverse clinical presentations that can escalate to acute liver failure. The worldwide increase in the use of psychotropic drugs, their long-term use on a daily basis, common comorbidities of psychiatric and metabolic disorders, and polypharmacy in psychiatric patients increase the incidence of psychotropics-induced DILI. During the last 2 decades, hepatotoxicity of various antidepressants (ADs) and antipsychotics (APs) received much attention. Comprehensive review and discussion of accumulated literature data concerning this issue are performed in this study, as hepatotoxic effects of most commonly prescribed ADs and APs are classified, described, and discussed. The review focuses on ADs and APs characterized by the risk of causing liver damage and highlights the ones found to cause life-threatening or severe DILI cases. In parallel, an overview of hepatic oxidative stress, inflammation, and steatosis underlying DILI is provided, followed by extensive review and discussion of the pathophysiology of AD- and AP-induced DILI revealed in case reports, and animal and in vitro studies. The consequences of some ADs and APs ability to affect drug-metabolizing enzymes and therefore provoke drug–drug interactions are also addressed. Continuous collecting of data on drugs, mechanisms, and risk factors for DILI, as well as critical data reviewing, is crucial for easier DILI diagnosis and more efficient risk assessment of AD- and AP-induced DILI. Higher awareness of ADs and APs hepatotoxicity is the prerequisite for their safe use and optimal dosing.

Antidepressant-lnduced Liver Injury

Objective:

To review principles of drug-induced liver injury (DILI), summarize characteristics of antidepressant-mediated liver Injury, and provide recommendations for monitoring and management.

Data Sources:

A search relating to antidepressant-induced liver injury was performed using MEDLINE (1966–March 2007). Search terms included antidepressant, cholestasis, hepatotoxicity, jaundice, liver injury, toxic hepatitis, and transaminases. Reference citations not Identified in the initial database search were also utilized.

Study Selection and Data Extraction:

All English-language case reports, letters, and review articles identified from the data sources were used. Case reports and letters relating to hepatotoxicity from antidepressant overdose were excluded.

Data Synthesis:

Antidepressant-induced liver injury described in published cases were of the idiopathic type and, by definition, cannot be predicted based on dose or specific risk factors. Paroxetine had the largest number of cases within the selective serotonin-reuptake inhibitor class. Nefazodone, a serotonin–norepinephrine reuptake inhibitor, appeared to have the most serious cases and is the only antidepressant agent that carries a Food and Drug Administration Black Box Warning regarding hepatotoxiciiy. The tricyclic antidepressants and monoamine oxidase Inhibitors are capable of producing hepatotoxicity, but fewer cases with these agents have been reported in the past 15 years, possibly due to a decline in their use. Causality has not been well established in all reports due to the concurrent use of other drugs and/or underlying liver disease.

Conclusions:

Most antidepressant agents have the potential to produce idiopathic liver injury. There is no way to prevent idiopathic DILI, but the severity of the reaction may be minimized with prompt recognition and early withdrawal of the agent. The clinician must be careful to provide ongoing therapy of the underlying depressive disorder and be aware of possible drug discontinuation syndromes should potential hepatotoxicity be suspected.

Pharmacologic Management of Upper Extremity Chronic Nerve Pain

The treatment of pain is a complex process that requires a team approach. This article provides an overview of the pharmaceutical treatments available. It gives providers treating upper extremity disorders more tools to treat their patients with chronic pain. Another goal is to improve hand providers' understanding of the medications their pain colleagues prescribe in shared patients. Pharmaceuticals are an important component in the treatment of chronic pain and opioids are often not a good solution. Knowing what other medications are available can improve the care for these challenging patients.

Pharmacokinetics of antidepressants in patients with hepatic impairment

Appropriate use of antidepressant in patients with hepatic impairment requires careful consideration of how the hepatic illness may affect pharmacokinetics. This review aims to analyze pharmacokinetic profile, plasma level variations so as the metabolism of several antidepressants relating to their use in patients with an hepatic impairment. Due to the lack of data regarding hepatic impairment itself, the review is focused mainly on studies investigating pharmacokinetics in hepatic cirrhosis or alcohol-related conditions. More data on reduced hepatic metabolism can be extrapolated by drug studies conducted in elderly populations. Dose adjustment of antidepressants in these patients is important as most of these drugs are predominantly metabolized by the liver and many of them are associated with dose-dependent adverse reactions. As no surrogate parameter is available to predict hepatic metabolism of drugs, dose adjustment according to pharmacokinetic properties of the drugs is proposed. There is a need for a more balanced assessment of the benefits and risks associated with antidepressants use in patients with hepatic impairment, particularly considering pharmacokinetic profile of the drugs to ensure that patients, who would truly benefit from these agents, are not denied appropriate treatment. In conclusion, kinetic studies for centrally acting drugs including antidepressants with predominant hepatic metabolism should be carried out in patients with liver disease to allow precise dose recommendations for enhanced patient safety.

Duloxetine-induced liver injury in patients with major depressive disorder

Duloxetine is a balanced serotonin-norepinephrine reuptake inhibitor. Duloxetine-induced liver injury in patients with preexisting liver disease or chronic alcohol use is known. However, we have found that duloxetine can also induce liver injury in cases without those risk factors. We recommend that clinicians should monitor liver function carefully following duloxetine treatment.

Reversible time-dependent inhibition of cytochrome P450 enzymes by duloxetine and inertness of its thiophene ring towards bioactivation

Duloxetine is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) approved to treat major depressive disorder and diabetic peripheral neuropathic pain. It is known to cause hepatotoxicity, in some cases leading to death. It has been reported that duloxetine causes time-dependent inhibition (TDI) of CYP1A2, CYP2B6, CYP2C19 and CYP3A4/5; but the nature of these TDI (whether reversible or irreversible) is not known. Irreversible TDI can cause clinically significant drug-drug interactions and also immune-mediated hepatotoxicity. Structurally, duloxetine possesses several toxicophores, i.e. the naphthyl and thiophene rings. It has been reported that the naphthyl ring undergoes epoxidation and was subsequently adducted to glutathione, but bioactivation related to the thiophene ring has not been completely elucidated. In this paper, the potential of duloxetine in causing irreversible TDI and generating reactive metabolites was investigated. Human liver microsomal assays demonstrated that duloxetine did not cause irreversible TDI of CYP1A2, CYP2B6, CYP2D6, CYP2C19 and CYP3A4/5. Subsequently, reactive metabolite trapping assays using soft nucleophiles (glutathione and glutathione ethyl ester) revealed a previously reported adduct at the naphthyl ring of duloxetine but not at the thiophene ring. Trapping assays utilizing a hard nucleophile (semicarbazide) did not demonstrate adducts with the thiophene ring, indicating an absence of thiophene ring opening. The hepatotoxicity of duloxetine is possibly not related to the irreversible TDI of CYP450 or the bioactivation of its thiophene moiety, but might be due to the epoxidation of its naphthyl ring.

Adverse reactions to duloxetine in depression

INTRODUCTION

Untreated or inadequately treated depression is the largest risk factor for suicide. However, treatment with different antidepressants can have considerable adverse effects, including the increase of the frequency of suicidal thoughts and behavior. This review summarizes the frequency and severity of adverse events observed during the treatment of depression with duloxetine and considers their relevance to clinical practice.

AREAS COVERED

A comprehensive review of the literature was conducted using PubMed and Medline databases listing data published until December 2010. Articles describing safety and tolerability of duloxetine were selected and reference lists of these articles were scrutinized for further relevant papers. In addition, US and EU Summaries of Product Characteristics were studied.

EXPERT OPINION

Treatment with duloxetine was associated with mild to moderate adverse events; sexual dysfunction, nausea, headache, dry mouth, somnolence and dizziness being the most frequent among them. No increase in death from suicide and suicidal thoughts and behavior were detected as compared to placebo. So as to avoid discontinuation syndrome as a consequence of abrupt withdrawal of duloxetine, 2 weeks tapering has been recommended before discontinuation. Overall, duloxetine was found to be well tolerated and can be safely administered even in older patients and in those with concomitant illnesses.

Duloxetine hepatotoxicity: a case-series from the drug-induced liver injury network

BACKGROUND

Case reports suggest that duloxetine hepatotoxicity may arise, but risk factors, presenting features and clinical course are not well-described.

AIM

To describe the presenting features and outcomes of seven well-characterized patients with suspected duloxetine hepatotoxicity.

METHODS

Patients enrolled in the Drug-Induced Liver Injury Network Prospective Study underwent an extensive laboratory and clinical evaluation to exclude competing aetiologies of liver injury as well as a standardized assessment for causality and disease severity.

RESULTS

Between 1/2006 and 9/2009, six of the seven cases of DILI attributed to duloxetine were assessed as definite or very likely. Median patient age was 49 years, six (86%) were women and the median latency from drug initiation to DILI onset was 50 days. Six patients developed jaundice and the median peak alanine aminotransferase in the five patients with acute hepatocellular injury was 1633 IU/L. Ascites developed in one patient and acute renal dysfunction in two others (29%). All patients recovered without liver transplantation even though three had pre-existing chronic liver disease. Liver histology in four cases demonstrated varying patterns of liver injury.

CONCLUSIONS

Duloxetine hepatotoxicity developed within 2 months of drug intake and led to clinically significant liver injury. A spectrum of laboratory, histological and extra-hepatic features were noted at presentation.

Cholestatic jaundice induced by duloxetine in a patient with major depressive disorder

Duloxetine is a balanced and potent serotonin and noradrenaline reuptake inhibitor (SNRI) and has adverse effects that are commonly associated with such drugs, including nausea, dry mouth, constipation, insomnia, and dizziness. Recently, duloxetine-induced liver injury has also been observed in patients with preexisting liver disease or chronic alcohol use. We investigated the effects of duloxetine in a healthy young adult with major depressive disorder (MDD) but no risk factors, and found that his total bilirubin level increased to 3.3 mg/dL and he developed jaundice after 5 months of duloxetine treatment. Discontinuation of duloxetine treatment saw his total bilirubin level decrease to 1.8 mg/dL. Thus, the administration of duloxetine might induce liver injury in a patient with MDD. However, the limitations of this single case report must be acknowledged. Although the cause of hepatic dysfunction in this case remains to be elucidated, clinicians should monitor liver function carefully after duloxetine treatment. Further investigations with a larger sample are needed.

A review of SSRIs and SNRIs in neuropathic pain

IMPORTANCE OF THE FIELD

Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs) are becoming increasingly used in the treatment of neuropathic pain and fibromyalgia. However, they are not without adverse effects and their efficacy has not been clear because of conflicting evidence.

AREAS COVERED IN THIS REVIEW

We have examined the current evidence on the efficacy of SSRIs and SNRIs in the treatment of neuropathic pain and fibromyalgia. Relevant randomized, placebo-controlled studies were identified through a MEDLINE search of English-language literature from January 1990 to December 2009.

WHAT THE READER WILL GAIN

The evidence for efficacy of SSRIs in the treatment neuropathic pain is moderate at best. However, SNRIs, venlafaxine and duloxetine have been shown to be effective in the treatment of painful diabetic neuropathy and polyneuropathy. With fibromyalgia, both SSRIs (fluoxetine and paroxetine) and SNRIs (duloxetine and milnacipran) have been shown to improve pain relief, function and quality of life.

TAKE HOME MESSAGE

SSRIs and SNRIs may be considered in the treatment of neuropathic pain if treatment with tricyclic antidepressants and anticonvulsants fails, or if there are contraindications to these drugs. There is also sufficient evidence to indicate that SNRIs are effective in the treatment of fibromyalgia and may be considered early in the treatment of fibromyalgia.

Review of Duloxetine and Venlafaxine in Depression

Objectives:

To compare the efficacy and pharmacologic, pharmacokinetic, drug interaction and adverse effect profiles of duloxetine and venlafaxine.

Methods:

A systematic review of the literature pertaining to duloxetine and venlafaxine was conducted using a computer-aided search of MEDLINE and EMBASE for the period January 1988 to May 2008 with the following search terms: venlafaxine and duloxetine and depression, clinical studies, pharmacology, drug interactions, pharmacokinetics, adverse effects, safety, case reports and review articles.

Results:

Duloxetine and venlafaxine have comparable efficacy and share similar pharmacologic profiles but differ somewhat in their pharmacokinetic profiles, drug interactions and adverse effects. Both agents block the reuptake of serotonin and norepinephrine and both are substrates for the cytochrome P450 2D6 isoenzyme; however, duloxetine inhibits these enzymes to a moderate extent, whereas venlafaxine is only a weak inhibitor. Furthermore, duloxetine is more extensively bound to protein than venlafaxine. Venlafaxine is more likely to elevate blood pressure in a dose-related manner. Both duloxetine and venlafaxine have the potential to cause hepatic injury.

Conclusions:

Although venlafaxine and duloxetine have similar efficacy in the treatment of depression, differences in their adverse effects and pharmacokinetic profiles suggest that one agent may be preferred over the other in certain patient groups.

The hepatic safety profile of duloxetine: a review

BACKGROUND

Hepatotoxicity related to the use of duloxetine resulted in rewording of the US product insert.

OBJECTIVE

To characterize the hepatic safety profile of duloxetine.

METHODS

We conducted a PubMed search of all English-language articles published between January 1990 and December 2007 and contacted the manufacturer (Eli Lilly, Inc.).

RESULTS

Elevations of alanine aminotransferase to three times the upper limit of normal occurs in 0.9-1.7% of duloxetine-treated patients versus 0.0-0.3% of placebo-treated patients. Hepatocellular, cholestatic and mixed hepatocellular-cholestatic forms of hepatic injury have been described.

CONCLUSION

Duloxetine does not appear to pose a greater hazard for hepatic toxicity when compared to other conventional antidepressants. Systematic monitoring of liver aminotransferases does not appear to be warranted with routine duloxetine use.

Drug-induced liver disease in 2006

PURPOSE OF REVIEW

To identify the key publications of 2006 dealing with drug-induced liver injury.

RECENT FINDINGS

When given in therapeutic doses over 14 days, acetaminophen produced significant asymptomatic elevations in alanine aminotransferase among healthy volunteers, suggesting that subclinical injury may be more common than previously thought. Acute liver failure in children was shown to differ in several important respects from that seen in adults, notably a much lower incidence of acetaminophen toxicity with nearly half of all cases being indeterminate in origin. The first cases of hepatotoxicity with telithromycin, a new class of ketolide antibiotic, were described along with reports suggesting liver injury from ezetimibe among other agents. The potential for chronic injury to develop after acute drug-induced liver injury was analyzed in a large Swedish database; 5-6% of cases were judged to become chronic, with drugs causing cholestatic injury predominating. Among well described hepatotoxins, new reports appeared with highly active antiretroviral therapy agents, herbal therapies and several antibiotics. Finally, the safe use of pravastatin and pioglitazone was demonstrated in patients with chronic liver disease in controlled clinical trials.

SUMMARY

Drug-induced liver injury remains an important concern for many existing drugs as well as for agents in development.

Epidemiology of acute liver failure

Acute liver failure (ALF) is an uncommon disorder that leads to jaundice, coagulopathy, and multisystem organ failure. Its definition is based on the timing from onset of jaundice to encephalopathy. In 2005, ALF accounted for 6% of liver-related deaths and 7% of orthotopic liver transplants (OLT) in the United States. Several classification systems have been developed for ALF, with the King's College criteria most widely used for prediction of OLT. Specific diagnostic tests should be implemented to identify the cause of ALF, which will help to determine its treatment and prognosis. Viral hepatitis was previously reported to be the most common cause of ALF in the United States, but acetaminophen overdose and idiosyncratic drug reactions have emerged as the most frequent causes in recent studies. Malignancy is an uncommon cause of ALF, and thus imaging studies may not be useful in this setting, but liver biopsy may be beneficial in selected cases. An overall strategy for ALF should start with identifying the cause, assessing the prognosis, and early transfer to a transplantation center for suitable candidates. OLT has emerged as a life-saving procedure leading to marked improvement in survival rates. Improved surgical techniques, immunosuppression, and comprehensive care have led to an overall survival rate of approximately 65% with OLT. N-acetylcysteine is effective in ALF caused by acetaminophen overdose, with results strongly related to how soon it is given rather than the route of administration. Liver support systems show potential for the treatment of ALF, but their role needs validation in large multicenter randomized trials.

Duloxetine in the management of depression

Duloxetine is a serotonin and noradrenalin reuptake inhibitor, and is hence in the same pharmacological class as venlafaxine. Randomized controlled trials have demonstrated it to be effective in the treatment of depression and also that it has analgesic properties in diabetic neuropathic pain, fibromyalgia and depressed patients with pain. To date, there is limited published data comparing duloxetine with other antidepressants. However, what data are available suggest that duloxetine is more effective than selective serotonin reuptake inhibitors in severely depressed patients (although the magnitude of this difference is uncertain) and equally effective as venlafaxine. While, theoretically, a serotonin and noradrenalin reuptake inhibitor may be more effective than a selective serotonin reuptake inhibitor in depressed patients with pain, there are no randomized, controlled trial data to support this hypothesis. Generally, duloxetine is well tolerated and there is no suggestion of the recent concerns of cardiotoxicity and toxicity in overdose that have been raised over venlafaxine. Duloxetine is an appropriate drug to consider for second-line treatment, after a selective serotonin reuptake inhibitor, for the management of depression.