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Feng Y, Zhao L, Zou Y, Liu Z, Xiao P, Wei D, Wu K, Yin T, Zhang Y, He H, Gou J, Wang Y, Tang X. Thermosensitive microemulsion gel incorporating nano-ZnO and black soybean tar improves treatment adherence and alleviates psoriasis-like skin disease. Colloids Surf B Biointerfaces 2025; 254:114812. [PMID: 40412289 DOI: 10.1016/j.colsurfb.2025.114812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2025] [Revised: 05/16/2025] [Accepted: 05/20/2025] [Indexed: 05/27/2025]
Abstract
Tar has been used as a natural product in the treatment of psoriasis for thousands of years and has achieved good clinical therapeutic effects. This study aimed to develop black soybean tar (BST)-zinc oxide (ZnO) composite thermosensitive microemulsion gels (BST-ZnO-MBGs) to improve the properties of BST, increase patient compliance, and enhance drug treatment effects. BST-ZnO20/500/3000-MBGs containing different sizes of ZnO were prepared by high pressure homogenization technology, and the rheology, zinc ion release and transdermal mechanism of the gels were studied. The pruritus model of guinea pigs and the psoriasis-like model of mice were used to evaluate the therapeutic effect. The addition of 20 nm ZnO ensured the best mechanical properties and therapeutic effect. It could increase the itching threshold of guinea pigs by more than 15 times and reduce the epidermal thickness of psoriatic mice by 75.45 % compared with the marketed BST ointment, and also had a strong anti-inflammatory effect. BST-ZnO-MBGs could significantly relieve psoriasis skin lesions and itching with fewer side effects. A promising approach for natural products of psoriasis was presented, and this study also provided new possibilities for the application of microemulsion gels to other skin diseases.
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Affiliation(s)
- Yupeng Feng
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Lei Zhao
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Yun Zou
- National Medical Products Administration Institute of Executive Development, Beijing 100073, PR China
| | - Zixu Liu
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Peifu Xiao
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Dandan Wei
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Kejia Wu
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Tian Yin
- School of Chinese Materia Medica, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Yu Zhang
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Haibing He
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Jingxin Gou
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China
| | - Yanjiao Wang
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China.
| | - Xing Tang
- Department of Pharmaceutics, School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110116, PR China.
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Agoglia L, Chindamo MC, Villela-Nogueira C. Psoriasis, metabolic syndrome and methotrexate: Is this association suitable for a new subcategory in steatotic liver disease? World J Hepatol 2025; 17:102978. [PMID: 40308817 PMCID: PMC12038415 DOI: 10.4254/wjh.v17.i4.102978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2024] [Revised: 03/08/2025] [Accepted: 03/27/2025] [Indexed: 04/25/2025] Open
Abstract
Psoriasis is a prevalent inflammatory disease that shares chronic inflammation pathways with the pathophysiology of metabolic syndrome (MetS), type-2 diabetes mellitus and atherosclerosis. A high prevalence of steatosis and advanced liver fibrosis has been described in psoriasis. The influence of MetS and its compounds, patatin-like phospholipase domain containing 3 and transmembrane 6 superfamily member 2 gene polymorphisms and the cumulative dose of methotrexate (MTX) in the progression of steatotic disease are still under debate. A suitable new classification for psoriasis-related liver disease, under the umbrella of steatotic liver disease (SLD), might be evaluated due to the potential impact of MTX on liver steatosis. Considering the interplay between the MetS, steatosis and MTX, a new definition for this complex disease might be discussed since it is not entirely addressed under the umbrella of SLD and metabolic-dysfunction associated SLD. Hence, shortly, a discussion could be raised on the feasible term "Met-Drug SLD", metabolic and drug-induced SLD, which comprises both metabolic dysfunction and drug-related SLD. This review aims to report the best evidence to accurately classify liver disease in psoriasis, considering the new definition of SLD, allowing appropriate management once it is carefully defined.
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Affiliation(s)
- Luciana Agoglia
- Department of Internal Medicine, School of Medicine, Section of Gastroenterology, Hospital Universitário Antônio Pedro, Federal University Fluminense, Niterói 24033-900, Rio de Janeiro, Brazil
| | - Maria Chiara Chindamo
- Department of Internal Medicine, School of Medicine and Hepatology Division, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Cristiane Villela-Nogueira
- Department of Internal Medicine, School of Medicine and Hepatology Division, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro 21941-913, Brazil.
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Agoglia L, Peixoto H, Cardoso AC, Barbosa L, Victer CSXL, Carneiro S, Salles GF, Villela-Nogueira CA, Chindamo MC. Psoriasis and cardiovascular risk: associated and protective factors. An Bras Dermatol 2025:S0365-0596(25)00021-2. [PMID: 40082144 DOI: 10.1016/j.abd.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 03/16/2025] Open
Abstract
BACKGROUND Psoriasis (Pso) is an inflammatory skin disease associated with Metabolic Syndrome (MetS), Steatotic Liver Disease (SLD) and cardiovascular risk. However, the effect of anti-inflammatory therapy on cardiovascular risk is uncertain. OBJECTIVES To determine the relationship between anti-inflammatory therapy and subclinical atherosclerosis in individuals with Pso, using the gold standard carotid-femoral Pulse Wave Velocity (cf-PWV) measurement. Additionally, to evaluate the association between cf-PWV, steatosis and Advanced Fibrosis (AF) using Transient Elastography (TE) by Fibroscan®. METHODS Cross-sectional study including Pso patients submitted to cf-PWV and TE. Steatosis was defined as a controlled attenuation parameter ≥ 275 dB/m, AF as liver stiffness measurement ≥ 10 kPa, and increased Aortic Stiffness (AoS) as cf-PWV ≥ 10 m/s. Significant cumulative methotrexate dose was ≥ 1500 mg (MTX1500). Logistic regression analysis evaluated the independent variables associated with increased AoS. RESULTS Eighty patients were included (mean age 56.2 ± 11.5-years, 57.5% female, BMI 28.6 ± 5.3 kg/m2). Prevalences of MetS, diabetes mellitus, dyslipidemia, systemic arterial hypertension, steatosis and AF were 57.5%, 40.0%, 67.5%, 70.0%, 50.0% and 16.3%, respectively. MTX1500 was present in 45%, immunobiological treatment in 33.8%, and cf-PWV ≥ 10 m/s in 21.2%. On logistic regression analysis, age was independently related to cf-PWV ≥ 10 m/s (OR = 1.21; 95% CI 1.06‒1.38; p = 0.003) and MTX1500 was a protective cardiovascular factor (OR = 0.18; 95% CI 0.038‒0.87; p = 0.033). No association was observed between steatosis, AF or immunobiological therapy and cf-PWV ≥10 m/s. STUDY LIMITATIONS Sample size. CONCLUSION In patients with Pso, increased AoS was associated with age, but not with steatosis or AF. A protective cardiovascular effect of MTX was found in a Pso population with a high prevalence of MetS and its components.
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Affiliation(s)
- Luciana Agoglia
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ Brazil; Section of Gastroenterology, Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brazil.
| | - Helena Peixoto
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Ana Carolina Cardoso
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Lívia Barbosa
- Dermatology Division, Hospital Federal de Bonsucesso, Rio de Janeiro, RJ, Brazil
| | - Cecília S X L Victer
- Dermatology Unit, Faculty of Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Sueli Carneiro
- Dermatology Unit, Faculty of Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Gil F Salles
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Cristiane A Villela-Nogueira
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Maria Chiara Chindamo
- Department of Internal Medicine, Faculty of Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ Brazil
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AkbariRad M, Rezaieyazdi Z, Tajik A, Ataei B, Sarabi M, MehradMajd H, Vossoughinia H, Firoozi A. The relationship between dose of methotrexate and incidence of liver fibrosis in patients with rheumatoid arthritis. Reumatologia 2025; 63:3-11. [PMID: 40206223 PMCID: PMC11977502 DOI: 10.5114/reum/199740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Accepted: 01/02/2025] [Indexed: 04/11/2025] Open
Abstract
Introduction Methotrexate (MTX) is a chemotherapy agent and immune system suppressant that can cause liver fibrosis in long-term usage. This study aimed to investigate the relationship between the dose of MTX and the incidence of liver fibrosis in patients with rheumatoid arthritis (RA). Material and methods This cohort study was conducted on RA patients with normal liver function who took MTX. Liver FibroScan and laboratory tests, including α2-macroglobulin, total bilirubin, g-glutamyltransferase, apolipoprotein A1, haptoglobin, and alanine transaminase was performed. The patients were divided into 2 groups regarding their cumulative dose of MTX and the rate of liver fibrosis incidence was compared between the 2 groups. Results In total, 60 RA patients with the mean age of 55.2 ±11.8 years were enrolled. The mean duration of MTX use in patients was 6.9 ±3.8 years, and it was higher in the higher cumulative dose MTX group (> 2 g) than in the lower cumulative dose group (< 2 g; p < 0.0001). The overall prevalence of grade 3 fibrosis was 3.33%. The prevalence of second- and third-degree liver fibrosis in patients receiving a lower cumulative dose was respectively 9 (28.1%) and 1 (3.1%), and in patients receiving a higher cumulative dose it was 7 (25%) and 1 (3.6%), respectively. There was no statistically significant difference between the 2 groups regarding the prevalence of liver fibrosis (p = 0.88). Both aspartate aminotransferase to platelet ratio index and Fibrosis Index Based on 4 Factors indices showed no significant difference between the 2 groups (p = 0.594, p = 0.232). Conclusions These results suggest that long-term treatment with a higher cumulative dose of MTX is not associated with a higher incidence of liver fibrosis in RA patients.
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Affiliation(s)
- Mina AkbariRad
- Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Iran
| | - Zahra Rezaieyazdi
- Rheumatic Disease Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Iran
| | - Ali Tajik
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Iran
| | - Banafshe Ataei
- Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Iran
| | - Mehrdad Sarabi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Iran
| | - Hasan MehradMajd
- Clinical Research Unit, Mashhad University of Medical Sciences, Iran
| | - Hasan Vossoughinia
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Iran
| | - Abdollah Firoozi
- Faculty of Pharmacy, Mashhad University of Medical Sciences, Iran
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Mao YM, Tang JT, Lu ZH, Shao M, Zhao WF, Zhan J, Huang ZX, Niu QH, Chen L, Chen ZF, Guo CH, Jia ZH, Li H, Liu B, Miao J, Peng ZT, Pu YL, Qu LH, Shen XM, Sun W, Wang HW, Lu XL, Xue JJ, Yang YY, Yang Z, Yang ZH, Zhang QG, Niu T, Zhu WD, Liu XL, Zhong W, Dong YN, Zhi Y, Li XY. Chinese Guideline for the Diagnosis and Management of Drug-Induced Liver Injury in Primary Care (2024). J Dig Dis 2025; 26:2-21. [PMID: 40198161 DOI: 10.1111/1751-2980.13337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2025] [Revised: 02/27/2025] [Accepted: 03/09/2025] [Indexed: 04/10/2025]
Abstract
Drug-induced liver injury (DILI) is a drug-induced disease that not only complicates the treatment of the primary disease but may also lead to acute liver failure or even death in severe cases. Drugs commonly used in primary care, such as anti-infective agents and nonsteroidal anti-inflammatory drugs, are major causes of DILI. In addition, a large elderly population, comorbidities, and combination therapy with multiple drugs increase the risk of DILI in primary care. Therefore, primary care providers should proactively screen and monitor high-risk patients to identify potential DILI timely. Currently, diagnosis of DILI relies on the exclusion of liver diseases of other etiologies. Collection of detailed medical history of the patients and careful exclusion of other potential liver injury of other etiologies are crucial for accurate diagnosis. This guideline, developed based on evidence-based medicine from the latest research, aimed to provide primary care providers with professional guidance on the timely identification of suspected DILI cases and standardized diagnosis and management in clinical practice.
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Affiliation(s)
- Yi Min Mao
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, China
| | - Jie Ting Tang
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, China
| | - Zhong Hua Lu
- Department of Hepatology, Affiliated Wuxi Fifth Hospital of Jiangnan Univeristy, Wuxi, Jiangsu Province, China
| | - Ming Shao
- Department of Infectious Diseases, Yuncheng Huiren Hospital, Yuncheng, Shanxi Province, China
| | - Wei Feng Zhao
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jun Zhan
- Department of Gastroenterology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zu Xiong Huang
- Department of Hepatology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Qing Hui Niu
- Department of Hepatology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Lin Chen
- Department of Infectious Diseases, Zhuji People's Hospital of Zhejiang Province, Zhuji, Zhejiang Province, China
| | - Zhan Feng Chen
- Department of Infectious Diseases, Shishi General Hospital, Quanzhou, Fujian Province, China
| | - Chun Hui Guo
- Department of Infectious Diseases, Jiangyin People's Hospital, Jiangyin, Jiangsu Province, China
| | - Zi Hui Jia
- Department of Gastroenterology, Gaobeidian Hospital, Baoding, Hebei Province, China
| | - Hai Li
- Department of Gastroenterology, Tianjin Xiqing Hospital, Tianjin, China
| | - Bo Liu
- Department of Gastroenterology, The People's Hospital of Zhangwu, Fuxin, Liaoning Province, China
| | - Jing Miao
- Department of Traditional Chinese Medicine, Tianjin Second People's Hospital, Tianjin, China
| | - Zhong Tian Peng
- Department of Infectious Diseases, The First Affiliated Hospital of University of South China, Hengyang, Hunan Province, China
| | - Yong Lan Pu
- Department of Infectious Diseases, The First People's Hospital of Taicang, Taicang, Jiangsu Province, China
| | - Li Hong Qu
- Department of Infectious Diseases, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Xiao Ming Shen
- Department of Infectious Diseases, Jiaxing No. 2 Hospital, Jiaxing, Zhejiang Province, China
| | - Wei Sun
- Department of Infectious Diseases and Hepatology, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Hong Wu Wang
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Xiao Lan Lu
- Department of Gastroenterology, Shanghai Pudong Hospital, Shanghai, China
| | - Jian Jun Xue
- Department of Infectious Diseases, People's Hospital of Hongtong County, Linfen, Shanxi Province, China
| | - Ya Yun Yang
- Department of Infectious Diseases, Mengzi People's Hospital, Mengzi, Yunnan Province, China
| | - Zheng Yang
- Department of Infectious Diseases, Jingzhou Central Hospital, Jingzhou, Hebei Province, China
| | - Zhong Hui Yang
- Department of Pharmacy, The First People's Hospital of Taicang, Taicang, Jiangsu Province, China
| | - Qing Ge Zhang
- Department of Hepatology of Integrated Traditional Chinese and Western Medicine, Xingtai People's Hospital, Xingtai, Hebei Province, China
| | - Tao Niu
- Department of Gastroenterology, People's Hospital of Dongxihu District, Wuhan, Hubei Province, China
| | - Wei Dong Zhu
- Department of Infectious Diseases, Changsu No. 2 People's Hospital, Changshu, Jiangsu Province, China
| | - Xiao Lin Liu
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Wei Zhong
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, China
| | - Yi Nuo Dong
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, China
| | - Yang Zhi
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, China
| | - Xiao Yun Li
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, China
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Tezcan D, Özer H, Topaloğlu ÖF, Hakbilen S, Durmaz MS, Yılmaz S, Öztürk M. Evaluation of liver parenchyma with shear wave elastography in patients with rheumatoid arthritis receiving disease-modifying antirheumatic drug therapy. JOURNAL OF CLINICAL ULTRASOUND : JCU 2025; 53:148-154. [PMID: 39304522 DOI: 10.1002/jcu.23847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Revised: 09/07/2024] [Accepted: 09/11/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Methotrexate (MTX) and leflunomide (LEF) play fundamental roles in rheumatoid arthritis (RA) treatment and require proper monitoring of side effects. Concerns about MTX/LEF-related liver fibrosis (LF) in patients with RA remain unclear. This study investigated liver stiffness using two-dimensional shear wave elastography (2D-SWE) in RA patients undergoing disease-modifying antirheumatic drug (DMARD) therapy. Moreover, 2D-SWE was employed to evaluate the correlations between liver stiffness, cumulative MTX and LEF doses and risk factors for substantial LF. METHODS We recruited 222 participants from the Department of Rheumatology. The participants were divided into healthy controls (n = 78) and patients with RA (n = 144). Pearson's correlation analysis was performed to assess the correlations between liver stiffness and the cumulative dose of MTX/LEF and other clinical and laboratory variables. RESULTS The mean elasticity modulus was 4.79 ± 0.92 kPa, excluding the presence of significant fibrosis. Mean 2D-SWE values were significantly lower in healthy controls than in RA treated with MTX and LEF. The cut-off ≥3.8 kPa 2D-SWE values with the sensitivity of 86.1%, specifity of 83.3%. 2D-SWE values were not significantly different across the strata of the cumulative MTX subgroups. CONCLUSIONS MTX and LEF increase liver stiffness but may be considered low risk for the development of LF.
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Affiliation(s)
- Dilek Tezcan
- Department of Internal Medicine, Division of Rheumatology, Gülhane Faculty of Medicine, University of Health Sciences Turkey, Ankara, Turkey
| | - Halil Özer
- Division of Radiology, Selcuk University Faculty of Medicine, Konya, Turkey
| | | | - Selda Hakbilen
- Division of Rheumatology, Selcuk University Faculty of Medicine, Konya, Turkey
| | | | - Sema Yılmaz
- Division of Rheumatology, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Mehmet Öztürk
- Division of Radiology, Selcuk University Faculty of Medicine, Konya, Turkey
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Agoglia L, Cardoso AC, Barbosa L, Victer CSXL, Carneiro S, de França PHC, Chindamo MC, Villela-Nogueira CA. Psoriasis and steatotic liver disease: Are PNPLA3 and TM6SF2 polymorphisms suitable for the hepato-dermal axis hypothesis? Ann Hepatol 2024; 29:101477. [PMID: 38360269 DOI: 10.1016/j.aohep.2024.101477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/29/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION AND OBJECTIVES A high prevalence of steatotic liver disease has been described in psoriasis. However, the influence of genetic polymorphisms has yet to be investigated in this scenario. This study aims to determine the frequency of steatosis, advanced liver fibrosis and PNPLA3/TM6SF2 genotypes in individuals with psoriasis and to evaluate the impact of genetic polymorphisms, metabolic parameters and cumulative methotrexate dose on steatosis and fibrosis. MATERIALS AND METHODS Cross-sectional study that prospectively included psoriasis outpatients, submitted to clinical and laboratory analysis, transient elastography (FibroScan®, Fr) and PNPLA3/TM6SF2 genotyping. Steatosis was defined by CAP ≥275 dB/m and advanced liver fibrosis as transient elastography ≥10 kPa. Logistic regression analysis evaluated the independent variables related to steatosis and fibrosis; p-value< 0.05 was considered significant. RESULTS One hundred and ninety-nine patients were enrolled (age 54.6 ± 12.6 years, 57.3% female). Metabolic syndrome (MetS), steatosis and advanced liver fibrosis prevalence were 55.8%, 54.8% and 9%, respectively. PNPLA3 and TM6SF2 genotypes frequencies were CC 42.3%/CG 49.5%/GG 8.2% and CC 88.7%/ CT 11.3%/ TT 0%. MetS (OR3.01 95%CI 1.51-5.98; p = 0.002) and body mass index (OR1.17 95%CI 1.08-1.26; p < 0.01) were independently associated with steatosis. Diabetes Mellitus (T2DM) (OR10.76 95%CI 2.42-47.87; p = 0.002) and harboring at least one PNPLA3 G allele (OR5.66 95%CI 1.08-29.52; p = 0.039) were associated with advanced fibrosis, but not TM6SF2 polymorphism or cumulative MTX dose. CONCLUSIONS MetS and T2DM confer higher odds for steatosis and advanced fibrosis in individuals with psoriasis. PNPLA3 G allele, but not TM6SF2 polymorphism, impacts a 5-fold odds of advanced liver fibrosis.
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Affiliation(s)
- Luciana Agoglia
- School of Medicine and Hepatology Unit, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Brazil; Section of Gastroenterology, Hospital Universitário Antônio Pedro, Federal University Fluminense, Niterói, Brazil.
| | - Ana Carolina Cardoso
- School of Medicine and Hepatology Unit, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Brazil
| | - Lívia Barbosa
- Dermatology Division, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | | | - Sueli Carneiro
- School of Medicine and Dermatology Unit, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Brazil
| | | | - Maria Chiara Chindamo
- School of Medicine and Hepatology Unit, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Brazil
| | - Cristiane Alves Villela-Nogueira
- School of Medicine and Hepatology Unit, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Brazil
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Hizli P, Oğuz ID, Kulakli S, Kiliç FA, Duyan A. Unveiling the impact of psoriasis on liver health: does methotrexate play a villainous role? Arch Dermatol Res 2024; 316:437. [PMID: 38940980 DOI: 10.1007/s00403-024-03193-9] [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: 05/11/2024] [Revised: 06/11/2024] [Accepted: 06/15/2024] [Indexed: 06/29/2024]
Abstract
Psoriasis might bring about an increased risk of liver diseases like nonalcoholic fatty liver disease and fibrosis. The impact of methotrexate on liver function is still a cause for concern, because of the studies suggesting an increased risk of liver damage and others finding no association. The focus of this study was the liver functions in psoriatic patients investigating the impact of long-term use of methotrexate on liver in psoriasis. A retrospective investigation including 140 patients with psoriasis receiving methotrexate treatment for at least 6 months and a control group consisted of 105 healthy ones was conducted. Liver function tests (AST, ALT, PLT) were assessed, and the association of baseline PASI with FIB-4 and APRI values was investigated. Additionally, FIB-4 and APRI values at baseline, 3rd, and 6th months of methotrexate treatment for psoriasis were compared. Compared with the controls, psoriatic patients exhibited significantly higher FIB-4 scores (p = 0.004). A moderate and significant correlation was observed between baseline PASI score and baseline FIB-4 score in psoriatic patients (p < 0.001, rho = 0.626). Long-term methotrexate use had no effect on APRI or FIB-4 (p = 0.104 and p = 0.475, respectively). Psoriatic patients face an elevated risk of liver fibrosis. Long-term methotrexate use does not adversely affect liver function in psoriatic patients. Noninvasive tools like APRI and FIB-4 scores can be employed to evaluate the risk of liver disease in these patients.
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Affiliation(s)
- Pelin Hizli
- Department of Dermatology, Faculty of Medicine, Balikesir University, Balikesir, Turkey.
| | - Işıl Deniz Oğuz
- Department of Dermatology, Faculty of Medicine, Giresun University, Giresun, Turkey
| | - Sevgi Kulakli
- Department of Dermatology, Faculty of Medicine, Giresun University, Giresun, Turkey
| | - Fatma Arzu Kiliç
- Department of Dermatology, Faculty of Medicine, Balikesir University, Balikesir, Turkey
| | - Ayser Duyan
- Department of Dermatology, Faculty of Medicine, Balikesir University, Balikesir, Turkey
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Nguyen HX, Kipping T, Banga AK. Polymeric Microneedles Enhance Transdermal Delivery of Therapeutics. Pharmaceutics 2024; 16:845. [PMID: 39065542 PMCID: PMC11280287 DOI: 10.3390/pharmaceutics16070845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/10/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024] Open
Abstract
This research presents the efficacy of polymeric microneedles in improving the transdermal permeation of methotrexate across human skin. These microneedles were fabricated from PLGA Expansorb® 50-2A and 50-8A and subjected to comprehensive characterization via scanning electron microscopy, Fourier-transform infrared spectroscopy, and mechanical analysis. We developed and assessed a methotrexate hydrogel for physicochemical and rheological properties. Dye binding, histological examinations, and assessments of skin integrity demonstrated the effective microporation of the skin by PLGA microneedles. We measured the dimensions of microchannels in the skin using scanning electron microscopy, pore uniformity analysis, and confocal microscopy. The skin permeation and disposition of methotrexate were researched in vitro. PLGA 50-8A microneedles appeared significantly longer, sharper, and more mechanically uniform than PLGA 50-2A needles. PLGA 50-8A needles generated substantially more microchannels, as well as deeper, larger, and more uniform channels in the skin than PLGA 50-2A needles. Microneedle insertion substantially reduced skin electrical resistance, accompanied by an elevation in transepidermal water loss values. PLGA 50-8A microneedle treatment provided a significantly higher cumulative delivery, flux, diffusion coefficient, permeability coefficient, and predicted steady-state plasma concentration; however, there was a shorter lag time than for PLGA 50-2A needles, base-treated, and untreated groups (p < 0.05). Conclusively, skin microporation using polymeric microneedles significantly improved the transdermal delivery of methotrexate.
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Affiliation(s)
- Hiep X. Nguyen
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, USA
- Faculty of Pharmacy, Phenikaa University, Yen Nghia, Ha Dong, Hanoi 12116, Vietnam;
| | - Thomas Kipping
- MilliporeSigma, a Business of Merck KGaA, Frankfurter Strasse 250, 64293 Darmstadt, Germany
| | - Ajay K. Banga
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, USA
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10
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Zhang Y, Guo Y, Zhang K, Fan L, Ma J, Li Y, Zhou Q, Zhao Q, Hou S, Wang H. Comorbidities among adult patients with psoriasis in Tianjin: a cross-sectional analysis of the Health Database study. BMJ Open 2024; 14:e083683. [PMID: 38772892 PMCID: PMC11110554 DOI: 10.1136/bmjopen-2023-083683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 04/11/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVES This study aims to examine the prevalence of comorbidities in adult patients with psoriasis and compare them with those in control subjects without psoriasis in Tianjin, China. DESIGN The study is a cross-sectionalanalysis. PARTICIPANTS The participants were established by identifying all patients (age ≥18 years) who visited hospitals and clinics in Tianjin between 1 January 2016 and 31 October 2019. SETTING The study group consisted of 20 678 adult patients with psoriasis, and a comparison group was created after 1:1 propensity score matching. Logistic regression analyses were conducted to examine the risk of 22 comorbidities for these two groups. RESULTS Patients with psoriasis had a significantly higher prevalence of 11 comorbidities and a lower prevalence of 2 comorbidities within 12 months of follow-up. Our results also showed that the proportion of psoriatic arthritis might account for approximately 2% of all patients with psoriasis. This psoriatic arthritis group had a higher average age and CCI (Charlson Comorbidity Index) index score (2.27 >1.62, p <0.001) than the non-arthritis group. CONCLUSIONS This study showed that psoriasis in Tianjin is associated with various comorbidities. It also emphasises the importance of clinical treatment in improving therapeutic effects and reducing the burden of psoriasis in China.
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Affiliation(s)
- Yiming Zhang
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
| | - Yali Guo
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
- Department of Dermatology, Tianjin Haihe Hospital, Tianjin, China
| | - Kaiyue Zhang
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
| | - Liyun Fan
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
| | - Jingyue Ma
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
| | - Yan Li
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
| | - Quan Zhou
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
| | - Qian Zhao
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
| | - Shuping Hou
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
| | - Huiping Wang
- Department of Dermatovenereology, Tianjin Medical University General Hospital/ Tianjin Institute of Sexually Transmitted Disease, Tianjin, China
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11
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Mao Y, Ma S, Liu C, Liu X, Su M, Li D, Li Y, Chen G, Chen J, Chen J, Zhao J, Guo X, Tang J, Zhuge Y, Xie Q, Xie W, Lai R, Cai D, Cai Q, Zhi Y, Li X. Chinese guideline for the diagnosis and treatment of drug-induced liver injury: an update. Hepatol Int 2024; 18:384-419. [PMID: 38402364 DOI: 10.1007/s12072-023-10633-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 12/18/2023] [Indexed: 02/26/2024]
Abstract
Drug-induced liver injury (DILI) is an important adverse drug reaction that can lead to acute liver failure or even death in severe cases. Currently, the diagnosis of DILI still follows the strategy of exclusion. Therefore, a detailed history taking and a thorough and careful exclusion of other potential causes of liver injury is the key to correct diagnosis. This guideline was developed based on evidence-based medicine provided by the latest research advances and aims to provide professional guidance to clinicians on how to identify suspected DILI timely and standardize the diagnosis and management in clinical practice. Based on the clinical settings in China, the guideline also specifically focused on DILI in chronic liver disease, drug-induced viral hepatitis reactivation, common causing agents of DILI (herbal and dietary supplements, anti-tuberculosis drugs, and antineoplastic drugs), and signal of DILI in clinical trials and its assessment.
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Affiliation(s)
- Yimin Mao
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, 200001, China.
| | - Shiwu Ma
- Department of Infectious Diseases, The 920th Hospital of Chinese PLA Joint Logistics Support Force, Kunming, 650032, Yunnan, China
| | - Chenghai Liu
- Institute of Liver Diseases, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Xiaoyan Liu
- Department of Pharmacy, Huangpu Branch of the 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200011, China
| | - Minghua Su
- Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Dongliang Li
- Department of Hepatobiliary Medicine, The 900th Hospital of Chinese PLA Joint Logistics Support Force, Fuzhou, 350025, Fujian, China
| | - Yiling Li
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, 110001, Liaoning, China
| | - Gongying Chen
- Department of Liver Diseases, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, 310015, Zhejiang, China
| | - Jun Chen
- Department of Infectious Diseases, Shenzhen Third People's Hospital, Shenzhen, 518112, Guangdong, China
| | - Jinjun Chen
- Hepatology Center, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Jingmin Zhao
- Department of Pathology and Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Xiaoyan Guo
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Jieting Tang
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, 200001, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Wen Xie
- Center of Liver Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, 100088, China
| | - Rongtao Lai
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Dachuan Cai
- Department of Infectious Diseases, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qingxian Cai
- Department of Infectious Diseases, Shenzhen Third People's Hospital, Shenzhen, 518112, Guangdong, China
| | - Yang Zhi
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, 200001, China
| | - Xiaoyun Li
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, 200001, China
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12
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Livzan MA, Gaus OV, Ekimov IN. Non-alcoholic fatty liver disease and psoriasis: mechanisms of comorbidity and approaches to therapy. MEDITSINSKIY SOVET = MEDICAL COUNCIL 2024:113-120. [DOI: 10.21518/ms2024-045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
Psoriasis is a chronic immune-mediated skin disease of a multifactorial nature, characterized by accelerated proliferation of keratinocytes and impaired differentiation, an imbalance between pro-inflammatory and anti-inflammatory cytokines, with frequent involvement of the musculoskeletal system in the pathological process. The etiology of psoriasis is unknown, but several risk factors have been identified, including family history, smoking and obesity. The high prevalence of obesity, diseases of the cardiovascular system and digestive organs in patients with psoriasis allows us to consider it as an indicator of the patient’s metabolic disorders. In the structure of comorbidity of patients with psoriasis, special attention is drawn to non-alcoholic fatty liver disease (NAFLD), which occupies a leading position in the structure of the incidence of chronic diffuse liver diseases among the adult population in many countries of the world, including Russia. Patients with psoriasis are more often diagnosed with NAFLD, regardless of the presence of metabolic syndrome and other traditional risk factors. The presence of NAFLD is associated with more severe psoriasis and worse outcomes. On the other hand, a negative effect of psoriasis on the course of liver pathology has been noted. In this regard, it seems particularly relevant to study the etiological factors and pathogenetic links underlying this comorbidity, as potential targets for targeted therapy, which can improve the effectiveness of treatment for this cohort of patients. The purpose of this review publication is to summarize and systematize the available data on the prevalence of comorbidity of psoriasis and NAFLD in the population, the mechanisms of its formation and approaches to patient management.
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13
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Costache DO, Blejan H, Cojocaru DL, Ioniță GA, Poenaru M, Constantin MM, Costache AC, Căruntu C, Balaban DV, Costache RS. Intersecting Pathways: Nonalcoholic Fatty Liver Disease and Psoriasis Duet-A Comprehensive Review. Int J Mol Sci 2024; 25:2660. [PMID: 38473907 PMCID: PMC10932248 DOI: 10.3390/ijms25052660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/17/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
Psoriasis is a chronic, immune-mediated, inflammatory disease that has a major impact on patients' quality of life. Common psoriasis-associated comorbidities include cardiovascular diseases, psoriatic arthritis, inflammatory bowel syndromes, type-2 diabetes, and metabolic syndrome. Nonalcoholic fatty liver disease (NAFLD) is affecting a substantial portion of the population and is closely linked with psoriasis. The interplay involves low-grade chronic inflammation, insulin resistance, and genetic factors. The review presents the pathophysiological connections between psoriasis and nonalcoholic fatty liver disease, emphasizing the role of cytokines, adipokines, and inflammatory cascades. The "hepato-dermal axis" is introduced, highlighting how psoriatic inflammation potentiates hepatic inflammation and vice versa. According to the new guidelines, the preliminary examination for individuals with psoriasis should encompass evaluations of transaminase levels and ultrasound scans as part of the initial assessment for this cohort. Considering the interplay, recent guidelines recommend screening for NAFLD in moderate-to-severe psoriasis cases. Treatment implications arise, particularly with medications impacting liver function. Understanding the intricate relationship between psoriasis and NAFLD provides valuable insights into shared pathogenetic mechanisms. This knowledge has significant clinical implications, guiding screening practices, treatment decisions, and the development of future therapeutic approaches for these chronic conditions.
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Affiliation(s)
- Daniel Octavian Costache
- Discipline of Dermatology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.O.C.); (M.M.C.)
- Dermatology Department, Carol Davila Central Emergency Military University Hospital, 010825 Bucharest, Romania; (H.B.); (M.P.)
| | - Horia Blejan
- Dermatology Department, Carol Davila Central Emergency Military University Hospital, 010825 Bucharest, Romania; (H.B.); (M.P.)
| | - Damian Lucian Cojocaru
- Gastroenterology Department, Carol Davila Central Emergency Military University Hospital, 010825 Bucharest, Romania; (D.L.C.); (G.A.I.); (D.V.B.); (R.S.C.)
| | - Georgiana Alexandra Ioniță
- Gastroenterology Department, Carol Davila Central Emergency Military University Hospital, 010825 Bucharest, Romania; (D.L.C.); (G.A.I.); (D.V.B.); (R.S.C.)
| | - Marcela Poenaru
- Dermatology Department, Carol Davila Central Emergency Military University Hospital, 010825 Bucharest, Romania; (H.B.); (M.P.)
| | - Maria Magdalena Constantin
- Discipline of Dermatology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.O.C.); (M.M.C.)
- 2nd Dermatology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Andrei Cătălin Costache
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Constantin Căruntu
- Discipline of Internal Medicine and Gastroenterology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Daniel Vasile Balaban
- Gastroenterology Department, Carol Davila Central Emergency Military University Hospital, 010825 Bucharest, Romania; (D.L.C.); (G.A.I.); (D.V.B.); (R.S.C.)
- Discipline of Physiology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Raluca Simona Costache
- Gastroenterology Department, Carol Davila Central Emergency Military University Hospital, 010825 Bucharest, Romania; (D.L.C.); (G.A.I.); (D.V.B.); (R.S.C.)
- Discipline of Physiology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Academy of Romanian Scientists, 050091 Bucharest, Romania
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14
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Schäfer A, Kovacs MS, Eder A, Nigg A, Feuchtenberger M. Longitudinal assessment of liver stiffness using ARFI technique does not support increased risk of fibrosis in rheumatoid arthritis patients on methotrexate. J Ultrasound 2024:10.1007/s40477-023-00843-y. [PMID: 38227146 DOI: 10.1007/s40477-023-00843-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/30/2023] [Indexed: 01/17/2024] Open
Abstract
AIMS To assess the liver stiffness in patients with rheumatoid arthritis treated with methotrexate monotherapy using non-invasive, ultrasound-based elastography (acoustic radiation force impulse (ARFI) imaging) in a longitudinal approach. METHODS In total, 23 MTX-naive patients were longitudinally assessed using acoustic radiation force impulse (ARFI) imaging. Baseline assessments were carried out between July 2018 and April 2019, and the follow-up evaluations took place after an average of 2.6 years. The main outcome variable was the mean shear wave velocity as measured by the ARFI method. It was calculated from 10 valid ARFI measurements for each patient. Inferential statistical analyses (within-group comparisons) were performed using t-tests for dependent samples or suitable nonparametric procedures. RESULTS The main finding was that observed ARFI shear wave velocities did not increase during the observation period. In fact, this parameter decreased over time from 1.07 m/s (SD = 0.23) at baseline without MTX exposure to 0.97 m/s (SD = 0.16) at follow-up after a mean of 2.6 years (P = 0.013). Moreover, the magnitude of the change in shear wave velocity could not be predicted by indicators of inflammation or disease activity, BMI, age, sex or NSAR intake (corresponding regression analysis: corrected R2 = 0.344; P = 0.296). CONCLUSIONS No increased risk of liver fibrosis was found in RA patients treated with MTX monotherapy during observation period.
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Affiliation(s)
- Arne Schäfer
- Diabetes Zentrum Mergentheim, Bad Mergentheim, Germany
- Medizinische Klinik und Poliklinik II, University Hospital Würzburg, Würzburg, Germany
| | | | - Anna Eder
- MVZ MED|BAYERN OST, Krankenhausstraße 1, 84489, Burghausen, Germany
| | - Axel Nigg
- MVZ MED|BAYERN OST, Krankenhausstraße 1, 84489, Burghausen, Germany
| | - Martin Feuchtenberger
- Medizinische Klinik und Poliklinik II, University Hospital Würzburg, Würzburg, Germany.
- MVZ MED|BAYERN OST, Krankenhausstraße 1, 84489, Burghausen, Germany.
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15
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Lertnawapan R, Chonprasertsuk S, Siramolpiwat S, Jatuworapruk K. Correlation between Cumulative Methotrexate Dose, Metabolic Syndrome and Hepatic Fibrosis Detected by FibroScan in Rheumatoid Arthritis Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1029. [PMID: 37374233 DOI: 10.3390/medicina59061029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Methotrexate (MTX) is routinely prescribed for rheumatoid arthritis (RA) patients, but high cumulative doses may lead to hepatic fibrosis. Additionally, a high proportion of RA patients suffer from metabolic syndrome, which also increases the risk of hepatic fibrosis. This cross-sectional study aimed to explore the association between a cumulative MTX dose, metabolic syndrome, and hepatic fibrosis in patients diagnosed with RA. Materials and Methods: RA patients undergoing treatment with MTX were examined using transient elastography (TE). All patients, regardless of having hepatic fibrosis, were compared to identify the risk factors. Results: Two hundred and ninety-five rheumatoid arthritis patients were examined using FibroScan. One hundred and seven patients (36.27%) were found to have hepatic fibrosis (TE > 7 kPa). After multivariate analysis, only BMI (OR = 14.73; 95% CI 2.90-74.79; p = 0.001), insulin resistance (OR = 312.07; 95% CI 6.19-15732.13; p = 0.04), and cumulative MTX dosage (OR 1.03; 95% CI 1.01-1.10; p = 0.002) were associated with hepatic fibrosis. Conclusions: While the cumulative MTX dose and metabolic syndrome are both the risk factors of hepatic fibrosis, metabolic syndrome, including a high BMI and insulin resistance, poses a greater risk. Therefore, MTX-prescribed RA patients with metabolic syndrome factors should be attentively monitored for signs of liver fibrosis.
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Affiliation(s)
- Ratchaya Lertnawapan
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand
| | - Soonthorn Chonprasertsuk
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand
| | - Sith Siramolpiwat
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand
| | - Kanon Jatuworapruk
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand
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16
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Di Martino V. Methotrexate-induced liver fibrosis: The end of a long-held belief. J Hepatol 2023; 78:896-897. [PMID: 36854346 DOI: 10.1016/j.jhep.2023.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 03/02/2023]
Affiliation(s)
- Vincent Di Martino
- Department of Hepatology, CHRU Jean Minjoz, EA 4266 EPILAB, UFR Santé, University of Franche-Comté, INSERM UMR RIGHT 1098, Besançon, France.
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17
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Fontana RJ, Liou I, Reuben A, Suzuki A, Fiel MI, Lee W, Navarro V. AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury. Hepatology 2023; 77:1036-1065. [PMID: 35899384 PMCID: PMC9936988 DOI: 10.1002/hep.32689] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Iris Liou
- University of Washington, Seattle, Washington, USA
| | - Adrian Reuben
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ayako Suzuki
- Division of Gastroenterology, Duke University, Durham, North Carolina, USA
| | - M. Isabel Fiel
- Department of Pathology, Mount Sinai School of Medicine, New York City, New York, USA
| | - William Lee
- Division of Gastroenterology, University of Texas Southwestern, Dallas, Texas, USA
| | - Victor Navarro
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
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18
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Di Martino V, Verhoeven DW, Verhoeven F, Aubin F, Avouac J, Vuitton L, Lioté F, Thévenot T, Wendling D. Busting the myth of methotrexate chronic hepatotoxicity. Nat Rev Rheumatol 2023; 19:96-110. [PMID: 36564450 DOI: 10.1038/s41584-022-00883-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
Methotrexate is a key component of the treatment of inflammatory rheumatic diseases and the mainstay of therapy in rheumatoid arthritis. Hepatotoxicity has long been a concern for prescribers envisaging long-term treatment with methotrexate for their patients. However, the putative liver toxicity of methotrexate should be evaluated in the context of advances in our knowledge of the pathogenesis and natural history of liver disease, especially non-alcoholic fatty liver disease (NAFLD). Notably, patients with NAFLD are at increased risk for methotrexate hepatotoxicity, and methotrexate can worsen the course of NAFLD. Understanding the mechanisms of acute hepatotoxicity can facilitate the interpretation of elevated concentrations of liver enzymes in this context. Liver fibrosis and the mechanisms of fibrogenesis also need to be considered in relation to chronic exposure to methotrexate. A number of non-invasive tests for liver fibrosis are available for use in patients with rheumatic disease, in addition to liver biopsy, which can be appropriate for particular individuals. On the basis of the available evidence, practical suggestions for pretreatment screening and long-term monitoring of methotrexate therapy can be made for patients who have (or are at risk for) chronic liver disease.
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Affiliation(s)
- Vincent Di Martino
- Department of Hepatology, CHRU de Besançon, Besançon, France.
- EA 4266 EPILAB, UFR Santé, University of Franche-Comté, Besançon, France.
- INSERM UMR RIGHT 1098, Besançon, France.
| | - Delphine Weil Verhoeven
- Department of Hepatology, CHRU de Besançon, Besançon, France
- EA 4266 EPILAB, UFR Santé, University of Franche-Comté, Besançon, France
- INSERM UMR RIGHT 1098, Besançon, France
| | - Frank Verhoeven
- Department of Rheumatology, CHRU de Besançon, Besançon, France
- EA 4267 PEPITE, UFR Santé, University of Franche-Comté, Besançon, France
| | - François Aubin
- INSERM UMR RIGHT 1098, Besançon, France
- Department of Dermatology, CHRU de Besançon, Besançon, France
| | - Jérome Avouac
- Department of Rheumatology, AP-HP Hôpital Cochin, Paris, France
- Cochin Institute, INSERM U1016 UMR 8104, Paris, France
| | - Lucine Vuitton
- EA 4267 PEPITE, UFR Santé, University of Franche-Comté, Besançon, France
- Department of Gastroenterology, CHRU de Besançon, Besançon, France
| | - Frédéric Lioté
- Department of Rheumatology, DMU Locomotion, AP-HP Nord & Inserm UMR 1132, Bioscar (Centre Viggo Petersen), Hôpital Lariboisière, Paris, France
- Université de Paris, UFR de Médecine, Paris, France
| | - Thierry Thévenot
- Department of Hepatology, CHRU de Besançon, Besançon, France
- EA 4266 EPILAB, UFR Santé, University of Franche-Comté, Besançon, France
- INSERM UMR RIGHT 1098, Besançon, France
| | - Daniel Wendling
- EA 4266 EPILAB, UFR Santé, University of Franche-Comté, Besançon, France
- Department of Rheumatology, CHRU de Besançon, Besançon, France
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19
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Risk of liver fibrosis associated with long-term methotrexate therapy may be overestimated. J Hepatol 2023; 78:989-997. [PMID: 36702175 DOI: 10.1016/j.jhep.2022.12.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/21/2022] [Accepted: 12/29/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND & AIMS The risk of significant liver fibrosis from prolonged methotrexate (MTX) exposure has been estimated at around 5%, prompting intensive monitoring strategies. However, the evidence is derived from retrospective studies that under-reported risk factors for liver disease. We evaluated the risk of long-term MTX therapy on liver fibrosis in a longitudinal cohort study using two non-invasive markers. METHOD Between 2014-2021, adult patients diagnosed with rheumatoid arthritis (RA) or psoriasis for ≥2 years were recruited prospectively from six UK sites. The MTX group included patients who received MTX for ≥6 months, whereas the unexposed group included those who never received MTX. All patients underwent full liver profiling, with transient elastography (TE) and enhanced liver fibrosis (ELF) marker measurements. RESULTS A total of 999 patients (mean age 60.8 ± 12 years, 62.3% females) were included. Of 976 with valid TE values, 149 (15.3%) had liver stiffness ≥7.9 kPa. Of 892 with a valid ELF, 262 (29.4%) had ELF ≥9.8. Age and BMI were independently associated with elevated liver stiffness and ELF. Neither MTX cumulative dose nor duration was associated with elevated liver stiffness. Diabetes was the most significant risk factor associated with liver stiffness ≥7.9 kPa (adjusted odds ratio = 3.19; 95% CI 1.95-5.20; p <0.001). Regular use of non-steroidal anti-inflammatory drugs showed the strongest association with ELF ≥9.8 (odds ratio = 1.76; 95% CI 1.20-2.56; p = 0.003), suggesting the degree of joint inflammation in RA may confound ELF as a non-invasive marker of liver fibrosis. CONCLUSION The risk of liver fibrosis attributed to MTX itself might have been previously overestimated; there is a need to consider modifying current monitoring guidelines for MTX. IMPACT AND IMPLICATIONS Current guidelines recommend intensive (2-3 monthly) monitoring strategies for patients on long-term methotrexate therapy due to the potential risk of liver fibrosis. Evaluation of the association using two validated non-invasive markers of liver fibrosis, liver stiffness and enhanced liver fibrosis score, in a large cohort of patients with rheumatoid arthritis or psoriasis shows that the reported risk has previously been overestimated. The clinical focus should be to improve patients' metabolic risk factors, diabetes and BMI, that are independently associated with liver stiffness. There is a need to consider modifying current treatment monitoring guidelines for methotrexate.
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In Vitro Models for Studying Chronic Drug-Induced Liver Injury. Int J Mol Sci 2022; 23:ijms231911428. [PMID: 36232728 PMCID: PMC9569683 DOI: 10.3390/ijms231911428] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/08/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022] Open
Abstract
Drug-induced liver injury (DILI) is a major clinical problem in terms of patient morbidity and mortality, cost to healthcare systems and failure of the development of new drugs. The need for consistent safety strategies capable of identifying a potential toxicity risk early in the drug discovery pipeline is key. Human DILI is poorly predicted in animals, probably due to the well-known interspecies differences in drug metabolism, pharmacokinetics, and toxicity targets. For this reason, distinct cellular models from primary human hepatocytes or hepatoma cell lines cultured as 2D monolayers to emerging 3D culture systems or the use of multi-cellular systems have been proposed for hepatotoxicity studies. In order to mimic long-term hepatotoxicity in vitro, cell models, which maintain hepatic phenotype for a suitably long period, should be used. On the other hand, repeated-dose administration is a more relevant scenario for therapeutics, providing information not only about toxicity, but also about cumulative effects and/or delayed responses. In this review, we evaluate the existing cell models for DILI prediction focusing on chronic hepatotoxicity, highlighting how better characterization and mechanistic studies could lead to advance DILI prediction.
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21
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Merola JF, Kavanaugh A, Lebwohl MG, Gniadecki R, Wu JJ. Clinical Efficacy and Safety of Psoriasis Treatments in Patients with Concomitant Metabolic Syndrome: A Narrative Review. Dermatol Ther (Heidelb) 2022; 12:2201-2216. [PMID: 36008702 PMCID: PMC9515257 DOI: 10.1007/s13555-022-00790-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/02/2022] [Indexed: 11/26/2022] Open
Abstract
Metabolic syndrome (MetS) is well recognized as a frequent comorbidity of psoriasis with important implications for efficacy and safety of psoriasis treatment. The presence of concomitant MetS is associated with decreased efficacy response to biologic treatment for psoriasis in observational studies. In post hoc analyses of clinical trial data, the anti–IL-23p19 antibody tildrakizumab appears to maintain efficacy in patients compared to those without MetS; no published subgroup analyses by MetS status are yet available for other biologics. However, there is some evidence that obese patients have decreased psoriasis treatment efficacy with biologics with certain mechanisms of action relative to overweight patients. This confounds interpretation of the effect of MetS due to the association between MetS and body weight. Because of the association between MetS and cardiovascular risk, treatment of psoriasis in patients with concomitant MetS requires special consideration for cardiovascular safety and attention to potential for exacerbation of MetS and related conditions, including nonalcoholic fatty liver disease. Additional studies are needed to clarify the risks for treatment failure and cardiovascular safety concerns in patients with psoriasis and concomitant MetS.
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Affiliation(s)
- Joseph F Merola
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | | | - Mark G Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, AB, Canada
| | - Jashin J Wu
- Department of Dermatology, University of Miami Miller School of Medicine, Miami, FL, USA
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22
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Li X, Tang J, Mao Y. Incidence and risk factors of drug-induced liver injury. Liver Int 2022; 42:1999-2014. [PMID: 35353431 DOI: 10.1111/liv.15262] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 03/08/2022] [Accepted: 03/26/2022] [Indexed: 12/17/2022]
Abstract
The epidemiology and aetiology of drug-induced liver injury (DILI) vary across different countries and populations. Overall, DILI is rare in the general population but has become more prevalent in hospitalized patients, especially among patients with unexplained liver conditions. In addition, drugs implicated in DILI differ between Western and Eastern countries. Antibiotics are the leading drugs implicated in DILI in the West, whereas traditional Chinese medicine is the primary cause implicated in DILI in the East. The incidence of herbal and dietary supplements-induced hepatotoxicity is increasing globally. Several genetic and nongenetic risk factors associated with DILI have been described in the literature; however, there are no confirmed risk factors for all-cause DILI. Some factors may contribute to the risk of DILI in a drug-specific manner.
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Affiliation(s)
- Xiaoyun Li
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Jieting Tang
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Yimin Mao
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
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23
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McPherson S, Armstrong MJ, Cobbold JF, Corless L, Anstee QM, Aspinall RJ, Barclay ST, Brennan PN, Cacciottolo TM, Goldin RD, Hallsworth K, Hebditch V, Jack K, Jarvis H, Johnson J, Li W, Mansour D, McCallum M, Mukhopadhya A, Parker R, Ross V, Rowe IA, Srivastava A, Thiagarajan P, Thompson AI, Tomlinson J, Tsochatzis EA, Yeoman A, Alazawi W. Quality standards for the management of non-alcoholic fatty liver disease (NAFLD): consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group. Lancet Gastroenterol Hepatol 2022; 7:755-769. [PMID: 35490698 PMCID: PMC7614852 DOI: 10.1016/s2468-1253(22)00061-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 12/12/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is common, affecting approximately 25% of the general population. The evidence base for the investigation and management of NAFLD is large and growing, but there is currently little practical guidance to support development of services and delivery of care. To address this, we produced a series of evidence-based quality standard recommendations for the management of NAFLD, with the aim of improving patient care. A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group produced the recommendations, which cover: management of people with, or at risk of, NAFLD before the gastroenterology or liver clinic; assessment and investigations in secondary care; and management in secondary care. The quality of evidence for each recommendation was evaluated by the Grading of Recommendation Assessment, Development and Evaluation tool. An anonymous modified Delphi voting process was conducted individually by each member of the group to assess the level of agreement with each statement. Statements were included when agreement was 80% or greater. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice. It is hoped that services will review their practice against our recommendations and key performance indicators and institute service development where needed to improve the care of patients with NAFLD.
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Affiliation(s)
- Stuart McPherson
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
| | - Matthew J Armstrong
- Liver Unit, Queen Elizabeth University Hospital Birmingham NHS Trust, Birmingham, UK; NIHR Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Jeremy F Cobbold
- Oxford Liver Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; UK NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Lynsey Corless
- Department of Gastroenterology, Hepatology and Endoscopy, Hull University Teaching Hospitals, Hull, UK
| | - Quentin M Anstee
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Stephen T Barclay
- Walton Liver Clinic, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Paul N Brennan
- Centre for Regenerative Medicine, University of Edinburgh, Edinburgh BioQuarter, Edinburgh, UK
| | - Tessa M Cacciottolo
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Wellcome Trust/MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Cambridge, UK
| | - Robert D Goldin
- Division of Digestive Diseases, Imperial College, London, UK
| | - Kate Hallsworth
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Kathryn Jack
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Helen Jarvis
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; The Bellingham Practice, Northumberland, UK
| | - Jill Johnson
- Liver Unit, Queen Elizabeth University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Wenhao Li
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
| | - Dina Mansour
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Queen Elizabeth Hospital, Gateshead NHS Foundation Trust, Gateshead, UK
| | - Mary McCallum
- Digestive Disorders Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Ashis Mukhopadhya
- Digestive Disorders Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital Leeds, Leeds, UK
| | - Valerie Ross
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Ankur Srivastava
- North Bristol Liver Unit, Southmead Hospital, North Bristol Trust, Bristol, UK
| | | | - Alexandra I Thompson
- Centre for Liver and Digestive Disorders, The Royal Infirmary, Edinburgh, Edinburgh, UK
| | - Jeremy Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Andrew Yeoman
- Gwent Liver Unit, The Grange University Health Board, Anuerin Bevan Health Board, Wales, UK
| | - William Alazawi
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
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24
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Acar H, Sorgun O, Yurtseve G, Bora ES, Erbaş O. Antifibrotic preventive effect of polyethylene glycol (PEG) 3350 in methotrexateinduced hepatoxicity model. Acta Cir Bras 2022; 37:e370507. [PMID: 35894304 PMCID: PMC9323303 DOI: 10.1590/acb370507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/20/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Liver damage caused by drugs and other chemicals accounts for about 5% of all cases. Methotrexate (MTX), a folic acid analogue, is a first-line synthetic antimetabolite agent routinely used in the treatment of rheumatoid arthritis and other autoimmune and chronic inflammatory diseases. Polyethylene glycol (PEG) has antioxidant activity. In this study, we evaluated biochemically and histopathologically the antifibrotic effect of PEG 3350 administered intraperitoneally to prevent methotrexate-induced liver damage in rats. METHODS A total of 30 male rats including 10 rats was given no drugs (normal group), and 20 rats received single-dose 20 mg/kg MTXfor induced liver injury in this study. MTX was given to 20 rats, which were divided in two groups. Group 1 rats was given PEG30 mg/kg/day (Merck) intraperitoneally, and Group 2 rats % 0.9 NaCl saline 1 mL/kg/day intraperitoneally daily for two weeks. RESULTS Transforming growth factor beta (TGF-β), plasma malondialdehyde (MDA), liver MDA, serum tumour necrosis factor alpha (TNF-α), alanine aminotransferase and plasma pentraxin-3 levels and, according to tissue histopathology, hepatocyte necrosis, fibrosis and cellular infiltration were significantly better in MTX+PEG group than in MTX+saline group. CONCLUSIONS PEG 3350 is a hope for toxic hepatitis due to other causes, since liver damage occurs through oxidative stress and cell damage, similar to all toxic drugs.
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Affiliation(s)
- Hüseyin Acar
- MD. Izmir Atatürk Training and Research Hospital - Department of Emergency Medicine - Izmir, Turkey
| | - Omay Sorgun
- MD. Ödemiş State Hospital - Department of Emergency Medicine - İzmir, Turkey
| | - Güner Yurtseve
- MD. Izmir Atatürk Training and Research Hospital - Department of Emergency Medicine - Izmir, Turkey
| | - Ejder Saylav Bora
- MD. Izmir Atatürk Training and Research Hospital - Department of Emergency Medicine - Izmir, Turkey
| | - Oytun Erbaş
- Associate professor. Demiroğlu Bilim University - Faculty of Medicine - Department of Physiology - Istanbul, Turkey
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25
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Drug-Induced Liver Injury during Consolidation Therapy in Childhood Acute Lymphoblastic Leukemia as Assessed for Causality Using the Updated RUCAM. Can J Gastroenterol Hepatol 2022; 2022:5914593. [PMID: 35369115 PMCID: PMC8970867 DOI: 10.1155/2022/5914593] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 12/19/2022] Open
Abstract
PURPOSE The presence of serious toxicities is a major problem in the treatment of childhood acute lymphoblastic leukemia (ALL). The objective of this research is to evaluate drug-induced liver injury (DILI) during consolidation therapy in childhood ALL. METHODS Clinical data of pediatric patients who received consolidation therapy between August 2012 and July 2018 were collected. Characteristics (incidences and patterns) of DILI at different stratifications were determined. Risks of DILI were evaluated using binary logistic regression analysis. Drug causality assessment was carried out by the updated Roussel Uclaf Causality Assessment Method (RUCAM). RESULTS Patients with high risk (HR) and standard risk (SR)/intermediate risk (IR) received 270 and 1539 courses of consolidation therapy, respectively; among these courses, 15 (5.6%) and 38 (2.5%) developed DILI. The occurrences of DILI in SR/IR patients were primarily associated with age (≤5.2 years), treatment course (≥5), and baseline serum parameters before treatment (cystatin C > 0.79 mg/L, albumin ≤45 g/L, and gamma-glutamyl transpeptidase (GGT) > 17 U/L). The ROC curve generated using the parameters assigned to specific values achieved an area under the curve (AUC) of 0.846 (95% CI 0.827-0.863) with a cutoff value of 3, and the sensitivity and specificity were 94.7% and 62.3%, respectively. For HR patients, a decrease in baseline albumin and elevation of baseline liver enzymes (GGT and aspartate aminotransferase) were observed in DILI cases compared with the non-DILI subjects. In the SR/IR group with DILI, the causality gradings for high-dose methotrexate (HD-MTX) were highly probable in 5 (13.2%) cases, probable in 31 (81.6%) cases, and possible in 2 (5.3%) cases. Among the DILI cases in HR-1, HR-2, and HR-3 groups, high causality gradings (probable + highly probable) were detected in "100% of HD-MTX + 57% of high-dose cytarabine (HD-Ara-C)," "100% of HD-MTX + 20% of pegylated asparaginase (PEG-ASP)," and "100% of HD-Ara-C + 33.3% of PEG-ASP," respectively. CONCLUSION Incidence of DILI in HR patients was significantly higher than that in SR/IR patients. A number of potential risk factors were identified, among which the preexisting liver conditions were suggested as shared risk factors in all stratification groups. HD-MTX, HD-Ara-C, and PEG-ASP were the main causative agents of DILI. The knowledge generated from this study will be helpful for understanding characteristics of DILI during consolidation treatment in childhood ALL.
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26
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Björnsson ES, Andrade RJ. Long-term sequelae of drug-induced liver injury. J Hepatol 2022; 76:435-445. [PMID: 34688732 DOI: 10.1016/j.jhep.2021.10.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/29/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023]
Abstract
Drug-induced liver injury (DILI) has a very variable clinical and biochemical phenotype and differs widely in severity, from mild injury to life-threatening liver failure. Chronic injury has also been reported to occur at a variable frequency, ranging from 3.4% to 39%, 6-12 months after discontinuing the implicated agent. This wide range is probably related to various definitions of chronic liver injury and variable selection of patients. The long-term sequalae of this chronic injury in terms of morbidity and mortality are unclear, although rare vanishing bile duct syndrome is associated with an unfavourable prognosis, with increased risk of chronic liver failure and need for liver transplantation. Other forms of long-term sequalae associated with DILI are progressive fibrosis, autoimmune-like hepatitis, secondary sclerosing cholangitis, sinusoidal obstruction syndrome and, as a common final stage, the development of cirrhosis, portal hypertension and its complications. Immune checkpoint inhibitors, which can cause an autoimmune-like phenotype have also recently been shown to cause sclerosing cholangitis with cytotoxic T CD8+ cell infiltration in biliary tracts. DILI has been shown to have a significant impact on health-related quality of life but very little is known about its psychological consequences in the long-term. Further investigations with structured long-term follow-up and periodic quality of life surveys are needed to assess the impact of DILI on psychological outcomes, particularly in those with chronic sequelae.
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Affiliation(s)
- Einar S Björnsson
- Faculty of Medicine, University of Iceland, Iceland; Department of Gastroenterology, Landspitali University Hospital Reykjavik, Iceland.
| | - Raul J Andrade
- Unidad de Gestión Clínica de Enfermedades Digestivas, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Malaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
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27
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Tomaszewski M, Dahiya M, Mohajerani SA, Punja H, Ko HH, Sun M, Ramji A. Hepatic steatosis as measured by the computed attenuation parameter predicts fibrosis in long-term methotrexate use. CANADIAN LIVER JOURNAL 2021; 4:370-380. [PMID: 35989896 PMCID: PMC9235122 DOI: 10.3138/canlivj-2020-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 05/15/2021] [Indexed: 08/10/2023]
Abstract
INTRODUCTION To determine predictors of hepatic steatosis by the computed attenuation parameter (CAP) and fibrosis via transient elastography (TE) in persons on methotrexate (MTX) therapy with rheumatologic and dermatologic diseases. METHODS A single-centred retrospective cohort study was performed. Patients on >6 months of MTX for a rheumatologic or dermatologic disease who had undergone TE from January 2015 to September 2019 were included. Multivariate analysis was performed to determine predictors of steatosis and fibrosis. RESULTS A total of 172 patients on methotrexate were included. Psoriasis was the most frequent diagnosis (n = 55), followed by rheumatoid arthritis (n = 45) and psoriatic arthritis (n = 34). Steatosis (CAP ≥245 dB/m) was present in 69.8% of patients. Multivariate regression analysis revealed that diabetes mellitus (OR 10.47, 95% CI 1.42-75.35), hypertension (OR 5.15, 95% CI 1.75-15.38), and BMI ≥30 kg/m2 (OR 16.47, 95% CI 5.56-45.56) were predictors of steatosis (CAP ≥245 dB/m). Predictors of moderate to severe fibrosis (Metavir ≥F2 = TE ≥8.0 kPa) by multivariate regression analysis included moderate to severe steatosis (CAP ≥270 dB/m) (OR 8.36, 95% CI 1.88-37.14), diabetes mellitus (OR 2.85, 95% CI 1.09-7.48), hypertension (OR 5.4, 95% CI 2.23-13.00), dyslipidemia (OR 3.71, 95% CI 1.50-9.18), and moderate alcohol use (OR 3.06, 95% CI 1.2-7.49). CONCLUSIONS In patients on MTX for rheumatologic and dermatologic diseases, hepatic steatosis as measured by CAP was common and moderate to severe steatosis predicted moderate to severe fibrosis.
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Affiliation(s)
- Marcel Tomaszewski
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Monica Dahiya
- Faculty of Medicine, University of Alberta., Edmonton, Alberta, Canada
| | - Seyed Amir Mohajerani
- Saint Paul’s Hospital, Gastrointestinal Research Institute, Vancouver, British Columbia, Canada
| | - Hanaa Punja
- Department of Biology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hin Hin Ko
- Clinical Associate Professor of Medicine, Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Muxin Sun
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alnoor Ramji
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Nast A, Altenburg A, Augustin M, Boehncke WH, Härle P, Klaus J, Koza J, Mrowietz U, Ockenfels HM, Philipp S, Reich K, Rosenbach T, Schlaeger M, Schmid-Ott G, Sebastian M, von Kiedrowski R, Weberschock T, Dressler C. German S3-Guideline on the treatment of Psoriasis vulgaris, adapted from EuroGuiDerm - Part 2: Treatment monitoring and specific clinical or comorbid situations. J Dtsch Dermatol Ges 2021; 19:1092-1115. [PMID: 34288477 DOI: 10.1111/ddg.14507] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/06/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Alexander Nast
- Department of Dermatology, Venereology and Allergology, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andreas Altenburg
- Dermatology, Venereology and Allergology, Immunology Center, Dessau Municipal Hospital, Dessau, Germany
| | - Matthias Augustin
- German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Wolf-Henning Boehncke
- Department of Dermatology and Venereology, University Hospital of Geneva, Geneva, Switzerland
| | | | | | | | - Ulrich Mrowietz
- Psoriasis Center, Department of Dermatology, Venereology, Allergology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | | | - Kristian Reich
- Center for Translational Research in Inflammatory Skin Diseases, Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | | | | | - Tobias Weberschock
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Frankfurt/Main, Germany and Working group Evidence-based Medicine Frankfurt, Institute for General Practice, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Corinna Dressler
- Department of Dermatology, Venereology and Allergology, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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29
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Nast A, Altenburg A, Augustin M, Boehncke WH, Härle P, Klaus J, Koza J, Mrowietz U, Ockenfels HM, Philipp S, Reich K, Rosenbach T, Schlaeger M, Schmid-Ott G, Sebastian M, von Kiedrowski R, Weberschock T, Dressler C. Deutsche S3-Leitlinie zur Therapie der Psoriasis vulgaris, adaptiert von EuroGuiDerm - Teil 2: Therapiemonitoring, besondere klinische Situationen und Komorbidität. J Dtsch Dermatol Ges 2021; 19:1092-1117. [PMID: 34288473 DOI: 10.1111/ddg.14507_g] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Alexander Nast
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - Andreas Altenburg
- Dermatologie, Venerologie und Allergologie, Immunologisches Zentrum, Städtisches Klinikum Dessau
| | - Matthias Augustin
- Kompetenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Eppendorf, Hamburg
| | | | | | | | | | - Ulrich Mrowietz
- Psoriasis-Zentrum, Klinik für Dermatologie, Venerologie, Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | | | | | - Kristian Reich
- Zentrum für Translationale Forschung bei entzündlichen Hauterkrankungen, Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen, Universitätsmedizin Hamburg-Eppendorf
| | | | | | | | | | | | - Tobias Weberschock
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt/Main und Arbeitsgruppe EbM Frankfurt, Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt
| | - Corinna Dressler
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
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Hepatotoxic potentials of methotrexate: Understanding the possible toxicological molecular mechanisms. Toxicology 2021; 458:152840. [PMID: 34175381 DOI: 10.1016/j.tox.2021.152840] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/10/2021] [Accepted: 06/22/2021] [Indexed: 12/12/2022]
Abstract
Methotrexate (MTX) is one of the most effective and widely used drugs in the management of autoimmune and dermatological diseases. Rheumatoid arthritis and psoriasis patients who are under long term MTX-therapy are at high risk of developing a liver injury. Accumulation of intracellular MTX-polyglutamate (MTX-PG), a metabolite of MTX triggers oxidative stress, inflammation, steatosis, fibrosis, and apoptosis in hepatocytes. MTX-PG causes oxidative stress in the liver by inducing lipid peroxidation thereby releasing reactive oxygen species and suppressing antioxidant response elements. MTX-PG induces several pro-inflammatory signaling pathways and cytokines such as tumor necrosis factor-α, nuclear factor kappa B and interleukin 6 (IL-6), IL- β1, IL-12. MTX-PG depletes hepatic folate level and decreases RNA and DNA synthesis leading to hepatocyte death. MTX-PG inhibits 5-aminoimidazole-4-carboxamide ribonucleotide transformylase enzyme and thereby causes accumulation of intracellular adenosine, which causes activation of hepatic stellate cells, extracellular matrix accumulation and hepatic fibrosis. MTX-PG induces hepatocytes apoptosis by activation of caspase 3 via the intrinsic pathway. Clinically, aggravation of underlying fatty liver to non-alcoholic steatohepatitis with fibrosis seems to be an important mechanism of liver injury in MTX-treated RA patients. Therefore, there is a need for monitoring liver injury in RA, psoriatic and cancer patients with NAFLD and fibrosis risk factors during MTX treatment. This review summarizes the possible molecular mechanism of MTX-induced hepatotoxicity. It may pave the way for early detection of liver injury and develop novel strategies for treating MTX mediated hepatotoxicity.
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Rattanakaemakorn P, Pinyowiwat P, Iamsumang W, Chanprapaph K, Suchonwanit P. Incidence and Risk Factors of Hepatic Fibrosis in Psoriatic Patients Receiving Methotrexate with Concomitant Acitretin Therapy and Methotrexate Monotherapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:2299-2307. [PMID: 34093007 PMCID: PMC8170124 DOI: 10.2147/dddt.s304168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/12/2021] [Indexed: 12/24/2022]
Abstract
Background The use of methotrexate-acitretin (MTX-ACI) combination therapy in treating psoriasis has been limited due to concerns related to hepatic fibrosis. However, in vitro evidence revealed a protective effect of acitretin in methotrexate (MTX)-induced liver fibrosis. Objective This study aimed to compare the real-life incidence of hepatic fibrosis in patients with psoriasis receiving MTX-ACI and MTX monotherapy and to investigate factors associated with hepatic fibrosis in MTX-exposed patients. Methods A retrospective cohort study was conducted based on a real-life registry containing data on patients with psoriasis who were administered MTX-ACI or MTX between 2008 and 2019 and underwent transient elastography according to cumulative MTX dose of 1.0–1.5 g and/or 3.5–4.0 g. Time-to-event analysis was performed to determine the cumulative incidence, incidence rate, and factors potentially affecting the occurrence of hepatic fibrosis. Results Of the 160 patients, 32 (20%) were treated with MTX-ACI, and 128 (80%) with MTX alone. Four patients (12.5%) in MTX-ACI group and 21 (16.4%) in MTX group developed hepatic fibrosis (p = 0.59). There was no statistically significant difference in cumulative incidence (16% in MTX-ACI vs 17% in MTX, p = 0.89) and incidence rate (37 cases per 1000 person-year in MTX-ACI vs 23 cases per 1000 person-year in MTX; hazard ratio [HR] = 1.07; p = 0.90) of hepatic fibrosis between the two groups. Diabetes and obesity were identified as significant factors associated with hepatic fibrosis (adjusted HR = 2.40, 95% confidence interval [CI]: 1.05–5.51; p = 0.04 and adjusted HR = 3.28, 95% CI: 1.18–9.16; p = 0.02, respectively) regardless of the cumulative MTX dose. Conclusion The incidence of hepatic fibrosis in a real-life clinical situation, determined by transient elastography in patients with psoriasis receiving MTX-ACI, was not increased compared to those receiving MTX monotherapy. Type 2 diabetes mellitus and obesity were identified as risk factors of hepatic fibrosis; hence, patients with these factors receiving long-term MTX therapy should be regularly monitored for this particular event.
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Affiliation(s)
- Ploysyne Rattanakaemakorn
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prinpat Pinyowiwat
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wimolsiri Iamsumang
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Poonkiat Suchonwanit
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Pannu S, Rosmarin D. Psoriasis in Patients with Metabolic Syndrome or Type 2 Diabetes Mellitus: Treatment Challenges. Am J Clin Dermatol 2021; 22:293-300. [PMID: 33586126 DOI: 10.1007/s40257-021-00590-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 12/14/2022]
Abstract
Psoriasis is a chronic inflammatory disease that affects 2-3% of the population worldwide. It is associated with plaques, psoriatic arthritis, and metabolic syndrome and its components, including obesity, diabetes, dyslipidemia, nonalcoholic fatty liver disease, and cardiovascular disease. In this review, we highlight the shared pathogenic pathways leading to the comorbid existence of both diseases and the impact of drugs used for psoriasis on metabolic syndrome and vice versa. Persistent inflammation is common to both diseases. They share increased inflammatory cytokines such as tumor necrosis factor (TNF)-α and interleukin-6. Biologics have revolutionized the treatment of plaque psoriasis and also have a positive impact on metabolic syndrome. There is some evidence that TNFα inhibitors decrease insulin resistance and improve glycemic indices. Some psoriasis treatments may result in decreased body weight. Lifestyle measures used in the management of metabolic syndrome, such as weight loss, exercise, and healthy diet, are beneficial in patients with psoriasis. Considering the association between metabolic syndrome and psoriasis, we recommend screening patients with psoriasis for metabolic syndrome with clinical examinations and laboratory tests. Patients with a co-diagnosis of these diseases deserve special attention for optimal treatment.
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Affiliation(s)
- Sukhmani Pannu
- The Department of Dermatology, Tufts Medical Center, Boston, MA, USA
| | - David Rosmarin
- The Department of Dermatology, Tufts Medical Center, Boston, MA, USA.
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Non-alcoholic fatty liver disease is associated with bacterial translocation and a higher inflammation response in psoriatic patients. Sci Rep 2021; 11:8593. [PMID: 33883616 PMCID: PMC8060289 DOI: 10.1038/s41598-021-88043-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/06/2021] [Indexed: 02/08/2023] Open
Abstract
Psoriasis and non-alcoholic fatty liver disease (NAFLD) are both inflammatory diseases. The study objective was to estimate the risk of NAFLD, non-alcoholic steatohepatitis, and liver fibrosis (by liver stiffness and liver biopsy) in patients with psoriasis and to determine the epidemiological, clinical, immunological (TNF-α, IL-2, IL-6, IL-12, IL-17, IL-23, and TGF-β) characteristics, and bacterial translocation. Of the 215 psoriatic patients included, 91 presented NAFLD (prevalence: 42.3%). Compared to patients with psoriasis alone, those with NAFLD were significantly more likely to have metabolic syndrome, diabetes, dyslipidemia, body mass index ≥ 30 kg/m2, homeostatic model assessment of insulin resistance ≥ 2.15, and greater psoriasis area severity index. NAFLD patients also had significantly higher levels of TNF-α (p = 0.002) and TGF-β (p = 0.007) and a higher prevalence of bacterial translocation (29.7% vs. 13.7%; p = 0.004). Liver stiffness measurement was over 7.8 kPa in 17.2% (15/87) of NAFLD patients; 13 of these underwent liver biopsy, and 5.7% (5/87) had liver fibrosis, while 1.1% (1/87) had advanced fibrosis or non-alcoholic steatohepatitis. In conclusion the prevalence of NAFLD in patients with psoriasis is high and associated with a higher prevalence of metabolic syndrome features, bacterial translocation and a higher pro-inflammatory state. It is worth mentioning that liver fibrosis and non-alcoholic steatohepatitis are not frequent in this population of patients.
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34
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Raikhelson KL, Kondrashina EA, Pazenko EV. Mixed steatohepatitis: more questions than answers (part 2). TERAPEVT ARKH 2021; 93:516-520. [DOI: 10.26442/00403660.2021.04.200755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 11/22/2022]
Abstract
In this review, we discussed the epidemiological and pathogenetic aspects of mixed steatohepatitis (SH), developed due to non-alcoholic fatty liver disease, metabolic associated fatty liver disease, drug-induced liver injury. We discussed the mechanisms of the mutually aggravating influence of etiological factors. Drugs can cause steatosis and SH, as well as contribute to the progressive course of existing SH, primarily of metabolic origin. The issues of interaction of pathogenetic factors, peculiarities of diagnostics and perspectives of pathogenetic and symptomatic treatment are considered. Therapy of mixed SH is based on avoidance of hepatotoxic drugs and lifestyle modification, medications with demonstrated efficacy (such as ademetionine) in certain SH might be used.
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35
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Pedraza L, Laosa O, Rodríguez-Mañas L, Gutiérrez-Romero DF, Frías J, Carnicero JA, Ramírez E. Drug Induced Liver Injury in Geriatric Patients Detected by a Two-Hospital Prospective Pharmacovigilance Program: A Comprehensive Analysis Using the Roussel Uclaf Causality Assessment Method. Front Pharmacol 2021; 11:600255. [PMID: 33613279 PMCID: PMC7892439 DOI: 10.3389/fphar.2020.600255] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/11/2020] [Indexed: 01/10/2023] Open
Abstract
Background/aim: A prospective evaluation of drug-induced liver injury (DILI) in two tertiary hospitals was conducted through a pharmacovigilance program from laboratory signals at hospital (PPLSH) to determine the principal characteristics of DILI in patients older than 65 years, a growing age group worldwide, which is underrepresented in the literature on DILI. Methods: All DILI in patients older than 65 years detected by PPLSH in two hospitals were followed up for 8 years in the La Paz Hospital and 2 years in the Getafe Hospital. A descriptive analysis was conducted that determined the causality of DILI and suspected drugs, the incidence of DILI morbidities, DILI characteristics, laboratory patterns, evolution and outcomes. Results: 458 DILI cases in 441 patients were identified, 31.0% resulting in hospitalisation and 69.0% developing during hospitalisation. The mean age was 76.61 years old (SD, 7.9), and 54.4% were women. The DILI incidence was 76.33/10,000 admissions (95%CI 60.78–95.13). Polypharmacy (taking >4 drugs) was present in 86.84% of patients, 39.68% of whom took >10 drugs. The hepatocellular phenotype was the most frequent type of DILI (53.29%), a higher proportion (65%) had a mild severity index, and, in 55.2% of the evaluated drugs the RUCAM indicated that the causal relationship was highly probable. The most frequently employed drugs were paracetamol (50-cases), amoxicillin-clavulanate (42-cases) and atorvastatin (37-cases). The incidence rate of in-hospital DILI per 10,000 DDDs was highest for piperacillin-tazobactam (66.96/10,000 DDDs). A higher risk of in-hospital DILI was associated with the therapeutic chemical group-J (antiinfectives for systemic use) (OR, 2.65; 95%CI 1.58–4.46) and group-N (central nervous system drugs) (OR, 2.33; 95%CI 1.26–4.31). The patients taking >4 medications presented higher maximum creatinine level (OR, 2.01; 95%CI 1.28–3.15), and the patients taking >10 medications had a higher use of group J drugs (OR, 2.08; 95%IC 1.31–3.32). Conclusion: The incidence rate of DILI in the patients older than 65 years was higher than expected. DILI in elderly patients is mild, has a good outcome, has a hepatocellular pattern, develops during hospitalisation, and prolongs the hospital stay. Knowing the DILI incidence and explanatory factors will help improve the therapy of the elderly population.
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Affiliation(s)
- Laura Pedraza
- Geriatric Research Group, Biomedical Research Foundation at Getafe University Hospital, Getafe, Spain
| | - Olga Laosa
- Geriatric Research Group, Biomedical Research Foundation at Getafe University Hospital, Getafe, Spain.,Centre of Network Biomedical Research on Frailty and Healthy Ageing (CIBERFES), Institute of Health Carlos III., Madrid, Spain
| | - Leocadio Rodríguez-Mañas
- Centre of Network Biomedical Research on Frailty and Healthy Ageing (CIBERFES), Institute of Health Carlos III., Madrid, Spain.,Division of Geriatrics, University Hospital of Getafe, Getafe, Spain
| | | | - Jesús Frías
- Clinical Pharmacology departments, La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - José Antonio Carnicero
- Geriatric Research Group, Biomedical Research Foundation at Getafe University Hospital, Getafe, Spain.,Centre of Network Biomedical Research on Frailty and Healthy Ageing (CIBERFES), Institute of Health Carlos III., Madrid, Spain
| | - Elena Ramírez
- Clinical Pharmacology departments, La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid, Madrid, Spain.,Clinical pharmacology department, University Hospital La Paz, La Paz, Spain
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Nast A, Smith C, Spuls P, Avila Valle G, Bata‐Csörgö Z, Boonen H, De Jong E, Garcia‐Doval I, Gisondi P, Kaur‐Knudsen D, Mahil S, Mälkönen T, Maul J, Mburu S, Mrowietz U, Reich K, Remenyik E, Rønholt K, Sator P, Schmitt‐Egenolf M, Sikora M, Strömer K, Sundnes O, Trigos D, Van Der Kraaij G, Yawalkar N, Dressler C. EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris – Part 2: specific clinical and comorbid situations. J Eur Acad Dermatol Venereol 2021; 35:281-317. [DOI: 10.1111/jdv.16926] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/13/2020] [Indexed: 12/15/2022]
Affiliation(s)
- A. Nast
- Charité – Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Dermatology, Venereology and Allergology Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - C. Smith
- St John’s Institute of Dermatology London UK
| | - P.I. Spuls
- Academic Medical Centre Amsterdam Amsterdam Netherlands
| | - G. Avila Valle
- Charité – Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Dermatology, Venereology and Allergology Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | | | - H. Boonen
- Office‐Based Dermatology Practice Geel Belgium
| | - E. De Jong
- Radboud University Medical Centre Nijmegen Nijmegen Netherlands
| | - I. Garcia‐Doval
- Unidad de Investigación. Fundación Piel Sana AEDV Madrid Spain
| | | | | | - S. Mahil
- Guy's and St Thomas' NHS Foundation Trust London UK
| | - T. Mälkönen
- Helsinki University Central Hospital Helsinki Finland
| | - J.T. Maul
- Department of Dermatology University Hospital of Zürich Zürich Switzerland
| | - S. Mburu
- International Federation of Psoriasis Associations (IFPA)
| | - U. Mrowietz
- Universitätsklinikum Schleswig‐Holstein Kiel Germany
| | - K. Reich
- Translational Research in Inflammatory Skin Diseases Institute for Health Services Research in Dermatology and Nursing University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | | | | | - P.G. Sator
- Municipal Hospital Hietzing Vienna Austria
| | - M. Schmitt‐Egenolf
- Dermatology Department of Public Health & Clinical Medicine Umeå University Umeå Sweden
| | - M. Sikora
- Department of Dermatology Medical University of Warsaw Warsaw Poland
| | - K. Strömer
- Office‐Based Dermatology Practice Mönchengladbach Germany
| | | | - D. Trigos
- International Federation of Psoriasis Associations (IFPA)
| | | | - N. Yawalkar
- Department of Dermatology, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
| | - C. Dressler
- Charité – Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Dermatology, Venereology and Allergology Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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37
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LaBranche TP, Kopec AK, Mantena SR, Hollingshead BD, Harrington AW, Stewart ZS, Zhan Y, Hayes KD, Whiteley LO, Burdick AD, Davis JW. Zucker Lean Rats With Hepatic Steatosis Recapitulate Asymptomatic Metabolic Syndrome and Exhibit Greater Sensitivity to Drug-Induced Liver Injury Compared With Standard Nonclinical Sprague-Dawley Rat Model. Toxicol Pathol 2020; 48:994-1007. [PMID: 33252024 DOI: 10.1177/0192623320968716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fatty liver disease is a potential risk factor for drug-induced liver injury (DILI). Despite advances in nonclinical in vitro and in vivo models to assess liver injury during drug development, the pharmaceutical industry is still plagued by idiosyncratic DILI. Here, we tested the hypothesis that certain features of asymptomatic metabolic syndrome (namely hepatic steatosis) increase the risk for DILI in certain phenotypes of the human population. Comparison of the Zucker Lean (ZL) and Zucker Fatty rats fed a high fat diet (HFD) revealed that HFD-fed ZL rats developed mild hepatic steatosis with compensatory hyperinsulinemia without increases in liver enzymes. We then challenged steatotic HFD-fed ZL rats and Sprague-Dawley (SD) rats fed normal chow, a nonclinical model widely used in the pharmaceutical industry, with acetaminophen overdose to induce liver injury. Observations in HFD-fed ZL rats included increased liver injury enzymes and greater incidence and severity of hepatic necrosis compared with similarly treated SD rats. The HFD-fed ZL rats also had disproportionately higher hepatic drug accumulation, which was linked with abnormal hepatocellular efflux transporter distribution. Here, we identify ZL rats with HFD-induced hepatic steatosis as a more sensitive nonclinical in vivo test system for modeling DILI compared with SD rats fed normal chow.
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Affiliation(s)
- Timothy P LaBranche
- 376392Pfizer Inc, Cambridge, MA, USA.,Blueprint Medicines, Cambridge, MA, USA.,*Timothy P. LaBranche and Anna K. Kopec contributed equally
| | - Anna K Kopec
- 2253Pfizer Inc, Groton, CT, USA.,*Timothy P. LaBranche and Anna K. Kopec contributed equally
| | | | | | - Andrew W Harrington
- 2253Pfizer Inc, Chesterfield, MO, USA.,Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, St Louis, MO, USA
| | - Zachary S Stewart
- 2253Pfizer Inc, Andover, MA, USA.,Hooke Laboratories, Lawrence, MA, USA
| | | | - Kyle D Hayes
- 2253Pfizer Inc, Andover, MA, USA.,Mallinckrodt Pharmaceuticals, Hazelwood, MO, USA
| | | | | | - John W Davis
- 376392Pfizer Inc, Cambridge, MA, USA.,Dyne Therapeutics, Waltham, MA, USA
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38
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Rivera R, Vilarrasa E, Ribera M, Roe E, Kueder-Pajares T, Zayas AI, Martínez-Molina L, Mataix Díaz J, Rodríguez-Nevado IM, Usero-Bárcena T, de la Mano D, García-Donoso C, Olveira A, Guinea G, Martín-Vázquez V, Ferran M. Unmet needs in patients with moderate-to-severe plaque psoriasis treated with methotrexate in real world practice: FirST study. J DERMATOL TREAT 2020; 33:1329-1338. [DOI: 10.1080/09546634.2020.1801977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Raquel Rivera
- Department of Dermatology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - E. Vilarrasa
- Department of Medicine, Universitat Autònoma de Barcelona, Spain
| | - M. Ribera
- Department of Dermatology, Hospital Universitari Parc Taulí, Barcelona, Sabadell, Spain
| | - E. Roe
- Department of Medicine, Universitat Autònoma de Barcelona, Spain
| | - T. Kueder-Pajares
- Department of Dermatology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - A. I. Zayas
- Department of Dermatology, Doctor Peset Universitary Hospital, Valencia, Spain
| | | | - J. Mataix Díaz
- Department of Dermatology, Marina Baixa Hospital, Alicante, Spain
| | - I. M. Rodríguez-Nevado
- Department of Dermatology, Hospital Infanta Cristina, Complejo Hospitalario Universitario de Badajoz, Spain
| | - T. Usero-Bárcena
- Department of Dermatology, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - D. de la Mano
- Department of Dermatology, Hospital San Agustín, Avilés, Principado de Asturias, Spain
| | - C. García-Donoso
- Department of Dermatology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - A. Olveira
- Department of Gastroenterology, Hospital Universitario La Paz, Madrid, Spain
| | - G. Guinea
- Medical Department, Novartis Farmacéutica, Barcelona, Spain
| | | | - M. Ferran
- Department of Dermatology, Hospital del Mar, Barcelona, Spain
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39
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Paroutoglou K, Papadavid E, Christodoulatos GS, Dalamaga M. Deciphering the Association Between Psoriasis and Obesity: Current Evidence and Treatment Considerations. Curr Obes Rep 2020; 9:165-178. [PMID: 32418186 DOI: 10.1007/s13679-020-00380-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Obesity and psoriasis represent chronic inflammatory states that are interconnected in a vicious cycle, sharing also a degree of synergy. In this review, we aim to decipher the various lines of evidence supporting the bidirectional association between psoriasis and obesity highlighting their pathophysiologic connections as well as we attempt to strategize a therapeutic holistic approach for obese psoriatic patients. RECENT FINDINGS Recent meta-analyses have shown that (1) genetically higher BMI increased the odds of psoriasis occurrence; (2) obesity is associated with higher incidence and prevalence of psoriasis as well as psoriasis severity; (3) obesity is associated with lower efficacy to anti-TNF agents and may predict biologic treatment discontinuation; and (4) weight loss through diet and physical exercise may improve pre-existing psoriasis and prevent from de novo psoriasis. Methotrexate, acitretin, and cyclosporine could worsen hypertension, liver steatosis, and dyslipidemia. Since infliximab and ustekinumab are weight adjusted, they may be ideal drugs to treat obese psoriatic patients. IL-17 inhibitors are very effective independently from body weight; however, they tend to present better clearance rates in normal weight patients. There is a paucity on weight data regarding the efficacious IL-23 inhibitors. Apremilast may induce weight loss as an adverse effect presenting also some beneficial metabolic actions. Finally, simvastatin and some antidiabetic drugs could decrease psoriasis severity. More mechanistic, observational studies and well-conducted RCTs are necessary to decipher the enigmatic link between psoriasis and obesity, and to provide evidence-based specific guidelines for the screening and management of obese psoriatic patients.
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Affiliation(s)
- Kyriaki Paroutoglou
- 2nd Department of Dermatology and Venereology, School of Medicine, National and Kapodistrian University of Athens, Attikon General University Hospital, 1 Rimini Street, Chaidari, 12462, Athens, Greece
| | - Evangelia Papadavid
- 2nd Department of Dermatology and Venereology, School of Medicine, National and Kapodistrian University of Athens, Attikon General University Hospital, 1 Rimini Street, Chaidari, 12462, Athens, Greece
| | - Gerasimos Socrates Christodoulatos
- Department of Biological Chemistry, School of Medicine, National and Kapodistrian University of Athens Medical School, 27 Mikras Asias Street, Goudi, 11527, Athens, Greece
| | - Maria Dalamaga
- 2nd Department of Dermatology and Venereology, School of Medicine, National and Kapodistrian University of Athens, Attikon General University Hospital, 1 Rimini Street, Chaidari, 12462, Athens, Greece.
- Department of Biological Chemistry, School of Medicine, National and Kapodistrian University of Athens Medical School, 27 Mikras Asias Street, Goudi, 11527, Athens, Greece.
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40
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Wang Z, Xu G, Wang H, Zhan X, Gao Y, Chen N, Li R, Song X, Guo Y, Yang R, Niu M, Wang J, Liu Y, Xiao X, Bai Z. Icariside Ⅱ, a main compound in Epimedii Folium, induces idiosyncratic hepatotoxicity by enhancing NLRP3 inflammasome activation. Acta Pharm Sin B 2020; 10:1619-1633. [PMID: 33088683 PMCID: PMC7564030 DOI: 10.1016/j.apsb.2020.03.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/20/2020] [Accepted: 03/09/2020] [Indexed: 12/12/2022] Open
Abstract
Idiosyncratic drug-induced liver injury (IDILI) is an infrequent but potentially serious disease that develops the main reason for post-marketing safety warnings and withdrawals of drugs. Epimedii Folium (EF), the widely used herbal medicine, has shown to cause idiosyncratic liver injury, but the underlying mechanisms are poorly understood. Increasing evidence has indicated that most cases of IDILI are immune mediated. Here, we report that icariside Ⅱ (ICS Ⅱ), the major active and metabolic constituent of EF, causes idiosyncratic liver injury by promoting NLRP3 inflammasome activation. ICS Ⅱ exacerbates NLRP3 inflammasome activation triggered by adenosine triphosphate (ATP) and nigericin, but not silicon dioxide (SiO2), monosodium urate (MSU) crystal or cytosolic lipopolysaccharide (LPS). Additionally, the activation of NLRC4 and AIM2 inflammasomes is not affected by ICS Ⅱ. Mechanistically, synergistic induction of mitochondrial reactive oxygen species (mtROS) is a crucial contributor to the enhancing effect of ICS Ⅱ on ATP- or nigericin-induced NLRP3 inflammasome activation. Importantly, in vivo data show that a combination of non-hepatotoxic doses of LPS and ICS Ⅱ causes the increase of aminotransferase activity, hepatic inflammation and pyroptosis, which is attenuated by Nlrp3 deficiency or pretreatment with MCC950 (a specific NLRP3 inflammasome inhibitor). In conclusion, these findings demonstrate that ICS Ⅱ causes idiosyncratic liver injury through enhancing NLRP3 inflammasome activation and suggest that ICS Ⅱ may be a risk factor and responsible for EF-induced liver injury.
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Affiliation(s)
- Zhilei Wang
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- China Military Institute of Chinese Materia, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Guang Xu
- China Military Institute of Chinese Materia, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Hongbo Wang
- Department of Hepatobiliary Surgery Center, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Xiaoyan Zhan
- China Military Institute of Chinese Materia, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Yuan Gao
- School of Chinese Materia Medica, Capital Medical University, Beijing 100029, China
| | - Nian Chen
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Ruisheng Li
- Research Center for Clinical and Translational Medicine, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Xueai Song
- Integrative Medical Center, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Yuming Guo
- Integrative Medical Center, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Ruichuang Yang
- Research Center for Clinical and Translational Medicine, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Ming Niu
- China Military Institute of Chinese Materia, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Jiabo Wang
- China Military Institute of Chinese Materia, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Youping Liu
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- Corresponding authors.
| | - Xiaohe Xiao
- China Military Institute of Chinese Materia, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
- Integrative Medical Center, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
- Corresponding authors.
| | - Zhaofang Bai
- China Military Institute of Chinese Materia, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
- Corresponding authors.
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García DS, Saturansky EI, Poncino D, Martínez-Artola Y, Rosenberg S, Abritta G, Ascimani-Peña C, Cravero A. "Hepatic toxicity by methotrexate with weekly single doses associated with folic acid in rheumatoid and psoriatic arthritis. What is its real frequency?". Ann Hepatol 2020; 18:765-769. [PMID: 31105018 DOI: 10.1016/j.aohep.2019.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/31/2019] [Accepted: 01/31/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Liver injury caused by methotrexate (MTX) has mostly been investigated without applying criteria for the assessment of causality of drug induced liver injury (DILI). Hence, the existence of DILI by MTX in many cases is debatable. This study aimed to describe the frequency and characteristics of liver injury caused by MTX, applying DILI diagnostic criteria. MATERIAL AND METHODS Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients who were treated with MTX in association with folic acid were included. Serial determinations of alanine amino transferase (ALT) and aspartate amino transferase (AST) were performed. The Roussel Uclaf Causality Assessment Method (RUCAM) was applied in cases of increases of ALT/AST over 1.5 upper limit of normal. Liver biopsy was considered when the total cumulative dosage (TCD) of MTX was ≥3.5g. RESULTS A total of 43 patients were analyzed (median follow up 32 (range: 1-48) months; 3.33 ALT/AST determinations per year). Five subjects presented an increase of ALT/AST. All presented a RUCAM score for MTX≤2 (improbable). Three had a RUCAM score for non-steroidal anti-inflammatory drugs ≥7 (probable) and two patients presented non-alcoholic fatty liver disease. Five patients with no other cause for liver disease consented to liver biopsy (TCD MTX: median 5.1; range: 3.5-7.4g). No significant fibrosis or steatosis was evident on histology. CONCLUSIONS No biochemical or significant histological liver toxicity for MTX was demonstrated when applying causality criteria for DILI. More studies with this methodology are necessary in order to improve the assessment of its frequency.
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Affiliation(s)
- Daniel S García
- Department of Hepatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina.
| | - Etel I Saturansky
- Department of Rheumatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Poncino
- Department of Hepatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Yamila Martínez-Artola
- Department of Hepatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Silvia Rosenberg
- Department of Rheumatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Gloria Abritta
- Department of Rheumatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Carlos Ascimani-Peña
- Department of Rheumatology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
| | - Amerys Cravero
- Department of Pathology, Sanatorio "Dr. Julio Méndez", Ciudad Autónoma de Buenos Aires, Argentina
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Chen M, Xu J, Wang Y, Wang Z, Guo L, Li X, Huang L. Arctium lappa L. polysaccharide can regulate lipid metabolism in type 2 diabetic rats through the SREBP-1/SCD-1 axis. Carbohydr Res 2020; 494:108055. [DOI: 10.1016/j.carres.2020.108055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/13/2020] [Accepted: 05/29/2020] [Indexed: 12/12/2022]
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Mori S, Arima N, Ito M, Ueki Y, Abe Y, Aoyagi K, Fujiyama S. Incidence, predictive factors and severity of methotrexate-related liver injury in rheumatoid arthritis: a longitudinal cohort study. Rheumatol Adv Pract 2020; 4:rkaa020. [PMID: 33134809 PMCID: PMC7585403 DOI: 10.1093/rap/rkaa020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/27/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The aims were to determine the incidence rate, predictive factors and severity of liver injury that develops during MTX treatment for RA and to evaluate the role of pretreatment hepatic fat deposition. METHODS We used an ongoing real-life registry containing RA patients who had started MTX between August 2007 and April 2018 at participating institutions. The liver-to-spleen attenuation ratio on CT scans at enrolment was used to evaluate pretreatment fat deposition quantitatively. Patients were followed until persistent transaminitis developed or until the end of the study. Liver biopsy was performed for patients who presented with persistent transaminitis. RESULTS We followed 289 new MTX users without pretreatment elevations of transaminases (mean follow-up time, 58.3 months). Hepatic fat deposition was detected in half of the patients at enrolment. During follow-up, persistent transaminitis occurred at a crude incidence rate of 3.13 per 100 person-years, and the cumulative incidence at 5 years was estimated to be 13%. A multivariate Fine-Gray regression analysis showed that the most important predictive factors were pre-existing moderate to severe fat deposition (adjusted hazard ratio, 7.69; 95% CI: 3.10, 19.10) and obesity (adjusted hazard ratio, 2.68; 95% CI: 1.37, 5.25). Non-alcoholic steatohepatitis (NASH) was the most predominant pattern in liver biopsy samples. Hepatic fibrosis was found in 90% of samples, but most cases were not advanced. CONCLUSION Aggravation of underlying fatty liver to NASH with fibrosis seems to be an important mechanism of liver injury that occurs in MTX-treated RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, National Hospital Organization Kumamoto Saishun Medical Center, Kohshi, Kumamoto
| | - Nobuyuki Arima
- Department of Pathology, Kumamoto Shinto General Hospital, Kumamoto
| | - Masahiro Ito
- Department of Pathology, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Omura, Nagasaki
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki
| | - Yasuyo Abe
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Kiyoshi Aoyagi
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Shigetoshi Fujiyama
- Department of Gastroenterology and Hepatology, Kumamoto Shinto General Hospital, Kumamoto, Japan
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Menter A, Gelfand JM, Connor C, Armstrong AW, Cordoro KM, Davis DMR, Elewski BE, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Kroshinsky D, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Paller AS, Parra SL, Pathy AL, Prater EF, Rahimi RS, Rupani RN, Siegel M, Stoff B, Strober BE, Tapper EB, Wong EB, Wu JJ, Hariharan V, Elmets CA. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol 2020; 82:1445-1486. [PMID: 32119894 DOI: 10.1016/j.jaad.2020.02.044] [Citation(s) in RCA: 201] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 2% of the world's population. In this guideline, we focus the discussion on systemic, nonbiologic medications for the treatment of this disease. We provide detailed discussion of efficacy and safety for the most commonly used medications, including methotrexate, cyclosporine, and acitretin, and provide recommendations to assist prescribers in initiating and managing patients on these treatments. Additionally, we discuss newer therapies, including tofacitinib and apremilast, and briefly touch on a number of other medications, including fumaric acid esters (used outside the United States) and therapies that are no longer widely used for the treatment of psoriasis (ie, hydroxyurea, leflunomide, mycophenolate mofetil, thioguanine, and tacrolimus).
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Affiliation(s)
| | - Joel M Gelfand
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | - Kelly M Cordoro
- Department of Dermatology, University of California, San Francisco School of Medicine, San Diego, California
| | | | | | | | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mt. Sinai, New York, New York
| | | | | | - Matthew Kiselica
- Patient Advocate, National Psoriasis Foundation, Portland, Oregon
| | | | - Neil J Korman
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Mark Lebwohl
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jason Lichten
- Patient Advocate, National Psoriasis Foundation, Portland, Oregon
| | - Henry W Lim
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | - Nehal N Mehta
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Amy S Paller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Arun L Pathy
- Colorado Permanente Medical Group, Centennial, Colorado
| | | | | | - Reena N Rupani
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Bruce E Strober
- Central Connecticut Dermatology, Cromwell, Connecticut; Yale University, New Haven, Connecticut
| | - Elliot B Tapper
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Emily B Wong
- San Antonio Uniformed Services Health Education Consortium, Joint-Base San Antonio, Texas
| | - Jashin J Wu
- Dermatology Research and Education Foundation, Irvine, California
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Abstract
Idiosyncratic drug-induced liver injury (DILI) is an underreported and underestimated adverse drug reaction. A recent population-based study found a crude incidence of approximately 19 cases per 100,000 a year. Amoxicillin-clavulanate continues to be the most commonly implicated agent in most Western countries, reported to occur in approximately 1 of 2300 users. In patients with drug-induced autoimmune hepatitis, liver tests often do not normalize with cessation of the drugs and require corticosteroids. DILI associated with jaundice can lead to death from liver failure or require liver transplantation in at least 10% of cases.
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Affiliation(s)
- Einar S Björnsson
- Department of Internal Medicine, Faculty of Medicine, Division of Gastroenterology and Hepatology, The National University Hospital of Iceland, University of Iceland, Hringbraut, Reykjavík 101, Iceland.
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46
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Zou ZY, Shen B, Fan JG. Systematic Review With Meta-analysis: Epidemiology of Nonalcoholic Fatty Liver Disease in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2019; 25:1764-1772. [PMID: 30918952 DOI: 10.1093/ibd/izz043] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is increasingly identified in patients with inflammatory bowel disease (IBD), but there are few systematic reviews and meta-analyses of the studies of NAFLD in IBD patients. METHODS MEDLINE, Web of Science, Cochrane Library, and Scopus were searched (until August 2018) to identify observational studies that reported the prevalence and risk factors for NAFLD in IBD patients. Pooled prevalence, odds ratios (OR), mean difference (MD), and 95% confidence intervals (95% CI) were calculated. Study quality was assessed using the modified Newcastle-Ottawa scale. RESULTS Of the 662 citations evaluated, 19 studies (including 5620 subjects) reported the prevalence of NAFLD in IBD population and were included for the analysis. The overall pooled prevalence was 27.5% (95% CI, 20.7%-34.2%). The prevalence was higher in older patients (MD = 8.22; 95% CI, 6.22-10.22), type 2 diabetes (OR = 3.85; 95% CI, 2.49-5.95), hypertension (OR = 3.18; 95% CI, 2.36-4.28), obesity (OR = 2.79; 95% CI, 1.73-4.50), insulin resistance (OR = 6.66; 95% CI, 1.28-34.77), metabolic syndrome (OR = 4.96; 95% CI, 3.05-8.05), chronic kidney disease (OR = 4.83; 95% CI, 1.79-13.04), methotrexate use (OR = 1.76; 95% CI, 1.02-3.06), surgery for IBD (OR = 1.28; 95% CI, 1.02-1.62), and longer duration of IBD (MD = 5.60; 95% CI, 2.24-8.97). CONCLUSIONS We found that NAFLD was not uncommon in the IBD population. Older age, metabolic risk factors, methotrexate use, prior surgery, and longer duration of IBD are predictors for the presence of NAFLD in IBD. Screening of NAFLD might be recommended among IBD patients with the aforementioned factors.
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Affiliation(s)
- Zi-Yuan Zou
- Center for Fatty Liver, Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- The First Clinical School, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jian-Gao Fan
- Center for Fatty Liver, Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Lab of Pediatric Gastroenterology and Nutrition, Shanghai, China
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47
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Abdelaziz AI, Mantawy EM, Gad AM, Fawzy HM, Azab SS. Activation of pCREB/Nrf-2 signaling mediates re-positioning of liraglutide as hepato-protective for methotrexate -induced liver injury (MILI). Food Chem Toxicol 2019; 132:110719. [PMID: 31362085 DOI: 10.1016/j.fct.2019.110719] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/18/2019] [Accepted: 07/26/2019] [Indexed: 02/08/2023]
Abstract
Methotrexate (MTX) is commonly used to treat several types of cancer and autoimmune diseases. However, there is increasing concern over its organs toxicities particularly liver toxicity. Liraglutide, a glucagon like peptide-1 agonist, possesses antioxidant and anti-inflammatory features. This study aimed to explore the potential protective effect of liraglutide pre-treatment in ameliorating MTX-induced hepatotoxicity and to further investigate the underlying mechanisms. Rats received 1.2 mg/kg liraglutide intraperitoneal twice daily for 7 days before MTX. Results revealed that liraglutide significantly decreased activities of liver enzymes and oxidative stress in hepatocytes. Furthermore, NF-kB expression and related inflammatory markers (TNF-α, COX-2 and IL-6) were reduced in the pre-treatment group of liraglutide. These data validate the advantageous effects of liraglutide in MTX hepatotoxic animals. In addition, liraglutide increased the expression of the antioxidant transcription factor nuclear factor-erythroid 2-related factor 2 (Nrf-2), along with the transcription of downstream phosphorylated cAMP response element-binding protein (pCREB) which increases the activity of Nrf-2. Additionally, caspase-3 expression/activity and BAX/Bcl-2 ratio were decreased following liraglutide pre-treatment. In conclusion, it was confirmed that liraglutide enhanced the antioxidant activity of liver cells by activating the Nrf-2 and pCREB signaling, thereby, reducing liver cell inflammation and apoptosis induced by MTX.
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Affiliation(s)
- Aya I Abdelaziz
- Department of Pharmacology, National Organization for Drug Control and Research (NODCR), Cairo, Egypt
| | - Eman M Mantawy
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Amany M Gad
- Department of Pharmacology, National Organization for Drug Control and Research (NODCR), Cairo, Egypt
| | - Hala M Fawzy
- Department of Pharmacology, National Organization for Drug Control and Research (NODCR), Cairo, Egypt
| | - Samar S Azab
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt.
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Tiberio R, Graziola F, Miglino B, Veronese F, Annali G, Savoia P. Secukinumab for Psoriasis in Obese Patients: Minireview and Clinical Experience. Case Rep Dermatol 2019; 11:29-36. [PMID: 31662736 PMCID: PMC6816128 DOI: 10.1159/000501990] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/05/2019] [Indexed: 12/20/2022] Open
Abstract
Psoriasis (PsO) has been associated with obesity, and its severity increases in obese subjects. The link between psoriatic condition and obesity is based on shared pathophysiological pathways where local and systemic inflammation promote each other; PsO is an inflammatory, immune-mediated disease, and the adipose tissue is the source of proinflammatory adipokines. Moreover, psoriatic arthritis (PsA) is an important comorbidity of PsO that reduces quality of life and makes difficult the patient's management. Treatment of obese subjects with moderate to severe PsO, even more if PsA is present, is challenging because of reduced efficacy of several systemic drugs and increased risk of adverse events. Secukinumab, a monoclonal antibody that selectively binds to and neutralizes interleukin 17A, shows efficacy on PsO in all body weight groups, even in the highest, whose response has a slight downward trend. Clinical features of two obese subjects, affected by PsO and PsA, successfully treated with secukinumab, are described.
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Affiliation(s)
- Rossana Tiberio
- Department of Health Sciences, A. Avogadro University of Eastern Piedmont, Novara, Italy
| | - Francesca Graziola
- Department of Health Sciences, A. Avogadro University of Eastern Piedmont, Novara, Italy
| | - Benedetta Miglino
- Department of Health Sciences, A. Avogadro University of Eastern Piedmont, Novara, Italy
| | - Federica Veronese
- Department of Health Sciences, A. Avogadro University of Eastern Piedmont, Novara, Italy
| | - Giordana Annali
- Department of Health Sciences, A. Avogadro University of Eastern Piedmont, Novara, Italy
| | - Paola Savoia
- Department of Health Sciences, A. Avogadro University of Eastern Piedmont, Novara, Italy
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FitzGerald O, Ritchlin C. Opportunities and challenges in the treatment of psoriatic arthritis. Best Pract Res Clin Rheumatol 2019; 32:440-452. [PMID: 31171314 DOI: 10.1016/j.berh.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In this chapter, we review the opportunities and challenges posed by the treatment options currently available in the treatment of psoriatic arthritis. Both established and new or emerging treatment options are discussed using a domain-based approach. Finally, approaches to how treatment can be optimized together with some clinical pearls are presented and discussed. With the increasing treatment options available, we need a better way of deciding which treatment should be considered for which patient. On the basis of current knowledge, some guidance is provided on how these choices might best be made.
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Affiliation(s)
- Oliver FitzGerald
- St. Vincent's University Hospital, Conway Institute for Biomolecular Research, University College Dublin, Ireland.
| | - Christopher Ritchlin
- Chief, Allergy, Immunology & Rheumatology Division, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
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50
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Andrade RJ, Aithal GP, Björnsson ES, Kaplowitz N, Kullak-Ublick GA, Larrey D, Karlsen TH. EASL Clinical Practice Guidelines: Drug-induced liver injury. J Hepatol 2019; 70:1222-1261. [PMID: 30926241 DOI: 10.1016/j.jhep.2019.02.014] [Citation(s) in RCA: 646] [Impact Index Per Article: 107.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/14/2019] [Indexed: 02/07/2023]
Abstract
Idiosyncratic (unpredictable) drug-induced liver injury is one of the most challenging liver disorders faced by hepatologists, because of the myriad of drugs used in clinical practice, available herbs and dietary supplements with hepatotoxic potential, the ability of the condition to present with a variety of clinical and pathological phenotypes and the current absence of specific biomarkers. This makes the diagnosis of drug-induced liver injury an uncertain process, requiring a high degree of awareness of the condition and the careful exclusion of alternative aetiologies of liver disease. Idiosyncratic hepatotoxicity can be severe, leading to a particularly serious variety of acute liver failure for which no effective therapy has yet been developed. These Clinical Practice Guidelines summarize the available evidence on risk factors, diagnosis, management and risk minimization strategies for drug-induced liver jury.
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