Nimesulide-induced severe hemolytic anemia and acute liver failure leading to liver transplantation

Thermal stability of amorphous nimesulide: from glass formation to crystal growth and thermal degradation

Thermally induced physico-chemical transformations in amorphous nimesulide were studied by means of differential scanning calorimetry (DSC), thermogravimetry, and Raman microscopy. The equilibrium glass transition temperature was found to be Tg0 = 10-15 °C, and the relaxation motions were found to be temperature-dependent. Crystal growth from the amorphous phase was found to be crucially dependent on the presence of mechanical defects that serve as centers for heterogeneous nucleation. The large amounts of mechanical defects significantly decrease the activation energy of the macroscopic crystallization; the positions of the crystallization peaks and their asymmetry/shape remain however almost unchanged. At laboratory temperature, powdered nimesulide fully crystallizes within several hours, with an absolute majority of the crystalline phase being formed as the thermodynamically stable form I polymorph. Amorphous nimesulide does not crystallize from the free smooth surface (no trace of formed crystallites was found by optical microscopy after 30 days at laboratory temperature). Nimesulide was found to be very stable at temperatures above its melting point of 147.5 °C; thermal degradation starts to proceed slowly at 200 °C. Mutual correlations between the macroscopic and microscopic crystal growth processes and between the viscous flow and structural relaxation motions were discussed based on the values of the corresponding activation energies. A link between the cooperativity of structural domains, parameters of the Tool-Narayanaswamy-Moynihan relaxation model, and microscopic crystal growth was proposed.

Serious liver injury induced by Nimesulide: an international collaborative study

Nimesulide is a non-steroidal anti-inflammatory drug still marketed in many countries. We aim to analyze the clinical phenotype, outcome, and histological features of nimesulide-induced liver injury (nimesulide-DILI). We analyzed 57 cases recruited from the Spanish and Latin American DILI registries. Causality was assessed by the RUCAM scale. Mean age of the whole case series was 59 years (86% women) with a median time to onset of 40 days. A total of 46 patients (81%) were jaundiced. Nimesulide-DILI pattern was hepatocellular in 38 (67%), mixed in 12 (21%), and cholestatic in 7 (12%) cases. Transaminases were elevated with a mean of nearly 20-fold the upper limit of normality (ULN), while alkaline phosphatase showed a twofold mean elevation above ULN. Total bilirubin showed a mean elevation of 13-fold the ULN. Liver histology was obtained in 14 cases (25%), most of them with a hepatocellular pattern. Median time to recovery was 60 days. Overall, 12 patients (21%) developed acute liver failure (ALF), five (8.8%) died, three underwent liver transplantation (5.3%), and the remaining four resolved. Latency was ≤ 15 days in 12 patients (21%) and one patient developed ALF within 7 days from treatment initiation. Increased total bilirubin and aspartate transaminase levels were independently associated with the development of ALF. In summary, nimesulide-DILI affects mainly women and presents typically with a hepatocellular pattern. It is associated with ALF and death in a high proportion of patients. Shorter (≤ 15 days) duration of therapy does not prevent serious nimesulide hepatotoxicity, making its risk/benefit ratio clearly unfavorable.

Nimesulide-induced hepatotoxicity: A systematic review and meta-analysis

Objective

This study aimed to evaluate the risk for hepatotoxicity with nimesulide, a non-steroidal anti-inflammatory drug (NSAID) available in Republic of Korea but withdrawn from the market in several countries.

Methods

A systematic review and meta-analysis were conducted of studies retrieved from PubMed, EMBASE, Cochrane, the Research Information Sharing Service and ClinicalTrials.gov up to September 2017. All studies reporting nimesulide-associated hepatotoxicity in patients as compared with the unexposed or the exposed to other NSAIDs were included. Studies using spontaneous reporting databases were included to estimate reporting odds ratio (ROR) of hepatotoxicity associated with nimesulide exposure. The association between nimesulide use and hepatotoxicity was estimated using relative risk (RR) and ROR with 95% confidence interval (CI).

Results

A total of 25 observational studies were eligible for review. In a meta-analysis of five observational studies, nimesulide was significantly associated with hepatotoxicity [RR 2.21, 95% CI 1.72–2.83]. From studies using spontaneous reporting databases (n = 6), rates of reported hepatotoxicity were significantly higher in patients using nimesulide, compared with those treated with other NSAIDs [pooled ROR 3.99, 95% CI 2.86–5.57]. Of a total of 33 patients from case studies and series, the majority (n = 28, 84.8%) were female, and the mean age (± standard deviation) was 56.8 (± 15.6) years. Almost half of the patients on nimesulide (45.5%) either required liver transplantation or died due to fulminant hepatic failure, of whom a third developed hepatotoxicity within less than 15 days of nimesulide administration.

Conclusions

Our study findings support previous reports of an increased risk for hepatotoxicity with nimesulide use and add to existing literature by providing risk estimates for nimesulide-associated hepatotoxicity. As the limited number of studies with primarily observational study designs were included in the analysis, more studies are needed to further describe the effects of dose and length of treatment on the risk for hepatotoxicity.

Comparative Evaluation of Anti-Inflammatory Activity of Curcuminoids, Turmerones, and Aqueous Extract of Curcuma longa

Curcuma longa is widely known for its anti-inflammatory activity in traditional system of medicine for centuries and has been scientifically validated extensively. The present study was conducted to evaluate the anti-inflammatory activity of curcuminoids and oil-free aqueous extract (COFAE) of C. longa and compare it with that of curcuminoids and turmerones (volatile oil), the bioactive components of C. longa that are proven for the anti-inflammatory potential. The activity against inflammation was evaluated in xylene-induced ear edema, cotton pellet granuloma models in albino Swiss mice and albino Wistar rats, respectively. The results showed that COFAE of C. longa at three dose levels significantly (P ≤ 0.05) inhibited inflammation in both models, as evidenced by reduction in ear weight and decrease in wet as well as dry weights of cotton pellets, when compared to the vehicle control. The COFAE of C. longa showed considerable anti-inflammatory effects against acute and chronic inflammation and the effects were comparable to those of curcuminoids and turmerones.

An update on oxidative stress-mediated organ pathophysiology

Exposure to environmental pollutants and drugs can result in pathophysiological situations in the body. Research in this area is essential as the knowledge on cellular survival and death would help in designing effective therapeutic strategies that are needed for the maintenance of the normal physiological functions of the body. In this regard, naturally occurring bio-molecules can be considered as potential therapeutic targets as they are normally available in commonly consumed foodstuffs and are thought to have minimum side effects. This review article describes the detailed mechanisms of oxidative stress-mediated organ pathophysiology and the ultimate fate of the cells either to survive or to undergo necrotic or apoptotic death. The mechanisms underlying the beneficial role of a number of naturally occurring bioactive molecules in oxidative stress-mediated organ pathophysiology have also been included in the review. The review provides useful information about the recent progress in understanding the mechanism(s) of various types of organ pathophysiology, the complex cross-talk between these pathways, as well as their modulation in stressed conditions. Additionally, it suggests possible therapeutic applications of a number of naturally occurring bioactive molecules in conditions involving oxidative stress.

Protective role ofPhyllanthus niruri against nimesulide induced hepatic damage

Present study aimed to evaluate the protective role of the aqueous extract of Phyllanthus niruri (P. niruri) against nimesulide-induced hepatic disoder in mice by determining levels of glutamate oxaloacetate transaminase (GOT), glutamate pyruvate transaminase (GPT) and alkaline phosphatase (ALP) in serum and also by measuring the hepatic content of the antioxidant enzymes, superoxide dismitase (SOD) and catalase (CAT); the free radical scavenger, reduced glutathione (GSH) and thiobarbituric acid reacting substances (TBARS). Aqueous extract of P. niruri was administered either orally or intraperitoneally in different doses and times as needed for the experiments. Intraperitoneal of the extract (100 mg/kg body weight for seven days) reduced nimesulide (750 mg/kg body weight for 3 days) induced increased levels of GOT (37.0±1.8 units/ml in control group vs. 91.8±2.0 units/ml in nimesulide treated group vs. 35.0±1.0 units/ml in extract treated group), GPT (30.0±2.1 units/ml in control group vs. 88.4±2.9 units/ml in nimesulide treated group vs. 34.1±1.8 units/ml in extract treated group), and ALP (7.86±0.47 KA units/ml in control group vs. 23.80±0.60 KA units/ml in nimesulide treated group vs. 7.30±0.40 KA units/ml, in extract treated group) to almost nomal. In addition, P. niruri restored the nimesulide induced alterations of hepatic SOD (550±20 units/mg total protein in control group vs. 310±13 units/mg total protein in nimesulide treated group vs. 515±10 units/mg total protein in extract treated group), CAT (99.5±2 units/mg total protein in control group vs. 25.0±1.5 units/mg total protein in nimesulide treated group vs. 81.0±0.8 units/mg total protein in extract treated group), GSH (90±3 nmoles/mg total protein in control group vs. 17±4.2 nmoles/mg total protein in nimesulide treated group vs. 81±1 nmoles/mg total protein in extract treated group) and TBARS (measured as MDA, 36.6±3.0 nmoles/g liver tissue in control group vs. 96.3±5.2 nmoles/g liver tissue in nimesulide treated group vs. 41.2±1.7 nmoles/g liver tissue in extract treated group) contents. Dose-dependent studies showed that the herb could protect liver even if the nimesulide-induced injury is severe. Intraperitoneal administration of the extract showed better protective effect than oral administration. Combining all, the data suggest that P. niruri possesses hepatoprotective activity against nimesulide-induced liver toxicity and probably acts via an antioxidant defense mechanism. To the best of our knowledge, this is the first report of the hepatoprotective action of P. niruri against nimesulide induced liver damage.

Non-steroidal anti-inflammatory drugs: What is the actual risk of liver damage?

Non-steroidal anti-inflammatory drugs (NSAIDs) constitute a family of drugs, which taken as a group, represents one of the most frequently prescribed around the world. Thus, not surprisingly NSAIDs, along with anti-infectious agents, list on the top for causes of Drug-Induced Liver Injury (DILI). The incidence of liver disease induced by NSAIDs reported in clinical studies is fairly uniform ranging from 0.29/100 000 [95% confidence interval (CI): 0.17-051] to 9/100 000 (95% CI: 6-15). However, compared with these results, a higher risk of liver-related hospitalizations was reported (3-23 per 100 000 patients). NSAIDs exhibit a broad spectrum of liver damage ranging from asymptomatic, transient, hyper-transaminasemia to fulminant hepatic failure. However, under-reporting of asymptomatic, mild cases, as well as of those with transient liver-tests alteration, in conjunction with reports non-compliant with pharmacovigilance criteria to ascertain DILI and flawed epidemiological studies, jeopardize the chance to ascertain the actual risk of NSAIDs hepatotoxicity. Several NSAIDs, namely bromfenac, ibufenac and benoxaprofen, have been withdrawn from the market due to hepatotoxicity; others like nimesulide were never marketed in some countries and withdrawn in others. Indeed, the controversy concerning the actual risk of severe liver disease persists within NSAIDs research. The present work intends (1) to provide a critical analysis of the dissimilar results currently available in the literature concerning the epidemiology of NSAIDS hepatotoxicity; and (2) to review the risk of hepatotoxicity for each one of the most commonly employed compounds of the NSAIDs family, based on past and recently published data.

Assessment of cytotoxic and clastogenic effects of nimesulide: an NSAID drug in somatic cells of BALB/c mice in vivo

The in vivo genotoxicity of nimesulide, a sulfononilide nonsteroidal anti-inflammatory drug (NSAID) with anti-inflammatory, analgesic, and antipyretic effects, was evaluated by employing a mouse in vivo chromosomal aberration test in bone marrow cells. Oral treatment of animals for 5 consecutive days with 1, 2.5, 5, and 7.5 mg/kg body weight of the drug resulted in a statistically nonsignificant reduction in mitotic index and increase in CAs/cell and percent abnormal metaphase. The results indicated that nimesulide does not induce cytotoxicity and is a weak clastogen in the bone marrow cells of the mouse in vivo. Thus, the drug presents a very weak genotoxic risk.

Involvement of mitochondria mediated pathways in hepatoprotection conferred by Fumaria parviflora Lam. extract against nimesulide induced apoptosis in vitro

Nimesulide, a popular nonsteroidal anti-inflammatory drug, has been associated with serious hepatotoxicity. Reactive oxygen species (ROS) and mitochondrial perturbations have been implicated in drug induced hepatotoxicity, although their role in the pathway needs exploration. Study was undertaken to elucidate the effect of Fumaria parviflora Lam. (Fp) on nimesulide induced cell death in primary rat hepatocyte cultures. Fp extract treated cells showed increased viability as compared to nimesulide stressed cells as assessed by MTT assay. LDH leakage increased significantly at 500microM nimesulide, and the data suggested that apoptosis was the predominant mechanism responsible for cell death. Nimesulide induced apoptosis was further confirmed by DNA fragmentation and chromatin condensation. Nimesulide exposure increased intracellular ROS, translocation of Bax and Bcl2 followed by mitochondrial depolarization and cytochrome c (Cyt c) release along with caspase-9/-3 activity confirming involvement of mitochondria in nimesulide induced apoptosis. Events like membrane depolarization of mitochondria, expression of Bax, Bcl2, externalization of phosphatidyl serine are substantially reversed by the pre-treatment of Fp extract. Thus, the study indicates that Fp extract modulates critical events regulating pro and anti-apoptotic proteins in mitochondria dependent apoptosis induced by nimesulide.

Nimesulide associated fulminant hepatic failure

PURPOSE

It is controversial whether the non-steroidal inflammatory drug nimesulide is associated with severe hepatotoxicity. Our objective was to determine whether nimesulide is associated with fulminant hepatic failure.

METHODS

Retrospective cohort study in the Irish national liver transplant unit. All patients who received a liver transplant for fulminant hepatic failure of unknown cause, between January 1994 and March 2007, were evaluated. New medications started within 6 months prior to transplant were identified. Likelihood of association assessed using the Naranjo and Roussel UCLAF Causality Assessment Method (RUCAM) scoring systems.

RESULTS

Thirty-two patients with sero-negative, non-paracetamol fulminant hepatic failure, who received an emergency liver transplant, were identified. Nimesulide had been started within 6 months in 6 patients. Five of the six were middle aged females. Nimesulide was assessed as probably associated with liver injury in all six cases.

CONCLUSIONS

Nimesulide was associated with fulminant hepatic failure requiring liver transplant in 6/32 cases of unknown origin. This association requires further investigation.

Evaluation of naranjo adverse drug reactions probability scale in causality assessment of drug-induced liver injury

BACKGROUND

Causality assessment in hepatotoxicity is challenging. The current standard liver-specific Council for International Organizations of Medical Sciences/Roussel Uclaf Causality Assessment Method scale is complex and difficult to implement in daily practice. The Naranjo Adverse Drug Reactions Probability Scale is a simple and widely used nonspecific scale, which has not been specifically evaluated in drug-induced liver injury.

AIM

To compare the Naranjo method with the standard liver-specific Council for International Organizations of Medical Sciences/Roussel Uclaf Causality Assessment Method scale in evaluating the accuracy and reproducibility of Naranjo Adverse Drug Reactions Probability Scale in the diagnosis of hepatotoxicity.

METHODS

Two hundred and twenty-five cases of suspected hepatotoxicity submitted to a national registry were evaluated by two independent observers and assessed for between-observer and between-scale differences using percentages of agreement and the weighted kappa (kappa(w)) test.

RESULTS

A total of 249 ratings were generated. Between-observer agreement was 45% with a kappa(w) value of 0.17 for the Naranjo Adverse Drug Reactions Probability Scale, while there was a higher agreement when using the Council for International Organizations of Medical Sciences/Roussel Uclaf Causality Assessment Method scale (72%, kappa(w): 0.71). Concordance between the two scales was 24% (kappa(w): 0.15). The Naranjo Adverse Drug Reactions Probability Scale had low sensitivity (54%) and poor negative predictive value (29%) and showed a limited capability to distinguish between adjacent categories of probability.

CONCLUSION

The Naranjo scale lacks validity and reproducibility in the attribution of causality in hepatotoxicity.

Herbal (Phyllanthus niruri) protein isolate protects liver from nimesulide induced oxidative stress

Present study was conducted to evaluate the role of a protein fraction (PI, protein isolate) of the herb, Phyllanthus niruri (P. niruri) against nimesulide-induced oxidative stress in vivo using a murine model. Mice were intraperitoneally treated with that at a dose of 5mg/kg body weight for 7 days before and separately 1-5 days after nimesulide (at a dose of 10mg/kg body weight for 7 days) administration to evaluate its preventive and curative role. Levels of reduced glutathione (GSH), antioxidant enzymes, superoxide dismutase (SOD) and catalase (CAT), as well as thiobarbituric acid reactive substances (TBARS) were measured in the liver homogenates of all study groups. Pretreatment with isolated P. niruri protein fraction significantly enhanced nimesulide-induced reduced levels of antioxidant enzymes and GSH as well as reduced the enhanced level of lipid peroxidation. Post-treatment studies showed that the recovery after nimesulide induced oxidative stress was more rapid if PI was administered compared to the spontaneous recovery of liver. Histological studies also suggest that this protein fraction could prevent as well as cure liver from nimesulide induced oxidative stress. DPPH radical scavenging assay showed that it could scavenge free radicals. Its antioxidant property was compared with that of a known potent antioxidant, Vitamin E. Besides, the effect of a non-relevant protein, BSA, was also included in the study. Heat treatment and trypsin digestion destroyed the biological activity of this protein fraction. In conclusion, data obtained suggest that the P. niruri protein fraction may protect liver from nimesulide-induced oxidative stress probably via promotion of antioxidant defense.

Physicochemical characterization and dissolution properties of nimesulide-cyclodextrin binary systems

The objective of this work is physicochemical characterization of nimesulide-cyclodextrin binary systems both in solution and solid state and to improve the dissolution properties of nimesulide (N) via complexation with alpha-, beta, and gamma-cyclodextrins (CDs). Detection of inclusion complexation was done in solution by means of phase solubility analysis, mass spectrometry, and 1H nuclear magnetic resonance (1H-NMR) spectroscopic studies, and in solid state using differential scanning calorimetry (DSC), powder x-ray diffractometry (X-RD), scanning electron microscopy (SEM), and in vitro dissolution studies. Phase solubility, mass spectrometry and 1H-NMR studies in solution revealed 1:1 M complexation of N with all CDs. A true inclusion of N with beta-CD at 1:2 M in solid state was confirmed by DSC, powder X-RD and SEM studies. Dissolution properties of N-CD binary systems were superior when compared to pure N.