1
|
Bessone F, Hillotte GL, Ahumada N, Jaureguizahar F, Medeot AC, Roma MG. UDCA for Drug-Induced Liver Disease: Clinical and Pathophysiological Basis. Semin Liver Dis 2024; 44:1-22. [PMID: 38378025 DOI: 10.1055/s-0044-1779520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Drug-induced liver injury (DILI) is an adverse reaction to medications and other xenobiotics that leads to liver dysfunction. Based on differential clinical patterns of injury, DILI is classified into hepatocellular, cholestatic, and mixed types; although hepatocellular DILI is associated with inflammation, necrosis, and apoptosis, cholestatic DILI is associated with bile plugs and bile duct paucity. Ursodeoxycholic acid (UDCA) has been empirically used as a supportive drug mainly in cholestatic DILI, but both curative and prophylactic beneficial effects have been observed for hepatocellular DILI as well, according to preliminary clinical studies. This could reflect the fact that UDCA has a plethora of beneficial effects potentially useful to treat the wide range of injuries with different etiologies and pathomechanisms occurring in both types of DILI, including anticholestatic, antioxidant, anti-inflammatory, antiapoptotic, antinecrotic, mitoprotective, endoplasmic reticulum stress alleviating, and immunomodulatory properties. In this review, a revision of the literature has been performed to evaluate the efficacy of UDCA across the whole DILI spectrum, and these findings were associated with the multiple mechanisms of UDCA hepatoprotection. This should help better rationalize and systematize the use of this versatile and safe hepatoprotector in each type of DILI scenarios.
Collapse
Affiliation(s)
- Fernando Bessone
- Hospital Provincial del Centenario, Facultad de Ciencias Médicas, Servicio de Gastroenterología y Hepatología, Universidad Nacional de Rosario, Rosario, Argentina
| | - Geraldine L Hillotte
- Instituto de Fisiología Experimental (IFISE-CONICET), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
| | - Natalia Ahumada
- Hospital Provincial del Centenario, Facultad de Ciencias Médicas, Servicio de Gastroenterología y Hepatología, Universidad Nacional de Rosario, Rosario, Argentina
| | - Fernanda Jaureguizahar
- Hospital Provincial del Centenario, Facultad de Ciencias Médicas, Servicio de Gastroenterología y Hepatología, Universidad Nacional de Rosario, Rosario, Argentina
| | | | - Marcelo G Roma
- Instituto de Fisiología Experimental (IFISE-CONICET), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
| |
Collapse
|
2
|
Progress in the treatment of drug-induced liver injury with natural products. Pharmacol Res 2022; 183:106361. [PMID: 35882295 DOI: 10.1016/j.phrs.2022.106361] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 12/13/2022]
Abstract
There are numerous prescription drugs and non-prescription drugs that cause drug-induced liver injury (DILI), which is the main cause of liver disease in humans around the globe. Its mechanism becomes clearer as the disease is studied further. For an instance, when acetaminophen (APAP) is taken in excess, it produces N-acetyl-p-benzoquinone imine (NAPQI) that binds to biomacromolecules in the liver causing liver injury. Treatment of DILI with traditional Chinese medicine (TCM) has shown to be effective. For example, activation of the Nrf2 signaling pathway as well as regulation of glutathione (GSH) synthesis, coupling, and excretion are the mechanisms by which ginsenoside Rg1 (Rg1) treats APAP-induced acute liver injury. Nevertheless, reducing the toxicity of TCM in treating DILI is still a problem to be overcome at present and in the future. Accumulated evidences show that hydrogel-based nanocomposite may be an excellent carrier for TCM. Therefore, we reviewed TCM with potential anti-DILI, focusing on the signaling pathway of these drugs' anti-DILI effect, as well as the possibility and prospect of treating DILI by TCM based on hydrogel materials in the future. In conclusion, this review provides new insights to further explore TCM in the treatment of DILI.
Collapse
|
3
|
Sanabria-Cabrera J, Tabbai S, Niu H, Alvarez-Alvarez I, Licata A, Björnsson E, Andrade RJ, Lucena MI. N-Acetylcysteine for the Management of Non-Acetaminophen Drug-Induced Liver Injury in Adults: A Systematic Review. Front Pharmacol 2022; 13:876868. [PMID: 35656297 PMCID: PMC9152180 DOI: 10.3389/fphar.2022.876868] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/14/2022] [Indexed: 12/30/2022] Open
Abstract
Introduction: Idiosyncratic drug-induced liver injury (DILI) is a rare adverse reaction to drugs and other xenobiotics. DILI has different grades of severity and may lead to acute liver failure (ALF), for which there is no effective therapy. N-acetylcysteine (NAC) has been occasionally tested for the treatment of non-acetaminophen drug-induced ALF. However, limited evidence for its efficacy and safety is currently available. Our aim was to elucidate the benefit and safety of NAC in DILI and evaluate its hepatoprotective effect. Methods: We conducted a systematic review to evaluate the management and prevention focused on NAC in idiosyncratic DILI. The main outcomes included mortality due to DILI, time to normalization of liver biochemistry, transplant-free survival, and adverse events. We included clinical trials and observational studies, either prospective or retrospective. Results: A total of 11 studies were included after literature screening. All studies had different methodologies, and some of them had important risk of bias that may lead to interpreting their findings with caution. The majority of the studies proved NAC efficacy in a cohort of patients with ALF due to different etiologies, where DILI represented a subgroup. NAC seemed to improve transplant-free survival; however, its benefit was inconclusive in terms of overall survival. With regard to safety, NAC showed an adequate safety profile. In prevention studies, NAC showed a possible hepatoprotective effect; however, this finding is limited by the lack of studies and presence of bias. Conclusion: NAC treatment seems to have some benefit in non-acetaminophen drug-induced liver failure patients with acceptable safety; however, due to the lack of evidence and limitations detected across studies, its benefit must be corroborated in clinical trials with adequate methodology.
Collapse
Affiliation(s)
- Judith Sanabria-Cabrera
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- UCICEC IBIMA, Plataforma ISCIII de soporte para la Investigación Clínica, Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Sara Tabbai
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- UCICEC IBIMA, Plataforma ISCIII de soporte para la Investigación Clínica, Málaga, Spain
| | - Hao Niu
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Ismael Alvarez-Alvarez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Màlaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Màlaga, Malaga, Spain
| | - Anna Licata
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
| | - Einar Björnsson
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Raul J. Andrade
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Màlaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Màlaga, Malaga, Spain
| | - M. Isabel Lucena
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- UCICEC IBIMA, Plataforma ISCIII de soporte para la Investigación Clínica, Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| |
Collapse
|
4
|
Tustumi F, Pinheiro Filho JEL, Stolzemburg LCP, Serigiolle LC, Costa TN, Pajecki D, Santo MA, Nahas SC. Management of biliary stones in bariatric surgery. Ther Adv Gastrointest Endosc 2022; 15:26317745221105087. [PMID: 36388729 PMCID: PMC9664186 DOI: 10.1177/26317745221105087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 05/16/2022] [Indexed: 11/25/2022] Open
Abstract
Morbidly obese and post-bariatric surgery patients are at increased risk for
biliary stones formation. The complications related to biliary stones may impose
complexity on their management. This study aimed to review the management of
biliary conditions in obese and bariatric patients. In this study, a narrative
review was performed of the medical, surgical, and endoscopic procedures for the
management of biliary stones and their related complications. Knowing the main
prophylactic and therapeutic interventions options is essential for clinicians
to properly manage the biliary stones in patients candidates or submitted to
bariatric surgery.
Collapse
Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Universidade de São Paulo, Av. Dr Eneas de Carvalho Aguiar, 255, Cerqueira Cesar, São Paulo 05403-000, SP, Brazil
- Department of Surgery, Faculdade de Medicina do ABC, Santo André, Brazil
| | | | | | | | | | - Denis Pajecki
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
| | - Marco Aurélio Santo
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
| | - Sérgio Carlos Nahas
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
5
|
Robles-Díaz M, Nezic L, Vujic-Aleksic V, Björnsson ES. Role of Ursodeoxycholic Acid in Treating and Preventing Idiosyncratic Drug-Induced Liver Injury. A Systematic Review. Front Pharmacol 2021; 12:744488. [PMID: 34776963 PMCID: PMC8578816 DOI: 10.3389/fphar.2021.744488] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/20/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction: Treatment is generally not available for drug-induced liver injury (DILI) patients except in some specific circumstances. The management of DILI is based on the withdrawal of the responsible drug and monitoring the patients and only a few patients need to be referred to a transplant center. Some studies on the role of ursodeoxycholic acid (UDCA) in DILI have been published. The aim of this study was to perform a systematic review of the role of UDCA in the treatment and prevention of DILI. Methods: A search was undertaken in PubMed, with the key words ursodeoxycholic acid, drug-induced liver injury and hepatotoxicity following the PRISMA guidelines. Results: A total of 33 publications were identified: 25 case reports and 8 case series. In 18 of the 25 cases reports (22 patients), authors reported improvement of liver injury associated with UDCA therapy whereas 7 case reports did not show clinical or biochemical improvement after UDCA treatment. There were 4 studies evaluating the role of UDCA in the treatment of DILI, three prospective (one being a clinical trial) and one retrospective studies. Three studies observed liver profile improvements associated with UDCA. In addition, four studies evaluated UDCA in the prevention of DILI: one pilot study, two randomized clinical trials (RCT) and one retrospective study. Three of these studies observed a lower percentage of patients with an increase in transaminases in the groups that used UDCA for DILI prevention. Conclusion: According to available data UDCA seems to have some benefits in the treatment and prevention of DILI. However, the design of the published studies does not allow a firm conclusion to be drawn on the efficacy of UDCA in DILI. A well designed RCT to evaluate the role of UDCA in DILI is needed.
Collapse
Affiliation(s)
- Mercedes Robles-Díaz
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Facultad de Medicina, Universidad de Málaga, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Málaga, Spain
| | - Lana Nezic
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Vesna Vujic-Aleksic
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina.,The Republic of Srpska Agency for Certification, Accreditation and Quality Improvement in Health Care, Banja Luka, Bosnia and Herzegovina
| | - Einar S Björnsson
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| |
Collapse
|
6
|
Kolaric TO, Nincevic V, Kuna L, Duspara K, Bojanic K, Vukadin S, Raguz-Lucic N, Wu GY, Smolic M. Drug-induced Fatty Liver Disease: Pathogenesis and Treatment. J Clin Transl Hepatol 2021; 9:731-737. [PMID: 34722188 PMCID: PMC8516847 DOI: 10.14218/jcth.2020.00091] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/08/2021] [Accepted: 07/01/2021] [Indexed: 12/12/2022] Open
Abstract
Metabolic dysfunction-associated fatty liver disease (commonly known as MAFLD) impacts global health in epidemic proportions, and the resulting morbidity, mortality and economic burden is enormous. While much attention has been given to metabolic syndrome and obesity as offending factors, a growing incidence of polypharmacy, especially in the elderly, has greatly increased the risk of drug-induced liver injury (DILI) in general, and drug-induced fatty liver disease (DIFLD) in particular. This review focuses on the contribution of DIFLD to DILI in terms of epidemiology, pathophysiology, the most common drugs associated with DIFLD, and treatment strategies.
Collapse
Affiliation(s)
- Tea Omanovic Kolaric
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Vjera Nincevic
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Lucija Kuna
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | | | - Kristina Bojanic
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
- Health Center Osijek, Osijek, Croatia
| | - Sonja Vukadin
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Nikola Raguz-Lucic
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - George Y Wu
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - Martina Smolic
- University of Osijek, Faculty of Medicine, Osijek, Croatia
- University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
- Correspondence to: Martina Smolic, University of Osijek, Faculty of Medicine, Department of Pharmacology; Faculty of Dental Medicine and Health, Department of Pharmacology and Biochemistry, J. Huttlera 4, Osijek 31000, Croatia. ORCID: https://orcid.org/0000-0002-6867-826X. Tel: + 385-31-512-800, Fax: +385-31-512-833, E-mail:
| |
Collapse
|
7
|
Li J, Zhang J, Xu X, Fang W, Qu S, Jin F, Zhou J, Han X, Raza HK, Li X, Mao Y. Hugan tablets for the treatment of RUCAM based drug-induced liver injury: a propensity score matching analysis using a nationwide database. Expert Rev Clin Pharmacol 2021; 14:1543-1550. [PMID: 34521298 DOI: 10.1080/17512433.2021.1981859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Drug-induced liver injury (DILI) is a major clinical challenge with no specific therapeutic drugs available. It is crucial to develop new agents to improve the clinical outcome of patients with DILI. This study evaluated the efficacy and safety of Hugan tablets in DILI patients using a nationwide database. RESEARCH DESIGN AND METHODS We analyzed the clinical data of DILI patients from a nationwide DILI database (www.hepatox.org). Patients who received oral Hugan tablets for DILI were defined as the Hugan group, and those who received no treatment for DILI were defined as the control group. RESULTS There were 111 cases in the Hugan group and 512 cases in the control group. One-to-one propensity score matching created 111 matched pairs. The normalization rates of alanine aminotransferase and aspartate aminotransferase in the Hugan group were significantly higher than those in the control group (50.45% vs. 26.13%, p ≤ .0002 and 67.57% vs. 41.75%, p ≤ .0001). There were no differences in the incidence of renal function impairment or blood abnormality between the two groups. CONCLUSIONS Hugan tablets are safe and effective in DILI treatment. Large-scale randomized controlled studies are needed to explore the effects of Hugan tablets on DILI induced by different offending drugs. TRIAL REGISTRATION The study protocol was posted on ClinicalTrials.gov with NCT number: NCT02407964.
Collapse
Affiliation(s)
- Jing Li
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianzhong Zhang
- Department of Medicine and Biostatistics, Unimed Scientific Inc, Wuxi, China
| | - Xiaorong Xu
- Department of Hepatology, Bozhou Huatuo Hospital of Traditional Chinese Medicine, Bozhou, China
| | - Weidong Fang
- Department of Infectious Diseases, Huangshan City People's Hospital, Huangshan, China
| | - Shilin Qu
- Department of Tuberculosis, Jingzhou Chest Hospital, Jingzhou, China
| | - Feng Jin
- Department of Thoracic Surgery, Shandong Provincial Chest Hospital, Jinan, China
| | - Jie Zhou
- Department of Extrapulmonary Tuberculosis, Tianjin Tuberculosis Control Center, Tianjin, China
| | - Xian Han
- Department of Medicine and Biostatistics, Unimed Scientific Inc, Wuxi, China
| | - Hafiz Khuram Raza
- Department of Medicine and Biostatistics, Unimed Scientific Inc, Wuxi, China
| | - Xiaoyun Li
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yimin Mao
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
8
|
Prevention and management of idiosyncratic drug-induced liver injury: Systematic review and meta-analysis of randomised clinical trials. Pharmacol Res 2021; 164:105404. [DOI: 10.1016/j.phrs.2020.105404] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023]
|
9
|
Abstract
Drug induced liver injury (DILI) is a relatively rare hepatic condition in response to the use of medications, illegal drugs, herbal products or dietary supplements. It occurs in susceptible individuals through a combination of genetic and environmental risk factors believed to modify drug metabolism and/or excretion leading to a cascade of cellular events, including oxidative stress formation, apoptosis/necrosis, haptenization, immune response activation and a failure to adapt. The resultant liver damage can present with an array of phenotypes, which mimic almost every other liver disorder, and varies in severity from asymptomatic elevation of liver tests to fulminant hepatic failure. Despite recent research efforts specific biomarkers are not still available for routine use in clinical practice, which makes the diagnosis of DILI uncertain and relying on a high degree of awareness of this condition and the exclusion of other causes of liver disease. Diagnostic scales such as the CIOMS/RUCAM can support the causality assessment of a DILI suspicion, but need refinement as some criteria are not evidence-based. Prospective collection of well-vetted DILI cases in established DILI registries has allowed the identification and validation of a number of clinical variables, and to predict a more severe DILI outcome. DILI is also in need of properly designed clinical trials to evaluate the efficacy of new DILI treatments as well as older drugs such as ursodeoxycholic acid traditionally used to ameliorate cholestasis or corticosteroids now widely tried in the oncology field to manage the emergent type of hepatotoxicity related to immune checkpoint inhibitors.
Collapse
|
10
|
Hernandez N, Pontet Y, Bessone F. Translating new knowledge on drug-induced liver injury into clinical practice. Frontline Gastroenterol 2019; 11:303-310. [PMID: 32587673 PMCID: PMC7307039 DOI: 10.1136/flgastro-2018-101120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/03/2019] [Accepted: 08/11/2019] [Indexed: 02/04/2023] Open
Abstract
Drug-induced liver injury (DILI) is one of the main reasons for drug withdrawal from the market, and a cause of worldwide morbidity. Although several issues on DILI are still unsolved, there have been significant advances in new definitions and diagnosis tools. DILI is the result of a complex interaction between genetic and environmental factors, and constitutes an expanding area of investigation. DILI can mimic virtually all known hepatopathies, including vascular disorders and liver tumours. As part of this broad spectrum of clinical presentations, DILI severity ranges from asymptomatic elevations of aminotransferases to acute liver failure. Although biomarkers are emerging as valuable diagnostic tools, they are not available in clinical practice. Accurate DILI diagnosis is a challenging issue, particularly the establishing of causal relationships with the culprit agent and the exclusion of competing causes of liver injury. Given that the understanding of the mechanisms inducing DILI is growing, and both DILI causality assessment scales and the performance of international DILI networks have been improved, hepatotoxicity may be recognised earlier in clinical practice. In this review, advances and results obtained by DILI registries around the world, case characterisations, particularly those relevant to newer definitions in DILI, and the behaviour of chronic liver disease induced by drugs will be updated. In addition, recently published data on herbal and dietary supplements and new predictive scores for acute liver failure assessment will also be discussed.
Collapse
Affiliation(s)
- Nelia Hernandez
- Gastroenterology and Hepatology, Facultad de Medicina, Hospital de Clínicas, UdelaR, Montevideo, Uruguay
| | - Yessica Pontet
- Gastroenterology and Hepatology, Facultad de Medicina, Hospital de Clínicas, UdelaR, Montevideo, Uruguay
| | - Fernando Bessone
- Gastroenterology and Hepatology, University of Rosario School of Medicine, Rosario, Argentina
| |
Collapse
|
11
|
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.
Collapse
|
12
|
Hassan A, Fontana RJ. The diagnosis and management of idiosyncratic drug-induced liver injury. Liver Int 2019; 39:31-41. [PMID: 30003672 DOI: 10.1111/liv.13931] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/25/2018] [Accepted: 07/10/2018] [Indexed: 12/13/2022]
Abstract
Drug-induced liver injury (DILI) is an uncommon but important cause of liver disease that can arise after exposure to a multitude of drugs and herbal and dietary supplements. The severity of idiosyncratic DILI varies from mild serum aminotransferase elevations to the development of severe liver injury that can progress to acute liver failure resulting in death or liver transplantation within days of DILI onset. Chronic liver injury that persists for more than 6 months after DILI onset is also becoming increasingly recognized in up to 20% of DILI patients. Host demographic (age, gender, race), clinical and laboratory features at DILI onset have been associated with the severity and outcome of liver injury in DILI patients. In addition to cessation of the suspect drug, other medical interventions including the use of N-acetylcysteine and corticosteroids in selected patients have shown some clinical benefit, but additional prospective studies are needed. A number of promising diagnostic, prognostic and mechanistic serum and genetic biomarkers may help improve our understanding of the pathogenesis and treatment of idiosyncratic DILI.
Collapse
Affiliation(s)
- Ammar Hassan
- Division of Gastroenterology, Department of internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Robert J Fontana
- Division of Gastroenterology, Department of internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| |
Collapse
|
13
|
Kleiner DE. Histopathological challenges in suspected drug-induced liver injury. Liver Int 2018; 38:198-209. [PMID: 28865179 DOI: 10.1111/liv.13584] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 08/25/2017] [Indexed: 12/13/2022]
Abstract
When a patient with suspected drug-induced liver injury (DILI) undergoes liver biopsy, the pathologist is confronted with two major challenges. The first and most important is to establish the pattern(s) of injury which are present. Patterns of injury represent stereotypical responses of an organ to injury and relate to specific aetiologies of liver damage. The pattern of injury and the histological details of that injury can then be analysed with respect to the patient's intercurrent diseases and medication history. The specific expertise of the pathologist can be used to weigh the prospect of DILI against the likelihood of other explanations of injury. The second challenge is to characterize specific types of injury and the severity of injury, both of which may have importance for clinical decision-making and prognosis. The pathologist's report should convey both an accurate description of the pathology as well its interpretation.
Collapse
Affiliation(s)
- David E Kleiner
- Post-Mortem Section, Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| |
Collapse
|
14
|
Abstract
Drug-induced hepatotoxicity (DIH) is a significant cause of acute liver failure and liver transplantation. Diagnosis is challenging due to the idiosyncratic nature, its presentation in the form of other liver disease, and the lack of a definite diagnostic criteria. Generation of reactive metabolites, oxidative stress, and mitochondrial dysfunction are common mechanisms involved in DIH. Certain risk factors associated with a drug and within an individual further predispose patients to DIH.
Collapse
Affiliation(s)
- Amina Ibrahim Shehu
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 3rd Floor Salk Pavillion, Pittsburgh, PA 15261, USA
| | - Xiaochao Ma
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 3rd Floor Salk Pavillion, Pittsburgh, PA 15261, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 718 Salk Hall, 3501 Terrace Street, Pittsburgh, PA 15261, USA.
| |
Collapse
|
15
|
Stine JG, Lewis JH. Current and future directions in the treatment and prevention of drug-induced liver injury: a systematic review. Expert Rev Gastroenterol Hepatol 2015; 10:517-36. [PMID: 26633044 PMCID: PMC5074808 DOI: 10.1586/17474124.2016.1127756] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While the pace of discovery of new agents, mechanisms and risk factors involved in drug-induced liver injury (DILI) remains brisk, advances in the treatment of acute DILI seems slow by comparison. In general, the key to treating suspected DILI is to stop using the drug prior to developing irreversible liver failure. However, predicting when to stop is an inexact science, and commonly used ALT monitoring is an ineffective strategy outside of clinical trials. The only specific antidote for acute DILI remains N-acetylcysteine (NAC) for acetaminophen poisoning, although NAC is proving to be beneficial in some cases of non-acetaminophen DILI in adults. Corticosteroids can be effective for DILI associated with autoimmune or systemic hypersensitivity features. Ursodeoxycholic acid, silymarin and glycyrrhizin have been used to treat DILI for decades, but success remains anecdotal. Bile acid washout regimens using cholestyramine appear to be more evidenced based, in particular for leflunomide toxicity. For drug-induced acute liver failure, the use of liver support systems is still investigational in the United States and emergency liver transplant remains limited by its availability. Primary prevention appears to be the key to avoiding DILI and the need for acute treatment. Pharmacogenomics, including human leukocyte antigen genotyping and the discovery of specific DILI biomarkers offers significant promise for the future. This article describes and summarizes the numerous and diverse treatment and prevention modalities that are currently available to manage DILI.
Collapse
Affiliation(s)
- Jonathan G. Stine
- University of Virginia Health System, Department of Medicine, Division of Gastroenterology and Hepatology, JPA and Lee Street, MSB 2145, PO Box 800708, Charlottesville VA 22908
| | - James H. Lewis
- Georgetown University Medical Center, Department of Medicine, Division of Gastroenterology and Hepatology, 3800 Reservoir Rd NW, Washington, DC 20007
| |
Collapse
|
16
|
Abstract
The care of the patient with cholestasis hinges on identifying the etiology, treating reversible causes, and managing chronic cholestatic processes. PBC and PSC are important causes of chronic cholestasis, and are the most common causes of cholestatic liver disease. Effective therapy is available for patients with PBC, whereas none exists for patients with PSC. Awareness of the complications that may be associated with cholestasis and implementing the appropriate management are essential.
Collapse
Affiliation(s)
- Andrea A Gossard
- Cholestatic Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
| | | |
Collapse
|
17
|
Goossens N, Spahr L, Rubbia-Brandt L. Severe immune-mediated drug-induced liver injury linked to ibandronate: a case report. J Hepatol 2013; 59:1139-42. [PMID: 23770145 DOI: 10.1016/j.jhep.2013.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/04/2013] [Accepted: 06/05/2013] [Indexed: 12/19/2022]
Abstract
Ibandronate is a widely used bisphosphonate with no previously well documented hepatotoxicity. We report the first case of ibandronate-related hepatotoxicity and, to our knowledge, the first case of immune-mediated drug-induced liver injury (DILI) related to bisphosphonates.
Collapse
Affiliation(s)
- Nicolas Goossens
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland.
| | | | | |
Collapse
|
18
|
Abstract
Cholestasis is defined as impairment of bile formation or bile flow. Care of the patient with cholestatic features is dependent on identifying the cause of the cholestasis, initiating appropriate treatment of reversible conditions, and the recognition and management of cholestasis-specific complications. Cholestasis may include extrahepatic ducts and intrahepatic bile ducts, or may be limited to one or the other. Jaundice and pruritus are the hallmarks of cholestasis clinically but biochemical evidence may, and often does, precede the clinical manifestations.
Collapse
Affiliation(s)
- Andrea A Gossard
- Cholestatic Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA.
| |
Collapse
|
19
|
Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol 2011; 105:259-273. [PMID: 20934625 DOI: 10.1016/j.anai.2010.08.002] [Citation(s) in RCA: 651] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/02/2010] [Indexed: 01/17/2023]
Abstract
Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient
Collapse
|
20
|
Herrero-Herrero JI, García-Aparicio J. Corticosteroid therapy in a case of severe cholestasic hepatitis associated with amoxicillin-clavulanate. J Med Toxicol 2010; 6:420-3. [PMID: 20237968 PMCID: PMC3550477 DOI: 10.1007/s13181-010-0019-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Amoxicillin-clavulanate is the most common drug involved in drug-induced liver injury and the single most frequently prescribed product leading to hospitalization for drug-induced liver disease in Spain. The liver damage most frequently associated with amoxicillin-clavulanate is cholestasic type. The latency period between first intake and onset of symptoms is 3-4 weeks on average. A 76-year-old man developed fever, pruritus, and jaundice 3 weeks after having completed treatment with amoxicillin-clavulanate. Liver function tests showed cholestasic hepatitis (up to 50.75 mg/dL of total serum bilirubin level). The ultrasound-guided liver biopsy revealed severe canalicular cholestasis and portal and lobular eosinophilic infiltrates. Prednisone and ursodeoxycholic acid therapy were then prescribed. The patient became symptom-free with normal liver function tests. Amoxicillin-clavulanate can cause hepatocellular, cholestasic, or mixed liver injury. The presence of eosinophilic infiltrates in the liver biopsy and the clinical signs of hypersensitivity in some of the cholestasic cases suggest a pathophysiological immunoallergic mechanism. For this reason, corticosteroid treatment should be considered for patients with severe cholestasic liver injury.
Collapse
Affiliation(s)
| | - Judit García-Aparicio
- Service of Internal Medicine–Los Montalvos, Universitary Hospital of Salamanca, Salamanca, Spain
| |
Collapse
|
21
|
Treeprasertsuk S, Silachamroon U, Krudsood S, Huntrup A, Suwannakudt P, Vannaphan S, Wilairatana P. Ursodeoxycholic acid and artesunate in the treatment of severe falciparum malaria patients with jaundice. J Gastroenterol Hepatol 2010; 25:362-8. [PMID: 19817958 DOI: 10.1111/j.1440-1746.2009.06007.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Plasmodium falciparum (PF) infection can lead to severe complications. Ursodeoxycholic acid (UDCA) is increasingly used for the treatment of cholestatic liver diseases. The present study aims to determine the effects of combined UDCA and artesunate compared to placebo and artesunate on the improvement of liver tests in severe PF jaundiced patients. METHODS All severe PF jaundiced patients, aged > or = 15 years and diagnosed as having severe malaria according to WHO 2000 criteria, were enrolled. Patients with evidence of biliary obstruction, other cholestatic liver diseases and those who were pregnant were excluded. Patients were randomized to receive either oral UDCA or placebo for 2 weeks in additional to artesunate. All patients were admitted for at least 14 days to monitor the result of the treatment. RESULTS Seventy-four severe PF malaria patients with jaundice were enrolled. Both groups had similar demographic and laboratory tests, with the exception being more males in the UDCA group than in the placebo group (P = 0.04). The median of percentage change of total bilirubin and aminotransferase levels at the end of weeks 1, 2, 3 and 4 showed no difference between the two groups. Only the median of percentage change of alkaline phosphatase at the end of week one compared with the baseline values showed less increment in the UDCA group than in the placebo group (P = 0.04). No serious adverse events were seen during the 4 weeks of follow up. CONCLUSIONS In severe PF malaria patients with jaundice, combined therapy with UDCA and artesunate is safe, but does not significantly improve liver tests compared to placebo and artesunate.
Collapse
|
22
|
Smith LA, Ignacio JRA, Winesett MP, Kaiser GC, Lacson AG, Gilbert-Barness E, González-Peralta RP, Wilsey MJ. Vanishing bile duct syndrome: amoxicillin-clavulanic acid associated intra-hepatic cholestasis responsive to ursodeoxycholic acid. J Pediatr Gastroenterol Nutr 2005; 41:469-73. [PMID: 16205517 DOI: 10.1097/01.mpg.0000178086.44155.73] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- L A Smith
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida 33617, USA
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Manolakopoulos S, Bethanis S, Armonis A, Economou M, Avgerinos A, Tzourmakliotis D. Toxic hepatitis after sequential administration of flutamide and cyproterone acetate. Dig Dis Sci 2004; 49:462-5. [PMID: 15139499 DOI: 10.1023/b:ddas.0000020504.41500.9c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
24
|
Hempfling W, Dilger K, Beuers U. Systematic review: ursodeoxycholic acid--adverse effects and drug interactions. Aliment Pharmacol Ther 2003; 18:963-72. [PMID: 14616161 DOI: 10.1046/j.1365-2036.2003.01792.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ursodeoxycholic acid is increasingly being used for the treatment of chronic cholestatic liver diseases. It appears to be generally well tolerated, but a systematic review on drug safety is lacking. AIM As experimental data suggest a role of bile acids in the regulation of hepatic drug metabolism at both the transcriptional and post-transcriptional level, the literature was screened for adverse drug reactions and drug interactions related to ursodeoxycholic acid. METHODS A systematic review of the literature was performed using a refined search strategy to evaluate the adverse effects of ursodeoxycholic acid and its interactions with other drugs. RESULTS Ursodeoxycholic acid caused diarrhoea in a small proportion of patients. Rare skin reactions were due to drug adjuvants rather than the active substance. Decompensation of liver cirrhosis was reported after the administration of ursodeoxycholic acid in single cases of end-stage primary biliary cirrhosis. Recurrent right upper quadrant abdominal pain was incidentally observed. The absorption of ursodeoxycholic acid was impaired by colestyramine, colestimide, colestipol, aluminium hydroxide and smectite. Metabolic drug interactions were reported for the cytochrome P4503A substrates, ciclosporin, nitrendipine and dapsone. CONCLUSIONS Ursodeoxycholic acid is generally well tolerated. Drug absorption interactions with anion exchange resins deserve consideration. Metabolic interactions with compounds metabolized by cytochrome P4503A are to be expected.
Collapse
Affiliation(s)
- W Hempfling
- Department of Medicine II, Klinikum Grosshadern, University of Munich, Munich, Germany
| | | | | |
Collapse
|
25
|
Abstract
Drugs may cause several overlapping syndromes of cholestasis, the pathophysiological syndrome resulting from impaired bile flow. These reactions comprise approximately 17% of all hepatic adverse drug reactions (ADRs) and they may be severe. Causes of 'pure' (bland) cholestasis include oestrogens and anabolic steroids; rarer associations are with antimicrobials and NSAIDs. 'Cholestatic hepatitis' is a common drug reaction in which liver injury and inflammation cause significant elevation of serum alanine aminotransferase (ALT) as well as cholestasis. Chlorpromazine and ketoconazole are classic examples, but it is now exemplified by amoxycillin-clavulanate and other oxy-penicillins. Chronic cholestasis results from small bile duct injury leading to the vanishing bile duct syndrome (VBDS), a disorder mimicking primary biliary cirrhosis, or from injury to larger bile ducts causing secondary sclerosing cholangitis. Whilst there is increasing evidence of a genetic predisposition to cholestatic drug reactions, there are currently no pretreatment tests to predict drug safety. Prevention of severe reactions therefore relies on early detection of liver injury and prompt drug withdrawal. Symptomatic management includes relief of pruritus and correction of fat-soluble vitamin deficiency. In small cohort studies, ursodeoxycholic acid (UDCA) arrested progressive cholestasis in two-thirds of cases, but evidence for use of corticosteroids is anecdotal. This review considers diagnosis, pathogenesis, prevention and management of drug-induced cholestasis, with particular reference to frequently- and newly-described causes.
Collapse
|
26
|
Abstract
Fatigue is an important symptom and a quality of life determinant in patients with cholestatic liver disease. The pathogenesis of fatigue is obscure, although alterations in central neurotransmission and peripheral muscle dysfunction have been incriminated. No effective treatment is available at present. The available literature on fatigue in cholestatic liver disease is reviewed.
Collapse
Affiliation(s)
- D Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | |
Collapse
|
27
|
Jordán T, González M, Casado M, Suárez JF, Pulido F, Guerrero E, Esteban J. [Amoxicillin-clavulanic acid induced hepatotoxicity with progression to cirrhosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:240-3. [PMID: 11975871 DOI: 10.1016/s0210-5705(02)70252-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Amoxicillin-clavulanic acid is a commonly used antibiotic in clinical practice. It is usually prescribed on an empirical basis and several cases of hepatotoxicity with cholestasis have been described. We report the case of a 42-year-old man who developed an acute hepatocellular lesion with progression to cirrhosis. The patient received amoxicillin-clavulanic acid twice with an interval of four months. Other causes of hepatic failure were excluded. Although amoxicillin-clavulanic acid-induced hepatotoxicity has been widely documented, there are no other reports describing its progression to cirrhosis in an adult.
Collapse
Affiliation(s)
- T Jordán
- Servicio de Aparato Digestivo, Hospital Torrecárdenas, Almería, Spain.
| | | | | | | | | | | | | |
Collapse
|
28
|
Lazaridis KN, Gores GJ, Lindor KD. Ursodeoxycholic acid 'mechanisms of action and clinical use in hepatobiliary disorders'. J Hepatol 2001; 35:134-46. [PMID: 11495032 DOI: 10.1016/s0168-8278(01)00092-7] [Citation(s) in RCA: 260] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
UDCA exerts its beneficial effect in liver diseases through a diverse, probably, complementary array of mechanisms. The clinical use and efficacy of UDCA in PBC have been evident. UDCA may also have a place in the management of PSC, ICP, cystic fibrosis, PFIC and GVHD involving the liver, although, more studies are needed to further determine its therapeutic potential in these diseases and in other hepatobiliary disorders such as liver allograft rejection, drug and TPN-induced cholestasis, NASH, and alcoholic liver disease.
Collapse
Affiliation(s)
- K N Lazaridis
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, 55905, USA
| | | | | |
Collapse
|
29
|
Abstract
This year's review is divided into several sections: the first describes drug withdrawals and new general reviews of drug-induced liver disease (DILD), including a review of a classification of drug injury. We review agents newly described as causing DILD, and new reports of DILD from established agents appearing in the year 2000. New aspects regarding the treatment of acetaminophen toxicity are included, and in the final section we deal with prevention of DILD as well as issues surrounding the use of potentially hepatotoxic medications in patients with underlying chronic disease.
Collapse
Affiliation(s)
- G Marino
- Division of Gastroenterology, Section of Hepatology, Georgetown University Medical Center, Washington, District of Columbia 20007, USA
| | | |
Collapse
|
30
|
Abstract
New insights into the regulation of hepatobiliary transport proteins have provided the basis for a better understanding of the pathogenesis of cholestatic liver diseases. Mutations of transporter genes can cause hereditary cholestatic syndromes, the study of which has shed much light on the basic mechanisms of bile secretion and cholestasis. Important new studies have been published about the pathogenesis, clinical features, and treatment of primary biliary cirrhosis, primary sclerosing cholangitis, cholestasis of pregnancy, total parenteral nutrition-induced cholestasis, and drug-induced cholestasis.
Collapse
Affiliation(s)
- M Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Karl Franzens University School of Medicine, Graz, Austria
| | | |
Collapse
|
31
|
Abstract
The treatment and prevention of drug-induced liver injury starts with the recognition of hepatotoxicity at the earliest possible time so that the suspected drug can be discontinued expeditiously. Both liver enzyme monitoring and vigilance for signs of hypersensitivity involving the liver are useful strategies for many agents known to cause hepatocellular necrosis leading to liver failure. Specific antidotes to prevent or limit hepatic damage exist for only a few drugs, the most important being N-acetylcysteine for the treatment of acetaminophen hepatotoxicity. Corticosteroids are of unproven benefit in the setting of fulminant failure. Ursodiol may be helpful in instances of cholestatic injury. For other agents, supportive measures and the increasing use of liver-assist devices as well as emergency liver transplantation are available when drug injury evolves into irreversible liver failure. It is hoped that a better understanding of hepatotoxicity mechanisms will lead to the development of more specific and effective forms of therapy in the near future.
Collapse
|