Rhabdomyolysis and Hepatotoxicity in a Female Body Builder

Hepatotoxicity due to dietary supplements: state-of-the-art, gaps and perspectives

Food supplements are products intended to complement the normal diet and consist of concentrated sources of nutrients or other substances with a nutritional or physiological effect. Although they are generally considered safe if the manufacturer's recommendations are followed, many of them have shown hepatotoxic properties. This can cause many diseases (e.g. steatohepatitis and cirrhosis) characterized by progressive damage and malfunction of the liver that in the long term can lead to death. A review of the literature was carried out to elucidate which dietary supplements have been associated with cases of hepatotoxicity in recent years, with emphasis on those relevant to the consumer and the new trends (e.g. cannabidiol). It has been reported that the supplements described as hepatotoxic are mainly of botanical origin (e.g. green tea or turmeric) and those used in sports (mainly anabolic androgenic steroids). There is a great variability of compounds described as causing liver damage, although sometimes it is not possible to identify them, because they are contaminants or adulterants of the products. In addition, the prevalence of toxic effects after the administration of supplements is difficult to define due to underreporting and the lack of specific studies. Globally regarding hepatotoxicity of dietary supplements, there is a paucity of well-conducted clinical trials on the efficacy of these compounds and the frequency of related liver damage, as the use of these products is largely uncontrolled.

Exploring the association between selective serotonin reuptake inhibitors and rhabdomyolysis risk based on the FDA pharmacovigilance database

Rhabdomyolysis is a syndrome potentially fatal and has been associated with selective serotonin reuptake inhibitors (SSRIs) treatment in a few case reports. Herein, we purpose to establish the correlation between SSRIs use and rhabdomyolysis using the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) database. We conducted an analysis on reports that were submitted to the FAERS database during the period between January 1, 2004, and December 31, 2022. Four algorithms, including reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and empirical Bayes geometric mean (EBGM), were employed to quantify the signals of rhabdomyolysis associated with SSRIs. In total, 16,011,277 non-duplicated reports were obtained and analyzed. Among 33,574 reports related to rhabdomyolysis, SSRIs were classified as primary suspected drug in 889 cases. Disproportionality analysis identified a positive signal between rhabdomyolysis and SSRIs (ROR: 2.86, 95% CI 2.67-3.05; PRR: 2.84, χ²: 1037.16; IC_0.25 = 1.39; EBGM_0.5 = 2.64). Among six SSRIs, fluvoxamine had the strongest signal (ROR: 11.64, 95% CI 8.00-16.93; PRR: 11.38, χ²: 265.51; IC_0.25 = 2.41; EBGM_0.5 = 8.31), whereas no significant signal of rhabdomyolysis was detected for paroxetine (ROR: 1.83, 95% CI 1.55-2.15; PRR: 1.82, χ²: 53.82; IC_0.25 = 0.73; EBGM_0.5 = 1.59). After excluding cases co-administered with statins, the signal of rhabdomyolysis associated with SSRIs remains significant. Our analysis reveals that there are differences in safety signals among six SSRIs in respect to the risk of rhabdomyolysis, with fluvoxamine displaying the highest risk signal, while paroxetine did not show a significant signal. Given the potentially lethal nature of rhabdomyolysis, healthcare professionals should inform patients of the potential risk of rhabdomyolysis associated with SSRIs prior to initiating treatment.

Sertraline-Induced Rhabdomyolysis, Trismus, and Cardiac Arrest in a Child

Selective serotonin reuptake inhibitors are a commonly used and often effective class of medications in the treatment of mood disorders such as anxiety and depression. Sertraline (1S,4S-N-methyl-4-[3,4-dichlorophenyl]-1,2,3,4-tetrahydro-1-naphthylamine [Zoloft; Pfizer, New York City, NY]) is a frequently used selective serotonin reuptake inhibitor that has shown efficacy in children, adolescents, and adults. We report the case of a 13-year-old boy with sertraline-induced rhabdomyolysis and renal failure, trismus, and cardiopulmonary arrest. Pharmacogenetic testing later revealed our patient had serotonin transporter polymorphisms and enzymatic alterations that put him at risk for increased levels of sertraline and greater likelihood for untoward side effects.

Antidepressant-lnduced Liver Injury

Objective:

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

Data Sources:

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

Study Selection and Data Extraction:

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

Data Synthesis:

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

Conclusions:

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

Role of Elevated Aminotransferases in ICU Patients with Rhabdomyolysis

To evaluate whether patients with rhabdomyolysis and serum alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) higher than 1000 IU/L had higher mortality that patients with low aminotransferases. Retrospective analysis of intensive care unit patients with rhabdomyolysis [creatine kinase (CK) higher than 5000 IU/L]. Patients were classified in two groups: low aminotransferases group, when AST and ALT were equal or lower to 1000 IU/L, and elevated aminotransferases group, when AST or ALT was above 1000 IU/L. Forty-six out of 189 patients included in the analysis (24.3%) had elevated aminotransferases. The mortality of patients with rhabdomyolysis was 25.9 per cent, being higher in patients with elevated aminotransferases compared with patients with low aminotransferases (60.9% vs 14.7%; P < 0.001). Mortality stratified by quartiles of CK in patients with low aminotransferases was independent of the level of CK ( P = 0.67). Logistic regression analysis showed that the independent variables associated with mortality were Simplified Acute Physiology Score II [1.11 (1.07–1.16) for each point of increase, P < 0.001], the international normalized ratio value [4.2 (1.6–10.7) for each point of increase, P = 0.003], and the need of renal replacement therapy [5.4 (1.7–17.2), P = 0.004]. Patients with rhabdomyolysis with elevated serum aminotransferases had higher mortality than patients with low serum aminotransferase levels.

Sertraline-Induced Rhabdomyolysis in an Elderly Patient with Dementia and Comorbidities

Objective:

To describe a case of sertraline-induced rhabdomyolysis in an elderly patient with dementia and comorbidities.

Case Summary:

A 71-year-old woman visited a psychiatrist in September 2007 for her depressed mood. Her medical history included vascular dementia accompanied by depression, arterial hypertension, and heart failure, as well as cardiac pacemaker implantation several years earlier for severe bradyarrythmia. She had begun taking amisulpride 50 mg/day and diazepam 2 mg at bedtime 6 months prior to the psychiatrist appointment, with poor relief of her depressed mood. Her drug therapy also included nicergoline 30 mg/day, amlodipine 5 mg/day, aspirin 100 mg/day, candesartan 16 mg/day, and atenolol 25 mg/day. At this psychiatrist visit, sertraline 50 mg/day was added for her depression, and was continued after a geriatrician visit in October. Her mood improved significantly. On December 18, 2007, she was admitted to the cardiology unit to undergo a pacemaker replacement. Laboratory tests revealed creatine kinase (CK) 7952 IU/L, lactate dehydrogenase 1021 IU/L, myoglobin 2322 U/L, and aspartate aminotransferase 362 IU/L, resulting in a diagnosis of iatrogenic rhabdomyolysis. Amisulpride and sertraline were discontinued. On December 24, serum CK was 839 IU/L and myoglobin was 91 U/L and the patient was discharged. On January 22, laboratory tests showed normal values of CK, CK-MB, and myoglobin. Sertraline 50 mg/day was again prescribed for the patient's persistent depressed mood. Fifteen days later, blood tests showed CK 1327 IU/L and myoglobin 324 U/L; therefore, the drug was discontinued. CK and myoglobin levels normalized a week later. On April 2, escitalopram was started. At time of writing, there was no evidence of any increase in CK, myoglobin, or other markers of rhabdomyolysis.

Discussion:

The Naranjo probability scale indicated a probable relationship between sertraline treatment and the onset of rhabdomyolysis. No relationship between amisulpride and rhabdomyolysis was found. Furthermore, rechallenge with sertraline caused CK and myoglobin to again increase, which was reversed following a discontinuation of sertraline. The patient's other comorbidities and medications have not been suggested as possible interactions with sertraline that can cause rhabdomyolysis. Genetic defects of sertraline demethylation and/or P-glycoprotein binding or concurrent circumstances may explain the onset of rhabdomyolysis in this particular patient.

Conclusions:

This patient's rhabdomyolysis was probably induced by sertraline therapy.

Rhabdomyolysis: a review of clinical presentation, etiology, diagnosis, and management

Rhabdomyolysis is a condition that results from many underlying etiologies and can present in a myriad of ways to the emergency physician. However, some clinical and laboratory features are almost always present and, if noted, can help in making the diagnosis. This review article will focus on the presenting symptoms, the various etiologies, the underlying mechanisms, and the current management of pediatric rhabdomyolysis.