Methylprednisolone-induced hepatotoxicity in a 16-year-old girl with multiple sclerosis

A Real-World Experience of Azathioprine Versus First-Line Disease-Modifying Therapy in Relapsing-Remitting Multiple Sclerosis-A Prospective Cohort Study

Azathioprine (AZA) has demonstrated efficacy in multiple randomized control trials (RCTs) for Relapsing-Remitting Multiple Sclerosis (RRMS). However, we still need comparative real-world data with other first-line disease-modifying therapies (DMTs). We aimed to assess AZA's effectiveness regarding relapses, disability progression, time to the first relapse, magnetic resonance imaging (MRI) activity, and safety compared with other approved first-line DMTs in an Indian population in a real-world setting. We conducted a single-center prospective study of treatment-naive RRMS patients between 2017 and 2019. We evaluated the effects of AZA and other approved DMTs on clinical and radiological measures. Among 192 eligible patients (F:M ratio 2.84:1), 68 patients (35.4%) were on AZA, 68 patients (35.4%) were on dimethyl fumarate (DMF), 32 patients (16.7%) on interferon (IFN beta-1a), and 16 patients (8.3%) on teriflunomide (TFL). Four treatment groups were comparable: AZA v/s DMF v/s TFL v/s IFN beta-1a. In primary outcomes, there was no significant difference between the groups in terms of change in the Expanded Disability Status Scale (EDSS) score at three months (p-value = 0.169), six months (p-value = 0.303), 12 months (p-value = 0.082), and 24 months (p-value = 0.639), the number of relapses (p-value = 0.229), and time to the first relapse (p-value > 0.05 in all groups). In the secondary outcome, there was no significant difference between the treatment groups on serial MRI parameters used according to "Magnetic Resonance Imaging in Multiple Sclerosis" (MAGNIMS) 2016 criteria (p-value > 0.05). In safety outcomes, leukopenia was significantly more common in the AZA group (p-value = 0.025), flu-like symptoms (p-value = 0.0001), and injection site reactions (p-value = 0.035) were significantly more common in the IFN beta-1a group. Our study suggests AZA is as effective as other approved DMTs and a good alternative as a first-line treatment for multiple sclerosis's clinical and radiological activity in real-world settings on short follow-up. Based on these results, more randomized controlled trials of AZA v/s DMF or other DMTs are needed for more robust outcomes.

Liver injury after methylprednisolone pulses: A disputable cause of hepatotoxicity. A case series and literature review

Background and Objectives

Corticosteroids are often empirically used to treat idiosyncratic hepatotoxicity with severe features. Interestingly, intravenous methylprednisolone (MP) is increasingly being recognized as being responsible for liver injury. We aimed to characterize MP-induced liver injury by analyzing demographical, clinical, laboratory and outcome data of three MP-induced hepatotoxicity cases and compared this information with that of previously published cases.

Case series

Three females with multiple sclerosis (MS) were treated intravenously with MP, mean daily dose 767 mg. Liver damage occurred 2 to 6 weeks after exposure. Severity was mild to moderate. Two patients suffered positive rechallenge.

Literature review

We identified 50 published cases of MP hepatotoxicity. Most of these cases were female (86%) and main treatment indications were MS (29 cases) and Graves' ophthalmopathy (13 cases). Hepatocellular damage predominated and mean time to onset was 6 weeks. Four patients died and rechallenge occurred in 19 cases.

Conclusion

MP pulses can induce severe liver injury, often with an autoimmune phenotype, particularly in patients with MS and Graves' ophthalmopathy. Consequently, these patient groups should have liver tests monitored when treated with MP to provide safer patient care.