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Perumal Kannabiran B, Palaniappan NA, Manoharan T, Paramasivam PK, Saini JK, Ansari MS, Jayabal L, Aggarwal AN, Garg R, Subramanyam B, Thakur D, Pantula S, P M R, GS V, Natarajan S, Ammayappan RK, Manpreet B, Ganesan M, Angamuthu D, Chinnaiyan P, Singh M, Chandrasekaran P, Swaminathan S. Safety and Efficacy of 25 mg/kg and 35 mg/kg vs 10 mg/kg Rifampicin in Pulmonary TB: A Phase IIb Randomized Controlled Trial. Open Forum Infect Dis 2024; 11:ofae034. [PMID: 38444824 PMCID: PMC10914527 DOI: 10.1093/ofid/ofae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024] Open
Abstract
Background Globally, no trial data are available on head-to-head comparison between 10 mg/kg and 25/35 mg/kg rifampicin in treating pulmonary tuberculosis during study initiation. Methods A multicentric, phase IIb randomized trial recruited 333 new culture-positive, drug-sensitive adult patients with pulmonary tuberculosis to compare safety and efficacy of high-dose rifampicin (R25/R35), against conventional dose (R10) given daily for 8 weeks followed by standard doses for 16 weeks. Main outcomes were treatment-emergent grade 3/4 adverse events (AEs) and time-to-culture conversion in liquid media, assessed by division of AIDS system for grading the severity of adverse events division of AIDS criteria and Kaplan-Meier methods. Results In a modified intention-to-treat population of 323 patients (R10: 105/R25: 112/R35: 106), grade 3/4 AEs were reported in 34 patients (R10: 9.5% [10/105], R25: 9.8% [11/112], R35: 12.3% [13/106]) during the intensive phase. Among 23 patients (R10: 3.8% [4/105], R25: 6.3% [7/112], R35: 11.3% [12/106]) with grade 3/4 hepatotoxicity, 15 (R10: 1.9% [2/105], R25: 3.6% [4/112], R35: 8.5% [9/106]) had grade 3/4 hyperbilirubinemia and 9 patients (R10: 1.0% [1/105], R25: 0.9% [1/112], R35: 6.6% [7/106]) developed clinical jaundice. Significant differences observed only between R10 and R35 with hepatotoxicity (P = .039), hyperbilirubinemia (P = .031), clinical jaundice (P = .032), and treatment interruption (P = .039). Eighteen serious AEs and 6 deaths (R10: 3/R25: 1/R35: 2) occurred during study period. Time to stable culture conversion in liquid media was faster in R25 (adjusted hazard ratio, 1.71; 95% confidence interval [CI], 1.26-2.31 [solid: 1.97; 95% CI, 1.46-2.67]) and R35 (1.81; 95% CI, 1.33-2.48 [solid: 2.24; 95% CI, 1.64-3.06]), than R10 (34 vs 44 days). R25 had no failure/relapse. Conclusions Hepatotoxicity, clinical jaundice, and treatment interruptions occurred significantly higher with R35 than R10. Because R25 was comparably safe as R10 and also highly efficacious than R10, it may be considered for implementation. Clinical Trials Registration. CTRI/2017/12/010951.
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Affiliation(s)
| | | | - Tamizhselvan Manoharan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Paul Kumaran Paramasivam
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Jitendra Kumar Saini
- Department of Pulmonary Oncology, National Institute for Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Mohammed Soheb Ansari
- Department of Respiratory Medicine, Bhagwan Mahavir Medical Hospital and Research Centre, Hyderabad, India
| | - Lavanya Jayabal
- District TB office, Greater Chennai Corporation, Chennai, India
| | - Ashutosh N Aggarwal
- Department of Respiratory Medicine, Post Graduate Institute of Medical Research, Chandigarh, India
| | - Rajiv Garg
- Department of Respiratory Medicine, King George's Medical University, Lucknow, India
| | - Balaji Subramanyam
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Deepika Thakur
- Department of Respiratory Medicine, Post Graduate Institute of Medical Research, Chandigarh, India
| | - Shilpa Pantula
- Department of Respiratory Medicine, Bhagwan Mahavir Medical Hospital and Research Centre, Hyderabad, India
| | - Ramesh P M
- Department of Respiratory Medicine, Government Thiruvotteeswarar Hospital of Thoracic Medicine, Chennai, India
| | - Vijayachandar GS
- Department of Respiratory Medicine, Institute of Thoracic Medicine, Chennai, India
| | - Saravanan Natarajan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Radha Krishnan Ammayappan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Bhalla Manpreet
- Department of Pulmonary Oncology, National Institute for Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Mangalambal Ganesan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Dhanalakshmi Angamuthu
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Ponnuraja Chinnaiyan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Manjula Singh
- Division of Communicable Diseases, Indian Council of Medical Research, New Delhi, India
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Hussain Z, Zhu J, Ma X. Metabolism and Hepatotoxicity of Pyrazinamide, an Antituberculosis Drug. Drug Metab Dispos 2021; 49:679-682. [PMID: 34074731 PMCID: PMC8407665 DOI: 10.1124/dmd.121.000389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/26/2021] [Indexed: 11/22/2022] Open
Abstract
Pyrazinamide (PZA) is an important component of a standard combination therapy against tuberculosis. However, PZA is hepatotoxic, and the underlying mechanisms are poorly understood. Biotransformation of PZA in the liver was primarily suggested behind its hepatoxicity. This review summarizes the knowledge of the key enzymes involved in PZA metabolism and discusses their contributions to PZA hepatotoxicity. SIGNIFICANCE STATEMENT: This review outlines the current understanding of PZA metabolism and hepatotoxicity. This work also highlights the gaps in this field, which can be used to guide the future studies on PZA-induced liver injury.
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Affiliation(s)
- Zahir Hussain
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Junjie Zhu
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xiaochao Ma
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
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Soni H, Kumar-M P, Mishra S, Bellam BL, Singh H, Mandavdhare HS, Medhi B, Dutta U, Sharma V. Risk of hepatitis with various reintroduction regimens of anti-tubercular therapy: a systematic review and network meta-analysis. Expert Rev Anti Infect Ther 2020; 18:171-179. [PMID: 31923369 DOI: 10.1080/14787210.2020.1714436] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Hariom Soni
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar-M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shubhra Mishra
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Balaji L Bellam
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal S Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Electroanalysis of isoniazid and rifampicin: Role of nanomaterial electrode modifiers. Biosens Bioelectron 2019; 146:111731. [PMID: 31614253 DOI: 10.1016/j.bios.2019.111731] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 02/02/2023]
Abstract
Thanks to operational simplicity, speediness, possibility of miniaturization and real-time nature, electrochemical sensing is a supreme alternative for non-electrochemical methodologies in drug quantification. This review, highlights different nanotech-based sensory designs for electroanalysis of isoniazid and rifampicin, the most important medicines for patients with tuberculosis. We first, concisely mention analyses with bare electrodes, associated impediments and inspected possible strategies and then critically review the last two decades works with focus on different nano-scaled electrode modifiers. We organized and described the materials engaged in several categories: Surfactants modifiers, polymeric modifiers, metallic nanomaterials, carbon based nano-modifiers (reduced graphene oxide, multi-walled carbon nanotubes, ordered mesoporous carbon) and a large class of multifarious nano composites-based sensors and biosensors. The main drawbacks and superiorities associated with each array as well as the current trend in the areas is attempted to discuss. Summary of 79 employed electrochemical approaches for analysis of isoniazid and rifampicin has also been presented.
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Iwo MI, Sjahlim SL, Rahmawati SF. Effect of Vernonia amygdalina Del. Leaf Ethanolic Extract on Intoxicated Male Wistar Rats Liver. Sci Pharm 2017; 85:E16. [PMID: 28333116 PMCID: PMC5489920 DOI: 10.3390/scipharm85020016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/16/2017] [Accepted: 03/16/2017] [Indexed: 11/17/2022] Open
Abstract
Vernonia amygdalina has been shown to have antioxidant activity, and is also expected to have hepatoprotective activity. This study was conducted to study the effect of V. amygdalina ethanol extracts on intoxicated rat livers. Fresh leaves were extracted in ethanol, and the hepatoprotective activity was tested on male Wistar rats induced with a combination of isoniazid (INH) and rifampicin. Parameters observed were the activity of the enzyme alanine transferase (ALT), serum albumin levels, liver index, and histopathological of the rat liver. The results showed that 50 and 100 mg/kg rat body weight of V. amygdalina ethanol extracts could prevent liver intoxication, starting on day 14. Based on serum albumin concentrations and ALT activity, the high dose extract (100 mg/kg) was more potent as a hepatoprotective agent compared to the extract at a low dose (50 mg/kg). The group of rats treated with a high dose extract showed normal liver index compared to the positive control. Through histology examination, the liver of rats treated with a high dose extract (100 mg/kg) showed minimal liver cell structure damage, and showed similar patterns to the normal rat. Based on these results, it can be concluded that V. amygdalina ethanol extracts can be used to protect the liver in a combination of INH and rifampicin as antituberculosis treatment.
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Affiliation(s)
- Maria Immaculata Iwo
- Pharmacology Clinical Pharmacy Research Group, School of Pharmacy, Institut Teknologi Bandung, Jl. Ganesha 10, Bandung 40132, Indonesia.
- Biotechnology Biomedical Research Center, Institut Teknologi Bandung, Jl. Ganesha 10, Bandung 40132, Indonesia..
| | - Sergia Louisa Sjahlim
- Pharmacology Clinical Pharmacy Research Group, School of Pharmacy, Institut Teknologi Bandung, Jl. Ganesha 10, Bandung 40132, Indonesia.
| | - Siti Farah Rahmawati
- Pharmacology Clinical Pharmacy Research Group, School of Pharmacy, Institut Teknologi Bandung, Jl. Ganesha 10, Bandung 40132, Indonesia.
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Latief M, Dar WR, Sofi N, Dar IA, Kasana B, Hussain M, Arshad F, Shah BA, Koul PA. Novel risk factors and early detection of anti tubercular treatment induced liver injury-Looking beyond American Thoracic Society Guidelines. Indian J Tuberc 2017; 64:26-32. [PMID: 28166913 DOI: 10.1016/j.ijtb.2016.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 08/16/2016] [Accepted: 11/01/2016] [Indexed: 01/22/2023]
Abstract
INTRODUCTION ATT remains the standard treatment for tuberculosis. Drug-induced liver injury (DILI) has been a long-standing concern in the treatment of tuberculosis (TB) infection. AIMS AND OBJECTIVES To study the occurrence and risk factors of DILI in patients on ATT by regular clinical and biochemical monitoring. MATERIALS AND METHODS 200 patients, in whom ATT was started, were enrolled in the study. None of the patients with established risk factor for DILI as recognized by ATS guidelines was included in our study population. Regular clinical and liver function test monitoring was done at the commencement of ATT and then at 2, 4, and 8 weeks in the intensive phase subsequently at 4 and 6 months. RESULTS DILI developed in 16 patients. Among those, 10 patients (62.5%) developed early DILI and 6 patients (37.5%) developed late DILI. Female gender and extrapulmonary tuberculosis were found to be associated with increased risk of ATT-induced DILI, whereas age, BMI, and serum albumin were not found to significantly increase DILI risk. CONCLUSION DILI is a common problem among patients on ATT in our population. Early detection not only reduces the risk of developing Hepatic Failure but also prevents mortality.
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Affiliation(s)
- Muzamil Latief
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Waseem Raja Dar
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India.
| | - Najeebullah Sofi
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Imtiyaz Ahmad Dar
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Basharat Kasana
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Moomin Hussain
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Faheem Arshad
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Bashir Ahmad Shah
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Parvaiz Ahmad Koul
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
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Meena A, Daga MK, Kar P. Reintroduction regimens in anti-tubercular therapy-induced hepatitis in extra-pulmonary tuberculosis patients – A pilot study. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2017. [DOI: 10.1016/j.injms.2016.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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8
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van’t Boveneind-Vrubleuskaya N, Daskapan A, Kosterink JGW, van der Werf TS, van den Hof S, Alffenaar JWC. Predictors of Prolonged TB Treatment in a Dutch Outpatient Setting. PLoS One 2016; 11:e0166030. [PMID: 27832142 PMCID: PMC5104463 DOI: 10.1371/journal.pone.0166030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 10/21/2016] [Indexed: 11/19/2022] Open
Abstract
Introduction Standard treatment duration for drug-susceptible tuberculosis (TB) treatment is 6 months. Treatment duration is often extended—and for various different reasons. The aim of this study was to determine the prevalence and to assess risk factors associated with extended TB treatment. Methods A cross-sectional study was conducted. Data including demographic, clinical, radiological and microbiological information from the Netherlands TB Register (NTR) of 90 patients with smear and culture positive pulmonary TB of the region Haaglanden, The Netherlands, was eligible for analysis. Results Treatment was extended to ≥ 200 days by 46 (51%) patients. Extended TB treatment was associated with a higher frequency of symptoms, presumed to be due to adverse drug reactions (ADR; OR 2.39 95% CI: 1.01–5.69), drug-induced liver injury (DILI) (OR: 13.51; 95% CI: 1.66–109.82) and longer than 2 month smear and culture conversion rate (OR: 11.00; 95% CI: 1.24–97.96 and OR: 8.56; 95% CI: 1.53–47.96). In the multivariable logistic analysis, development of DILI emerged as the single statistically strong risk factor necessitating extension of TB treatment. Conclusion This finding will need further confirmation in a prospective study, exploring the possible mutual role of pharmacokinetic and pharmacogenetic determinants of DILI among TB patients.
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Affiliation(s)
- Natasha van’t Boveneind-Vrubleuskaya
- Department of Public Health TB Control, Metropolitan Public Health Service, The Hague, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
- * E-mail:
| | - Alper Daskapan
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Jos G. W. Kosterink
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Tjip S. van der Werf
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, The Netherlands
| | - Susan van den Hof
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Jan-Willem C. Alffenaar
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
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Agrawal S, Dhiman RK. Hepatobiliary quiz-6 (2013). J Clin Exp Hepatol 2013; 3:171-6. [PMID: 25755495 PMCID: PMC3940316 DOI: 10.1016/j.jceh.2013.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence. Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Hepatotoxicity Related to Anti-tuberculosis Drugs: Mechanisms and Management. J Clin Exp Hepatol 2013; 3:37-49. [PMID: 25755470 PMCID: PMC3940184 DOI: 10.1016/j.jceh.2012.12.001] [Citation(s) in RCA: 255] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 12/12/2012] [Indexed: 02/07/2023] Open
Abstract
Development of idiosyncratic hepatotoxicity is an intricate process involving both concurrent as well as sequential events determining the direction of the pathways, degree of liver injury and its outcome. Decades of clinical observation have identified a number of drug and host related factors that are associated with an increased risk of antituberculous drug-induced hepatotoxicity, although majority of the studies are retrospective with varied case definitions and sample sizes. Investigations on genetic susceptibility to hepatotoxicity have so far focused on formation and accumulation reactive metabolite as well as factors that contribute to cellular antioxidant defense mechanisms and the environment which can modulate the threshold for hepatocyte death secondary to oxidative stress. Recent advances in pharmacogenetics have promised the development of refined algorithms including drug, host and environmental risk factors that allow better tailoring of medications based on accurate estimates of risk-benefit ratio. Future investigations exploring the pathogenesis of hepatotoxicity should be performed using human tissue and samples whenever possible, so that the novel findings can be translated readily into clinical applications.
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Key Words
- ALT, alanine transaminase
- ART, anti-retroviral therapy
- AST, aspartate transaminase
- ATP, adenosine triphosphate
- ATS, American Thoracic Society
- BSEP, bile salt exporter pump
- BTB, broad complex, tramtrack, bric-a-brac domain
- BTS, British Thoracic Society
- CNC, cap‘n’collar type of basic region
- CYP, cytochrome P450
- DILI, drug-induced liver injury
- DOTS, directly observed short-course therapy
- FDA, Food and Drug Administration
- GST, glutathione S-transferase
- HAART, highly active anti-retroviral therapy
- HBV, hepatitis B virus
- HCV, hepatitis C virus
- HLA, human leukocyte antigen
- INH, isoniazid
- MHC, major histocompatibility complex
- MPT, mitochondrial permeability transition
- MnSOD, manganese superoxide dismutase
- NAC, N-acetyl cysteine
- NAT2, N-acetyltransferase 2
- NICE, National Institute for Clinical Excellence
- Nrf2, nuclear factor erythroid 2-related factor-2
- OR, odds ratio
- PXR, pregnane X receptor
- ROS, reactive oxygen species
- SH, sulfhydryl
- SNP, single-nucleotide polymorphism
- TB, tuberculosis
- ULN, upper limit of normal range
- WHO, World Health Organization
- drug-induced liver injury
- genetic
- hepatotoxicity
- pathogenesis
- tuberculosis
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Sahota T, Della Pasqua O. Feasibility of a fixed-dose regimen of pyrazinamide and its impact on systemic drug exposure and liver safety in patients with tuberculosis. Antimicrob Agents Chemother 2012; 56:5442-9. [PMID: 22777045 PMCID: PMC3486525 DOI: 10.1128/aac.05988-11] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 06/28/2012] [Indexed: 01/05/2023] Open
Abstract
Historically, dosing regimens for the treatment of tuberculosis (TB) have been proposed in an empirical manner. Dose selection has often been the result of efficacy trials in which drugs were administered regardless of the magnitude of the effect of demographic factors on drug disposition. This has created challenges for the prescription of fixed-dose combinations with novel therapeutic agents. The objectives of this investigation were to evaluate the impact of body weight on the overall systemic exposure to pyrazinamide (PZA) and to assess whether the use of one fixed dose, without adjustment according to weight, would ensure target exposure and safety requirements across the overall patient population. Using a population pharmacokinetic model, simulation scenarios were explored based on population demographics from clinical trials in TB patients and on historical hepatotoxicity data. The systemic drug exposure (area under the concentration-time curve [AUC]), peak concentrations (the maximum concentration of drug in serum [C(max)]), the time above the MIC (t > MIC), and the risk of hepatotoxicity were evaluated for the current weight-banded regimen and compared to fixed doses under the assumption that pharmacokinetic differences are the primary drivers of toxicity. Evaluation of the standard weight banding reveals that more than 50% of subjects in the weight range of 45 to 55 kg remain below the proposed target exposure to PZA. In contrast, the use of a fixed 1,500-mg dose resulted in a lower proportion of subjects under the target value, with a 0.2% average overall increase in the risk of hepatotoxicity. Our results strongly support the use of a fixed-dose regimen for PZA in coformulation or combination with novel therapeutic agents.
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Affiliation(s)
- Tarjinder Sahota
- Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline, Uxbridge, United Kingdom
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline, Uxbridge, United Kingdom
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, Netherlands
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Al-Salmi Z. Anti-tuberculosis drug-induced hepatitis in renal transplant patient with pulmonary and extra pulmonary tuberculosis. Saudi Pharm J 2012; 20:181-5. [PMID: 23960791 DOI: 10.1016/j.jsps.2011.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 09/08/2011] [Indexed: 11/30/2022] Open
Abstract
Hepatotoxicity is a major side-effect of the medicines used in tuberculosis therapy. Although the guidelines for the management of antituberculosis drug induced hepatitis have been published from varieties of health institutes and organizations, they are to a great extent highly similar, there are nevertheless some important differences. We report a case of hepatitis in a renal transplant recipient admitted with pulmonary and extra pulmonary (abdominal) tuberculosis and review the literature on this topic. The introduction of antimicrobial teams, including specialist pharmacists, microbiologists and infectious disease physicians, is a major factor to improve the quality of care and faces the overcoming of antimicrobial resistance. Reintroducing one antituberculosis drug at a time with close monitoring of liver enzymes seems to be the optimal approach in the management of antituberculosis drug induced hepatitis. With multi-disciplinary clinical approach the patient has been successfully cured and has returned to normal active life.
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Affiliation(s)
- Zaher Al-Salmi
- Ministry of Health, Royal Hospital, Pharmacy Department, P.O. Box 1331, CPO, Postal Code 111, Muscat, Sultanate of Oman, Oman
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Abstract
Antibiotics used by general practitioners frequently appear in adverse-event reports of drug-induced hepatotoxicity. Most cases are idiosyncratic (the adverse reaction cannot be predicted from the drug's pharmacological profile or from pre-clinical toxicology tests) and occur via an immunological reaction or in response to the presence of hepatotoxic metabolites. With the exception of trovafloxacin and telithromycin (now severely restricted), hepatotoxicity crude incidence remains globally low but variable. Thus, amoxicillin/clavulanate and co-trimoxazole, as well as flucloxacillin, cause hepatotoxic reactions at rates that make them visible in general practice (cases are often isolated, may have a delayed onset, sometimes appear only after cessation of therapy and can produce an array of hepatic lesions that mirror hepatobiliary disease, making causality often difficult to establish). Conversely, hepatotoxic reactions related to macrolides, tetracyclines and fluoroquinolones (in that order, from high to low) are much rarer, and are identifiable only through large-scale studies or worldwide pharmacovigilance reporting. For antibiotics specifically used for tuberculosis, adverse effects range from asymptomatic increases in liver enzymes to acute hepatitis and fulminant hepatic failure. Yet, it is difficult to single out individual drugs, as treatment always entails associations. Patients at risk are mainly those with previous experience of hepatotoxic reaction to antibiotics, the aged or those with impaired hepatic function in the absence of close monitoring, making it important to carefully balance potential risks with expected benefits in primary care. Pharmacogenetic testing using the new genome-wide association studies approach holds promise for better understanding the mechanism(s) underlying hepatotoxicity.
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Affiliation(s)
- Raúl J Andrade
- Hepatology Unit, Gastroenterology Service, Virgen de la Victoria University Hospital Department of Medicine, University of Málaga, Spain
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14
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Abstract
Hepatotoxic effects attributable to antituberculosis therapy are considered unique among drug-related liver problems because almost all first-line antituberculosis medications have such adverse effects, which vary in severity according to the drug and the regimen. In addition, all regimens for the treatment of active tuberculosis include a combination of medications that must typically be administered for at least 6 months to ensure complete cure of the disease and to minimize the development of drug-resistant bacterial strains. Hepatotoxic effects are a serious problem in patients who are undergoing treatment for tuberculosis, not only because of the morbidity and mortality they directly cause, but also because the liver symptoms can necessitate interruption of therapy or affect a patient's adherence to it, which can limit the efficacy of the antitubercular regimen.
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Affiliation(s)
- Bahaa E Senousy
- Internal Medicine Department, Ain Shams University, Abbassia 11566, Cairo, Egypt
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Affiliation(s)
- Wing Wai Yew
- Tuberculosis and Chest Unit, Grantham Hospital, Hong Kong, China.
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Tostmann A, Boeree MJ, Aarnoutse RE, de Lange WCM, van der Ven AJAM, Dekhuijzen R. Antituberculosis drug-induced hepatotoxicity: concise up-to-date review. J Gastroenterol Hepatol 2008; 23:192-202. [PMID: 17995946 DOI: 10.1111/j.1440-1746.2007.05207.x] [Citation(s) in RCA: 437] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The cornerstone of tuberculosis management is a 6-month course of isoniazid, rifampicin, pyrazinamide and ethambutol. Compliance is crucial for curing tuberculosis. Adverse effects often negatively affect the compliance, because they frequently require a change of treatment, which may have negative consequences for treatment outcome. In this paper we review the incidence, pathology and clinical features of antituberculosis drug-induced hepatotoxicity, discuss the metabolism and mechanisms of toxicity of isoniazid, rifampicin and pyrazinamide, and describe risk factors and management of antituberculosis drug-induced hepatotoxicity. The reported incidence of antituberculosis drug-induced hepatotoxicity, the most serious and potentially fatal adverse reaction, varies between 2% and 28%. Risk factors are advanced age, female sex, slow acetylator status, malnutrition, HIV and pre-existent liver disease. Still, it is difficult to predict what patient will develop hepatotoxicity during tuberculosis treatment. The exact mechanism of antituberculosis drug-induced hepatotoxicity is unknown, but toxic metabolites are suggested to play a crucial role in the development, at least in the case of isoniazid. Priorities for future studies include basic studies to elucidate the mechanism of antituberculosis drug-induced hepatotoxicity, genetic risk factor studies and the development of shorter and safer tuberculosis drug regimens.
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Affiliation(s)
- Alma Tostmann
- Department of Pulmonary Diseases, and University Lung Center Dekkerswald, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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