Drug-Induced Liver Injuries (Clinical Guidelines for Physicians)

Metabolic dysfunction-associated steatotic liver disease and drug-induced injuries: Pathogenetic aspects, treatment and prevention

Metabolic-associated fatty liver disease or metabolic dysfunction-associated steatotic liver disease is a common chronic disease  characterized by increased fat accumulation in the liver and underlying metabolic dysfunction. In the occurrence of this disease, cardiometabolic factors are important: dyslipidemia, impaired carbohydrate metabolism, insulin resistance, which increase as metabolic dysfunction- associated steatotic liver progresses and most often contribute to the development of cardiovascular pathology. Currently, metabolic dysfunction-associated steatotic liver is a multisystem disease associated with obesity, type 2 diabetes, cardiovascular diseases, chronic kidney disease, oncology, etc. Metabolic dysfunction- associated steatotic liver most often affects comorbid patients who take a considerable number of medications. Over the past decades, many drugs have been identified that have the potential to cause steatohepatitis in susceptible individuals. The range of drugs that have hepatotoxicity is quite large. More than 300 drugs are known to cause drug-induced liver injury. However, the true prevalence of drug-induced liver injury remains unknown, since it is not always possible to determine the true cause of liver damage or a specific drug. In this regard, the issue of management tactics for patients with metabolic dysfunction-associated steatotic liver and drug-induced liver injury remains relevant, especially when it comes to the need to take medications that are vital for the patient. The article provides a review of the literature on the etiopathogenetic, clinical and diagnostic aspects of both metabolic dysfunction-associated steatotic liver and in combination with drug-induced liver injury, features of the management of comorbid patients with metabolic dysfunction-associated steatotic liver and drug-induced liver injury. Therapeutic approaches are reviewed with an emphasis on comprehensive management (non-pharmacological and pharmacotherapy). Prescribing essential phospholipids may be effective in the treatment of such patients.

Adverse event profiles of drug-induced liver injury caused by antidepressant drugs: a disproportionality analysis

BACKGROUND

Antidepressants are widely used to manage depression and other psychiatric diseases. A previous study revealed that hepatotoxicity was the main adverse event related to antidepressants. Therefore, drug-induced liver injury (DILI) caused by antidepressants deserves more attention.

OBJECTIVES

To investigate DILI adverse events reported due to antidepressant use in the United States Food and Drug Administration Adverse Events Reporting System (FAERS) database.

RESEARCH DESIGN

A disproportionality analysis of spontaneously reported adverse events was conducted to assess the association between antidepressant drugs and DILI.

METHODS

FAERS data from 1 January 2004 to 31 December 2021 were compiled and analyzed using the reporting odds ratio (ROR) and information component (IC).

RESULTS

As per the FAERS database, of the 324,588 cases that were administered antidepressants, 10,355 were identified as cases with DILI. Among the identified 42 antidepressants, nefazodone (n = 47, ROR = 7.79, IC = 2.91), fluvoxamine (n = 29, ROR = 4.69, IC = 2.20), and clomipramine (n = 24, ROR = 3.97, IC = 1.96) had the highest ROR for cholestatic injury; mianserin (n = 3, ROR = 21.46, IC = 3.99), nefazodone (n = 264, ROR = 18.67, IC = 3.84), and maprotiline (n = 15, ROR = 5.65, IC = 2.39) for hepatocellular injury; and nefazodone (n = 187, ROR = 12.71, IC = 0.48), clomipramine (n = 35, ROR = 2.07, IC = 0.26), and mirtazapine (n = 483, ROR = 1.96, IC = 0.94) for severe drug-related hepatic disorders. Only nefazodone elicited hepatic failure signals (n = 48, ROR = 18.64, IC = 4.16). There are limited reports on the adverse reactions of relatively new antidepressant drugs, such as milnacipran, viloxazine, esketamine, and tianeptine, and those not approved by the Food and Drugs Administration, such as reboxetine and agomelatine.

CONCLUSION

A significant association was observed between DILI and nefazodone. Duloxetine and clomipramine were associated with three DILI categories, except hepatic failure. The disproportionality analysis cannot conclude on a definite causal link between antidepressants and DILI. Additional research is required to assess new-generation antidepressants for their propensity to cause DILI.

Assessment of Comorbidity in Patients with Drug-Resistant Tuberculosis

A wide range of comorbidities, especially in multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) patients, markedly complicates selecting effective treatment of tuberculosis (TB) and preventing the development of adverse events. At present, it is impossible to assess the severity of comorbid pathologies and develop indications for the administration of accompanying therapy in TB patients. The aim of this study was to identify the difference in the range of comorbidities between patients with MDR-TB and XDR-TB and assess the impact of comorbidities on TB treatment. Materials and Methods: A retrospective, prospective study was conducted where 307 patients with MDR-TB and XDR-TB pulmonary tuberculosis aged 18 to 75 years who received eTB treatment from 2016 to 2021 in St. Petersburg hospitals were analyzed. The analysis showed that the comorbidity level in MDR-TB and XDR-TB patients with TB treatment success and treatment failure was comparable with the use of the Charlson Comorbidity Index (CCI). The CCI demonstrated declining data in terms of TB treatment outcome period in both groups. A slight predominance of CCI score (3 to 4 points) in XDR-TB (22.7%) vs. MDR-TB (15.4%) patients was found. In the case of an TB treatment failure, the CCI level in MDR-TB vs. XDR-TB patients was characterized by a significantly higher rate of low magnitude (ranging from 1 to 2 points) in 21.1% vs. 4.5% (p < 0.05), which was higher in XDR-TB patients (ranging from 4 to 5 points, in 10.0% vs. 0, χ2 = 33.7 (p < 0.01)). Chronic viral hepatitis B and C infection, cardiovascular pathology, chronic obstructive pulmonary disease, and chronic alcoholism were found to be significant comorbidity factors that influenced the TB treatment success. Conclusions: It is evident that XDR-TB patients comprise a cohort with the most severe disease course due to comorbidities impacting TB treatment efficacy. The obtained data pointed to the need to determine comorbidity severity in patients with drug-resistant Mbt prior to administering TB treatment schemes.

[Drug-induced liver injury: diagnosis of exclusion]

Drug-induced liver injury (DILI) is a relevant issue in clinical practice and is still a diagnosis of exclusion. Despite the low incidence in the general population, DILI is the cause of most cases of acute hepatic injury and has a mortality rate of up to 50%. Despite many reports in the medical literature about the DILI mechanisms, a clear causal relationship between them, drugs, and risk factors has not been established. Current clinical practice is based on a combination of a thorough study of a history of risk factors, the timing of drug and dietary supplements' administration, and the analysis of laboratory and instrumental tests. It aligns with the international criteria of the Rousell Uclaf Causality Assessment Method (RUCAM), which is considered one of the main diagnostic algorithms for DILI. The article addresses current DILI classification, risk factors, diagnostic algorithms, causalities, clinical evaluation, promising liver function biomarkers, and specific treatment.

Gastrointestinal disorders in post-COVID syndrome. Clinical guidelines

Summary Post- COVID syndrome refers to the long-term consequences of a new coronavirus infection COVID-19, which includes a set of symptoms that develop or persist after COVID-19. Symptoms of gastrointestinal disorders in post- COVID syndrome, due to chronic infl ammation, the consequences of organ damage, prolonged hospitalization, social isolation, and other causes, can be persistent and require a multidisciplinary approach. The presented clinical practice guidelines consider the main preventive and therapeutic and diagnostic approaches to the management of patients with gastroenterological manifestations of postCOVID syndrome. The Guidelines were approved by the 17th National Congress of Internal Medicine and the 25th Congress of Gastroenterological Scientifi c Society of Russia.

Treatment of toxic hepatitis in COVID-19 patients

Background. The article reflects the clinical significance of the early diagnosis of toxic hepatitis in patients who have undergone a new coronavirus infection with the determination of clinical and laboratory predictors of the response to therapy. A dynamic analysis of the effectiveness of toxic hepatitis therapy in patients of three experimental groups and a control group is presented. Aim. The aim of the present study is to increase the effectiveness of the treatment of toxic hepatitis in patients who have undergone COVID-19. Materials and methods. On the basis of the newly created infection centers of the Central Clinical Hospital RZhD-Medicine and Vishnevsky 3-rd Central Military Clinical Hospital 996 patients with COVID-19, who had clinical and laboratory signs of toxic liver damage (cytolytic and/or cholestatic syndromes) against the background of COVID-19 therapy. Results. On the 14th day from the start of therapy in group 3, there was a significant decrease in the clinical manifestations of jaundice in 163 (72.8%) patients, on the 21st day of treatment, this symptom was stopped in all patients. In groups 1 and 2, the decrease in clinical manifestations of jaundice was significantly lower 122 (55.2%) and 134 (58.8%); p0.05. At the end of therapy, no manifestations of jaundice were observed in all experimental groups, while in the control group, symptom reduction was achieved only in 47 (14.5%) patients. Conclusion. The use of drugs with hepatoprotective effect in the form of monotherapy in groups 1 (UDCA) and 2 (ademethionine) showed a low therapeutic effect with positive dynamics of clinical and laboratory indicators of toxic hepatitis activity. The use of combined treatment in group 3 (UDCA and ademethionine) demonstrated the maximum therapeutic effect, pronounced positive dynamics in the form of normalization of clinical and laboratory indicators of toxic hepatitis activity.

Steatohepatitises: etiological variants, principles of diagnosis and management

Steatohepatitises is an etiologically heterogeneous group of pathological changes in the liver, which are characterized by the inflammatory infiltration of the hepatic parenchyma with underlying fatty degeneration of hepatocytes. Whatever is the etiological cause, the clinical significance of steatohepatitis involves the formation of liver fibrosis and, as a result, an increased risk of developing liver cirrhosis and hepatocellular carcinoma, which are life-threatening conditions. It is common practice to identify the following etiological variants of steatohepatitis: metabolic (55–65% of cases), alcoholic (45–55% of cases) and drug-induced (approximately 5% of cases). The pathogenetic basis of metabolic steatohepatitis lies in the mechanisms of increased lipolysis, excess free fatty acid pool and reduced β-oxidation stemming from obesity and insulin resistance. Pathogenetic factors mediating the development of alcoholic steatohepatitis are the toxic activity of acetaldehyde and increased CYP2E1 activity. Intake of some hepatotoxic drugs increases lipogenesis in  hepatocytes and disrupts the electron transport chain, which leads to the formation of liver steatosis followed by transformation into steatohepatitis. Whatever is the etiological varient, steatohepatitis is asymptomatic in the prevailing majority of cases. However, some patients may present complaints of weakness, discomfort, or indolent pain in the right hypochondrium. A detailed history taking is essential for the establishment of the etiological cause of liver damage. Laboratory tests allow to diagnose steatohepatitis in increased levels of hepatic transaminases, usually not exceeding 2–3 times the normal values. In addition to liver enzymes, increased levels of alkaline phosphatase and GGTP can also be observed in steatohepatitis. Ultrasound imaging is the most accessible instrumental tool in clinical practice to establish the primary diagnosis of hepatic steatosis. Indirect elastometry is an equally informative non-invasive method for diagnosing steatohepatitis, which allows to measure both the degree of steatosis (the function of determining the ultrasonic controlled attenuation parameter (CAP) and liver fibrosis. 

Monooxygenase System and NO Metabolism in Liver Microsomes of Rats with Toxic Hepatitis and the Effect of Sesquiterpene Lactones

We analyzed changes in activities of enzymes of phases I and II of xenobiotic biotransformation and parameters of NO metabolism in liver microsomes of rats with toxic CCl₄-induced hepatitis after a 14-day course of sesquiterpene lactones from Artemisia leucodes (10 mg/kg). It was found that toxic hepatitis was associated with significant inhibition of NADPH-cytochrome c-reductase, benzo(a)pyrene hydroxylase, and NADPH-diaphorase, reduced cytochrome P-450 content, and enhanced induction of nitrate/nitrite reductase with accumulation of NO metabolites in the liver. Administration of sesquiterpene lactones stimulated activity of the studied components of the cytochrome P-450 system and promoted recovery of the NOergic system components; the effects were most pronounced in 7 and 14 days after treatment.

Role of N-acetyltransferase 2 gene polymorphism in the human pathology

Nowadays multiple heterogeneous chemicals affect the human body. They include drugs, household chemicals, dyes, food supplements and others. The human organism can modify, inactivate, and eliminate the chemicals by biotransformation enzymes. But it is well known that biotransformation can lead to toxification phenomenon. Individuals differ from each other by the rate of chemical modification that promotes accumulation of toxins and carcinogens in some patients. An N-acetyltransferase 2 enzyme participates in the aromatic amines second phase metabolism. This work reviews the acetyltransferase gene polymorphism possible role in diseases development including drug-induced organs damage.

Gene of acetyltransferase has polymorphisms associated with two haplotypes of  fast and slow substrate acetylation. Gene alleles combine in three genotypes: fast, intermediate, and slow acetylators. Acetylation rate plays a significant role in side effects development during tuberculosis treatment and cancer pathogenesis. Recently, new data described the role of enzyme in development of non-infectious diseases in the human. Scientists consider that slow acetylation genotype in combination with high xenobiotic load result in accumulation of toxic substances able to damage cells.

Therefore, acetyltransferase genotyping helps to reveal risk groups of cancer and non-infectious disease development and to prescribe more effective and safe doses of drugs. 

Liver drug damage: possibilities of polyionic succinate-methioninic complex during the pandemic of new coronavirus infection (COVID-19)

Medicinal liver damage is an important problem not only in the framework of hepatology and gastroenterology, but also for internal medicine in  general, which is due to the  difficulties of  correct and timely diagnosis of  this pathology. In  the  first part of the review, the main mechanisms of liver tissue damage and clinical and formological manifestations of drug-induced liver damage are considered.

The pandemic of the new coronavirus infection (COVID-19), spread by the SARS-CoV-2 virus, has become a challenge to health systems around the world. The global clinical experience gained over the past year in the management of patients with a new coronavirus infection makes it possible to highlight a number of relevant clinical aspects, one of which is drug-induced liver damage associated with the treatment of COVID-19. In the second part of the review, the possible mechanisms of influence of COVID-19 on the hepatobiliary system are considered, which include viral cytotoxicity, a secondary effect of immune dysregulation; hypoxia as a result of respiratory failure and subsequent ischemic liver damage; reactivation of already existing liver pathology and drug damage to the liver. It has been established that a large number of drugs used to treat COVID-19 - antiviral agents, antibacterials, non-steroidal anti-inflammatory drugs, steroids and others - have hepatoxic effects and can cause liver damage. In the context of the COVID-19 pandemic, for patients with a new coronavirus infection and drug-induced liver damage, a rational, pathogenetically justified choice of a hepatoprotective drug is of particular importance. In the final part of the review, the possibilities of the polyionic succinate-methionine complex in the treatment of drug-induced liver damage are considered and a clinical example of the drug application in a patient with drug-induced liver damage during treatment with COVID-19 is given.

A medicinal liver injury with an immunomodulatory drug of natural origin. Case report

As practice shows, there are many alternative drugs that cause drug damage to the liver. A case of medicinal damage to the liver with an immunomodulatory herbal preparation Immunostimulating collection, which included St. John's wort, Elecampane, Kopeichnik, Echinacea, Licorice, Rosehip, is presented. A 39-year-old patient came to the clinic with complaints of yellowing of the skin, whites of the eyes, heaviness in the epigastrium after eating, lightening of feces, dark urine, sour taste in the mouth, bloating, pruritus, decreased appetite, pronounced general weakness, drowsiness 10 days after you start taking herbal immunostimulant. The diagnosis of drug damage to the liver was made taking into account the history and laboratory parameters, since the patient had negative markers of viral hepatitis and increasing of biochemical blood tests: alanine transferase up to 2800 U/l (norm up to 32 U/L), aspartate transferase up to 1776 U/l (norm up to 31 U/l), total bilirubin up to 577 U/l (norm up to 21 U/l), direct bilirubin up to 116 U/l (norm up to 4.3 U/l), alkaline phosphatase up to 112 U/l (norm up to 98 U/l). After the withdrawal of the immunomodulator and the appointment of therapy, including diet, enzyme replacement therapy, drugs clinical and laboratory manifestations of liver drug damage completely disappeared. This confirms the leading role of the immunoactive drug, which the patient took in the toxic effect on the liver.

Management of patients with digestive diseases during the COVID-19 pandemic. Clinical Practice Guidelines by the Russian scientific medical society of internal medicine (RSMSIM) and the Gastroenterological Scientific Society of Russia (2nd edition)

The presented clinical practice guidelines of the Gastroenterological Scientific Society of Russia (GSSR), diagnostic, and therapeutic approaches for patients with digestive diseases during the COVID-19 pandemic. The guidelines were approved by the XXIII Congress of the GSSR and the 22nd International Slavonic-Baltic Scientifi c Forum “St. Petersburg - Gastro-2020 ON-LINE” (St. Petersburg, June 11, 2020). The presented clinical practice guidelines of the Russian Scientific Medical Society of Internal Medicine (RSMSIM) and the Gastroenterological Scientific Society of Russia (GSSR), diagnostic, and therapeutic approaches for patients with digestive diseases during the COVID-19 pandemic. The recommendations were approved at the XV National Congress of Internal Medicine, XXIII Congress of NOGR on the basis of the 1st edition, adopted at the 22nd International Slavic- Baltic Scientific Forum “St. Petersburg - Gastro-2020 ON-LINE”.

Mixed steatohepatitis: more questions than answers (part 2)

In this review, we discussed the epidemiological and pathogenetic aspects of mixed steatohepatitis (SH), developed due to non-alcoholic fatty liver disease, metabolic associated fatty liver disease, drug-induced liver injury. We discussed the mechanisms of the mutually aggravating influence of etiological factors. Drugs can cause steatosis and SH, as well as contribute to the progressive course of existing SH, primarily of metabolic origin. The issues of interaction of pathogenetic factors, peculiarities of diagnostics and perspectives of pathogenetic and symptomatic treatment are considered. Therapy of mixed SH is based on avoidance of hepatotoxic drugs and lifestyle modification, medications with demonstrated efficacy (such as ademetionine) in certain SH might be used.

Evaluation of the Protective Effect of Ademetionine, Cytoflavin, and Dihydroquercetetine on Blood Enzymes Activity in Rats Treated with High Doses of Sodium Valproate

We evaluated the protective effect of ademetionine, cytoflavin, and dihydroquercetin on activity of serum enzymes in rats treated with high doses of sodium valproate for 28 days. Ademetionine and cytoflavin produced the greatest protective effect, the effect of dihydroquercetin was less pronounced. In rats treated with ademetionine, AST activity decreased as soon as on day 7 and remained at this level until the end of the experiment; ALT, alkaline phosphatase, and γ-glutamyl transferase activities decreased on days 21 and 28 of the study. Cytoflavin produced similar effects, the effect of dihydroquercetin was observed on days 21 and 28 for AST, ALT, alkaline phosphatase and on day 28 for γ-glutamyl transferase. These results substantiate the use of hepatoprotective drugs in case of long-term treatment with anticonvulsants in patients with epilepsy.