Gradual dosing of ursodeoxycholic acid in mothers with intrahepatic cholestasis of pregnancy may improve composite neonatal outcome

INTRODUCTION AND OBJECTIVES

Intrahepatic cholestasis of pregnancy (ICP) is often accompanied by fetal and maternal complications.

MATERIALS AND METHODS

Retrospective review of the clinical course of women with ICP and their neonates treated at our medical center over a 10-year period. Special attention was paid to the maternal and neonatal response to 2 different modes of ursodeoxycholic acid (UDCA) administration.

RESULTS

Neonates of mothers with high total bile acid levels had a poorer composite neonatal outcome. Twenty-seven women who presented at an advanced stage of their pregnancies did not receive UDCA. UDCA was administered in 2 modes: either a full dose at admission (76 women) or a gradually increasing dose until the desired dosage was reached (25 women). The mean gestational age at delivery for the 94 neonates that were exposed to full UDCA dose was the lowest (36±2.3 weeks for the full dose, 37±1.4 weeks for the 30 neonates from the gradually increasing dose, 38±1.6 weeks for the 29 neonates from the no treatment group, p<0.001). The group of neonates that were exposed to full UDCA dose had the highest rate of unfavorable composite neonatal outcome (53% for full dose, 30% for gradually increasing dose, 24% for the no treatment group, p=0.006).

CONCLUSIONS

Compared to the administration of a full UDCA dose, the administration of a gradually increasing dose of UDCA may be associated with a greater gestational age at delivery and fewer events of unfavorable composite neonatal outcomes. These novel findings should be retested prospectively in a large cohort of patients.

Efficacy and Safety of Elafibranor in Primary Biliary Cholangitis

BACKGROUND

Primary biliary cholangitis is a rare, chronic cholestatic liver disease characterized by the destruction of interlobular bile ducts, leading to cholestasis and liver fibrosis. Whether elafibranor, an oral, dual peroxisome proliferator-activated receptor (PPAR) α and δ agonist, may have benefit as a treatment for primary biliary cholangitis is unknown.

METHODS

In this multinational, phase 3, double-blind, placebo-controlled trial, we randomly assigned (in a 2:1 ratio) patients with primary biliary cholangitis who had had an inadequate response to or unacceptable side effects with ursodeoxycholic acid to receive once-daily elafibranor, at a dose of 80 mg, or placebo. The primary end point was a biochemical response (defined as an alkaline phosphatase level of <1.67 times the upper limit of the normal range, with a reduction of ≥15% from baseline, and normal total bilirubin levels) at week 52. Key secondary end points were normalization of the alkaline phosphatase level at week 52 and a change in pruritus intensity from baseline through week 52 and through week 24, as measured on the Worst Itch Numeric Rating Scale (WI-NRS; scores range from 0 [no itch] to 10 [worst itch imaginable]).

RESULTS

A total of 161 patients underwent randomization. A biochemical response (the primary end point) was observed in 51% of the patients (55 of 108) who received elafibranor and in 4% (2 of 53) who received placebo, for a difference of 47 percentage points (95% confidence interval [CI], 32 to 57; P<0.001). The alkaline phosphatase level normalized in 15% of the patients in the elafibranor group and in none of the patients in the placebo group at week 52 (difference, 15 percentage points; 95% CI, 6 to 23; P = 0.002). Among patients who had moderate-to-severe pruritus (44 patients in the elafibranor group and 22 in the placebo group), the least-squares mean change from baseline through week 52 on the WI-NRS did not differ significantly between the groups (-1.93 vs. -1.15; difference, -0.78; 95% CI, -1.99 to 0.42; P = 0.20). Adverse events that occurred more frequently with elafibranor than with placebo included abdominal pain, diarrhea, nausea, and vomiting.

CONCLUSIONS

Treatment with elafibranor resulted in significantly greater improvements in relevant biochemical indicators of cholestasis than placebo. (Funded by GENFIT and Ipsen; ELATIVE ClinicalTrials.gov number, NCT04526665.).

A Phase 3 Trial of Seladelpar in Primary Biliary Cholangitis

BACKGROUND

Effective treatments for patients with primary biliary cholangitis are limited. Seladelpar, a peroxisome proliferator-activated receptor delta agonist, has potential benefits.

METHODS

In this phase 3, 12-month, double-blind, placebo-controlled trial, we randomly assigned (in a 2:1 ratio) patients who had had an inadequate response to or who had a history of unacceptable side effects with ursodeoxycholic acid to receive oral seladelpar at a dose of 10 mg daily or placebo. The primary end point was a biochemical response, which was defined as an alkaline phosphatase level less than 1.67 times the upper limit of the normal range, with a decrease of 15% or more from baseline, and a normal total bilirubin level at month 12. Key secondary end points were normalization of the alkaline phosphatase level at month 12 and a change in the score on the pruritus numerical rating scale (range, 0 [no itch] to 10 [worst itch imaginable]) from baseline to month 6 among patients with a baseline score of at least 4 (indicating moderate-to-severe pruritus).

RESULTS

Of the 193 patients who underwent randomization and treatment, 93.8% received ursodeoxycholic acid as standard-of-care background therapy. A greater percentage of the patients in the seladelpar group than in the placebo group had a biochemical response (61.7% vs. 20.0%; difference, 41.7 percentage points; 95% confidence interval [CI], 27.7 to 53.4, P<0.001). Normalization of the alkaline phosphatase level also occurred in a greater percentage of patients who received seladelpar than of those who received placebo (25.0% vs. 0%; difference, 25.0 percentage points; 95% CI, 18.3 to 33.2, P<0.001). Seladelpar resulted in a greater reduction in the score on the pruritus numerical rating scale than placebo (least-squares mean change from baseline, -3.2 vs. -1.7; least-squares mean difference, -1.5; 95% CI, -2.5 to -0.5, P = 0.005). Adverse events were reported in 86.7% of the patients in the seladelpar group and in 84.6% in the placebo group, and serious adverse events in 7.0% and 6.2%, respectively.

CONCLUSIONS

In this trial involving patients with primary biliary cholangitis, the percentage of patients who had a biochemical response and alkaline phosphatase normalization was significantly greater with seladelpar than with placebo. Seladelpar also significantly reduced pruritus among patients who had moderate-to-severe pruritus at baseline. The incidence and severity of adverse events were similar in the two groups. (Funded by CymaBay Therapeutics; RESPONSE ClinicalTrials.gov number, NCT04620733; EudraCT number, 2020-004348-27.).

Primary biliary cholangitis

Primary biliary cholangitis is an autoimmune liver disease that predominantly affects women. It is characterised by a chronic and destructive, small bile duct, granulomatous lymphocytic cholangitis, with typical seroreactivity for antimitochondrial antibodies. Patients have variable risks of progressive ductopenia, cholestasis, and biliary fibrosis. Considerations for the cause of this disease emphasise an interaction of chronic immune damage with biliary epithelial cell responses and encompass complex, poorly understood genetic risks and environmental triggers. Licensed disease-modifying treatment focuses on amelioration of cholestasis, with weight-dosed oral ursodeoxycholic acid. For patients who do not respond sufficiently, or patients with ursodeoxycholic acid intolerance, conditionally licensed add-on therapy is with the FXR (NR1H4) agonist, obeticholic acid. Off-label therapy is recognised as an alternative, notably with the pan-PPAR agonist bezafibrate; clinical trial agents are also under development. Baseline characteristics, such as young age, male sex, and advanced disease, and serum markers of liver injury, particularly bilirubin and ALP, are used to stratify risk and assess treatment responsiveness. Parallel attention to the burden of patient symptoms is paramount, including pruritus and fatigue.

Improvement in Jowl Fat following ATX-101 Treatment: Results from a Single-Site Study

BACKGROUND

Jowl fat overhang can reduce jawline definition. The most common treatment to reduce jowl fat is liposuction. ATX-101 (deoxycholic acid injection), a minimally invasive treatment approved for submental fat reduction, may also be an effective treatment for jowl fat. The current study evaluated the efficacy and safety of ATX-101 treatment for reducing jowl fat.

METHODS

In this prospective single-site study, 66 adults were treated for excess jowl fat with ATX-101 (area-adjusted dose: 2 mg/cm). Eligible patients had pinchable fat on the jawline and relatively minimal skin laxity in the jowl. Depending on the size of the treatment area, ATX-101 injections of 0.2 ml spaced 1.0 cm apart or 0.1 ml spaced 0.50 to 0.75 cm apart were administered. Improvement in jowl appearance was assessed 6 months or more after the last treatment in person by the clinician. Improvement was also assessed by the patient and two independent plastic surgeons using blinded before/after treatment photographs. Safety was evaluated via adverse events.

RESULTS

The mean number of ATX-101 treatments received was 1.8, with a mean injection volume of 0.8 ml per treatment per jowl. The majority of patients (98 percent) experienced an improvement in jowl appearance. Common adverse events were injection-site edema, numbness, tenderness, and bruising. Injection-site marginal mandibular nerve paresis and alopecia were experienced by three patients each; all events resolved without sequelae.

CONCLUSIONS

ATX-101 effectively reduced jowl fat and was well tolerated in this small cohort. Care should be taken when injecting ATX-101 into jowl fat to avoid underlying anatomic structures such as the marginal mandibular nerve.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Impact of liver inflammation on whole body insulin resistance : a case report on primary biliary cholangitis

Chronic liver diseases such as hepatitis C or non-alcoholic fatty liver disease could be associated with insulin resistance, even in the absence of cirrhosis or significant fibrosis. In this report, we present the case of a patient who was diagnosed with primary biliary cholangitis and metabolic syndrome. Initial evaluation also revealed diabetes with elevated fasting plasma glucose and glycated hemoglobin. After eight weeks of treatment with ursodeoxycholic acid, a complete normalization of the hepatic biological tests was observed. A few months later, while body weight and abdominal perimeter remained stable, fasting blood glucose and glycated hemoglobin decreased significantly, compatible with diabetes disappearance. This finding supports the concept that the inflamed liver plays a major role in the pathogenesis of insulin resistance and diabetes occurrence in chronic liver diseases, including primary biliary cholangitis.

Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial

BACKGROUND

Intrahepatic cholestasis of pregnancy, characterised by maternal pruritus and increased serum bile acid concentrations, is associated with increased rates of stillbirth, preterm birth, and neonatal unit admission. Ursodeoxycholic acid is widely used as a treatment without an adequate evidence base. We aimed to evaluate whether ursodeoxycholic acid reduces adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy.

METHODS

We did a double-blind, multicentre, randomised placebo-controlled trial at 33 hospital maternity units in England and Wales. We recruited women with intrahepatic cholestasis of pregnancy, who were aged 18 years or older and with a gestational age between 20 weeks and 40 weeks and 6 days, with a singleton or twin pregnancy and no known lethal fetal anomaly. Participants were randomly assigned 1:1 to ursodeoxycholic acid or placebo, given as two oral tablets a day at an equivalent dose of 500 mg twice a day. The dose could be increased or decreased at the clinician's discretion, to a maximum of four tablets and a minimum of one tablet a day. We recommended that treatment should be continued from enrolment until the infant's birth. The primary outcome was a composite of perinatal death (in-utero fetal death after randomisation or known neonatal death up to 7 days after birth), preterm delivery (<37 weeks' gestation), or neonatal unit admission for at least 4 h (from birth until hospital discharge). Each infant was counted once within this composite. All analyses were done according to the intention-to-treat principle. The trial was prospectively registered with the ISRCTN registry, number 91918806.

FINDINGS

Between Dec 23, 2015, and Aug 7, 2018, 605 women were enrolled and randomly allocated to receive ursodeoxycholic acid (n=305) or placebo (n=300). The primary outcome analysis included 304 women and 322 infants in the ursodeoxycholic acid group, and 300 women and 318 infants in the placebo group (consent to use data was withdrawn for 1 woman and 2 infants). The primary composite outcome occurred in 74 (23%) of 322 infants in the ursodeoxycholic acid group and 85 (27%) of 318 infants in the placebo group (adjusted risk ratio 0·85 [95% CI 0·62-1·15]). Two serious adverse events were reported in the ursodeoxycholic acid group and six serious adverse events were reported in the placebo group; no serious adverse events were regarded as being related to treatment.

INTERPRETATION

Treatment with ursodeoxycholic acid does not reduce adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy. Therefore, its routine use for this condition should be reconsidered.

FUNDING

National Institute for Health Research Efficacy and Mechanism Evaluation Programme.

Clinical effect of the extract of TCM Fructus akebiae combined with ursodeoxycholic acid on nonalcoholic fatty liver disease

.Fructus akebiae extract (FAE) is a commonly used drug in the clinical treatment of liver cancer. FAE has many pharmacological activities, such as liver protection, anti-tumor, spasmolysis, pain relief and antifungal activity. Its clinical application is extensive, so far no toxic reports have been reported, and new drugs can be developed. This study was designed to investigate the therapeutic effect of predictor extract on non-alcoholic fatty liver disease (NAFLD). 180 patients with NAFLD were randomly divided into 2 groups. The control group was treated with ursodeoxycholic acid (UDCA), and the experimental group was treated with Fructus akebiae extract combined with ursodeoxycholic acid. The results showed that the comprehensive clinical efficacy of the treatment group was 95.56%, which was higher than that of the control group (93.33%), and P < 0.01. In the experimental group, 63 cases (70%) were improved after one course of treatment, main symptom score as (5.09 ±3.98), body mass index as (24.65±3.86), and liver CT value increased. It can be seen that the addition of FAE can significantly improve the clinical symptoms and serum biochemical indicators such as ALT, AST, TG and TC in patients with non-alcoholic fatty liver disease, which is supported by some histological evidence. These findings suggest that FAE combined with Ursodeoxycholic Acid is safe and effective in the treatment of fatty liver.

Ursodeoxycholic acid after common bile duct stones removal for prevention of recurrence: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The recurrence rate of common bile duct stones (CBDS) after removal has been reported to exceed 10% and no established pharmacologic treatment exists for the prevention of recurrent CBDS. Many studies indicated ursodeoxycholic acid (UDCA) has the potential to prevent the recurrence of CBDS. The aim of this systematic review is to evaluate the effects of UDCA for prevention of recurrence after common bile duct stones removal.

METHODS AND ANALYSIS

We will systematically screen all randomized controlled trials (RCTs) published through electronically and hand searching. The following search engines including Ovid Medline, EMBASE, Cochrane CENTRAL, Proquest, Scopus, Web of Science, Pubmed, the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, VIP Information, Wanfang Data. Supplementary sources will be searched including gray literature, conference proceedings, and potential identified publications in OpenGrey.eu and Google Scholar databases. Two reviewers will independently conduct the trial inclusion, data extraction and assess the quality of studies. The recurrence rate of CBDS will be assessed as the primary outcomes. The adverse event that required discontinuation of UDCA intervention and the drop-outs (lost to follow-up) before the end of the study will be measured as secondary outcomes. Methodological quality will be evaluated according to the Cochrane risk of bias. All analyses will be applied by RevMan (version 5.3).

RESULTS

This systemic review and meta-analysis will evaluate the effects of UDCA for prevention of recurrence after CBDS removal in RCTs.

CONCLUSION

Our study will provide evidence to judge whether UDCA is an effective intervention to prevent the recurrence after CBDS removal.

Effect of combined ursodeoxycholic acid and glucocorticoid on the outcome of Kasai procedure: A systematic review and meta-analysis

INTRODUCTION

Multiple studies have investigated the effect of ursodeoxycholic acid (UDCA) or glucocorticoid (GC) on the outcome of the hepatoportoenterostomy (Kasai procedure) in patients with biliary atresia (BA). However, the combined effect of these drugs (UDCA + GC) is little understood.

METHODS

This meta-analysis specifically evaluated the effect of UDCA + GC after the Kasai procedure in patients with BA. A comprehensive literature search was conducted for all relevant articles in the electronic databases Medline, PubMed, Cochrane, Excerpta Medica Database (EMBASE), China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database on Disc (CBM-disc), and Vendor Information Pages (VIP).

RESULTS

Eight studies with BA patients were finally included in our meta-analysis. The 8 identified studies consisted of 3 case-control, 3 cohort, and 2 randomized controlled trials (RCTs) with overall 530 subjects (144, 152, and 234 subjects, respectively). Among them, 312 patients were treated with UDCA + GC, while 218 received placebo or other intervention. The meta-analysis indicated that groups that received UDCA + GC had significantly lower rates of postoperative jaundice relative to the controls (pooled, odds ratio [OR] = 2.41; 95% confidence interval [CI] 1.44-4.04; Z = 3.34; P = .0008), while rates of cholangitis were similar (pooled, OR = 0.87; 95% CI 0.43-1.74; Z = 0.40; P = .69).

CONCLUSIONS

Combined UDCA and GC intervention was superior to that of the control in accelerating the clearance of serum bilirubin in patients with BA after the Kasai procedure. However, this conclusion requires further confirmation using RCTs of high methodological quality.

Microbiota-Derived Metabolic Factors Reduce Campylobacteriosis in Mice

BACKGROUND & AIMS

Campylobacter jejuni, a prevalent foodborne bacterial pathogen, exploits the host innate response to induce colitis. Little is known about the roles of microbiota in C jejuni-induced intestinal inflammation. We investigated interactions between microbiota and intestinal cells during C jejuni infection of mice.

METHODS

Germ-free C57BL/6 Il10-/- mice were colonized with conventional microbiota and infected with a single dose of C jejuni (109 colony-forming units/mouse) via gavage. Conventional microbiota were cultured under aerobic, microaerobic, or anaerobic conditions and orally transplanted into germ-free Il10-/- mice. Colon tissues were collected from mice and analyzed by histology, real-time polymerase chain reaction, and immunoblotting. Fecal microbiota and bile acids were analyzed with 16S sequencing and high-performance liquid chromatography with mass spectrometry, respectively.

RESULTS

Introduction of conventional microbiota reduced C jejuni-induced colitis in previously germ-free Il10-/- mice, independent of fecal load of C jejuni, accompanied by reduced activation of mammalian target of rapamycin. Microbiota transplantation and 16S ribosomal DNA sequencing experiments showed that Clostridium XI, Bifidobacterium, and Lactobacillus were enriched in fecal samples from mice colonized with microbiota cultured in anaerobic conditions (which reduce colitis) compared with mice fed microbiota cultured under aerobic conditions (susceptible to colitis). Oral administration to mice of microbiota-derived secondary bile acid sodium deoxycholate, but not ursodeoxycholic acid or lithocholic acid, reduced C jejuni-induced colitis. Depletion of secondary bile acid-producing bacteria with antibiotics that kill anaerobic bacteria (clindamycin) promoted C jejuni-induced colitis in specific pathogen-free Il10-/- mice compared with the nonspecific antibiotic nalidixic acid; colitis induction by antibiotics was associated with reduced level of luminal deoxycholate.

CONCLUSIONS

We identified a mechanism by which the microbiota controls susceptibility to C jejuni infection in mice, via bacteria-derived secondary bile acids.

Glucocorticoids in combination with ursodesoxycholic acid in the treatment of autoimmune hepatitis

Autoimmune hepatitis (AH) is usually manifested as chronic hepatitis in clinics; it may evolve to liver cirrhosis, hepatic failure, and even death if treatment is delayed. To investigate the clinical efficacy of glucocorticoids in combination with ursodesoxycholic acid in the treatment of glucocorticoids in combination with ursodesoxycholic acid, one hundred and twenty patients with AH who were admitted to the hospital from February 2014 and February 2016 were selected and randomly divided into an observation group and a control group using random number table. Patients in the control group were treated by glucocorticoids only, while patients in the observation group were treated by ursodesoxycholic acid and glucocorticoids. Patients in both groups were treated for six months. The clinical efficacy of the two groups was evaluated after treatment. The levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), direct bilirubin (DBIL) and total bilirubin (TBIL) of the two groups both decreased after treatment (P less than 0.05), the improvement of the level of liver function of the observation group was superior to that of the control group, and the difference was statistically significant (P less than 0.05); after treatment, the levels of serum immunoglobulin G (IgG) and immunoglobulin m (IgM) of both groups significantly reduced after treatment, and the difference within groups before and after treatment had no statistical significance (P less than 0.05). The reduction of the immunological indicators of the observation group was more remarkable after treatment, and the difference between the two groups had statistical significance (P>0.05). The complete remission rate of the observation group was significantly higher than that of the control group; the incidence of adverse reactions was lower than that of the control group, and the difference had statistical significance (P less than 0.05). Thus it can be concluded that glucocorticoids in combination with ursodesoxycholic acid has favorable efficacy in treating AH as it can promote the improvement of liver function and effectively reduce the dose of glucocorticoids and the incidence of adverse reactions. The therapy is of great clinical values.

The bile acid-sequestering resin sevelamer eliminates the acute GLP-1 stimulatory effect of endogenously released bile acids in patients with type 2 diabetes

AIMS

Discovery of the specific bile acid receptors farnesoid X receptor (FXR) and Takeda G protein-coupled receptor 5 (TGR5) in enteroendocrine L cells has prompted research focusing on the impact of bile acids on glucagon-like peptide-1 (GLP-1) secretion and glucose metabolism. The aim of the present study was to assess the GLP-1 secretory and gluco-metabolic effects of endogenously released bile, with and without concomitant administration of the bile acid-sequestering resin, sevelamer, in patients with type 2 diabetes.

MATERIALS AND METHODS

We performed a randomized, placebo-controlled, double-blinded cross-over study including 15 metformin-treated patients with type 2 diabetes. During 4 experimental study days, either sevelamer 3200 mg or placebo in combination with intravenous infusion of cholecystokinin (CCK) (0.4 pmol sulfated CCK-8/kg/min) or saline was administered in randomized order. The primary endpoint was plasma GLP-1 excursions as measured by incremental area under the curve. Secondary endpoints included plasma responses of glucose, triglycerides, insulin, CCK, fibroblast growth factor-19 and 7α-hydroxy-4-cholesten-3-one (C4). In addition, gallbladder dynamics, gastric emptying, resting energy expenditure, appetite and ad libitum food intake were assessed.

RESULTS

CCK-mediated gallbladder emptying was demonstrated to elicit a significant induction of GLP-1 secretion compared to saline, whereas concomitant single-dose administration of the bile acid sequestrant sevelamer was shown to eliminate the acute bile acid-induced increase in plasma GLP-1 excursions.

CONCLUSIONS

Single-dose administration of sevelamer eliminated bile acid-mediated GLP-1 secretion in patients with type 2 diabetes, which could be explained by reduced bile acid stimulation of the basolaterally localized TGR5 on enteroendocrine L cells.

Primary cutaneous amyloidosis associated with autoimmune hepatitis-primary biliary cirrhosis overlap syndrome and Sjögren syndrome: A case report

RATIONALE

Primary cutaneous amyloidosis (PCA) is a localized skin disorder characterized by the abnormal deposition of amyloid in the extracellular matrix of the dermis. The association between PCA and other diseases, although rare, has been documented for various autoimmune diseases. PCA associated with autoimmune hepatitis-primary biliary cirrhosis (AIH-PBC) overlap syndrome and Sjögren syndrome (SS) has not been previously reported in the literature.

PATIENT CONCERNS

A 50-year-old woman presented with progressive abnormal liver enzyme levels and was referred to our department.

DIAGNOSES

Due to the patient's symptoms, laboratory test results, radiographic findings, and pathologic results, she was diagnosed with PCA associated with AIH-PBC overlap syndrome and SS.

INTERVENTIONS

She was subsequently treated with a combination of ursodeoxycholic acid (UDCA), prednisone, and azathioprine.

OUTCOMES

While this treatment can achieve therapeutic success, it cannot prevent complications from cirrhosis. This patient remains alive but experienced an emergent gastrointestinal hemorrhage.

LESSONS

While we acknowledge that this is a single case, these findings extend our knowledge of immunological diseases associated with PCA and suggest a common, immune-mediated pathogenic pathway between PCA, AIH-PBC overlap syndrome, and SS. After 12 years of follow up, clinical manifestations have developed, and these autoimmune diseases have progressed. The combination of UDCA, prednisone, and azathioprine can achieve therapeutic success but cannot prevent disease progression. Routine follow up for this patient is necessary to document disease progression.

Future Applications of Deoxycholic Acid in Body Contouring

Deoxycholic acid (KybellaTM, Allergan Pharmaceuticals, Irvine, CA) is a novel injectable treatment used for the cosmetic reduction of redundant submental fat. By inducing adipose cell lysis, the soft tissue alteration induces subsequent contour change and sharpening of the cervicomental angle.The safety and efficacy have been well established in several prospective clinical trials and subsequent FDA approval for this purpose. This has provided an effective and less invasive alternative to surgical liposuction with virtually no recovery time and less overall discomfort. Given its success for use in this context, a logical step would be to extrapolate to other regions of the body where cosmetic deformity is caused by excessive adipose tissue. In the current article, the authors propose potential options for further use in various targeted areas where subcutaneous fat may be amenable to reduction with deoxycholic acid injection, understanding that such uses would be off-label and require an understanding of the regional anatomy and possible complications. J Drugs Dermatol. 2017;16(1):43-46.

Histopathologic and metabolic effect of ursodeoxycholic acid treatment on PCOS rat model

The aim of this study was to determine the effect of ursodeoxycholic acid (UDCA) treatment on a polycystic ovary syndrome (PCOS) rat model. Thirty-two female Wistar-Albino rats were randomly divided into four groups as follows - group 1: sham group (n: 8), group 2: letrozole-induced PCOS group (n: 8), group 3: letrozole-induced PCOS plus metformin-treated (500 mg/kg) group (n: 8) and group 4: letrozole-induced PCOS plus UDCA (150 mg/kg)-treated group (n: 8). Histopathologic examination of the ovaries, circulating estrone (E1), estradiol (E2), testosterone, androstenedione, glucose, insulin and lipid profiles were evaluated. Histopathologic examination results revealed that groups 3 and 4 had significantly lower cystic and atretic follicles compared to group 2. Besides, group 4 had significantly higher antral follicles than group 2 (8.5 ± 2.9 versus 5.4 ± 1.1; p: 0.001). Furthermore, total testosterone (4.9 ± 2.8 versus 8.8 ± 2.9; p= 0.004) and insulin levels were significantly lower in group 4 compared to group 2 (1.7 ± 0.08 versus 2.1 ± 0.5; p = 0.02). However, lipid parameters, E1, E2, glucose and HOMA-IR were comparable between the groups. Our study results demonstrated that UDCA therapy improves ovarian morphology and decreases total testosterone and insulin levels.

The Association of Ursodeoxycholic Acid Use With Colorectal Cancer Risk: A Nationwide Cohort Study

Data from preclinical studies suggest that ursodeoxycholic acid (UDCA) has a chemopreventive effect on colorectal cancer (CRC) development, but no large observational study has examined this possibility. The aim of this study was to investigate the association of UDCA use with CRC risk in a nationwide population-based cohort. This nationwide population-based cohort study used data from the Taiwan National Health Insurance Research Database for the period from 2000 through 2010. This study included data from 7119 Taiwanese adults who received ≥28 cumulative defined daily doses (cDDDs) of UDCA and 14,238 patients who did not receive UDCA (<28 cDDDs). UDCA nonusers were matched 1:2 for age, sex, enrollment date, and presence of chronic liver disease, viral hepatitis, cholelithiasis, and alcoholic liver disease. The 2 cohorts were followed until December 31, 2010 or occurrence of CRC. Cox proportional hazards regression with robust Sandwich variance estimator, which can cooperate with matching design, was used to examine the association between UDCA use and CRC risk. During 109,312 person-years of follow-up (median, 5 years), 121 patients had newly diagnosed CRC: 28 UDCA users (76.7 per 100,000 person-years) and 93 nonusers (127.7 per 100,000 person-years) (log-rank test, P = 0.0169). After multivariate adjustment for age, UDCA use was associated with a reduced risk of CRC (hazard ratio, 0.60; 95% confidence interval [CI], 0.39-0.92). The adjusted hazard ratios were 0.55 (95% CI, 0.35-0.89), 0.89 (95% CI, 0.36-2.20), and 0.63 (95% CI, 0.16-2.53) for patients with 28 to 180, 181 to 365, and >365 cDDDs, respectively, relative to nonusers. UDCA use was associated with reduced risk of CRC in a cohort mainly comprising patients with chronic liver diseases. However, further studies are needed to determine the optimal dosage of UDCA.

Liraglutide-related cholelithiasis

Liraglutide is a glucagon-like peptide-1 analog and recently started to be using as an incretin-based treatment for diabetes mellitus. Liraglutide causes some adverse affects including nausea, vomiting, acute nasopharyngitis and acute pancreatitis. However, development of liraglutide-dependent cholelithiasis has not been reported in the literature. A 75-year-old female patient had been diagnosed with type 2 diabetes mellitus for 10 years and she has been treated by liraglutide for 6 months. The patient was admitted to the emergency service due to sudden onset of abdominal pain. After laboratory and imaging studies, she was diagnosed with acute cholecystitis and cholelithiasis. And then patient's oral intake was stopped, intravenous fluid and ceftriaxone 2 g/day were started. Furthermore, liraglutide treatment discontinued and ursodeoxycholic acid (UDCA) was started to treat cholelithiasis. During follow-up, abdominal pain completely relieved. Hepatobiliary ultrasonography in sixth month follow-up showed entirely regression of cholelithiasis. Any liraglutide-related cholelithiasis case has not been reported in the literature previously. Therefore, our case is the first case. Especially, elderly diabetic patients who are started to liraglutide treatment should be monitored closely for the formation of cholelithiasis. UDCA treatment would be an alternative prior to surgical treatment for liraglutide-related cholelithiasis.

Intrahepatic cholestasis of pregnancy: observational study of the treatment with low-dose ursodeoxycholic acid

BACKGROUND

To exam the biochemical, obstetric management and pregnancy outcome in women with intrahepatic cholestasis of pregnancy (ICP) and treatment with ursodeoxycholic acid (UDCA).

METHODS

Pregnancy outcome in patients with ICP (N = 307) was studied and patients treated with UDCA (N = 208) vs. no UDCA were compared. The data of the antenatal visits, deliveries and neonatal outcome of 307 pregnancies with ICP was collected from the hospital computerized delivery room log book. UDCA was used in 208 pregnancies. The diagnosis was made by maternal pruritus and elevation of total fasting bile acid (BA) (>6 μmol/l) and elevation of serum alanine aminotransferases (ALT) (>45 U/l). Maternal and neonatal data was analysed and data of the patients who used UDCA during pregnancy was analysed separately and compared with the data from patients without medication.

RESULTS

UDCA was well tolerated. Mothers receiving UDCA had ICP diagnosed five weeks earlier than mothers without medication. At the diagnosis, levels of total BA and ALT were higher in the group using UDCA compared to the group without medication. Most deliveries were induced and perinatal outcome was good. Apgar scores at 5 min were significantly lower in UDCA group (p < 0.05), but fetal umbilical artery pH values were similar in both groups (p > 0.05). There were 30 patients with total BA > 40 μmol/l at diagnosis, 24 with UDCA and 6 without medication and those deliveries were induced soon after diagnosis. The preterm labour was also more common in these patents (p < 0.05). Women with preterm babies had significantly early onset pruritus and ICP was diagnosed earlier. Serum ALT and total BA levels were significantly higher in those pregnancies at diagnosis and also at first control.

CONCLUSIONS

Preterm labour was associated in severe ICP (total BA > 40 μmol/l), ALT levels were also significantly higher and ICP was diagnosed earlier (p < 0.05). Apgar scores were lower in preterm babies (p < 0.05), but umbilical artery pHvalues were not significantly lower. UDCA was well tolerated by pregnant women. With low-dose UDCA treatment the obstetric outcome was good. We still recommend careful obstetrical follow-up.

Delayed Development of Primary Biliary Cirrhosis in a Patient with Acute Glomerulonephritis: A Possible Pitfall of a Self-limiting Disease

Acute poststreptococcal glomerulonephritis (APSGN) is a well-established disease. Although various immune responses are thought to be involved in the pathogenesis of APSGN, the disease has a self-limiting nature in clinical practice, despite the presence of severe acute symptoms. We herein report the case of a 78-year-old woman with APSGN who developed primary biliary cirrhosis (PBC) after achieving remission of renal manifestations, including anasarca and elevation of serum creatinine, indicating that persistent alterations in the immune system can cause extrarenal disorders. This case provides insights into the appropriate clinical management of ASPGN and pathogenesis of PBC.

Celiac and the cranial mesenteric arteries supply gastrointestinal sites that regulate meal size and intermeal interval length via cholecystokinin-58 in male rats

The site(s) of action that control meal size and intermeal interval (IMI) length by cholecystokinin-58 (CCK-58), the only detectable endocrine form of CCK in the rat, are not known. To test the hypothesis that the gastrointestinal tract may contain such sites, we infused low doses of CCK-58 (0.01, 0.05, 0.15 and 0.25nmol/kg) into the celiac artery (CA, supplying stomach and upper duodenum), the cranial mesenteric artery (CMA, supplying small and most of the large intestines), the femoral artery (FA, control) and the portal vein (PV, draining the gastrointestinal tract) prior to the onset of the dark cycle in freely fed male rats. We measured the first meal size (chow), second meal size, IMI and satiety ratio (SR, IMI/meal size). We found that (1) all doses of CCK-58 given in the CA and the highest dose given in the CMA reduced the first meal size, (2) all doses of CCK-58 given in the CA reduced the second meal size, (3) a CCK-58 dose of 0.15nmol/kg given in the CA and 0.15 and 0.25nmol/kg given in the CMA prolonged the IMI, (4) CCK-58 (0.05, 0.15, 0.25nmol/kg) given in the CA and 0.25nmol/kg given in the CMA increased the SR, and (5) CCK-58 given in the FA and PV had no effect on the meal size or intermeal interval. These results support our hypothesis that the gastrointestinal tract contains sites of action that regulate meal size and IMI length via CCK-58. The stomach and upper duodenum may contain sites regulating meal size, whereas the small intestine and part of the large intestine may contain sites regulating the IMI.

Effect of taurocholic acid on fetoplacental arterial pressures in a dual perfusion placental cotyledon model: a novel approach to intrahepatic cholestasis of pregnancy

OBJECTIVE

To determine if continuous infusion of taurocholic acid into the fetoplacental and intervillous circulation of a placental cotyledon affects the fetal arterial pressure response after injection of the thromboxane mimetic U44619. Taurine conjugated bile acid is one bile acid putatively mediating intrahepatic cholestasis of pregnancy (ICP).

STUDY DESIGN

We selected 5 placentas from normal, unlabored patients. Two cotyledons from each placenta were isolated and dually perfused. Taurocholic acid was continuously infused into the fetoplacental and intervillous circulation of the test cotyledon. After 30 minutes U44619 was injected into both the test and control cotyledon vascular circuits. Pressure excursions were measured and compared to baseline pressures using a paired Student's t test.

RESULTS

There was significant attenuation of the pressure excursion in the cotyledons perfused with taurocholic acid as compared to controls after injection of U44619. The difference from baseline in the taurocholic cotyledon compared with controls was 44.2 mmHg vs. 71.8 mmHg (p = 0.009).

CONCLUSION

The perfusion of taurocholic acid attenuated the pressure response to thromboxane mimetic U44619 in the fetoplacental arterial circulation of a placental cotyledon as compared to control. This finding in our ex-vivo model may represent changes that occur in the placental vasculature with intrahepatic cholestasis of pregnancy. These placentas may have dysregulated vascular tone, which could contribute to the adverse fetal effects observed in ICP.

All-trans-retinoic acid improves cholestasis in α-naphthylisothiocyanate-treated rats and Mdr2-/- mice

Chronic cholestasis results in liver injury and eventually liver failure. Although ursodeoxycholic acid (UDCA) showed limited benefits in primary biliary cirrhosis, there is an urgent need to develop alternative therapy for chronic cholestatic disorders. Previous studies from our laboratory demonstrated that all-trans-retinoic acid (atRA) is a potent suppressor of CYP7A1, the rate-limiting enzyme in bile acid synthesis. atRA also repressed the expression of tumor growth factor-β and collagen 1A1 in activated primary human stellate cells and LX2 cells. When administered together with UDCA to bile duct-ligated rats, this combined therapy significantly reduced the bile acid pool size and improved liver conditions. To further examine whether atRA alone or in combination with UDCA has greater beneficial effects than UDCA treatment alone, we assessed this treatment in two additional chronic cholestatic rodent models: α-naphthylisothiocyanate (ANIT)-treated rats and the Mdr2(-/-) (Abcb4(-/-)) knockout mouse. atRA alone significantly reduced bile duct proliferation, inflammation, and hydroxyproline levels in ANIT-treated rats, whereas the combination of atRA and UDCA significantly reduced plasma bile salt level compared with UDCA treatment. atRA alone or in combination with UDCA significantly reduced plasma levels of alkaline phosphatase and bile salts in 12-week-old Mdr2(-/-) mice. Reduced bile duct proliferation and inflammation were also observed in the livers of these mice. Together, atRA alone or in combination with UDCA significantly reduced the severity of liver injury in these two animal models, further supporting the combination treatment of atRA and UDCA as a potential new therapy for patients with chronic cholestatic liver disease who have not responded fully to UDCA.

Peripheral injections of cholecystokinin, apelin, ghrelin and orexin in cavefish (Astyanax fasciatus mexicanus): effects on feeding and on the brain expression levels of tyrosine hydroxylase, mechanistic target of rapamycin and appetite-related hormones

The effects of intraperitoneal injections of cholecystokinin (CCK), apelin, ghrelin, and orexin on food intake were examined in the blind cavefish Astyanax fasciatus mexicanus. CCK (50ng/g) induced a decrease in food intake whereas apelin (100ng/g), orexin (100ng/g), and ghrelin (100ng/g) induced an increase in food intake as compared to saline-injected control fish. In order to better understand the central mechanism by which these hormones act, we examined the effects of injections on the brain mRNA expression of two metabolic enzymes, tyrosine hydroxylase (TH), and mechanistic target of rapamycin (mTOR), and of appetite-regulating peptides, CCK, orexin, apelin and cocaine and amphetamine regulated transcript (CART). CCK injections induced a decrease in brain apelin injections, apelin injections induced an increase in TH, mTOR, and orexin brain expressions, orexin treatment increased brain TH expression and ghrelin injections induced an increase in mTOR and orexin brain expressions. CART expression was not affected by any of the injection treatments. Our results suggest that the enzymes TH and mTOR and the hormones CCK, apelin, orexin, and ghrelin all regulate food intake in cavefish through a complex network of interactions.

[Approaches to the treatment of patients with climacteric disorders complicated with menopausal metabolic syndrome with cholestasis]

RESEARCH OBJECTIVE

Development of the individual comprehensive program of follow treatment of patients with climacteric disorders complicated MMS (menopausal metabolic syndrome) with cholestasis; on the basis of application of low-dose hormone replacement therapy in combination with ursodeoxycholic acid, to improve the quality of life.

MATERIALS AND METHODS

We observed 101 woman with climacteric syndrome, obesity and cholestasis; conducted a comprehensive clinical and laboratory examination, ultrasound of the hepatobiliary system, measurement modified menopausal index (MMI), the measurement of the quality of life on questionnaire SF-36 before treatment and after 6 and 12 months.

THE RESULTS

Positive and statistically significant changes in lipid spectrum, the activity of transaminases, bilirubin and its fractions, improvement of MMI and quality of life, the indices of coagulation remained virtually unchanged.

CONCLUSION

Low-dose hormone replacement therapies in combination with ursodeoxycholic acid are highly effective drugs for the treatment of menopausal syndrome, which normalize lipid profile of patients and the performance of the hepatobiliary system.

[The treatment of gallbladder cholesterosis in children]

The article contains the results of studies indicating the benefits of conservative therapy in children with gallbladder cholesterosis (GBC). The high efficiency of ursodeoxycholic acid in the treatment of GBC in childhood is shown in the study. Our research in the field of GBC in children allows the authors to propose management algorithm of such patients.

[The choleretic and hepatoprotective effect of Hypecoum erectum extract]

The choleretic and hepatoprotective effect of Hypecoum erectum L. dry extract on toxic hepatitis was studied. Experimental hepatitis was caused by the introduction of D-galactosamine to Wistar white rats in the dose of 500 mg/kg of the animal weight once a day for 3 days. The H. erectum extract was administered per os in the dose of 50 mg/kg for 7 days. It has been established that H. erectum extract has a marked hepatoprotective effect in the case of D-galactosamine hepatitis in white rats that is characterized by inhibition of the disturbances in cholate-synthetic functions of the liver, increase of bile secretion rate, preservation of cholate concentration in the bile. The tested remedy diminishes dystrophic and necrotic processes, decreases the intensity of inflammatory infiltration in the liver and stimulates regeneration of liver cells in D-galactosamine hepatitis.

[Influence of ursodeoxycholic acid on the immune status of patients with cholesterosis of gall-bladder depending on cholesterol index in blood]

Application of ursodeoxycholic acid in a standard dosage for 3 months provided a positive effect in relation to the indexes of the immune system for patients with the cholesterosis of gall-bladder. It is shown that medicine assists renewal of T-cell immunity, renders positive influence on B-link and renewal of index of immunoregulation can be seen. Reliable increase of specific receptors to CD25, HLA-DR and high level of CD95 testifies about including of the scray reaction of organism under influence of ursodeoxycholic acid on the remaining high indexes of B-cell of immunity. At the initial indexes of lipid spectrum, corresponding to the norm, the efficiency of normalization of immunological changes is more considerable than at the higher level of general cholesterol of serum of blood.

[New aspects of pharmacological effects of ursodeoxycholic acid]

The paper reviews the use of hepatoprotective agents in chronic liver diseases (CLD) and biliary disorders. A variety of clinical studies have shown the beneficial effect of ursodeoxycholic acid (UDCA) in liver disease worldwide. Besides the well-known mechanisms of action of UDCA we could show its prebiotic effect. Several studies have demonstrated that UDCA serves as a potential therapeutic agent for a number non-hepatobiliary disorders including cardiovascular disease, immune disorders, organ transplantation and other.

[Cycle and maintenance treatments in patients with reflux esophagitis after gastrectomy or gastric resection]

AIM

To evaluate the efficiency and safety of Livodexa monotherapy in patients with reflux esophagitis (RE) after gastric resection or gastrectomy.

SUBJECTS AND METHODS

The investigators examined 30 patients (16 men, 14 women) after gastrectomy (n = 15) or gastric resection (n = 15) who had anacidity as shown by pH-metry and the clinical and/or endoscopic signs of RE. During 4 months, Groups 1 and 2 patients received the drug in doses of 10 and 15 mg/kg/day, respectively. Maintenance treatment was performed for 2 months. The maintenance therapy group included 25 patients, including 12 patients who took Livodexa in a dose of 2.5 mg/kg/day (Group 1) and 13 patients who had 5 mg/kg/day (Group 2) during 2 months.

RESULTS

Treatment with ursodeoxycholic acid (Livodexa) resulted in the significantly reduced frequency and intensity of the major symptoms of the disease (heartburn, retrosternal pain, bitter eructation), by achieving a maximum effect at 4 months of therapy. Endoscopic remission was observed in 63.3 and 83.3% of the patients at 4 and 6 months of treatment, respectively. There was a significant and steady rise in the quality of life as evidenced by a visual analogue scale. The ursodeoxycholic acid dose of 10 mg/kg was effective in patients with grade 1 RE (single erosions) while it should be increased up to 15 mg/kg in those with more significant esophageal mucosal injury (grades 2-3 RE). Some patients receiving a maintenance dose of 2.5 mg/kg/day were recorded to have recurrent reflux disease with a relapse of clinical manifestations and a morphological substrate as catarrhal esophagitis. The group of patients receiving maintenance therapy (5 mg/kg/day) retained the achieved clinical and morphological remission.

CONCLUSION

The findings suggest that Livodexa is effective in patients of this category.

[Beneficial effects of preoperative administration of Inchinkoto in patients undergoing major hepatectomy]

Inchinkoto (ICKT) is one of the most commonly used herbal medicines and is a hepatoprotective agent. Among the numerous chemical compounds included in ICKT, geniposide is the most abundant component. After oral intake, geniposide is converted into the active metabolite genipin by intestinal bacteria and absorbed in the portal circulation. The biological properties of ICKT and its major active ingredient genipin have been studied in numerous experiments using cells and animals. ICKT or genipin administration exerts a choleretic effect through upregulation of multidrug resistance-associated protein 2 in hepatocytes. ICKT also exerts antiapoptoic activity by inhibiting the transforming growth factor beta 1- or tumor necrosis factor alpha-dependent signaling pathway. The excessive inflammatory response induced by various forms of hepatic stress is also attenuated by ICKT preadministration. Proinflammatory cytokine-induced upregulation of inducible nitric oxide synthase is strongly attenuated by ICKT in both in vivo and in vitro experiments. Moreover, ICKT enhances antioxidant enzymes in the liver under oxidative stress. These experimental results clearly indicate the effects of ICKT on hepatic stress. To date, however, clinical data on the benefits of ICKT for liver disease are very rare. To extend the clinical applications of ICKT in humans, it is crucial to design and perform a rigorous clinical trial. In this review article, recent evidence relating to the hepatoprotective effects of ICKT in the field of basic and clinical science is summarized and discussed.

Effects of rectal administration of taurocholic acid on glucagon-like peptide-1 and peptide YY secretion in healthy humans

Glucagon-like peptide-1 (GLP-1) and peptide YY (PYY), secreted by enteroendocrine L-cells located most densely in the colon and rectum, are of fundamental importance in blood glucose and appetite regulation. In animal models, colonic administration of bile acids can stimulate GLP-1 and PYY by TGR5 receptor activation. We evaluated the effects of taurocholic acid (TCA), administered as an enema, on plasma GLP-1 and PYY, as well as gastrointestinal sensations in 10 healthy male subjects, and observed that rectal administration of TCA promptly stimulated secretion of both GLP-1 and PYY, and increased fullness, in a dose-dependent manner. These observations confirm that topical application of bile acids to the distal gut may have potential for the management of type 2 diabetes and obesity.

Long-term combined therapy with very-low-dose peginterferon and ursodeoxycholic acid decreased the spleen size in a patient with hepatitis C virus-related cirrhosis

A 42-year-old woman with hepatitis C virus-related cirrhosis underwent peginterferon alpha-2b therapy combined with ribavirin but could not achieve a sustained viral response. Following discontinuation of this combined therapy, the patient's serum transaminase levels suddenly became elevated. Therefore, the administration of very-low-dose peginterferon alpha-2a with ursodeoxycholic acid was introduced. Thereafter, the patient's serum transaminase levels gradually improved. Four years later, enhanced computed tomography showed shrinkage of the spleen and enlargement of the liver. Long-term combined therapy with very-low-dose peginterferon and ursodeoxycholic acid may be effective not only in preventing disease progression, but also in improving portal hypertension in patients hepatitis C virus-related cirrhosis.

[Efficiency of ursodeoxycholic acid therapy in non-alcoholic fatty liver disease associated with metabolic syndrome]

INTRODUCTION

Nonalcoholic Fatty Liver Disease (NAFLD) is one of the most common liver disease. Its prevalence is 20-30% in the population of developed countries, its prevalence is 26% in Russia. NAFLD is observed in many patients with Metabolic Syndrome. Because of the wide prevalence of this disease it is required to find best drugs influencing mechanisms of its development, chronicity and progression.

MATERIALS AND METHODS

36 patients were included to the study. Mean age of patients was 43 +/- 3.9 years. Patients of the main group received the ursodeoxycholic acid within 2 months. Patients of the control group received the plant origin hepatoprotective medicine. All patients before and after treatment were carried out the biochemical analysis of blood, the liver ultrasound examination, the bioimpedance body composition analysis, the microbiological examination of faeces, the examination of metabolites of microorganisms in the blood by the method of gas-liquid chromatography - mass spectrometry, developed by Osipov G. A.

RESULTS

The reduction of hepatic transaminases, the trend to normalization of the lipid profile, the reduction of body weight, the reduction of amount of adipose tissue in the body, the increase of Bifidobacterium spp., Lactobacillus spp., Enterococcus spp., the increase of levels of Bifidobacterium spp., Lactobacillus spp. Metabolites, the decrease of endotoxin plasma level and the decrease of total microbial load were observed after the UDCA treatment. The results of the study showed the prospectivity of the using of UDCA for NAFLD associated with Metabolic Syndrome.

[Comparative evaluation of various methods of conservative therapy of early stage of cholelithiasis]

THE AIM OF INVESTIGATION: To explore the possibilities of use of conservative therapy in the early stage of cholelithiasis.

MATERIALS AND METHODS

In the treatment of patients with early stage of gallstone disease in 103 patients was used mineral water Uvinskaya, in 96--Ursosan and in 118--Ursosan combined with mineral water Uvinskaya.

RESULTS

The comparative evaluation of different variants of therapy showed that combined use of Ursosan and mineral water Uvinsky was the most effective to eliminate the clinical symptoms of the disease and reduce the lithogenic properties of bile.

[Biliary sludge: diagnosis and treatment at an outpatient's clinic]

The purpose of the study--to develop a diagnostic and management tactics for patients with biliary sludge (BS) in an outpatient setting. The study included 115 patients who, according to the ultrasound revealed a BS. Own methodological approach used by ultrasound scan of the gall bladder and the interpretation of ultrasonographic BS types: Type 1 (suspension echo-positive particles) was set at 59.1%, type 2 (low level of mobile like putty echo-positive bile)--23.5%, 3 type (like putty bile in the form of mobile and/or fixed clots)--17.4%. For the treatment of BS used drugs ursodeoxycholic acid. The daily dosage depends upon the type BS. For the treatment of type 1 requires a minimum of 1 month, 2 types--not less than 3 months. Sludge was the most resistant type 3, which is the duration of treatment was 6-12 months or more. Allocation of risk factors forming the BS is the basis for the formation of risk groups and prevention activities (including pharmacotherapeutic).

Cholecystokinin elevates mouse plasma lipids

Cholecystokinin (CCK) is a peptide hormone that induces bile release into the intestinal lumen which in turn aids in fat digestion and absorption in the intestine. While excretion of bile acids and cholesterol into the feces eliminates cholesterol from the body, this report examined the effect of CCK on increasing plasma cholesterol and triglycerides in mice. Our data demonstrated that intravenous injection of [Thr28, Nle31]-CCK at a dose of 50 ng/kg significantly increased plasma triglyceride and cholesterol levels by 22 and 31%, respectively, in fasting low-density lipoprotein receptor knockout (LDLR^−/−) mice. The same dose of [Thr28, Nle31]-CCK induced 6 and 13% increases in plasma triglyceride and cholesterol, respectively, in wild-type mice. However, these particular before and after CCK treatment values did not achieve statistical significance. Oral feeding of olive oil further elevated plasma triglycerides, but did not alter plasma cholesterol levels in CCK-treated mice. The increased plasma cholesterol in CCK-treated mice was distributed in very-low, low and high density lipoproteins (VLDL, LDL and HDL) with less of an increase in HDL. Correspondingly, the plasma apolipoprotein (apo) B48, B100, apoE and apoAI levels were significantly higher in the CCK-treated mice than in untreated control mice. Ligation of the bile duct, blocking CCK receptors with proglumide or inhibition of Niemann-Pick C1 Like 1 transporter with ezetimibe reduced the hypercholesterolemic effect of [Thr28, Nle31]-CCK in LDLR^−/− mice. These findings suggest that CCK-increased plasma cholesterol and triglycerides as a result of the reabsorption of biliary lipids from the intestine.

Primary sclerosing cholangitis, Crohn's disease and HLA-B27 in black South African women

Crohn's disease is rare in South African black people and primary sclerosing cholangitis (PSC) is also rare in black patients with IBD, from South Africa. The presence of HLA-B27 is generally associated with seronegative spondylo-arthropathies and correlates with the occurrence of ankylosing spondylitis, recurrent mouth ulcers and uveitis, in patients with IBD. We describe two women with the combination of Crohn's disease, PSC and HLA-B27 from our cohort of the last 5 years of three black patients with Crohn's disease. Crohn's disease, PSC and HLA-B27 respectively, occur rarely in black South Africans and their concurrent presence in two black women suggests a pathogenetic link of HLA-B27 between Crohn's disease and PSC in this population. Female gender might be an additional determinant in this setting.

Ursodeoxycholic acid versus placebo, and early term delivery versus expectant management, in women with intrahepatic cholestasis of pregnancy: semifactorial randomised clinical trial

OBJECTIVES

To test whether ursodeoxycholic acid reduces pruritus in women with intrahepatic cholestasis of pregnancy, whether early term delivery does not increase the incidence of caesarean section, and the feasibility of recruiting women with intrahepatic cholestasis of pregnancy to trials of these interventions.

DESIGN

First phase of a semifactorial randomised controlled trial.

SETTING

Nine consultant led maternity units, United Kingdom.

PARTICIPANTS

125 women with intrahepatic cholestasis of pregnancy (pruritus and raised levels of serum bile acids) or pruritus and raised alanine transaminase levels (>100 IU/L) recruited after 24 weeks' gestation and followed until delivery. 56 women were randomised to ursodeoxycholic acid, 55 to placebo, 30 to early term delivery, and 32 to expectant management.

INTERVENTIONS

Ursodeoxycholic acid 500 mg twice daily or placebo increased as necessary for symptomatic or biochemical improvement until delivery; early term delivery (induction or delivery started between 37+0 and 37+6) or expectant management (spontaneous labour awaited until 40 weeks' gestation or caesarean section undertaken by normal obstetric guidelines, usually after 39 weeks' gestation).

MAIN OUTCOME MEASURES

The primary outcome for ursodeoxycholic acid was maternal itch (arithmetic mean of measures (100 mm visual analogue scale) of worst itch in past 24 hours) and for the timing of delivery was caesarean section. Secondary outcomes were other maternal and perinatal outcomes and recruitment rates.

RESULTS

Ursodeoxycholic acid reduced itching by -16 mm (95% confidence interval -27 mm to -6 mm), less than the 30 mm difference prespecified by clinicians and women as clinically meaningful. 32% (14/44) of women randomised to ursodeoxycholic acid experienced a reduction in worst itching by at least 30 mm compared with 16% (6/37) randomised to placebo. The difference of 16% (95% confidence interval -3 to 34); this would represent a number needed to treat of 6, but it failed to reach significance. Early term delivery did not increase caesarean sections (7/30 (23%) in the early term delivery group versus 11/32 (33%) in the expectant management group (relative risk 0.70, 95% confidence interval 0.31 to 1.57). No serious harms were noted in either trial. 22% (73/325) of eligible women participated in the drug trial and 19% (39/209) in the timing of delivery trial; both groups had a similar spectrum of disease severity to non-participants.

CONCLUSIONS

Ursodeoxycholic acid significantly reduces pruritus, but the size of the benefit may be too small for most doctors to recommend it, or for most women to want to take it. Women are, however, likely to differ in whether they consider the benefit to be worthwhile. Planned early term delivery seems not to increase incidence of caesarean section, although a small increase cannot be excluded. A trial to test whether ursodeoxycholic acid reduces adverse perinatal outcomes would have to be large, but is feasible. A trial to test the effect of early term delivery on adverse fetal outcomes would have to be significantly larger and may not be feasible.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN37730443.

[Pharmacotherapy of the upper gastrointestinal tract diseases in children with birth defects and minor anomalies of the heart development]

The high frequency of formation diseases of upper gastrointestinal tract (UIT) in children with congenital defects (CGD), and minor anomalies of the heart (MAOH) is the need to improve their treatment tactics. In this regard, we have worked out the optimal scheme of conservative therapy in the observed groups of children. The aim of treatment tactics has been leveling the inflammatory and functional disorders UIT, ultimately contributing to improved quality of life of patients with CHD, and MAOH.

[Specific features of hypolipidemic therapy in patients with abdominal ischemic disease]

AIM

To evaluate the efficiency and safety of combined drug therapy incorporating Ursofalk (Dr Falk Pharma GmbH, Germany) and a low-dose statin on the clinical course of the disease and blood lipid composition parameters in high-risk patients with abdominal ischemic disease (AID) and hepatic ischemic steatosis resulting from atherosclerotic lesion of the abdominal aorta (AA) and its unpaired visceral branches (UVB).

SUBJECTS AND METHODS

One hundred and thirty-nine patients (95 (68.3%) men and 44 (31.7%) women, aged 18-87 years) with AID and ischemic hepatopathy were examined and treated. AID in the examinees was verified by color duplex scanning and computed tomographic angiography of AA UVB, as well as by X-ray contrast aortography. The patients were treated with Ursofalk 10-15 mg/kg/day in combination with atorvastatin 10-20 mg/day.

RESULTS

Due to the combination therapy, abdominal pains became less significant in the majority of patients and disappeared in some subjects. The same positive changes were also observed in the signs of intestinal dysfunction. There was an improvement in blood lipid composition parameters. No substantial weight changes were noted in the patients during the treatment. No adverse reactions occurred due to the combined use of Ursofalk and atorvastatin.

CONCLUSION

It is reasonable to co-administer urosofalk and statins as an agent of hypolipidemic therapy in patients with AID concurrent with disseminated atherosclerosis and dyslipidemia that is accompanied by fatty infiltration of the liver with elements of fibrosis in 90% of cases and that is a pre-stage of steatohepatitis.

[Interstitial lung disease in patients with primary biliary cirrhosis]

Primary biliary cirrhosis (PBC) is a chronic autoimmune disorder of unknown etiology. The disease affects middle-aged women and is characterized by the destruction of the intralobular bile ducts that causes consequent cholestasis. AMA is a hallmark of PBC, composed mostly of IgG and IgM class. The M2 antibody is the most specific one, with sensitivity range of 54-98% depending on type of test used. PBC is often accompanied by other autoimmune diseases, such as Sjögrens syndrome, thyroiditis, rheumatoid arthritis, dermatomyositis, polymyositis. Interstitial lung disease (ILD) has been reported in patients with primary biliary cirrhosis but its frequency and nature are poorly understood. We report pulmonary involvement in the course of PBC in 4 middle-aged women. Histopatological examination of lung specimens was available in three patients: two presented with sarcoid - like granulomas, one with lymphocytic interstitial pneumonia (LIP). In one patient the diagnosis of pulmonary fibrosis was based on clinical and radiological features. Because of abnormal pulmonary function tests (PFT) results all the patients were treated with prednisone, one, additionally with azathioprine. The treatment was successful in all of the patients.

[Innovations in the diagnosis and treatment of cholelithiasis]

AIM

To determine the density of densitometric gallstones and biliary sludge in order to clarify the possibility of lithotherapy in patients with gallstone disease (GSD).

MATERIALS AND METHODS

70 patients were carried out a comprehensive clinical examination with determination of densitometric density of gallstones and/or biliary sludge by means of computer tomography (CT), ultrasound of the abdomen, biochemical blood analysis. Assigned to the complex lithotherapy (Ursofalk and Kholit) in standard dosages, the results were evaluated in a year.

RESULT

It was found that the density of bile in patients with GSD was ranging from +4 to +10 HU, sludge - +17,5 HU, gall stones - over +20 HU. The main factor of the exoediency of conservative therapy of GSD is to determine the density of gallstone by CT, which should not exceed +54 HU (+29,6 +/- 3,4 HU). Visualization of stones on CT is much higher (30%) than in Rg (10%), and its density is observed at more than +75,0 HU. Sludge particle less than 2.0 mm, but having a density more than +20,0 HU, should be viewed as a gallstone. Kholit, a herbal medicine, improves functional and structural indicators of biliary tract, digestive processes of cavity, and may be recommended as a monotherapy in stage I of GSD, as well as a component of combination therapy of cholelithiasis.

[Modern approaches to the treatment of biliary pathology in young patients with obesity]

The therapeutic efficiency of ursosan in 64 overweight patients with chronic noncalculous cholecystitis and dysfunction of biliary tract was evaluated. Including of ursosan in the complex therapy of patients with chronic noncalculous cholecystitis enhances the efficiency of therapy, causes the positive changes in clinical symptoms and indicators of the biliary tract function, diminishes the lithogenic properties of bile, normalize the food behavior.

In PSC with colitis treated with UDCA, most colonic carcinomas develop in the first years after the start of treatment

BACKGROUND

Patients with PSC and IBD have a high incidence of colonic carcinomas (CRC), and the annual incidence of CRC increases with duration of disease. UDCA treatment has been suggested to reduce colonic dysplasias and carcinomas.

AIMS

The annual incidence of colorectal carcinomas after long-term UDCA treatment was studied.

METHODS

Patients included in a prospective study on the outcome after ursodeoxycholic acid (UDCA) treatment were evaluated.

RESULTS

A total of 120 of 171 PSC patients included had IBD (108 UC and 12 CD). All patients were treated with UDCA for a median time of 6.7 years. Seven patients with PSC and IBD developed a CRC yielding a prevalence of 5.8%. In years 0-3 (n = 120) after the start of UDCA, the annual incidence rate of CRC was 0.62/100 patient years; in years 3-6 (n = 93) it increased to 1.28 and decreased thereafter in years 6-9 (n = 67) to 1.17, then in years 9-12 (n = 42) to 0 and after >12 years (n = 24) it remained 0. In PSC with IBD, Kaplan-Meier estimate of CRC formation increased with time in the first years of treatment and reached a plateau after 9 years; after treatment for ≥ 9 years, no further CRC were observed.

CONCLUSION

After the start of UDCA, the annual incidence of CRC increased up to 6 years and subsequently decreased. In PSC with IBD treated with UDCA, most colonic carcinomas develop in the first years after the start of treatment.