Hepatotoxicity due to Ribociclib and Echinacea. Case Report

Abstract

The consumption of medicinal herbs has increased especially in recent years. There is little evidence about its real benefits and few publications about its possible adverse effects, especially about its possible interactions with other drugs. Ribociclib in combination with an aromatase inhibitor for women with HR-positive, HER2-negative advanced or metastatic breast cancer, as initial endocrine-based therapy. We present a case of a 55-year-old woman, with no relevant medical history, with a recent diagnosis of luminal B de novo metastatic breast cancer. The patient starts first-line treatment with ribociclib in combination with letrozole. After 2 months, a partial response is achieved. Nevertheless, the patient presents grade 4 hepatotoxicity with elevated bilirubin and transaminases. She is admitted to the Hospital for symptomatic treatment and ruling out other causes of liver failure. The patient recognised she has started to take Echinacea two months ago. After stopping the medicinal herb and ribociclib, liver function improves only partially. This limits the choice of a second line for the treatment of metastatic breast cancer. Imaging tests show disease progression after 7 months and finally the patient died. Both Echinacea and ribociclib present hepatic metabolism through cytochrome p450, so a potential interaction between the two could exist. This is the firs reported case of a potential interaction between ribociclib and Echinaea. We highly recommend avoiding the concomitant use of both medicationts.