TWO HITS FOR LACTIC ACIDOSIS: A STUDY IN DRUG-DRUG INTERACTION

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Tumors with high mitotic activity undergo oxidative phosphorylation for ATP synthesis. In acute myelogenous leukemia (AML) new therapies that target energy metabolism and mitochondrial protein synthesis are being studied. When these new drugs are combined with medications that also effect mitochondrial activity serious complications may occur. Particularly when side-effects from new investigation therapies are not widely known, nor available to automated electronic medical record (EMR) drug interaction checks. We present a case of life-threatening lactic acidosis due to the use of a STAT3 (signal transduction activator of transcription) inhibitor - a drug currently in clinical trials -- in a patient also receiving linezolid, in whom the risk of a life-threatening drug interaction and toxicity was not fully appreciated. CASE PRESENTATION: A 61 year-old man with a history of refractory AML in a clinical trial with a STAT 3 inhibitor presented with sepsis, but despite appropriate antibiotics his clinical status declined requiring mechanical ventilation. Lab studies showed a rapidly worsening lactic acidosis (3.9 to 18 mmol/L) over a few hours. Later it was discovered that he had completed a prolonged course of linezolid for vancomycin-resistant enterococcus bacteremia the day prior to admission. Though inputted in the medical record as an investigation study drug, the drug-drug interaction with linezolid was not registered by the EMR. Plasmapheresis and dialysis were used to remove residual linezolid and the study drug. Subsequently his lactate decreased to 2.4 and he was extubated. However, given the lack of treatment options for refractory AML the family decided to pursue comfort measures. DISCUSSION: STAT3 is a member of the STAT family of proteins involved in intracellular and extracellular signals to the nucleus, controlling gene expression. STAT3 is involved in AML cells, antiapoptosis genes, cell cycle regulators and promotes OXPHOS (oxidative phosphorylation). A major concern for the use of OXPHOS inhibitors is lactic acidosis. Similarly, linezolid decreases mitochondrial respiratory chain enzyme activity, hence disrupting cellular energy production. In our patient, it is likely that the use of two OXPHOS inhibitors resulted in severe mitochondrial toxicity and lactic acidosis. With new medications being developed that inhibit mitochondrial oxidative phosphorylation, intensive care units may see patients who are suffering from their side effects. CONCLUSIONS: This case highlights the importance of reviewing mechanisms and adverse effects of study drugs. Our case also reminds us that study drugs may not be included in the EMR or not flagged by computerized drug interaction alerts. We believe the use of STAT3 inhibitor and other new OXPHOS inhibitors warrant careful monitoring, particularly when used simultaneously with other medications that increase the risk of mitochondrial toxicity. Reference #1: Redell MS, Ruiz MJ, Alonzo TA, Gerbing RB, Tweardy DJ. Stat3 signaling in acute myeloid leukemia: ligand-dependent and -independent activation and induction of apoptosis by a novel small-molecule Stat3 inhibitor. Blood. 2011;117(21):5701-9. DISCLOSURES: No relevant relationships by Alan Gandler, source=Web Response No relevant relationships by Alexys Monoson, source=Web Response No relevant relationships by David Oxman, source=Web Response No relevant relationships by MRINALINI VENKATA SUBRAMANI, source=Web Response