Acute Drug-induced Liver Injury Research Articles

Gynura segetum-induced liver injury leading to acute liver failure: a case report and literature review

BackgroundGynura segetum (GS) is widely used in medical care and in community settings in China as the herbal remedy. It is widely thought to have antiphlogistic properties and pain relief in traditional Chinese medicine. It has been reported that GS can cause chronic drug-induced liver injury (DILI), manifested as hepatic sinusoid obstruction syndrome (HOSO). But case reports of acute DILI developing acute liver failure (ALF) due to GS are extremely rare.Case presentationWe report a case of a 63-year-old female patient with hepatolithiasis for more than 6 years. There were no deterioration of liver function and no history of viral liver disease, autoimmune liver disease, blood transfusion or surgical allergy before operation. ALF and grade II liver encephalopathy occurred after partial hepatectomy. To follow up the medical history, the patient has been taking GS (Tusanqi) for a year and a half. The causality assessment was done by the updated Roussel Uclaf Causality Assessment Method, and the possibility of DILI caused by GS as highly probable for the score was 6 points. Excluding other causes, a diagnosis of DILI-associated ALF was established. After symptomatic support and artificial liver support system (ALSS) treatment, the clinical symptoms and signs of the patients were significantly improved. After discharge, the liver function of the patients returned to normal.ConclusionsBased on this rare case of severe liver injury, we recommend that timely prevention, identification, and appropriate management of DILI is essential for patients with a history of taking GS and other hepatotoxic drugs, and careful monitoring of liver function for patients with DILI could avoid ALF as far as possible.

Establishment of a Stable Acute Drug-Induced Liver Injury Mouse Model by Sodium Cyclamate.

ObjectiveTo establish a stable acute DILI mouse model and explore its possible pathogenesis.MethodsMice were randomly divided into control, low-dose, middle-dose and high-dose sodium cyclamate groups. Mice in the model group were intraperitoneally injected with corresponding doses of sodium cyclamate, and in the control group intraperitoneally injected with 0.9% normal saline. The toxic effects of sodium cyclamate on liver, heart, kidney were evaluated by biochemical index level and histomorphologically observed. The expression of TNF-α and IL-1β were measured by immunohistochemistry.Results1. The level of ALT in the low-dose and middle-dose groups at 24h, 72h, 120h and 168h were increased, also in the high-dose group at 24h, 72h and 120h. The level of AST in the low-dose group at 72h, 120h, 168h and in the middle-dose group at 168h were increased, also in the middle-dose and high-dose groups at 24h, 72h and 120h. The levels of CK, CK-MB and cTnT in the low-dose and middle-dose groups at 168h were increased, also in the high-dose group at 24h, 72h and 120h. 2. The damage of hepatocytes increased with the increase of sodium cyclamate dosage and treated time. 3. At 120h, the IOD/Area of TNF-α and IL-1β positive expression increased in the liver tissues with the increase of the dosage. In the heart and kidney tissues, the IOD/Area of TNF-α and IL-1β positive expression in the high-dose group increased significantly. In the kidney tissues, the IOD/Area of IL-1β positive expression in the middle-dose group increased significantly.ConclusionSodium cyclamate-induced acute DILI mouse model can be established by intraperitoneal injection of 6000 mg/kg/day sodium cyclamate for 5 days successfully. The toxicity of sodium cyclamate to liver showed a dose-response and time-response relationship. Sodium cyclamate induced liver, heart and kidney injury closely related to the inflammatory response mediated by TNF-α and IL-1β.

Rebuttal to: The Benevolent Bile: Bile Acids as Stimulants of Liver Regeneration.

Rebuttal to: The Benevolent Bile: Bile Acids as Stimulants of Liver Regeneration.

The Benevolent Bile: Bile Acids as Stimulants of Liver Regeneration

The Benevolent Bile: Bile Acids as Stimulants of Liver Regeneration

Management of Psychiatric Disorders in Patients with Hepatic and Gastrointestinal Diseases.

Management of Psychiatric Disorders in Patients with Hepatic and Gastrointestinal Diseases.

Liver Transplantation for Acute Liver Injury in Asians Is More Likely Due to Herbal and Dietary Supplements.

Drug-induced liver injury (DILI) due to medications and herbal and dietary supplements (HDSs) is a major cause of acute liver injury leading to liver transplantation (LT). This study used United Network for Organ Sharing LT data to analyze severe HDS-induced acute liver injury in the United States. By convention, patients with acute DILI are listed as "Acute Hepatic Necrosis" (AHN) under the subheading "AHN: Drug Other Specify." All patients waitlisted from 1994 to 2020 were divided into 3 subgroups: "HDS DILI," "Non-HDS DILI," and "AHN: unknown drug." Analyses were performed to identify epidemiologic differences between patients with HDS DILI and non-HDS DILI. A subanalysis was performed for transplanted patients, including longitudinal changes. Of 1875 patients waitlisted for LT, 736 (39.2%) underwent LT. The proportion of Asian patients in the HDS DILI group was significantly higher compared with that in the non-HDS DILI group (17.4% versus 3.8%; P<0.001). Excluding acetaminophen cases, the proportion of Black patients in the HDS DILI versus non-HDS group was significantly lower (8.7% versus 25.3%; P<0.001). Waitlisted patients with HDS DILI were significantly older (median age, 38 years for HDS DILI versus 31 years for non-HDS DILI; P=0.03). Lastly, the number of patients requiring LT due to HDS DILI increased significantly over time with more than 70% of cases occurring in the last 10years (2010-2020) compared with the prior 15years (1994-2009; Ptrend =0.001). Ethnicity may help in identifying the cause of severe acute DILI, a growing problem as more patients experiment with HDS.

Deletion of p38γ attenuates ethanol consumption- and acetaminophen-induced liver injury in mice through promoting Dlg1.

Acetaminophen (APAP) is one of the major causes of drug-induced acute liver injury, and ethanol may aggravate APAP-induced liver injury. The problem of ethanol- and APAP-induced liver injury becomes increasingly prominent, but the mechanism of ethanol- and APAP-induced liver injury remains ambiguous. p38γ is one of the four isoforms of P38 mitogen activated protein kinases, that contributes to inflammation in different diseases. In this study we investigated the role of p38γ in ethanol- and APAP-induced liver injury. Liver injury was induced in male C57BL/6 J mice by giving liquid diet containing 5% ethanol (v/v) for 10 days, followed by gavage of ethanol (25% (v/v), 6 g/kg) once or injecting APAP (200 mg/kg, ip), or combined the both treatments. We showed that ethanol significantly aggravated APAP-induced liver injury in C57BL/6 J mice. Moreover, the expression level of p38γ was up-regulated in the liver of ethanol-, APAP- and ethanol+APAP-treated mice. Knockdown of p38γ markedly attenuated liver injury, inflammation, and steatosis in ethanol+APAP-treated mice. Liver sections of p38γ-knockdown mice displayed lower levels of Oil Red O stained dots and small leaky shapes. AML-12 cells were exposed to APAP (5 mM), ethanol (100 mM) or combined treatments. We showed that P38γ was markedly increased in ethanol+APAP-treated AML-12 cells, whereas knockdown of p38γ significantly inhibited inflammation, lipid accumulation and oxidative stress in ethanol+APAP-treated AML-12 cells. Furthermore, we revealed that p38γ could combine with Dlg1, a member of membrane-associated guanylate kinase family. Deletion of p38γ up-regulated the expression level of Dlg1 in ethanol+APAP-treated AML-12 cells. In summary, our results suggest that p38γ functions as an important regulator in ethanol- and APAP-induced liver injury through modulation of Dlg1.

Efficacy of miR-122 Nanoparticle Drug Delivery System on the Patients with Drug-Induced Liver Injury

In order to explore the effect of MiR-122 nanoparticle (NP) drug delivery system (NPDDS) on the condition and curative effect of patients with drug-induced liver injury (DILI). The phosphate buffered saline solution was added to the solution of Monoammonium Glycyrrhizanate (MAG) NPs to make the suspension. Then, 50 μL of the MAG β-cyclodextrin star-shaped cationic polymer solution was added to the 100 μg/mL MiR-122 solution and form MAG/MiR-122 co-loaded NPs. 40 cases of acute DILI patients in hospital were selected as the research subjects. Control group, polymer group, drug-loaded group, and co-loaded group were set up, and fluorescence quantitative PCR was employed to measure the expression level of MiR-122 in the cells. The untreated DILI cells were set as control group, while the MAG/MiR-122 co-loaded NPs-treated DILI cells were set as treatment group. The treatment effects of the two groups were analyzed and compared. The results showed that the MAG/MiR co-loaded NPs prepared were of regular round shape and uniform particle size distribution. The expression of MiR-122 was low in control group, and its content in injured cells was extremely low. The expression of MiR-122 in the co-loaded group was superior to drug-loaded group. The effective rate of drug treatments in treatment group was significantly superior to control group, and the differences were substantial (P &lt; 0.05). The number of red blood cells (RBC) of treatment group decreased notably relative to controls, while differences on white blood cells (WBC) and platelets (PLT) between two groups were not considerable (P &gt; 0.05). In conclusion, MAG/MiR co-loaded NPs can effectively improve the therapeutic effect of DILI. Moreover, early DILI screening can be implemented by detecting the expression level of MiR-122 in the cells of DILI patients.

The Immunological Mechanisms and Immune-Based Biomarkers of Drug-Induced Liver Injury.

Drug-induced liver injury (DILI) has become one of the major challenges of drug safety all over the word. So far, about 1,100 commonly used drugs including the medications used regularly, herbal and/or dietary supplements, have been reported to induce liver injury. Moreover, DILI is the main cause of the interruption of new drugs development and drugs withdrawn from the pharmaceutical market. Acute DILI may evolve into chronic DILI or even worse, commonly lead to life-threatening acute liver failure in Western countries. It is generally considered to have a close relationship to genetic factors, environmental risk factors, and host immunity, through the drug itself or its metabolites, leading to a series of cellular events, such as haptenization and immune response activation. Despite many researches on DILI, the specific biomarkers about it are not applicable to clinical diagnosis, which still relies on the exclusion of other causes of liver disease in clinical practice as before. Additionally, circumstantial evidence has suggested that DILI is mediated by the immune system. Here, we review the underlying mechanisms of the immune response to DILI and provide guidance for the future development of biomarkers for the early detection, prediction, and diagnosis of DILI.

Potential Effects of Dietary Isoflavones on Drug-Induced Liver Injury

Numerous prescribed drugs and herbal and dietary supplements have been reported to cause drug-induced acute liver injury, which is a frequent cause of acute liver failure (ALF). It is a tremendous challenge with ever-increasing drug application in the medication system for huge populations. Drug-induced acute liver injury can lead to diverse pathologies similar to acute and chronic hepatitis, acute liver failure, biliary obstruction, fatty liver disease, and so on. Recently, extensive work demonstrated that isoflavones play an essential and protecting role in drug-induced liver injury (DILI). The isoflavones mediated hepatoprotection by modulating specific genes linked with control of cellular redox homeostasis and inflammatory responses. Isoflavones upregulate oxidative stress-responsive nuclear factor erythroid 2-like 2 (Nrf2), downregulate inflammatory nuclear factor-κB (NF-κB) signaling pathways, and modulate a balance between cell survival and death. Moreover, isoflavones actively inhibit the expression of cytochromes P450 (CYPs) enzyme during drug metabolism. Moreover, isoflavones are also linked with farnesoid X receptor (FXR) activation and signal transducer and activator of transcription factor 3 (STAT3) phosphorylation in hepatoprotection DILI. In vivo and in vitro studies clearly stated that isoflavones bear strong antioxidant potential and promising agents for hepatotoxicity prevention and stressed their potential role as therapeutic supplements in DILI. The current review will elaborate on isoflavones’ preventive and therapeutic potential concisely and highlight various molecular targets to exert a protective effect on DILI.

ZnT8 Deficiency Protects From APAP-Induced Acute Liver Injury by Reducing Oxidative Stress Through Upregulating Hepatic Zinc and Metallothioneins.

Zinc transporter 8 (ZnT8) is an important zinc transporter highly expressed in pancreatic islets. Deficiency of ZnT8 leads to a marked decrease in islet zinc, which is thought to prevent liver diseases associated with oxidative stress. Herein, we aimed to investigate whether loss of islet zinc affects the antioxidant capacity of the liver and acute drug-induced liver injury. To address this question, we treated ZnT8 knockout (KO) or wild-type control mice with 300 mg/ kg acetaminophen (APAP) or phosphate-buffered saline (PBS). Unexpectedly, we found that loss of ZnT8 in mice ameliorated APAP-induced injury and was accompanied by inhibition of c-Jun N-terminal kinase (JNK) activation, reduced hepatocyte death, and decreased serum levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). An increase in hepatic glutathione (GSH) was observed, corresponding to a decrease in malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE) levels. APAP-induced inflammation and glycogen depletion were alleviated. In contrast, no significant changes were observed in cytochrome P450 family 2 subfamily E member 1 (CYP2E1), the main enzyme responsible for drug metabolism. Elevated levels of hepatic zinc and metallothionein (MT) were also observed, which may contribute to the hepatoprotective effect in ZnT8 KO mice. Taken together, these results suggest that ZnT8 deficiency protects the liver from APAP toxicity by attenuating oxidative stress and promoting hepatocyte proliferation. This study provides new insights into the functions of ZnT8 and zinc as key mediators linking pancreatic and hepatic functions.

CD36 deficiency ameliorates drug-induced acute liver injury in mice

BackgroundAcetaminophen (APAP) overdose causes hepatotoxicity and even acute liver failure. Recent studies indicate that sterile inflammation and innate immune cells may play important roles in damage-induced hepatocytes regeneration and liver repair. The scavenger receptor CD36 has its crucial functions in sterile inflammation. However, the roles of CD36 in APAP induced acute liver injury remain unclear and warrant further investigation.MethodsWT C57BL/6 J and CD36−/− mice were intraperitoneally injected with APAP (300 mg/kg) after fasting for 16 h. Liver injury was evaluated by serum alanine aminotransferase (ALT) level and liver tissue hematoxylin and eosin (H&E) staining. Liver inflammatory factor expression was determined by real-time polymerase chain reaction (PCR). The protein adducts forming from the metabolite of APAP and the metabolism enzyme cytochrome P450 2E1 (CYP2E1) levels were measured by Western blot. Liver infiltrating macrophages and neutrophils were characterized by flow cytometry. RNA sequencing and Western blot were used to evaluate the effect of damage-associated molecular patterns (DAMP) molecule high mobility group B1 (HMGB1) on WT and CD36−/− macrophages. Moreover, PP2, a Src kinase inhibitor, blocking CD36 signaling, was applied in APAP model.ResultsThe expression of CD36 was increased in the liver of mice after APAP treatment. Compared with WT mice, APAP treated CD36−/− mice show less liver injury. There was no significant difference in APAP protein adducts and CYP2E1 expression between these two strains. However, reduced pro-inflammatory factor mRNA expression and serum IL-1β level were observed in APAP treated CD36−/− mice as well as infiltrating macrophages and neutrophils. Moreover, CD36 deficiency impaired the activation of c-Jun N-terminal kinase (JNK) caused by APAP. Interestingly, the lack of CD36 reduced the activation of extracellular regulated protein kinases (Erk) and v-akt murine thymoma viral oncogene homolog (Akt) induced by HMGB1. RNA transcription sequencing data indicated that HMGB1 has a different effect on WT and CD36−/− macrophages. Furthermore, treatment with PP2 attenuated APAP induced mouse liver injury.ConclusionOur data demonstrated that CD36 deficiency ameliorated APAP-induced acute liver injury and inflammatory responses by decreasing JNK activation. CD36 might serve as a new target to reduce acute liver injury.

Wavelength-Tunable, Long Lifetime, and Biocompatible Luminescent Nanoparticles Based on a Vitamin E-Derived Material for Inflammation and Tumor Imaging.

Luminescence imaging is one of the most effective noninvasive strategies for detection and stratification of inflammation and oxidative stress that are closely related to the pathogenesis of numerous acute and chronic diseases. Herein biocompatible nanoparticles based on a peroxalate ester derived from vitamin E (defined as OVE) are developed. In combination with different fluorophores, OVE can generate luminescence systems with emission wavelengths varying from blue to the near-infrared light in its native and nanoparticle forms, in the presence of hydrogen peroxide (H2 O2 ). The OVE-based nanoprobes exhibit high luminescence signals with extremely long lifetime, upon triggering by inflammatory conditions with abnormally elevated H2 O2 . Activated neutrophils and macrophages can be illuminated by this type of luminescent nanoprobes, with luminescence intensities positively correlated with inflammatory cell counts. In mouse models of peritonitis, alcoholic liver injury, drug-induced acute liver injury, and acute lung injury, the developed luminescence nanoprobes enable precision imaging of inflammation and disease progression. Moreover, tumors expressing a high level of H2 O2 can be shined. Importantly, the OVE-based nanoplatform shows excellent in vitro and in vivo biocompatibility.

Clinical features of patients with different types of acute drug-induced liver injury: A comparative analysis

Clinical features of patients with different types of acute drug-induced liver injury: A comparative analysis

Exogenous activation of toll-like receptor 5 signaling mitigates acetaminophen-induced hepatotoxicity in mice

Acetaminophen (APAP) poisoning is the most common cause of drug-induced acute liver injury (ALI). Our results showed that toll-like receptor 5 (TLR5) was abundantly expressed in hepatocytes and dramatically downregulated in the toxic mouse livers. Hence, we herein investigated the role of TLR5 signaling after APAP overdose. Mice were intraperitoneally (i.p.) injected with APAP to induce ALI, and then injected with flagellin at one hour after APAP administration. Flagellin attenuated APAP-induced ALI based on decreased histopathologic lesions, serum biochemical, oxidative stress, and inflammation. Furthermore, the protective effects of flagellin were abolished by TH1020 (a TLR5 antagonist) treatment. These results suggest that flagellin exerted protective effects on ALI via TLR5 activation. Mechanistically, flagellin injection promoted the translocation of nuclear factor erythroid 2-related factor 2 (Nrf2) to the nucleus in hepatocytes. Consistent with the in vivo results, flagellin increased the activation of Nrf2 in hepatocytes, resulting in decreased APAP toxicity. ML385, a selective inhibitor of Nrf2, abolished the flagellin-mediated hepatoprotective effects in damaged livers and hepatocytes. Additionally, the flagellin-induced Nrf2 translocation was dependent upon the activation of TLR5-JNK/p38 pathways. These findings suggest that TLR5 signaling-induced Nrf2 activation, at least partially, contributed to the protection against APAP-induced ALI by flagellin treatment.

High Serum Estradiol Reduces Acute Hepatotoxicity Risk Induced by Epirubicin Plus Cyclophosphamide Chemotherapy in Premenopausal Women with Breast Cancer.

Aim: We evaluated whether acute drug-induced liver injury (DILI) caused by adjuvant chemotherapy with epirubicin plus cyclophosphamide for early breast cancer was associated with estradiol (E2), luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Methods: Reproductive hormone test results of breast cancer patients were collected in the first chemotherapy cycle. E2, LH, and FSH levels were loge-transformed to normally distributed variables and were assessed using Student’s t-test to determine significant differences between the case and control groups. Hormone levels were classified according to the interquartile range and analyzed by logistic regression to determine their association with DILI caused by chemotherapy. Results: Among the 915 enrolled patients (DILI group: 204; control group: 711), menopausal status, along with serum E2, LH, and FSH levels, did not substantially differ between case and control groups. However, in the premenopause subgroup (n = 483), we found a significant difference in the E2 level between the case and control groups (p = 0.001). After adjusting for age and body mass index, premenopausal patients with 152–2,813 pg/mL E2 showed a lower risk of chemotherapy-induced DILI than patients with ≤20 pg/mL E2 (odds ratio: 0.394; 95% confidence interval: 0.207–0.748). The linear trend χ2 test revealed that E2 levels in premenopausal patients with breast cancer were inversely associated with the development of DILI. Conclusion: High serum E2 levels are associated with a reduced DILI risk in premenopausal patients with breast cancer undergoing epirubicin plus cyclophosphamide adjuvant chemotherapy.

A highly selective ratiometric molecular probe for imaging peroxynitrite during drug-induced acute liver injury.

Drug-induced acute liver injury (DIALI) is a common liver disease, affecting a number of people worldwide with increasing morbidity each year. Thus, it is vital to develop new tools for intervention and diagnosis. Peroxynitrite (ONOO-), a highly reactive species, plays an important role in the DIALI process. Thus, in situ molecular imaging of endogenous ONOO- levels is considerably significant for detecting ONOO-. In this work, we present two destroyed-type ratiometric fluorescent probes, AHC and AHMC, for ONOO- detection by using a molecular hybridization strategy. The probe AHMC was developed by introducing the ester structure to AHC directly to enhance its membrane penetrability for living cell imaging. Probe AHC exhibited good analytical performance toward ONOO- compared to other reactive species, with a low detection limit (≈1.8 nM) and a strong ratiometric fluorescence response (134-fold). In cell imaging experiments, AHMC showed outstanding selectivity, favourable biocompatibility and mitochondria-targeting ability, which not only was used to detect endogenous and exogenous ONOO- changes, but also enabled noninvasive visualization of ONOO- generation in a different drug-induced DIALI model. We hope that these ratiometric probes can be useful chemical tools for the in-depth research of drug-induced acute hepatotoxicity.

Clinical manifestations and typing of drug-induced liver injury

Drug-induced liver injury (DILI) is one of the most common and severe adverse drug reactions in humans, which may lead to liver failure and even death in some patients. Liver injury caused by different drugs has various clinical manifestations and severities, and most patients with DILI have no symptoms or have mild symptoms. There are various typing methods for DILI based on clinical features, course of disease, and pathogenesis. According to the R value, DILI can be classified into hepatocellular injury type (R ≥5), cholestasis type (R ≤2), and mixed type (2 < R < 5); according to the course of the disease, DILI can be classified into acute DILI and chronic DILI; according to the pathogenesis, DILI can be classified into intrinsic DILI, idiosyncratic DILI, and indirect DILI. A comprehensive understanding of the clinical manifestations and typing methods of DILI helps to reveal its pathogenesis and perform diagnosis and treatment in a timely manner.

Design Strategy of Fluorescent Probes for Live Drug-Induced Acute Liver Injury Imaging

Drug-induced acute liver injury (DIALI) is increasingly recognized as a significant cause of acute liver injury (ALI), which is characterized by a rapid loss of hepatocyte function in patients without pre-existing liver diseases. Evaluation of corresponding biomarkers, including alanine transaminase and aspartate amino transferase, is available as a diagnostic tool for hepatotoxicity. However, these blood tests have certain limitations: (1) they are generally not available for early estimation; (2) it is difficult to visualize and identify hepatotoxicity unambiguously in real-time; and (3) the biomarkers are not unique and are usually influenced by a variety of diseases, leading to potential false results. It is of grave importance and burgeoning demand to develop an early diagnostic approach for such diseases, but the ideal toolkit remains an unresolved challenge.As an alternative, molecular optical probes (fluorescence, chemiluminescence, bioluminescence, etc.) display a lot of advantages, such as high sensitivity, noninvasive fast analysis, and real-time in situ detection. They have emerged as potent and promising tools for the biomedical study of DIALI in living system. Until now, a number of optical probes for DIALI have been reported with some great potential for clinical trials. However, most of the probes still suffer from false signals because of the limitations in clinical application, including poor selectivity, low sensitivity, and biocompatibility. One key challenge that probes face in the ALI environment is the excessive exposure to reactive oxygen/nitrogen species and diffusivity, which may lead to false-positive or negative signals.Our group has employed multiple rational approaches to engineer high-performance optical probes for DIALI. With such development, we have successfully achieved the accurate detection of DIALI with minimal false signals both ex vivo and in vivo. While marching firmly toward understanding the biogenesis and progression of DIALI, we ultimately aim at the early stage clinical diagnosis of the disease, as well as mechanism understanding for clinical trials. In this Account, we summarize and present our three new approaches for the development of high-fidelity optical probes: (1) a combined screening and rational design strategy, (2) a double-locked probe design strategy, and (3) in situ imaging based on the release of a precipitating fluorochrome strategy. Using these strategies, we have formulated probes for a range of biological species that are biomarkers of DIALI, including reactive nitrogen species (ONOO-), reactive sulfur species (H2S and H2Sn), and enzymes (LAP, MAO, and ALP). We have highlighted the rationale for our design and screening strategy and methods to achieve high-fidelity optical probes. Some recent examples of optical probes developed by our laboratory and collaborations are mainly illustrated herein. We anticipate the strategies summarized here to inspire future molecular optical probe design, to contribute to studies of the detailed molecular mechanisms underlying liver diseases, and to improve the efficiency of the diagnosis and treatment of these diseases in clinical settings.

Consensus Guidelines: Best Practices for Detection, Assessment and Management of Suspected Acute Drug-Induced Liver Injury During Clinical Trials in Adults with Chronic Viral Hepatitis and Adults with Cirrhosis Secondary to Hepatitis B, C and Nonalcoholic Steatohepatitis.

With the widespread development of new drugs to treat chronic liver diseases (CLDs), including viral hepatitis and nonalcoholic steatohepatitis (NASH), more patients are entering trials with abnormal baseline liver tests and with advanced liver injury, including cirrhosis. The current regulatory guidelines addressing the monitoring, diagnosis, and management of suspected drug-induced liver injury (DILI) during clinical trials primarily address individuals entering with normal baseline liver tests. Using the same laboratory criteria cited as signals of potential DILI in studies involving patients with no underlying liver disease and normal baseline liver tests may result in premature and unnecessary cessation of a study drug in a clinical trial population whose abnormal and fluctuating liver tests are actually due to their underlying CLD. This position paper focuses on defining best practices for the detection, monitoring, diagnosis, and management of suspected acute DILI during clinical trials in patients with CLD, including hepatitis C virus (HCV) and hepatitis B virus (HBV), both with and without cirrhosis and NASH with cirrhosis. This is one of several position papers developed by the IQ DILI Initiative, comprising members from 16 pharmaceutical companies in collaboration with DILI experts from academia and regulatory agencies. It is based on an extensive literature review and discussions between industry members and experts from outside industry to achieve consensus regarding the recommendations. Key conclusions and recommendations include (1) the importance of establishing laboratory criteria that signal potential DILI events and that fit the disease indication being studied in the clinical trial based on knowledge of the natural history of test fluctuations in that disease; (2) establishing a pretreatment value that is based on more than one screening determination, and revising that baseline during the trial if a new nadir is achieved during treatment; (3) basing rules for increased monitoring and for stopping drug for potential DILI on multiples of baseline liver test values and/or a threshold value rather than multiples of the upper limit of normal (ULN) for that test; (4) making use of more sensitive tests of liver function, including direct bilirubin (DB) or combined parameters such as aspartate transaminase:alanine transaminase (AST:ALT) ratio or model for end-stage liver disease (MELD) to signal potential DILI, especially in studies of patients with cirrhosis; and (5) being aware of potential confounders related to complications of the disease being studied that may masquerade as DILI events.Electronic supplementary materialThe online version of this article (10.1007/s40264-020-01014-2) contains supplementary material, which is available to authorized users.