8 june 2004ncac society of toxicology1 detecting liver injury: drug-induced or not ? john r. senior,...

8 June 2004 NCAC Society of Toxicology 1

Detecting Liver Injury:Drug-Induced or Not ?

John R. Senior, M.D., HepatologistAssociate Director for Science

Office of Pharmacoepidemiology and Statistical Science

Food and Drug Administration (FDA)


Material presented here is based on the experiences of the speaker for 20 years in academic hepatology and gastroenterology, 5 years as a senior executive in the pharmaceutical industry, 11 years in private consulting to industry. Then at the FDA, 4 years medical reviewer for new gastrointestinal drugs, 3 years senior scientific advisor for hepatology in the Office of Drug Safety, and 2 years as Associate Director for Science, Office of Pharmacoepidemiology and Statistical Science. The comments do not reflect official policies or positions of the Agency, but are personal opinions of the presenter based on the diverse experiences mentioned.


First Ask:

• Is there liver injury or disease?

• Is it progressive or serious?–progressive = getting worse or likely to do so–serious = disabling, life-threatening, fatal

• Drug-induced or some other cause?– no pathognomonic test for DILI, including biopsy– DILI may mimic any known liver disease


Let’s look first at “some other causes”

• What are they?– acute/chronic; viral, immune, vascular, metabolic

• How can they be detected?– serum transaminases, other enzymes, bilirubin, INR

• How to distinguish from DILI?– no pathognomonic test for DILI, including biopsy– DILI may mimic any known liver disease


Cooperative research between the pharmaceutical industry and FDA

“Adventures with a Placebo Database”

October 2001 - presentJohn R. Senior, M.D., FDA

Robert W. Tipping, M.S., Merck


Special thanks to

Peter Honig, M.D., (FDA); Merck

Harry Guess, Ph.D., (Merck); UNC

Paul Seligman, M.D., FDA

...who made this work possible


Why study placebo participants?• obtain data on incidence of AEs not due to drug

– fundamental assumption: placebos do no harm

• they should be subtracted from those seen on drug• focus on hepatic injury evidence: tests, symptoms• search database for cases of liver injury or disease• aim to establish background rate for incidence• determine what tests are most accurate and how

best to make true attribution of causality• one of the initiatives of the PM “white paper” 2001


What to Look For and Why ?

1) evidence of serious or potentially serious liver diseasenot much interested in transient serum transaminase bumps;liver is a very adaptive organ, handles xenobiotics well

2) ultimate aim - to distinguish drug-induced liver injurydiagnosis of exclusion; must rule out other causes

3) critical need for accurate differential diagnosis need to see serial data, time course of abnormal patterns

what really is causing the abnormal pattern?need more information than just lab test numbers


AFCAPS/TexCAPS Study - 1

• carried out 1990-7, San Antonio & Fort Worth TX• 6605 participants (85% men), 3301 to placebo• men >45 and women >55, up to 73; ambulatory no

previously diagnosed cardiovascular disease• modestly high total cholesterol, reduced HDL-chol• no pre-existing liver disease, or other major disease• willing and able to participate for 4-6 years• aim: show lovastatin-related reduced cardiac events • results published JAMA 1998 and AmJCardiol 2001


AFCAPS/TexCAPS Study - 2

• 5-year observation, 20 (+) visits/test sets/participant• visits: 3 q 2wks (baseline); 8 q 6wks, 9 q 6 mos; • each visit: serum ALT, AST, ALP, TBL, CPK• we chose PLACEBO group (3248 had 5-yr data)• search database for cases of liver injury or disease• our aim: to establish background rate for incidence


Looking for Liver Disease/Injuryhow should the search be done ?

We looked for; 1) any two: ALTx3; (AST/ALP/TBL)x2; CPKx5 @ peak 2) confirmed ALT or AST at least 3xULN 3) ALT or AST 3+xULN AND concurrent TBL 2+xULN 4) symptoms, complaints, diagnoses, AE reports 5) clinical narratives for selected cases 6) review of case report forms if lab abnormalities

12NCAC Society of Toxicology8 June 2004

Distribution of Abnormalitiespeak values among 3301 studied for 5 years

x ULN ALTx ASTx ALPx TBLx CPKxup to 1 2373 2762 3162 2307 1691

<1.50 621 382 122 757 795

<2.00 163 93 10 161 333

<3.00 101 34 3 65 259

<5.00 27 18 1 7 137

<8.00 9 9 3 2 51<10.00 3 1 0 1 12

10+ 4 2 0 1 23


The “First 44” Cases

trt sex age ALTx3 ASTx2 ALPx2 TBLx2 CPKx5

P M 61 2.45 2.35 5.59 7.0 0.72

P M 52 1.50 2.19 0.50 0.8 10.83

P M 70 9.60 3.54 2.42 2.9 0.68

P F 65 5.00 2.59 0.50 0.8 0.55

P F 56 4.35 3.30 1.45 0.6 1.45

P M 59 3.15 7.95 6.65 6.7 4.10

P M 55 3.90 3.03 0.55 0.9 1.12

P M 57 50.25 40.76 1.38 8.8 0.84

etc. to 44 cases


Case M 61, placebo

Day ALTx ASTx ALPx TB Lx CPKx-34 0.45 0.38 0.47 0.7 0.44-14 0.53 0.41 0.48 0.7 0.361 0.50 0.38 0.45 0.7 0.2343 0.38 0.32 0.49 0.8 0.2885 0.50 0.41 0.51 1.0 0.22127 0.38 0.30 0.42 0.5 0.30169 0.53 0.38 0.40 0.7 0.27211 0.48 0.43 0.36 0.6 0.27253 0.40 0.35 0.40 0.8 0.46295 0.40 0.41 0.43 0.7 0.35337 0.38 0.41 0.42 0.8 0.72421 0.40 0.35 0.42 0.8 0.41547 0.45 0.43 0.40 0.7 0.54729 0.75 0.62 0.58 0.4 0.71839 2.20 1.97 2.71 0.9919 2.45 2.35 5.59 7.0 0.36


Time Course of Serum TestsParticipant M 61, placebo

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Days on Study Drug

Log(

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f Rat

io to

ULN

ALT

AST

ALP

TBL

CPK

stopstart died, amyloidosis

3.2 xULN

upper limit of normal, ULN

10 x ULN

32 x ULN


Time Course of Serum TestsParticipant , M 70, placebo

-1.0

-0.5

0.0

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Log(

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f Rat

io to

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ALT

AST

ALP

TBL

CPK

start

10 x ULN

32 x ULN

3.2 x ULN

stop

gallstones!

2 x ULN

chronic cholecystitis flare


Time Course of Serum TestsParticipant, M 49, placebo

-1.0

-0.5

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f Rat

io to

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AST

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TBL

CPK

start

upper limit of normal

3.2 x ULN

10 x ULN

32 x ULNacute calculous cholecystitis

2 x ULN

lap cholecx



-1.0

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Days on Study Drug

Lo

g(1

0)

of

Rati

on

to

UL

N

ALT

AST

ALP

TBL

CPK

start stop

viral hepatitis B

2 x ULN

ULN

3.2 x ULN

10 x ULN

32 x ULN



-1.0

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of R

atio

to

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ALT

AST

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TBL

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startstop

metastatic CA to liver


2 x ULN

3.2 x ULN

10 x ULN

32 x ULN

died



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LN

ALT

AST

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CPKstart

upper limit of normal, ULN 2 x ULN

3.2 x ULN

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32 x ULN

acute hepatitis A



-1.0

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6012

018

024

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Days on Study Drug

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start

Gilbert's syndrome


Time Course of Serum TestsParticipant, F 64, placebo

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start


3.2 x ULN

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32 x ULN


The “Next 87” Cases - 2

• Liver function abnormality (no symptom) 27

• Cholecystitis, cholelithiasis, or both 37• 3 acute, 1 gangrenous, 1 perforated, 1 pancreatitis

• Pruritus 9; Fatty Liver 7; Cholesteatoma 2

• Cholangiocarcinoma, Hepatitis, Liver Cyst, Cholestasis, Jaundice: 1 each


Sensitivity-Specificity for 6 of 3248

Test Criteria test + detected sensitivity specificity PPP FP error

(ALT or AST) >2xULN 144 6 100.0% 95.74% 4.2% 4.26%

(ALT or AST) >3 xULN 44 5 83.3% 98.80% 11.4% 1.20%

(ALT) >3 xULN 38 5 83.3% 98.98% 13.2% 1.02%

(ALT or AST) >3 xULN, confirmed 11 2 33.3% 99.72% 18.2% 0.28%

(ALT or AST) >5 xULN 18 4 66.7% 99.57% 22.2% 0.43%

(ALT or AST) >5 xULN, confirmed 2 2 33.3% 100.00% 100.0% 0.00%

(ALT or AST)>3xULN & TBL>2xULN 6 5 83.3% 99.97% 83.3% 0.03%


Conclusions - so far

• Serum transaminase elevations not “disease” often may represent transient adaptations

• Requiring “confirming” tests may miss cases unless done very promptly within a few days

• Additional information beyond lab test scores needed for making true causal attribution• AST elevations don’t add much to ALTs, (see

in alcoholic hepatitis, cirrhosis, muscle)• Concurrent total bilirubin elevation suggests

that serum ALT >3xULN may be serious• “Hy’s Rule” may become validated by data


Rich Findings in Placebo Data

I. Concurrent bilirubin rise adds specificity to ALT testing, without losing sensitivity

II. Serum transaminase activities vary greatly, CPK even more, but ALP less so


Where Do Elevated Serum Transaminases Come From

?

John R. Senior, M.D., FDA

Robert W. Tipping, M.S., Merck


The “First 44” Cases

trt sex age ALTx3 ASTx2 ALPx2 TBLx2 CPKx5

P M 61 2.45 2.35 5.59 7.0 0.72

P M 52 1.50 2.19 0.50 0.8 10.83

P M 70 9.60 3.54 2.42 2.9 0.68

P F 65 5.00 2.59 0.50 0.8 0.55

P M 59 3.15 7.95 6.65 6.7 4.10

P M 55 3.90 3.03 0.55 0.9 1.12

P M 57 50.25 40.76 1.38 8.8 0.84

etc. to 44 cases


But, no evidence of liver disease:

trt sex age ALTx3 ASTx2 ALPx2 TBLx2 CPKx5P M 52 1.50 2.19 0.50 0.8 10.8

So, why the rises in transaminases?


sex age CPKx ASTx ALTx remarksM52 10.83 2.19 1.50 recent carpentry work, with some expected muscle soreness

M55 14.92 1.51 0.98 no new AEs or meds

M61 16.54 1.35 0.65 no new AEs or meds; total serum bilirubin increased

M53 15.87 1.84 0.83 pushed lawn mower, asymptomatic

M48 13.59 1.30 1.08 asymptomatic, normal aldolase (Day -68)

M59 13.28 1.97 0.98 asymptomatic, no cause noted

M57 21.18 2.78 1.78 started weight program at gym 5 days/week, mild soreness

M58 29.53 1.84 1.18 performing laborious work prior to lab draw

M53 12.54 1.11 0.58 heavy yard work day prior to draw, asymptomatic

M54 12.20 1.49 0.98 repetitive heavy weight lifting

M56 21.11 1.51 0.50 asymptomatic, no cause noted

M54 11.55 2.62 0.78 working out with weights

M48 10.86 1.51 0.88 worked out with weights and jogged, no chest pain

M53 30.51 3.08 1.48 working out at gym for 1.5 weeks

M47 24.06 2.30 1.63 is working out a lotM45 10.25 0.59 0.33 extensive yard work recently

M69 16.66 2.24 0.78 moved furniture weekend before blood draw

M47 10.02 2.16 1.18 no cause identified

M58 17.42 3.89 1.00 started going to gym

M47 96.82 7.38 3.33 weight lifting, tried too much weight

M60 13.68 1.65 0.78 no known cause

F58 12.01 1.00 1.38 "repeat CPK normal; likely lab fault" (Day -47)

F69 13.34 1.27 0.48 asymptomatic; no trauma or vigorous activity


AST & ALT and CPK Rises

sex age CPKx ASTx ALTxM47 10.02 2.16 1.18M45 10.25 0.59 0.33M52 10.83 2.19 1.50M48 10.86 1.51 0.88M54 11.55 2.62 0.78F58 12.01 1.00 1.38M54 12.20 1.49 0.98M53 12.54 1.11 0.58M59 13.28 1.97 0.98F69 13.34 1.27 0.48M48 13.59 1.30 1.08M60 13.68 1.65 0.78M55 14.92 1.51 0.98M53 15.87 1.84 0.83M61 16.54 1.35 0.65M69 16.66 2.24 0.78M58 17.42 3.89 1.00M56 21.11 1.51 0.50M57 21.18 2.78 1.78M47 24.06 2.30 1.63M58 29.53 1.84 1.18M53 30.51 3.08 1.48M47 96.82 7.38 3.33

sort data by ascendingCPK values:


Transaminase Elevations with CPK >10xULN

0

1

2

3

4

5

6

7

80 10 20 30 40 50 60 70 80 90 100

Serum CPK Activity xULN

Ser

um A

ST

& A

LT,

xULN

ASTx

ALTx

AST slope 0.067; r 0.87

ALT slope 0.029; r 0.83


Two questions:

1) What is the source of the elevated

serum transaminase activities?

2) Does CPK >10xULN really indicate muscle disease (“myopathy”)?


muscle liver

alanine aminotransferase (ALT) 750:1 7600:1

aspartate aminotransferase (AST) 5200:1 9000:1

lactate dehydrogenase LDH) 1400:1 1400:1

pyruvate kinase (PK) 6200:1 1400:1

creatine phosphokinase (CK) 20000:1 300:1

Geigy Scientific Tables, 1984: Volume 3, page 169

Organ/Serum Activity Ratios


Body Composition(Geigy Scientific Tables, 1993; 70- kg man)

• skeletal muscle - 43% about 30 kg• skin, s.c. tissues - 26% about 18 kg• bony skeleton - 17% about 12 kg• liver - 2.1% about 1.5 kg• brain - 2.0% about 1.3 kg• intestines - 2.0% about 1.3 kg• kidneys - 0.5% about 0.3 kg• heart - 0.5% about 0.3 kg


• acute muscle breakdown - rhabdomyolysis (both ALT, AST and bilirubin elevations)

• various muscular dystrophies, myopathies

• muscular exertion; anorexia nervosa

• acute myocardial infarction• intestinal celiac disease, untreated

(becomes normal on gluten-free diet)

Non-Liver Transaminasemia


Can Muscle Injury Be Confused with Hepatotoxicity ?

• aspartate (AST) & alanine aminotransferase (ALT), in addition to creatine phosphokinase (CPK) released;

• release of muscle myoglobin into plasma - contains one molecule of heme that can become bilirubin;

• renal failure (hepatorenal syndrome) also seen with acute liver failure . . . reversed by liver transplantation


But they’re still saying . .

“Whereas ALT is localized primarily to the liver, AST is present in a variety of tissues, including liver, heart, skeletal muscle, kidney, brain, pancreas, lungs, leukocytes, and erythrocytes.”

Zakim and Boyer. HEPATOLOGY, A Textbook

of Liver Disease, 4th Edition, 2003. Friedman, Martin, Munoz: page 662.


Functions of the Adult Liver• extract and process nutrients from gut

• synthesize proteins, other molecules

• regulate intermediary metabolism

• metabolize steroid hormones, insulin

• extract bilirubin from plasma, excrete

• control cholesterol metabolism/bile acids

• handle xenobiotic substances, drugs• but NOT to regulate serum enzyme levels !


Commonly Used Tests

enzymes

“transaminases”: ALT (SGPT)

AST (SGOT)

alkaline phosphatase

gamma-glutamyl transferase

substances

bilirubin

albumin

prothrombin

injury

hepatocellular

obstructive

function

excretory

synthetic

synthetic


Is Serum ALT a Liver Function Test ?

• serum enzyme activity not just from liver but from skeletal and heart muscle, gut, etc.

• . . . so let’s not say “liver”

• it is not a function or job of the liver to regulate the level of serum enzyme activity

• . . . so let’s not say “function”

• elevated serum ALT activity MAYMAY indicate hepatocellular injury


Maybe we should look closer . . .

• Note if serum transaminases elevated at the same time as serum CPK;

• Work up immediately, with daily measures of CPK, AST, ALT, plus ALP, TBL and DBL, PT (INR), maybe GST, Cr;

• Get full history of muscle exertion or injury and of liver diseases, alcohol, viruses A-C


Two questions:

1) What is the source of the elevated

serum transaminase activities?

2) Does CPK >10xULN really indicate muscle disease (“myopathy”) or

rhabdomyolysis ?


Serum CPK-Transaminase Values#13, White Male 47, lifted too heavy weights

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Log1

0 (x

ULN

)

CPK

AST

ALT

2xULN3xULN

10xULN

ULN

100xULN


Serum CPK-Transaminase Values#10 White Male 56 - asymptomatic

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Time Course of Serum Tests#13, WM 53, worked in gym 10 days

-1.0

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f R

ises

xU

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AST

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TBL

CPK

upper limit of normal

3.2 xULN

10 xULN

32 xULN

worked out at gym


“Myopathy” (muscle disease) ? :

1) Unexplained muscle pain or weakness

2) CPK >10xULN


Rhabdomyolysis:

1) Severe muscle breakdown

2) Myoglobinuria

3) Renal insufficiency


rhabdo - myo - lysis (striped - muscle - dissolution)

SKELETAL CARDIAC VISCERAL

striated striated smooth

voluntary involuntary involuntary


Heme-positive Urine

Hemoglobinuria• from red blood cells• MW 64,500• 4 hemes/molecule

• Cren slow, pink plasma

• methemalbuminemia

• HbO2 576-8 nm

• COHb 571 nm

Myoglobinuria• from muscle cells• MW 17,500• 1 heme/molecule

• Cren fast, clear plasma

• no methemalbuminemia

• MbO2 581-3 nm

• COMb 579 nm


Is it worthwhile ?• “statins” becoming most used drugs in world

• widespread belief that the ALT, AST rises reflect liver injury

• hepatotoxicity probably vastly overstated

• mild muscle injury is not rhabdomyolysis, or even myopathy

• need data on closely time-related correlations of serum CPK, ALT, AST, other changes


More Conclusions• serum transaminase elevations not all hepatic

• investigate AST, ALT elevations – do CPK

• statin hepatotoxicity probably much overstated

• moderate exertional mild muscle injury is not rhabdomyolysis, or even myopathy

• need data on closely time-related correlations of serum CPK, ALT, AST, other changes

• serum T1/2 of CPK < AST <ALT – needs proof


Rich Findings in Placebo Data

I. Concurrent bilirubin rise adds specificity to ALT testing, without losing sensitivity

II. Serum transaminase activities vary greatly, as do CPK, and ALP less so

III. Some AST, a little ALT comes from muscle

IV. “Baseline” better determined by >1 point


It may be DILI if it’s nothing else

1. Diagnosis of exclusion; no test FOR DILI2. Must gather data to rule out other causes3. Need to educate people to do it better4. Develop model for quantitative likelihood5. Prospective large studies needed

- for true incidence- for risk factors- for ‘omic analyses (gen-, prote-, metabon-) specimens- for mechanism elucidation

8 june 2004ncac society of toxicology1 detecting liver injury: drug-induced or not ? john r. senior,...

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