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Dr. Bob is Robert Hsiung, MD,
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Posted by Phillipa on January 2, 2014, at 20:47:49
Seems now that liver injury that is irreversible is common with certain antidepressants. Another not good new finding. PJ
Medscape Medical News > PsychiatryAntidepressant-Induced Liver Injury Underestimated
Megan Brooks
December 31, 2013
All antidepressant drugs may potentially cause liver injury, even at recommended doses, and some groups are more vulnerable than others, French researchers report.
"Antidepressant liver toxicity has been underestimated in the scientific literature," say Gabriel Perlemuter, MD, PhD, from AP-HP Hôpital Bicêtre, Kremlin-Bicêtre, France, and colleagues.
In some cases, antidepressant-induced liver injury can be irreversible. Given that there currently is no strategy available to prevent antidepressant-induced liver injury, "early detection and prompt drug discontinuation remain critical," they say.
Their research was published online December 20 in the American Journal of Psychiatry.
Liver Injury Unpredictable
The investigators reviewed clinical data on antidepressant-induced liver injury from 158 reports, including 88 case reports, 38 original articles, and 32 reviews.
They calculate that 0.5% to 3% of patients treated with antidepressants may develop asymptomatic mild elevation of serum alanine aminotransferase (ALT) levels.
In most cases, liver damage is "idiosyncratic and unpredictable, and it is generally unrelated to drug dosage," they say. Liver damage may occur between several days and 6 months after initiation of an antidepressant.
All antidepressants can induce hepatotoxicity, especially in elderly patients and those who take multiple pharmaceutical agents. However, there is not enough evidence to draw "rigorous conclusions" about the prevalence and severity of antidepressant-induced liver injury, the investigators say.
Based on the evidence, the antidepressants associated with highest risk for hepatotoxicity are monoamine oxidase (MAO) inhibitors, tricyclic/tetracyclic antidepressants, nefazodone, bupropion, duloxetine, and agomelatine. Those with seemingly lower risks are citalopram, escitalopram, paroxetine, and fluvoxamine.
Life-threatening or severe drug-induced liver injury has been reported for some antidepressants, including MAO inhibitors, tricyclic/tetracyclic antidepressants, venlafaxine, duloxetine, sertraline, bupropion, nefazodone, trazodone, and agomelatine, Dr. Perlemuter and colleagues report.
Although no dose-response relationship has been clearly demonstrated, it is best to stick to the minimum effective dosages of antidepressants to reduce the risk for liver injury, they advise.
Use With Caution
Dr. Perlemuter and colleagues say that antidepressants with a higher potential for hepatotoxicity "should be used with caution in elderly patients, in patients with coprescriptions, and in patients with substantial alcohol use, illicit substance use, or evidence of chronic liver disease."
"Systematic pretherapeutic screening and regular assessment of hepatic enzymes during treatment may be useful for antidepressants with a high potential for hepatotoxicity and for patients with known risk factors," they add.
It is also important to tell patients taking an antidepressant about the possibility of liver abnormalities, to encourage them to report any clinical symptoms suggestive of liver problems, and to stop treatment if jaundice develops, the researchers say.
Antidepressants "should be discontinued immediately" in any patient with suspected drug-induced liver injury, they write.
Dr. Perlemuter has received travel funds from Janssen, Gilead, and Roche, consulting fees from Bayer, Biocodex, Physiogenex, and Servier, and royalties from Elsevier-Masson. The original article contains a complete list of author disclosures.
Am J Psychiatry. Published online December 20, 2013
Posted by vbs on January 5, 2014, at 14:52:26
In reply to Antidepressant Liver Injury Common Certain Ad's, posted by Phillipa on January 2, 2014, at 20:47:49
I think liver injury is more common if you consume alcohol on top of your AD.
Posted by PaulM78704 on January 17, 2014, at 15:07:47
In reply to Antidepressant Liver Injury Common Certain Ad's, posted by Phillipa on January 2, 2014, at 20:47:49
They are not saying severe and irreversible liver damage is "common". "They calculate that 0.5% to 3% of patients treated with antidepressants may develop asymptomatic mild elevation of serum alanine aminotransferase (ALT) levels."
Oddly, According to the American Gastroenterological Association (AGA), 1 to 4 percent of the asymptomatic population have elevated serum liver chemistries! See http://www.aafp.org/afp/2005/0315/p1105.html
So I am not clear how many cases of elevated ALT or AST are related to medications. However just search for Wellbutrin and liver damage and you will see it is a known risk.
Asymptomatic mild elevation of ALT, suggesting that the liver is under stress, would not be surprising as the liver has to metabolize drugs, as well as alcohol etc. But that does not mean severe irreversible liver damage: in December 2009, 3 months after I stopped drinking, my ALT level was 69 (0 to 44 is normal) but by September 2011 it was back to 21. I am 63 and taking multiple medications for comorbid ADD, major depression, and Generalized Anxiety Disorder with a past history of severe alcohol abuse, so I imagine I am at higher risk than normal.
My psychiatrist orders blood tests at least once a year, and this is stated in the prescribing instructions for drugs like Wellbutrin and Cymbalta (see http://www.webmd.com/mental-health/news/20051017/fda-broadens-liver-warning-for-cymbalta)
ALT, AST and other liver enzyme levels need to be checked for patients at higher risk (elderly, multiple medications, and those taking the higher risk drugs).
The antidepressants associated with highest risk for hepatotoxicity are monoamine oxidase (MAO) inhibitors, tricyclic/tetracyclic antidepressants, nefazodone (Serzone), bupropion (Welbutrin), duloxetine (Cymbalta), and agomelatine (Valdoxan).
The investigators admit that the evidence is scanty, but they say nothing that suggests severe liver damage is common. I would suggest it is rare, except for those with prior liver damage, often caused by past alcohol or drug abuse. Very few cases are irreversible. You are more likely to get liver damage from Tylenol or even taking excessive vitamins (such as Vitamin A or Niacin).
Posted by Phillipa on January 17, 2014, at 21:18:23
In reply to Re: Antidepressant Liver Injury Common Certain Ad's, posted by PaulM78704 on January 17, 2014, at 15:07:47
That's good to know. Older also. Phillipa
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