# Presentation: 121017

## More Adventures: Placebo Database

***John R. Senior, M.D., Hepatologist***
- Associate Director for Science
- Office of Pharmacoepidemiology & Statistical Science
- Food and Drug Administration (FDA)

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Where Do Elevated Serum Transaminases Come From ?

***John R. Senior, M.D., FDA***
***Robert W. Tipping, M.S., Merck***

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## CONFIDENTIAL !
(unpublished information)

     Material and comments presented here are 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 8.5 years at the FDA (4.5 years as a medical reviewer for new gastrointestinal drugs and 4 as senior scientific advisor for hepatology , Office of Drug Safety and associate director for science, Office of Pharmacoepidemiology and Statistical Science).
     They do not reflect official policies or positions of the Agency, but are the personal opinions of the presenter based on the diverse experiences mentioned. Do not cite.

**(unpublished information)**
*     **Material and comments presented here are 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 8.5 years at the FDA (4.5 years as a medical reviewer for new gastrointestinal drugs and 4 as senior scientific advisor for hepatology , Office of Drug Safety and associate director for science, Office of Pharmacoepidemiology and Statistical Science).*
*     **They do not reflect official policies or positions of the Agency, but are the personal opinions of the presenter based on the diverse experiences mentioned. Do not cite.*

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## AFCAPS/TexCAPS Study - 1

-  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

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## AFCAPS/TexCAPS Study - 2

-  carried out 1990-7, San Antonio & Fort Worth TX
-  6605 participants (85% men), 3301 to placebo
-  5-year observation, 20 (+) visits/test sets/participant
-  visits: 3 q 2wks, 8 q 6wks, 9 q 6 mos;
-  each visit: serum ALT, AST, ALP, TBL, CPK
-  search database for cases of liver injury or disease
-  aim to establish background rate for incidence

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## We found . . .

-  using serum transaminase activities to search for peak values in serial measurements, in people _on placebo_, 44 with ALT or AST >3xULN, out of 3248 people followed for up to 5 years
-  but most of them were transient, not progressive to serious or diagnosed liver disease (seen with fatty liver, undiagnosed chronic hepatitis C, other low grade problems)
-  only 6 cases were serious (all hospitalized, 2 died)
-  all 6 showed concurrent transaminase and bilirubin elevations, and none were false positive, but had obstructive features (ALP elevations) and would not have met “Hy’s Law” criteria for drug-induced hepatotoxicity
-  the combined test is sensitive and much more specific for detecting serious liver diseases than transaminases alone

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Conclusions - so far

** ****Serum transaminase elevations not “disease” **
***often may represent transient adaptations***
** ****Requiring “confirming” tests may miss case**
***unless done very promptly within a few days***
*** *****Additional information beyond lab test scores     ****	****needed for making true causal attribution**
** ****Concurrent total bilirubin elevation suggests that ****	****serum ALT >3xULN may be serious**
** ****Still need to validate “Hy’s Rule” by analyses of ****	****data in patients exposed to drugs**

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## The “First 44” Cases

**ALLOC****	****trt****	****sex****	****age****	****ALTx3****	****ASTx2****	****ALPx2****	****TBLx2****	****CPKx5***	*
- 0138	P	M	61	2.45**	****2.35****	****5.59****	****7.0****	**0.72
- 0158	P	M	52	1.50	**2.19****	**0.50	0.8	**10.83****	**
- 1540	P	M	70	**9.60****	****3.54****	****2.42****	****2.9****	**0.68
- 9298	P	F	65	**5.00****	****2.59****	**0.50	0.8	0.55
- 9899	P	F	56	**4.35****	****3.30****	**1.45	0.6	1.45
- 4870	P	M	59	**3.15****	****7.95****	****6.65****	**6.7	4.10
- 6162	P	M	55	**3.90****	****3.03****	**0.55	0.9	1.12
- 5243	P	M	57	**50.25****	****40.76****	**1.38	8.8	0.84
- 				etc.	to 44 cases

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## But, no evidence of liver disease:

**ALLOC****	****trt****	****sex****	****age****	****ALTx3****	****ASTx2****	****ALPx2****	****TBLx2****	****CPKx5***	*
- 0158	P	M	52	1.50	**2.19****	**0.50	0.8	**10.8**
**So, why the rises in transaminases?**

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

- <footer>

- <date/time>

## AST & ALT and CPK Rises

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Two questions:

**1)  What**** ****is the source of the elevated ****	****	****serum transaminase activities?**
**2)  Does CPK >10xULN really indicate ****	****muscle disease (“myopathy”)?**

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

##                                              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

- <footer>

- <date/time>

-                                              **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)

- <footer>

- <date/time>

- 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)

- <footer>

- <date/time>

-   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

## Serum Bilirubin

- <footer>

- <date/time>

***poor aqueous solubility -- mostly albumin-bound***
***    ******reversible -- hydrophobic/electrostatic***
***    ******irreversible in long-standing jaundice -- covalent***

##   red blood cell physiologic senescence
  hemoglobin, m.w. 64,500; 4 hemes/Hb
cytochromes, catalase, peroxidase, 		other enzymes turnover
  minor contribution quantitatively
  muscle pathologic breakdown
  myoglobin, m.w. 17,500; 1 heme/Mb

- <footer>

- <date/time>

-   red blood cell physiologic senescence
-   hemoglobin, m.w. 64,500; 4 hemes/Hb
- cytochromes, catalase, peroxidase, 		other enzymes turnover
-   minor contribution quantitatively
-   muscle pathologic breakdown
-   myoglobin, m.w. 17,500; 1 heme/Mb

- Sources of Heme

## Slide 19

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Slide 20

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Can Muscle Injury Be Confused with Hepatotoxicity ?

- <footer>

- <date/time>

**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.*

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## 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 !***

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Commonly Used Tests

- <footer>

- <date/time>

*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 ***MAY*** indicate hepatocellular injury

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## 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

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Two questions:

**1)  What**** ****is the source of the elevated ****	****	****serum transaminase activities?**
**2)  Does CPK >10xULN really indicate ****	****muscle disease (“myopathy”)?**

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Slide 28

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Slide 29

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Slide 30

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Slide 31

| APPARENT SERUM HALFTIMES OF CPK |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
|  |  | CPK  | Values |  |  |
| # | sex-age | ?peak | follow | days | T1/2 |
|  |  |  |  |  |  |
| 2 | M 55 | 2910 | 247 | 7 | 1.97 |
| 4a | M 48 | 2650 | 511 | 5 | 2.11 |
| 10 | M 56 | 7620 | 387 | 10 | 2.33 |
|  |  | 4117 | 340 | 32 | 8.89 |
|  |  | 15820 | 1191 | 14 | 3.75 |
| 12 | M 48 | 2117 | 300 | 9 | 3.19 |
| 13 | M 53 | 5950 | 567 | 5 | 1.47 |
| 16 | M 69 | 3248 | 332 | 2 | 0.61 |
|  |  |  |  |  |  |
| Note: |                                                                                                                                                                                                                                                |  |  |  |  |
|  |  |  |  |  |  |

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## “Myopathy”  ? :

**1)  Unexplained muscle pain or weakness**
**2)  CPK >10xULN**

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Rhabdomyolysis:

**1)  Severe muscle breakdown**
**2)  Myoglobinuria**
**3)  Renal insufficiency**

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

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

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Case - January 1957

- <footer>

- <date/time>

**Case - January 1957**

- JA, 28-year-old Afro-American man admitted with 5-day history of head cold, malaise, slight cough, feverishness, and dark brown-red urine.
- Also noted weakness, backache, leg pain -- never had red urine before, no injury or exertion.
- Fever 1024, rales @ left base, normal Hb & WBC, UN 21, Cr 1.7, urine protein-heme positive, but no rbc casts, plasma not red

## Case - 2

- <footer>

- <date/time>

**Case - 2**

- Fever rose to 103 next day, UN to 42, Cr to 2.3, but urine cleared rapidly, pharynx & sputum cultures showed streptococci, left lower lobe pneumonia.
- Attending physician thought post-streptococcal acute glomerulonephritis was the diagnosis,
- But resident (*JRS*) disagreed, because no urinary red calls and no hypertension, no edema, strep not Group A, urine pigment not Hb but Mb...

## Case - 3

- <footer>

- <date/time>

**Case - 3**

- Urine spectral curve suggested Mb not Hb, but the urine cleared before CO-derivatives could be made.
- Collection of 24-hour urine showed increased Cr and creatine, serum SGOT (AST) raised to 217, and quadriceps biopsy showed degeneration.
- Rapid improvement and recovery, much faster than AGN course, renal function normal 10 days

## 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

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## “Monday Morning Sickness”

- <footer>

- <date/time>

*“**Monday Morning Sickness”*

- Veterinarians familiar with disease of draft horses, worked  after rest and feeding, seen in heavily muscled horses: Belgians, Percherons, Clydesdales
- Kreuzlähme des Pferdes (Carlström 1931) - within few minutes or hours of work, horse staggers, sweats, lame, muscles stiff-hard-swollen-weak, reflexes disappear, muscles paralyzed, fever, red urine with protein and pigmented casts, blood urea-creatinine-potassium rise, death within a week in 20-70% of cases

## Acute Myoglobinuria in Manwhat was known in 1957 ?

- <footer>

- <date/time>

**Acute Myoglobinuria in Man*****what was known in 1957 ?***

- heavy exertion - marathons, weight lifting, deep squats or jumping, acrobatic ice skating;           R. Fleischer (Berlin Klin Wochenschr 1881)
- idiopathic - Haff disease (1932); dystrophies
- ischemia or trauma to muscles - crush syndrome London blitz WW2 (1941); electrical shock
- hereditary muscle phosphorylase deficiency - McArdle syndrome (1951), ?Meyer-Betz (1910)

## “Haff Disease”Haffkrakenheit, Königsberg, East Prussia

- <footer>

- <date/time>

**“****Haff Disease”****Haffkrakenheit, Königsberg, East Prussia**

**described in German literature, 1932-3;**
**after eating fish or eels from large shore-lakes around vicinity of Königsberg, polluted by industrial wastes of cellulose factories, poisonous pitch compounds;**
**people show muscle pain, stiffness, weakness, difficulty walking, myoglobinuria; striated muscle breakdown;**
**not the first instance of toxic rhabdomyolysis: cf. the Jews in Sinai - from eating quail (Numbers 11:31-4)**

## Divine Punishment(Hebrews in Sinai - Numbers 11:31-4)

- <footer>

- <date/time>

**Divine Punishment****(Hebrews in Sinai - Numbers 11:31-4)**

***And when the people complained, it displeased the Lord, and his***
***anger was kindled . .***** .**
**31) And there went forth a wind from the Lord, and brought quails from the sea, and let them fall by the camp . . . two cubits high upon the face of the earth.**
**32) And the people gathered the quails . . .**
**33) And while the flesh was yet between their teeth . . . the wrath of the Lord was kindled . . . and the Lord smote the people with a very great plague.**
**34) And he called the place Kibrothhattaavah: because there they buried the people that lusted.**

## Quail Myotoxicity

- <footer>

- <date/time>

**Quail Myotoxicity**

- _[Aparicio](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10074634&dopt=Abstract)__[ R, ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10074634&dopt=Abstract)__[Onate](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10074634&dopt=Abstract)__[ JM, ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10074634&dopt=Abstract)__[Arizcun](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10074634&dopt=Abstract)__ A, Alvarez T, Alba A, Cuende JI, Miro M._ ***Quails that eat Galeopsis ladanum seeds cause rhabdomyolysis***.
- [Epidemic rhabdomyolysis due to the eating of quail. A clinical, epidemiological and experimental study]Med Clin (Barc). 1999 Feb 6;112(4):143-6. Spanish.
- _Lopez Briz E, Ibanez G, Guevara Serrano J, Ortega Garcia MP._
- [Stachydrin ++, quails and biblic plagues] ibid,113:598-9.
**Conn H.** **How do you like your quail prepared?**Am J Gastroenterol 2001 Sep;96(9):2790-2

## Ischemic Muscle Necrosisair-raid casualties 1940-1; Bywaters, Lancet 1944

- <footer>

- <date/time>

**Ischemic Muscle Necrosis****air-raid casualties 1940-1; Bywaters, Lancet 1944**

- after being buried under rubble several hours, pale, cold, sweaty, hemoconcentrated, shocky;
- compressed areas erythematous, then blistered, then swollen and hard, muscles numb-paralyzed, then doughy-pitted;
- urine scanty, brown, acidic, hematin granules, heme-positive but Mb; renal failure, high serum potassium, death in 67%

## McArdle SyndromeB. McArdle, Guy’s Hospital, Clin Sci 1951

- <footer>

- <date/time>

**McArdle Syndrome****B. McArdle, Guy’s Hospital, Clin Sci 1951**

- 30-year old man with long history of muscle pain after exertion, with weakness and stiffness, worse if prolonged or heavy exertion;
- test exercise caused stiffness pain after 75 steps, had to crawl, panting, heart rate 160; any muscle exercised would show the effects;
- blood lactate*** fell*** after exercise, blood flow 5x normal after exercise, poor muscle glycogenolysis

## Causes of Rhabdomyolysis - 2000 (David WS, Neurol Clin 18:215-41)

- <footer>

- <date/time>

- Causes of Rhabdomyolysis - 2000 (David WS, Neurol Clin 18:215-41)

- trauma, compression
- ischemia of muscle
- stressful exertion
- electrical current
- McArdle, other genetic
- poisoned fish, eels
- hyperthermia
- infections: various

- snake and insect venoms
- muscular dysptrophies
- myositis, polymyositis
- hyperthyroidism
- hypokalemia, other
- alcoholic binges
- heroin, cocaine, Ecstasy
- approved drugs*

## Drugs Causing Rhabdomyolysis (Vanholder R, et al., J Am Soc Neurol 2000; 11:1553-61)(Staffa J, et al., N Engl J Med 2002 Feb 14; 346(7):539-40)

- <footer>

- <date/time>

- Drugs Causing Rhabdomyolysis *(Vanholder R, et al., J Am Soc Neurol 2000; 11:1553-61)**(Staffa J, et al., N Engl J Med 2002 Feb 14; 346(7):539-40)*

- antimalarials
- colchicine
- corticosteroids
- fibrates
- isoniazid
- diuretics, licorice
- narcotics, depressants
- zidovudine, others

- “-vastatins”
- lo- (Mevacor), 1987
- pra- (Pravachol), 1991
- sim- (Zocor), 1991
- flu- (Lescol), 1993
- ator- (Lipitor), 1996
*ceri- (Baycol), 1997*
- rosu- under review

## Effects of Rhabdomyolysis

- <footer>

- <date/time>

- release of muscle constituents into plasma - myoglobin, enzymes*, creatine, creatinine, carnitine, potassium, uric acid, organic and inorganic phosphates;
- *creatine phosphokinase (CPK, CK), aldolase (ALD), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), alanine aminotransferase (ALT), . . .
- renal tubular Mb casts, renal tubular necrosis, oliguria, renal failure; sometimes hypotension, shock; plasma K levels may be cardioplegic; vasoconstrictors, cytokines

## 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

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## New 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

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## 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**

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004

## Acknowledgements

***...******for intellectual contributions and ideas***
***	******Peter Honig, M.D., (FDA); Merck***
***	******Robert Temple, M.D., FDA***
***	******Harry Guess, Ph.D., Merck***
***	******Polly Beere, M.D., Ph.D., (Merck)***
***	******Robert O’Neill, Ph.D., FDA***
***	******Paul Seligman, M.D., FDA***
***	******Roger Ulrich, Ph.D., Merck***

- Hep Tox Steering Group - CONFIDENTIAL

- 5 February 2004