More Adventures: Placebo Database

5 February 2004 Hep Tox Steering Group - CONFIDENTIAL

1

More Adventures: Placebo DatabaseJohn R. Senior, M.D., Hepatologist

Associate Director for Science

Office of Pharmacoepidemiology & Statistical Science

Food and Drug Administration (FDA)


2

Where Do Elevated Serum Transaminases Come From

?

John R. Senior, M.D., FDA

Robert W. Tipping, M.S., Merck


3

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(unpublished information)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 Do not cite.


4

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


5

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


6

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


7

Conclusions - so far

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

• Requiring “confirming” tests may miss caseunless 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


8

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


9

But, no evidence of liver disease:

ALLOC trt sex age ALTx3 ASTx2 ALPx2 TBLx2 CPKx50158 P M 52 1.50 2.19 0.50 0.8 10.8

So, why the rises in transaminases?

10Hep Tox Steering Group - CONFIDENTIAL

5 February 2004

Pt No. sex age CPKx ASTx ALTx remarks0158 M52 10.83 2.19 1.50 recent carpentry work, with some expected muscle soreness

0168 M55 14.92 1.51 0.98 no new AEs or meds

0473 M61 16.54 1.35 0.65 no new AEs or meds; total serum bilirubin increased

1055 M53 15.87 1.84 0.83 pushed lawn mower, asymptomatic

1422 M48 13.59 1.30 1.08 asymptomatic, normal aldolase (Day -68)

2028 M59 13.28 1.97 0.98 asymptomatic, no cause noted

2433 M57 21.18 2.78 1.78 started weight program at gym 5 days/week, mild soreness

2510 M58 29.53 1.84 1.18 performing laborious work prior to lab draw

2780 M53 12.54 1.11 0.58 heavy yard work day prior to draw, asymptomatic

3012 M54 12.20 1.49 0.98 repetitive heavy weight lifting

3091 M56 21.11 1.51 0.50 asymptomatic, no cause noted

4599 M54 11.55 2.62 0.78 working out with weights

4954 M48 10.86 1.51 0.88 worked out with weights and jogged, no chest pain

4981 M53 30.51 3.08 1.48 working out at gym for 1.5 weeks

5011 M47 24.06 2.30 1.63 is working out a lot5074 M45 10.25 0.59 0.33 extensive yard work recently

5773 M69 16.66 2.24 0.78 moved furniture weekend before blood draw

5901 M47 10.02 2.16 1.18 no cause identified

6320 M58 17.42 3.89 1.00 started going to gym

6402 M47 96.82 7.38 3.33 weight lifting, tried too much weight

6439 M60 13.68 1.65 0.78 no known cause

9330 F58 12.01 1.00 1.38 "repeat CPK normal; likely lab fault" (Day -47)

9805 F69 13.34 1.27 0.48 asymptomatic; no trauma or vigorous activity


11

AST & ALT and CPK Rises

Pt. No. sex age CPKx ASTx ALTx5901 M47 10.02 2.16 1.185074 M45 10.25 0.59 0.330158 M52 10.83 2.19 1.504954 M48 10.86 1.51 0.884599 M54 11.55 2.62 0.789330 F58 12.01 1.00 1.383012 M54 12.20 1.49 0.982780 M53 12.54 1.11 0.582028 M59 13.28 1.97 0.989805 F69 13.34 1.27 0.481422 M48 13.59 1.30 1.086439 M60 13.68 1.65 0.780168 M55 14.92 1.51 0.981055 M53 15.87 1.84 0.830473 M61 16.54 1.35 0.655773 M69 16.66 2.24 0.786320 M58 17.42 3.89 1.003091 M56 21.11 1.51 0.502433 M57 21.18 2.78 1.785011 M47 24.06 2.30 1.632510 M58 29.53 1.84 1.184981 M53 30.51 3.08 1.486402 M47 96.82 7.38 3.33


12

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


13

Two questions:

1) What is the source of the elevated

serum transaminase activities?

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


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

Organ/Serum Activity Ratios


5 February 2004

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


5 February 2004

• 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


5 February 2004

Serum Bilirubin

poor aqueous solubility -- mostly albumin-bound

reversible -- hydrophobic/electrostatic

irreversible in long-standing jaundice -- covalent

NH

NH

NH

NH

CH2

CH3

CH2

CH3CH3

OO

CH2

CH3

COOHHOOC


5 February 2004

• 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


19

N

NN

N

HOOC COOH

Fe

CH3

CH2

H2C CH3

H3C

H3C

iron protoporphyrin IX

heme

heme oxygenase


20

HOOCCOOH

CH3

CH2

H2CCH3

H3C

H3C

N

NH

NH

NH

OO

CO

Fe

biliverdin

COOH

CH3

CH2

H2CCH3

H3C

H3C

NH

N

N

N

OHOH

HOOCbilirubin

2H


5 February 2004

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


22

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.


23

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 !


5 February 2004

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


25

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


26

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


27

Two questions:

1) What is the source of the elevated

serum transaminase activities?

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


28

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

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

Study Day

Log1

0 (x

ULN

)

CPK

AST

ALT

2xULN3xULN

10xULN

ULN

100xULN


29

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

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

-120 -6

0 0 60 120

180

240

300

360

420

480

540

600

660

720

780

840

900

960

1020

1080

1140

1200

1260

1320

1380

1440

1500

1560

1620

1680

1740

1800

1860

1920

1980

2040

2100

2160

2220

2280

2340

2400

2460

2520

Study Day

Log1

0(xU

LN)

CPK

AST

ALT

3xULN

10xULN

100xULN

ULN


30

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

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0-6

0 0 60 120

180

240

300

360

Days on Study Drug

Lo

g(1

0) o

f R

ises

xU

LN

ALT

AST

ALP

TBL

CPK

upper limit of normal

3.2 xULN

10 xULN

32 xULN

worked out at gym


31

APPARENT SERUM HALFTIMES OF CPKCPK 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:


32

“Myopathy” ? :

1) Unexplained muscle pain or weakness

2) CPK >10xULN


33

Rhabdomyolysis:

1) Severe muscle breakdown

2) Myoglobinuria

3) Renal insufficiency


34

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

SKELETAL CARDIAC VISCERAL

striated striated smooth

voluntary involuntary involuntary


5 February 2004

Case - January 1957JA, 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


5 February 2004

Case - 2Fever 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...


5 February 2004

Case - 3Urine 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


38

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


5 February 2004

“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


5 February 2004

Acute Myoglobinuria in Manwhat 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)


5 February 2004

“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)


5 February 2004

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.


5 February 2004

Quail Myotoxicity

Aparicio R, Onate JM, Arizcun 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

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10074634&dopt=Abstract






5 February 2004

Ischemic Muscle Necrosisair-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%


5 February 2004

McArdle SyndromeB. 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


5 February 2004

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*


5 February 2004

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


5 February 2004

Effects of Rhabdomyolysis

• 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


49

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


50

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


51

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


52

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

More Adventures: Placebo Database

Documents

Transcript of More Adventures: Placebo Database