Background: The drug landscape has shifted significantly in North America with changes in the availability, use and types of Illicit fentanyl analogs. Despite their presence, there remains a substantial gap in understanding these fentanyl analogs.

Aims: This study aims to characterize the trends, concentrations and co-occurrences of fentanyl, carfentanil, para-fluorofentanyl (pFF) and ortho-methylfentanyl (oMF) in urine samples from an opioid dependant population. Additionally, it seeks to evaluate cross-reactivities with a fentanyl immunoassay.

Methods: Urine samples were collected and analyzed over nine-months for fentanyl, norfentanyl, carfentanil, norcarfentanil and pFF. oMF testing was conducted over four months. Immunoassay data was obtained using an Olympus AU480 with the Thermo Scientific DRI Fentanyl assay. Mass spectrometry analysis was performed using an internally developed method on an Agilent 6470 triple quadrupole instrument.

Results: Among 5280 urine samples, 27% tested positive for fentanyl. Of these, 79% contained pFF, 75% oMF, 4% carfentanil, and 8% norcarfentanil. A trend indicated declining prevalence of pFF and oMF, while carfentanil is increasing. Concentrations are decreasing for pFF and oMF and increasing for fentanyl and carfentanil. Co-occurrence is common, with norfentanyl detected in 98% of carfentanil-positive, 97% of pFF-positive, and 98% of oMF-positive samples. pFF demonstrated 41% cross-reactivity with the fentanyl immunoassay, while OMF had <2% cross-reactivity.

Conclusions: Our findings highlight the widespread presence of fentanyl analogs in opioid-dependent populations, with pFF, oMF and carfentanil frequently co-occurring with each other and fentanyl. We observed fluctuations in the prevalence and concentrations of these analogs over time. Cross-reactivity varies among the fentanyl analogs.

Background
N-acetylcysteine (NAC) is commonly used to treat non-paracetamol-induced acute liver failure (ALF). While it is an established therapy, prolonged use can lead to significant financial costs. However, its cost-effectiveness in improving clinical outcomes remains unclear.

Aims
This study aims to compare the direct medical costs of standard (≤72 hours) and extended (>72 hours) NAC therapy, focusing on drug acquisition, laboratory tests, and hospitalization expenses.

Methods
This retrospective study analyzed hospital data from 2018 to 2024. Drug acquisition costs, including the drug and administration-related personnel expenses, were calculated. Hospitalization costs covered ward charges and laboratory investigations.

Results
Patients receiving extended NAC therapy had longer hospital stays (13.5 vs. 8 days, p=0.004) and delayed INR normalization (4 vs. 1 day, p<0.001). They also presented with higher MELD scores (29 vs. 15, p=0.007), indicating more severe liver disease. The total direct cost for extended NAC therapy was RM7371.06, compared to RM3567.47 for standard therapy (p=0.02).

Conclusions
In Malaysia, extended NAC therapy significantly increases direct medical costs due to longer hospital stays and delayed INR normalization. Despite the higher costs, the improvement in MELD scores suggests that extended therapy improves patient survival, making it a valuable option for critically ill patients.

Keywords
N-acetylcysteine (NAC), Acute liver failure (ALF), cost comparison, hospitalization costs, MELD score

Background: Andrographis paniculata and echinacea are herbal medicines popular for COVID-19 symptoms. These medicines can elicit hypersensitivity adverse drug reactions (ADRs), including anaphylaxis, in susceptible individuals. The Therapeutic Goods Administration (TGA) legislated new warning labels for andrographis and echinacea in Dec-2019 to combat ADRs. The effectiveness of these new labels in ADR prevention is poorly understood.

Aims: This study investigated the prevalence of hypersensitivity ADRs to these medications in the Australian population from 2015-2024; before and after implementation of the TGA's new label requirements.

Methods: Data from the TGA Database of Adverse Event Notifications (DAEN) was exported to Excel. Reports from 2015-2024 with hypersensitivity symptoms, defined by the Brown Scale, were included (n=513). ADR reports of glucosamine/chondroitin were used as a control given their usage should not have increased due to COVID-19 (n=25). Data was analysed alongside Australian influenza and COVID statistics.

Results: Five years before legislation change in May 2020, there was an average of 2.3 ADRs reported per month, compared to 7.3 per month after legislation, revealing an increase in hypersensitivity ADRs. The ADR rates were not constant but formed distinct peaks. Most peaks in ADR reports correlate with preceding increases in influenza-like illnesses. Average ADR reports for glucosamine and chondroitin remain stable.

Conclusions: Despite the TGA’s new warning label requirements, influenza-like illnesses peaks are associated with an increase in andrographis/echinacea hypersensitivity ADRs.This indicates the need for a review of TGA warning label sizing and placement, and educating the public of ADRs associated with andrographis and echinacea use.

Background
Endotherial growth factor receptor (EGFR) tyrosine kinase inhibitors (EGFR-TKI) is known to cause drug-induced nephrotoxicity (DIN). We have reported that covalent binding of drugs induces the release of damage-associated molecular patterns (DAMPs) that activate immune cells, leading to the idiosyncratic drug-induced serious adverse effects. Afatinib, dacomitinib, and osimertinib have a covalent group in their structural formula, which may cause immune related DIN.

Aims
In this study, we examined whether EGFR-TKI can activate inflammasomes in the human renal proximal tubule epithelial cells (RPTECs) and the human macrophage cell line (THP-1 cell).

Methods
Human RPTECs were respectively added afatinib, dacomitinib, erlotinib, gefitinib, and osimertinib and cultured at 37ºC, 5% CO2 for 28 days. The supernatant from the RPTECs was added to human macrophage cell line (THP-1 cell), which was incubated for 24 hr. IL-1β concentration of the culture supernatants and caspase-1 activity of THP-1 cells were measured. The protein of heat shock protein（HSP）40, HSP60, HSP70, HSP90, S100A6, S100A8, S100A9 and S100A11 were measured by the western blotting.

Results
The supernatant from an incubation of RPTECs with afatinib increased the IL-1β production and caspse-1 activity of THP-1 cells. In addition, the production of IL-1β and caspase-1 activation were inhibited by adding YVAD. HSP90 was significantly increased in the supernatants from RPTECs incubated with afatinib.

Conclusions
These results demonstrated that the covalent binding of afatinib can cause the release of HSP 90 and activate inflammasomes, which can cause immune-related adverse events including DIN.

Background: Lorlatinib, which is approved for non-small cell lung cancer, might cause idiosyncratic liver injury as severe adverse events. However, the details of the mechanism are unknown. In our previous study, it is reported that reactive metabolites may cause the release of damage-associated molecular patterns (DAMPs), which leads to activate immune cells.

Aims: We evaluated whether lorlatinib or its reactive metabolites can activate inflammasomes in the human macrophage cell line (THP-1 cell).

Methods: Three-dimensional cultured human hepatocarcinoma functional liver cell-4 (FLC-4) cells were incubated with 0.01-3.0 μM lorlatinib for 7 days. The supernatants from the FLC-4 cells was added to THP-1 cells, which was incubated for 24 hr. IL-1β production in the supernatants of THP-1 cells and caspase-1 activity of THP-1 cells were measured. One-aminobenzotriazole (ABT, 1 mM) and Ac-YVAD-cmk (YVAD, 1 µM) were used to inhibit cytochromes P450 activities and caspase-1 activity, respectively. DAMPs and IL-6 levels in the culture medium of FLC-4 cells were measured by western blotting.

Results: The supernatant from FLC-4 cells treated with lorlatinib significantly increased IL-1β production and caspase-1 activity of THP-1 cells. These increase were inhibited by ABT or YVAD. In addition, IL-6 expression in the supernatant from FLC-4 cells treated with lorlatinib was significantly increased.

Conclusions: There results suggested that reactive metabolites of lorlatinib can cause the release of IL-6 and activate inflammasome in THP-1 cells. IL-6 may be predictive biomarkers of liver injury with lorlatinib.

Key Words: ALK tyrosine kinase inhibitors, Lorlatinib, Reactive metabolites, Danger-related molecular patterns, Inflammasome

Background: Eltrombopag is metabolized to its acyl glucuronide (AG) by uridine diphosphate glucuronosyltransferase (UGT) 1A1. Although several AGs have the potential to cause drug-induced liver injury, the impact of eltrombopag-AG on liver injury is unclear.

Aims: We examined the effects of serum eltrombopag and its AG concentrations on the occurrence of liver dysfunction in patients with aplastic anemia.

Methods: Serum eltrombopag and its AG concentrations, UGT1A1 genotype, and liver dysfunction (elevations in aminotransferases or bilirubin) were examined in 41 patients with aplastic anemia. The association of eltrombopag and its AG concentrations with prediction of liver dysfunction was assessed using receiver operating characteristic (ROC) analysis.

Results: Higher serum eltrombopag and its AG concentrations were observed in patients with liver dysfunction compared with those with the normal function (eltrombopag: 25.8 ± 20.2 vs. 11.0 ± 9.9 µg/mL, P < 0.001; eltrombopag-AG: 5.5 ± 4.3 vs. 1.7 ± 1.2 µg/mL, P < 0.001). Eltrombopag-AG concentration demonstrated a higher predictive performance for liver dysfunction compared with eltrombopag (area under the ROC curve: 0.81 vs. 0.71, both P < 0.001), with the cut-off values of 3.1 and 17.7 µg/mL, respectively. UGT1A1 extensive metabolizers (*1/*1) exhibited higher eltrombopag-AG concentrations than intermediate and poor metabolizers (*6, *28 carriers) (3.7 ± 3.9 vs. 2.1 ± 1.9 µg/mL, P = 0.082), and had a higher occurrence rate of liver dysfunction (43% vs. 10%, P = 0.018).

Conclusions: Serum eltrombopag-AG concentrations, especially in UGT1A1 extensive metabolizers, are associated with eltrombopag-induced liver dysfunction.

Key Words: eltrombopag, acyl glucuronide metabolite, liver dysfunction

Background: Nephrotoxicity is a typical adverse effect of vancomycin (VCM). Although several drugs have been reported to prevent vancomycin-induced nephrotoxicity (VIN) in basic research, their real-world effectiveness remains unclear.

Aims: This study aimed to identify novel drugs that prevent VIN using medical big data.

Methods: We used a large Japanese electronic medical record database with information on approximately 20 million individuals. Patients who underwent intravenous VCM between April 1996 and March 2022 were included in this study. Several known VIN risk factors (covariates) and potential protective drugs based on basic studies were selected as explanatory variables, and a multivariate logistic regression analysis was performed. Propensity score matching was used to validate the prophylactic effects of the candidate drugs extracted using logistic regression analysis. The study protocol was approved by the Ethics Committee of Keio University (Number 221125–1).

Results: Among 12,411 eligible patients, VIN occurred in 2,267 (18.3%). Seventeen factors affecting VIN were identified, replicating previous findings. Vitamin E preparations [odds ratio (OR): 0.459, 95% confidence interval (CI): 0.239–0.883] and ramelteon (OR: 0.691, 95% CI: 0.556–0.858) were observed as preventive effects against VIN. After propensity score matching, vitamin E and ramelteon reduced VIN by approximately 8% (17.46% to 9.52%) and 6% (21.38% to 15.38%), respectively. Sensitivity analyses, using different definitions of concomitant drug use, revealed consistent trends.

Conclusions: Vitamin E and ramelteon have been identified as potential prophylactic agents for VIN. Further investigations are necessary to verify these novel findings.

Keywords: vancomycin, nephrotoxicity, medical big data, ramelteon, vitamin E

Background: The optimal duration of N-acetylcysteine (NAC) therapy in non-paracetamol-induced acute liver failure (ALF) remains uncertain. While NAC is widely used, its impact on clinical and biochemical outcomes with prolonged therapy is not well established.

Aims: This study aims to evaluate patient outcomes following NAC treatment for non-paracetamol-induced liver injury by comparing standard (≤72 hours) and extended (>72 hours) NAC therapy. It specifically examines patient characteristics, time to INR normalization, and biomarkers of hepatic recovery between both treatment durations.

Methods: A retrospective cohort study was conducted on patients receiving NAC for non-paracetamol-induced ALF. Clinical outcomes, including hospital length of stay (LOS) and time to INR normalization (<1.5), were analyzed. Kaplan-Meier survival analysis was performed to assess time to INR normalization and all-cause mortality at 3 weeks, with statistical significance determined by the log-rank test.

Results: Patients in the extended NAC group had a longer hospital stay (13.5 vs. 8 days, p=0.004) and delayed INR normalization (4 vs. 1 day, p<0.001). Kaplan-Meier analysis showed a lower probability of early INR normalization (log-rank p<0.001). The extended group had higher MELD scores (25 vs. 12, p=0.004), elevated serum creatinine (250 vs. 76 μmol/L, p<0.001), and higher ALP and bilirubin levels, suggesting more severe liver dysfunction and cholestasis. However, Kaplan-Meier analysis also showed no significant difference in survival the two groups (log-rank p=0.473).

Conclusions: Extended NAC therapy was linked to prolonged hospitalization, delayed INR normalization, and greater hepatic and renal dysfunction. Tailoring NAC duration based on disease severity may help optimize patient management.

Background:Glycyrrhizic acid (GA), a key bioactive component of licorice, has shown protective effects against drug-induced liver injury (DILI).
Aims: This study aimed to evaluate GA's potential to stimulate liver regeneration following acetaminophen (APAP)-induced hepatotoxicity.
Methods: GA was administered intraperitoneally to C57BL/6J mice for three days, followed by APAP to induce liver injury. Serum and liver tissues were analyzed 36 hours post-APAP. In vitro, AML12 cells were treated with APAP and GA, with the β-catenin inhibitor XAV-939 used to explore GA's mechanisms.
Results:GA increased PCNA, cyclinD1, and CDK4 expression, promoting liver regeneration post-APAP injury. In vitro, GA enhanced hepatocyte proliferation and activated the β-catenin signaling pathway, an effect diminished by XAV-939.
Conclusions:GA mitigates APAP-induced liver injury by promoting liver regeneration, potentially through β-catenin signaling activation, indicating its therapeutic potential for hepatoprotection.
Keywords:Glycyrrhizic acid, Liver regeneration, β-catenin signaling pathway, Liver injury, Acetaminophen

Background: Limited data exist on pharmacokinetics of cannabinoids in pregnancy and how altered disposition may affect results of drug testing. This case-report describes a woman detained in an addiction treatment ward in late pregnancy due to admitted occasional use of cannabis. She was subjected to urine drug testing every 3 to 8 days, extending into the postpartum period. The woman denied any further use following admission.

Aims: To emphasize challenges in interpreting cannabinoid drug test results in a largely unstudied population, where positive results may have severe consequences.

Methods: 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THCCOOH) was quantified in urine by liquid chromatography-tandem mass spectrometry with a cut-off ≥10.3 ng/ml. Creatinine-normalization was applied for comparison.

Results: THCCOOH concentrations decreased from 276.6 ng/ml to 10.3 ng/ml, over a period of 78 days. Creatinine-normalized levels did not decline as steadily as expected and fluctuated in the low concentration range. The observed excretion pattern would have indicated recent use had traditional algorithms for interpretation been applied. Drug testing was continued for 10 weeks after the last positive specimen, with negative results.

Conclusions: Assuming that the woman’s account is reliable, urinary detection-time of THCCOOH was >11 weeks after the last consumption, which is prolonged compared to what has previously been reported in occasional cannabis users. Further research is needed to assess whether established algorithms for interpretation are applicable to a pregnant population in differentiating residual cannabis excretion from recent use. We suggest interpreting urine THCCOOH test results, especially at low-range concentrations, with caution.

Keywords: Pharmacokinetics, pregnancy, cannabis, drug testing