More Adventures: Placebo Database

1. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 1 More Adventures: Placebo Database John R. Senior, M.D., Hepatologist Associate Director for Science Office of Pharmacoepidemiology & Statistical Science Food and Drug Administration (FDA)

2. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 2 Where Do Elevated Serum Transaminases Come From ? John R. Senior, M.D., FDA Robert W. Tipping, M.S., Merck

3. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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 (unpublished information) Material and comments presented here are based on the experiences of the speaker for 20 years in academic hepatology and gastroenterology, 5 years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 Do not cite.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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 7 Conclusions - so far

8. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 8 The �First 44� Cases

9. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 9 But, no evidence of liver disease:

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11. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 11 AST & ALT and CPK Rises

12. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 12

13. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 13 Two questions:

14. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 14 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

15. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 15 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

16. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 16 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

17. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 17

18. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 18 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

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21. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 21 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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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 !

24. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 24

25. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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 MAY indicate hepatocellular injury

26. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 27 Two questions:

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31. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 31

32. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 32 �Myopathy� ? :

33. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 33 Rhabdomyolysis:

34. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 34 rhabdo - myo - lysis (striped - muscle - dissolution)

35. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 35 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

36. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 36 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...

37. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 37 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

38. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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

39. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 39 �Monday Morning Sickness� Veterinarians familiar with disease of draft horses, worked after rest and feeding, seen in heavily muscled horses: Belgians, Percherons, Clydesdales Kreuzl�hme des Pferdes (Carlstr�m 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

40. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 40 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)

41. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 41 �Haff Disease�Haffkrakenheit, K�nigsberg, East Prussia described in German literature, 1932-3; after eating fish or eels from large shore-lakes around vicinity of K�nigsberg, 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)

42. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 42 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.

43. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 43 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

44. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 44 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%

45. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 45 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

46. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 46 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*

47. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 47 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

48. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 48 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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 51 Rich Findings in Placebo Data

52. 5 February 2004 Hep Tox Steering Group - CONFIDENTIAL 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