A systematic review of NSAIDs withdrawn from the market due to hepatotoxicity: lessons learned from the bromfenac experience

Abstract

Drug-induced hepatotoxicity is the leading cause of acute liver failure (ALF) in the US and the most common adverse event causing drug non-approval and drug withdrawal by the U.S. Food and Drug Administration (FDA). Three different nonsteroidal anti-inflammatory drugs (NSAIDs) have been withdrawn in the UK and/or the US due to hepatotoxicity (bromfenac, ibufenac, and benoxaprofen). A systematic review of clinical trials data for these drugs was performed in an effort to identify possible early signals that could have predicted post-marketing serious hepatoxicity. There were very limited published data on benoxaprofen and none on ibufenac or bromfenac. The publicly accessible archives of the FDA provided information on bromfenac. Flu-like symptoms associated with hepatic enzyme elevation and a case of possible drug-related hepatocellular jaundice may in retrospect have been signals for serious hepatotoxicity in the database of 1195 subjects reviewed by the FDA. Following approval, rates of acute liver failure for bromfenac were estimated to be in the range of 1:10 000. In addition, the safety databases of several drugs also accessed through FDA archives have been reviewed (simvastatin, tacrine, troglitazone, and ximelagatran). These data suggest that while ALT elevations alone do not reliably signal serious hepatotoxicity, elevated transaminases in association with symptomatic hepatitis or jaundice may be predictors of an increased risk of ALF. At present, however, pre-approval databases are generally not large enough to rule out low rates of serious hepatotoxicity. Therefore, it remains critical that clinicians report such cases to the FDA through the MEDWATCH system and that active post-marketing monitoring studies be used to identify potential rare cases of hepatotoxicity.

NSAIDs for Musculoskeletal Pain Management: Current Perspectives and Novel Strategies to Improve Safety

“…91,92 Several NSAIDs, such as oral bromfenac and lumiracoxib, were withdrawn or never approved in the United States because of hepatotoxicity concerns. 92,93 The mechanism for liver injury is not clearly known, although it appears to be immunologically mediated and idiosyncratic. NSAIDs and strategies for prevention of side effects; however, the recommendations vary.…”

The Evaluation of Safety and Analgesic Efficacy of Paracetamol and Ibuprofen Followed by Impacted Third Molar Surgery

“…Goldkind and Laine (29) suggested that ALT elevations alone do not reliably signal serious hepatotoxicity, elevated ALT and AST may be predictors of an increased risk of acute liver failure. Page (8) reported the simultaneously decreasing of protrombin time with increasing hepatic transaminase (AST, ALT), LDH and bilirubin levels.…”

Herbal and polymeric approaches for liver-targeting drug delivery: novel strategies and their significance

“…This species was shown to be severely hepatotoxic for mice (Hawkins et al, 1985). Note: Drugs like troglitazone, bromfenac, ticrynafen, benoxaprofen, trovafloxacin, ebrotidine, nimesulide, nefazodone, ximelagatran and pemoline have been withdrawn due to hepatotoxicity (Xu et al, 2004;Smith et al, 2005;Goldkind & Laine, 2006).…”