Impact of Silymarin Dosages to Decrease Drug-induced Elevated Liver Enzymes Compared to Placebo

Prof. Dr. Frank Behrens19 enrolled

Overview

In this clinical study silymarin will be administered in different dosages and compared to placebo in order to address if the liver protecting features of silymarin, measured by changes of liver enzyme concentration, can be improved in patients with drug-induced elevated liver enzymes or drug-induced hepatocellular liver injury with higher systemic bioavailabilities due to administration of higher oral dosages or administration of higher administration frequency over a 35-day treatment period.

In clinical routine care, drug-induced elevation of liver enzymes occurs often in parallel to new treatment initiation, possibly leading to interruption of treatment strategies if liver enzyme elevation does not normalize within 2 to 4 weeks. Liver injury from medications usually occurs within 6 months of drug initiation and typically within the first 1-4 weeks1. In general, drug-induced liver injury (DILI) is related to the class of drug, the quantity of drug consumed, the patient's age and sex, and such concurrent factors as diabetes mellitus, excessive alcohol intake, e.g. high caloric diet, which can lead to NAFLD/steatosis, or the use of other medications. Drugs administered in higher doses are more likely to cause liver injury, especially drugs that require extensive hepatic metabolism1. Different forms of drug-induced elevation of liver enzymes can be differentiated according to localisation of the injury: hepatocellular or cholestatic liver injury or a mixture of both.Besides methotrexate and isozid, other medications have been reported to induce hepatocellular liver injury: acarbose, allopurinol, amiodarone, baclofen, bupropion, fluoxetine, ketoconazole, lisinopril, losartan, non-steroidal anti-inflammatory drugs (NSAIDs), omeprazole, paracetamol, paroxetine, pyrazinamide, rifampicin, risperidone, sertraline, statins, tetracyclines, trazodone, and valproic acid. Silymarin containing oral preparations are widely used for their liver protecting characteristics. The milk thistle ingredient silibinin is registered for continuous intravenous administration in the case of acute liver intoxications such as consumption of amanita mushrooms. Although its mode of action is still not clear, the clinical therapeutic benefits in patients with liver diseases are documented. Pharmacokinetics of silymarin after oral administration are well understood. Due to its poor solubility in aqueous media, absorption from the intestinal tract is generally limited. Silymarin's systemic bioavailability of marketed products is therefore rather low, also because of predominant first pass biliary elimination. Exact PK/PD relations of the compound have not been assessed so far. Hence, in this clinical study silymarin will be administered in different dosages and compared to placebo in order to address the following question: Can liver protecting features of silymarin, measured by changes of liver enzyme concentration, be improved in patients with drug-induced elevated liver enzymes or drug-induced hepatocellular liver injury with higher systemic bioavailabilities due to administration of higher oral dosages or administration of higher administration frequency over a 35-day treatment period?

Conditions

Drug-induced Liver Injury

Interventions

PlaceboDRUG

1 capsule per day of placebo

2x 140 mg per dayDRUG

2 capsule per day of silimarit

3x 280 mg per dayDRUG

3 capsule per day of silimarit

1x 1120 mg

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: Evidence of hepatocellular drug-induced injury due to treatment\* * ALT/AP ratio ≥ 5 ((ALT level/ALT upper limit of normal (ULN))/(AP level/AP ULN)) OR Evidence of drug-induced elevation of liver-enzymes * ALT \> 40 U/L and ≤ 2 x ULN * ALT (\> 40 U/L) ≥ 2 weeks and ≤ 3 months 3. Documentation (within the last 4 weeks before screening) of exclusion of liver tissue damage using either ultrasonography of the liver or Fibroscan with results ≤ 7 kPa (fibrosis score of F0 to F1) 4. BMI ≥ 18 and ≤ 30 5. Liver enzyme elevation inducing medication stable for ≥ 8 weeks before screening in the discretion of the treating physician 6. Written informed consent, after having been informed about potential benefit and potential risks of the clinical trial 7. Willing and capable to understand informed consent and follow the protocol Exclusion Criteria: 1. Use of silymarin within the last 6 months 2. Current intake and intake within the last 4 weeks of drugs that have been shown to induce cholestatic or mixed hepatocellular/cholestatic liver injury (inducing cholestatic liver injury: amoxicilline and clavulanic acid, anabolic steroids, chlorpromazine, clopidogrel, erythromycin, irbesartan, mirtazapine, estrogen, terbinafine; inducing mixed liver injury: amitriptyline, azathioprine, captopril, carbamazepine, clindamycin, co-trimoxazole, cyproheptadine, enalapril, flutamide, nitrofurantoin, phenobarbital, phenytoin, sulphonamide, trazodone, verapamil) 3. Patients with chronic liver disease, existing fibrosis or cirrhosis 4. Patients with acute viral hepatitis, autoimmune hepatitis or immune-mediated hepatitis (e.g., with immune checkpoint inhibitor treatment), acute Budd-Chiari syndrome, Wilson disease, and ischemic liver injury 5. Cholestatic or mixed hepatocellular/mixed liver injury 6. Patients with diabetes types 1 or 2 7. Any malignancy within the past 5 years 8. Patients with chronic intestinal diseases (e.g., ulcerative colitis) and intestinal barrier dysfunction in the discretion of the treating physician (e.g., patient can be included if disease is judged as stable by the treating physician with no likely interference with the study outcomes and the safety of the patient) 9. Evidence of significant uncontrolled concomitant diseases or serious and/or uncontrolled diseases that are likely to interfere with the evaluation of the patient's safety and of the study outcome 10. History of relevant central nervous system (CNS) and/or psychiatric disorders and/or currently treated CNS and/or psychiatric disorders 11. Known allergic reactions to the active ingredients used or to constituents of the pharmaceutical preparations, e.g. milk thistle, soy oil, peanut (according to Summary of Product Characteristics (SmPc)) 12. Contraindications to use the investigational medicinal product (IMP), e.g. hereditary galactose intolerance, genetic lactase deficiency or glucose-galactose malabsorption (according to SmPC) 13. Subjects with severe or moderate allergies or multiple drug allergies unless it is judged as not relevant for the clinical trial by the investigator 14. Laboratory values other than target parameters out of normal range unless the deviation from normal is judged as not relevant for the clinical trial by the investigator 15. Positive anti-HIV-test, antiHBs- or anti-HCV-test at Screening 16. History of or current drug or alcohol dependence 17. Subjects with a positive drug test at screening (incl. alcohol) 18. Regular intake of alcoholic food or beverages of ≥ 40 g pure ethanol for male or ≥ 20 g pure ethanol for female per day 19. Participation in a clinical trial during the last two months prior to individual enrolment of the subject or current participation 20. Use of drugs during the last two weeks prior Baseline that can affect absorption (e.g. laxatives, metoclopramide, loperamide, antacids, H2-receptor antagonists) 21. Subjects who are unable to understand the written and verbal instructions, in particular regarding the risks and inconveniences they will be exposed to during their participation in the clinical trial 22. Subjects who do not agree to apply adequate contraceptive methods as defined in Note for Guidance on Non-Clinical Safety Studies for the Conduct of Human Clinical Trials for Pharmaceuticals (CPMP/ICH/286/95, modification), November 2000

Locations (2)

Universtity Hospital - clinic for dermatology, venerology and allergology

Frankfurt, Hessia, Germany

CIRI

Frankfurt, Hessia, Germany

Outcomes

Primary Outcomes

Change in blood ALT (Alanine-Aminotransferase) in IU/L

Change in blood ALT in IU/Lin all treatment groups

Time frame: at day 35

Secondary Outcomes

Liver enzyme blood parameter AST (Aspartate-Aminotransferase)

Change of Liver enzyme blood parameter AST in IU/Lin all treatment groups

Time frame: Baseline (prior treatment)

Liver enzyme blood parameter AST

Change of Liver enzyme blood parameter AST in IU/Lin all treatment groups

Time frame: Day 7

Liver enzyme blood parameter AST

Change of Liver enzyme blood parameter AST in IU/Lin all treatment groups

Time frame: Day 14

Liver enzyme blood parameters: AST

Change of Liver enzyme blood parameter AST in IU/Lin all treatment groups

Time frame: Day 21

Liver enzyme blood parameter AST

Change of Liver enzyme blood parameter AST in IU/Lin all treatment groups

Time frame: Day 28

Change Liver enzyme blood parameter AST

Change of Liver enzyme blood parameter AST in IU/Lin all treatment groups

Time frame: Day 35

Change Liver enzyme blood parameter ALT

Change of Liver enzyme blood parameter ALT in IU/Lin all treatment groups

Time frame: Baseline

Data from ClinicalTrials.gov

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Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

SINGLE

Enrollment

8 capsule per day of silimarit

Change Liver enzyme blood parameter ALT

Change of Liver enzyme blood parameter ALT in IU/Lin all treatment groups

Time frame: Day 7

Change Liver enzyme blood parameter ALT

Change of Liver enzyme blood parameter ALT in IU/Lin all treatment groups

Time frame: Day 14

Change Liver enzyme blood parameter ALT

Change of Liver enzyme blood parameter ALT in IU/Lin all treatment groups

Time frame: Day 21

Change Liver enzyme blood parameter ALT

Change of Liver enzyme blood parameter ALT in IU/Lin all treatment groups

Time frame: Day 28

Change Liver enzyme blood parameter ALT

Change of Liver enzyme blood parameter ALT in IU/Lin all treatment groups

Time frame: Day 35

Change Liver enzyme blood parameter GGT (Gamma-Glutamyl-Transferase)

Change of Liver enzyme blood parameter GGT in IU/Lin all treatment groups

Time frame: Baseline

Change Liver enzyme blood parameter GGT (Gamma-Glutamyl-Transferase)

Change of Liver enzyme blood parameter GGT in IU/Lin all treatment groups

Time frame: Day 7

Change Liver enzyme blood parameter GGT (Gamma-Glutamyl-Transferase)

Change of Liver enzyme blood parameter GGT in IU/Lin all treatment groups

Time frame: Day 14

Change Liver enzyme blood parameter GGT (Gamma-Glutamyl-Transferase)

Change of Liver enzyme blood parameter GGT in IU/Lin all treatment groups

Time frame: Day 21

Change Liver enzyme blood parameter GGT (Gamma-Glutamyl-Transferase)

Change of Liver enzyme blood parameter GGT in IU/Lin all treatment groups

Time frame: Day 28

Change Liver enzyme blood parameter GGT (Gamma-Glutamyl-Transferase)

Change of Liver enzyme blood parameter GGT in IU/Lin all treatment groups

Time frame: Day 35

Change Liver enzyme blood parameter AP (Alkaline phosphatase )

Change of Liver enzyme blood parameter AP in IU/Lin all treatment groups

Time frame: Baseline

Change Liver enzyme blood parameter AP (Alkaline phosphatase )

Change of Liver enzyme blood parameter AP in IU/Lin all treatment groups

Time frame: Day 7

Change Liver enzyme blood parameter AP (Alkaline phosphatase )

Change of Liver enzyme blood parameter AP in IU/Lin all treatment groups

Time frame: Day 14

Change Liver enzyme blood parameter AP (Alkaline phosphatase )

Change of Liver enzyme blood parameter AP in IU/Lin all treatment groups

Time frame: Day 21

Change Liver enzyme blood parameter AP (Alkaline phosphatase )

Change of Liver enzyme blood parameter AP in IU/L in all treatment groups

Time frame: Day 28

Change Liver enzyme blood parameter AP (Alkaline phosphatase )

Change of Liver enzyme blood parameter AP in IU/L in all treatment groups

Time frame: Day 35

Change Liver enzyme blood parameter bilirubin

Change of Liver enzyme blood parameter bilirubin in all treatment groups

Time frame: Baseline

Change Liver enzyme blood parameter bilirubin

Change of Liver enzyme blood parameter bilirubin in all treatment groups

Time frame: Day 7

Change Liver enzyme blood parameter bilirubin

Change of Liver enzyme blood parameter bilirubin in all treatment groups

Time frame: Day 14

Change Liver enzyme blood parameter bilirubin

Change of Liver enzyme blood parameter bilirubin in all treatment groups

Time frame: Day 21

Change Liver enzyme blood parameter bilirubin

Change of Liver enzyme blood parameter bilirubin in all treatment groups

Time frame: Day 28

Change Liver enzyme blood parameter bilirubin

Change of Liver enzyme blood parameter bilirubin in all treatment groups

Time frame: Day 35

Change Liver enzyme blood parameter INR (International Normalized Ratio)

Change of Liver enzyme blood parameter INR in all treatment groups

Time frame: baseline

Change Liver enzyme blood parameter INR (International Normalized Ratio)

Change of Liver enzyme blood parameter INR in all treatment groups

Time frame: Day 7

Change Liver enzyme blood parameter INR (International Normalized Ratio)

Change of Liver enzyme blood parameter INR in all treatment groups

Time frame: Day 14

Change Liver enzyme blood parameter INR (International Normalized Ratio)

Change of Liver enzyme blood parameter INR in all treatment groups

Time frame: Day 21

Change Liver enzyme blood parameter INR (International Normalized Ratio)

Change of Liver enzyme blood parameter INR in all treatment groups

Time frame: Day 28

Change Liver enzyme blood parameter INR (International Normalized Ratio)

Change of Liver enzyme blood parameter INR in all treatment groups

Time frame: Day 35

Change Liver enzyme blood parameter Quick value

Change of Liver enzyme blood parameter Quick value in all treatment groups

Time frame: baseline

Change Liver enzyme blood parameter Quick value

Change of Liver enzyme blood parameter Quick value in all treatment groups

Time frame: Day 7

Change Liver enzyme blood parameter Quick value

Change of Liver enzyme blood parameter Quick value in all treatment groups

Time frame: Day 14

Change Liver enzyme blood parameter Quick value

Change of Liver enzyme blood parameter Quick value in all treatment groups

Time frame: Day 21

Change Liver enzyme blood parameter Quick value

Change of Liver enzyme blood parameter Quick value in all treatment groups

Time frame: Day 28

Change Liver enzyme blood parameter Quick value

Change of Liver enzyme blood parameter Quick value in all treatment groups

Time frame: Day 35

Change ALT/AP ratio

Change of ALT/AP ratio in all treatment groups

Time frame: baseline

Change ALT/AP ratio

Change of ALT/AP ratio in all treatment groups

Time frame: Day 7

Change ALT/AP ratio

Change of ALT/AP ratio in all treatment groups

Time frame: Day 14

Change ALT/AP ratio

Change of ALT/AP ratio in all treatment groups

Time frame: Day 21

Change ALT/AP ratio

Change of ALT/AP ratio in all treatment groups

Time frame: Day 28

Change ALT/AP ratio

Change of ALT/AP ratio in all treatment groups

Time frame: Day 35

Lipids analysis

LDL (Low Density Lipoproteins) in all treatment groups

Time frame: Baseline

Lipids analysis LDL

LDL (Low Density Lipoproteins) in all treatment groups

Time frame: Day 7

Lipids analysis LDL

LDL (Low Density Lipoproteins) in all treatment groups

Time frame: Day 14

Lipids analysis LDL

LDL (Low Density Lipoproteins) in all treatment groups

Time frame: Day 21

Lipids analysis LDL

LDL (Low Density Lipoproteins) in all treatment groups

Time frame: Day 28

Lipids analysis LDL

LDL (Low Density Lipoproteins) in all treatment groups

Time frame: Day 35

Lipids analysis

HDL (High Density Lipoproteins) in all treatment groups

Time frame: baseline

Lipids analysis

HDL (High Density Lipoproteins) in all treatment groups

Time frame: Day 7

Lipids analysis

HDL (High Density Lipoproteins) in all treatment groups

Time frame: Day 14

Lipids analysis

HDL (High Density Lipoproteins) in all treatment groups

Time frame: Day 21

Lipids analysis

HDL (High Density Lipoproteins) in all treatment groups

Time frame: Day 28

Lipids analysis

HDL (High Density Lipoproteins) in all treatment groups

Time frame: Day 35

Lipids analysis