Nevirapine (NVP) can cause serious idiosyncratic drug reactions (IDRs); specifically, skin rash and hepatotoxicity. Treatment of rats or mice with NVP led to covalent binding to hepatic proteins. Studies of this covalent binding including the use of a deuterated analog of NVP leading to a decrease in oxidation of the methyl group indicated that the metabolite responsible for covalent binding in the liver is a quinone methide.
Covalent binding in NVP-treated rats was also observed in the epidermis but by a different pathway. Incubation of 12-OH-NVP sulfate with homogenized human and rat skin led to extensive covalent binding. Inhibition of sulfation in the liver significantly decreased 12-OH-NVP sulfate in the blood, but it did not prevent covalent binding in the skin or the rash. In contrast, topical application of a sulfotransferase inhibitor prevented covalent binding in the skin as well as the rash, but only where it was applied. In contrast to rats, treatment of mice with NVP did not result in covalent binding in the skin or skin rash. These findings provide compelling evidence that 12-OH-NVP sulfate formed in the skin is responsible for the skin rash.
IL-1β and IL-18 production in the skin of rats treated with NVP were increased. An anti-IL-1ß antibody significantly decreased rash severity. These cytokines were also produced by incubation of human keratinocytes with 12-OH-NVP sulfate. These data indicate that 12-OH-NVP sulfate activates the NLRP3 inflammasome, a pathway known to be responsible for contact hypersensitivity rashes.
In summary, NVP was found to produce two different reactive metabolites, a quinone methide species in the liver, and a benzylic sulfate in the skin. Significant liver injury did not occur, presumably due to immune tolerance. Although it is usually assumed that reactive metabolites are responsible for most IDRs, this is the first example to actually demonstrate that a specific reactive metabolite is responsible for an IDR. This is also the first study to show that sulfotransferase in the skin is responsible for bioactivation of a drug leading to a skin rash. It is likely that there are other drugs that cause skin rashes by a similar mechanism.
| Identifer | oai:union.ndltd.org:LACETR/oai:collectionscanada.gc.ca:OTU.1807/43720 |
| Date | 14 January 2014 |
| Creators | Sharma, Amy |
| Contributors | Uetrecht, Jack |
| Source Sets | Library and Archives Canada ETDs Repository / Centre d'archives des thèses électroniques de Bibliothèque et Archives Canada |
| Language | en_ca |
| Detected Language | English |
| Type | Thesis |
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