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Ask Dr. Craig: Drug-Induced Liver Damage

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Dr. Craig is a BellaNaija columnist and one of the doctors who writes for BN Doctors’ Lounge {Get familiar here}. The idea behind ‘Ask Dr. Craig!‘ is for BN readers to get quick sharp answers to niggling medical issues that they have. This does not in anyway mean that readers should not go to their doctors. However, sometimes you just need a human face to give answers to those fast, burning medical concerns our readers have.

Send your questions for Dr. Craig to features(at)bellanaija(dot)com stating your full name and where you are writing from. (Your name will never be published) The editor reserves the right to edit submissions for content brevity and clarity. We regret that we cannot provide individual answers to questions sent in and cannot state at which exact date answers would be published.

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Dear Dr Craig,

I received with great sadness the news of the passing of Eric Arubayi. There are some deaths that just hurt deeply and this was one of them. I did not know him personally but I felt it in my spirit, and I don’t feel just anybody like that, which confirms that this guy was a true gem.

Can you please enlighten us from the medical perspective, how taking expired drugs can shut down the liver and lead to death so quickly.

Seriously Sad,
Nigeria
***
Dear Seriously,

I knew Eric and the news of his death has left my heart too broken for words. My only comfort comes from knowing that he lived his life for Jesus and he died in the Lord.
May his soul rest in peace!

According to Eric’s brother, he died as a result of rapidly progressive liver failure caused by taking some medications which were alleged to have expired. I am not sure what medication he took or how long it had been out of date, but the description of his illness fits a recognised clinical condition known as Drug Induced Liver Damage (DILD)

The liver is arguably one of the most important organs of the human body and it is also the heaviest internal organ. Below are a few of the most important liver functions, but this list is far from complete as the liver has over 500 vital functions that it carries out in conjunction with other organs and systems. Any damage to the liver can cause a ripple effect on almost every other part of the body.


Fig 1: The position of the Liver

Defence
The liver’s most remarkable function is its role in the body’s defence system. Think of it as part of the body’s border control. Everything that enters the body through the blood (absorbed food and drugs from the stomach and intestines, substances inhaled through the lungs, as well as substances injected directly into the blood) must first pass through the liver to be screened. The liver cells will carefully remove1 any toxin or harmful chemical as well as infectious organisms from the body and completely filter the blood, ensuring that it is safe before allowing it to flow to all the other parts of the body. In fact, only after blood has passed through the liver and has been cleared, will it be allowed to go to the heart, from where it is pumped all around the body.

Protein synthesis
The liver produces a huge number of enzymes which are essential for the breakdown of proteins from food, so they can be digested and used by the body. Damaged liver cells can’t produce adequate enzymes, and this can cause a dangerous lack of protein in the body. In addition to helping break down proteins, the liver also manufactures specialised proteins that are required for many of the body’s vital life functions including immunity.

Bile Production, Cholesterol metabolism and Blood clotting
The liver makes bile. Bile breaks down fat from food to make it easier to digest. It also helps the small intestine absorb cholesterol and some vitamins most important of which is vitamin K. The body uses vitamin K to make blood clot so that when a person is injured they don’t bleed out. If the liver doesn’t make enough bile, the body will absorb less vitamin K and make less blood clotting factors.

Blood sugar regulation
The liver helps the body metabolize carbohydrates. The body breaks down carbohydrates from food into glycogen, which is stored in the liver. The liver breaks down glycogen into glucose and releases it into the blood to maintain normal blood sugar levels. When the liver is damaged, glycogen storage capacity is severely affected and can cause fluctuations in blood sugar levels

Vitamin Storage
The liver stores vitamin A, D, E, K and B12. It also stores iron, which it releases so the body can make new red blood cells.

Because the liver2 is so important and is depended on by almost all the other organ systems for their optimum function, it is one of the only organs in the body that can auto regenerate. What this means is that if up to ¾ of the liver is removed surgically or damaged chemically the organ can grow back to its normal size in the space of months (similar to what happen when you cut off a lizards tail). However for a person to survive for the duration it takes the liver to regenerate, there must be fast and specialized medical interventions3 to take over the many vital functions of the liver.

There is a list of drugs that are known to be hepatotoxic (damaging to the liver) and the most severe form of acute liver damage can occur within hours of taking these medications. This is because the entire liver can be affected at the same time, and all the liver cells can face severe damage simultaneously thereby leaving no cells available to carry out the liver’s vital functions and leaving no room for the all important liver regeneration.

Malaria parasites are also known to prefer red blood cells and liver cells for their reproduction. When the parasite reproduces it can multiply several hundred times inside a single cell and when it has completed this multiplication, the new parasites burst4 open the red blood cell or liver cell that was their host and will then be released into the body where they enter nearby cells ready for the next cycle of reproduction. In severe malaria that has infected the liver cells, there is usually a significant damage to liver function. If in addition to this a patient takes a substance that is hepatotoxic (damaging to the liver) it can add insult to the already existing injury and can further worsen the problem.

Fig2: Life cycle of the malaria parasite

Fig 3: Malaria Parasite incubation in a red blood cell which is about to burst and surrounded by healthy cells.
Unless treated the surrounding red blood cells will also eventually get infected and become factories for parasite incubation.

So to answer your question- yes, it is very possible for a hepatotoxic drug to rapidly affect a large percentage of the liver cells, and if these are significantly damaged, it can severely affect the vital life functions that the liver is essential for. This disruption in the liver function can quickly spread to almost all other systems including blood, digestion, immunity, circulation and hormone regulation. With all these critical failures happening simultaneously, even the systems not directly affected will be stretched beyond capacity while attempting to correct for the disruption. This can lead to a multi-organ failure5 where all the systems start to shut down one by one and eventually lead to death.

It is easy to look for someone to blame when things like this happen, and sometimes there might even be a genuine case of negligence or incompetence, though this is not always the case. When malpractice is identified, we as doctors unanimously agree that it must be punished to the full extent of the law. Medicine is a sacred profession and we know that we literally hold the lives of our patients in our hands.

It is important to note however that the healthcare system (along with every other sector in the country), bears the scars of many, many years of underfunding and poor leadership, caused by the systemic corruption in Nigeria. In a society where the basics of life can sometimes be a luxury, people will often do anything to survive. This includes importers who bring in fake drugs, retailers who sell expired medications, and hospitals that are so stretched for funds, that they may sometimes go for the cheapest supplier just to stay afloat.

In all of this, we must remember that there are thousands of healthcare professionals across the country, who have dedicated their life to their patients, and who despite the inhospitable and archaic system, continue to provide what best care they can for their patients around the clock. These are the heroes of our health care system and they are those for whom this profession is not just a job but a calling.

We didn’t get into this situation overnight and we can’t get out in an instant either. We as a people must all come together to fight for the soul of our nation and save her from the jaws of corruption. Together we can make Nigeria great again!

  1. Liver cells are like the bodyguards of the human body and many times a liver cell literally dies fighting. A hepatocyte – as they are also known, will rather die than let a toxin or infectious organism slip past it.
  2. There is a reason this organ is called the liver. You cannot LIVE without your LIVER (Okay that’s a joke but you get the point)
  3. Liver Support Units are usually only available in large specialist hospitals and have to be on high alert, and must respond within hours of a diagnosis of acute Drug induced Liver Damage for there to be a positive outcome. Virtually all the major functions of the liver are taken over by the provision of specialised infusions of protein, blood filtration, infection prevention, glucose monitoring, blood clotting monitoring, and bile production.
  4. Malaria parasites exhibit a feature known as the Cinderella Phenomenon. All the parasites seem to divide at the same rate and at the same time in different cells of their human host. The parasites will synchronise the time when they burst out of their host cells (often at midnight) and it is not uncommon to have thousands of cells rupturing at the exact same time to release millions of newly spawned parasites into the blood stream.
  5. This does not in any way suggest that Eric died from Multi Organ Failure unless confirmed by post mortem


***
Disclaimer: This column is written for patient education. It is not intended to diagnose or prescribe treatment and does not replace the advice of your physician. It does not attempt to cover the full medical scope of this condition.

Photo Credit:
Figure 1: By Tvanbr – Own work, Public Domain

Figure 2: Public domain 

Figure 3: By Rick Fairhurst and Jordan Zuspann, National Institute of Allergy and Infectious Diseases, National Institutes of Health 

25 Comments

  1. Anon

    February 13, 2017 at 4:32 pm

    Thank you for doing this and answering those questions asked by people in response to your comment on Eric’s death.

    This is an education.

    • Tobi

      February 13, 2017 at 5:37 pm

      I hear you but i doubt very much that a malaria drug could have shut down the liver so quickly

      The American Medical Association (AMA) concluded in 2001 that the actual shelf life of some products is longer than the labeled expiration date. ……Solid dosage forms, such as tablets and capsules, appear to be most stable past their expiration date. Drugs that exist in solution or as a reconstituted suspension, and that require refrigeration (such as amoxicillin suspension), may not have the required potency if used when outdated.

      I work in pharmaceutical and malaria drugs are in tablets form , most are not potent after expiration date ………..THERE IS MORE TO THIS STORY THAN THE FAMILY IS TELLING .
      Rest in peace

    • slice

      February 13, 2017 at 5:48 pm

      I’ve been wondering about this too.

    • Asa

      February 13, 2017 at 6:03 pm

      Please shut up o jare, just shut up. You aren’t even sensitive tot he loss of a very young man. Do the family owe you any explanation at all? Which kind of rubbish entitlement is it that makes you question the information they gave? was he related to you abi you are his young wife that has to bear his loss? Of what use would lying to you be? What are you/what are we to them that they would feel the need to lie to us? Biko no dey rub salt for injury abeg. na your type for viallage dey ask widow if no be she kill im husband.

      I don’t normally fight people on BN, but your insensitivity got to me. Finally, biko are you a Doctor? Did you study medicine? Dr. Craig that just said it was a possibility, you get medical degree take to challenge am? Go joor!

    • LagosismyHome

      February 13, 2017 at 6:08 pm

      @Tobi it might actually be a fake drug who knows more than an expired drugs or a combination of both……. the truth might lies somewhere in between since you are finding what the family is not telling …………..(i think that statement is unnecessary, let them grieve biko )

      Nigeria health care is a mess so many aviodable deaths due to poor health care and also do not under estimate the war against fake drugs in circulation in Nigeria…

      It is very real and looks abstract until it hits home and kills a love one (God forbids) . Also the issue of expiration who knows if the drug had expired 3 to 4 years ago. Until you have the full facts in front of you be cautious with doubts …

      May his gentle soul rest in peace . …Nigeria please sort out your mess

    • Mary

      February 13, 2017 at 6:17 pm

      Asa ; this doctor might say so but other literature online and other doctor work says otherwise. I went online to check since the story broke out

    • Olamide Craig

      February 13, 2017 at 6:53 pm

      Thank you @Tobi.
      I agree that solid state medicines have an extremely long shelf life and as far as I know none of the modern antimalarials on sale today have a significantly fatal hepatotoxic profile,

      In my article I was careful not to attribute anything to the antimalarial per se but instead opted for the broader term hepatotoxics. I also stated quite clearly that I do not know which drugs were taken and used the word allegedly when describing the fact of their expiry. One thing we do know is that he was said to have suffered acute liver damage and that this was attributed to a drug.

      Whether this was induced by an antimalarial, or was hepatotoxicity due to an interaction of different medications he might have been taking, or caused by a fake drug, or a known hepatotoxic sold in the guise of an antimalarial,is not the focus of this article. What I set out to explain was the mechanisms by which a hepatotoxic medication in conjunction with severe acute malaria, as described by the family, might lead to liver failure and eventually death.

    • Seriously

      February 13, 2017 at 7:14 pm

      Thank you, Dr Craig for taking out of your time to share invaluable information with BN readers. Also, I implore Nigerians to take realistic, practical approach to their health not theorise and spiritualize it. Do not underestimate anything.

      @Tobi
      Yeah, there could be more to it. However, the emphasis is “fake drug” which means it could easily be a drug that’s not specifically used for malaria or knocked off version of the real drug. Like China designers vs the real designers.
      I had a discussion with a Nigerian pharmacist who practiced in Nigeria specifically the North. He mentioned, many who don’t have money to buy the real medications, or want a reduced price end up going through private companies, clinics and even individuals to get their medical treatments and drugs. Majority of them are not approved by FDA and definitely less accountability. He confessed, him and group of pharmacists mixed up medications and sold it. Or sell other alternatives that’s not completely the prescribed drug for the specific illness. Many of those small pharmaceutical stores sell expired medications all the time. They don’t want to throw them away because they will lose money, so will leave it on the counter longer than they should. In the U.S, after a specific period of time, all medications are replaced and changed no matter the circumstance. Although, he emphasized what he did is illegal but since there’s not intense scrutiny and inspection on private clinics, and individual practice, many get away with a lot. Unfortunately, many also go through back door because they don’t want to disclose their illness, or be in the record so that’s also their way of being discreet.
      He mentioned how he was a millionaire in Nigeria as a pharmacist. And U.S restricts you a lot. And i said, there must be other things you did, that’s when he confessed.

    • Icrossmyheart

      February 13, 2017 at 7:26 pm

      @Asa why are you always violent with your words. Kai kai. I pity your circle of friends. By saying shut up like what three times, are you now satisfied that you have gotten your point across?

      There is some element of truth to what Tobi is saying, sensitivity or not. Most drugs lose their potency after expiration date especially malaria drugs. However, there are many ‘fake’ malaria drugs in the packet and because of corruption the said expiration date may not ACTUALLY BE THE EXPIRATION DATE. SO said drug may still be very very active and hence, toxic.

    • Somebody

      February 13, 2017 at 8:59 pm

      His brother said he had existing liver issues that escalated due to the expired drug

    • See

      February 13, 2017 at 10:47 pm

      You work in a pharmaceutical company? So you do know you don’t know so much about acute hepatic failure and it’s causes. Many different drugs can cause liver damage, and you should also know that individuals may react differently to different drugs. Yes, drugs can shut down the liver asap in an otherwise healthy person.

  2. Noms

    February 13, 2017 at 5:24 pm

    Thank you…as a biochemistry undergrad years ago,our lecturer always told us that the best way to love is with the liver and not the heart…she was just trying to tell us how much work the liver does as compared to the heart. Not that the heart isnless important though.
    RIP,Eric…

  3. Anony

    February 13, 2017 at 6:28 pm

    The expiration date doesn’t really indicate a point at which the medication is no longer effective or has become unsafe to use. Medical authorities state expired drugs are safe to take, even those that expired years ago. A rare exception to this may be tetracycline, but the report on this is controversial among researchers. It’s true the effectiveness of a drug may decrease over time, but much of the original potency still remains even a DECADE AFTER THE EXPIRATION DATE . Excluding nitroglycerin, insulin, and liquid antibiotics, most medications are as long-lasting as the ones tested by the military.

    Is the expiration date a marketing ploy by drug manufacturers, to keep you restocking your medicine cabinet and their pockets regularly? You can look at it that way. Or you can also look at it this way: The expiration dates are very conservative to ensure you get everything you paid for. And, really, if a drug manufacturer had to do expiration-date testing for longer periods it would slow their ability to bring you new and improved formulations.

    • Anony

      February 13, 2017 at 6:30 pm

    • Olamide Craig

      February 13, 2017 at 7:08 pm

      Hello @Anony
      The trouble with this article from Harvard is that no clinician worth his medical degree will ever confidently instruct his patient to take medication that has expired.

      When you go to a hospital will you be happy to be given a drug that expired 1 year, 5 years or 10 years ago?

    • Bimbo

      February 13, 2017 at 8:04 pm

      DR Craig your statement is a valid one but not really the focus topic. The focus is what is the potency or clinical implication when you take an expired drug

      It definitely not the ideal and should not be encouraged but clinical research states that most medications are not lethal/ fatal after expiration date . The expiration date is put much forward due to marketing purposes so u quickly keep buying with the notion that its out of date…hence why pharamactical companies are so rich

      This story i am leaning more towards a drug that was fake than expired or what is more common in Nigeria. Eric was given the wrong medication or misdiagnosed

  4. Victor Adegoke

    February 13, 2017 at 6:57 pm

    Thanks to Bella Naija for introducing a medic to us for counselling us on our health.

  5. Ini

    February 13, 2017 at 7:34 pm

    @Tobi,
    I’m pretty sure you read this sentence as written in the article: “yes, it is very possible for a hepatotoxic drug to rapidly affect a large percentage of the liver cells”. I’m still looking for the part where Dr Craig said expired drugs can shut down the liver….
    It’s funny how you read an article like this and miss the salient message just because you want to comment and counter.
    I think there’s a good reason why the good doctor is a columnist and you’re a commentator.
    Please read right and in context and stop using other people’s articles to announce your occupation…mbok!?

    • Dare

      February 13, 2017 at 8:56 pm

      Ini what does coloumist or commentator have to do with anything..do u know what the other person has written or done. BN is faceless so all these kind comments including Hater usually sound dull…..
      Its a sensible discussion and its good to promote a lively participation so people can learn and be better informed …your comment really irritates me

    • Ini

      February 13, 2017 at 10:00 pm

      @Dare, I don’t think I get you. Opening the stage for lively participation is good. But misinterpreting what the other has written and doing so brashly, that I don’t agree with.

  6. Marian

    February 13, 2017 at 10:59 pm

    Nigerians need to also be educated about over the counter drugs like Paracetamol that can lead to liver damage. I feel like people just pop it like it’s candy.

    Can someone shed more light on the active ingredient inside Alabukun? That’s another drug Nigerians abuse.

  7. o

    February 13, 2017 at 11:57 pm

    Most likely a case of fake, unadulterated drugs than expired drugs. Or maybe a preexisting or underlying condition further aggravated by it. I have knowingly used expired drugs. I tend to have a lot of medication at home. Should I need to take a particular one, even if it’s past its expiry date by months, I take it. It’s BEST BEFORE, not like it’s bad by that date. Just better taken before then. It’s so unfortunate that Eric had to die. May his soul rest in peace

  8. Dr. Craig

    February 14, 2017 at 10:11 am

    @Dare @Ini
    Discussion is good. That is what these forums are for.
    But I’m surprised that we are not talking about the elephant in the room but rather are focusing on the colour of the curtains.

    Our health system is under equipped and incapable of handling complex acute cases. We have some of the best doctors in the world but our system stifles innovation and kills productivity.

    Do we have National Level1 trauma centres, Dedicated Liver transplant centres, or Neonatal intensive care units? No we don’t. Can we afford them? Of course we can. But the money for these life saving equipment sits in a mud house in Kaduna or a titanium vault in Switzerland.

  9. Anonymous

    February 14, 2017 at 3:22 pm

    Thank you to the good Dr. for this comment. And to think we finally have an administration even trying to bring them to book and all e do is complain! We must defeat corruption in Nigeria! Practically everything wrong with our system stems directly from corruption!

    • Baby810

      February 25, 2017 at 1:57 pm

      What do we expect when our president and other top officials seek medical treatment abroad. Trauma Centers, intensive care units and adequate technology and equipments should be in every teaching hospitals, general hospitals and federal medical Centers so when situations like this arise, there will be hope at least the caregivers can try to save the person.
      It’s unfortunate Eric is a victim of this may his soul rest in peace and Dear Lord grant his family and friends the fortitude to bear this huge loss.

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