title: Utility of the Roussel Uclaf Causality Assessment Method (RUCAM) to analyze the hepatic findings in a clinical trial program: evaluation of the direct thrombin inhibitor ximelagatran.
abstract: OBJECTIVE
  Causality assessment in drug-induced liver injury is often based on circumstantial evidence rather than a formal, systematic review. The Roussel Uclaf Causality Assessment Method (RUCAM) provides a more objective means of assessing causality of a suspected hepatotoxin but, to our knowledge, has never been used in the assessment of a single drug with unknown hepatotoxic potential in a clinical trial setting.
  
  
  METHODS
  We studied the utility of RUCAM in assessing the hepatic events during the long-term clinical trials of the oral direct thrombin inhibitor ximelagatran, which has been associated with an increased incidence of alanine aminotransferase (ALT) elevations. A total of 233 subjects with elevated ALT values signalling possibly severe hepatic injury were eligible for RUCAM analysis (198 ximelagatran and 35 comparator anticoagulants).
  
  
  RESULTS
  RUCAM scores, calculated independently by the assessors, using the existing numerical criteria provided in its methodology, suggested a possible or probable causal relationship between ALT and ximelagatran in 37 and 27% of cases, respectively. Causality was excluded or unlikely in the remaining 36% of cases. However, in the course of utilizing RUCAM, several limitations to the methodology came to light, including awarding additional points for age > 55 years, an unspecified use of alcohol, and a latency period of < 90 days, which may have had the unintentional effect of raising the overall score. Moreover, rechallenge is highly rewarded by RUCAM but is seldom done in clinical practice or in clinical trials. We also found ambiguities in the extent to which other causes of liver injury were excluded, what constitutes a significant hepatotoxic concomitant medication, and whether a clinical trial drug should be considered as having an unknown hepatotoxic potential for purposes of RUCAM scoring. Increasing familiarity with the RUCAM over the course of the study allowed for only a slight improvement in concordance between and among the assessors regarding the scoring.
  
  
  CONCLUSIONS
  While the results indicate that RUCAM can provide for an objective assessment of causality of the hepatotoxicity of a drug under development in the clinical trial setting, this study highlights a number of problems with the current scoring system that should be addressed by future enhancements of the methodology.
authors.affiliation: Georgetown University Medical Center, Washington, DC 20854, USA. lewisjh@gunet.georgetown.edu
authors.forename: J H
authors.initials: JH
authors.lastname: Lewis
authors.forename: D
authors.initials: D
authors.lastname: Larrey
authors.forename: R
authors.initials: R
authors.lastname: Olsson
authors.forename: W M
authors.initials: WM
authors.lastname: Lee
authors.forename: L
authors.initials: L
authors.lastname: Frison
authors.forename: M
authors.initials: M
authors.lastname: Keisu
mesh_terms: D000367:Age Factors; D000410:Alanine Transaminase / Q000187:drug effects / Q000378:metabolism; D000428:Alcohol Drinking / Q000009:adverse effects; D000925:Anticoagulants / Q000009:adverse effects*; D001384:Azetidines / Q000009:adverse effects*; D001596:Benzylamines / Q000009:adverse effects*; D002986:Clinical Trials as Topic; D006801:Humans; D008099:Liver / Q000187:drug effects* / Q000473:pathology; D008107:Liver Diseases / Q000209:etiology*; D008111:Liver Function Tests / Q000379:methods; D008875:Middle Aged; D012307:Risk Factors; D013997:Time Factors
chemical_list: D000925:Anticoagulants; D001384:Azetidines; D001596:Benzylamines; C426686:ximelagatran; D000410:Alanine Transaminase