title: Hepatotoxicity by combination treatment of temozolomide, artesunate and Chinese herbs in a glioblastoma multiforme patient: case report review of the literature.
abstract: Glioblastoma multiforme (GBM) represents an aggressive tumor type with poor prognosis. The majority of GBM patients cannot be cured. There is high willingness among patients for the compassionate use of non-approved medications, which might occasionally lead to profound toxicity. A 65-year-old patient with glioblastoma multiforme (GBM) has been treated with radiochemotherapy including temozolomide (TMZ) after surgery. The treatment outcome was evaluated as stable disease with a tendency to slow tumor progression. In addition to standard medication (ondansetron, valproic acid, levetiracetam, lorazepam, clobazam), the patient took the antimalarial drug artesunate (ART) and a decoction of Chinese herbs (Coptis chinensis, Siegesbeckia orientalis, Artemisia scoparia, Dictamnus dasycarpus). In consequence, the clinical status deteriorated. Elevated liver enzymes were noted with peak values of 238 U/L (GPT/ALAT), 226 U/L (GOT/ASAT), and 347 U/L (γ-GT), respectively. After cessation of ART and Chinese herbs, the values returned back to normal and the patient felt well again. In the literature, hepatotoxicity is well documented for TMZ, but is very rare for ART. Among the Chinese herbs used, Dictamnus dasycarpus has been reported to induce liver injury. Additional medication included valproic acid and levetiracetam, which are also reported to exert hepatotoxicity. While all drugs alone may bear a minor risk for hepatotoxicity, the combination treatment might have caused increased liver enzyme activities. It can be speculated that the combination of these drugs caused liver injury. We conclude that the compassionate use of ART and Chinese herbs is not recommended during standard radiochemotherapy with TMZ for GBM.
authors: Institute of Pharmacy and Biochemistry, Johannes Gutenberg University, Mainz, Staudinger Weg 5, 55128, Mainz, Germany. efferth@uni-mainz.de.
authors: Thomas
authors: T
authors: Efferth
authors: Institute of Pharmacy and Biochemistry, Johannes Gutenberg University, Mainz, Staudinger Weg 5, 55128, Mainz, Germany.
authors: Ursula
authors: U
authors: Schöttler
authors: Institute for Infection and Immunity, St. George's, University of London, London, UK.
authors: Sanjeev
authors: S
authors: Krishna
authors: Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany.
authors: Peter
authors: P
authors: Schmiedek
authors: Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany.
authors: Frederik
authors: F
authors: Wenz
authors: Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany.
authors: Frank A
authors: FA
authors: Giordano
mesh_terms: D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage / Q000009:adverse effects*; D037621:Artemisinins / Q000008:administration & dosage; D000077332:Artesunate; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology* / Q000503:physiopathology; D059248:Chemoradiotherapy / Q000379:methods; D003606:Dacarbazine / Q000008:administration & dosage / Q000031:analogs & derivatives; D004365:Drugs, Chinese Herbal / Q000008:administration & dosage; D005260:Female; D005909:Glioblastoma / Q000473:pathology / Q000628:therapy*; D006801:Humans; D000077204:Temozolomide
chemical_list: D037621:Artemisinins; D004365:Drugs, Chinese Herbal; D000077332:Artesunate; D003606:Dacarbazine; D000077204:Temozolomide
keywords: Adverse side effects; Asteraceae; Cancer; Chemotherapy; Toxicity; Traditional Chinese medicine