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Diclofenac-induced liver injury: a paradigm of idiosyncratic drug toxicity
Abstract
The nonsteroidal antiinflammatory drug diclofenac causes rare but significant cases of serious hepatotoxicity, typically with a delayed onset (>1-3 months). Because there is no simple dose relationship and because liver injury cannot be reproduced in current animal models, individual patient-specific susceptibility factors have been evoked to account for the increased risk. While these patient factors have remained undefined, a number of molecular hazards have been characterized. Among these are metabolic factors (bioactivation by hCYP2C9 or hCYP3A4 to thiol-reactive quinone imines, activation by hUGT2B7 to protein-reactive acyl glucuronides and iso-glucuronides, and 4'-hydroxylation secondary to diclofenac glucuronidation), as well as kinetic factors (Mrp2-mediated concentrative transport of diclofenac metabolites into bile). From the toxicodynamic view, both oxidative stress (caused by putative diclofenac cation radicals or nitroxide and quinone imine-related redox cycling) and mitochondrial injury (protonophoretic activity and opening of the permeability transition pore) alone or in combination have been implicated in diclofenac toxicity. In some cases, immune-mediated liver injury is involved, inferred from inadvertent rechallenge data and from a number of experiments demonstrating T cell sensitization. Why certain underlying diseases (e.g., osteoarthritis) also increase the susceptibility to diclofenac hepatotoxicity is not clear. To date, cumulative damage to mitochondrial targets seems a plausible putative mechanism to explain the delayed onset of liver failure, perhaps even superimposed on an underlying silent mitochondrial abnormality. Increased efforts to identify both patient-specific risk factors and disease-related factors will help to define patient subsets at risk as well as increase the predictability of unexpected hepatotoxicity in drug development.
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“Genetic polymorphisms, drug overdosage, or interactions with other medications can lead to variations in the activity of these enzymes, thereby influencing the metabolic rate of diclofenac and the generation of toxic intermediates, ultimately increasing the risk of liver toxicity [28,29].”
From Decellularized liver scaffolds for constructing drug-metabolically functional ex vivo human liver models (2025) · cites this paper as [28]
In the citing paper
“Previous studies have shown that diclofenac is biotransformed primarily through specific drug-metabolizing enzymes, including members of the CYP family such as CYP2C9 and CYP3A4.”
From Decellularized liver scaffolds for constructing drug-metabolically functional ex vivo human liver models (2025) · cites this paper as [28]
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Metadata
- Authors
- Boelsterli, U.
- Affiliations
- University of Basel (CH)
- Corresponding author
- Boelsterli, U
- Venue
- Toxicology and Applied Pharmacology
- Publisher
- Elsevier BV
- Published
- 2003-11-01
- Volume
- 192
- Issue
- 3
- Pages
- 307-322
- ISSN
- 0041-008X (ISSN-L)
- OpenAlex
- W2003181581
- Cited by
- 403
- References
- 101
- Citations by year
- 2026: 11 · 2025: 10 · 2024: 8 · 2023: 17 · 2022: 12 · 2021: 20 · 2020: 17 · 2019: 18 · 2018: 15 · 2017: 23 · 2016: 30 · 2015: 17 · 2014: 17 · 2013: 20 · 2012: 20
- FWCI
- 8.24
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Toxicology and Applied Pharmacology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Pharmacology › Drug-Induced Hepatotoxicity and Protection
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Pharmacology › Pharmacogenetics and Drug Metabolism
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Toxicology › Pharmacovigilance and Adverse Drug Reactions
- Keywords
- diclofenac, hepatotoxicity, idiosyncratic drug toxicity, nonsteroidal anti-inflammatory drugs, CYP2C9, CYP3A4, UGT2B7, quinone imines, acyl glucuronides, MRP2, bile transport, oxidative stress, mitochondrial injury, mitochondrial permeability transition pore, immune-mediated liver injury, T cell sensitization, osteoarthritis, toxicodynamics
- MeSH terms
- Animals, Anti-Inflammatory Agents, Non-Steroidal, Diclofenac, Humans, Chemical and Drug Induced Liver Injury, Drug-Related Side Effects and Adverse Reactions
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