Quantitative In Silico analysis of transient metabolism of acetaminophen and associated causes of hepatotoxicity in humans

PURPOSE: Although safe at therapeutic levels, excess intake of acetaminophen can lead to hepatic injury or acute liver failure (ALF). A number of different factors influence metabolism and hepatotoxicity of acetaminophen in patients. Three of the most important are a patient’s physiological response to fasting, alcohol consumption, and chronic acetaminophen consumption. The molecular and enzymatic underpinnings for these processes have been extensively studied. The purpose of this study is to examine and quantify the effects of the noted conditions, provide possible reasons for conflicting clinical observations, and examine dangers associated with uptake of therapeutic doses of acetaminophen. METHODS: In order to gain a better understanding of the transient hepatic changes associated with each physiological and nutritional process, examine risks of ALF associated with individuals based on their unique lifestyle and health issues, and predict improved dosing strategies, a multi-compartmented physiologically-based pharmacokinetic (PBPK) model of acetaminophen metabolism in adult humans was developed. By varying the parameters of this model, changes in metabolism of acetaminophen and its toxic byproducts for a variety of medically relevant conditions were assessed. RESULTS: Simulated results indicate that in case of chronic ingestion of acetaminophen, the increased rate of glucuronidation plays a significant role in protecting patients from liver damage following uptake of excessive quantities. Analysis of metabolism of acetaminophen in persons who have imbibed excessive amounts of alcohol show that the primary reason for hepatotoxicity in such individuals is decreased availability of glutathione in the liver and not the observed increased production of toxic byproducts. When the glutathione depleting effects of alcohol consumption are combined with those associated with chronic acetaminophen use, intake of slightly higher quantities than the recommended therapeutic doses of acetaminophen can result in initiation of hepatotoxicity. CONCLUSIONS: The results of simulations show that, in healthy and well-fed individuals, chronic uptake of acetaminophen doses even five times the therapeutic recommendations should be safe. However, in persons who have diminished hepatic glutathione regeneration capacities, depending on the magnitude of this deleterious shortcoming, minor overdoses can result in hepatotoxicity. Hence, it can be concluded that for such persons, acetaminophen is just as toxic as any other compound that would generate reactive oxidative species.