Exemestane
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Exemestane Cholestatic liver injury : case report
A woman in her 60s [exact age not stated] developed cholestatic liver injury during treatment with exemestane for breast carcinoma [route and dosage not stated]. The woman was diagnosed with right ductal, HR positive, microinvasive carcinoma in March 2000 (i.e. at the age of 59 years). She underwent a lumpectomy, axillary dissection, adjuvant radiation and was then started on tamoxifen. During adjuvant therapy, she was noted to have hyperphosphatasemia and was subsequently diagnosed with primary biliary cirrhosis [aetiology not stated] which was managed with ursodeoxycholic-acid [ursodiol]. After two years of tamoxifen treatment, she was transitioned to anastrozole due to symptoms of hot flashes and depression secondary to tamoxifen therapy. She completed 5 years of adjuvant therapy with anastrozole. In March 2007, she was diagnosed with grade 1, HR positive, human epidermal growth factor receptor 2 (HER2) negative, pT1cN0M0 invasive ductal carcinoma of the left breast. She underwent a lumpectomy, sentinel node biopsy and adjuvant radiation therapy, and started adjuvant endocrine therapy with exemestane. Approximately four weeks after starting exemestane, she developed generalised pruritis and diarrhoea. These symptoms were treated with loperamide as needed and daily colestyramine [cholestyramine]. Following 6 weeks on loperamide and colestyramine, she showed no improvement. As a result, she was evaluated by a gastroenterologist and was found to have cholestatic liver abnormalities with an elevation of her total bilirubin to 1.1 mg/dL and an elevation of her ALT to 123 IU/L and AST to 62 IU/L. The woman’s therapy with exemestane was discontinued. Her laboratory abnormalities and symptoms resolved over 4 weeks. Approximately 2 months after the discontinuation of exemestane, the woman was re-started on exemestane. After 1 week of exemestane re-initiation, pruritis, diarrhoea and the liver laboratory abnormalities appeared again. Exemestane was then switched to letrozole and she completed 5 years of letrozole therapy. She presented in August 2018 with right sided ptosis secondary to a superior rectus mass. The pathology showed HR positive, HER2 negative, carcinoma, consistent with metastatic breast cancer recurrence. She was re-started on exemestane. Three weeks after re-starting exemestane, she reported severe pruritus and diarrhoea. Liver function tests showed grade 2 transaminitis and grade 1 hyperbilirubinaemia. A clinical pharmacist was asked to review her medication list including over the counter medications and supplements [details not stated] and none were thought to be contributing to the patient’s clinical picture. Her symptoms persisted and liver function tests showed increasing total bilirubin and transaminitis. Therefore, exemestane was discontinued. The transaminitis and hyperbilirubinaemia resolved 1 week following the discontinuation of exemestane. Anastrozole was re-started. She stopped colestyramine. Her liver function tests normalised and rema
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