Hepatotoxicity quinidine

Hepatotoxicity Hepatotoxicity (including granulomatous hepatitis) due to quinidine hypersensitivity has occurred. 

Hypersusceptibihty reactions to quinidine include granulomatous hepatitis. In one retrospective series of 487 patients, 32 had evidence of hypersusceptibility, 10 of whom had hepatotoxicity (44). In another series of 1500 patients, quinidine-induced hepatitis was identified in 33 (2.2%) (45) these represented one-third of all cases of drug-induced hepatitis in those patients. In all cases the liver damage resolved on withdrawal. 

The oxidative reactions of this sequence are catalyzed by the microsomal P-450 system [69, 70, 71]. A P-450 system from rat liver can also oxidize morphine [72]. One product of this oxidation is morphinone, a highly toxic electrophile that couples with thiol groups. The latter reaction may deplete glutathione and in other ways may account for the hepatotoxicity of morphine [73, 74]. The demethylation of codeine to morphine probably accounts for the analgesic action of codeine, and people with a defect in this demethylating system probably get no analgesia from codeine [75, 76]. Rats, too, show strain differences in the ability to demethylate codeine to morphine [77]. Quinidine, quinine, or sparteine inhibit the conversion of codeine to morphine, presumably by inhibiting the P-450 enzyme [71, 78]. While O-demethylation converts codeine to morphine, N-demethylation also occurs and produces norcodeine [79]. 

With the introduction of RiF in 1967, the duration of combination therapy for the treatment of TB was significantiy reduced (from 18 to 9 months). Rifampin is nearly always used in combination with one or more other antitubercuiin agents. The drug is potentially hepatotoxic and may produce Gl disturbances, rash, and thrombocytopenic purpura. Rifampin is known to induce hepatic microsomai enzymes (cytochrome P450) and may decrease the effectiveness of oral contraceptives, corticosteroids, warfarin, quinidine, methadone, zidovudine, clarithromycin, and the azoie antifungai agents (see Chapter 10) (33). 

---