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Copyright © 1998 by The American Society for Pharmacology and Experimental Therapeutics JPET 288:65–72, 1998

Vol. 288, No. 1 Printed in U.S.A.

Diclofenac Toxicity to Hepatocytes: A Role for Drug Metabolism in Cell Toxicity 1








Unidad de Hepatologı´a Experimental, Centro de Investigacio´ n, Hospital Universitario “La Fe”, Valencia, Spain (R.J., M.J.G.-L., R.B., J.V.C.); Departamento de Bioquı´mica, Facultad de Medicina, Universidad de Valencia, Valencia, Spain (R.B., R.J., J.V.C.); and Departamento de Parasitologı´a y Biologı´a Celular, Facultad de Ciencias Biolo´ gicas, Universidad de Valencia, Valencia, Spain (X.P.)

Accepted for publication July 21, 1998

This paper is available online at

ABSTRACT Diclofenac, a 2-arylacetic acid, nonsteroidal anti-inflammatory drug, has been reported to cause adverse hepatic effects in certain individuals. To discriminate among possible mecha- nisms of hepatotoxicity, we examined the effects of diclofenac on human and rat hepatocytes and hepatic cell lines (HepG2, FaO), investigated the major biochemical events in the course of diclofenac cytotoxicity (calcium homeostasis, lipid peroxida- tion, and mitochondrial dysfunction), and investigated whether cytotoxicity could be related to drug metabolism by cyto- chrome P-450. Acute diclofenac-induced toxicity in hepato- cytes was preluded by a decrease in ATP levels, whereas no significant oxidative stress (decrease in glutathione and lipid peroxidation) or increase in intracellular calcium concentration could be observed at early incubation stages. Diclofenac was more cytotoxic to drug metabolizing cells (rat and human pri-

mary cultured hepatocytes) than to nonmetabolizing cell lines (HepG2, FaO). Despite the fact that diclofenac itself was effec- tive in impairing ATP synthesis by mitochondria, we found evidence that toxicity was also related to drug metabolism and was reduced by the addition of cytochrome P-450 inhibitors (proadifen and ketoconazole) to culture medium. The in vitro cytotoxicity correlated well with the formation by hepatocytes of 5-hydroxydiclofenac and, in particular, N,5-dihydroxydiclofe- nac, a minor metabolite first characterized in this article. He- patic microsomes showed the ability to both oxidize 5-hydroxy- diclofenac to N,5-dihydroxydiclofenac and back reduce the latter to 5-hydroxydiclofenac with the consumption of NADPH. The experimental results suggest that the toxic effect of diclofe- nac on hepatocytes may be caused by drug-induced mitochon- drial impairment, together with a futile consumption of NADPH.

Diclofenac is a frequently prescribed nonsteroidal anti- inflammatory drug. Although diclofenac-associated hepatitis was thought to be rare, there are clinical reports of severe hepatic reactions associated with their use (Helfgott et al., 1990; Sallie, 1990; Ouellette et al., 1991; Purcell et al., 1991). In addition to this, there are indications that borderline increases in serum transaminases occur in approximately 15% of patients taking the drug regularly, which suggests that diclofenac-associated hepatotoxicity might be more com- mon than previously recognized (Ciccolunghi et al., 1978; Iveson et al., 1990). Although in some case reports, the ad- verse hepatic effects of diclofenac showed features compati- ble with a drug hypersensitivity reaction (Breen et al., 1986; Schapira et al., 1986; Salama et al., 1991; Romano et al.,

Received for publication April 8, 1998. 1 This study was supported, in part, by the BIOMED II Research Program of the European Union and the Fondo de Investigaciones Sanitarias, Spanish Ministry of Health. R.B. was recipient of a predoctoral fellowship from the Consellerı´a de Educacio´n y Ciencia, Generalitat Valenciana.

1994), the clinical findings in other patients appear to be more consistent with a direct toxic effect of the drug or a drug metabolite (Helfgott et al., 1990; Iveson et al., 1990; Sallie, 1990; Scully et al., 1993). The mechanism by which diclofenac causes liver alter- ations in certain individuals is not yet fully understood, and both the formation of a toxic metabolite and covalent binding of the drug to hepatic proteins have been invoked to explain its toxicity. Diclofenac was found to generate protein adducts in the livers of treated mice as well as in rat hepatocytes via protein acylation by the drug glucuronide (Pumford et al., 1993). In vitro experiments with cultured rat hepatocytes have shown, however, that the covalent binding of diclofenac is neither the only nor the major cause of acute cytotoxicity (Kretz-Rommel and Boelsterli, 1993). Moreover, previous work has suggested that diclofenac is cytotoxic to rat hepa- tocytes after cytochrome P-450 (CYP)-mediated metabolism (Schmitz et al., 1992; Jurima-Romet et al., 1994). Recently, the formation of reactive metabolite(s) by drug oxidation,

ABBREVIATIONS: BHT, buthylated hydroxytoluene; BSO, L-buthionine-[S,R]-sulfoximine; CYP, cytochrome P-450; MDA, malondialdehyde; DEM, maleic acid diethyl ester; MTT, 3-[4,5-dimethylthiazol-2-yl]-3,5-diphenylformazan; PBS, phosphate-buffered saline; 4 -OHdic, 4 -hydroxy- diclofenac; 5-OHdic, 5-hydroxydiclofenac; N,5-(OH) 2 dic, N,5-dihydroxydiclofenac; [Ca ] i , intracellular calcium; GSH, glutathione; HPLC-MS, high-performance liquid chromatography-mass spectrometry.


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Bort et al.

which could be related to drug toxicity, has been reported (Miyamoto et al., 1997). Diclofenac undergoes hepatic metabolism both in rat and human hepatocytes, and the main biotransformation reac- tions (aromatic hydroxylations and conjugations at various sites of the molecule) are common to several animal species (Riess et al., 1978; Stierling et al., 1979). In human liver microsomes, the major oxidative metabolic pathway is the formation of 4 -hydroxydiclofenac (4 -OHdic) by CYP2C9 (Smith and Jones, 1992; Leemann et al., 1993). Formation of 5-hydroxydiclofenac (5-OHdic), 3 -hydroxydiclofenac, 4 ,5- dihydroxydiclofenac, and 3 -hydroxy-4 -methoxydiclofenac has also been reported in humans, but to a much lesser

extent (Riess et al., 1978; Faigle et al., 1988). In the rat,

4 -OHdic together with 5-OHdic are the major urine me-

tabolites (Stierling et al., 1979). We have investigated the acute effects of diclofenac on the

viability and functionality of cultured hepatocytes to discrim- inate between possible mechanisms of toxicity and found that

a decrease in ATP levels preluded cell death. Despite the fact

that diclofenac itself was effective in impairing ATP synthe- sis by mitochondria, we found evidence that toxicity was also related to drug metabolism, in particular with the formation of 5-OHdic and N,5-dihydroxydiclofenac (N,5-(OH) 2 dic).

Both metabolites can easily interchange by oxidation and reduction and both cause a continuous consumption of NADPH. Thus, in addition to the effects of diclofenac and its

major metabolites on mitochondrial function, the existence of

a futile red-ox cycle could also contribute to the mechanism of toxicity.

Materials and Methods

Vol. 288

Evaluation of Toxicity of Diclofenac to Hepatocytes. In- creasing concentrations of the drug in phosphate-buffered saline (PBS) were added to cultures after medium renewal. After a 24-h incubation, microtiter plates were washed twice with 50 l of PBS/ well, and cytotoxicity was assessed either by measuring the loss of intracellular lactate dehydrogenase (Ponsoda et al., 1991) or by the 3-[4,5-dimethylthiazol-2-yl]-3,5-diphenylformazan (MTT) test (Car- michael et al., 1987). The effects of diclofenac on gluconeogenesis were investigated in glycogen-depleted hepatocytes incubated with the drug and with lactate as the only gluconeogenic precursor, as described in detail previously (Castell et al., 1985). The gluconeogenic rate was deter- mined from the rate of glucose production by hepatocytes. The synthesis and secretion of albumin by hepatocytes was mon- itored by a competitive enzyme-linked immunosorbent assay in ali- quots of culture medium taken at regular time intervals (Castell et al., 1985). Glutathione (GSH) was measured by a fluorimetric reaction with o-phthaldialdehyde adapted to microscale measurements (Jover et al., 1992). Briefly, cells were detached and homogenized by ultra- sound. The resulting homogenates were deproteinized and centri- fuged in the same 96-well plate. Aliquots of the supernatant were

transferred to microtiter plates and allowed to react with o-phthal- dialdehyde. Fluorescence was measured in a multiwell plate fluorim- eter (excitation filter: 355 35 nm; emission filter: 460 25 nm). Known amounts of GSH (0–5000 pmol/well) were used as reference standards. Lipid peroxidation was determined by measuring the generation

of MDA in the culture media by the fluorimetric reaction with thio-

barbituric acid (Castell et al., 1997). After incubation for 60 min in a boiling bath, the fluorochrome formed was extracted with n-butanol and the fluorescence of the organic phase was measured at 530 25 nm excitation and 590 35 nm emission. MDA bis(dimethylacetal) diluted in culture medium was used as standard. Results were re- ferred to intracellular protein content. To monitor intracellular calcium ([Ca ] i ), cells previously incu-

Materials. Diclofenac sodium salt, flurbiprofen, proadifen, -naphthoflavone, phenytoin (5,5-diphenyl-hydantoin), maleic acid diethyl ester (DEM), L-buthionine-[S,R]-sulfoximine (BSO), buthyl- ated hydroxytoluene (BHT), deferoxamine mesylate, nifedipine, ( )- verapamil, rhodamine 123, and o-phthaldialdehyde were obtained from Sigma Chemical Co. (St. Louis, MO). Malondialdehyde (MDA) bis(dimethylacetal) was obtained from Merck (Darmstadt, Germa- ny). Fluo-3-AM and pluronic F-127 were obtained from Molecular Probes, Inc. (Eugene, OR). -Glucuronidase/arylsulfatase, collage- nase, the Glucose GOD-Perid test, and the ATP bioluminescence CLS test were obtained from Boehringer Mannheim (Mannheim, Germany). Calf serum was obtained from GIBCO (Paisley, UK), and culture media were obtained from Flow Labs. (Irvine, CA). Diclofe-

bated with diclofenac were loaded with 5 M of Fluo-3-AM 0.075% (w/v) pluronic F-127 in culture medium for 30 min at 37°C. The cells were washed three times with HEPES-buffered Krebs-Henseleit so- lution (10 mM HEPES, pH 7.4, 25°C) containing 1% bovine serum albumin, and immediately thereafter fluorescence was measured with a multiwell plate fluorimeter (Cytofluor 2350, Millipore; exci- tation, 485 22 nm; emission, 530 30 nm) (Jover et al., 1993). Fluorescence readings were calibrated to calculate [Ca ] i . First the hydrolysed, cytosolic Fluo-3 was released out of cells into medium containing 2 mM CaCl 2 by treating cells with 30 M digitonin for 4 min, and fluorescence (F max ) was recorded. Next, 10 mM EGTA was added to quench Ca , and fluorescence (F min ) was again recorded. [Ca ] i was calculated for any previous fluorescence signal (F) using

nac metabolites (4 -OHdic, 5-OHdic, and 4 ,5-OHdic) were synthe- sized as described (Bort et al., 1996). All other reagents used in this study were of analytical grade. Cell Cultures. MDCK, FaO, and HepG2 cells were cultured in

K d of 400 nM for the Fluo-3-Ca complex (Minta et al., 1989), according to the following equation: [Ca ] i K d ((F-F min )/ (F max F)). ATP synthesis was determined in cultured hepatocytes incubated


Dulbecco’s minimal essential medium supplemented with 10% of


HEPES-buffered saline medium with glucose as the only energetic

fetal calf serum and containing 50 g of streptomycin/ml and 50 mU of penicillin/ml. Cells were routinely seeded in 3.5-cm plates at a

substrate and 500 M diclofenac. At regular time intervals, cells were washed with PBS and homogenized in 1 ml of 3% HClO 4 at 0°C.

density of 14 10 3 cells in 0.1 ml medium per well and used 24 h

Samples were centrifuged (5 min 9000g) and the supernatant kept

later (75% monolayer confluence).


4°C until analysis. The ATP concentration of the diluted samples

Rat hepatocytes were obtained from 200- to 300-g Sprague-Dawley

(1:4900) was measured using the luciferin/luciferase assay according

male rats by perfusion of the liver with collagenase as described in


the manufacturer’s instructions. Bioluminescence was quantified

detail elsewhere (Go´mez-Lecho´n et al., 1984). Human hepatocytes


a Lumat LB luminescence photometer (Berthold GmbH, Wildbad,

were obtained from small liver biopsies from patients undergoing cholecystectomy, after informed consent. The patients had not re- ceived any medication for at least a week before surgery. Cell sus- pensions were obtained as described in detail elsewhere (Go´mez- Lecho´n et al., 1990). Hepatocytes were seeded on fibronectin-coated culture plates (3.5 g/cm 2 ) at a density of 80 10 3 cells/cm 2 . Unat- tached cells were removed by changing the medium 1 h after seeding.

Germany). Mitochondrial membrane potential was assayed in the same con- ditions as ATP, but rhodamine 123 (final concentration 1 M) was also added. After incubations at different times, medium was re- moved and monolayers were processed to measure fluorescence in the mitochondrial compartment as described elsewhere (Nieminen et al., 1990). The fluorescence of samples was measured (excitation, 505

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Mechanisms of Diclofenac Hepatotoxicity



emission, 523 nm) in a Hitachi F-2000 fluorescence spectropho-

aromatic) and mass spectra (m/z 293, molecular peak for both deriv-

tometer (Hatachi Scientific Instruments, Mountain View, CA) . Isolation of Mitochondria from Rat Liver. Sprague-Dawley

atives) were consistent with the assigned chemical structure of the two cyclic diclofenac derivatives.


were euthanized and their livers immediately removed, washed,

Microsome Incubations. Rat microsomes were obtained by ho-


homogenized in 4 ml/g ice-cold homogenization buffer (0.25 M

mogenization of liver samples in 0.25 M potassium phosphate buffer,

sucrose, 5 mM Tris, 1 mM EDTA, pH 7.4). Mitochondria were iso- lated by centrifugation in sucrose as described elsewhere (Cain and

pH 7.25, containing 1 mM EDTA and 0.15 M KCl, followed by differential ultracentrifugation (Boobis et al., 1980). The microsomal

Skilleter, 1987) and finally resuspended in 0.7 ml of the assay solu-

fraction was stored in the same buffer containing 30% v/v glycerol.


(0.25 M sucrose, 10 mM Tris, 1 mM EDTA, 5 mM KH 2 PO 4 , 2 mM

Assays were performed in a buffer containing 75 mM Tris-hydrochlo-

MgCl 2 , pH 7.4) per gram of liver. ATP Measurement in Isolated Mitochondria. A mitochon-

ride buffer, pH 7.4, 3 mM magnesium chloride, and 500 g of micro- somal protein. Samples were preincubated for 5 min at 37°C, and the

drial suspension (final concentration 2 mg/ml protein) containing 2.5

reaction was started by the addition of NADPH (final concentration


ADP and variable concentrations of diclofenac or its metabolites

1.2 mM). The reaction was stopped by the addition of 1 ml of cold


preincubated at 30°C for 5 min. Then substrates were added (2.5

acetonitrile. Controls were incubated either without NADPH or


glutamate, 2.5 mM malate, final concentration) and after 5 min,

without microsomes. Samples were analyzed by HPLC as described


l was taken and dropped on 900 l of boiling buffer (100 mM


Tris, 4 mM EDTA, pH 7.75). ATP was measured as described above. Metabolism of Diclofenac. Biotransformation of the drug was studied both in vitro and in vivo. For in vitro studies, diclofenac was added to hepatocyte cultures and incubated for 20 h. Aliquots of culture medium were enzymatically deconjugated (50 mU of -glu-

Statistical Analysis. Each experiment was done in at least three different cultures. Each determination was done in four plates (eight wells for cytotoxicity experiment) from each culture, and the results shown are the mean value S.E.M. To estimate IC 10 and IC 50 values (concentrations that produce a 10% and 50% inhibitory effect, re-

curonidase/ml, 30 mU of arylsulfatase/ml; acetate buffer 0.1 M, pH

spectively), the typical sigmoid dose-effect curves were linearized

4.5) for 4 h at 37°C. The reaction was stopped by adding acetonitrile to the samples (1:1, v/v). The resulting precipitate was removed by centrifugation (10 min, 9000 rpm). The supernatant was diluted with

using the LOGIT transformation, and the IC values were interpo- lated mathematically. The statistical significance of the experimen- tal data was analyzed by the Student’s t test.


mM phosphate buffer (pH 7.4) to reach 25% (v/v) acetonitrile.

Flurbiprofen (2 l of a 4.5-mM solution in PBS) was added to sam-

ples as an internal standard.

For in vivo studies, diclofenac was administered i.p. to Sprague- Dawley rats (40 mg/kg) and urine was collected over cold (0°C) acetate buffer (0.1 M, pH 4.5) during the next 20 h. Metabolites were extracted from acidified urine with ethyl acetate either before or after deconjugation. Metabolites were routinely analyzed by high-performance liquid chromatography (HPLC) in deconjugated and nondeconjugated sam- ples (Leemann et al., 1993). Samples (20 l) were injected into a

200 4.6-mm C-18 reverse-phase column (Spherisorb ODS 5 m,

Phase Separations Ltd., Queensferry, UK) furnished with a precol- umn (ODS 5 m; 50 4.6 mm). The mobile phase (75% triethanol- amine 0.02% in 100 mM phosphate buffer pH 7.4, 25% acetonitrile)

was delivered at 1 ml/min. The column effluent was monitored at 282

nm. Diclofenac eluted at 12.2 min and flurbiprofen at 7.4 min. Identification of Diclofenac Metabolites. Culture superna- tants were collected, deconjugated, and extracted with ethyl acetate as described above. The organic extracts were dried under vacuum, resuspended in methanol, and analyzed by HPLC-mass spectrome- try (MS) (Waters Alliance equipped with a therma beam detector; Waters Scientific, Milford, MA). Samples (25 l) were injected into a


2.1-mm C-18 reversed-phase column (Simmetry; Waters). A

HPLC method was developed to adjust it to this specific detec- tor. The mobile phase was changed to 63% 20 mM ammonium ace-



buffer (pH 6.5)/37% methanol and it was delivered at 0.3 ml/min.


column effluent was also monitored at 282 nm using a photo-

diode detector (M996; Waters). Diclofenac eluted at 29.8 min. The

UV, mass spectra, and 1 H NMR (d 6 -acetone, Varian Gemini 300 MHz

spectrometer, Palo Alto, CA) of the main metabolites were obtained

and compared with chemically synthesized standards.

4 -OHdic and 5-OHdic were prepared as described in detail pre- viously (Bort et al., 1996). The lactams of 4 -OHdic and 5-OHdic

were synthesized by reacting the corresponding hydroxyderivative of diclofenac with a 10% molar excess of dicyclohexyl carbodiimide in

dry chloroform. Upon completion of the reaction (5 h at room tem-

perature), the solution was brought to dryness, dissolved in ethyl acetate, filtered to remove the dicyclohexyl urea formed, and crys- tallized by the addition of petroleum ether. The UV-(4 -OHdic-

lactam: max 239 and 5-OHdic-lactam: max 250 nm), 1 H NMR- (4 -OHdic-lactam: 3.7, s 2H, Ar-CH 2 -CO-, 7.4–6.8, m, 6H, aro- matic; 5-OHdic-lactam: 3.9, s 2H, Ar-CH 2 -CO-, 7.4–6.8, m, 6H,


Cytotoxicity of Diclofenac on Hepatic and Nonhe- patic Cells. Diclofenac showed a characteristic concentra- tion-dependent cytotoxicity when added to cultured human or rat hepatocytes, as assessed by the MTT test (Fig. 1). Similar results were obtained (data not shown) when the leakage of intracellular lactate dehydrogenase was deter- mined as a parameter for cell viability. The estimated IC 50 values for rat and human hepatocytes (concentration causing 50% cell death) were closely related: 392 34 M (n 16) and 331 7 M (n 6), respectively. To elucidate whether these effects were hepatocyte-specific, cytotoxicity was also evaluated in human and rat hepatomas, as well as in the nonhepatic cell line MDCK. Figure 1 shows that hepatoma

the nonhepatic cell line MDCK. Figure 1 shows that hepatoma Fig. 1. Cytotoxicity of diclofenac in

Fig. 1. Cytotoxicity of diclofenac in different cellular systems. Human, rat hepatocytes, rat hepatocytes cultured in the presence of 10 M proadifen, and cell lines (FaO, HepG2, and MDCK) were cultured in microwells and incubated with increasing concentrations of diclofenac. After 24 h, cell viability was determined by the MTT test. Values are the mean of quin- tuplicated wells S.D. of a representative culture.

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Bort et al.

cells were less sensitive to diclofenac than primary cultures

of hepatocytes (HepG2 763 61 M, n 4 and FaO 682 64

M, n 3,), with concentration-toxicity curves shifting to higher concentrations of the drug (i.e., higher IC 50 values) but more sensitive than the nonhepatocyte cell line MDCK (908 56 M, n 2). The differences in diclofenac toxicity observed in primary cultured hepatocytes, hepatomas, and nonhepatic cells could reflect the different sensitivity of cell lines versus hepato- cytes to the drug or to differences in the ability of these cells to metabolize diclofenac. In fact, HPLC analysis of culture medium after a 24-h incubation with a subtoxic concentra-

tion of the drug (100 M) showed that rat and human hepa- tocytes metabolized diclofenac at similar rates (310 and 340 pmol min 1 mg 1 , respectively), whereas cell lines were un- able to metabolize it to a measurable extent (data not shown). Incubation of rat hepatocytes with a noncytotoxic concentra- tion (10 M) of proadifen, a broad CYP inhibitor, signifi- cantly reduced the toxicity of the drug (IC 50 : 489 32, p .005; Fig. 1). Ketoconazole (25 M), which inhibits the 2C and 3A subfamilies, also reduced diclofenac toxicity significantly (IC 50 : 514 38, p .005), whereas -naphthoflavone-specific CYP1A inhibitor did not apparently modify cytotoxicity (IC 50 : 392 81, N.S.). Moreover, we found evidence showing

a good correlation between cytotoxicity (IC 50 ) and the extent

of diclofenac metabolization (r 0.95, p .001; Fig. 2). Major Biochemical Events in Course of Diclofenac Toxicity. Analysis of toxicologically relevant biochemical parameters in hepatocytes exposed to diclofenac (GSH levels, lipid peroxidation, changes in [Ca ] i , and ATP) revealed that upon incubation of cells with toxic concentrations of the drug, no significant accumulation of MDA was found in the medium after several hours. In control experiments, addition of 1 mM t-butyl hydroperoxide resulted in an immediate, dramatic increase in thiobarbituric-reactive substances (Fig. 3A). In agreement with these findings, we did not observe a decrease in toxicity (increased IC 50 ) when cells were incu-

in toxicity (increased IC 5 0 ) when cells were incu- Fig. 2. Correlation between cytotoxicity

Fig. 2. Correlation between cytotoxicity and drug metabolization. Rat hepatocytes were incubated with different concentrations (100–750 M) of diclofenac and the cytotoxicity was expressed as IC 50 . In parallel, the metabolism of diclofenac was investigated by HPLC analysis in cell culture media incubated with 250 M diclofenac, and the results ex- pressed as percentage of metabolized drug. Solid line, regression; dashed line, confidence interval.

Vol. 288

dashed line, confidence interval. V o l . 2 8 8 Fig. 3. Evaluation of diclofenac

Fig. 3. Evaluation of diclofenac toxicity to hepatocytes. Effects of diclofe- nac on lipid peroxidation, GSH content, [Ca ] i, mitochondrial mem- brane potential, and ATP content of cultured rat hepatocytes. Diclofenac was added to hepatocytes and aliquots of culture medium were taken at regular time intervals. After reaction with thiobarbituric acid, fluores- cence was determined and expressed as nanomoles of MDA. As a positive control, 1 mM t-butyl hydroperoxide (t-BOOH) was added to cells. B, in parallel, GSH was measured in cells incubated with diclofenac or the GSH inhibitor BSO. [Ca ] i was fluorimetrically measured at regular time intervals (C) in cells incubated with the diclofenac or t-butyl hy- droperoxide. D, diclofenac (400 M) was added to cultured rat hepato- cytes. Plates were washed and cells detached with 3% HClO 4. ATP con- tent was measured by means of luminescence production by luciferase. For evaluation of mitochondrial membrane potential, cells were incu- bated with rhodamine 123. Remaining fluorescence in medium was mea- sured fluorimetrically as described in Materials and Methods. For a better interpretation of results, cell viability of the same experiment (LDH) is also depicted. Values represented as mean of five wells S.D. of a representative culture.

bated in the presence of the antioxidant BHT (50 M) or 10

mM deferoxamine (data not shown.).

We also investigated the effects of diclofenac on intracel- lular GSH levels. An IC 50 concentration of diclofenac did not cause significant changes in intracellular GSH during the 5 h following incubation (Fig. 3B). As expected, the presence of BSO caused a rapid GSH depletion in cells. Neither BSO nor

DEM (500 M) increased the toxicity of diclofenac (IC 50


12 and 367 47 M, respectively, versus control at


34 M).

The possibility that calcium could be involved in the early stages of toxicity by diclofenac was also investigated. The

addition of an IC 50 concentration of diclofenac did not result in an increase in intracellular Ca during the first 120 min of incubation (Fig. 3C). After much longer incubation times

( 6 h), we observed a gradual increase in [Ca ] i (ca. 150–

200% over controls; data not shown). Addition of 25 M verapamil or 100 M nifedipine to culture medium (concen- trations effectively blocking calcium influx in cells, Jover et al., 1993) was moderately effective in decreasing diclofenac

cytotoxicity (IC 50 415 92 and 507 30 M, respectively). Diclofenac, however, caused an important, fast depletion of


in hepatocytes kept in glucose as the only energy source.


dropped to 10% of initial levels after 120 min of exposure

to the drug. This rapid ATP depletion preceded cell death, which in these experiments began to be noticeable 120 min after addition of the drug (Fig. 3D). In agreement with this

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finding, increasing diclofenac in culture medium resulted in a concentration-dependent inhibition of gluconeogenesis and albumin synthesis, two specific hepatic functions that re- quire substantial amounts of ATP. This inhibition was no- ticeable at subcytotoxic concentrations of diclofenac. The IC 50 were 110 12 and 108 9 M, respectively. Metabolism of Diclofenac. Analysis by HPLC of culture media of hepatocytes incubated with diclofenac allowed the identification of several metabolites. A peak with a retention time of 3.8 min was assigned to 4 -OHdic, while the peak with a retention time of 5.1 min was identified as 5-OHdic, by comparison of the UV-, mass-, and 1 H-NMR spectra of chemically synthesized metabolites. Other minor peaks at 10.4 and 13.5 min were identified as lactams of 4 -OHdic and 5-OHdic. A minor peak (retention time 2.9 min) was present with variable intensity in the different culture supernatants as- sayed. This metabolite was found in culture media mainly in its conjugated form ( 95%). The compound was analyzed by HPLC-MS and 1 H NMR, and the most relevant spectral features are summarized in Table 2 and Fig. 4. The molecu- lar ion peak (M ) was at m/z 327, and the presence of isotopic peaks at m/z 329 and 331 confirmed the presence of two Cl. When compared with the mass spectra of diclofenac, the M peak of this metabolite suggested the existence of two hy- droxy substituents. The 1 H NMR spectra of the purified metabolite (Table 1) showed the same number of aromatic H (7.4–6.4 m, 6H) and ethylenic H ( 3.68 s, 2H, Ar-CH 2 - COOH) as 5-OHdic, which excludes an aromatic hydroxyla- tion. Interestingly, the displacement to a high field of the signal of H(3), as compared with that recorded for 5-OHdic, points to the proximal N as the site of oxidation. The com- pound showed the features of an acid and a UV maximum displacement to 268 nm (versus 282 nm, 5-OHdic). Based on these data, we assigned the N,5-(OH) 2 dic structure to this metabolite (Fig. 4).

Mechanisms of Diclofenac Hepatotoxicity


To exclude an artifactual formation of N,5-(OH) 2 dic in the course of in vitro experiments, its occurrence was investi- gated in rat urine 20 h after i.p. administration of diclofenac. In control experiments, 5-OHdic was added to urine of un- treated rats and processed as described in Materials and Methods. Approximately 28% of the in vivo administered diclofenac was found in urine as hydroxylated metabolites. In addition to 4 -OHdic and 5-OHdic, both in free and conju- gated forms, the presence of conjugated N,5-(OH) 2 dic un- equivocally demonstrated the cellular formation of this me- tabolite (Table 3). N,5-(OH) 2 dic is found only as a conjugate, both in culture media and in vivo, and its concentration is greater inside cells than in culture medium (3.2 versus 0.2 M), which suggests that conjugation may be crucial for this metabolite to escape from the cell. In control experiments, no spontaneous formation of N,5-(OH) 2 dic was observed. In the experiment shown in Fig. 5, the cytotoxicity of diclofenac (IC 50 ) was determined under an array of different incubation conditions (100–750 M drug in the presence or absence of selective CYP inhibitors) and was correlated with the amount of metabolites formed by cells incubated with 250 M diclofenac. A poor correlation was observed in the case of the major metabolite 4 -OHdic (r 0.52, Fig. 5A). Con- versely, the IC 50 correlated with 5-OHdic (r 0.84; Fig. 5B) and with N,5-(OH) 2 dic formation (r 0.92; Fig. 5B). Effects of Diclofenac and Its Metabolites on Hepato- cyte Mitochondrial Function. According to the results shown in Fig. 4D, the decrease in ATP was an early event in diclofenac toxicity, which could be attributable either to the drug or to any of its metabolites. In view of the fact that ATP depletion was paralleled by a decrease in mitochondrial membrane potential, we investigated the role of diclofenac and each metabolite on mitochondria by monitoring the syn- thesis of ATP. As shown in Fig. 6, the mitochondrial ATP synthesis was effectively impaired by 30 M diclofenac (con- centration found in the portal blood of rats given the drug

centration found in the portal blood of rats given the drug Fig. 4. Structure and mass

Fig. 4. Structure and mass spectra of N,5-(OH) 2 dic.

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TABLE 1 Relevant proton chemical shifts of aromatic hydrogens of N,5-(OH) 2 dic a compared to 5-OHdic

Bort et al.

Vol. 288


Aromatic Hydrogens

2H (3 ,5 )

1H (4 )

1H (6)

1H (4)

1H (3)


7.40, doublet ortho (J 7.8)

7.01, triplet ortho (J 7.8)

6.76, doublet metha (J 2.7)

6.59, double doublet ortho (J 8.7) metha (J 2.7)

6.41, doublet ortho (J 8.7)

N,5-(OH) 2 dic

7.40, doublet ortho (J 7.8)

7.10, triplet ortho (J 7.8)

6.65, doublet metha (J 2.7)

6.43, double doublet ortho (J 8.7) metha (J 2.7)

6.68, doublet ortho (J 8.7)

a N,5-(OH) 2 dic was purified from rat urine after extraction with ethyl acetate and purification by thin-layer chromatography.

ethyl acetate and purification by thin-layer chromatography. Fig. 5. Correlation between cytotoxicity and diclofenac

Fig. 5. Correlation between cytotoxicity and diclofenac metabolites for- mation. Rat hepatocytes were incubated with differents concentrations (100–750 M) of diclofenac in the presence or absence of CYP inhibitors and the cytotoxicity was expressed as IC 50 . In parallel, the metabolism of diclofenac was investigated by HPLC analysis in 24-h cell culture media incubated with 250 M diclofenac, and the formation of 4 -OHdic (A) and 5-OHdic and N,5-(OH) 2 dic (B) correlated with the cytotoxicity deter- mined for each cell culture. 1, control A; 2-ketoconazole B; 3, proadifen B; 4, control B; 5, control C; 6, ketoconazole E; 7, phenytoin B; 8, ketocon- azole D; 9, proadifen D; 10, control D; 11, phenytoin D; 12, control E. Solid line, regression; dashed line, confidence interval.

orally; Tabata et al., 1996), as well as by its hydroxylated metabolites. Interconversion between 5-OHdic and N,5-(OH) 2 dic by Liver Microsomes. We examined whether 5-OHdic and N,5-(OH) 2 dic, whose formation correlated with the toxicity of diclofenac, could also indirectly alter the energetic status of cells. Incubation of 5-OHdic with rat liver microsomes in aerobic conditions resulted in the formation of N,5-(OH) 2 dic (Fig. 7A), whereas the incubation of N,5-(OH) 2 dic in pres- ence of microsomes and NADPH yielded 5-OHdic (Fig. 7B). This reduction did not take place in the absence of either NADPH or microsomes. Most interestingly, when the NADPH content of the incubation mixture was monitored, a biphasic behavior was observed: a rapid NADPH decrease that coincided with the reduction of most N,5-(OH) 2 dic to 5-OHdic, followed by a sustained NADPH consumption once

to 5-OHdic , followed by a sustained NADPH consumption once Fig. 6. Effects of diclofenac and

Fig. 6. Effects of diclofenac and its metabolites on hepatocyte mitochon- drial function. A mitochondrial suspension (final concentration 2 mg/ml protein) containing 2.5 mM ADP and 30 M diclofenac or diclofenac metabolites was preincubated for 5 min at 30°C. Then substrates were added (2.5 mM glutamate and 2.5 mM malate) and after 5 min 100- l samples of the incubation mixture were dropped in 900 l of boiling buffer (100 mM Tris, 4 mM EDTA, pH 7.75). The ATP concentration was measured using the luciferin/luciferase assay according to the manufac- turer’s instructions. Bioluminescence was quantified in a Lumat LB luminescence photometer.

the equilibrium between the two metabolites was reached. Under the same experimental conditions, incubation of 4 - OHdic did not result in either metabolism or in NADPH consumption (Fig. 7C).


Diclofenac is an anti-inflammatory drug for which a cer- tain number of severe adverse hepatic reactions have been reported (Ciccolunghi et al., 1978; Helfgott et al., 1990; Ive- son et al., 1990; Sallie, 1990; Ouellette et al., 1991; Purcell et al., 1991; Scully et al., 1993). Detailed analysis of some indi- vidual case reports revealed clinical features that could be compatible with a direct toxic effect of diclofenac (or any of its metabolites), rather than a drug-allergy mechanism (Helf- gott et al., 1990; Iveson et al., 1990; Sallie, 1990; Scully et al., 1993). In the present study, we investigated possible linkages between drug metabolism and cell injury to better under- stand the mechanisms of hepatotoxicity. Among the several biochemical parameters examined, ATP was the earliest affected by the cytotoxic concentrations in short-term experiments (Fig. 3D). Parallel to this, a decrease in mitochondrial membrane potential was observed. These re- sults, together with the previously reported protective effect of

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April 26, 2011 Downloaded from 1998 Fig. 7. Interconversion of N ,5-(OH) 2 dic and

Fig. 7. Interconversion of N,5-(OH) 2 dic and 5-OHdic by liver micro- somes. Pure 5-OHdic was incubated in the presence of microsomes and the formation of N,5-(OH) 2 dic was monitored by HPLC analysis (A). B, N,5-(OH) 2 dic was incubated in presence of microsomes and NADPH and the formation of 5-OHdic followed by HPLC (B). C, the consumption of NADPH was monitored by HPLC analysis of the same samples as in B. Also the control and 4 -OHdic incubations are depicted.

fructose on diclofenac toxicity (Ponsoda et al., 1995), lead us to consider a mitochondrial bioenergetic dysfunction to be one of the possible events causing diclofenac toxicity. The fact that subcytotoxic concentrations of diclofenac (100 M), close to the portal concentration in the rat (30 M; Tabata et al., 1996), caused a 50% inhibition of two characteristic ATP-consuming hepatocyte functions, namely gluconeogenesis and albumin synthesis, would favor this hypothesis. Both are “service” func- tions of hepatocytes and have in common the fact that they are not essential for hepatocyte survival but both require substan- tial amounts of ATP. On the other hand, the fact that no significant changes in oxidative stress parameters (i.e., GSH and MDA levels) were observed, and the lack of a clear effect on the cytotoxicity of

Mechanisms of Diclofenac Hepatotoxicity


radical scavengers (BHT) and inhibitors of the formation of active oxygen species (deferoxamine), or compounds depleting intracellular GSH (BSO, DEM), did not support the hypothesis that this mechanism is a key event in diclofenac toxicity. [Ca ] i levels did not increase during the early stages of cell exposure to diclofenac (Fig. 3C), which is in agreement with previous reports (Schmitz et al., 1995). Only after a longer incubation of cells with diclofenac did [Ca ] i increase moderately, parallel to a decrease in cell viability. We believe this event may be simply concomitant with cell death, and the slight decrease in cell toxicity (not significant) that we observed agrees with this interpretation. A decrease in ATP impairs plasma membrane and endoplasmic reticulum ATP- dependent calcium pumps and leads to a sustained rise in intracellular free calcium (Nicotera et al., 1992). It is thus conceivable that the decrease in cellular ATP observed in hepatocytes incubated with diclofenac could be at the root of the late [Ca ] i elevation. The experiments also revealed a possible link between drug metabolism and toxicity to hepatocytes. Several facts support this assessment. First of all, the ability of cells to metabolize diclofenac (human rat [tmt] FaO HepG2 MDCK) was inversely related to the IC 50 values, and inhibition of drug metabolism resulted in a decrease in toxicity (Fig. 1). Second, there was a direct correlation between cytotoxicity and the extent of diclofenac metabolization by hepatocytes (Fig. 2). Third, analysis of culture media of hepatocytes revealed more precisely that cytotoxicity to hepatocytes was related to the formation of 5-OHdic and N,5-(OH) 2 dic (Fig. 5B). The chemical structure of this new metabolite was identi- fied by the combined use of HPLC-MS, 1 H NMR (Table 1), UV spectra, and chemical data. In a recent article, Miyamoto et al. (1997) reported the formation of an iminoquinone by HOCl oxidation of diclofenac in activated neutrophils. The authors also reported that hepatic microsomes could oxidize 5-OHdic to the same iminoquinone, which was trapped with GSH. This compound shows strong chemical similarities with the one reported in this study: dehydration of N,5- (OH) 2 dic would render the hypothesized iminoquinone. In fact, a compound showing similar fragments by HPLC-MS (electron impact fragmentation) than those obtained by Miy- amoto et al. (1997) using MS-MS, was detected in prepara- tions of N,5-(OH) 2 dic and in culture media of cells [m/z: 309 (M ), 267, 229, 201, 195, and 166]. The presence of N,5-(OH) 2 dic in culture medium, as well as in urine of rats given diclofenac, excluded an artifactual, noncellular formation of the metabolite (Table 2). The fact that it appeared only as a conjugate reinforced this hypoth- esis and could also indicate that this compound escapes from the hepatocyte only after conjugation. Indeed, we have found that the concentration of this metabolite inside cells is ap- proximately 16 times grater than in culture medium.

TABLE 2 In vitro and in vivo metabolism of diclofenac


N,5-(OH) 2 dic

4 -OHdic



Rat hepatocytes

3.2 2.5 (100%) a 1 0.8

59 14

38 17


Culture media



Rat urine

80 24

20 9





Data represent relative abundance of metabolites in each analyzed sample. a Data in parentheses represent the approximate percentage of conjugated me- tabolite.

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Bort et al.

Despite the fact that ATP is the most relevant biochemical event observed, it is noteworthy that neither N,5-(OH) 2 dic nor 5-OHdic showed much higher toxicity to mitochondria than diclofenac, as the data shown in Fig. 5B anticipated. Looking for other possible links between metabolite formation and cytotox- icity, we observed that the hydroxylamine generated by oxida- tion of 5-OHdic with microsomes (Fig. 7A) could be back- reduced to generate 5-OHdic in the presence of active microsomes and NADPH (Fig. 7B). Cellular enzymes able to carry out both types of reaction are known to exist (Yamada et al., 1988; Clement and Kunze, 1992). If both reactions take place simultaneously, this would allow N,5-(OH) 2 dic and 5-OHdic to enter a futile cycle resulting in NADPH oxidation by O 2 . This is what the data presented in Fig. 7C suggest:

addition of N,5-(OH) 2 dic to microsomes resulted first in a rapid decrease in NADPH by the reduction of N,5-(OH) 2 dic to 5-OHdic, followed by a sustained decrease in the nucleotide concentration when both metabolites had reached equilibrium (Fig. 7B). This is not the case for 4 -OHdic, a metabolite that is not further metabolized by microsomes, and its formation by cells does not apparently correlate with cytotoxicity. The feasi- bility of this futile cycle is further supported by the fact that N,5-(OH) 2 dic tends to accumulate inside the cell. Conse- quently, in addition to the inhibitory effects that diclofenac and its metabolites show on mitochondrial ATP synthesis, futile depletion of NADPH by 5-OHdic/N,5-(OH) 2 dic oxido-reduc- tion could be at the root of the mechanism of hepatocyte toxicity induced by diclofenac. Variable formation of 5-OHdic and N,5-(OH) 2 dic is ob- served in cultures of hepatocytes from different human do- nors when incubated with diclofenac, and recent evidence from our laboratory suggests that this could be due to a different expression of CYP2C19, which is involved in the 5-hydroxylation of diclofenac in the liver (R. Bort, submitted for publication). There is great variability in the expression of this enzyme in humans (Relling et al., 1990). It is thus suggestive to speculate that one factor contributing to the idiosyncratic nature of diclofenac hepatotoxicity could be the different expression of the CYPs metabolizing the drug into reactive/toxic metabolites.


We thank Carmen Lorenzo and Epifanı´a Belencho´n for their ex- pert technical help. The assistance of Dr. Luis Martı´nez in conduct- ing spectroscopic analysis is acknowledged. We are indebted Dr. Miguel Angel Miranda for his skillful advice in mass spectrometry and 1 H NMR data interpretation.


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