Apixaban Level and Its Influence on Immunosuppression and Graft Outcome in Kidney Transplant Recipients With Atrial Fibrillation.

BACKGROUND: Currently, there is limited information on the level of apixaban in kidney transplant (KT) patients with atrial fibrillation and the influence of apixaban therapy on the level of immunosuppression and graft function. METHODS: This was a cross-sectional prospective study of 19 KT patients treated with apixaban. The levels of apixaban were measured using a chromogenic assay calibrated for apixaban and compared with those predicted by the manufacturer. Mean immunosuppression trough levels before and after apixaban treatment initiation were calculated using 3 consecutive measurements. Apixaban levels were compared with a historical control group comprising of 20 nontransplant patients with atrial fibrillation who were treated with the standard 5-mg bid apixaban dosage. RESULTS: All KT patients should have been treated with the standard 5-mg bid apixaban dosage according to the clinical parameters; however, 7 were inappropriately treated with a reduced dosage (2.5-mg bid). There was no significant difference in apixaban level between KT patients treated with the 5-mg bid dosage and nontransplant patients. No KT patient administered the standard dose had out-of-range levels. Peak GM level was significantly lower in KT patients administered an inappropriately reduced dose (P = 0.05). Two patients had below-range peak levels. Apixaban treatment initiation had minimal influence on the level of immunosuppression. Furthermore, it had no adverse impact on graft function. CONCLUSIONS: Similar to nontransplant patients, KT patients administered the standard 5-mg bid dosage had apixaban levels that were well within the recommended manufacturers' expected ranges. In addition, this dosage had minimal influence on immunosuppression and no effect on graft function.

Using Machine Learning to Predict Rehabilitation Outcomes in Postacute Hip Fracture Patients.

OBJECTIVE: To use machine learning-based methods in designing a predictive model of rehabilitation outcomes for postacute hip fracture patients. DESIGN: A retrospective analysis using linear models, AdaBoost, CatBoost, ExtraTrees, K-Nearest Neighbors, RandomForest, Support vector machine, XGBoost, and voting of all models to develop and validate a predictive model. SETTING: A university-affiliated 300-bed major postacute geriatric rehabilitation center. PARTICIPANTS: Consecutive hip fracture patients (N=1625) admitted to an postacute rehabilitation department. MAIN OUTCOME MEASURES: The FIM instrument, motor FIM (mFIM), and the relative functional gain on mFIM (mFIM effectiveness) as a continuous and binary variable. Ten predictive models were created: base models (linear/logistic regression), and 8 machine learning models (AdaBoost, CatBoost, ExtraTrees, K-Nearest Neighbors, RandomForest, Support vector machine, XGBoost, and a voting ensemble). R2 was used to evaluate their performance in predicting a continuous outcome variable, and the area under the receiver operating characteristic curve was used to evaluate the binary outcome. A paired 2-tailed t test compared the results of the different models. RESULTS: Machine learning-based models yielded better results than the linear and logistic regression models in predicting rehabilitation outcomes. The 3 most important predictors of the mFIM effectiveness score were the Mini Mental State Examination (MMSE), prefracture mFIM scores, and age. The 3 most important predictors of the discharge mFIM score were the admission mFIM, MMSE, and prefracture mFIM scores. The most contributing factors for favorable outcomes (mFIM effectiveness > median) with higher prediction confidence level were high MMSE (25.7±2.8), high prefacture mFIM (81.5±7.8), and high admission mFIM (48.6±8) scores. We present a simple prediction instrument for estimating the expected performance of postacute hip fracture patients. CONCLUSIONS: The use of machine learning models to predict rehabilitation outcomes of postacute hip fracture patients is superior to linear and logistic regression models. The higher the MMSE, prefracture mFIM, and admission mFIM scores are, the higher the confidence levels of the predicted parameters.

Antibiotic modification versus withhold in febrile patients without evidence of bacterial infection, unresponsive to initial empiric regimen: a multicentre retrospective study conducted in Israel.

Prescribing antibiotics for febrile patients without proof of bacterial infection contributes to antimicrobial resistance. Lack of clinical response in these patients often leads to antibiotic escalation, although data supporting this strategy are scarce. This study compared outcomes of modifying, withholding, or continuing the same antibiotic regimen for such patients. Febrile or hypothermic stable patients with suspected infection, unresponsive to empiric antibiotic treatment, admitted to one of 15 internal medicine departments in three hospitals during a 5-year study period, were included. Patients with a definitive clinical or microbiological bacterial infection, malignancy, immunodeficiency, altered mental status, or need for mechanical ventilation were excluded. Participants were divided into groups based on treatment strategy determined 72 h after antibiotic initiation: antibiotic modified, withheld or continued. Outcomes measured included in-hospital and 30-day post-discharge-mortality rates, length of hospital stay (LOS) and days of antimicrobial therapy (DOT). A total of 486 patients met the inclusion criteria: 124 in the Antibiotic modified group, 67 in the Antibiotic withheld group and 295 in the Initial antibiotic continued group. Patient characteristics were similar among groups with no differences in mortality rates in-hospital (23% vs. 25% vs. 20%, p = 0.58) and within 30 days after discharge (5% vs. 3% vs. 4%, p = 0.83). Changing antibiotics led to longer LOS (9.0 ± 6.8 vs. 6.2 ± 5.6 days, p = 0.003) and more DOT (8.6 ± 6.0 vs. 3.2 ± 1.0 days, p < 0.001) compared to withholding treatment. Withholding as compared to modifying antibiotics, in febrile patients with no clear evidence of bacterial infection, is a safe strategy associated with decreased LOS and DOT.

[PSYCHOTROPHIC AND ANTICHOLINERGIC DRUG BURDEN AMONG ELDERLY ISRAELI PATIENTS INVOLVED IN TRAFFIC ACCIDENTS].

INTRODUCTION: The population is ageing. This trend is expected to cause an increase in the number of driver licenses among the elderly, and in their mobility. The effect of medications on driving capability may be significant. OBJECTIVES: To characterize the comorbidities among elderly patients involved in traffic accidents who were hospitalized at Beilinson Hospital and the psychotropic drugs taken prior to the accident, to assess the prevalence of anticholinergic drug load in this population and to examine its effect on clinical outcomes after the accident among the drivers. METHODS: This is a retrospective cross-sectional study of the elderly over the age of 65, who were involved in a traffic accident between the years 2005-2015 (drivers and pedestrians) and were hospitalized. For each patient, a Charlson comorbidity index score was calculated and 3 months pre-accident drug dispensing data were extracted. The evaluation of the anticholinergic drug load for each patient was performed using the Anticholinergic Cognitive Burden (ACB) scale. RESULTS: The study included 291 patients (98 drivers, 193 pedestrians). Pedestrians were injured more severely in comparison to the drivers' subgroup. The population received an average of 8.1 systemic drugs during the 3 months period prior to the accident. Approximately 36.7% were prescribed psychotropic medication (27.1%, 16.4% and 2.4% benzodiazepines, antidepressants and antipsychotics respectively); 32.3% had significant anticholinergic load (ACB score> 1). No significant differences were found in the prevalence of use of psychotropic drugs and/or ACB score between pedestrian and drivers or with post-accident clinical outcomes between drivers with high versus low anticholinergic drug load. CONCLUSIONS: The prevalence of psychotropic and anticholinergic drug burden is high among elderly involved in traffic accidents. Pre-accident anti-cholinergic drug load does not affect clinical outcomes after the accident. Elderly pedestrians are injured more severely than elderly drivers.

Hypnotic drug use and rehabilitation outcomes in post-acute geriatric hip fracture patients: A retrospective study.

INTRODUCTION: The use of hypnotic drugs is common in the elderly and is associated with negative health outcomes. Our aim was to evaluate the prevalence of hypnotic drug usage amongst hip fracture patients undergoing a rehabilitation program and investigate any potential associations between hypnotic drug use and rehabilitation outcomes in a post-acute care setting. METHODS: A retrospective analysis of 440 geriatric hip fracture patients was conducted from 1/1/2019 to 12/2021 in a geriatric rehabilitation center. The main outcome measures were the Functional Independence Measure (FIM), the motor FIM effectiveness and length of stay (LOS). RESULTS: Two hundred and twenty-eight (51.7 %) patients out of the entire cohort (440)), were prescribed hypnotic drugs. These patients exhibited a significantly lower rate of diabetes (p = 0.025), a higher rate of depression (p = 0.003), and lower albumin levels (p = 0.023) upon admission to rehabilitation in comparison to untreated patients. No significant differences were observed between the two patient groups in functional rehabilitation outcomes or LOS. Moreover, no correlation was established between the hypnotic drug burden during rehabilitation and the outcome measures. Furthermore, no significant differences were found between patients treated with hypnotic drugs on admission and those who were prescribed these drugs during rehabilitation. The type of hypnotic drug did not affect these results. CONCLUSION: The use of hypnotic drugs by elderly individuals undergoing a rehabilitation program after a hip fracture is unlikely to have an adverse impact on their short-term rehabilitation outcomes. Consequently, there may not be an immediate necessity to discontinue these drugs upon admission. Nevertheless, the use of hypnotic drugs should be approached with caution and minimized whenever possible due to an increased fall risk and other adverse effects.

Anticoagulation drug use and rehabilitation outcomes in post-acute hip fractured patients.

PURPOSE: To assess the relationship between anticoagulant use and rehabilitation outcomes in post-acute hip fracture patients. METHODS: A retrospective study (1/2017 to 5/2019) of 299 hip fractured patients. OUTCOME MEASURES: Functional Independence Measure (FIM) and the motor FIM's effectiveness. RESULTS: Patients treated with anticoagulation drugs exhibited a significant longer latency time from fracture to surgery (U = -4.37, p < 0.001) and from surgery to rehabilitation (U=-2.27, p = 0.023), and a significantly higher rate of cardiovascular diseases (χ2=0.15, p= 0.023) compared with untreated patients. No significant differences between the two patient groups were found regarding the rate of blood transfusions, perioperative complications (infections, reoperation), or functional outcome measures. CONCLUSIONS: Oral anticoagulants are not associated with rehabilitation outcomes of hip fracture patients.Implications rehabilitationAnticoagulation drug use is not associated with functional outcome of post-acute hip fracture patients.It is recommended to renew oral anticoagulants for patients on chronic treatment after surgery since no negative outcomes were found during rehabilitation under anticoagulant treatment and in light of the importance of these drugs in preventing thromboembolic complications.

Levetiracetam Interaction with Direct Oral Anticoagulants: A Pharmacovigilance Study.

BACKGROUND: Levetiracetam is widely used in post-stroke epilepsy. However, it is suspected to possess P-glycoprotein (P-gp) induction properties, and therefore, a potentially significant interaction with direct oral anticoagulants (DOACs). We aimed to search for ischemic stroke signals with levetiracetam and the DOACs. METHODS: In this retrospective pharmacovigilance study, we used the FAERS database to identify ischemic stroke events associated with DOACs and concomitant use of levetiracetam. We evaluated disproportionate reporting by the adjusted reporting odds ratio (adjROR) and the lower bound of the shrinkage 95% confidence interval. When shrinkage is positive, an increased risk of a specific adverse event occurrence is emphasized over the sum of the individual risks when these same drugs are used separately. RESULTS: We identified 1841 (1.5%), 3731 (5.3%), 338 (4.9%), and 1723 (1.3%) ischemic stroke reports with apixaban, dabigatran, edoxaban, and rivaroxaban, respectively. The adjROR of the interaction effect was 3.57 (95% CI 2.81-4.58) between DOACs and levetiracetam. The shrinkage analysis detected an interaction between each of the DOACs and levetiracetam. The logistic model and shrinkage analysis failed to detect an interaction when queried for hemorrhagic stroke. A significant signal in the classical enzyme inducer, carbamazepine, strengthened our results (adjROR; 8.47, 95% CI 5.37-13.36). CONCLUSIONS: Our study shows a strong signal for the levetiracetam interaction with the DOACs. Our findings suggest implementation of a drug monitoring strategy.

Vitamin D levels in post-acute hip fractured patients and their association with rehabilitation outcomes.

PURPOSE: To report on serum 25-hydroxyvitamin D (25(OH)D) levels in post-acute hip fractured patients, revealed the associations between serum 25(OH)D levels and hip fractured patients' baseline characteristics and rehabilitation outcomes. MATERIALS AND METHODS: A retrospective study (9/2017-9/2020) of 493 hip fractured patients. 25(OH)D levels were recorded following the patient's baseline characteristics and outcome measures, including the functional independence measure and motor functional independence measure effectiveness. The sample was divided into three groups: deficient (<30 nmol/l), insufficient (30-75 nmol/l) and sufficient (>75 nmol/l) 25(OH)D levels. ANOVA and chi-square test tests compared the groups. Multiple linear analysis assessed the associations between the 25(OH)D and discharge functional independence measure score. RESULTS: 25(OH)D deficiency was found in 20.3% of the patients. The only baseline characteristic significantly associated with serum 25(OH)D levels was dementia. The group with deficient levels of 25(OH)D exhibited a significantly higher rate of low education, low admission albumin levels and a reduced handgrip strength compared to the insufficient/sufficient groups. All functional measure scores were significantly lower in the deficient (25(OH)D) group compared with the insufficient/sufficient patient groups. 25(OH)D levels were found to be significantly associated with the discharge functional independence measure score. CONCLUSIONS: Routine screening for 25(OH)D levels is mandatory in post-acute hip fracture patients as it may affect rehabilitation outcomes.Implications for Rehabilitation25-hydroxyvitamin D 25(OH)D levels are associated with rehabilitation outcomes in post-acute hip fractured patients.A routine screening for 25(OH)D levels and standardized supplementation protocol during the acute and post-acute rehabilitation setting is recommended as it may improve the quality of care.

Medication regimen complexity index and rehabilitation outcomes in post-acute hip fracture patients study: a retrospective study.

BACKGROUND: Polypharmacy is a common problem amongst the elderly population. The complexity of the drug regimen refers not only to a simple medication count, but also to the number of daily doses, frequency, and special instructions given for their use. Medication regimen complexity may affect health outcomes, including an increase in hospitalization rates, drug non-adherence, and mortality rates. AIM: To assess whether the admission medication regimen complexity index score is associated with rehabilitation outcomes in hip fracture patients; secondary- to assess whether changes in the medication regimen complexity index scores during rehabilitation are associated with rehabilitation outcomes. METHOD: A retrospective study of 336 hip fracture patients admitted to a post-acute rehabilitation hospital. Primary rehabilitation outcome was assessed via the discharge functional independence measure score. Secondary outcomes included functional independence measure score changes, length of stay and discharge destination. RESULTS: Patients with low admission medication regimen complexity index scores attained significantly higher admission and discharge motor functional independence measure scores (40.1 vs. 37.1, p = 0.044; 57.1 vs. 52.9, p = 0.014, respectively), a higher motor functional independence measure score effectiveness (36.1 vs. 31.3, p = 0.030) and a higher rate of favorable motor functional independence measure effectiveness score (58.1% vs. 42.0%, p = 0.004). A multiple linear regression analysis revealed that the admission medication regimen complexity index score was not associated with the discharge functional independence measure score (standardized coefficient = - 0.058; p = 0.079). CONCLUSION: A high medication regimen complexity which usually implies severe comorbidity should not be considered a barrier for the rehabilitation of older patients.

The Association Between Antipsychotic Drug Use and Rehabilitation Outcome in Post-Acute Hip Fractured Patients: A Retrospective Cohort Study.

Antipsychotic (AP) use may lead to numerous side effects which may affect rehabilitation outcomes. A retrospective cohort study was carried out on 448 hip fractured patients admitted to a post-acute geriatric rehabilitation center. Functional improvement was measured by the Functional Independence Measure (FIM), motor FIM (mFIM), and mFIM effectiveness. A multiple linear regression model and regression analysis was used to evaluate the level of association between AP use and achievement of favorable functional gain. AP users exhibited lower functional ability on admission and at discharge, achieved a significantly lower functional gain and required longer rehabilitation time compared with nonusers. AP use by post-acute hip fractured patients negatively affects their chances of achieving favorable rehabilitation outcome after adjustment for confounders.

Seven key parameters that facilitate clinical pharmacy practice: a comparison between Israel and the United States.

Clinical pharmacists have advanced training that enables them to manage medication therapy, including prescribing, titrating, and discontinuing medications, in order to achieve therapeutic goals. In some countries, such as the United States, advances in training, responsibility, legal frameworks, and public acceptance of new roles have proceeded in parallel to expand the scope and contribution of clinical pharmacists over several decades. In this manuscript, we detail seven discrete key parameters of professional advancement for clinical pharmacists, corresponding to the seven areas in which they must advance in order to contribute fully to delivering high-quality medical care. For each key parameter, we briefly summarize the progress made in the United States to date, as well as goals for future progress. We then compare this to the development of the analogous key parameter in Israel. We found that on some key parameters, the development of clinical pharmacy in Israel lags behind the United States. This manuscript can provide a roadmap for the future advancement of clinical pharmacy in Israel, toward its full realization as a profession that can contribute to delivering high-quality medical care.

Association between anticholinergic drug prescription changes and rehabilitation outcome in post-acute hip fractured patients.

Purpose: To follow changes in anticholinergic drug prescriptions throughout hip fractured patients' rehabilitation; to assess whether a change in anticholinergic burden affects rehabilitation outcome.Methods: Retrospective study of 869 hip fractured patients admitted between January 2011 to October 2015, performed in a post-acute geriatric rehabilitation center. The Anticholinergic Cognitive Burden Scale quantified the anticholinergic burden. Main outcome measures: Functional Independence Measure, motor Functional Independence Measure, Montebello Rehabilitation Factor Score on motor Functional Independence Measure and length of stay. Multiple linear regression analysis tested for independent association between admission anticholinergic burden and anticholinergic burden change during rehabilitation, and rehabilitation outcomes.Results: One hundred and sixty two (18.7%) patients were prescribed additional anticholinergic medications upon discharge; 76 (8.7%) were prescribed fewer. Patients with high admission anticholinergic burden presented with a significantly higher rate of higher education, less likely to reside at home, less independent pre-fracture, exhibited a significantly lower admission and discharge Functional Independence Measure score, a lower Functional Independence Measure score change and a lower Montebello Rehabilitation Factor Score. Admission anticholinergic burden, but not changes in anticholinergic burden during rehabilitation, was found to be independently associated with rehabilitation outcome (discharge FIM score).Conclusions: High admission anticholinergic burden is associated with lower functional ability in hip fractured patients. Changes in anticholinergic drug prescription during rehabilitation were not associated with rehabilitation outcomes.Implications for rehabilitationClinicians should make an effort to reduce AC drug use in hip fractured patients on admission to post-acute rehabilitation.AC burden should be carefully monitored throughout the rehabilitation period and reduced whenever possible.When functional ability does not improve as expected, AC burden should be considered as an intervening factor.

Initial functional recovery as a measure for rehabilitation outcome in post-acute hip fractured patients.

BACKGROUND: The assessment of immediate functional change after hip fracture surgery may assist in predicting rehabilitation outcome and improve program efficiency. OBJECTIVE: To evaluate the potential of the initial functional recovery measure in predicting rehabilitation outcome of hip fractured patients. DESIGN: Retrospective cohort study. SETTING: Post-acute geriatric rehabilitation center. PARTICIPANTS: A total of 630 hip fractured patients admitted from 1/2016-6/2019. METHODS: The initial functional recovery, a measure of functional change from the time of surgery to rehabilitation was calculated for each patient. The association between initial functional recovery and clinical and demographic variables was assessed by the Mann-Whitney and chi-square tests. A multiple linear regression model evaluated the association between initial functional recovery and the discharge functional independence measure score. Regression analysis estimated the association between initial functional recovery and the achievement of a favorable outcome measure. RESULTS: A good correlations were found between initial functional recovery and rehabilitation outcomes but not length of stay (p < 0.001). Multiple linear regression analysis showed that after adjustment for potential confounding variables, the higher the initial functional recovery, the better the discharge functional independence measure score (r2 = 0.783; p < 0.001). Logistic regression revealed that a high initial functional recovery was significantly associated with a higher probability of achieving a favorable functional gain (OR = 1.093; 95% CI = 1.04-1.15, P < 0.001). CONCLUSION: Initial functional recovery is a good predictor of rehabilitation outcomes in hip fractured patients, and may be utilized in decision-making regarding the rehabilitation program in addition to coordinating expectations with patients and their caregivers.

Apixaban Levels in Octogenarian Patients with Non-valvular Atrial Fibrillation.

BACKGROUND: There is a paucity of data on apixaban levels among octogenarians with non-valvular atrial fibrillation (NVAF). We aimed to compare apixaban levels between octogenarians (with and without dose reduction) and younger patients, to assess the frequency of high and above-range drug levels. METHODS: A cross-sectional, prospective study of 80 patients treated with apixaban for NVAF was conducted. Apixaban levels were compared among octogenarians treated with 5 mg twice daily (bid), octogenarians with appropriately reduced dose (2.5 mg bid), octogenarians with inappropriately reduced dose and younger patients (age < 70 years). Trough and peak levels were measured by a chromogenic assay calibrated for apixaban and compared to predicted manufacturer levels. RESULTS: A significant proportion of the cohort had above-range trough [n = 11 (13.8%)] and peak [n = 16 (20%)] levels, especially octogenarians with the 5-mg bid dosage [n = 6 (30%) for trough and n = 8 (40%) for peak]. No significant differences were found in the trough or peak geometric mean (GM) levels among the groups, apart from the peak GM levels between the 5-mg octogenarian group and the other two 2.5-mg bid octogenarian groups (p = 0.0004). The frequency of apixaban peak levels within the upper quartile was significantly higher in the 5-mg octogenarian group compared to the other groups [n = 12 (60%) of measurements, p = 0.019), whereas trough levels were comparable between groups. CONCLUSION: High and above-range peak apixaban steady-state levels are highly prevalent in octogenarians receiving the appropriate dosage of 5 mg bid for NVAF stroke prevention. Age above 80 strongly affects apixaban levels. TRIAL REGISTRATION: ClinicalTrials.gov Identifier number NCT02623049.

The Association between Anticholinergic Drug Use and Rehabilitation Outcome in Post-Acute Hip Fractured Patients: A Retrospective Cohort Study.

BACKGROUND: Anticholinergic (AC) drugs are associated with significant impairment in cognitive and physical function which may affect rehabilitation in older people. We aimed to evaluate whether AC burden is associated with rehabilitation achievement in post-acute hip-fractured patients. METHODS: A retrospective cohort study carried out in a post-acute geriatric rehabilitation center on 1019 hip-fractured patients admitted from January 2011 to October 2015. The Anticholinergic Cognitive Burden Scale (ACB) was used to quantify the AC burden. Main outcome measures included the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM, and length of stay (LOS). The study population was divided into two groups: individuals with low admission AC burden (ACB ≤ 1) and those with high admission AC burden (ACB ≥ 2). The relationship between the admission AC burden and clinical, demographic and comorbidity variables was assessed using the Mann-Whitney and Chi square tests. A multiple linear regression model was used to estimate the association between admission AC burden and discharge FIM score after controlling for sociodemographic characteristics and chronic diseases. RESULTS: Patients with a high admission AC burden had a significantly higher rate of high education, a significantly lower rate reside at home, they waited a longer period of time from surgery to rehabilitation, were less independent pre-fracture, and presented with a higher rate of vascular disorders and depression compared with patients with a lower admission AC burden. These patients also exhibited a significantly lower FIM score on admission and at discharge, a lower FIM score change, and a lower achievement on the MRFS compared with patients with a lower admission AC burden. A multiple linear regression analysis showed that admission AC burden was significantly associated with the discharge FIM score after adjustment for confounding variables. CONCLUSION: High admission AC drug burden is significantly associated with less favorable discharge functional status in post-acute hip-fractured patients, independent of relevant risk factors.

A Case of Hepatotoxicity Induced by Adulterated "Tiger King", a Chinese Herbal Medicine Containing Sildenafil.

Detection of Phosphodiesterase Type 5 (PDE-5) inhibitors and their analogues in "100% natural" or "herbal" supplements have been described in numerous reports. However, few reports have been published in relation to actual harm caused by counterfeit erectile dysfunction herbal supplements. We describe a case of a 65-year old male admitted to a tertiary hospital with acute liver toxicity, possibly induced by adulterated "Chinese herbal" supplement "Tiger King" for sexual enhancement. Chemical analysis of the tablets discovered the presence of therapeutic doses of sildenafil with no other herbal components. Other medications were excluded as potential causes of the hepatic impairment. According to the Naranjo adverse drug reaction scale and the Roussel Uclaf Causality Assessment Method (RUCAM) the probability of association of Hepatotoxicity with Sildenafil was "possible" and "probable" respectively (Naranjo score of 4, RUCAM score of 7). Within three days of admission, the patient's clinical status and liver function improved without any specific treatment. His liver function tests normalized 30 days post discharge. Further pharmacovigilance actions should be taken by regulatory authorities and pharmaceutical companies in order to determine the relation between sildenafil and hepatotoxicity. This case emphasizes the importance of raising public awareness on the potential dangers of "Tiger king" in particular, and other counterfeit medications or herbal supplements of unknown origin.