Alternative Cosmetic and Medical Applications of Injectable Deoxycholic Acid: A Systematic Review.

BACKGROUND: Beyond submental fat reduction, injectable deoxycholic acid (DCA) has gained popularity in recent years for various minimally invasive lipolysis applications. OBJECTIVE: To summarize and evaluate the evidence of off-label uses of injectable DCA. METHODS: MEDLINE, Embase, CINAHL, Web of Science, and CENTRAL were searched. The outcomes measured included applications of DCA, treatment regimen, and its efficacy. An overall success rate for each condition was calculated based on the improvement defined in the included studies. RESULTS: Eleven studies evaluated the cosmetic use of DCA for excess adipose tissue on various anatomical locations. The outcomes were evaluated at time points ranging from 1 to 21 months post-treatment, with overall success rates over 85%. Eight case reports and series reported the success of using DCA treating lipomas, xanthelasmas, paradoxical adipose hyperplasia, fibrofatty residue of infantile hemangioma, piezogenic pedal papules, and HIV-associated lipohypertrophy. Although the preliminary efficacies were high, the overall recommendations for off-label uses are weak because of the lack of high-level studies. CONCLUSION: The review emphasizes the diversity of injectable DCA as a minimally invasive technique for lipolysis. Further high-level studies demonstrating consistent treatment regimens and methods of evaluation are warranted to make more definitive recommendations regarding off-label DCA use.

pH-sensitive chitosan-deoxycholic acid/alginate nanoparticles for oral insulin delivery.

Oral absorption of peptides/proteins is usually compromised by various gastrointestinal tract barriers. To improve delivery efficiency, chitosan-conjugated deoxycholic acid (CS-DCA) coupled with sodium alginate (ALG) was prepared to load insulin into pH-sensitive nanoparticles. The insulin-loaded chitosan-deoxycholic acid/alginate nanoparticles (CDA NPs) were characterized by size (143.3 ± 10.8 nm), zeta potential (19.5 ± 1.6 mV), entrapment efficiency (61.14 ± 1.67%), and insulin drug loading (3.36 ± 0.09%). The CDA NPs exhibited pH-triggered release characteristics in vitro and protected the wrapped insulin from gastric degradation. Stability of the CDA NPs in enzyme-containing simulated gastrointestinal fluids suggested that the NPs could partially protect the wrapped insulin from enzymatic degradation. Additionally, CS-DCA-modified NPs promoted the permeability of Caco-2 cells and enhanced intracellular absorption of FITC-labeled insulin by 9.4 and 1.2-folds, when compared to insulin solution and unmodified NPs, respectively. The positively charged NPs increased intestinal villi adhesion and enhanced insulin absorption in the intestines of diabetic rat models. Furthermore, the hypoglycemic test showed that CDA NPs prolonged insulin release in vivo and exerted a remarkable hypoglycemic effect on diabetic rats with an oral bioavailability of 15%. In conclusion, CDA NPs is a potential oral insulin delivery system.

Sodium alginate microencapsulation improves the short-term oral bioavailability of cannabidiol when administered with deoxycholic acid.

BACKGROUND: Cannabidiol (CBD) confers therapeutic effects in some neurological disorders via modulation of inflammatory, oxidative and cell-signalling pathways. However, CBD is lipophilic and highly photooxidative with low oral bioavailability in plasma and brain. In this study, we aimed to design and test a CBD microencapsulation method as a drug delivery strategy to improve the absorption of CBD. Additionally, we evaluated the brain uptake of CBD capsules when administered alongside capsules containing a permeation-modifying bile acid, deoxycholic acid (DCA). METHODS: Microcapsules containing either CBD or DCA were formed using the ionic gelation method with 1.5% sodium alginate formulations and 100 mM calcium chloride. C57BL/6J wild type mice randomly assigned to three treatment groups (3-4 mice per group) were administered CBD in the following preparations: 1) CBD capsules, 2) CBD capsules + DCA capsules and 3) naked CBD oil (control). To assess the short-term bioavailability of CBD, plasma and brain samples were collected at 0.3, 1 and 3 hours post administration and CBD levels were analysed with liquid chromatography mass spectrometer. RESULTS: We produced spherical capsules at 400 ± 50 µm in size. The CBD capsules were calculated to have a drug loading of 2% and an encapsulation efficiency of 23%. Mice that received CBD capsules + DCA capsules showed a 40% and 47% increase in CBD plasma concentration compared to mice on CBD capsules and naked CBD oil, respectively. Furthermore, the CBD capsules + DCA capsules group showed a 48% and 25% increase in CBD brain concentration compared to mice on CBD capsules and naked CBD oil, respectively. In mice treated with CBD capsules + DCA capsules, the brain CBD concentration peaked at 0.3 hours with a 300% increased availability compared to CBD capsules and naked CBD oil groups, which peaked at 1 hour after administration. CONCLUSIONS: The microencapsulation method combined with a permeation enhancer, DCA increased the short-term bioavailability of CBD in plasma and brain.

Randomized, Placebo-Controlled Phase 1/2 Study to Determine the Appropriate ATX-101 Concentration for Reduction of Submental Fat.

BACKGROUND: ATX-101 is indicated for submental fat treatment. OBJECTIVE: Evaluate ATX-101 versus placebo for reducing submental fat. MATERIALS AND METHODS: Adults with unwanted submental fat across 6 global sites were randomized to ATX-101 (0.5%, 1.0%, or 2.0%) or placebo for ≤4 treatments every 28 days. Outcomes included safety (adverse events and pain visual analog scale) throughout the study and efficacy (submental fat rating, patient satisfaction, and submental fat improvements) at Week 16. RESULTS: Eighty-four of 85 enrolled patients received ≥1 ATX-101 treatment (0.5% [n = 20], 1.0% [n = 20], 2.0% [n = 22] or placebo [n = 22]). Most patients (n = 82) experienced adverse events, which were mostly mild/moderate, seemed to be dose-related, and led to no study discontinuations. The mean pain scores were highest in the ATX-101 1.0% and 2.0% groups. Week-16 change from baseline in the submental fat rating scale was significantly greater for ATX-101 0.5% and 1.0% versus placebo (p ≤ .05). At Week 16, 71%, 74%, 53%, and 40% of patients in the ATX-101 0.5%, 1.0%, 2.0%, and placebo groups, respectively, achieved a ≥1-grade reduction in submental fat from baseline. Satisfaction with appearance and patient-assessed global improvement ratings increased in all ATX-101 treatment groups versus placebo. CONCLUSION: All ATX-101 concentrations were safe and efficacious for moderate/severe submental fat reduction.

Safety and Efficacy of Deoxycholic Acid Injection for Hypogastric Fat Reduction: A Pilot Study.

BACKGROUND: Although deoxycholic acid (DCA) has been proposed for use in other areas, it is used primarily for treating moderate-to-severe fat in the submental area. OBJECTIVE: To evaluate the safety and efficacy of DCA for fat reduction in the hypogastric region. MATERIALS AND METHODS: A prospective, longitudinal, nonrandomized, open-label, interventional pilot study was performed. Deoxycholic acid was transcutaneously injected in upper right, upper left, lower right, and lower left hypogastric zones. Fat thickness was assessed using calipers, ultrasound, and 3-dimensional scanning. The primary end point safety was evaluated by laboratory tests and the incidence of adverse events. RESULTS: Fourteen patients (54 treatment sessions) were included. The mean total volume administered was 26.6 mL. The main local adverse events were edema (94.4%), bruising (90.7%), and erythema (79.6%), all being self-limited (the mean duration 9.6, 7, and 2 days, respectively). A DCA dose was significantly associated with erythema duration (p = .0421) but not with edema duration (p = .1611) or bruising incidence (p = .1013). Measurement using calipers, ultrasound, and 3-dimensional scanning revealed significant fat thickness reduction. Patient-reported outcome measure scores revealed a significant improvement in patient satisfaction. CONCLUSION: Deoxycholic acid may be a safe and effective option for reducing fat thickness in the hypogastric region, although given the cost/benefit ratio probably should be reserved for small deposits.

Ambulatory induction phase treatment of cryptococcal meningitis in HIV integrated primary care clinics, Yangon, Myanmar.

BACKGROUND: Cryptococcal meningitis (CM) is a common HIV-associated opportunistic-infection worldwide. Existing literature focusses on hospital-based outcomes of induction treatment. This paper reviews outpatient management in integrated primary care clinics in Yangon. METHOD: This retrospective case note review analyses a Myanmar HIV-positive patient cohort managed using ambulatory induction-phase treatment with intravenous amphotericin-B-deoxycholate (0.7-1.0 mg/kg) and oral fluconazole (800 mg orally/day). RESULTS: Seventy-six patients were diagnosed between 2010 and 2017. The median age of patients diagnosed was 35 years, 63% were male and 33 (45%) were on concurrent treatment for tuberculosis. The median CD4 count was 60 at the time of diagnosis. Amphotericin-B-deoxycholate infusions precipitated 56 episodes of toxicity, namely hypokalaemia, nephrotoxicity, anaemia, febrile reactions, phlebitis, observed in 44 patients (58%). One-year survival (86%) was higher than existing hospital-based treatment studies. CONCLUSION: Ambulation of patients in this cohort saved 1029 hospital bed days and had better survival outcomes when compared to hospital-based studies in other resource constrained settings.

Efficacy of induction regimens for cryptococcal meningitis in HIV-infected adults: a systematic review and network meta-analysis.

Cryptococcal meningitis (CM) is the most fatal adult meningitis in patients with human immunodeficiency virus (HIV). There is no conclusive evidence for the superiority of 1-week amphotericin B deoxycholate (AmphB) + flucytosine (5-FC) regimen over other antifungals in the management of HIV patients with CM (HIV-CM patients). We aimed to evaluate the differences in efficacy and tolerability of different antifungal agents in HIV-CM patients by conducting a current network meta-analysis NMA. Overall, 19 randomized controlled trials were included with 2642 participants. A regimen indicated a possibly lower early mortality rate, namely, AmphB + 5-FC + Azole (OR = 1.1E-12, 95% CIs = 1.3E-41 to 0.06) comparing to AmphB + 5-FC. The current NMA provides evidence that AmphB + 5-FC + Azole are superior to all the investigated treatments for induction regimen in HIV-CM patients.

Efficacy and safety of injectable deoxycholic acid for submental fat reduction: a systematic review and meta-analysis of randomized controlled trials.

Objective: To investigate the efficacy and safety of deoxycholic acid (DOC) for SMF reduction.Methods: We conducted a systematic review and meta-analysis of randomized controlled trials. We searched PubMed/MEDLINE, EMBASE, and Cochrane databases until June 2020. Efficacy outcomes: Clinician-Reported Submental Fat Rating Scale; Patient-Reported Submental Fat Rating Scale; Subject Self-Rating Scale; SMF reduction measured using caliper and resonance magnetic imaging; Early therapeutic success. Safety outcomes: Withdrawals due to adverse events (AEs), Rates of AEs, Skin laxity.Results: Five studies were included, comprising 1,838 participants. DOC (1 or 2 mg/cm2) had greater improvement in all efficacy measures compared to placebo. No differences were seen between both doses of DOC. Withdrawals due to AEs were low with 1 and 2 mg/cm2 of DOC (6.8% vs. 9.9%, respectively), and there was no difference between the two doses (p = 0.22). AEs were usually associated with the injection site, were predominantly transient, and commonly resolved within the treatment session interval. Injection site pain, hematoma, anesthesia/numbness, erythema, and swelling/edema were the most common AEs. There was no difference in their prevalence between both doses of DOC.Conclusions: DOC is effective and safe for SMF reduction with no differences between doses of 1 and 2 mg/cm2.

Deoxycholic Acid-Induced Gut Dysbiosis Disrupts Bile Acid Enterohepatic Circulation and Promotes Intestinal Inflammation.

BACKGROUND: A Western diet is a risk factor for the development of inflammatory bowel disease (IBD). High levels of fecal deoxycholic acid (DCA) in response to a Western diet contribute to bowel inflammatory injury. However, the mechanism of DCA in the natural course of IBD development remains unanswered. AIMS: The aim of this study is to investigate the effect of DCA on the induction of gut dysbiosis and its roles in the development of intestinal inflammation. METHODS: Wild-type C57BL/6J mice were fed an AIN-93G diet, either supplemented with or without 0.2% DCA, and killed at 24 weeks. Distal ileum and colon tissues were assessed by histopathological analysis. Hepatic and ileal gene expression was examined by qPCR, and the gut microbiota was analyzed by high-throughput 16S rRNA gene sequencing. HPLC-MS was used for fecal bile acid quantification. RESULTS: Mice fed the DCA-supplemented diet developed focal areas of ileal and colonic inflammation, accompanied by alteration of the composition of the intestinal microbiota and accumulation of fecal bile acids. DCA-induced dysbiosis decreased the deconjugation of bile acids, and this regulation was associated with the repressed expression of target genes in the enterohepatic farnesoid X receptor-fibroblast growth factor (FXR-FGF15) axis, leading to upregulation of hepatic de novo bile acid synthesis. CONCLUSIONS: These results suggest that DCA-induced gut dysbiosis may act as a key etiologic factor in intestinal inflammation, associated with bile acid metabolic disturbance and downregulation of the FXR-FGF15 axis.

Isavuconazole as Salvage Therapy for Refractory Pediatric Coccidioidal Meningitis.

Coccidioidal meningitis remains difficult to treat. The newer triazole, isavuconazole, has demonstrated efficacy in invasive fungal disease with less side effects than other azoles. We describe a case of refractory pediatric coccidioidal meningitis with disease stabilization and improvement on isavuconazole after failing treatment with other antifungal agents.

Continuous ambulatory peritoneal dialysis-associated Histoplasma capsulatum peritonitis: a case report and literature review.

BACKGROUND: Fungal peritonitis (FP) is a rare complication of peritoneal dialysis. We herein describe the second case in Asia of Histoplasma capsulatum peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD). CASE PRESENTATION: An 85-year-old woman with end-stage renal disease (ESRD) who had been on CAPD for 3 years and who had a history of 3 prior episodes of peritonitis presented with intermittent abdominal pain for 2 weeks and high-grade fever for 3 days. Elevated white blood cell (WBC) count and rare small oval budding yeasts were found in her peritoneal dialysis (PD) fluid. From this fluid, a white mold colony was observed macroscopically after 7 days of incubation, and numerous large, round with rough-walled tuberculate macroconidia along with small smooth-walled microconidia were observed microscopically upon tease slide preparation, which is consistent with H. capsulatum. The peritoneal dialysis (PD) catheter was then removed, and it also grew H. capsulatum after 20 days of incubation. The patient was switched from CAPD to hemodialysis. The patient was successfully treated with intravenous amphotericin B deoxycholate (AmBD) for 2 weeks, followed by oral itraconazole for 6 months with satisfactory result. The patient remains on hemodialysis and continues to be clinically stable. CONCLUSION: H. capsulatum peritonitis is an extremely rare condition that is associated with high morbidity and mortality. Demonstration of small yeasts upon staining of PD fluid, and isolation of slow growing mold in the culture of clinical specimen should provide important clues for diagnosis of H. capsulatum peritonitis. Prompt removal of the PD catheter and empirical treatment with amphotericin B or itraconazole is recommended until the culture results are known.

Uncommon Adverse Effects of Deoxycholic Acid Injection for Submental Fullness: Beyond the Clinical Trials.

Deoxycholic acid (BELKYRATM, Allergan, Markham, ON, Canada) is a minimally invasive injectable treatment approved by Health Canada for the nonsurgical reduction of submental fullness. Multiple phase III clinical trials have proven the efficacy and safety of deoxycholic acid. In the clinical trials, the most common adverse events (AEs) reported, such as injection site pain, numbness, swelling, bruising and induration, were transient and mild-to-moderate in severity. Additional postmarketing AEs have been reported in the literature. In this study, we reviewed the uncommon reported events and aimed to increase clinician awareness of the potential adverse effects for patient counselling of risks and benefits, identify AEs of procedures that may be performed outside of the medical environment, and identify factors that increase the risk of an adverse event. Beyond the clinical trials, real-world case reports and case series have been reported for the AEs of alopecia, transient neuropraxia, vascular occlusive events/vascular injury, and skin necrosis. Dermatologists need to be aware of these risks, for the treatment and management of their own patients and for those patients who may be treated outside the medical clinic environment that present for medical management of these AEs.

Messenger RNA/polymeric carrier nanoparticles for delivery of heme oxygenase-1 gene in the post-ischemic brain.

Ischemic stroke is a cerebrovascular disease caused by narrowed cerebral arteries. Thrombolytic agents such as tissue-plasminogen activators have been used for recanalization of the blood supply into the ischemic region. However, ischemia-reperfusion damage continues to increase the infarction volume. In this study, heme oxygenase-1 (HO1)-mRNA was delivered into the brain, using a non-viral carrier. Various non-viral carriers such as polyethylenimine (25 kDa, PEI25k), lipofectamine, dexamethasone-conjugated PEI2k (Dexa-PEI2k), deoxycholic acid-conjugated PEI2k (DA-PEI2k), and R3V6 peptides were evaluated as carriers of mRNA into the brain. Gene delivery assays showed that DA-PEI2k and lipofectamine had a higher mRNA delivery efficiency than the other carriers in Neuro2A cells in vitro and a rat brain in vivo. Cytotoxicity assays showed that lipofectamine had higher toxicity than DA-PEI2k. Therefore, DA-PEI2k was used for delivery of HO1-mRNA. Unlike plasmid DNA (pDNA), mRNA is expressed in the cytosol without nuclear translocation. This suggests that mRNA may have higher gene expression than pDNA, since the nuclear location of pDNA is an inefficient step. Indeed, in in vitro transfection assays, HO1-mRNA/DA-PEI2k had higher gene expression than HO1-pDNA/DA-PEI2k without induction of a pro-inflammatory cytokine. The therapeutic effects of HO1-mRNA delivery using DA-PEI2k were evaluated in the middle cerebral artery occlusion animal model after local injection. HO1-mRNA delivery had higher gene expression than HO1-pDNA delivery 24 h after the local injection. In addition, HO1-mRNA delivery reduced the infarct size more efficiently than HO1-pDNA delivery. The results suggest that the delivery of mRNA using DA-PEI2k may be useful for gene therapy of ischemic stroke.

Hyodeoxycholic acid (HDCA) suppresses intestinal epithelial cell proliferation through FXR-PI3K/AKT pathway, accompanied by alteration of bile acids metabolism profiles induced by gut bacteria.

Bile acids (BAs) have been implicated in regulation of intestinal epithelial signaling and function. This study aimed to investigate the effects of hyodeoxycholic acid (HDCA) on intestinal epithelial cell proliferation and explore the underlying mechanisms. IPEC-J2 cells and weaned piglets were treated with HDCA and the contributions of cellular signaling pathways, BAs metabolism profiles and gut bacteria were assessed. In vitro, HDCA suppressed IPEC-J2 proliferation via the BAs receptor FXR but not TGR5. In addition, HDCA inhibited the PI3K/AKT pathway, while knockdown of FXR or constitutive activation of AKT eliminated the inhibitory effects of HDCA, suggesting that FXR-dependent inhibition of PI3K/AKT pathway was involved in HDCA-suppressed IPEC-J2 proliferation. In vivo, dietary HDCA inhibited intestinal expression of proliferative markers and PI3K/AKT pathway in weaned piglets. Meanwhile, HDCA altered the BAs metabolism profiles, with decrease in primary BA and increase in total and secondary BAs in feces, and reduction of conjugated BAs in serum. Furthermore, HDCA increased abundance of the gut bacteria associated with BAs metabolism, and thereby induced BAs profiles alternation, which might indirectly contribute to HDCA-suppressed cell proliferation. Together, HDCA suppressed intestinal epithelial cell proliferation through FXR-PI3K/AKT signaling pathway, accompanied by alteration of BAs metabolism profiles induced by gut bacteria.

Improvement in Jowl Fat following ATX-101 Treatment: Results from a Single-Site Study.

BACKGROUND: Jowl fat overhang can reduce jawline definition. The most common treatment to reduce jowl fat is liposuction. ATX-101 (deoxycholic acid injection), a minimally invasive treatment approved for submental fat reduction, may also be an effective treatment for jowl fat. The current study evaluated the efficacy and safety of ATX-101 treatment for reducing jowl fat. METHODS: In this prospective single-site study, 66 adults were treated for excess jowl fat with ATX-101 (area-adjusted dose: 2 mg/cm). Eligible patients had pinchable fat on the jawline and relatively minimal skin laxity in the jowl. Depending on the size of the treatment area, ATX-101 injections of 0.2 ml spaced 1.0 cm apart or 0.1 ml spaced 0.50 to 0.75 cm apart were administered. Improvement in jowl appearance was assessed 6 months or more after the last treatment in person by the clinician. Improvement was also assessed by the patient and two independent plastic surgeons using blinded before/after treatment photographs. Safety was evaluated via adverse events. RESULTS: The mean number of ATX-101 treatments received was 1.8, with a mean injection volume of 0.8 ml per treatment per jowl. The majority of patients (98 percent) experienced an improvement in jowl appearance. Common adverse events were injection-site edema, numbness, tenderness, and bruising. Injection-site marginal mandibular nerve paresis and alopecia were experienced by three patients each; all events resolved without sequelae. CONCLUSIONS: ATX-101 effectively reduced jowl fat and was well tolerated in this small cohort. Care should be taken when injecting ATX-101 into jowl fat to avoid underlying anatomic structures such as the marginal mandibular nerve. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.