drug - induced phospholipidosis ( pld ) is a lipid storage disorder characterized by the intralysosomal accumulation of polar lipids , membranous lamellar inclusions , and drug .
common primary tissue targets are alveolar macrophages , hepatic kupffer cells , bile duct epithelia , and peripheral blood mononuclear cells , although numerous other cellular targets have been reported .
most have basic and hydrophobic physicochemical properties ( amphiphilic cations ) that enable binding with phospholipids , crossing of biological membranes , and lysomotropism ( partitioning of drug into lysosomes once it is protonated at acidic intralysosomal ph ) .
lysomotropic properties and drug accumulation potential are underscored by studies employing lysosomal modulators which have a demonstrated ability to abolish the ph gradient from cytoplasm to lysosome , preclude accumulation of drug in the lysosome ( depot effect ) , and/or rescue cells in vitro [ 46 ] .
there is a consensus view that pld itself is largely an adaptive rather than an adverse response to xenobiotics as a number of ex vivo studies have failed to consistently reveal specific functional detriment in responding phospholipidotic tissues [ 2 , 79 ] .
yet there is suggestive evidence that phospholipogenic compounds are associated with concurrent toxicities preclinically and clinically .
these toxicities include liver necrosis ( amiodarone ) , motor neuropathies ( imipramine , amitriptyline ) , proximal tubule kidney injury ( gentamicin ) , pulmonary alveolitis that can progresses to fibrosis ( amiodarone ) , pneumonitis ( fluoxetine ) , peripheral neuropathies ( suramin , amiodarone , chloroquine , perhexiline ) , and corneal opacity ( chloroquine , amiodarone ) [ 1015 ] . despite this potential association , to date
, there have been no comprehensive published reviews of pharmaceutical industry data that enumerate these risks or that probe the statistical connection between phospholipogenic compounds and concurrent toxicities .
understanding whether such a connection exists would help define the relative importance of thorough pathological characterization of phospholipidosis and concurrent toxicities in early drug discovery and assist in reducing attrition in drug development .
to investigate the link between phospholipogenic compound administration and the incidence of preclinical histological signals , phospholipogenic and nonphospholipogenic compounds were identified in an internal astrazeneca in vivo toxicology report database and their histological results annotated .
we herein report on a robust , unbiased analysis revealing that in vivo phospholipogenic compounds are statistically more likely to demonstrate non - pld histologic changes in all organs investigated .
this observation is even more compelling when one considers that , in these studies , the nominal dose ( or exposures ) for nonphospholipogenic compounds typically exceeded that for phospholipogenic compounds .
an internal astrazeneca database containing repeat - dose in vivo toxicology reports was searched to identify phospholipogenic compounds using the common pld indicator terms phospholipidosis , histiocytosis , foamy macrophages , lamellar lysosomes , and myeloid bodies . to identify reports on nonphospholipogenic compounds ,
species , study duration , histological findings , nominal doses , and plasma exposures were the key data extracted .
we focused on nine responding organs : adrenal gland ; bone marrow ; kidney ; liver ; lung ; lymph node ; reproductive organs ; spleen ; thymus .
( while we have observed nervous and muscle tissue phospholipidosis in our studies , reports were not archived in time , or search terms were inadequate for the purpose of performing an unbiased analysis . ) reports were individually read to verify the presence or absence of indicator terms , and both pld and all non - pld histologic findings were recorded and annotated .
although pld often presents as vacuolation by light microscopy , due to its common occurrence , by itself , this finding was not considered sufficient for pld classification .
one or more of the following was considered an additional confirming measure for membership in the phospholipogenic dataset : a positive result in an in vitro pld assay , a positive prediction from our in - house in silico pld model , a pathologist interpretation / description of pld in the report ( pld had to be considered by the pathologist a familiar and salient finding and not that of background ) , or an electron microscopic finding of pld , the latter being the gold standard for detecting lysosomal phospholipid - laden myeloid inclusions indicative of pld .
one or more of the following was considered an additional confirming measure of a compound having a nonphospholipogenic status : a negative result in an in vitro pld assay or a negative result in our in silico pld predictive model .
nominal dose ( mol / kg ) , aucmhr and cmax ( m ) plasma exposure data for the two compound classes were extracted from the study reports if available ( table 1 ) .
if a study had four dose groups , the second lowest dose was designated as the low dose .
auc exposure information for at least two doses was available for 77% of the phospholipogenic reports and 86% of the negative 's reports ; cmax exposure information for at least 2 doses was available for 73% of the phospholipogenic compounds and 79% of the nonphospholipogenic compounds .
exposures were not adjusted for plasma protein binding as complete measurements were not available for a majority of the studies .  
statistically significant differences between the two datasets for organ histological findings were assessed using chi square analysis at a 95% confidence level .
statistically significant differences are indicated by chi square values greater than 3.84 in table 2 .

 in vivo data extracted from an internal in vivo toxicology report archive resulted in compilation of forty - six phospholipogenic compounds and sixty - two nonphospholipogenic compounds . to obtain the forty - six phospholipogenic compound set , fifty - three compounds initially identified as phospholipogenics based on verbal descriptors in the study reports were tested in our in vitro pld assay , found to be positive , and selected for further analysis . the majority of these compounds exhibited in vitro ec50 values less than 50  m ( mean 44  m , sd 66 ; ranging from 2.4 to 273  m ) . for comparison , the phospholipogenics amiodarone , chloroquine , and citalopram yield 4.8 , 12 , and 38  m ec50 values in this assay , demonstrating that many positives selected for analysis were intrinsically weaker in their phospholipidosis inducing potential than these standard reference drugs .
clustering based on 2-dimensional molecular fingerprints resulted in seventy - five sets of compounds , with the largest cluster containing eight compounds .
physical and computed molecular properties also revealed this diversity , with molecular weights ( mw ) ranging from 139 to 696 ( mean 434 , sd 115 ) , polar surface area ( psa ) between 20.5 and 194.9 ( mean 85.9 , sd 33.4 ) , and clogp between 2.53 and 8.95 ( mean 3.0 , sd 2.0 ) .
the number of hydrogen bond donors ranged from 0 to 4 ( mean 1.7 , sd 1.2 ) and hydrogen bond acceptors from 2 to 14 ( mean 6.9 , sd 2.4 ) . at ph 7 , the phospholipogenic compounds were predicted to contain 37 bases , 4 neutrals , 3 zwitterions , and 1 acid , while the nonphospholipogenic compounds contain 9 bases , 34 neutrals , 1 zwitterion , and 18 acids .
the mw for the phospholipogenic compounds ranged between 256 and 645 ( mean 476 , sd 85 ) and 139 and 695 ( mean 404 , sd 124 ) for the negative compounds .
clogp for the phospholipogenic compounds range between 0.67 and 8.95 ( mean 3.8 , sd 1.6 ) and for the negative compounds between 2.53 and 7.46 ( mean 2.4 , sd 2.0 ) .
psa for the phospholipogenics ranged between 30.6 and 138.1 ( mean 76.4 , sd 25 ) , while , for the nonphospholipogenic compounds it ranges between 20.5 and 194.9 ( mean 92.8 , sd 37.2 ) .
the number of hydrogen bond donors ranges between 0 and 4 ( mean 1.5 , sd 1.1 ) and the number of hydrogen bond acceptors between 3 and 12 ( mean 6.9 , sd 1.8 ) for the phospholipogenic compounds and between 0 and 4 ( mean 1.8 , sd 1.2 ) and 2 and 14 ( mean 6.9 , sd 2.7 ) , respectively , for the negatives . aside from the obvious difference in the ionization characteristics of the two sets , these simple physical chemical parameters alone do not appear to effectively distinguish between phospholipogenic and nonphospholipogenic compounds .
mouse , rat , and dog are the three species represented in the compound datasets .
study durations ranged from five days to two years , with the majority of repeat dose studies having been conducted for 1 to 4 weeks duration .  
there were on average 4.8 ( 4.6 sd ) and 3.2 ( 2.3 sd ) reports per compound in the phospholipogenic and nonphospholipogenic datasets , respectively .
where there were multiple study reports for a compound tested in the same species , reports were counted as a single  report  to minimize weighting bias .
there were some notable differences in the distribution of study species and duration for both compound classes .
there were 29% ( of the total ) ( or 1.6-fold ) more rat study 
reports  available in the phospholipogenic dataset than the negatives dataset , whereas there were 28% ( of the total ) ( or 2.8-fold ) more dog study  reports  available in the negative dataset than the phospholipogenic dataset .
the two - week and four - week groupings had the greatest variation in study duration distribution
. there were 15% ( of the total ) ( or 1.7-fold ) more 2-week  reports  available for the phospholpogenic dataset than for the negatives ; there were 26% ( of total ) ( or 1.7-fold ) more  reports  available for the negative dataset than for the phospholpogenics . except for mouse where aucmhr and cmax ( m ) exposure data were similar between datasets at high nominal doses , nominal dose ( mol / kg ) , aucmhr , and cmax ( m ) values for the negative compounds were on average higher for the other two species ( table 1 ) .
multiorgan pld was more likely to occur when predicted percent free compound ( free of protein binding ) was greater than ~10% , whereas pld more often occurred in only one to two organs when the predicted percent free was less than 10% .
lung , lymph node , and spleen presented with the highest incidence , bone marrow , and thymus the lowest .
in contrast , the rank order of non - pld histologic findings incidence for this dataset differed from that of organ pld ranking ( figure 5 ) .
liver and thymus exhibited the highest incidences of non - pld findings , lung , and bone marrow the lowest . to ascertain which
dataset was associated with more histologic findings , frequencies of non - pld histologic findings were compared .
phospholipogenic compounds consistently exhibited more non - pld histologic changes for all organs ( figure 6 ) , and among these the liver exhibited the highest percentage of histologic findings for both datasets .
compared to nonphospholipogenic compounds , phospholipogenic compounds yielded a statistically significant higher percentage of liver necrosis findings ( table 2 ) .
for those phospholipogenic compounds in this subset where exposure data were available ( i.e. , 11 of 22 compounds that caused necrosis ) , top plasma exposures did not on average exceed those phospholipogenics that did not cause necrosis ( data not shown ) .
a statistically significant , higher frequency of lymphocytolysis / lymphoid depletion in lymphoid organs increased apoptosis in spleen , and alveolitis / pneumonitis in lung were observed with this subset of compounds .
finally , statistically significant higher levels of  no histologic findings  in the liver , lung , thymus , lymph nodes , and spleen were reported for the nonphospholipogenic compounds .
the purpose of this study was to test whether pharmaceutically relevant phospholipogenic compounds were associated with a higher frequency of histologic changes in repeat dose in vivo preclinical toxicology studies than that for nonphospholipogenic compounds . for the comparison ,
forty - six phospholipogenic compounds were identified ; sixty - two negative compounds were identified .
phospholipogenic administrations were found to yield proportionally more non - pld histologic changes in general in all organs examined and for select histological findings in liver , lung , thymus , lymph node , and spleen but not for kidney and adrenal glands .
phospholipogenic compounds exhibited statistically significant increases in lung alveolitis / pneumonitis and in true toxicities relating to liver necrosis . not surprisingly , phospholipogenic compounds demonstrating  no liver findings  tended to exhibit fewer histological findings across the 9 organs overall ( data not shown ) . increased incidences of lymphocytolysis and/or lymphoid depletion in three lymphoid tissues ( thymus , lymph nodes , and spleen ) were also observed in the phospholipogenic dataset . lymphocytolysis / lymphoid depletion is often attributed to high - dose - mediated stress responses ; but they may in some instances represent a true toxicological response . without other hematologic
correlates it is not possible to shed light on this matter , and for this reason labeled these results conservatively simply as excess histological findings .
finally , it also appears from the study duration analysis that two - week study designs and the rat model are typically sufficient to capture phospholipidotic signals in vivo .
although concurrent toxicities were not specified , it is of interest that a recent report indicates that a 24  h duration may be sufficient to detect / predict phospholipidosis accurately by employing a small biomarker set in toxicogenomic evaluation .
several additional comparisons were made for the phospholipogenic dataset , particularly regarding physical - chemical properties and toxicokinetic behavior .
consistent with the well - described cationic amphiphilic nature of phospholipogenic compounds , the phospholipogenic dataset was comprised mostly of amphiphilic bases and the negative dataset contained primarily neutrals and acids with only a few bases .
plasma exposures tended to be lower in animals dosed with phospholipogenic compounds . for the dog and mouse
, this pharmacokinetic behavior can be explained in part by the selection of lower phospholipogenic compound nominal doses in the study designs but not entirely since relative exposures are still lower if dose - normalized ( data not shown ) .
nominal doses for rat were on average higher than that of the nonphospholipogenic dataset , but plasma exposures in the phospholipogenic dataset were considerably lower .
there is an acknowledged general tendency for bases , and particularly lipophilic bases , to have higher volumes of distribution , although it has recently been demonstrated that this property alone does not differentiate phospholipogenics from nonphospholipogenics .
finally , it should be noted that not only were the average doses and exposures of the nonphospholipogenic compounds higher , but , as can be seen in figure 2 , the average duration of their studies is somewhat longer as well .
all of these factors should bias the number of nonphospholipidosis histological findings profile towards the higher dose , higher exposure , longer study duration group , but , as demonstrated in this study , we see the opposite .
this thorough and systematic analysis of a large preclinical toxicology dataset containing both confirmed phospholipogenics and nonphospholipogenic compounds indicates that phospholipogenic administration is likely to be associated with more and various histological findings , including liver toxicities , than do nonphospholipogenic administrations . the data , while compelling , are correlative and can not be used to prove causality between phospholipidosis and toxicities .
it should also be noted that speculation on functional compromise can not be made and that histologic findings identified in this exercise were not equal in severity .
findings ranged from relatively benign to severe , and we did not apply risk assessment analysis where it may be found that compounds could proceed normally through the drug development process , taking concurrent toxicities , tissues affected , severity , and safety margins ( therapeutic window ) into account . even with these caveats , it is clear that phospholipogenic compounds tend to produce more histological findings and may require additional monitoring and risk assessment , thereby increasing the overall burden on a drug development project .
 while phospholipidosis is thought to be an adaptive response to chemical challenge , many phospholipogenic compounds are known to display adverse effects in preclinical species and humans . to investigate the link between phospholipogenic administration and incidence of preclinical histological signals , an internal astrazeneca in vivo toxicology report database 
 was searched to identify phospholipogenic and nonphospholipogenic compounds . 
 the datasets assembled comprised 46 phospholipogenic and 62 nonphospholipogenic compounds . 
 the phospholipogenic potential of these compounds was confirmed by a pathologist 's interpretation and was supported by well - validated in silico and in vitro models . 
 the phospholipogenic dataset contained 37 bases , 4 neutral compounds , 3 zwitterions , and 1 acid , whereas the nonphospholipogenic dataset contained 9 bases , 34 neutrals , 1 zwitterion , and 18 acids . 
 histologic findings were tracked for adrenal gland ; bone marrow ; kidney ; liver ; lung ; lymph node ; spleen ; thymus ; and reproductive organs . 
 on average , plasma exposures were higher in animals dosed with the nonphospholipogenics . 
 phospholipogenics yielded proportionally more histologic changes ( exclusive of phospholipidosis itself ) in all organs . 
 statistically significant higher frequencies of liver necrosis , alveolitis / pneumonitis , as well as lymphocytolysis in the thymus , lymph nodes , and spleen occurred in response to phospholipogenics compared to that for nonphospholipogenics . 
1. Introduction
2. Methods
3. Results
4. Discussion and Conclusions