Effects of Thymol on Co-amoxiclav-Induced Hepatotoxicity in Rats

Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] International Journal of Medical Laboratory 2021;8(1):44-54. Original Article Effects of Thymol on Co-amoxiclav-Induced Hepatotoxicity in Rats Hamid Reza Jamshidi 1,2* Ph.D., Sina Negintaji 1 Pharm.D. 1 Department of Toxicology-Pharmacology, Faculty of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran 2 Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran ABSTRACT Article history Received: 10 Aug 2020 Accepted: 6 Sep 2020 Available online: 4 Mar 2021 Keywords Co-amoxiclav Hepatotoxicity Rat Thymol Background and Aims: Hepatotoxicity induced by Co-amoxiclav has been indicated in multiple studies. Thymol is the main constituent of the Thymus vulgaris essential oil that has antioxidant properties. Even though thymol can exhibit antioxidant activity in vivo models, there is a lack of evidence about the thymol’s effectiveness in drug-induced liver injury. Thus, the present study was conducted to explore the thymol anti-hepatotoxic effects. Materials and Methods: Thirty male rats were randomly divided into five groups of six. The control group received corn oil (0.25 ml/100 g body weight). CoA group was given only co-amoxiclav in doses of 10 mg/kg daily by gastric tube. CoA+T50, CoA+T150, and CoA+T300 groups orally received Co-amoxiclav at the same dose as the second group along with thymol at a daily dose of 50, 150, and 300 mg/kg for 7 consecutive days. At the termination of the treatment, all animals fasted overnight, and then blood samples were collected to determine alanine transaminase, aspartate transaminase, alkaline phosphatase, glutathione S-transferases, and bilirubin. Results: Administration of thymol at the dose of 300 mg/kg with co-amoxiclav resulted in a significant decrease in direct and total bilirubin levels. Findings also revealed that the concomitant administration of thymol at the 150 mg/kg dose caused a significant reduction in the total bilirubin level. Additionally, the concomitant administration of thymol at the doses of 150 mg/kg and 300 mg/kg resulted in a significant reduction of alanine transaminase, aspartate transaminase, and alkaline phosphatase serum activities along with increased plasma Glutathione S-transferase activity compared to co-amoxiclav group. Conclusion: Administration of thymol can cause a significant ameliorative effect against co-amoxiclav-induced hepatotoxicity in rats. Corresponding Author: Department of Toxicology-Pharmacology, Faculty of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. Email: [email protected] * HR. Jamshidi and S. Negintaji Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] Introduction Hepatoxicity is defined as a liver injury caused therapy recommendations of more severe by exposure to a drug or another non- infections or those caused by drug-resistant infectious substance [1, 2]. Drug-induced liver bacteria [4]. injury (DILI) is considered a rare but drug- Despite the useful applications assigned to this related severe adverse effect [3]. Several drug, CoA-induced hepatotoxicity has been studies have illustrated that oxidative stress indicated plays a significant role in DILI development Conversely, CoA is considered as one of the [4-6]. Oxidative stress is a broad term used to leading causes of hospitalization for hepatic define cells or tissues’ challenge to elevated adverse drug reactions [18, 19]. The liver levels of highly reactive molecules such as injury associated with CoA is related mainly reactive oxygen species [7, 8]. to the clavulanic acid component due to the Antibiotics, also known as antibacterials, low occurrence of hepatic reactions with are a pharmacological group most often amoxicillin alone [20, 21]. Studies have shown associated with DILI [7, 9, 10]. Amoxicillin / that CoA-induced liver injury is frequently clavulanic acid (Augmentin®), also known as associated with cholestasis features resulting co-amoxiclav (CoA), is an antibacterial drug from hypersensitivity drug allergy, which may combination consisting of amoxicillin and progress to hepatocellular damage [20, 22, 23]. clavulanate potassium [11]. Amoxicillin, a Although the exact cause of CoA-induced semisynthetic penicillin derivative, is a p- hepatotoxicity remains unknown [24, 25], hydroxy analog of ampicillin posing the same oxidative stress has been suggested as one of broad-spectrum the possible mechanisms involved in the of bactericidal activity in multiple studies [16, 17]. ampicillin against many gram-positive and hepatotoxic effect of CoA [11, 26]. also some gram-negative bacteria [12]. The On the other hand, natural products and their clavulanic acid component, also known by derivatives represent almost half of all the its potassium salt form clavulanate, has a agents used in liver therapy and [27, 28]; β-lactamase-inhibiting property that will therefore, there have been a lot of efforts to allow the β-lactam antibiotic work uninhibited develop new herbal medicines in order to [13, 14]. CoA has become one of the reduce DILI [29]. Thymol, chemically known most commonly prescribed antibiotics and is as 2-isopropyl-5-methyl phenol, is the main now widely used as first-line therapy constituent of the thyme (Thymus vulgaris L., for community-acquired respiratory tract Lamiaceae) essential oil [30]. Thymol, in infections [15]. Throughout the years, different addition to its antimicrobial property, implies combinations of amoxicillin to clavulanate potent have been introduced worldwide to enhance properties [31]. Despite the fact that thymol the dosing convenience, prescribing needs, and can exhibit antioxidant activity in both cellular International Journal of Medical Laboratory 2021;8(1):44-54. anti-inflammatory and antioxidant 45 Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] EFFECTS OF THYMOL ON CO-AMOXICLAV-INDUCED HEPATOTOXICITY IN RATS and in vitro models [30, 32], there is a lack control and received corn oil (0.25 ml/100 g of of evidence about the effectiveness of the body weight) once daily by gastric tube. Group thymol in DILI. Thus, the present study was II was given only CoA in doses of 10 mg/kg conducted anti- daily by gastric tube. Group III, IV, and V hepatotoxic effect against the CoA-induced orally received CoA at the same dose as the hepatotoxicity in rats. second group along with thymol at daily doses to explore the thymol of 50, 150, and 300 mg/kg, respectively. Doses Materials and Methods used in the present study were selected based Chemicals on previous studies conducted on CoA induced CoA was available in the form of 200 mg/ 28.5 liver injury and thymol effects on drug- mg/ 5 ml oral suspension that contained 200 induced hepatoxicity [26, 33]. Thymol was mg amoxicillin (as amoxicillin trihydrate) and given 28.5 mg clavulanic acid (as potassium administration. All groups were treated over 7 clavulanate) per 5 ml. It was obtained from consecutive days. At the termination of the Cosar Iran. treatment, the rats were anesthetized through a Thymol was purchased from the Sigma slight diethyl ether exposure. Blood samples Chemical Corporation (St Louis, MO, USA). were obtained by cardiac puncture procedure Corn oil was obtained from the local market. using sterile and disposable syringes and Thymol solution was prepared separately by needles. Blood samples were collected from dissolving various amounts in 0.5 ml of corn each rat into heparin and serum separator oil. All other reagents were of analytical grade. tubes Animals and treatments sacrificed, and serum separator tubes were Thirty male albino rats (180-200 g) were transported to the Danesh Medical Laboratory obtained from the animal house of Shahid (Yazd, Iran) immediately on ice to determine Sadoughi University of Medical Sciences, the activity of serum alanine transaminase, Yazd, Iran. The rats were housed at a aspartate temperature of 20-22°C under artificial light phosphatase (ALP), and measure serum total for a 12-h light/dark cycle with access to water bilirubin and conjugated bilirubin values. and standard rodent chow ad libitum. All the Heparinized experiments reported here were carried out centrifugation at 3000 rpm for 10 min and under protocols approved by the local stored, protected from light, at -80°C for later Institutional Animal Ethics Committee of analysis of Glutathione-S-transferase (GST) Shahid Sadoughi University of Medical activity. Sciences. After one week of acclimatization, Assay of serum biochemical parameters the animals were divided into five groups of The activity of liver function enzymes, six rats each. Finally, the groups were including serum AST, alanine transaminase arranged as follows: Group I was used as a (ALT), and ALP alongside total bilirubin and 46 Pharmaceutical Co, Tehran, within 1 hour simultaneously. transaminase plasma following Rats were (AST), was CoA then alkaline prepared by International Journal of Medical Laboratory 2021;8(1): 44-54. Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] HR. Jamshidi and S. Negintaji conjugated bilirubin values, were determined of CoA group comparing the CoA+ thymol 50 using the photometric method provided by the (CoA+T50) group (p>0.05). diagnostic kits (Man company, Iran). The serum AST activity Measurement of GST activity According to the results shown in Figure 2, there GST activity was determined calorimetrically was a statistically significant difference in the (412 nm) using a ZellBio GmbH assay kit serum AST activity between the control group obtained from ZellBio, ULM, Germany. The and CoA group (p<0.001). There was also a assay was performed according to the instruction significant difference in AST activity between manuals supplied with the kit. The research was animals in CoA+T150 group and CoA+T300 approved by the Research Deputy and Ethics group compared to CoA group (p<0.05). At the Committee of Shahid Sadoughi University of same time, there was no significant difference Medical between the AST activity in the blood serum of Science, Yazd, Iran. (Approval Number: IR.SSU.MEDICINE. REC.1398.128). animals of CoA group and CoA+T50 group Statistical analysis (p>0.05). The obtained data were analyzed with SPSS Ver. The serum ALP activity 25.0 software. Data were expressed as mean According to the results shown in Figure 3, a values ± standard error of the mean (SEM). For statically significant difference was noticed in the comparison of the group mean values, one- the activity of ALP in the blood serum of the way analysis of variance (ANOVA), and for control group comparing the CoA group the determination of the intergroup differences, (p<0.001). There Tukey test was used. The value with P<0.05 was difference in the activity of ALP among animals considered significant. in CoA+T150 group and CoA group (p<0.05). Results Besides, ALP activity in the blood serum of The serum ALT activity animals of the CoA+T300 group had a According to the results shown in Figure 1, there significant decrease comparing the CoA group was a statistically significant difference between (p<0.01). However, no significant decrease was the activity of serum ALT enzyme in animals of observed in the activity of ALP in the blood CoA group and control group (p<0.001). Also, serum of the CoA+50T group comparing the the activity of the ALT in the animals’ blood CoA group (p>0.05). serum of CoA group was significantly different The serum total bilirubin level from the activity of this enzyme in animals’ According to the results shown in Figure 4, there blood serum of CoA+ thymol 150 (CoA+T150) was a significant difference in the amount of and CoA+ thymol 300 (CoA+T300) groups total bilirubin in the animals’ blood serum of the (p<0.01 and p<0.05, respectively). On the other control group compared to the CoA group hand, no significant difference was observed in (p<0.05). A significant reduction was also the activity of ALT in the animals’ blood serum noticed in the amount of total bilirubin of was also a significant CoA+T150 and CoA+T300 groups comparing International Journal of Medical Laboratory 2021;8(1):44-54. 47 CoA group (p<0.05). There was no significant conjugated bilirubin in the animals’ blood serum difference in the total serum bilirubin levels of of the control group (p<0.01) and the CoA+T300 animals in the CoA+T50 group compared to the group CoA group (p>0.05). Conversely, there was no significant difference The serum conjugated bilirubin level in this index’s level in the blood serum of According to the results shown in Figure 5, there animals of the CoA group comparing CoA+T50 was a significant difference in the amount of and CoA+T150 groups (p>0.05). Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] EFFECTS OF THYMOL ON CO-AMOXICLAV-INDUCED HEPATOTOXICITY IN RATS comparing CoA group (p<0.05). Fig. 1. Comparison of the activity of ALT in the blood serum of treated animals. Respectively: groups 1- Corn oil (control group), 2- Co-amoxiclav, 3- Co-amoxiclav + Thymol 50, 4- Coamoxiclav + Thymol 150 and 5- Co-amoxiclav + Thymol 300 mg / kg. * denotes the result of statistical analysis of the co-amoxiclav group, which was statistically significant with the corn oil group (*p<0.001). # denotes the result of statistical analysis of different treatment groups, which was statistically significant with the co-amoxiclav group (#p<0. 05, ##p<0. 01). Fig. 2. Comparison of the activity of the AST in the blood serum of treated animals. Respectively: groups 1- Corn oil (control group), 2- Co-amoxiclav, 3- Co-amoxiclav + Thymol 50, 4- Coamoxiclav + Thymol 150 and 5- Co-amoxiclav + Thymol 300 mg / kg. * denotes the result of statistical analysis of the co-amoxiclav group, which was statistically significant with the corn oil group (*p<0.001). # denotes the result of statistical analysis of different treatment groups, which was statistically significant with the co-amoxiclav group (#p< 0.05). 48 International Journal of Medical Laboratory 2021;8(1): 44-54. Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] HR. Jamshidi and S. Negintaji Fig. 3. Comparison of the activity of ALP in the blood serum of treated animals. Respectively: groups 1- Corn oil (control group), 2- Co-amoxiclav, 3- Co-amoxiclav + Thymol 50, 4- Coamoxiclav + Thymol 150 and 5- Co-amoxiclav + Thymol 300 mg / kg. * denotes the result of statistical analysis of the co-amoxiclav group, which was statistically significant with the corn oil group (*p<0.001). # denotes the result of statistical analysis of different treatment groups that were statistically significant with the co-amoxiclav group (#p <0.05 and ##p> 0. 01). Fig. 4. Comparison of the activity of total bilirubin in the blood serum of treated animals. Respectively: groups 1- Corn oil (control group), 2- Co-amoxiclav, 3- Co-amoxiclav + Thymol 50, 4- Co-amoxiclav + Thymol 150 and 5- Co-amoxiclav + Thymol 300 mg / kg. * denotes the result of statistical analysis of the co-amoxiclav group, which was statistically significant with the corn oil group (*p<0.05). # denotes the result of statistical analysis of different treatment groups that were statistically significant with the co-amoxiclav group (#p <0.05). The plasma GST activity According to the results shown in Figure 6, the blood plasma of the control group there in comparing the CoA group (p<0.001). There glutathione S-transferase enzyme activity in was also a significant difference in the was a significant difference International Journal of Medical Laboratory 2021;8(1):44-54. 49 activity of glutathione S-transferase enzyme CoA+T150 group (p<0.01) and CoA+T300 in group comparing CoA group (p <0.001). Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] EFFECTS OF THYMOL ON CO-AMOXICLAV-INDUCED HEPATOTOXICITY IN RATS the blood plasma of animals of Fig. 5. Comparison of the activity of conjugated bilirubin in the blood serum of treated animals. Respectively: groups 1- Corn oil (control group), 2- Co-amoxiclav, 3- Co-amoxiclav + Thymol 50, 4- Co-amoxiclav + Thymol 150 and 5- Co-amoxiclav + Thymol 300 mg / kg. * denotes the result of statistical analysis of the co-amoxiclav group, which was statistically significant with the corn oil group (*p<0.01). # denotes the result of statistical analysis of different treatment groups, which was statistically significant with the co-amoxiclav group (#p <0. 05). Fig. 6. Comparison of the activity of glutathione S-transferase enzyme in the blood plasma of treated animals. Respectively: groups 1- Corn oil (control group), 2- Co-amoxiclav, 3- Coamoxiclav + Thymol 50, 4- Co-amoxiclav + Thymol 150 and 5- Co-amoxiclav + Thymol 300 mg/ kg. * denotes the result of statistical analysis of the co-amoxiclav group, which was statistically significant with the corn oil group (*p<0.001). # denotes the result of statistical analysis of different treatment groups, which was statistically significant with the co-amoxiclav group (#p<0.01, ##p <0.001). 50 International Journal of Medical Laboratory 2021;8(1): 44-54. HR. Jamshidi and S. Negintaji Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] Discussion The results’ assessment shows a significant consistent with previous studies on the difference in ALT, AST, and ALP activity in protective effect of thymol on liver damage the blood serum of animals treated with CoA [16, 34]. We also observed a significant alone (CoA group) compared with the control increase in total bilirubin levels and direct group. This event is in line with previous bilirubin levels in the blood serum of animals studies’ results, which have indicated an treated with CoA alone compared to the increase in liver function enzymes’ values in control group. This event could be due to liver damage caused by CoA [9, 11]. The the liver damage caused by CoA. Several concomitant administration of thymol at the studies have demonstrated an increase in dose level of 50, 150, and 300 mg/kg of body bilirubin levels due to CoA administration weight with CoA resulted in decreased ALT in rats [9, 11]. In the present study, the activity, AST, and ALP in the blood serum of administration of thymol at a dose level of the studied animals. Notably, there was a 50 mg/kg reduced the amount of total bilirubin significant reduction in the activity of ALT, and conjugated in the blood serum of animals AST, and ALP in the treated animals with compared to the treated group CoA alone; thymol at the dose level of 150 and 300 mg/kg however, the difference was not statistically (CoA+T150 and CoA+T300 groups) compared significant (p>0.5). It is important to note to the animals in the treated group with CoA that alone (CoA group). The treatment of rats with increasing doses of thymol (CoA+T150 and thymol at the dose level of 50 mg/kg CoA+T300 groups), a significant decrease in (CoA+T50 group) has partially reduced the total bilirubin levels was observed in the blood activity of the transaminases and ALP in the serum of animals compared to animals treated blood serum of animals; however, these with CoA alone. On the other hand, the level reductions were not significantly different of conjugated bilirubin in the blood serum of compared to the activity level of these animals treated with CoA alone was only enzymes in the blood serum of animals that significantly different from those treated with were treated with CoA alone. In general, by the thymol at the dose level of 300 mg/kg. comparing the results, it can be noticed that These results once again demonstrate the dose- the most significant decrease in the activity of dependent hepato-protective effect of thymol ALP has been observed in the blood serum of against CoA induced hepatotoxicity. Although animals treated with thymol at a dose of 300 little research has been conducted on the effect mg/kg. Subsequently, the gradual increase in of thymol on bilirubin indicators in liver thymol has significantly reduced ALT, AST, damage, studies on carvacrol (another and ALP activity compared to the group important component of thyme essential oil administered CoA alone. The results are phenol which, like thymol, have antioxidant International Journal of Medical Laboratory 2021;8(1):44-54. following the administration of 51 Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] EFFECTS OF THYMOL ON CO-AMOXICLAV-INDUCED HEPATOTOXICITY IN RATS effects) [35, 36]; has demonstrated the administration of thymol at daily doses of 150, effect of the carvacrol on a significant and reduction in the rate of bilirubin indicators in significant elevation of GST activity. liver damage [37]. In the present study, the assessment of animal blood serum indicators 300mg/kg resulted in a statically Conclusion revealed ALT/ALP ratio less than 2 that a In the present study, the administration of hyperbilirubinemia CoA developed hepatotoxicity in rats. We has accompanied in animals treated with CoA alone, which can be propose signs of cholestatic liver damage [26]. This administration result is consistent with the findings of hepatoprotective effect attributed to the previous studies on the type of liver damage thymol’s antioxidant activity. The assessment caused by CoA [17, 38]. Additionally, of prescribing reduced hepatoprotective activity of thymol was glutathione S-transferase activity in the blood dose-dependent, suggesting that it can be more plasma of animals in the treated group with effective at higher doses. CoA significantly CoA alone compared to the control group. This incident can be due to the oxidative effect of CoA that can cause the depletion of reduced glutathione. glutathione is an important hydrophilic antioxidant that protects cells that thymol's with CoA concomitant can exert the results also revealed that a the Conflict of Interest The authors declare that there is no conflict of interest regarding the publication of this article. Acknowledgment The authors declare no acknowledgment. against exogenous and endogenous toxins. GST activity can be decreased by the depletion of glutathione [4, 11]. In addition, References [1]. Bahirwani R, Reddy KR, editors. Drug-induced liver injury due to cancer chemotherapeutic agents. Seminars in Liver Disease Thieme Medical Publishers 2014; 34(2): 162-71. [2]. Lee WM. Drug-induced hepatotoxicity. New Eng J Med. 2003; 349(5): 474-85. [3]. Andrade RJ, Robles M, Fernández-Castañer A, López-Ortega S, López-Vega MC, Lucena MI. Assessment of drug-induced hepatotoxicity in clinical practice: a challenge for gastroenterologists. World J Gastroenterol. 2007; 13(3): 329. [4]. El-Hosseiny L, Alqurashy N, Sheweita S. Oxidative stress alleviation by sage essential oil 52 in co-amoxiclav induced hepatotoxicity in rats. Int J Biomed Sci. 2016; 12(2): 71. [5]. Lin Y, Li Y, Hu X, Liu Z, Chen J, Lu Y, et al. The hepatoprotective role of reduced glutathione and its underlying mechanism in oxaliplatin-induced acute liver injury. Oncol Lett. 2018; 15(2): 2266-272. [6]. Mahmoud AM, Alexander MY, Tutar Y, Wilkinson FL, Venditti A. Oxidative stress in metabolic disorders and drug-induced injury: the potential role of Nrf2 and PPARs activators. Hindawi 2017; 2508909: 1-4. [7]. Ferrajolo C, Verhamme KM, Trifirò G, W‘t Jong G, Giaquinto C, Picelli G, et al. Idiopathic acute liver injury in paediatric outpatients: incidence and International Journal of Medical Laboratory 2021;8(1): 44-54. Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] HR. Jamshidi and S. Negintaji signal detection in two European countries. Drug Safety 2013; 36(10): 1007-1016. [8]. Halliwell B, Gutteridge JM. Free radicals in biology and medicine. 5th ed, USA: Oxford University Press; 2015. [9]. Meier Y, Cavallaro M, Roos M, Pauli-Magnus C, Folkers G, Meier PJ, et al. Incidence of druginduced liver injury in medical inpatients. Euro J Clin Pharmacol. 2005; 61(2): 135-43. [10]. Robles M, Toscano E, Cotta J, Isabel Lucena M, Andrade RJ. Antibiotic-induced liver toxicity: mechanisms, clinical features and causality assessment. Curr Drug Safety 2010; 5(3): 212-22. [11]. Olayinka ET, Olukowade I, Oyediran O. Amoxycillin/clavulanic acid combinations (Augmentin 375 and 625 tablets) induceoxidative stress, and renal and hepatic damage in rats. Afr J Pharmacy Pharmacol. 2012; 6(33): 2441-449. [12]. Tallarida RJ. TOP 200: a compendium of pharmacologic and therapeutic information on the most widely prescribed drugs in America: Springer; 1982. [13]. Drawz SM, Bonomo RA. Three decades of βlactamase inhibitors. Clin Microbiol Rev. 2010; 23(1): 160-201. [14]. Gilbert N. Four stories of antibacterial breakthroughs. Nature 2018; 555(7695). [15]. White AR, Kaye C, Poupard J, Pypstra R, Woodnutt G, Wynne B. Augmentin® (amoxicillin/clavulanate) in the treatment of community-acquired respiratory tract infection: a review of the continuing development of an innovative antimicrobial agent. J Antimicrob Chemother. 2004; 53(S1): 3-20. [16]. Beraldo DO, Melo JF, Bonfim AV, Teixeira AA, Teixeira RA, Duarte AL. Acute cholestatic hepatitis caused by amoxicillin/clavulanate. World J Gastroenterol. 2013; 19(46): 8789. [17]. Jordan T, Gonzalez M, Casado M, Suarez J, Pulido F, Guerrero E, et al. Amoxicillinclavulanic acid induced hepatotoxicity with progression to cirrhosis. Gastroenterologia y hepatologia 2002; 25(4): 240. [18]. Leise MD, Poterucha JJ, Talwalkar JA. Druginduced liver injury. Mayo Clin Proc. 2014; 89(1): 95-106. [19]. Salvo F, Polimeni G, Moretti U, Conforti A, Leone R, Leoni O, et al. Adverse drug reactions related to amoxicillin alone and in association with clavulanic acid: data from spontaneous reporting in Italy. J Antimicrob Chemotherapy 2007; 60(1): 121-26. [20]. Bolzan H, Spatola J, Castelletto R, Curciarello J. Intrahepatic cholestasis induced by amoxicillin alone. Gastroenterologia y Hepatologia 2000; 23(5): 237-39. [21]. De Abajo FJ, Montero D, Madurga M, Rodríguez LAG. Acute and clinically relevant drug‐induced liver injury: a population based case‐control study. Br J Clin Pharmacol. 2004; 58(1): 71-80. [22]. Berg P, Hahn EG. Hepatotoxic reactions induced by beta-lactamase inhibitors. European J Med Res. 2001; 6(12): 535-42. [23]. Chaabane NB, Safer L, Njim L, Zakhama A, Saffar H. Cholestatic hepatitis related to amoxicillin. Drug Chem Toxicol. 2011; 34(4): 357-58. [24]. Health NIo. LiverTox: clinical and research information on drug-induced liver injury. [electronic database]. Available from: https://livertox.nih.gov; 2017. [25]. Stephens C, López-Nevot MÁ, Ruiz-Cabello F, Ulzurrun E, Soriano G, Romero-Gómez M, et al. HLA alleles influence the clinical signature of amoxicillin-clavulanate hepatotoxicity. PloS one 2013; 8(7): 68111. [26]. El-Sherbiny GA, Taye A, Abdel-Raheem IT. Role of ursodeoxycholic acid in prevention of hepatotoxicity caused by amoxicillin-clavulanic acid in rats. Ann Hepatol. 2009; 8(2): 134-40. [27]. Xiong F, Guan Y-S. Cautiously using natural medicine to treat liver problems. World J Gastroenterol. 2017; 23(19): 3388. [28]. Zhang A, Sun H, Wang X. Recent advances in natural products from plants for treatment of liver diseases. Euro J Med Chem. 2013; 63(4): 570-77. [29]. Madkour FF, Khalil WF, Dessouki AA. Protective effect of ethanol extract of Sargassum dentifolium (Phaeophyceae) in carbon tetrachloride-induced hepatitis in rats. Int J Pharm Pharm Sci. 2012; 4(5): 637-41. [30]. Amiri H. Essential oils composition and antioxidant properties of three thymus species. Evidence-Based Complementary and Alternative Medicine 2012; 728065: 1-8. [31]. Mishra RK, Baker MT. Seizure prevention by the naturally occurring phenols, carvacrol and thymol in a partial seizure-psychomotor model. Bioorgan Med Chem Lett. 2014; 24(23): 5446449. [32]. Ündeğer Ü, Başaran A, Degen G, Başaran N. Antioxidant activities of major thyme ingredients and lack of (oxidative) DNA damage in V79 Chinese hamster lung fibroblast cells at low levels of carvacrol and thymol. Food Chemical Toxicol. 2009; 47(8): 20372043. [33]. Alam K, Nagi M, Badary O, Al-Shabanah O, Al-Rikabi A, Al-Bekairi A. The protective action of thymol against carbon tetrachloride hepatotoxicity in mice. Pharmacol Res. 1999; 40(2): 159-63. [34]. Aboelwafa HR, Yousef HN. The ameliorative effect of thymol against hydrocortisone-induced hepatic oxidative stress injury in adult male rats. Biochem Cell Biol. 2015; 93(4): 282-89. International Journal of Medical Laboratory 2021;8(1):44-54. 53 [35]. Mastelic J, Jerkovic I, Blažević I, PoljakBlaži M, Borović S, Ivančić-Baće I, et al. Comparative study on the antioxidant and biological activities of carvacrol, thymol, and eugenol derivatives. J Agricul Food Chem. 2008; 56(11): 3989-996. [36]. Yanishlieva NV, Marinova EM, Gordon MH, Raneva VG. Antioxidant activity and mechanism of action of thymol and carvacrol in two lipid systems. Food Chemistry 1999; 64(1): 59-66. [37]. Aristatile B, Al-Numair K, Veeramania C, Pugalendi KV. Antihyperlipidemic effect of carvacrol on D-galactosamine induced hepatotoxic rats. J Basic Clin Physiol Pharmacol. 2009; 20(1): 15-28. [38]. O’donohue J, Oien K, Donaldson P, Underhill J, Clare M, MacSween R, et al. Co-amoxiclav jaundice: clinical and histological features and HLA class II association. Gut. 2000; 47(5): 717-20. Downloaded from ijml.ssu.ac.ir at 15:21 IRDT on Sunday March 28th 2021 [ DOI: 10.18502/ijml.v8i1.5672 ] EFFECTS OF THYMOL ON CO-AMOXICLAV-INDUCED HEPATOTOXICITY IN RATS 54 International Journal of Medical Laboratory 2021;8(1): 44-54.