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Use one row for each author. List authors in order of appearance in the document. Add rows to add more authors. For institutional author, enter the name of the institution in the Given Name(s) column.
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Olaparib is a small molecule inhibitor of poly ADP-ribose polymerase and is used as an antineoplastic agent in the therapy of refractory and advanced ovarian carcinoma. Olaparib therapy is associated with a low rate of transient elevations in serum aminotransferase during therapy and has been linked to several instances of clinically apparent liver injury which can be severe and even fatal.
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Olaparib (oh lap' a rib) is a small molecule inhibitor of poly adenine diphosphate (ADP)-ribose polymerase (PARP), an enzyme involved in DNA transcription and repair. Patients with mutations of the BRCA 1 and 2 genes are at increased risk for cancer, particularly ovarian and breast cancer in women. The BRCA gene encodes DNA repair enzymes, and tumor cells with BRCA mutations are dependent upon other DNA repair pathways and thus have an increased sensitivity to inhibition of PARP. Clinical trials of olaparib in women with BRCA 1 and 2 germline mutations and advanced, refractory ovarian carcinoma have shown response rates of 30% to 40% and prolongation of progression-free survival. Olaparib is also under evaluation as therapy for advanced breast cancer and other malignant diseases associated with mutations in BRCA or other DNA repair enzymes. Olaparib received approval for use in the United States in 2014 for therapy of advanced and refractory ovarian carcinoma in women with BRAC 1 and 2 mutations. Subsequently, indications were expanded to other refractory tumors (pancreatic and prostate cancers) with BRAC mutations. Olaparib is available in 100 and 150 mg tablets under the brand name Lynparza. The recommended dose is 300 mg by mouth twice daily. Lower doses are recommended for patients with renal impairment. Common side effects include anemia, fatigue, nausea, diarrhea, dyspepsia, abdominal pain, anorexia, cough, muscle and join pain, headache and rash. Uncommon, but potentially severe side effects include pneumonitis, venous thrombosis and thromboembolic events, myelodysplastic syndromes, acute myelogenous leukemia, acute liver injury, and embryo-fetal toxicity.
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In pre-registration clinical trials of olaparib, abnormalities in routine liver tests were uncommon with serum aminotransferase elevations occurring in 4% of patients and values above 5 times the upper limit of normal (ULN) in 1% or less. In early trials of olaparib in patients with various advanced solid tumors there were no reports of hepatitis with jaundice or liver failure. However, after its approval and more widescale use, there have been several published reports of clinically apparent liver injury attributed to olaparib, some of which have been severe and some fatal. The onset of injury arose after 2 to 3 months of therapy and was typically hepatocellular with marked elevations in serum ALT and AST but only modest elevations in alkaline phosphatase levels. Rash and fever were uncommon, but low titers of ANA and SMA were reported, and clinical features as well as a rapid response to corticosteroid therapy were typical. Liver biopsies demonstrated hepatocellular injury with variable amounts of lobular necrosis and intense portal infiltration with lymphocytes and eosinophils with rare plasma cells. Thus, olaparib appears to be a definite cause of idiosyncratic liver injury and regular monitoring of liver tests is now recommended.
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Likelihood score: C (probable rare cause of clinically apparent liver injury).
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The mechanism of injury with olaparib therapy is not known but it appears to be immune mediated. Olaparib is metabolized in the liver largely through the CYP 3A4 pathway and liver injury may be related to production of a toxic or immunogenic intermediate. Because it is a substrate for CYP 3A4, olaparib is susceptible to drug-drug interactions with agents that inhibit or induce hepatic CYP 3A activity.
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H3. Outcome and Management
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Serum aminotransferase elevations above 5 times the upper limit of normal (if confirmed) during olaparib therapy should lead to dose reduction or temporary cessation. Patients with severe or symptomatic liver injury should avoid rechallenge as recurrent injury is typically more rapid in onset and worse in severity. Interestingly, there does not appear to be cross reactivity in risk for hepatic injury between olaparib and other PARP inhibitors such as rucaparib or niraparib, but switching to another PARP inhibitor after olaparib hepatotoxicity should be done with caution and with careful monitoring for recurrence.
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Other PARP Drugs: Niraparib, Rucaparib
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REPRESENTATIVE TRADE NAMES
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Product labeling at DailyMed, National Library of Medicine, NIH
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H2. CHEMICAL FORMULA AND STRUCTURE
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Table.
DRUG | CAS REGISTRY NO. | MOLECULAR FORMULA | STRUCTURE |
Olaparib | 763113-22-0 | C24-H23-F-N4-O3 | SID: 135261055 |
Table footprint: 2 rows, 8 cells
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H2. ANNOTATED BIBLIOGRAPHY
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References updated: 18 May 2026
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Abbreviations used: PARP, poly adenine diphosphate-ribose polymerase
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Zimmerman HJ. Hepatotoxicity: the adverse effects of drugs and other chemicals on the liver. 2nd ed. Philadelphia: Lippincott, 1999.
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(Review of hepatotoxicity published in 1999 before the availability of protein kinase or PARP inhibitors such as olaparib).
reference
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DeLeve LD. Kinase inhibitors. Cancer chemotherapy. In, Kaplowitz N, DeLeve LD, eds. Drug-induced liver disease. 3rd ed. Amsterdam: Elsevier, 2013, pp. 556.
reference
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(Review of hepatotoxicity of cancer chemotherapeutic agents discusses several kinase inhibitors including gefitinib, erlotinib and crizotinib, but not the PARP inhibitors such as olaparib).
reference
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Chabner BA, Barnes J, Neal J, Olson E, Mujagic H, Sequist L, Wilson W, et al. Targeted therapies: tyrosine kinase inhibitors, monoclonal antibodies, and cytokines. In, Brunton LL, Chabner BA, Knollman BC, eds. Goodman & Gilman's pharmacological basis of therapeutics. 12th ed. New York: McGraw-Hill, 2011, pp. 1731-54.
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(Textbook of pharmacology and therapeutics).
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Audeh MW, Carmichael J, Penson RT, Friedlander M, Powell B, Bell-McGuinn KM, Scott C, et al. Oral poly (ADP-ribose) polymerase inhibitor olaparib in patients with BRCA1 or BRCA2 mutations and recurrent ovarian cancer: a proof-of-concept trial. Lancet 2010; 376 (9737): 245-51. PMID: 20609468
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(Among 57 women with BRAC 1 or 2 mutations and advanced, refractory ovarian carcinoma treated with 400 vs 100 mg of olaparib twice daily, objective response rates were 33% vs 13%, while dose interruptions and reductions for adverse events were more frequent with the higher dose; no mention of ALT elevations or hepatotoxicity).
reference
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Tutt A, Robson M, Garber JE, Domchek SM, Audeh MW, Weitzel JN, Friedlander M, et al. Oral poly (ADP-ribose) polymerase inhibitor olaparib in patients with BRCA1 or BRCA2 mutations and advanced breast cancer: a proof-of-concept trial. Lancet 2010; 376 (9737): 235-44. PMID: 20609467
reference
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(Among 54 women with BRCA 1 or 2 mutations and advanced, refractory breast cancer treated with 400 vs 100 mg of olaparib twice daily, objective response rates were 41% and 22%, while dose interruptions and reductions for adverse events were more frequent with the higher dose; no mention of ALT elevations or hepatotoxicity).
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Gelmon KA, Tischkowitz M, Mackay H, Swenerton K, Robidoux A, Tonkin K, Hirte H, et al. Olaparib in patients with recurrent high-grade serous or poorly differentiated ovarian carcinoma or triple-negative breast cancer: a phase 2, multicentre, open-label, non-randomised study. Lancet Oncol 2011; 12: 852-61. PMID: 21862407
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(In an open label trial of olaparib [400 mg twice daily] in women with advanced ovarian or breast cancer, objective responses occurred in 18 of 63 [29%] women with ovarian carcinoma, but none of 26 with breast cancer; no mention of ALT elevations or hepatotoxicity).
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Ledermann J, Harter P, Gourley C, Friedlander M, Vergote I, Rustin G, Scott C, et al. Olaparib maintenance therapy in platinum-sensitive relapsed ovarian cancer. N Engl J Med 2012; 366: 1382-92. PMID: 22452356
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(Among 265 women with advanced ovarian cancer who had a partial or complete response to platinum based chemotherapy, progression free survival was higher with olaparib than placebo [8.4 vs 4.8 months], and adverse events included nausea [68% vs 35%], fatigue [49% vs 38%] and anemia [17% vs 5%], and "there were no unexpected changes in biochemical laboratory measurements").
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Kaye SB, Lubinski J, Matulonis U, Ang JE, Gourley C, Karlan BY, Amnon A, et al. Phase II, open-label, randomized, multicenter study comparing the efficacy and safety of olaparib, a poly (ADP-ribose) polymerase inhibitor, and pegylated liposomal doxorubicin in patients with BRCA1 or BRCA2 mutations and recurrent ovarian cancer. J Clin Oncol 2012; 30: 372-9. PMID: 22203755
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(Among 97 women with BRCA 1 or 2 mutations and advanced ovarian cancer treated with olaparib [200 or 400 mg twice daily] or doxorubicin [intravenously every 28 days], progression free survival was similar in all 3 groups and specific adverse events were not mentioned).
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Garnett MJ, Edelman EJ, Heidorn SJ, Greenman CD, Dastur A, Lau KW, Greninger P, et al. Systematic identification of genomic markers of drug sensitivity in cancer cells. Nature 2012; 483 (7391): 570-5. PMID: 22460902
reference
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(Correlation of mutated cancer genes identified in cancer cell lines with their sensitivity to growth inhibition by antineoplastic agents revealed the possible role of PARP inhibition in several tumors including Ewing sarcoma).
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Ledermann J, Harter P, Gourley C, Friedlander M, Vergote I, Rustin G, et al. Olaparib maintenance therapy in patients with platinum-sensitive relapsed serous ovarian cancer: a preplanned retrospective analysis of outcomes by BRCA status in a randomized phase 2 trial. Lancet Oncol 2014; 15: 852-61. PMID: 24882434
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(Among 265 women with BRCA 1 or 2 mutations and relapsed, platinum-sensitive ovarian cancer treated with olaparib or placebo [Ledermann 2012], further follow up showed prolongation of progression free, but not overall survival with olaparib therapy and adverse events were similar to those previously reported).
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Ledford H. Resurrected cancer drug faces regulators. Nature 2014; 510 (7506): 454. PMID: 24965630
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(News report on olaparib, the initial PARP inhibitor, which in early clinical trials showed little effect on survival in women with ovarian carcinoma, but on reassessment limiting analysis to cases with BRCA mutations found evidence of an effect on cancer growth, reviving interest in pursuing olaparib as therapy of selected patients with ovarian cancer).
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Kaufman B, Shapira-Frommer R, Schmutzler RK, Audeh MW, Friedlander M, Balmaña J, Mitchell G, et al. Olaparib monotherapy in patients with advanced cancer and a germline BRCA1/2 mutation. J Clin Oncol 2015; 33: 244-50. PMID: 25366685
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(Among 298 patients with refractory advanced cancers and BRCA 1 or 2 mutations treated with olaparib [400 mg twice daily], the overall objective response rate was 26% and was higher in women with ovarian [31%] than breast cancer [13%]; there were no liver related serious adverse events).
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Gunderson CC, Moore KN. Olaparib: an oral PARP-1 and PARP-2 inhibitor with promising activity in ovarian cancer. Future Oncol 2015; 11: 747-57. PMID: 25757679
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(Review of the development, mechanism of action, clinical efficacy and safety of olaparib in ovarian cancer; mentions that the most frequent adverse events are gastrointestinal toxicity and myelosuppression; no mention of ALT elevations or hepatotoxicity).
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Bao Z, Cao C, Geng X, Tian B, Wu Y, Zhang C, Chen Z, Li W, et al. Effectiveness and safety of poly (ADP-ribose) polymerase inhibitors in cancer therapy: A systematic review and meta-analysis. Oncotarget 2016; 7: 7629-39. PMID: 26399274
reference
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(Systematic review of the efficacy and safety of PARP inhibitors in cancer chemotherapy mentioned that in 5 placebo controlled trials, ALT elevations were no more frequent with the PARP inhibitors than in “controls”, but neither were any other adverse events).
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Konecny GE, Kristeleit RS. PARP inhibitors for BRCA1/2-mutated and sporadic ovarian cancer: current practice and future directions. Br J Cancer 2016; 115: 1157-73. PMID: 27736844
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(Review of role of BRCA 1 and 2 mutations in tumorigenesis and the mechanism of action of PARP inhibitors).
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Ledermann JA. PARP inhibitors in ovarian cancer. Ann Oncol 2016; 27 Suppl 1: i40-i44. PMID: 27141070
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(Review of possible role of PARP inhibitors in ovarian cancer; mentions that cells with defective BRCA proteins are deficient in repair of double-stranded breaks in DNA by homologous recombination and rely on other pathways, notably PARP that detects single DNA strand breaks and activates effector proteins to initiate repair).
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Ledermann JA, Harter P, Gourley C, Friedlander M, Vergote I, Rustin G, Scott C, et al. Overall survival in patients with platinum-sensitive recurrent serous ovarian cancer receiving olaparib maintenance monotherapy: an updated analysis from a randomised, placebo-controlled, double-blind, phase 2 trial. Lancet Oncol 2016; 17: 1579-89. PMID: 27617661
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(Among 265 women with platinum-sensitive recurrent ovarian carcinoma treated with olaparib [400 mg twice daily] or placebo [Ledermann 2012], 5 year follow up showed little effect on median overall survival [29.8 vs 27.8 months]; there were no liver related severe adverse events requiring discontinuation).
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Olaparib (Lynparza) for advanced ovarian cancer. Med Lett Drugs Ther 2016; 58 (1489): e32-3. PMID: 26938702
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(Concise review of the mechanism of action, clinically efficacy, safety and costs of olaparib shortly after its approval in the US; does not mention ALT elevations or hepatotoxicity).
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Domchek SM, Aghajanian C, Shapira-Frommer R, Schmutzler RK, Audeh MW, Friedlander M, Balmaña J, et al. Efficacy and safety of olaparib monotherapy in germline BRCA1/2 mutation carriers with advanced ovarian cancer and three or more lines of prior therapy. Gynecol Oncol 2016; 140: 199-203. PMID: 26723501
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(Among 193 women with BRCA 1 or 2 mutations and advanced refractory ovarian cancer treated with olaparib [400 mg twice daily], 34% had an objective response and side effects were common, but only 3 patients [2%] developed ALT elevations above 5 times ULN and none had clinically apparent liver injury).
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Bang YJ, Xu RH, Chin K, Lee KW, Park SH, Rha SY, Shen L, et al. Olaparib in combination with paclitaxel in patients with advanced gastric cancer who have progressed following first-line therapy (GOLD): a double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Oncol. 2017;18:1637-1651. PMID: 29103871
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(Among 525 Asian adults with advanced, refractory gastric cancer treated with paclitaxel with either olaparib [100 mg] or placebo twice daily, median overall survival was similar in both groups [8.8 vs 6.9 months] but serious adverse events were more frequent with olaparib [35% vs 25%] including ALT elevations in 12% vs 6%, above 5 times ULN in 1.5% vs 0.7%, and 1 olaparib recipient died of acute liver failure [no details provided]).
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Tufoni M, Serena Ricci C, Zaccherini G. A case of immune-mediated liver injury induced by olaparib. Hepatology. 2018;68:2039-2041. PMID: 30070367.
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(61 year old Italian woman with ovarian cancer developed abnormal liver tests 3 months after starting olaparib [bilirubin 1.7 rising to 3.8 mg/dL, ALT 1453 U/L, Alk P 275 U/L, GGT 364 U/L, ANA 1:160] and liver biopsy showing acute hepatitis with eosinophils and rare plasma cells, enzymes rapidly improving with prednisone therapy, and all tests falling to normal within 2 months and remaining normal despite stopping corticosteroids).
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Rolfo C, Isambert N, Italiano A, Molife LR, Schellens JHM, Blay JY, Decaens T, et al. Pharmacokinetics and safety of olaparib in patients with advanced solid tumours and mild or moderate hepatic impairment. Br J Clin Pharmacol. 2020;86:1807-1818. PMID: 32227355
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(Pharmacokinetic study in 31 patients with advanced cancer with or without liver disease found no differences in peak olaparib levels or total concentration in patients with either mild or moderate hepatic impairment compared to controls without liver abnormalities).
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Alshelleh M, Park J, John V, Rishi A, Bernstein D, Roth N. Olaparib-induced immune-mediated liver injury. ACG Case Rep J. 2022;9:e00735. PMID: 35028326
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(56 year old woman with endometrial cancer developed jaundice 3.5 months after starting olaparib [bilirubin 11.4 mg/dL, ALT 3350 U/L, Alk P 215 U/L, INR 1.9], biopsy showing submassive necrosis; prednisone therapy led to rapid improvement, and all liver tests were normal 2 months later and remained normal after stopping corticosteroids).
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Zhu K, Drew Y, Jayakumar S. Challenges in PARP inhibitor therapy: A case of olaparib-induced liver injury and successful rechallenge with niraparib. Gynecol Oncol Rep. 2024;54:101439. PMID: 39035031
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(70 year old woman with ovarian cancer developed serum enzyme abnormalities without jaundice or symptoms 3 months after starting olaparib, 300 mg twice daily, [bilirubin 0.6 mg/dL, ALT 871 U/L, Alk P 163 U/L, GGT 139 U/L], improving on stopping but worsening again on restarting at half dose [ALT 878 U/L, bilirubin 2.8 mg/dL], resolving again on stopping, and not recurring on niraparib).
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H2. OTHER REFERENCE LINKS
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H2. [figs-and-tables] Figures, Tables and Boxes Appendix (do not delete)
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“In-line” figures (e.g. equations) and tables should be placed within the main text in their desired final location.