Drug-Induced Liver Injury
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Liver injury due to prescription medications, over-the-counter (OTC) medications, and herbal supplements.
Incidence
A.Estimated annual incidence is 10% of all cases of acute hepatitis; the most common cause of acute liver failure in the United States.
Pathogenesis
A.Over 1,000 medications and herbal products have been implicated in the development of drug-induced liver injury (DILI).
B.Most common drug in acute DILI in the United States is acetaminophen.
Predisposing Factors
A.Women—more susceptible due to smaller size.
B.Alcohol abuse.
C.Malnutrition.
Subjective Data
A.Common complaints/symptoms.
1.Itching.
2.Jaundice.
3.Malaise.
4.Low grade fever.
5.Nausea and vomiting.
6.Right upper quadrant (RUQ) pain.
7.Dark urine.
8.Clay-colored stools.
B.Common/typical scenario.
1.Patients may be asymptomatic with incidental finding of elevated liver tests.
2.Ask patients about recent antibiotic use, herbal supplements, weight loss products, or OTC medications.
3.Thorough medication reconciliation.
C.Family and social history.
1.Be culturally sensitive to nontraditional medicine and the patient’s use of herbal products.
2.Alcohol use.
D.Review of systems.
1.Same as common complaints.
2.Rash.
3.Pruritus.
4.Weight loss.
Physical Examination
A.Depending on the severity, no physical findings or the following:
B.Scleral icterus.
C.Generalized jaundice.
D.Skin excoriations from scratching.
E.RUQ tenderness.
F.Hepatomegaly.
Diagnostic Tests
A.Lab workup includes: Complete blood count (CBC), comprehensive metabolic panel (CMP), international normalized ratio (INR), hepatitis A, B, and C serologies, antinuclear antibody (ANA), antimitochondrial antibody (AMA), anti smooth muscle antibody (ASMA), liver kidney microsomal type 1 (LKM1), ceruloplasmin (Wilson’s disease), iron, ferritin (hemochromatosis), Alpha 1 antitrypsin.
B.Hepatic function panel will show cholestatic, hepatocellular, or mixed pattern of injury.
C.Imaging: Ultrasound (US), MRI.
D.Liver biopsy: If labs and imaging are nondiagnostic, biopsy may be considered.
Differential Diagnosis
A.Acute viral hepatitis.
B.Alcoholic liver disease.
C.Nonalcoholic fatty liver disease.
D.Autoimmune hepatitis.
E.Wilson’s disease.
F.Biliary obstruction: Primary biliary cholangitis (PBC) or primary sclerosing cholangitis (PSC).
Evaluation and Management Plan
A.General plan.
1.Obtaining a careful drug history and ruling out other causes.
2.Monitoring for improvement of symptoms and serologic markers after stopping the offending drug.
B.Patient/family teaching points.
1.Regular liver tests at recommended interval to monitor for improvement.
2.Avoid alcohol.
3.Normalization of liver tests may take several months.
4.Do not start any new medications or OTC supplements.
5.Teach signs and symptoms associated with hepatic injury.
6.Follow-up with gastrointestinal (GI)/hepatology.
C.Pharmacotherapy.
1.Primary treatment is withdrawal of the offending drug.
2.Recovery will occur in the majority of patients once the medication is stopped.
3.In acetaminophen toxicity, treatment is N-acetylcysteine.
D.Discharge instructions.
1.Monitor labs.
2.Follow-up with gastroenterologist or hepatologist.
Follow-Up
A.Gastroenterologist/hepatologist should be monitoring labs and seeing the patient on a regular basis.
Consultation/Referral
A.May refer for liver transplant if there is no recovery of liver function.
Special/Geriatric Considerations
A.Treatment of older patients with liver disease may require different or longer interventions.
B.Maintain pharmacokinetic precautions in geriatric patients.
Bibliography
Goldberg, E., & Chopra, S. (2018, June 14). Cirrhosis in adults: Overview of complications, general management, and complications. In K. M. Robson (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/cirrhosis-in-adults-overview-of-complicationsgeneral-management-and-prognosis
Larson, A. M. (2017, July 10). Drug-induced liver injury. Retrieved from https://www.uptodate.com/contents/drug-induced-liver-injury