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Drug-Induced Liver Injury

Herbert L. Bonkovsky, Dean P. Jones, Mark W. Russo, and Steven I. Shedlofsky

ADR adverse drug reaction
AERS Adverse Events Reporting System
ALF acute (or subacute) liver failure
ALT alanine aminotransferase
ANT adenine nucleotide translocase
AP alkaline phosphatase
ARE antioxidant response element
AST aspartate aminotransferase
CAM complementary and alternative

CYP cytochrome P450

DILI drug-induced liver injury
ER endoplasmic reticulum
ERCP endoscopic retrograde

FDA Food and Drug Administration

5-FU 5-fluorouracil
GSH glutathione

HAART highly active antiretroviral

HIPAA Health Insurance Portability and
Accountability Act
LT Liver test
MMPT mitochondrial membrane
permeability transition
6-MP 6-mercaptopurine
MTX methotrexate
NAPQI N-acetyl-p-benzoquinoneimine
NIDDK National Institute of Diabetes
and Digestive and Kidney
NNRTI nonnucleoside reverse
transcriptase inhibitor
NRTI nucleoside analogue reverse
transcriptase inhibitor

In humans and other higher organisms the liver is the principal site for the metabolism of foreign substances. It is responsible for absorbing, detoxifying, and excreting an astonishing
array of chemical substances, encountered both from outside
the organism (i.e., xenobiotics) and from within the organism,
including many substances synthesized by the liver itself. In
the toxicology literature, there is a distinction between toxins,
which are naturally occurring poisons, and toxicants, which
can be derived from any source. In general, the liver and
kidneys are chiefly responsible for maintenance of the internal
milieu of chemicals within narrow concentration gradients.
These organs also function to remove potentially toxic compounds from organisms. In general, toxic compounds of lower
molecular weight and higher water solubility are excreted
chiefly by the kidneys through glomerular filtration and/or
tubular secretion. In contrast, larger, more lipophilic substances must be absorbed and undergo initial metabolism by
the liver before their excretion either in the bile and feces or
in the urine.
The multistep process for the metabolism of drugs and
chemicals is summarized in Figure 25-1. Most such chemicals
are ingested orally and absorbed, chiefly in the proximal small

PAPS 3-phosphoadenosine-5phosphosulfate

PI protease inhibitor
PPAR peroxisome proliferatoractivated

PXR pregnane X receptor

RNS reactive nitrogen species
ROS reactive oxygen species
RUCAM Roussel-Uclaf Causality
Assessment Method

SLE systemic lupus erythematosus

SOS sinusoidal obstruction syndrome
TNF- tumor necrosis factor alpha
UDPGA uridine diphosphoglucuronic

ULN upper limit of normal

VDAC voltage-dependent anion channel
WHO World Health Organization

intestine. Some of them undergo initial metabolism within

the gastrointestinal tract. Parent compounds and/or metabolites then enter the splanchnic blood, from which they are
eventually delivered by the portal circulation to the liver.
Depending upon the xenobiotic in question, cells within the
liver absorb a variable proportion of the compound. This
initial removal of compounds from the portal blood, which
is the chief blood supply to the liver, is called the first-pass
effect of the liver.
The uptake into liver cells occurs primarily, but not solely,
into hepatocytes. During the past several years a number of
transporters of cations and anions have been described and
have been identified as important in the uptake of endogenous
chemicals and xenobiotics (drugs, foreign chemicals) by liver
cells. Once inside hepatocytes, these chemicals undergo further
intracellular binding and transport. The intracellular mechanisms responsible for such transport are less well understood.
It is likely that highly lipophilic compounds dissolve readily
into the membranes of cells and diffuse widely and quickly
within and across such membranes. In contrast, more hydrophilic compounds require protein binding and other means
for transport.
As shown in Figure 25-1, many (but certainly not all) drugs
and chemicals require an initial oxidation reaction, termed


Section IVToxinMediated Liver Injury

Oral ingestion

II metabolism
Conjugation reactions
III transport into
bile or blood
I metabolism
CYPs OH-ation


bile duct

Portal vein

Small intestine

low MW filtered
at glomerulus
and/or secreted by
tubular cells


Excretion in urine
more hydrophilic
smaller compounds

Excretion in feces
more lipophilic, higher MW
larger compounds

Fig. 25-1 Disposition of xenobiotics in humans.

phase I metabolism. The most common example is hydroxylation catalyzed by 1 of the 57 varieties of cytochrome P450
(CYP). Many of these CYPs are found in hepatocytes, and they
carry out hydroxylation reactions in concert with NADPH (as
a source of electrons) and cytochrome P450 reductase; for
some chemicals, cooperation with another heme-containing
protein called cytochrome b5 is also required. These enzymes
and reactions occur principally in the smooth endoplasmic
Following the initial hydroxylation reaction, one of several
additional reactions leads to the addition of more watersoluble moieties to the initial hydroxylated product. The
enzymes responsible for this so-called phase II metabolism
are chiefly glucuronosyl transferases, sulfotransferases, and
enzymes that add glutathione or products of the reduced
thiol form of glutathione (e.g., GSH transferases). The key
substrates for these conjugation reactions are uridine dipho
sphoglucuronic acid (UDPGA), 3-phosphoadenosine-5phosphosulfate (PAPS), and reduced glutathione (GSH, the
tripeptide l--glutamyl-l-cysteinyl-glycine).
The third phase of hepatic drug metabolismthe transport
of the parent drug and/or its metabolites out of hepatocytes
can occur in one of the following ways: drugs and/or metabolites can be transported across the plasma membrane, with

eventual excretion of water-soluble hydrophilic products in

the urine; alternatively, drugs can be transported across the
apical membrane domain of hepatocytes into bile canaliculi
(secretion into the bile), with eventual excretion in the feces.
Subsequent metabolism of drug conjugates can be complex,
with some undergoing metabolism in the intestines and
further metabolism in the liver in a process dependent upon
enterohepatic circulation. Others are metabolized in other
organs; for instance, glutathione conjugates are metabolized
by hydrolysis and acetylation to mercapturic acids, which are
the primary excreted product.
Drug-induced liver injury (DILI) is the major toxic effect
of drugs. It is the principal reason for abandonment of the
development of possible new drugs, for the failure of new
drugs to achieve approval by the U.S. Food and Drug Administration (FDA), and for the withdrawal of new drugs from the
market after initial approval. Adverse drug reactions (ADRs),
which are detected in preclinical studies in cells or experimental animals, usually lead to abandonment of the drug as a
candidate for further development, unless there is a unique
and highly important desirable effect of such compounds.
Those new drugs that survive this initial level of scrutiny then
proceed through phases 1 to 3 of clinical development and
testing. In these phases, only a limited number of highly
selected subjects, typically between 2000 and 10,000, receive
the medication. As a result, clinically significant but relatively
rare ADRs usually are not detected until after drugs have been
approved and are in use by a larger number of persons. These
ADRs are often associated with other underlying problems or
conditions, which may increase the risk of development of
ADRs. Thus continued monitoring of new drugs during phase
4 (postapproval surveillance) is now recognized by the FDA
and by the pharmaceutical industry to be of paramount
As described previously, DILI is a rare event, occurring in
only a small percentage of persons who take drugs. The reasons
for this are not fully understood. However, based on a combination of experimental results in cell models and wholeanimal models and careful clinical observations, and by
analogy to numerous other disorders, drug-induced liver injuries are caused and modulated by an interplay of at least
the following three factors: (1) the drug, (2) the host (i.e., the
person ingesting the drug), and (3) the environment of the
host. This interaction is depicted in Figure 25-2.
It is difficult to establish a diagnosis of DILI. This is because
there are numerous other potential causes of liver injury, and
because there is no single pathognomonic test to establish that
a given drug in a given subject is the cause of liver injury.
Furthermore, the clinical and laboratory manifestations of
DILI vary markedly, from asymptomatic laboratory abnormalities, which may resolve even though the drug is continued
(so-called adaptation), to severe, life-threatening acute (or
subacute) liver failure (ALF). Because of these factors, a diagnosis of DILI is frequently delayed or may be missed entirely.
Similar considerations also apply to herbal remedies and
complementary and alternative medications (CAM), which
are not regulated with the same rigorous standards as prescription medications. The scope of this chapter is to provide
a review and update of drug-induced liver injury attributable
to over-the-counter and prescription drugs. The hepatic
effects and toxicities of herbal remedies and CAM are considered elsewhere (see Chapter 26).

Chapter 25Drug-Induced Liver Injury


Genetic factors
Immunol. factors
Other diseases

Other toxins, chemicals
Antioxidants, probiotics

Fig. 25-2 Factors believed to be involved in pathogenesis of DILI.

Epidemiology: Scope
of the Problem
Although the occurrence of drug toxicities, and in particular
hepatotoxicities, should be an expected consequence of the
widespread use of complex and potent medications, the U.S.
public generally expects the FDA to keep toxic drugs off the
market. Regulatory agencies in Europe, Australia, and other
developed countries serve a similar function to protect their
populations. However, there are many drugs with known,
well-described hepatotoxicities, including acetaminophen,
isoniazid, valproate, phenytoin, and propylthiouracil, that
remain available because their medical benefits are deemed to
outweigh the risks. Nevertheless, between 1990 and 2002,
acute liver failure from these five drugs accounted for 15% of
all liver transplantations in the United States, with 51% of the
cases attributable to ADRs after drugs were taken with therapeutic intent, not to suicide attempts from acetaminophen
overdose.1 ADRs were estimated to be the fourth to sixth most
common cause of U.S. in-hospital mortality in the 1990s.2
For drugs that have been introduced into the market since
the FDA began stringent regulatory control in 1962, the
required animal toxicity studies and/or human trials eliminated most new chemical entities that were likely to cause
predictable and dose-related organ toxicity.3 However, some
drugs that appeared safe were withdrawn in the postmarketing period because of serious ADRs that became apparent
only after many more patients were exposed to the drug (Table
25-1). These withdrawals represented huge economic setbacks
for the pharmaceutical companies that had developed the
drugs, and they sometimes frustrated patients and their providers who were satisfied with, and depended on the availability of, the withdrawn drugs. Hepatotoxicity was the reason
for withdrawal in almost half the cases. Noteworthy is that
drug withdrawals attributable to hepatotoxicity were the most
common reasons before 1990, and have occurred less frequently since 1990, suggesting improved preclinical assessment of risk.
If a new medication causes a serious ADR with risk of
mortality in as few as 1 in 10,000 exposed persons, society


Table 25-1 Drugs Approved by the U.S. FDA

but Withdrawn in the Postmarketing Setting



Iproniazid (Marsalid)



Thalidomide (Thalomid)

Limb deformities


Ibufenac (in Europe)



Ticrynafen (Selacryn)



Benoxaprofen (Oraflex)



Perihexilene (in



Dilevalol (in Ireland,




Encainide (Enkaid)






Flosequinan (Manoplex)



Bromfenac (Duract)



Mibefradil (Posicor)

Multiple drug


Terfenadine (Seldane)



Troglitazone (Rezulin)



Cisapride (Propulsid)



Alosetron (Lotronex)

Ischemic colitis


Cerivastatin (Baycol)



Rofecoxib (Vioxx)

Cardiac mortality


*Made available again on a severely restricted basis in 1998.

Made available again on a severely restricted basis in 2000.

Made available again on a severely restricted basis in 2002.

Drugs not approved in United States and withdrawn in other countries.

deems this unacceptable, especially if there are alternative

drugs available. Phase 1 to 3 trials generally include fewer
than 10,000 carefully selected subjects. Although this is a large
number, it is not large enough to reliably identify serious
idiosyncratic ADRs that occur less frequently than 1 to 2
times in 10,000 subjects. Therefore postmarketing surveillance
has become critically important in identifying ADRs. In
January 2002 the FDA organized an Office of Drug Safety,
which oversees a large database of ADRs entered into its
Adverse Events Reporting System (AERS) at its MedWatch
website ( or by fax
or post. Similar pharmacovigilance efforts have been mounted
in Europe. The World Health Organization (WHO) maintains
the Uppsala Monitoring Centre ( that
receives and analyzes ADRs from around the world, including
reports from the U.S. FDA.4
With these efforts, it would seem possible to accurately
report epidemiologic trends in ADRs and identify offending
medications quickly. However, most of the reporting systems
rely on voluntary submission of information. Also, even


Section IVToxinMediated Liver Injury

though submission of personal health data to MedWatch is

exempt from Health Insurance Portability and Accountability
Act (HIPAA) privacy restrictions,5 very few healthcare providers take the time to submit reports. It is estimated that only
about 1% to 10% of ADRs are reported.5 Furthermore, the
databases consist of large numbers of reports (184,702 were
submitted to the FDAs AERS in 2002) varying in both quality
and detail and submitted by pharmaceutical companies (as
required by law) or by physicians.4 Because of the potential
economic impact on pharmaceutical companies, and because
of complex legal liabilities, the raw data from all of these ADRs
are not easily available in the public domain. The FDA allows
public access to extracts of AERS data through the National
Technical Information Service report. The WHOs Uppsala
Monitoring Centre has contracted with VigiBase Services
(, which can provide customized
data but at a substantial cost. This service is chiefly designed
for regulatory agency professionals and pharmaceutical companies who study drug safety and utilize data mining
Currently, the incidence and impact of ADRs from specific
agents remain largely unknown. Many healthcare providers
now use one or more of the available web-based drug information services such as the Physicians Desk Reference
( or Epocrates ( to review
drug toxicity data. However, such sources do not provide specific information regarding the incidence and types of hepatotoxicity caused. We therefore rely upon regulatory agencies
such as the FDA to monitor ADRs and either issue black box
warnings or recommend voluntary withdrawal of the drug.
Because of medicolegal liabilities, most pharmaceutical companies voluntarily withdraw their products when evidence of
hepatotoxicity or other toxicities begins to mount. However,
it is likely that if physicians and other healthcare providers
were more conscientious in suspecting and reporting ADRs,
the collective data would lead to better patient care and fewer
ADRs. With current electronic web-based reporting systems,
such reports are now relatively easy and quick to submit. Furthermore, there is an expectation that high-throughput technologies will allow individualized therapeutics to become a
central component of developing capabilities in personalized

Causality Assessment
A continuing challenge in the study of adverse effects of drugs
and chemicals on the liver (and other organs) is that of causality assessment, the process whereby the likelihood of the diagnosis DILI is determined. This process of deduction involves
analysis of the relevant data and should include an assessment
of the temporal relationship, clinical features, laboratory data,
histologic data (if available), and current knowledge about the
drug in question. From a statistical standpoint the most scientifically sound approach is to use Bayes theorem. Using this
technique, an attempt is made to estimate the overall probability of a particular adverse event occurring in a particular individual in a particular situation (posterior probability), given
the probability of this event occurring in a group of individuals similarly exposed (prior probability). Individual and situational details considered include the subjects clinical history,
temporal relationships, histologic pattern of injury, and

resolution with discontinuation of the agent, as well as whether

rechallenge with the agent resulted in recurrence of the adverse
event. These details are used to develop a likelihood ratio; the
product of this ratio and the prior probability is a measure of
the posterior probability. The major problems that limit the
application of Bayes theorem in practice are that it is timeconsuming and data needed to compute the likelihood ratio
(e.g., background incidence) are often unavailable.
Although several scoring systems and tools for assessing
whether drugs are the cause of liver injury have been developed,6-9 they are not widely used in practice because they take
time to complete and because key information is often lacking.
Probably, the best known and most widely used of these is
RUCAMthe Roussel-Uclaf Causality Assessment Method.6,7
However, numerous ambiguities and problems with application of RUCAM have been found, and its reproducibility, even
among experts in DILI, has been poor.10 Thus there is need
for a more robust evidence-based instrument. Until this is
developed, the Delphic approach, using a structured process,
appears to produce higher agreement rates and likelihood
A major problem is that data needed to assess causality,
especially to exclude other possible causes of DILI, often are
missing. Elements that should be included in reports of DILI
have been proposed recently12 (Table 25-2). Often missing are
records of the presence of underlying diseases; history of
alcohol, herbal, or other drug use; tests to exclude viral hepatitis (especially hepatitides A, B, and C; cytomegalovirus
[CMV]; Epstein-Barr virus [EBV]; herpes simplex virus
[HSV]); tests to exclude autoimmune hepatitis (antinuclear
antibody [ANA], antismooth muscle antibody [ASMA]);
and abdominal imaging studies to exclude biliary tract disease.
Based on the degree of certainty of a causal interaction
between drug intake and hepatic injury, different terms are
used to describe the strength of the relationship. Definite is
usually supported by a signature clinical pattern, a strong
temporal correlation, including a positive rechallenge, and
exclusion of all other potential causes. Weaker relationships
are termed very likely, probable, possible, and unlikely
in descending order of strength; these terms are used when
the relevant evidence is judged to be less compelling.11
One problematic issue is whether the subject in question
has DILI or autoimmune hepatitis, because the former may
trigger the latter and because subjects with autoimmunoallergic diatheses are probably more prone to develop DILI of
the immunoallergic type. In all cases of suspected cholestatic
DILI, it is important to exclude biliary tract disease and/or
biliary obstruction.

Mechanisms of Hepatic
Injury Due to Drugs
and Chemicals
Apoptosis and Necrosis
Necrosis and apoptosis are terms used to describe patterns of
morphologic changes associated with cell death. Both morphologies include a spectrum of biochemical processes, can
occur concomitantly, and often vary in appearance, depending
on the unique properties of the toxic agent, the time course

Chapter 25Drug-Induced Liver Injury

Table 25-2 Minimal Elements for Reporting

Drug-Induced Liver Injury
Patient gender and age
Drug and its dose
Primary disease (for which drug was prescribed)
Concomitant diseases (with special attention to heart failure
or episodes of hypotension, sepsis, or receipt of parenteral
Pertinent medical history (including previous exposure to
drug, previous reaction to drug or other drugs, history of
liver disease, and risk factors for liver disease)
History of alcohol use
Dates of start and discontinuation of therapy (or time from
onset of event)
Date of onset
List of pertinent symptoms (fatigue, weakness, nausea,
anorexia, abdominal pain, dark urine, jaundice, pruritus,
rash, and fever)
Pertinent physical findings at the time of presentation (with
special mention of whether or not there is fever, rash,
jaundice, hepatic tenderness, or signs of chronic liver
Medication history (other medications taken in 3 months
before onset of liver injury with dose, generic name, and
Laboratory tests
Date and time of first abnormal laboratory test result
Laboratory test results from before drug exposure
(specifically liver tests)
Initial laboratory results at presentation (bilirubin, ALT, AP,*
INR, or PT, and eosinophil count or percentage)
Laboratory results needed to exclude other causes (IgM
anti-HAV, IgM anti-HBc, HBsAg, anti-HCV, HCV RNA, and
Course of serum bilirubin, ALT, AP, and INR levels
(preferably in a table with entries dated from time of
starting and stopping drug and until resolution)
Imaging studies (abdominal ultrasound, CT, or MR)
Liver histologic results (if obtained and date of procedure in
relation to episode of drug-induced liver injury)
Whether rechallenge with same medication as performed
and, if so, results of challenge
From Agrawal VK, etal. Important elements for the diagnosis of
drug-induced liver injury. Clin Gastroent Hepatol 2010;8:463470.
ANA, antinuclear antibody; AP, alkaline phosphatase; CT, computed
tomography; HAV, hepatitis A virus; HBc, hepatitis B core antibody;
HBsAg, hepatitis B surface antigen; HCV, hepatitis C virus; Ig,
immunoglobulin; INR, International normalized ratio; MR, magnetic
resonance; PT, prothrombin time

and dose dependence of exposure, and the interactions with

other host and environmental factors (see Fig. 25-2). The
most common recognized morphologic form of cell death in
the liver is necrosis, which is characterized by cellular and
organellar swelling and membranal lysis with release of cytoplasmic contents. After the occurrence of such changes, the
outlines of cells are often indistinct and cells have an amorphous or coarsely granular appearance.
Detailed morphologic studies of pathologic as well as
normal tissues revealed a second, distinct morphology of cell
death, originally termed shrinkage necrosis13 and now
termed apoptosis.14 These distinct morphologies are now recognized to represent two general cellular phenomena that can
occur concomitantly. In apoptosis, typical changes include cell


shrinkage, organellar compaction, nuclear condensation, fragmentation of cells into smaller apoptotic bodies, and the
appearance of phagocytosis signals on the cell surface.15 Apoptotic cells are rapidly removed by phagocytosis. Necrosis generally represents a loss of osmotic regulation and cell lysis,
whereas apoptosis represents activation of an enzymemediated autolytic cell disposal system. Both are often linked
to bioenergetic changes, mitochondrial failure, and oxidative
stress. Thus consideration of the distinctions between necrosis
and apoptosis is important not only for pathologic evaluation
of hepatotoxicity but also for investigation of underlying
mechanisms of cell injury.
Although apoptosis is defined morphologically, it is generally used to refer specifically to a series of cellular changes that
result from the activation of a family of highly conserved
enzymes termed caspases. These enzymes are proteases that
cleave specific target amino acid sequences, resulting in characteristic morphologic changes and leading to cell elimination
by phagocytosis.16 Activation occurs through plasma
membraneassociated death receptor activation of caspase8,17 through mitochondria-mediated activation of caspase-9,18
and through endoplasmic reticulummediated activation of
caspase-12.19 These activation mechanisms normally function
in homeostatic control of the liver and represent a mechanism
to eliminate damaged cells and allow replacement by mitosis.
Chemicals that alter the expression and function of the death
receptor components, disrupt mitochondrial function, or
disturb the secretory pathway can therefore be expected to
activate apoptosis (Fig. 25-3). In addition, disruption of the
cell cycle and inhibition of proteosomes also activate apoptosis. Thus many agents previously believed to kill cells by disruption of homeostatic processes are now believed to do so by
activation of apoptosis. Of critical importance is that an
increase in apoptosis is often a more sensitive indicator of
tissue injury than necrosis. However, because the liver is always
undergoing renewal and this process involves apoptosis, definition of the lower limit of toxicity in terms of an increase in
apoptosis can be difficult without detailed examination of a
large number of cells.
An extension of this concept to higher doses and increased
activation of apoptosis reveals that a true distinction between
necrosis and apoptosis as causative mechanisms in liver toxicity may not be possible. If apoptosis occurs at a rate that
exceeds the capacity of phagocytic cells (itself variable) to
remove the apoptotic cells, large fields of contiguous cells will
swell and lyse, producing characteristics of necrosis. On the
other hand, if the toxic insult causes rapid loss of ionic homeostasis, cells may rapidly swell and lyse (i.e., undergo necrosis),
even though the apoptotic cascade has been activated.
Many toxicants show a dose-dependent switch between
apoptosis and necrosis attributable to differential effects on
mitochondrial function and energy metabolism. Disruption
of only a fraction of mitochondria can result in sufficient
cytochrome c release to activate the caspase-9/caspase-3
pathway without disrupting cellular energetics. Under these
conditions, cells maintain osmotic regulation and undergo
apoptosis. However, with greater disruption of mitochondria,
cellular energetics are impaired, osmotic regulation is lost, and
cells undergo swelling and lysis. Because of this, the mechanisms involved in activation of caspases and/or loss of osmotic
regulation are key to understanding chemical-induced liver


Section IVToxinMediated Liver Injury

Conditioning events


Induced expression of death

receptors on plasma
Triggering events


Ligand binding to death

Signal transduction
Critical increase in mitochondrial
permeability (MMPT)
Leakage of cytochrome C
Activation of caspases


Shrinkage of cells with

recognizable organelles
DNA cleaved into
oligonucleosomal lengths
Phosphatidyl serine exposed
on cell surface
Resolution (clean-up)
Apoptotic bodies engulfed by
macrophages and digested

Fig. 25-3 The apoptotic pathway for cell death.

Mitochondria are a common target of toxicity in liver and

play a central role in both apoptosis and necrosis. A recent
model integrates major features of energy metabolism, oxidative stress, and apoptosis through central regulatory functions
of complex III and aconitase. In oxidative phosphorylation,
essentially all electrons flow from coenzyme Q to cytochrome
c through complex III to drive the production of adenosine
triphosphate (ATP). The electron flow through this complex
is partitioned between reduction of cytochrome c and
1-electron reduction of O2 to produce the reactive oxygen
species superoxide ion. The superoxide ion provides an
oxidant source for the regulation of aconitase, a key enzyme
in the citric acid cycle; for oxidation of cardiolipin, a key step
in the release of cytochrome c and activation of the caspase-9/
caspase-3 cascade; and for opening of the mitochondrial
membrane permeability transition (MMPT) pore, a generalized trigger for both cytochrome c release and loss of ATP
production. This complex can therefore serve as a sensor for
energetic and redox homeostasis, integrating ATP supply
requirements, the efficacy of GSH and other antioxidant
systems, calcium homeostasis, and nutritional supply of oxidizable substrates. Consequently, physiologic variations such
as food supply and hepatic O2 supply (e.g., hypoxia) can
function as important modulators of the biochemical mechanisms and morphology associated with specific toxicant

During the past decade, rapidly developing knowledge

about the mechanisms of apoptosis has dramatically changed
the perception of how chemicals induce hepatic injury. In
the past, injury was considered to be due to failure of critical
cell machinery, especially that controlling Ca2+ homeostasis.
Now, however, attention has shifted to mechanisms of apoptosis, which is executed by the caspase proteolytic cascade
that is activated by specific signaling involving death receptors or disruption of mitochondria, endoplasmic reticulum
(ER), or nuclei, for example. Central features of chemicalinduced liver injury remain the same; however, death is now
viewed as occurring through targeted cleavage of specific
proteins rather than generalized failure. Bioactivation of
organic compounds to reactive electrophiles occurs prominently in the liver because of the presence of high concentrations of enzyme systems designed to aid in the elimination
of foreign compounds (see Fig. 25-1). Electrophilic agents
covalently modify macromolecules, disrupting normal functions, including proteinprotein interactions and protein
degradation by proteosomes. Oxidants alter the expression
of death receptor machinery, enhancing death receptor
mediated apoptosis, and target the MMPT pore, triggering
mitochondria-mediated apoptosis. Protection against reactive
electrophiles and oxidants occurs through systems that
depend upon GSH, and maintenance of GSH is a key mechanism for protection against chemical-induced liver injury. As
mass spectrometry and proteomic techniques become widely
used in toxicologic research, the possibility of applying
systems biology approaches to define toxicity improves. By
incorporating a broad spectrum of potential targets into the
toxicologic models, this approach is likely to yield a more
nearly complete and accurate understanding of the mechanisms of hepatotoxicity.

Bioactivation of
Xenobiotic Agents
Some compounds are not toxic to the liver in the parent form
but are bioactivated to reactive species. One of the more
common mechanisms of bioactivation involves conversion to
compounds with electron-seeking properties (i.e., to electrophiles). In most cases, these electrophiles are the result of
phase I metabolism by CYP-dependent reactions. Epoxides are
an important class of toxic electrophiles. Bromobenzene and
aflatoxin B1 are metabolized by hepatic mixed-function oxidases to the epoxide intermediates bromobenzene-3,4oxide20,21 and aflatoxin B1-8,9-oxide,22 respectively. Other
electrophilic species include alkyl and aryl halides, carbonium
and diazonium ion intermediates, aldehydes, esters, ,unsaturated carbon compounds, and compounds containing
double-bonded nitrogen (e.g., isothiocyanates, isocyanates,
quinazolines).23 Phase II metabolism also may result ultimately in toxic electrophiles, exemplified by toxic GSH
S-conjugates, glucuronides, and sulfates24,25; these metabolites
may be toxic to the liver as well as to extrahepatic organs.
Reactive electrophiles generated during bioactivation react
with specific macromolecules or sites to cause toxicity.26 For
instance, earlier research showed that calcium transport
systems in the plasma membrane27 and endoplasmic reticulum28,29 contain reactive cysteine thiol groups that are critical

for function. More recent studies show that molecular chaperones, proteolytic systems, and transcription factors are susceptible to redox modifications.30-32 DNA may be a target of
electrophiles, in which case the lesion may cause acute hepatocellular death or lead to carcinogenicity. The epoxide of
aflatoxin B1 formed during hepatic biotransformation binds
guanine residues in DNA at the N-7 position, which may
ultimately result in hepatocarcinogenesis.22,33 Covalent modification of proteins may result in the formation of a neoantigen against which an immune response is mounted, giving rise
to immunoallergic DILI. Metabolites of halothane, phenytoin,
and numerous other drugs may cause liver injury by this type
of idiosyncratic mechanism.34,35

Role of Glutathione
in Chemical Detoxification
of Reactive Electrophiles
Glutathione (GSH) is a major low-molecular-weight thiol
compound that constitutes more than 90% of the acid-soluble
thiol pool in hepatocytes and accounts for about 30% of the
total thiol groups in liver.36 GSH serves many important functions, including detoxifying peroxides and electrophiles (see
Oxidative Stress and Free Radical Reactions in Hepatotoxicity), maintaining protein thiols in a reduced state, serving
as a nontoxic storage form of cysteine, and participating in
the synthesis of leukotrienes and prostaglandins as well as the
reduction of ribonucleotides to deoxyribonucleotides.36 The
liver is very active in synthesis of GSH, not only for detoxification functions but also to provide a reservoir of cysteine
through an interorgan transport mechanism.37 Sulfur amino
acid homeostasis also depends on the presence of the cystathionine pathway in the liver, which provides the major site
for conversion of methionine to cysteine.38 Cirrhotic changes
in the liver therefore not only affect the sensitivity of the liver
to toxicity, but also affect the sensitivity of other organ systems
to toxicity attributable to impaired cysteine supply and glutathione regulation.
Of great relevance to chemical toxicity is that GSH is a key
compound involved in the detoxification of electrophiles. The
thiol group of GSH is a nucleophilic center that undergoes
S-conjugation with electrophiles; in most cases this leads to
detoxification. Many electrophiles form GSH S-conjugates
nonenzymatically to some extent, which is a function of
charge localization of both electrophile and nucleophile.39
Hepatocytes and other cells do not rely on nonenzymatic conjugation of electrophiles; instead, they contain enzymes
termed GSH S-transferases that catalyze S-conjugation of
GSH to electrophiles. Four major classes of cytosolic GSH
S-transferase (i.e., , , , ) and one microsomal enzyme
have been characterized in mammalian tissues.40 The cytosolic
GSH S-transferases have been studied in the greatest detail
and have been shown to be a multigene family of enzymes.
Each cytosolic GSH S-transferase is a dimer, a discrete gene
codes for each subunit, only subunits of the same class form
dimers, and dimers may contain identical subunits (homodimers) or different subunits (heterodimers). The cytosolic
enzymes are expressed to various extents in different tissues
and are important in detoxification of several groups of xenobiotics, including polycyclic aromatic hydrocarbons, aflatoxins, aromatic amines, and alkylating agents.41 The liver is most

Chapter 25Drug-Induced Liver Injury


active in GSH-dependent detoxification of electrophiles, and

human liver is particularly rich in GSH S-transferases of the
class; in other species, such as rat, the class of GSH
S-transferases also is abundant in liver.
The generation of large quantities of electrophiles in liver
ultimately depletes cellular GSH pools, resulting in enhanced
covalent binding to critical macromolecules and cell death.
Because GSH and the GSH S-transferases play such an integral
role in detoxification of electrophilic species in liver, physiologic or pathophysiologic conditions that either decrease or
elevate levels or activities in liver would be expected to affect
chemical detoxification in the anticipated direction. Experimentally, this has been demonstrated for a variety of electrophiles. For example, depletion of hepatocellular GSH
exacerbates hepatotoxicity associated with electrophiles,
including metabolites of acetaminophen42 and bromobenzene.21 Fasting for 1 or 2 days decreases hepatic GSH content
by 30% to 50%43 and enhances liver injury caused by many
electrophilic agents. Diurnal variation in hepatic GSH stores
of about 25% to 30%44 may influence hepatotoxicity as a
result of the availability of GSH for detoxification. Diurnal
variation in plasma GSH levels also occurs, but a larger variation is observed in plasma cysteine levels,45 and acetaminophen at therapeutic levels alters plasma cysteine level
without affecting plasma GSH level.46 Cysteine prodrugs
(N-acetylcysteine or oxothiazolidine-4-carboxylate) and GSH
esters47 can increase hepatic GSH levels and protect against the
hepatotoxicity caused by acetaminophen overdose.48
Similar to the CYPs, the GSH S-transferases have relatively
broad and overlapping substrate specificities and their activities may be increased following exposure to certain drugs,
environmental chemicals, and dietary components. This
occurs chiefly through a well-characterized transcription
enhancer system, consisting of an antioxidant response
element (ARE)-binding sequence in the DNA and the Nrf-2/
Maf transcription factor system.49,50 Nrf-2 is normally present
as an inactive complex with Keap-1, bound to cytoskeletal
components in the cytoplasm. Keap-1 has several cysteine
thiols that are sensitive to oxidation and alkylation. Modification of these thiols results in the release of Nrf-2, which translocates to the nucleus, interacts with small Maf proteins and
binds to the ARE, and activates transcription of a broad range
of phase 2 detoxification systems (Fig. 25-4). Dietary inducers
contained in cruciferous vegetables induce GSH S-transferases
and other protective phase 2 enzymes without having a significant effect on the CYPs.51-54 These results suggest that
increased intake of foods containing these agents may provide
a simple and effective means to prevent toxicity as well as
cancer caused by toxicants.
A prototypic example of bioactivation and covalent binding
in hepatotoxicity is provided by the analgesic acetaminophen
(N-acetyl-p-aminophenol; paracetamol). In overdose, acetaminophen results in severe hepatocellular necrosis in zone 3
of the hepatic acini (centrilobular necrosis) (Fig. 25-5).55 Bioactivation occurs via hepatic CYP to the electrophilic intermediate N-acetyl-p-benzoquinoneimine (NAPQI)56 (see Fig.
25-4). In humans, CYPs 2E1 and 1A2 account for the largest
fraction of this conversion.57 At low rates of production,
NAPQI is detoxified by S-conjugation with GSH; however, at
higher rates of NAPQI production, hepatocellular GSH pools
are depleted and extensive covalent binding to cellular macromolecules occurs.58,59 Ultrastructural and functional studies


Section IVToxinMediated Liver Injury







CYPs 2E1






Oxidative stress
covalent binding to
critical macromolecules
mitochondrial toxicity



Reactive, toxic intermediate




GSH depletion
oxidative stress
Translocation to nucleus





UDPGTs, HO-1, etc.

Fig. 25-4 Hepatic metabolism and effects of acetaminophen and the Nfr2, Maf, ARE system for cytoprotection.

however, large numbers of adducted proteins have also been

detected, and other mechanisms of toxicity have also been

Oxidative Stress and Free Radical

Reactions in Hepatotoxicity

Fig. 25-5 Submassive (zone 3) coagulative necrosis attributable to

an overdose of acetaminophen. Viable hepatocytes surround the
portal areas, and the terminal hepatic venules are surrounded by necrotic
tissue. Inset shows the necrotic hepatocytes at high magnification.

have shown that mitochondria are an early target in the hepatocellular necrosis caused by acetaminophen60-63; however,
acetaminophen metabolites also form adducts to hepatic proteins in the cytosol, microsomes, nuclei, and plasma membranes.35 Arylation of specific proteins has been reported64-66;

Oxidative stress is an imbalance between oxidants and antioxidants in favor of the oxidants, leading to a disruption of
redox signaling and control and/or molecular damage.74
Although it was earlier viewed as a global balance, increasing
knowledge of redox signaling mechanisms indicates that
toxicants can disrupt redox signaling and control without
necessarily altering major systems that control overall redox
balance, indicating a specificity in mechanisms.75 Key mechanisms involve reactive oxygen species (ROS), reactive nitrogen
species (RNS), and a range of free radicals generated by
bioactivation of xenobiotics. All of the classes of cellular
macromolecules can be the target of oxidant-induced liver
injury. As discussed previously for covalent modification,
proteins are most often considered the critical targets in
acute necrosis, but oxidants also are genotoxic. Nonradical
oxidants, such as hydrogen peroxide and lipid hydroperoxides,
are quantitatively most important under most conditions75;
however, free radicals can also be important in medicating

Chapter 25Drug-Induced Liver Injury



Cytochrome P450

Low oxygen

Covalent binding to
cellular macromolecules
Abstraction of hydrogen from
PUFA to form CHCl3 and a
lipid radical

Reaction with GS

High oxygen

Formation of CCl3OO with

subsequent lipid peroxidation
and termination reactions





Decomposition of CCl3OO
to CCl2O, which can react
with GSH or bind covalently
to cellular macromolecules

Termination reactions with

itself or lipid radicals
Fig. 25-6 Hepatic metabolism and oxygen-dependent effects of
carbon tetrachloride (CCl4). CCl3, trichloromethyl radical. GS,
glutathione thiolate anion; GSH, glutathione; PUFA, polyunsaturated
fatty acid.


2-electron reduction



Free radicals can be generated in the liver in several ways.

CYP enzymes generate radicals from xenobiotics by three different mechanisms: 1-electron oxidation to form a cation
radical (R R+ + e); 1-electron reduction to yield an anion
radical (R + e R); or homolytic bond scission to yield
a neutral radical (RR R + R).76 Hepatotoxicants of
occupational/environmental (e.g., CCl4) as well as of clinical
importance (e.g., halothane) are bioactivated in liver to free
radical species. CCl4 toxicity provides a useful model and is
representative of a large number of halogenated hydrocarbons
that can be similarly activated.
CCl4 is a prototypical hepatotoxin that causes centrilobular
necrosis and associated fatty liver. Caspase-3 is activated and
released into the plasma with a time course suggesting initial
activation of apoptosis followed by secondary necrosis.77 A
primary event in the pathogenesis is the reductive dehalogenation of CCl4 to the trichloromethyl free radical (CCl3) by
hepatic mixed function oxidases (Fig. 25-6). The free radical
CCl3 can initiate lipid peroxidation, and in the presence of
oxygen it forms the more reactive trichloromethylperoxy free
radical (CCl3OO), which also decomposes to phosgene
(CC2O). The lipid peroxidation in liver associated with CCl4
has been viewed as a critical event because it occurs early and
is associated with reductions of enzyme activities78 and inactivation of the Ca2+ sequestering capacity of endoplasmic
reticulum.79,80 Elevation of cellular Ca2+ concentration establishes conditions for activation of the mitochondrial permeability transition, with associated cytochrome c release and
caspase activation (see Fig. 25-3).
In addition to free radicals of the parent compound, other
reactive oxygen and reactive nitrogen species are often involved
in hepatotoxicity. Reactive oxygen species such as the hydroxyl
radical (OH) are generated during redox cycling of several
xenobiotics, following activation of the respiratory burst in


Fig. 25-7 Redox cycling of menadione, an example of a hepatotoxic drug that produces superoxide (O2). NAD+, nicotinamide
adenine dinucleotide; NADH, nicotinamide adenine dinucleotide (reduced
form); NAD(P)+, nicotinamide adenine dinucleotide phosphate; NADPH,
nicotinamide adenine dinucleotide phosphate (reduced form).

host phagocytic cells, and during exposure to ionizing radiation. Reactive nitrogen species can also be involved in these
toxic processes because of the formation of the free radical
nitric oxide (NO), an important signaling agent that reacts
with superoxide anion (O2) to generate peroxynitrite.81-83
Redox cycling refers to a pathway whereby a compound
undergoes a series of cyclic 1-electron reductions and oxidations with concomitant generation of toxic oxygen species. A
variety of flavoproteins catalyze 1-electron reductions. In the
presence of oxygen, the reduced product can spontaneously
oxidize back to the parent compounds, and this oxidation is
coupled to the reduction of molecular oxygen to the superoxide radical ion O2 (Fig. 25-7). Many redox cycling agents
cause toxicity to hepatocytes in vitro, but also usually cause
toxicity to other organ systems when administered in vivo.
Examples are the lung injury associated with paraquat84 and
the cardiotoxicity caused by adriamycin.62 This probably
reflects a relative resistance of liver parenchyma, attributable
to the large capacity of the liver to detoxify reactive oxygen


Section IVToxinMediated Liver Injury

Menadione (2-methyl-l,4-naphthoquinone; vitamin K3) is

a therapeutic quinone compound that can cause liver injury
attributable to redox cycling. Menadione undergoes 1-electron
reduction to the semiquinone free radical, which is catalyzed
by many flavoenzymes, including NADPH:cytochrome P450
reductase.76 In hepatocytes and other cells, it can also undergo
a 2-electron reduction to the hydroquinone in a reaction catalyzed by NADPH:quinone reductase, a cytosolic enzyme also
known as DT-diaphorase (see Fig. 25-7). This 2-electron
reduction provides a detoxification reaction because the
hydroquinone can be conjugated by sulfotransferases or
uridine diphosphoglucuronic acid glucuronosyltransferases
(UDPGT). DT-diaphorase knockout mice are more sensitive
to the hepatotoxicity of menadione.85
The oxidative stress caused by redox cycling of menadione
leads to irreversible cell injury via a complex interplay between
oxidation of soluble thiols (e.g., GSH) and that of protein
thiols, causing a sustained rise in Ca2+ concentration that is
critical to the activation of mitochondria-mediated apoptosis.
Oxidation of critical protein thiols decreases microsomal Ca2+
sequestering capacity28,29 and plasma membrane extrusion of
Ca2+ from cells.27 Oxidation of soluble thiols precedes this and
is a contributing factor in inhibition of the microsomal Ca2+
pump because GSH keeps the protein thiols in a reduced and
functional form. In the presence of elevated Ca2+ concentration mitochondria load Ca2+, and this loading sets conditions
appropriate for activation of the mitochondrial membrane
permeability transition (MMPT).86
The GSH system is complemented by thioredoxindependent antioxidant proteins termed peroxiredoxins.87
Thioredoxin 1 is present in the nucleus and cytoplasm and
serves to support peroxide elimination by peroxiredoxins 1
and 2. Thioredoxin 2 is present in the mitochondria and
supports peroxide metabolism by peroxiredoxins 3 and 5.
These systems are very active, and some estimates indicate
that a majority of peroxide may be eliminated by peroxiredoxins rather than by GSH peroxidases.88 Thioredoxins also
bind to apoptosis-regulating kinase-1 (Ask-1), inhibiting
activity. When thioredoxin becomes oxidized, Ask-1 is
released and signals apoptosis.89 In this way, toxicants that
cause oxidation of either mitochondrial or cytoplasmic thioredoxin can activate cell death without causing macromolecular damage.
The MMPT occurs in response to the opening of a highconductance channel in the mitochondrial inner membrane.86
Ordinarily, the inner membrane is highly impermeable to
solutes. However, in the presence of matrix Ca2+, certain agents
trigger the opening of the high-conductance MMPT pore. The
prevailing interpretation is that the pore is a protein complex
containing adenine nucleotide translocase (ANT, inner membrane), voltage-dependent anion channel (VDAC, outer
membrane), cyclophilin D (associated with ANT), and peripheral benzodiazepine receptor (associated with VDAC). Sensitivity to oxidants and thiol reagents, especially arsenicals,
indicates that the pore contains thiols, probably vicinal thiols,
which control opening. Thus, in the presence of elevated Ca2+
levels, oxidants trigger opening of the MMPT pore, with
resulting swelling and release of cytochrome c90 and other
pro-apoptotic components.69,91,92 Cytochrome c binds to
APAF-1, an assembly protein that allows the recruitment and
activation successively of procaspase-9 and procaspase-3 (see
Fig. 25-3).18

Lipid peroxidation can occur as a consequence of activation of any of the aforementioned free radical processes.
Lipid peroxidation decreases membrane fluidity and is associated with inactivation of membrane-bound receptors and
enzymes, increased permeability of membranes, and generation of toxic degradation products of lipid peroxidation.78,93
GSH plays a central role in protection against lipid peroxidation through enzyme-catalyzed reactions and through nonenzymatic reduction of other antioxidants (vitamins C and
E). GSH is required for degradation of lipid hydroperoxides
and other hydroperoxides in reactions catalyzed by the
selenium-dependent GSH peroxidase. For this reduction,
the fatty acid hydroperoxides must be released first from
the bulk lipid by the action of phospholipase A2.94,95 However,
a separate selenium-dependent phospholipid hydroperoxide
GSH peroxidase that directly detoxifies phospholipid hydroperoxides without a requirement for phospholipase A2 has
been characterized.96,97 A selenium-independent GSH peroxidase, which has been ascribed to GSH S- transferases of
the class,98 also detoxifies lipid hydroperoxides; like the
selenium-dependent GSH peroxidase, it requires release of
the fatty acid peroxide from the membrane. The seleniumindependent form also is active in detoxification of cumene
hydroperoxide and nucleic acid hydroperoxides.99 GSH also
detoxifies toxic degradation products of lipid hydroperoxides,
most notably the 4-hydroxyalkenals (e.g., 4-hydroxynonenal)
via S-conjugation. 4-Hydroxynonenal is an extremely toxic
product of lipid peroxidation, with submicromolar concentrations causing genotoxic lesions to cultured rat hepatocytes.100 Its conjugation with GSH is catalyzed by a specific
form of glutathione S-transferase,101,102 suggesting that this
reaction may be fundamentally important in the prevention
of free radicalmediated liver injury.

Clinicopathologic Patterns
of Drug-Induced
Liver Injury
Drugs and foreign chemicals produce manifold and varied
damage and changes to the liver. Although not absolute, drugs
typically produce patterns of injury that are characteristic for
each individual drug. It is been found useful to categorize
these patterns as hepatocellular (or hepatitic), cholestatic,
mixed, or steatotic. Some key features of these four patterns
are summarized in Table 25-3.

Hepatocellular (Hepatitic)
Pattern of Injury
The majority of drugs that cause DILI produce principally a
pattern of hepatocellular type injury.1,50,103-109 Most of these
instances are asymptomatic and mild. When they are unusually severe, patients typically develop symptoms similar to
those manifested in acute viral hepatitisfatigue, loss of
appetite (especially for smoking), and nausea. Patients with
very severe cases may suffer from vomiting, which can be
intractable, and hypersomnia; usually a complaint of abdominal pain, primarily in the epigastrium and right upper quadrant, is given.

Serum ALT, AST < 5 ULN

Serum AP > 2 ULN
Serum TBR, DBR > 2 ULN
(often >5 ULN)
Resembles biliary obstruction or
cholestatic phase of acute
hepatitis A

Serum ALT, AST > 5 ULN

Serum AP < 2 ULN
Serum TBR, DBR variable
May resemble acute ischemic or
viral hepatitis


Normal liver or diffuse,

homogeneous hepatomegaly,
perhaps with changes
compatible with diffuse fatty
change or phospholipidosis
No biliary dilation
Pancreatic swelling may be

Acute viral hepatitis

Ischemic hepatitis
Acute congestive hepatitis
Budd-Chiari syndrome
Hepatic decompensation due to
Wilson disease
Autoimmune hepatitis


Value of R



Biliary obstruction due to

gallstones, tumors, strictures,
pancreatic diseases
Primary biliary cirrhosis
Primary sclerosing cholangitis
Overlap syndromes of
autoimmune cholangitis/

Normal liver or diffuse,

homogeneous hepatomegaly
No biliary dilatation
No pancreatic abnormalities
No changes to suggest chronic
liver disease or cholecystitis

Jaundice; pruritus; nausea,

anorexia, when very severe

Nausea, anorexia (vomiting)

Loss of taste for food, smoking
Upper abdominal pain

Typical clinical


Hepatocellular (Hepatitic)


Biliary obstruction due to

gallstones, tumors,
strictures, pancreatic
Primary biliary cirrhosis
Primary sclerosing
Overlap syndromes of
autoimmune cholangitis/

Normal liver or diffuse,

No biliary dilatation
No pancreatic abnormalities
No changes to suggest
chronic liver disease or


Serum ALT, AST > 3 ULN

Serum AP > 2 ULN
Serum TBR, DBR > 2 ULN
Features of both
hepatocellular and
cholestatic patterns

Jaundice; pruritus; nausea,

anorexia, when very



Table 25-3 Clinicopathologic Patterns of Drug-Induced Liver Injury

Reyes syndrome
Acute fatty liver of
Inborn or other acquired
defects in mitochondrial
functionfatty acid
oxidation and/or ATP

Normal liver
No biliary dilatation
Normal pancreas
Normal spleen
No changes to suggest
chronic liver disease or


Serum ALT, AST 5-25 ULN

Serum AP 1-3 ULN
Serum TBR, DBR variable,
often normal
Resembles acute viral

Nausea, anorexia
Somnolence (hepatic



Alcoholic liver disease

Liver disease associated
with metabolic
syndrome: NAFL, NASH
Inborn or other acquired
defects in normal
hepatic lipid

Diffuse, generalized
Increased echogenicity
Decreased attenuation
No biliary dilatation
Normal or fatty
No changes to suggest
chronic liver disease or


Serum ALT, AST 1-5 ULN

Serum AP 1-3 ULN
Serum TBR, DBR variable,
usually normal
Resembles alcoholic

Upper abdominal
discomfort, heaviness
Nausea, anorexia

Mixed Micro-/


Stop offending drug

Ursodeoxycholic acid 20-30mg/
Cholestyramine, phenobarbital
(rifampicin) for severe pruritus

Protracted cholestatic syndrome

lasting weeks to months
Severity often increases even after
offending drug has been
Great majority of patients recover,
apparently nearly completely
(although few follow-up
biopsies are done)
Small minority (perhaps 1%)
develop vanishing bile duct
syndrome or course that
resembles sclerosing cholangitis
or biliary cirrhosis

Rapid improvement in symptoms,

signs, and lab tests, with >50%
decreases within 8-30 days

Stop offending drug

N-Acetylcysteine for
prednisolone 20-30mg/d,
azathioprine 1-2mg/kg/d for
severe immunoallergic disease

Follow Hys rule: 10% develop

jaundice 10% of those who
develop jaundice die
If FHF develops, case-fatality rate
for non-acetaminophen cases is
For acetaminophen cases is 25%
A minority (perhaps 15-30%)
with smoldering presentations
may develop bridging fibrosis
or cirrhosis
Triggering of ongoing AI hepatitis
by drugs is very rare (<0.5%)

Typical course
after inciting

Usual therapy

Course and

A mixture of prognoses
listed for cholestatic

Stop offending drug

Prednisolone 20-30mg/d,
azathioprine 1-2mg/kg/d,
for severe immunoallergic
Ursodeoxycholic acid
phenobarbital (rifampicin)
for severe pruritus

Variable course
Usually more protracted
than hepatocellular, but
less than cholestatic

Cholestasis without acute

cholangitis or
Zone 3 hepatocytic swelling
No bile lakes or other
features typical of
extrahepatic obstruction
Acute zone 3 necrosis
Findings indistinguishable
from acute viral hepatitis
Increased eosinophils and/or
acute granulomas may be
Fat (usually mainly in zone
3) may be present;
steatohepatitis may be


Full recovery
No progression to chronic
liver disease

Stop offending drug

Supportive care, nutrition
Urgent liver transplant for
severe disease with
grade 3-4

Rapid improvement in
symptoms, signs, and
labs with >50%
decreases within 8-30

Hepatocytic swelling
with foamy appearance
of cytoplasm and
centrally located nuclei
Apoptotic bodies
hepatocyte dropout with
minimal inflammation
No or minimal fibrosis


Variable, depending
upon underlying
conditions and
duration and nature of
prior injury

Stop offending drug

Supportive care, nutrition
Consider prednisone
pentoxfylline 400mg
tid for severe disease
(DF > 32 or renal

Variable, depending
upon drug
accumulation, half-life
Often, underlying alcohol
or metabolic syndrome
effects persist

Variable amounts of
neutral fat
accumulation in
hepatocytes, usually
mainly in zones 3 and 2
Hepatocyte nuclei pushed
to periphery of cells by
macrovesicular steatosis
Apoptotic bodies,
hepatocyte dropout
Variable inflammation
Variable fibrosis, usually
Lipogranulomas common
in zone 3

Mixed Micro-/


AI, autoimmune; ALT, alanine aminotransferase; AP, alkaline phosphatase; AST, aspartate aminotransferase; DBR, direct-reacting bilirubin; FHF, fulminant hepatic failure; R, ratio of serum ALT/ULN for ALT to serum AP/ULN for AP;
TBR, total bilirubin; ULN, upper limit of normal

Gradual improvement thereafter,

but may require >180 days to

Protracted course with symptoms,

signs, and labs worsening or
remaining for 30-60 days

Cholestasis without acute

cholangitis or pericholangitis
Zone 3 hepatocytic swelling
No bile lakes or other features
typical of extrahepatic

Acute zone 3 necrosis

Findings indistinguishable from
acute viral hepatitis
Increased eosinophils and/or
acute granulomas may be
Fat (usually mainly in zone 3) may
be present; steatohepatitis may
be present

Typical findings
on liver


Hepatocellular (Hepatitic)



Table 25-3 Clinicopathologic Patterns of Drug-Induced Liver Injurycontd

Chapter 25Drug-Induced Liver Injury

The laboratory features of this type of injury typically

include a normal complete blood count, although a mild
increase in white blood cell count may occur, and a minority
of patients with immunoallergic-type reactions will show
peripheral eosinophilia. Because the underlying pathogenesis
involves primarily apoptosis and/or necrosis of hepatocytes,
serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are markedly elevated. In the case of
acute poisoning with intrinsic hepatotoxins, such as acetaminophen, carbon tetrachloride, or other halogenated hydrocarbons, the elevations in levels of serum aminotransferases may
be extreme (more than 100 times the upper limit of normal
[ULN]). For the larger number of drugs that produce idiosyncratic, unpredictable, nondose-dependent DILI, the degree
of elevation of serum ALT and AST levels generally is less
marked (10 to 25 times the ULN). The serum alkaline phosphatase (AP) level is generally normal or mildly elevated (less
than twice the ULN). Serum total and direct bilirubin levels
are variable. They may remain normal, although with the
more severe forms of injury they are invariably increased. The
degree of increase in serum bilirubin level may be extreme,
and it is one of the negative prognostic factors for hepatocellular type injury. R is defined as the ratio of serum ALT/ULN
of ALT divided by serum AP/ULN of AP, with ALT and AP
concentrations in units per liter. In hepatocellular DILI, R is
>5, by definition.
Hepatobiliary-pancreatic imaging in such injury shows a
normal liver or diffuse homogeneous hepatomegaly. For some
drugs, changes compatible with diffuse fatty change (Table
25-4), Mallory-Denk bodies (Table 25-5), or phospholipidosis
(Table 25-6) may be present. Of particular importance, especially when patients are jaundiced, is the lack of evidence of
dilatation of the biliary tree or cholecystitis. Of course, preexisting gallstones may be present, making it somewhat more
difficult to arrive at a correct diagnosis. Some drugs, such as
acetaminophen, can also cause acute pancreatic, myocardial,
or renal injury. If pancreatitis occurs, the pancreas on imaging
studies generally shows diffuse enlargement or edema. Typically, changes suggestive of chronic underlying liver disease are
absent, although there is nothing about preexisting liver
disease that prevents patients from developing DILI. Therefore such changes may be present.

Table 25-4 Some Drugs and Chemicals that

Produce Hepatic Steatosis
Aflatoxin 1

Fialuridine [FIAU]
Valproic acid


The major considerations for the differential diagnosis

of acute hepatocellular injury attributable to drugs include
acute ischemic liver injury; acute viral hepatitis, which may
be due to any of the agents that are capable of causing
this syndrome (see Chapters 29 to 34); acute congestive
hepatitis, including Budd-Chiari syndrome; autoimmune
hepatitis; or hepatic decompensation caused by Wilson
When liver biopsy is performed on patients with acute
hepatocellular injury caused by drugs, typical findings are
variable and highly dependent upon the offending agent. The
most common hepatotoxic drug (namely, acetaminophen)
causes acute necrosis first and foremost in zone 3 of the
hepatic acinus. When very severe, necrosis extends into and
through zone 2 as well (see Fig. 25-5).
Other common histologic findings include variable
inflammation of the portal tracts, often with a considerable
number of polymorphonuclear or eosinophilic forms. Acute
granulomas may also occur. Indeed, drug-induced liver
injury is one of the common causes of granulomas in the
liver.110-112 Some drugs and chemicals are well-known to
produce fatty change in the liver. Usually this is primarily
in zone 3, although it is certainly not restricted to this zone.
All of the features of steatohepatitis may sometimes be
In most instances of hepatocellular injury, particularly
when it has been sudden and acute in onset, there is a rapid
improvement in symptoms, signs, and laboratory features
when the offending agent is discontinued. This does not
always occur, however, and in rare individuals drugs appear to
be capable of triggering the development of self-perpetuating
autoimmune hepatitis.109,113

Table 25-5 Some Drugs and Chemicals that

May Produce Mallory-Denk Bodies


Table 25-6 Some Drugs that Produce

All amphiphilic drugs



Section IVToxinMediated Liver Injury

The short-term and long-term prognosis of hepatocellular

type injury follows Hys rule. This was popularized by
Hyman Zimmerman, a clinical hepatologist with special
interest in drug-induced liver injury.103 Hys rule states that
about 10% of patients with drug-induced liver injury of
the hepatocellular type develop jaundice and that among
those who develop jaundice, approximately 10% will die of
drug-induced liver injury. Several recent reports have confirmed the accuracy of Hys rule.104-108 The case fatality rate
for persons who develop fulminant hepatic failure attributable to drugs is very high (around 75%) for drugs other
than acetaminophen. In contrast, the case fatality rate for
acetaminophen-induced fulminant hepatic failure is much
lower, with only about 25% of patients dying and/or requiring liver transplant.
For the most part there is no specific therapy for druginduced liver injury beyond identifying the offending agent
and discontinuing its use. It is clear that acute acetaminophen
overdose should be treated immediately with N-acetylcysteine.
For adults with acetaminophen ingestion less than 24
hours before presentation, an N-acetylcysteine loading dose
of 140mg/kg/body weight should be given, followed by
70mg/kg every 4 hours for 17 doses, starting 4 hours after the
loading dose. It has been suggested that N-acetylcysteine may
be of benefit in other forms of fulminant hepatic failure, and
indeed there seems little to be lost by administering it in other
forms of acute hepatitic failure.
Particularly when hepatocellular type injury is severe, and/
or when it is accompanied by evidence of immunoallergic
features, a corticosteroid, such as prednisolone (20 to
30mg/day), and azathioprine (1 to 2mg/kg body weight per
day) often are administered as well.

Cholestatic Pattern of Injury

The typical presentation of cholestatic hepatitis attributable
to drugs is jaundice and pruritus. Nausea, anorexia, or vomiting typically occurs only when the reaction is very severe. The
typical laboratory features are those of any cholestatic syndrome, with elevations primarily in serum AP level, which is
more than twice the ULN, and serum total and direct bilirubin
levels, which also are at least twice the ULN. In the pure cholestatic case, levels of serum aminotransferases are normal or
only mildly elevated, and certainly less than three times the
ULN. R is <2.
The typical hepatobiliary-pancreatic imaging findings in
cholestatic DILI are primarily important because they show
no evidence of biliary dilatation and no pancreatic abnormalities. The liver is usually normal or nearly normal, and there is
nothing to suggest chronic liver disease or cholecystitis (see
Table 25-3).
The major differential diagnosis for cholestatic DILI
includes biliary obstruction (resulting from gallstones, tumors,
strictures, or pancreatic diseases) and autoimmune disorders
that affect chiefly the bile ducts, such as primary biliary cirrhosis or primary sclerosing cholangitis. There are also
overlap syndromes of autoimmune cholangitis and autoimmune hepatitis. These are considered in greater detail in
Section VI (Immune Diseases of the Liver).
Typical findings on liver biopsy in cholestatic DILI are the
presence of bile in hepatocytes, bile plugs in canaliculi, and
hepatocyte swelling in zone 3 (Fig. 25-8). Bile lakes or other

Fig. 25-8 A, Cholestatic injury. This biopsy, from a patient who became
jaundiced while taking the NSAID nabumetone, shows relatively bland
cholestasis with numerous canalicular bile plugs (arrows) but relatively
little hepatocellular injury. The peak serum bilirubin level in the patient
was 110mg/dl. B, Cholestatic injury. This biopsy, from a patient who
became jaundiced after a course of amoxicillin, shows a combined hepatocellular and cholestatic injury with canalicular bile plugs (arrows) as
well as hepatocyte injury, apoptosis, and dropout with Kupffer cell hypertrophy and lymphocytic inflammation, producing disarray of the liver cell

features of extrahepatic obstruction are absent, and as a rule

there are no findings of acute cholangitis or pericholangitis,
such as one would expect to see in bacterial ascending
The typical course of cholestatic hepatitis is quite different from that of hepatocellular DILI in being more protracted. In fact, it is not uncommon for signs and laboratory
worsening to continue after the offending drug has been
discontinued, sometimes for as long as 30 to 180 days.
There is gradual improvement thereafter, unless the offending agent or another like it is readministered. There are
rare instances in which the disease does not resolve but
instead evolves to produce the adult vanishing bile duct
syndrome, sometimes with progression to secondary biliary

Chapter 25Drug-Induced Liver Injury


The usual therapy for cholestatic DILI is to stop the offending drug and administer ursodeoxycholic acid. It is our recommendation that ursodeoxycholic acid be given at a dosage of
20 to 30mg/kg/day in two divided doses. If pruritus is severe
the usual treatment is cholestyramine; however, this must be
given at times other than when ursodeoxycholic acid or other
drugs are administered, because it will bind the drugs and
prevent their absorption. We generally recommend that the
cholestyramine be administered in the morning, when there
is maximal turnover of the biliary pool. Other helpful measures to control pruritus include plasmapheresis and administration of phenobarbital, rifampicin, or naltrexone, although
all of these drugs, especially rifampicin, may also cause hepatotoxicity on their own.

Mixed Pattern of Injury

This pattern, as the name implies, involves features of both
hepatocellular and cholestatic injury (see Table 25-3). The
typical clinical presentation is nausea, anorexia, and vomiting
when severe. Jaundice and pruritus may also be present.
The typical laboratory findings are for serum aminotransferase levels to be greater than three times the ULN and for
serum AP and total and direct bilirubin levels to be more than
twice the ULN. The biopsy features are also a mixture of the
features described previously for the other two types of injury.
R is between 2 and 5.
The considerations for differential diagnosis must include
ischemic hepatitis, acute congestive hepatitis, acute viral hepatitis, autoimmune hepatitis, or overlap syndromes of autoimmune cholangitis and hepatitis; hepatic decompensation
caused by Wilson disease, primary biliary cirrhosis, primary
sclerosing cholangitis, and biliary obstruction attributable to
gallstones, tumors, strictures, or primary pancreatic diseases
should also be included in the differential diagnosis.
The typical treatments are the same as those already
described for hepatocellular and cholestatic injuries. The
typical course is somewhat longer than for hepatocellular
injury, but somewhat shorter than for typical cases of pure
cholestatic DILI.

Steatotic (Fatty Liver)

Pattern of Injury
As shown in Table 25-3, there are two major types of disease
that produce primarily fatty change in the liver: microvesicular steatosis results in changes in pure small-droplet fat particles whereas macrovesicular steatosis is associated with
alterations in fewer large-droplet fat molecules. Typically,
however, macrovesicular steatosis is present with at least a
mild degree of microvesicular steatosis.
Microvesicular steatosis is due principally to mitochondrial
toxicity, leading both to a deficiency in mitochondrial
-oxidation of free fatty acids and to critical compromise of
mitochondrial ATP production. Patients with these defects
commonly present with nausea, anorexia, vomiting, confusion, or coma, the latter attributable to hepatic encephalopathy with prominent and severe hyperammonemia. They often
have significant lactic acidosis because of the critical defect in
mitochondrial respiration and oxidative phosphorylation.
The typical laboratory features are moderate to marked
increases in levels of serum aminotransferases; serum AP level

Fig. 25-9 Microvesicular steatosis in a child taking valproic acid.

Most of the hepatocytes have small vacuoles of fat, and liver cell dropout
with Kupffer cell hypertrophy and a mild lymphocytic infiltrate are visible.

is normal or only slightly increased, and serum bilirubin levels

are variable, depending on the severity of the injury. R is >5.
Typical hepatobiliary-pancreatic imaging studies in patients
with microvesicular steatosis show a normal liver, pancreas,
and spleen as well as the absence of biliary dilatation or any
imaging findings to suggest portal hypertension or chronic
liver disease. The major differential diagnosis is Reyes syndrome or inborn or other acquired defects in mitochondrial
function, particularly fatty acid metabolism or ATP
The findings on liver biopsy are remarkably mild (Fig.
25-9). To clearly visualize the lipid, it may be necessary to
perform oil red O staining on frozen sections. The reason is
that there is diffuse lipid accumulation in very small droplets,
often smaller than the limit of resolution by light microscopy.
There is no displacement of hepatocytic nuclei, such that the
lipid may not be apparent in formalin-fixed tissue stained in
the routine way. There is minimal inflammation, although
apoptotic bodies and evidence of hepatocytic dropout may be
present, and there is usually no fibrosis.
The usual course is one of rapid improvement if the inciting
agent is discontinued. However, some patients have such
severe defects that they may be unable to recover unless they
receive urgent liver transplantation. Certainly, all such patients
who might be transplant candidates and who develop higher
grades of hepatic encephalopathy should rapidly be transferred to a transplant center. If patients can be nursed successfully through the acute phase of disease, complete recovery
with no progression to chronic liver disease will ensue. Examples of drugs that produce microvesicular steatosis are summarized in Table 25-4.

Macrovesicular or Mixed
Microvesicular and
Macrovesicular Steatosis
The accumulation of fat is probably the most common liver
abnormality. Potential causes of fatty liver are manifold and
discussed in greater detail in Chapter 53. Drugs and chemicals


Section IVToxinMediated Liver Injury

Table 25-7 Some Drugs and Chemicals that

May Produce Peliosis Hepatis
Anabolic steroids
Contraceptive steroids

Vinyl chloride
Vitamin A excess

are among the important causes of fatty liver. Indeed, if one

considers ethanol as a drug, they are probably the most
common causes. Most people with fatty liver attributable to
alcohol or other conditions that produce macrovesicular
steatosis are asymptomatic. When the fatty deposition is
severe, hepatomegaly ensues, and patients may have upper
abdominal discomfort and a sense of heaviness. It is rare
for more severe symptoms, such as nausea, anorexia, vomiting, or jaundice, to occur. Laboratory studies may be entirely
normal or may show mild increases in levels of serum aminotransferases. Although serum AP levels may be slightly
increased, -glutamyltranspeptidase levels are usually more
elevated. Typical findings on hepatobiliary-pancreatic imaging
are diffuse, generalized hepatomegaly. Ultrasound shows evidence of increased echogenicity, whereas CT scanning shows
a decrease in hepatic attenuation. There is generally no biliary
dilatation and the pancreas appears normal or may show
increased echogenicity indicative of a fatty deposition in the
In addition to heavy alcohol use, macrovesicular steatosis is
commonly caused by liver disease associated with metabolic
syndrome (nonalcoholic fatty liver and nonalcoholic steatohepatitis; see Chapter 53). The typical findings on liver biopsy
in patients with drug-induced macrovesicular steatosis are
indistinguishable from those caused by alcohol or by nonalcoholic fatty liver. It is common for patients to have these
changes because of an element of alcohol and nonalcoholic
fatty liver plus one or more drugs. Mallory-Denk bodies may
develop as a result of alcoholic or nonalcoholic steatohepatitis,
and have been associated with several drugs (see Table 25-5).
The usual therapy is to stop the offending drug. However, if
the fatty change is mild and asymptomatic and if the drug is
essential for other reasons, such as methotrexate for the management of rheumatoid arthritis or psoriasis, the decision may
be made to continue the drug with careful monitoring. In
addition to the histopathologic features already described,
drugs can cause the accumulation of phospholipids in hepatocytes and other cells (see Table 25-6), vascular lesions in the
liver (including peliosis hepatis) (Table 25-7), sinusoidal
obstruction or venoocclusive disease, and arterial vascular
compromise, which is manifest as a syndrome that resembles
sclerosing cholangitis.

Predictable versus
Unpredictable DILI
Another useful way to categorize DILI is as predictable or
intrinsic injury versus unpredictable or idiosyncratic. By

far the most important example of the former is acetaminophen, which, by mechanisms already described, will produce
liver injury in virtually everyone who takes a sufficient dose.
Examples of other drugs or toxins that act similarly are listed
in Table 25-8.
Most drugs, however, cause DILI unpredictably and in only
a small percentage of subjects. Such reactions are called idiosyncratic reactions and are further subdivided according to
the accompanying presence or absence of immunoallergic
manifestations. Such manifestations include symptoms such
as fever, peripheral eosinophilia, skin rash, arthralgia, and
arthritis. As shown in Table 25-8, many drugs are recognized
as capable of causing idiosyncratic DILI either with or without
an immunoallergic phenotype, stressing the importance of
genetic host factors in modulating the response to injury (see
Fig. 25-2).
The mechanisms that probably lead to immunoallergic
injury are summarized in Figure 25-10. According to this
figure, drugs may produce antigens by binding to host proteins (perhaps altering them), which are recognized as foreign
and against which the hosts immune system mounts a T- or
B-lymphocyte response. Because such neoantigens are displayed on hepatocytes, where most drug metabolism occurs,
the net effect may resemble autoimmune hepatitis. Indeed,
ingestion of drugs appears to trigger autoimmune hepatitis
in rare individuals.109,113 The importance of host immune
responses in pathogenesis of DILI is emphasized by the fact
that nearly all genetic associations with risks of DILI thus far
identified, mostly from genomewide or candidate-gene association studies, have been to HLA alleles (Table 25-9). In
several cases (amoxicillin/clavulanic acid, carbamazepine, flucloxacillin) the causative drugs result in immunoallergic
disease, whereas in others (isoniazid [INH], ximelagatran)
they do not. This suggests that immune reactions are important in most cases of clinically important DILI, even in the
absence of classical immunoallergic features.

DILI Due to Specific

Of the agents currently in use to induce and maintain anesthesia, only the halogenated volatile agents have clinically significant hepatotoxicity. Beginning with halothane in the 1950s,
the halogenated anesthetics replaced the routine use of ether
and chloroform. Halothane, besides being nonflammable, had
much better pharmacokinetics than ether, and had fewer
respiratory and cardiac side effects than chloroform. However,
postoperative liver injury was soon recognized, especially in
patients reexposed to halothane,103,128,129 and it was also an
occupational hazard for those administering the anesthetic.130
The development of other halogenated agents, such as enflurane, isoflurane, desflurane, and sevoflurane, was associated
with less hepatotoxicity, most likely because these agents
underwent less hepatic metabolism. However, all have been
reported to cause liver injury,131-134 and although sevoflurane
may be the safest,135 reports still appear of hepatotoxicity.136
The incidence of hepatotoxic reactions after halothane administration has been estimated between 1:3,000 and 1:30,000.137
The incidence after enflurane use has been estimated to be

Chapter 25Drug-Induced Liver Injury


Table 25-8 Classification of DILI: Comparison of Intrinsic (Predictable)

vs. Idiosyncratic (Unpredictable) DILI




All subjects given high doses
will develop hepatotoxicity
Regularly produced in
experimental animals

Low/slight or nil
Most subjects will not develop
hepatotoxicity, regardless of dose
Not reproducible in experimental

Low/slight or nil
Most subjects will not develop
hepatotoxicity, regardless of dose
Not reproducible in experimental


Toxic damage to other

tissues also occurs
Drug-induced renal,
pancreatic injury common

Fever, skin rash, peripheral

adenopathy, eosinophilia
Development of autoantibodies
(ANA, ASMA), hyperglobulinemia

No extrahepatic manifestations of
immunoallergic responses

Underlying risk

Induction (without
inhibition) of enzymes
that increase formation of
toxic intermediates
Conditions that decrease
detoxification, and
removal of toxic

Allergic diathesis
Other host genetic factors presumed
to play a role such as presence of
certain HLA types, factors that
influence Th1 vs. Th2 phenotypes
Women more susceptible than men
(like most autoimmune diseases)

Other host genetic factors

presumed to play a role, such as
genetic variations that influence
expression of phase I-II enzymes
of drug metabolism
Presence of underlying liver disease,
especially chronic viral hepatitis in
subjects receiving HAART and
fatty liver in subjects receiving
methotrexate or dugs implicated
in producing steatohepatitis

Typical pattern
of injury

Hepatocellular, acute

Hepatocellular, acute
Less often, cholestatic or mixed

Hepatocellular, acute
Less often, cholestatic or mixed

Response to

Reproduced promptly and


Very rapid recurrence (1-3 doses)

Variablemay be delayed for

several weeks, usually more rapid
than initial episode

Examples of
inciting agents

Amanita toxins
Carbon tetrachloride
White phosphorus

Amoxicillin/clavulanic acid
Statins (very rarely)

Amoxicillin/clavulanic acid
Chlorpromazine (other
Glitazones (rosi-, pio-, troglitazone)
Statins (rarely)

Typical duration
of exposure,
before onset

Very brief (<1 week) (e.g.,

acetaminophen overdose
in attempted suicide)

Brief (1-5 weeks) (e.g., development

of allergic reaction to phenytoin)

Valproic acid
Highly variable, depending upon
poorly defined host susceptibility
factors (1-100 weeks) (e.g.,
variable onset of glitazoneinduced DILI)


approximately 1:800,000.138 The newer agents have an even

lower incidence.
Studies of pathogenesis support an immune mechanism for
liver injury,109,139 with identification of halothane metabolite
modified neoantigens in injured livers140 and IgG antibodies
to neoantigens in sera of patients.141 CYP2E1 appears to be the
cytochrome P450 responsible for the oxidative generation of
the reactive metabolite.142 When halothane, isoflurane, and
sevoflurane were administered to dogs,143 all caused elevations
in aminotransferase levels postoperatively, but halothane

caused toxicity much earlier and to a greater degree than the

other agents.
The clinical features of halogenated anesthestic liver injury
were reviewed both years ago103,128,130 and more recently.144,145
Most individuals had undergone anesthesia on multiple occasions and there can be cross-sensitization between agents.
Nonspecific symptoms, including fever and malaise, occur
days to weeks postoperatively and are followed by marked
elevations of aminotransferase levels and then jaundice. Onset
is variable, with jaundice occasionally taking more than 1


Section IVToxinMediated Liver Injury

Parent drug

Modified protein
Native protein


Modified protein

Reactive metabolite

Kupffer cell


Dendritic cell

Helper T cell
MHC class 2

Processed Ag
T cell activation
+ proliferation

T cells

B cells

T cell-mediated
killing of

Fig. 25-10 Likely mechanisms for pathogenesis of drug-induced immunoallergic hepatitis.

month to develop. The usual histologic pattern of liver injury

is centrilobular necrosis146; however, cholestatic features can
also occur.147 The most frequently affected patients are obese
women between 40 and 60 years old. A small percentage of
patients proceed to fatal fulminant liver failure, with some
rescued by transplantation. However, complete resolution
without residual liver dysfunction occurs in the majority of
cases. Patients who have survived such reactions should not
be reexposed to any halogenated anesthetics.
Anesthetic agents not reported to cause DILI include the
barbiturates (thiopental [Pentothal], methohexital [Brevital]),
ketamine (Ketalar), propofol (Diprivan), the opioids (alfentanil [Alfenta], fentanyl [Sublimaze], remifentanil [Ultiva],
sufentanil [Sufenta]), etomidate (Amidate), dexmedetomidine (Precedex), and all the topical -caines.

Many anticonvulsants have potential hepatotoxic effects
(Table 25-10), including agents that have been in use for
decades (e.g., phenytoin, valproic acid, carbamazepine) as well
as newer drugs such as felbamate and lamotrigine. Because of
the clinical importance of seizure control, all of these agents
remain in use despite their potential toxicities. Felbamate is
considered an adjunct second-line agent, to be used only if

other agents are ineffective. Vigabatrin (i.e., vinyl-GABA) has

restricted use in the U.S. market because it has caused visual
field defects.148,149 However, the drug may be useful for treating
methamphetamine and cocaine addiction.150 Many other anticonvulsant agents will probably become available in the
future,149 and careful postmarketing monitoring will be
required to elucidate their toxicities.
Phenytoin has been known for decades to cause hepatotoxicity in association with hypersensitivity reactions.151-153 The
majority of patients taking phenytoin develop mild elevations
of AP and gamma glutamyl transpeptidase (GGTP) levels
within the first few months of therapy that normalize with
continued use of the drug. These changes are part of hepatic
adaptation and generally do not require cessation of therapy.
It is the hypersensitivity reaction that is most worrisome.154
The formation of the reactive arene oxide metabolite by
CYP2C9, followed by formation of the o-quinone by CYPs
2C9, 2C19, and 3A4, leads to haptens and immune activation.
The incidence of this idiosyncratic nondose-related hepatotoxicity is estimated to be <1:10,000, and 56% of phenytoin
hypersensitivity is associated with some hepatotoxicity.154
Liver failure necessitating transplantation still occurs.1
The clinical symptoms usually manifest within 1 to 8 weeks
of drug exposure and include fever, malaise, lymphadenopathy, splenomegaly, and rash. Serum aminotransferase levels

Chapter 25Drug-Induced Liver Injury


Table 25-9 Reported Genetic Associations with Risk of DILI





OR (95% CI)


HLA Genes
Abacavir; 114, 115

DRB*5701, DR7, DQ3



117 (29-481)
822 (43-15,675)

clavulanic acid;








9.2 (N/A)
2.45 (1.37-4.8)
4.14 (1.73-9.95)
2.8 (2.1-3.8)

Flucloxacillin; 121




80.6 (22.8-285)

INH; 122




2.1 (1.0-4.18)
0.2 (0.04-0.69)

Lapatinib; 123




9.0 (2-53)

Lumiracoxib; 124

(GWAS rs3129900)



6.3 (4.1-9.7)

Ticlopidine; 124

A*3303 (Japanese)



13 (4.4-38.6)

Ximelagatran; 125




4.41 (2.22-8.87)
4.41 (2.21-8.80)

CYP2E1 [c1/c1] (wild

CYP2E1 [c1/c1] +
NAT2 slow



2.52 (NR)

NAT2 slow acetylator


Most significant association

observed for haplotype
A*201-B*0702-DRB1*1501DQB1*0602 (ORs 13-20)
Study among Asian Indians
Protective allele
For ALT > 5 ULN
Part of haplotype DRB1*1501DQA1*0102-DQB1*0602DRB5*0101 associated with
amoxicillin/clavulanic acid
DILI and multiple sclerosis

Non-HLA Genes
INH; 126

INH; 127

7.43 (NR)


5.41 (1.76-16.59)

No association between CYP2E1

genotype and anti-Tb drug

ALT, serum alanine aminotransferase; CI, confidence interval; HLA, human leukocyte antigen; NAT, N-acetyltransferase; NR, not reported; OR, odds ratio; ULN, upper
limit of normal

are elevated 2- to 100-fold (ALT > AST) and AP levels 2- to

8-fold.152,154,155 Leukocytosis and atypical lymphocytes suggesting mononucleosis and eosinophilia are common, with a
lupus-like syndrome and pseudolymphoma reported occasionally. Other organ system toxicities can include interstitial
nephritis, myositis and rhabdomyolysis, pneumonitis, and
marrow suppression. The clinical presentation can also simulate viral hepatitis. When liver biopsies are performed, the
histologic analysis shows a panlobular mixed mononuclear
and polymorphonuclear infiltrate with prominent eosinophilia. In 10% of cases cholestasis is the predominant finding.
The findings are not specific, however.
Therapy is discontinuation of the drug, which in most cases
leads to resolution of toxicity. However, once liver failure
develops, the case/fatality ratio can be as high as 40%. Because
of cross-reactivity with carbamazepine and oxcarbamazepine,153,156 these latter agents should not be used to replace
phenytoin for seizure control in patients who have

experienced symptomatic phenytoin toxicity. A phosphate

ester prodrug of phenytoin, fosphenytoin, developed for parenteral administration157 should also be avoided.
Carbamazepine, like phenytoin, can also cause asymptomatic mild elevations in serum GGTP (64%) and AP (14%)
levels that do not require discontinuation of therapy.154
However, increases in aminotransferase levels, seen in 22% of
patients, may indicate susceptibility to develop the more
serious idiosyncratic hypersensitivity reaction. A Swedish
analysis158 estimated the risk to be about 1 in 6000, which is
more common than with phenytoin. The hypersensitivity
reaction is also due to formation of a reactive metabolite,
probably an unstable epoxide formed by CYP3A4.159 Drug
toxicity usually occurs within 8 to 16 weeks of therapy and
presents with fever, rash, and peripheral eosinophilia. Marrow
suppression, nephritis, and pneumonitis can also occur. Carbamazepine is more likely than phenytoin to cause a pure
cholestatic pattern of hepatotoxicity, which occurs in 30% of


Section IVToxinMediated Liver Injury

Table 25-10 Anticonvulsants and DILI



Reported to Cause DILI

Phenytoin (Dilantin)
Fosphenytoin (Cerebyx)

Immunoallergic; hepatitic
> cholestatic

Valproic acid, divalproex sodium



Clonazepam (Klonopin)

Very rare idiosyncratic

(one case report174)

Carbamazepine (Tegretol,


Oxcarbazepine (Trileptal)
Felbamate (Felbatol)

Hepatitic > cholestatic

Lamotrigine (Lamictal)

Cholestatic > hepatitic

Topiramate (Topamax)
Levetiracetam (Keppra)

1 case fulminant failure

Zonisamide (Zonegran)

1 case vanishing bile ducts

Not Reported to Cause Hepatotoxicity

Ethosuximide (Zarontin), phenobarbital,* primidone
(Mysoline), tiagabine (Gabitril)
*Phenobarbital activates the orphan nuclear receptor CAR and exerts
well-known proliferative effects on hepatocytes.

reactions. A mixed pattern of liver injury with elevations in

AP, bilirubin, and aminotransferase levels occurs in 50% of
cases. A predominantly hepatocellular injury may have a
worse prognosis.154 Consistent with the cholestatic clinical
picture, histopathologic study commonly demonstrates a
granulomatous reaction with eosinophilia.160 Resolution of
injury takes several weeks after drug withdrawal. Because the
injury is immune mediated, rechallenge is not recommended,
and both phenytoin and oxcarbamazepine should also be
avoided.156,161 The keto analogue of carbamazepine, oxcarbazepine, was first introduced in 1990 in Denmark and has
recently become available in most countries, including the
United States. It is considered to be a safe and useful anticonvulsant162 with fewer P450-related drug interactions than carbamazepine.149 However, it has also been reported to cause
acute liver failure as a result of hypersensitivity,163 with a
similar clinical presentation to that of carbamazepine and
Valproic acid (VPA) may be the most widely prescribed
anticonvulsant worldwide,164 and in general is considered very
safe, with the incidence of hepatotoxicity in adults and children older than 2 years being approximately 1 in 35,000.165
However, in children younger than 2 years, especially those
taking other anticonvulsants, the incidence may be as frequent
as 1 in 600. It is also clear that patients with genetic mitochondrial enzyme defects are at greater risk,166,166a most likely
because of valproates depletion of coenzyme A levels and its
metabolism via mitochondrial oxidation. Persons with the
Alpers-Huttenlocher syndrome are at especially high risk, and
this is related to mutations in the mitochondrial polymerase
gamma gene.166a Hepatotoxicity usually occurs within the first
3 to 6 months of therapy,154 although delays as long as 2788
days have been reported.166a

Valproates hepatotoxicity is most likely dose related,166

although epidemiologic studies have suggested that other host
factors and polypharmacy may be more important.165 Up to
40% of patients have transient, asymptomatic elevations in
ALT concentration that improve with dose reduction.154 High
doses of drug, in addition to young age and polypharmacy, are
significantly associated with higher excretion of thiol conjugates of the toxic valproate metabolite (E)-2,4-diene-VPA.167
Therefore ALT monitoring is recommended for the first 6
months of therapy and after dose increases. Patients taking
olanzepine in addition to valproate had higher ALT level elevations than with either drug alone.168 Although no specific
degree of ALT level elevation has been identified as an indicator of impending hepatic failure, a greater than threefold
elevation should prompt drug cessation. If fever, nausea, vomiting, and abdominal pain accompany laboratory evidence of
developing hepatic failure and poor seizure control, then liver
failure will probably become irreversible.
The characteristic histopathology of valproate hepatotoxicity is that of microvesicular steatosis, similar to Reyes syndrome, seen mainly in zones 2 and 3.154 These changes may
occur without toxicity. In one recent report 61% of patients
receiving long-term valproate had sonographic evidence of
fatty liver,169 with the majority having normal concentrations
of serum aminotransferases. Valproate therapy has also been
reported to decrease serum albumin concentrations by up to
30% without apparent toxicity in a small study of children
with severe neurologic disabilities.170
Because of the potential for valproate to damage mitochondrial function, l-carnitine was suggested as a protective
agent171 and may improve survival with severe valproate hepatotoxicity,172 especially if administered intravenously. Oral
supplementation of 100mg/kg/day is recommended for
infants and young children taking valproate, and for patients
with symptomatic hyperammonemia or multiple risk factors
for hepatotoxicity.173 Prophylactic use of l-carnitine decreases
the risk of valproate hepatotoxicity and is recommended.

Newer Anticonvulsants
Felbamate was approved for use in 1993; it was the first
new anticonvulsant approved in the United States since the
introduction of valproate in 1978. However, during its first
year of use an incidence of hepatic failure of 1 in 6000 (and
an aplastic anemia incidence of 1 in 3000) prompted restriction of its use to severe epilepsy not responding to other
agents.149 However, felbamate is still considered an important
drug, with more than 8000 patients treated annually in the
United States. By 1996, 36 cases of hepatotoxicity had been
collected by the FDA, with 5 deaths.175 However, since then
no further cases of hepatotoxicity have been reported and
it is considered very safe.176 The mechanism of toxicity appears
to involve the formation of an aldehyde monocarbamate177
that is activated to atropaldehyde.154,178,179 Because felbamate
is usually given with other anticonvulsants and is a CYP3A4
substrate, studies of drug interactions have been carried
out. A recent in vivo study179 suggests that felbamate
may heteroactivate CYP3A4 to promote the formation of
carbamazepine-10,11-epoxide when these agents are used
together. The paucity of reported cases makes it difficult
to describe the clinical characteristics and histopathology
of felbamate hepatotoxicity. However, presentation occurs

between 3 weeks and 6 months of initiation of therapy, with
a possible female preponderance.154
Clonazepam is listed in and as having hepatotoxicity as a serious adverse
event. However, only one case report could be found in the
Lamotrigine is a chlorinated phenyltriazine anticonvulsant
that has been in use for more than a decade. The first case of
fulminant hepatic failure attributable to its use was reported
in 1995.181 Another severe case of an 8-year-old boy who
recovered was reported in 1998.182 Despite more than 2 million
prescriptions written,149 only 9 cases of hepatotoxicity have
been reported so far in the literature183 and most of these were
polytherapy patients. The most common adverse event of
lamotrigine is a skin rash,184,185 which occurs in 3% to 10%
of patients154 and can be severe. Whether the metabolism of
lamotrigine to a reactive arene oxide186 is responsible for both
the cutaneous toxicity and the rare hepatotoxicity is not yet
Topirimate, also marketed to prevent migraines, is related
to carbonic anhydrase inhibitors and can cause metabolic acidosis. It has been considered very safe with few side effects
(the majority involving the CNS), especially if started at low
doses and increased slowly (<50mg/week).187 Only one case
of acute liver failure necessitating a transplant has been
reported, in a woman also taking carbamazepine.188 Five additional cases of reversible hepatotoxicity in three children and
two adults, all of whom were also taking valproate, have since
been reported.189-191
Levetiracetam is minimally metabolized (only 34%)192 with
few long-term side effects193; however, it did appear to cause
fulminant liver failure in an Australian patient, who required
a transplant.194 Unfortunately, inadvertent reexposure to the
drug injured the new liver.
Zonisamide is hepatically metabolized, but has few drug
interactions.195 A case of vanishing bile duct syndrome has
been reported.196

Psychotropic Drugs
Methylphenidate is a commonly used and possibly overused
stimulant agent that can cause liver test (LT) abnormalities,
but has only been reported to cause hepatotoxicity with IV
abuse in high doses.197 It has also been reported to precipitate
an autoimmune hepatitis.198 However, these hepatic adverse
events appear to be very rare.
Atomoxetine is a nonstimulant-selective norepinephrine
reuptake inhibitor often used instead of methylphenidate
because it is not a controlled substance. It is metabolized by
CYP2D6 and has been reported to rarely cause serious hepatotoxicity in postmarketing surveillance.199 CYP2D6 rapid
metabolizers may have fewer ADRs.

AntipsychoticsFirst Generation
The phenothiazine neuroleptics, including chlorpromazine,
prochlorperazine, perphenazine, and thioridazine, are wellknown to cause both hepatocellular and cholestatic injury,

Chapter 25Drug-Induced Liver Injury


most likely by immunoallergic mechanisms.200 Fluphenazine,

thioproperazine, and trifluoperazine appear to cause cholestasis only. In a pharmacovigilance study using a British
database,201 chlorpromazine was found to be the agent most
often associated with drug-induced liver injury, with an
adjusted odds ratio of 416. If serial LFTs are drawn, 42% of
patents receiving chlorpromazine show abnormalities. The
butyrophenone haloperidol can also rarely cause cholestasis,
which is sometimes prolonged.

AntipsychoticsSecond Generation
The second-generation antipsychotics have largely replaced
the first-generation agents because of greater efficacy and
fewer side effects, including less hepatotoxicity. However,
clozapine commonly causes abnormal LT results, in up to
40% of patients,202 but only two cases of fatal fulminant liver
failure have been reported.203 When clozapine was compared
with ziprasidone in an 18-week study of 147 patients, no
hepatotoxicity was found for either drug.204 Olanzapine,
which has become popular because it is well tolerated, causes
transiently abnormal LT results in 10% of patients, and three
cases of reversible hepatitis with jaundice have been
reported.205 However, in the last case report,205 the patient
had also been taking risperidone, for which there are numerous case reports of acute hepatitis from the 1990s.200 Interestingly, the Epocrates database does not mention hepatotoxicity
as an adverse event for risperidone. Quetiapine is listed as
causing abnormal LT results, and there is one case report of
cholestatic injury.206 No reports of liver injury have yet been
submitted for aripiprazole, paliperidone, pimozide, and iloperidone. Therefore although these agents all have numerous
serious side effects, hepatotoxicity appears to be rare and
monitoring of LT results has not been recommended for any
of them.

The tricyclic antidepressants, especially amitriptyline and
imipramine, cause transient elevations in aminotransferase
levels in up to 10% to 20% of patients, but only rarely cause
fulminant hepatitis and prolonged cholestasis.200 In fact, hepatitis is listed as a possible ADR in the Epocrates database for
many tricyclic antidepressants, including amoxapine, clomipramine, desipramine, doxepin, nortriptyline, and trimipramine. The tricyclics are metabolized by CYP2D6 and toxicity
is more common in 2D6-poor metabolizers. Amineptine, no
longer marketed, could also be metabolized by CYP3A4 to
reactive metabolites that were more likely to cause an immunoallergic reaction. It was shown that amitriptyline and its
N-dealkylated metabolite, nortriptyline, can be bioactivated
by CYPs 2D6 and 3A4 to an arene oxide intermediate.207
The monoamine oxidase inhibitors phenelzine and tranylcypromine are also listed as causing hepatitis; however, no
case reports of significant liver injury were found. Phenelzine,
in particular, is a potent inhibitor of hepatic P450s, especially
CYPs 3A4 and 2C19.208 Iproniazid, withdrawn from the U.S.
market in 1956 due to hepatotoxicity, was associated with an
antimitochondrial antibody against a different antigen than
what is seen in primary biliary cirrhosis.200
Selective serotonin reuptake inhibitors (SSRIs) rarely cause
liver injury and they are not mentioned in the Epocrates


Section IVToxinMediated Liver Injury

database. However, paroxetine has been reported to cause

acute hepatitis in a small number of cases209 and fluoxetine,
citalopram, escitalopram, fluvoxamine, and sertraline have
all had a few case reports of liver damage, with only 2 out of
30 being fatal.209
Two newer serotonin and norepineprine reuptake inhibitors
reported209-211 to cause DILI. Although duloxetine was estimated to have a likelihood of producing severe hepatic injury
in only 0.7/100,000,212 in an analysis of 17,615 subjects, the
incidence of serum ALT levels >5 ULN was 500/100,000.213
Postmarketing surveillance identified 406 cases of presumed
DILI from duloxetine, of which 58 were judged to be clinically
significant, with 2 fatalities: 1 in a woman also taking mirtazapine and the second in a man with chronic alcohol
abuse.212 This led to a warning in the package insert that
duloxetine should ordinarily not be prescribed to patients
with substantial alcohol use or evidence of chronic liver
disease. Seven additional cases of clinically important DILI
attributable to duloxetine have been described from the U.S.
Drug-Induced Liver Injury Network (DILIN) Registry. Five of
the cases were hepatocellular; two were cholestatic, and three
occurred in subjects with preexisting chronic liver disease. In
two patients, acute renal failure also occurred. Venlafaxine was
associated with fatal fulminant failure in two cases, although
the first was an overdose210 and the other case was in association with trazodone211an atypical antidepressant with far
more reported hepatotoxicity.209
The other atypical antidepressants, besides trazodone,
include bupropion (also FDA approved for nicotine addiction), mirtazapine, and nefazodone. All of these drugs have
hepatotoxicity listed in the Epocrates database. Nefazodone,
a phenylpiperazine, appears to be more hepatotoxic than the
rest209 with an estimated incidence of liver failure 1:250,000
patient years of use and 5 of 10 reported cases requiring transplant or causing death. Trazodone, a chemical congener of
nefazodone, also causes primarily a hepatocellular injury, but
mixed-type and immunoallergic injuries can occur. Mirtazapine has not had any new reports of hepatotoxicity since the
two cases in 2002, and it is therefore probably not very

Anxiolytic and Soporific Agents

The anxiolytic benzodiazepines have been in use since the
1950s and significant hepatotoxicity is rare. There is no liver
toxicity listed in the Epocrates database for alprazolam, midazolam, triazolam, lorazepam, or temazepam. Diazepam,
chlordiazepoxide, flurazepam, and oxazepam have all rarely
been reported to cause various types of liver injury.200
Although hepatotoxicity is listed as the first serious ADR in
Epocrates for clorazepate, this appears to be based on only
one 1979 case report. Similarly, clonazepam has hepatotoxicity listed as the second most serious ADR; however, this
appears to be based on only one 1988 case report. In general,
all benzodiazepines appear not to cause DILI. This is also the
case for the nonbenzodiazepine anxiolytics buspirone and
Of the four agents used in the treatment of insomnia
zaleplon, zolpidem, eszopiclone, and ramelteonthere
is only one case of hepatotoxicity reported in 1999 for

Agents Used in the Treatment

of Parkinsons Disease, Migraines,
and Alzheimers Disease
In 1998 tolcapone, a catechol-O-methyltransferase (COMT)
inhibitor, was the first of its drug class to be approved for
adjunctive therapy with levodopa in Parkinsons disease (Table
25-11).215 Although no DILI was reported before its approval,
subsequent clinical trials noted ALT level elevations more than
three times normal in about 1% of patients receiving 100mg/
day tolcapone, and 3% of those patients taking 200mg/day.216
Three fatal cases of acute liver failure occurred in 1998 out of
60,000 patients administered the drug, which led to the drugs
withdrawal in Europe and Canada, and restrictions on its use
in the United States.215,216 More than 90% of cases of serious
toxicity occurred within 6 months of starting therapy. Tolcapone, but not the subsequently approved COMT inhibitor
entacapone, was shown to uncouple oxidative phosphorylation in rat liver mitochondria.217 Oxidative metabolism by
CYPs 1A2 and 2E1 may activate a tolcapone amine or acetylamine metabolite to a reactive species.218 In 2000 an expert
panel suggested that tolcapone was safe to use with frequent
ALT concentration monitoring during the first 6 months of
therapy, and that the drug should be discontinued if the ALT
level was twofold to threefold elevated;219 this approach was
reaffirmed more recently.220
Pergolide is a dopamine agonist approved for adjunctive
treatment of Parkinsons disease, and is also useful in the

Table 25-11 Anti-Parkinsons, Antimigraine,

Anti-Alzheimers, Other Neurologic
Drugs and DILI


Reported to Cause DILI

Tolcapone (Tasmar)

ALT, acute liver failure (4 cases)


Only one 1981 case report

Pergolide (Permax)

Hepatitis in database, but no


Tacrine (Cognex)

ALT common and must

discontinue or acute liver

Glatiramer (Copaxone)

Hepatotoxicity in database,
but no citations

Riluzole (Rilutek)

ALT, 3 cases of acute hepatitis

Modafinil (Provigil)

ALT in database, but no


Gabapentin (Neurontin)

1 case of cholestasis

Pregabalin (Lyrica)

1 case of hepatitis

Varenicline (Chantix)

1 case of acute hepatitis

Not Reported to Cause Liver Injury

Amantidine (Symmetrel), benztropine (Cogentin), biperiden
(Akineton), bromocriptine (Parlodel), carbidoba/levodopa
(Sinemet), donepezil (Aricept), entacapone (Comtan),
galantamine (Reminyl), memantine (Nameda), pramipexole
(Mirapex), rivastigmine (Exelon), ropinirole (Requip),
selegiline (Eldepryl), trihexyphenidyl (Artane), all the

treatment of restless leg syndrome221 and prolactinomas.222
Both the Epocrates database ( and the
medications package insert ( mention abnormal
ALT levels and hepatitis as possible ADRs. However, no literature reports of liver toxicity were found.
Methazolamide, a carbonic anhydrase inhibitor used in the
treatment of glaucoma, can also be used for therapy of essential tremor. The Epocrates database lists hepatic necrosis and
dysfunction as ADRs. However, only one possible case of hepatitis in association with red blood cell aplasia was reported
in 1981.223
Tacrine is an acetylcholinesterase inhibitor that has a mild
beneficial effect on Alzheimers disease, but can cause severe
hepatocellular injury.224,225 Analysis of multicenter clinical
trials in the United States, France, and Canada226,227 demonstrated that 25% of patients who take tacrine develop asymptomatic ALT elevations more than three times normal, usually
within the first 6 to 12 weeks of therapy. Hepatic abnormalities
are usually reversible, and only one fatal case of hepatotoxicity
has been reporteda 75-year-old woman who had taken
tacrine for 14 months.225 Tacrine is metabolized by CYP1A2
and its mechanism of toxicity has been suggested to involve a
hypoxia-reoxygenation injury mediated via the sympathetic
nervous system228 and an alteration in membrane fluidity that
is not related to lipid peroxidation.229
Glatiramer is an injectable preparation of synthetic polypeptides related to myelin basic protein. It may have some
efficacy in slowing the progression of relapsing-remitting
multiple sclerosis,230 although a recent Cochrane Review has
not supported this claim.231 The Epocrates database mentions
hepatotoxicity in its long list of adverse events. However, no
citation could be found, and liver injury was not mentioned
in the Cochrane Review.
Riluzole is a centrally acting glutamate antagonist. It has
been used in Europe since 1995 and was the first drug to be
approved by the FDA for amyotrophic lateral sclerosis (ALS).
It appears to prolong survival in ALS patients by approximately 1 month.232 It is regarded as relatively safe, although
three cases of acute hepatitis have been reported233,234 and
biopsies showed inflammation and microvesicular steatosis.
No deaths attributable to hepatic failure have been reported.
Recent reviews232,235 list ALT level elevation as one of the most
frequent adverse events, and serum ALT levels more than three
times normal are observed in 10% to 15% of patients.236 This
last report recommends strict ALT level monitoring of patients,
and avoiding the drug if ALT levels are already elevated.
Modafinil is approved for narcolepsy and sleep apnea, and
this drug is listed in the Epocrates database as causing elevated
levels of aminotransferases. However, no citation could be
found, and a study of 151 patients did not report any instances
of liver test abnormalities.237
Varenicline is an agent now very widely used for smoking
cessation. Only one case of reversible acute liver injury was
reported after 4 weeks of therapy in a patient with alcohol and
hepatitis Cinduced liver disease.238
Gabapentin239 and pregabalin240 have each been rarely
reported to cause acute reversible liver injury.

Antidiabetic Agents
As a group, the sulfonylureas have a very low incidence of
hepatotoxicity. The Epocrates database lists rare cholestatic

Chapter 25Drug-Induced Liver Injury


events as occurring after glipizide, glyburide, and chlorpropamide use, which is most likely due to a hypersensitivity reaction.241 Although tolbutamide, glimepiride, and tolazamide
are not listed in the database, reports of acute cholestatic
hepatitis, chronic vanishing bile duct syndrome, and granulomas have been submitted for all of these agents.155,242
Repaglinide is a benzoic acid derivative that is listed in the
Epocrates database as causing rare hepatic dysfunction.
However, a review of five large long-term trials did not
mention liver toxicity243 (and in addition found no liver toxicity with glyburide). Despite these data, there was one report
of acute hepatotoxicity.244 Because repaglinide is metabolized
by CYP2C8, caution is advised when also using inhibitors of
this CYP, such as trimethoprim.245
Metformin is the only remaining biguanide medication
available for use. The other two agents in this class, buformin
and phenformin, were withdrawn in the 1950s because of
a high incidence of lactic acidosis.246 Metformins risk of
lactic acidosis is lower, and the drug is considered safe as
long as dose adjustments are made for renal impairment,
liver impairment, surgery, and the use of radiologic contrast.247 Although the Epocrates database does not mention
hepatotoxicity due to metformin, several cases of acute cholestatic hepatitis have been reported.248,249 The mechanism
of toxicity is not known. Metformin is believed to have added
risks when used in patients with liver disease,241,246 because
it increases insulin sensitivity at the receptor level,250,251 nevertheless, it is often used in patients with nonalcoholic
Thiazolidinediones are peroxisome proliferatoractivated
receptor- (PPAR) agonists that have complex metabolic
effects on adipose cells, myocytes, and hepatocytes to improve
overall insulin sensitivity.252 Troglitazone was the first of
this class to reach the market, in 1997, but was withdrawn
in 2000 after a large number of cases of serious hepatotoxicity, a number of which were fatal or required liver transplantation.252 Analysis of postmarketing and other data by
FDA reviewers estimated a high risk of liver failure (1:600
to 1:1500) at 26 months of troglitazone use.252 The other
two agents, pioglitazone and rosiglitazone, have a lesser
tendency to cause hepatotoxicity, although cases have been
reported.252-256 In an analysis of 13 clinical trials,257 the frequency with which troglitazone caused increases in serum
ALT levels more than three times the ULN was 1.91%, compared with only 0.26% for pioglitazone and 0.17% for rosiglitazone. Furthermore, 0.68% of the subjects taking
troglitazone developed serum ALT levels more than 10 times
ULN, whereas no one developed such increases while taking
the other agents.
The mechanism of liver injury for troglitazone is unknown.
The drug does undergo metabolism, probably by CYP3A4 and
to a lesser extent CYP2C8, to a reactive sulfonium ion that
covalently binds to microsomal protein and GSH. A reactive
metabolite may also adversely affect basolateral organic anion
transporters.257 However, the parent drug is also hepatotoxic.
The clinical presentation of hepatotoxicity in the reported
cases was generally delayed, with a mean presentation after 4
months of use.252 Therefore current recommendations relating to glitazone use include avoiding starting the drug if the
baseline serum ALT level is more than 2.5 times the ULN and
monitoring the ALT level every 2 months for the first year. In
addition, the drug should be stopped and immediate medical


Section IVToxinMediated Liver Injury

care obtained if unexplained nausea, vomiting, abdominal

pain, fatigue, anorexia, or dark urine develops, or if the ALT
level becomes more than three times the ULN. These recommendations notwithstanding, the value of regular monitoring
of serum ALT level has not been established, and for troglitazone 19 of 94 patients progressed from normal tests to irreversible liver injury within 1 month.252

Antimicrobial Agents
Antimicrobial agents are among the most common drugs
associated with DILI. In the U.S. DILIN Registry, antimicrobial agents (antibacterial, antiviral, antituberculosis drugs)
were the most common class of drugs, accounting for 45.5%
of cases.106 Similarly, in the Spanish prospective study antimicrobial agents were the most common class of drugs,
accounting for 32% of cases, with amoxicillin-clavulanate as
the single most common drug.105 Although serious DILI from
antimicrobial agents is rare (estimated incidence of 0.03%),
patients who develop jaundice requiring hospitalization from
DILI caused by antimicrobial agents have a high mortality.258
Severe DILI led to black box warning or removal from the
market of telithromycin and trovafloxacin in the United

Table 25-12 Antifungal, Antiparasitic,

Antitubercular Drugs and DILI


Reported to Cause DILI

Ketoconazole (Nizoral)

Hepatitic > cholestatic

Fluconazole (Diflucan)

Hepatitic, ?Cholestatic

Itraconazole (Sporanox)

Cholestatic, hepatitic

Voriconazole (Vfend)

Too new, incidence unknown

Terbinafine (Lamisil)

Cholestatic > hepatitic


Very low incidence

Caspofungin (Cancidas IV)

Too new, incidence unknown

Flucytosine (Ancobon)


Thiabendazole (Mintezol)

Cholestatic > hepatitic

Mebendazole (Vermox)


Albendazole (Albenza)



Very rare

Amodiaquine (not available

in U.S.)

Very rare


Idiosyncratic hepatitic

Amphotericin B


Idiosyncratic hepatitic

Significant hepatotoxicity is very unlikely based on this drugs

widespread use for so many years and the paucity of reports
(a total of three documented cases260) describing DILI. In
animal studies features of hepatotoxicity on liver biopsy
include macrophage vacuolation, hepatocellular necrosis,
foamy macrophage accumulation, and fatty infiltration.261
One study of 64 severely immunocompromised patients conducted over a 10-year period reported that none of the patients
developed evidence of serious hepatotoxicity on liver biopsy.261
A study of bone marrow transplant recipients reported
that one third of recipients developed marked increases in
bilirubin levels after treatment with liposomal amphotericin,
compared to 8% of recipients treated with flucanazole.262 Nevertheless, nephrotoxicity from amphotericin is its most important toxic side effect (Table 25-12).


Idiosyncratic hepatitic

Ethambutol (Myambutol)




Rifapentine (Priftin)

Idiosyncratic hepatitic

Ethionamide (Trecator-SC)

Idiosyncratic hepatitic

Not Reported to Cause Hepatotoxicity

Amphotericin (only mild ALT), clotrimazole (Mycelex),
miconazole (Monistat), nystatin (Mycostatin)
Chloroquine (Aralen), hydroxychloroquine (Plaquenil),
primaquine, mefloquine (Lariam LFTs), atovaquone/
proguanil (Malarone LFTs), pyrimethamine (Deraprim)

Ketoconazole and Other Azoles

Ketoconazole is an imidazole oral antifungal drug and a
potent competitive inhibitor of hepatic CYP3A.263,264 This
latter property has probably led to more adverse drug reactions than to direct hepatotoxicity. However, shortly after its
introduction in 1981, ketoconazole was noted to cause an
acute hepatitic or mixed form of acute liver injury, often
with jaundice, which was more common in women and
elderly patients.265-267 Pure cholestatic injury occurred in 10%
of cases. Evidence of allergy was rare. Injury was noted on
average after 8 weeks of therapy. Fatalities were uncommon,
and usually associated with continuation of the drug. A more
recent prospective cohort study268 showed that 18% of patients

Pentamidine (Pentam), atovaquone (Mepron), praziquantel

(Biltricide), pyrantel (Antiminth), ivermectin (Stromectol
LFTs), nitazoxanide (Alinia)
Streptomycin, rifabutin (Mycobutin), cycloserine (Seromycin

have transient asymptomatic elevations of serum ALT levels

that normalize with continued therapy (adaptation), but
3% develop clinical hepatitis. Another recent cohort study269
tracked acute liver injury in more than 69,000 patients
taking various oral antifungal drugs and found the following

incidences: ketoconazole, 1 in 750 person-months; itrac
onazole, 1 in 10,000; terbinafine, 1 in 40,000. Although
ketoconazoles idiosyncratic injury is not considered immunemediated, a recent report of a woman developing severe
hepatitis just 48 hours after an unintentional rechallenge
suggests that an immune reaction can occur.270 Another case
report suggests that cirrhosis may develop despite withdrawal
of the drug and resolution of acute liver injury.271
The mechanism of ketoconazole liver injury appears to
involve formation of an N-deacetyl metabolite that is
converted to a toxic dialdehyde by the flavin-containing
monooxygenases.272,273 Treatment is drug cessation, and ursodeoxycholate may help prevent progressive cholestatic
Itraconazole, a less potent CYP3A inhibitor than ketoconazole,264 also causes less hepatotoxicity.269 In a pharmaceutical
database study of >54,000 itraconazole and fluconazole
users,275 serious adverse liver events were reported in only
1 in 30,000 prescriptions for either drug. If itraconazole was
given as pulse therapy (1 week/month 3), then no serious
hepatotoxicity was found.276 However, three cases of cholestatic liver injury were reported in patients taking itraconazole
long term. These patients presented with jaundice, and ductopenia was noted in two of the three biopsies.277 Focal
nodular hyperplasia has been linked to itraconazole in one
patient who had been taking the drug for 4 months.278 Fluconazole is considered very safe, with only 5% of 562 children
developing transient elevations of serum ALT levels.279 In
some reports of DILI, fluconazole was found to have been
administered with nitrofurantoin280 or amphotericin B.281
Voriconazole is probably still too new for its incidence of
hepatotoxicity to be known, and no literature citations have
been found. However, recent safety reviews suggest that both
liver tests and visual changes should be monitored in patients
using voriconazole.282,283

This allylamine antifungal has replaced pulse itraconazole for
the treatment of onychomycosis, and is widely advertised. The
incidence of hepatobiliary dysfunction in postmarketing surveillance has been reported to be as low as 1 in 40,000.269,284
However, recent case reports,285-287 and many others too
numerous to cite, suggest a higher incidence with a predominance of cholestatic reactions, including one liver transplant
patient who was initially thought to have acute rejection 5
years after his transplant.288 Toxicity can be seen as early as
after 1 week of use.287 The mechanism of injury might be the
formation of an N-dealkylated allylic aldehyde that is conjugated with GSH and transported across the canalicular

This older antifungal agent has been the mainstay of therapy
for tinea capitis, but may now be supplanted by the newer
antifungals that require only 2 to 3 weeks of therapy instead
of 6 weeks.290 Although gastrointestinal side effects of the drug
are common, only one case report from 1976 described griseofulvin hepatotoxicity.291 A more recent prospective study268
showed no liver test abnormalities in 74 patients treated for 3

Chapter 25Drug-Induced Liver Injury


This echinocandin antifungal is the first of its kind to be
approved and is only available for intravenous use. It can be
used by itself or with liposomal amphotericin B, or with voriconazole for refractory invasive aspergillosis and candidiasis
in immunosuppressed patients282,292-294; however, it is not an
effective agent in the treatment of cryptococcus infection. The
drug inhibits fungal cell wall -(1,3)-glucan synthesis. It
appears to be metabolized by hepatic P450s and may inhibit
CYP3A4.295 Caution is therefore required when it is used with
cyclosporin A296 and other calcineurin inhibitors. However,
nelfinavir did not alter its pharmacokinetics.297 Because of a
paradoxic loss of efficacy against Candida spp. at high concentrations,295 it may best be used for complicated infections in
combination with other drugs. Because phase 1 and 2 trials
commonly reported elevated levels of liver enzymes,292 its
long-term safety and incidence of hepatotoxicity are still to be

This oral antifungal, available since the 1970s, is known to
cause elevations of serum ALT levels in 5% to 15% of
patients.260 Its mechanism of hepatic injury is unknown, but
appears to be dose related.298 Its main use currently is for the
treatment of severe fungal infections. It has been used successfully in combination with fluconazole299 for cryptococcosis in
a liver transplant patient. Because its use is so limited, it is
doubtful that its mechanism of hepatotoxicity will ever be

The toxicities of most antimalarials, such as chloroquine and
hydroxychloroquine, are chiefly neurologic and hematologic.
However, pyrimethamine/sulfadoxine300,301 and amodiaquine300,302 have been associated with DILI and ALF when the
drugs have been continued after the onset of jaundice. The
incidence of serious hepatotoxicity is estimated to be 1 in
11,000 to 15,000.300 Amodiaquine is not available in the United
States, but is widely used in countries with endemic malaria
where drug-resistant strains are a problem.303,304

Benzimidazole Antiparasitics
Thiabendazole, mebendazole, and albendazole all seem to
occasionally cause elevations of serum ALT levels305; however,
only thiabendazole, available since 1964, has been reported to
cause a cholestatic hepatitis that has led to ductopenia and
cirrhosis.306-309 The incidence appears to be low, but has not
been determined, and no recent case reports have appeared.

Isoniazid, Rifampicin, and Pyrazinamide

Isoniazid (INH), available since the 1960s, is well-known to
be a hepatotoxic drug that causes an idiosyncratic hepatitic
reaction leading to overt clinical hepatitis in 0.3% to 1.0%
of patients when used as monotherapy.310,311 It is the second
most common drug responsible for ALF requiring liver transplantation in the United States.1 Hepatotoxicity increases
when used in combination with other agents, such as


Section IVToxinMediated Liver Injury

rifampicin311 and pyrazinamide.312 Despite the risks, INH

continues to be used because it is still the most effective agent
for Mycobacterium tuberculosis therapy.310 For patients with
latent tuberculosis (TB) infection, the use of INH monotherapy for 6 or 9 months is considered the therapy of
choice,313 but compliance is often low314 (<65%). A 2-month
course of INH, rifampicin, and pyrazinamide, given twice
weekly, was shown to improve compliance, but was three
times more likely to cause serious hepatotoxicity than INH
alone.315-318 Therefore this drug combination is unlikely to
supplant INH. Of patients taking INH alone, 10% develop
elevations of serum ALT levels, most of which normalize with
continued therapy, but 0.6% progress to overt clinical hepatitis that requires drug cessation.311 With INH and rifampicin,
serum ALT level increases occur in 35% of patients and 2.73%
develop overt, clinical hepatitis.
Overt hepatotoxicity usually presents within 6 weeks of
INH monotherapy, and with INH and rifampicin usually in
the first 2 weeks,319 but can be as early as a few days.311 When
INH is used with rifampicin and pyrazinamide, hepatotoxicity
beginning after 4 weeks is more ominous than early toxicity.319
Histologic changes resemble those of acute hepatitis A or B,
and include diffuse lobular inflammation with ballooning or
confluent necrosis, and occasionally macrovesicular fat.320
The mechanism of INH hepatotoxicity involves the formation of acetylisoniazid that is hydrolyzed to monoacetylhydrazine. It is hypothesized that CYP2E1 then activates the
monoacetylhydrazine to a toxic metabolite. The exact mechanism of toxicity remains unclear, and is complicated by the
fact that INH is often used with other agents. INH itself
appears to inhibit a number of human CYPs, including 1A2,
2A6, 2C19, and 3A4,321,322 whereas rifampicin is a potent
inducer of CYPs 2B6,323 2C8,324 2C9,325 3A4, and 3A5,326 as well
as some phase II enzymes, all via activation of the pregnane
X receptor (PXR). Pyrazinamide does not appear to inhibit
CYPs321; the mechanism employed by pyrazinamide to enhance
toxicity with INH or rifampicin also remains unknown. A
study in which patients were receiving multiple antituberculosis drugs in addition to isoniazid also reported that the
NAT2 polymorphism associated with slow acetylator status
was associated with DILI from isoniazid.327 In both of these
studies the NAT2*6/*6 and NAT2*6/*7 genotypes were associated with slow acetylation and DILI from isoniazid. Shimizu
and colleagues also reported that the NAT2 genotype associated with slow acetylation was associated with DILI from isoniazid. A total of 80% of slow acetylators and 9.1% of rapid
acetylators developed AST or ALT level elevations more than
twice the upper limit of normal (p < 0.05).328 Similar findings
were reported by others.329 Polymorphisms in GSTT1 and
GSTM1 have been associated with DILI from isoniazid.330 In
a study of 37 subjects there was a higher prevalence of the null
mutation for GSTM1 in patients who developed DILI from
INH compared with controls (52% vs. 24%; p < 0.05).
Besides slow acetylator status, age is the next most important predictor of hepatotoxicity. Although DILI attributable
to INH is rare in patients younger than age 20 and increases
to 2.3% in those older than age 50,310 pediatric Japanese
patients younger than 5 years had an unexpectedly high
rate of severe hepatotoxicity331 (>8%), to which the use of
pyrazinamide may have contributed. A study from
India also implicated the use of pyrazinamide.312 Other
variablesincluding female sex; underlying liver disease

related to alcohol, hepatitis B, and hepatitis C; and

malnutritionhave all been variably implicated in increasing
the incidence of severe hepatotoxicity.310,312 A case of hyperacute liver failure in a young patient also receiving carbamazepine was recently reported.332
In an effort to avoid overt hepatitis, complex algorithms
have been developed313 that include baseline laboratory testing
for all but the most healthy young (<35 years) nonHIVinfected adults, and monitoring at monthly intervals if the
patient is taking INH alone. If the patient is also taking rifampicin and/or pyrazinamide, more intense monitoring is recommended319 (e.g., twice weekly for 2 weeks, then every 2
weeks up to 2 months, and then monthly). INH should be
stopped if ALT levels become more than three times the ULN
with symptoms, or more than five times the ULN without
symptoms. Patients must be advised to observe for side effects
and report them immediately. If overt clinical hepatitis develops, all therapy must be stopped. Because antitubercular
therapy must usually be resumed, some experts333 recommend
a stepwise reintroduction of drugs, starting with INH at a low
dose, then pyrazinamide, and finally rifampicin, with careful
monitoring. Only 7% of patients rechallenged in this way
developed subsequent hepatotoxicity.

This agent is added to INH, rifampicin, and pyrazinamide to
treat active TB when INH resistance is suspected. Although
fatal hepatotoxicity is listed as a rare adverse event in the drug
databases, no specific citations could be found to suggest this
agent has significant hepatotoxicity. Because it is almost always
given as part of a multidrug regimen with known hepatotoxic
agents, liver injury ascribed to ethambutol would be difficult
to identify and characterize.

Dapsone is a second-line agent for TB and is used for other
disorders such as dermatitis herpetiformis, leprosy, malaria,
and Pneumocystis carinii pneumonia in HIV-infected patients.
It is metabolized by CYPs 2E1 and 2C isoforms334 to a hydroxylamine that can cause hemolysis, methemoglobinemia, and
agranulocytosis.335 A cutaneous syndrome is also described336
that is often associated with mild hepatotoxicity. When
dapsone is given with pyrimethamine, the rate of serious
hepatotoxicity has been estimated to be low, only 1 in

It is hoped that this long-acting cyclopental derivative of
rifampicin, which can be given once weekly, will improve
adherence to antitubercular treatment regimens. It has been
shown to be safe and effective in HIV-negative pulmonary TB
patients,337,338 and no dosage adjustments are required in
patients with cirrhosis.339 However, in one study of its use with
INH, adverse events were twice as high with rifapentine as
compared with rifampicin.340 Because rifapentine is also an
inducer of CYPs, it has significant drug interactions. Hepatotoxicity is listed in the drug databases, with an incidence of
serum ALT level elevations during combination TB therapy
being slightly less than that found with rifampicin.

This agent is rarely used, but hepatotoxicity was recognized
and reported in the 1960s.341 Because it is related to INH, its
toxicity is probably attributable to an idiosyncratic hepatitis.
The American Thoracic Society statement on hepatotoxicity of antituberculosis therapy recommends monitoring of
ALT levels during treatment of latent TB in individuals who
chronically consume alcohol; take concomitant hepatotoxic
drugs; have viral hepatitis or other preexisting liver disease,
abnormal baseline ALT levels, or a history of prior INH hepatitis; are pregnant or within 3 months postpartum; or are
co-infected with HIV. It is also recommended that monitoring
be considered in individuals older than 35 years.342 The committee recommends that treatment should be interrupted in
individuals with ALT level elevations more than three times
the upper limit of normal in the presence of hepatitis symptoms and/or jaundice, or five times the upper limit of normal
in the absence of symptoms.

Chapter 25Drug-Induced Liver Injury

Table 25-13 Antiviral Drugs and DILI



Lamivudine (Epivir)
Zidovudine (Retrovir)
Didanosine (Videx)
Stavudine (Zerit)
Emtricitabine (Emtriva)
Abacavir (Ziagen)
Zalcitabine (Hivid)


(low incidence)
(low incidence)
(low incidence)
(low incidence)

Anti-HIV, PIs


Amprenavir (Agenerase)
Lopinavir (Kaletra, with
Saquinavir (Fortovase,
Indinavir (Crixivan)
Atazanavir (Reyataz)
Nelfinavir (Viracept)
Ritonavir (Norvir)

Anti-HIV Agents

Fosamprenavir (Lexiva)

With the development of effective antiviral agents for HIV and

the dramatic decrease in mortality from AIDS in the 1990s,
primarily attributable to the development of highly active
antiretroviral therapy (HAART), liver disease in HIV patients
has emerged as an important cause of morbidity and mortality. The main culprits in promoting liver disease in this population are believed to be sequelae of co-infection with HIV and
hepatitis viruses B and/or C.343-346 Different algorithms have
been proposed for monitoring patients on HAART, depending
on whether there is preexisting liver disease or co-infection
with hepatitis B or C.347 The mechanism by which co-infection
increases DILI and mortality is still a subject of controversy.
Some studies suggest that hepatitis C hampers the effectiveness of HAART.348,349 Others suggest that hepatitis C has no
impact on survival.350 Liver damage by hepatitis B was probably controlled with lamivudine, which was a component of
most HAART regimens, and now other effective agents are
available for lamivudine-resistant strains. Therefore the
increasing incidence of liver failure in HIV patients could be
drug related (Table 25-13).351,352
Serious or severe drug-related ADRs occurred in 16% of
patients in one large study,353 but very few of these were liver
related, despite 20% of patients being noted to have asymptomatic increases in serum ALT levels. Characterizing DILI is
difficult in this complex patient population; typically, these
patients not only take multiple therapeutic drugs and herbal
remedies but also have a high incidence of alcoholism (in
those patients with a history of IV drug abuse) and hepatitis
C co-infection (32% to 68%)343,349,350 concomitant with frequent opportunistic infections. Several recent comprehensive
reviews of the hepatic injury from these agents have been
Regular monitoring of liver function tests is considered
mandatory for patients beginning HAART,347,352 with monthly
testing for the first 3 months and then every 3 months
thereafter. Avoidance of alcohol should always be recommended. Asymptomatic increases in serum ALT levels that
are less than five times the ULN are considered relatively


ALT and inhibits UDPGT
ALT and most potent
CYP3A4 inhibitor

Efavirenz (Sustiva)
Nevirapine (Viramune)
Delavirdine (Rescriptor)

ALT, ?immune features

Anti-HIV, Anti-HBV NRTIs

Tenofovir (Viread)
Adefovir (Hepsera)

Very rare
Very rare

Cidofovir (Vistide)

Very rare

Not Reported to Cause DILI

Anti-CMV: ganciclovir (Cytovene LFTs), foscarnet (Foscavir),
valganciclovir (Valcyte)
Anti-herpes: acyclovir (Zovirax), famciclovir (Famvir),
valacyclovir (Valtrex)
Anti-influenza: amantidine (Symmetrel), rimantadine
(Flumadine), zanamivir (Relenza), oseltamivir (Tamiflu)
ALT, alanine aminotransferase; CMV, cytomegalovirus; HIV, human
immunodeficiency virus; NNRTI, nonnucleoside reserve transcriptase inhibitor;
NTRI, nucleoside analogue reserve transcriptase inhibitor

safe, but must be checked monthly until resolved, and

other causes of hepatitis should be investigated. If serum
ALT levels are more than five times the ULN without symptoms, monitoring should be every 2 weeks. However, if clinical
symptoms exist, or if serum ALT levels are >10 times the
ULN, especially with lactic acidosis, HAART and other potentially hepatotoxic drugs must be discontinued.

Nucleoside Analogue Reverse

Transcriptase Inhibitors
The most ominous toxic effect of nucleoside analogue reverse
transcriptase inhibitors (NRTIs) is the development of mitochondrial toxicity that leads to lactic acidosis and liver failure,


Section IVToxinMediated Liver Injury

similar to Reyes syndrome.356 It is thought that depletion

of mitochondrial DNA (mtDNA) by NRTIs causes the mitochondrial dysfunction. This supposition was strengthened
by findings that stavudine, didanosine, and zalcitabine, which
are known to deplete mtDNA in cultured hepatocytes,358 are
associated with lower mtDNA levels in liver biopsy samples
and higher serum lactate levels in HIV/HCV co-infected
patients, compared with patients taking zidovudine, lamivudine, and abacavir, which do not deplete mtDNA levels.359
DILI from NRTIs usually occur within the first 9 months
although liver test elevations may occur later. Hepatitis C
infection by itself might cause mitochondrial dysfunction;360
however, it is not yet clear whether co-infection increases
the risk of mitochondrial toxicity. Stavudine is associated
with more cases of lactic acidosis than other NRTIs,361 but
all have been associated with cases of microvesicular steatosis
and liver failure.354 Some experts343,356,361,362 advise the use of
coenzyme Q (30 to 60 mg three times daily), carnitine
(1 to 3 g/day), riboflavin (50 mg/day), and/or thiamine
(100 mg/day) in the event of lipoatrophy or severe lactic
acidosis, but most of these interventions have not been
studied in the setting of liver failure. Abacavir has been
associated with a hypersensitivity reaction characterized by
fever and generalized rash. There has been an association
with HLA-B*5701. This class of drugs should not be used
with ribavirin.

Protease Inhibitors
The introduction of protease inhibitors (PIs) in the 1990s
marked the beginning of HAART and control of HIV. All
of the PIs (see Table 25-13) are used in combination with
other antivirals, and increased serum ALT or AST levels
more than five times the ULN occurred in 1% to 9.5% of
patients during the original registration trials.355 Ritonavir
used in higher doses caused liver injury more frequently
than the other agents, and is now given in lower doses in
combination with other PIs to boost drug levels. A characteristic of all PIs is that they are metabolized by and are
inhibitors of hepatic CYPs, primarily 3A4, and ritonavir is
the most potent.363 Furthermore, all PIs, except possibly
indinavir, appear to be mechanism-based inhibitors of P450,
which means they irreversibly inactivate the enzyme. Nelfinavir may also affect CYP2C19.364 Indinavir also causes a
reversible inhibition of UDPGT that leads to benign unconjugated hyperbilirubinemia in 12% of patients. Because
ritonavir inhibits CYP3A so well, it is given with lopinavir
in one of the more commonly used PI combinations, to
prevent lopinavirs metabolism. Liver toxicity with this combination is not greater than that found with nelfinavir-based
The mechanism whereby PIs cause liver injury is not yet
known.355 Whether asymptomatic ALT level elevations
promote more rapid progression of fibrosis in patients
co-infected with hepatitis B or C is another source of debate.
Because PIs are always given in combination with other agents
to patients, sorting this out will be complex. However, inhibition of CYPs by PIs causes the most important clinically relevant ADRs. One example is the effect of lopinavir/ritonavir
therapy on HIV in liver transplant patients who are receiving
tacrolimus; these patients need profound dose reductions in

Nonnucleoside Reverse
Transcriptase Inhibitors
Of the three available nonnucleoside reverse transcriptase
inhibitors (NNRTIs), nevirapine and efavirenz have been utilized to a much greater extent than delavirdine, possibly
because delavirdine is an inhibitor of several CYPs.367 A
number of large cohort studies have shown that, when administered with NRTIs and/or PIs, nevirapine is two to three times
as likely as efavirenz to cause increases in serum ALT levels
more than five times the ULN.353,368-373 The incidence across
multiple studies with nevirapine was 10%,370 with clinical
symptoms in 4.9%. The hepatotoxicity with both nevirapine
and efavirenz was often delayed, being recognized 3 to 9
months (median 5.5 months) after therapy began,373 and was
more common in patients co-infected with hepatitis B and
hepatitis C. Another study has suggested that HAART regimens that contain nevirapine are associated with more rapid
progression of hepatic fibrosis in hepatitis C patients,374 and
that co-infected patients receiving PIs do better than those
being administered NNRTIs. Nevirapine has also been
reported to cause severe hepatotoxicity and cutaneous reactions, both when used alone and when used with other antivirals for postexposure prophylaxis in non-HIV patients.375
These authors recommended avoiding nevirapine in prophylaxis regimens. The mechanism of hepatotoxicity for the
NNRTIs may involve an idiosyncratic response with immune
features, and this may explain why the hepatotoxicity is worse
in non-HIV subjects and is delayed in HIV patients. Nevirapine has been associated with a hypersensitivity reaction, and
individuals with HLA-DRB*0101 may be at increased risk for
this reaction.

Nucleotide Reverse Transcriptase Inhibitors

Tenofovir is effective against HIV and does not appear to
deplete mitochondrial DNA.376 Both tenofovir and adefovir
are effective against hepatitis B.377,378 Although the Epocrates
database lists hepatotoxicity as a serious reaction for both
drugs, no citations could be found and adverse liver effects are
not mentioned in the package inserts for either drug.

Fusion Inhibitors and Integrase Inhibitor

The fusion inhibitors (enfuviritide, selzentry, vicriviroc, ibalizumab) have been associated with a 5% rate of elevation of
liver tests. The development of aplaviroc was abandoned
because of grade 2 or higher elevations in ALT levels in 6% of
subjects and grade 2 or higher elevations in total bilirubin
levels in 10% of subjects. Drug-induced liver injury from
raltegravir appears to be less common compared with ART,
but this may be because it is not as frequently prescribed and
a newer agent.

This anti-CMV agent, approved to treat CMV retinitis in
HIV patients, causes nephrotoxicity and neutropenia as its
major side effects ( Hepatotoxicity is mentioned
in the Epocrates database, but no citations could be found.
Almost all of the anti-CMV agents appear to be devoid of

Chapter 25Drug-Induced Liver Injury

Penicillins and Cephalosporins
In general, the -lactam antibiotics and structurally related
cephalosporins have a very low incidence of hepatotoxicity,
most of which is idiosyncratic with immune features that can
manifest as either primarily hepatitic, primarily cholestatic,
mixed, and/or granulomatous (Table 25-14).260,305 The ability
of the same agent to present in several ways suggests that host
factors must dictate the type of allergic injury. -Lactamaseresistant agents and penicillins with -lactamase inhibitors,
such as sulbactam and clavulanate, more often cause a cholestatic response,379-382 occasionally with a prolonged clinical
course.383 The incidence of DILI with amoxicillin alone is 1 in
30,000, but with clavulanate it is 1 in 6000.382 If older patients
are given repeated courses, the incidence may be as high as 1
in 1000. Piperacillin with another -lactamase inhibitor, tazobactam, was noted to cause only mild increases in serum ALT
levels in clinical trials,384 and no reports of cholestatic injury
have yet been made. Flucloxacillin, one of the earlier
-lactamase-resistant agents, had a very high incidence of
chronic cholestasis385,386 and is no longer used in the United
States. Only oxacillin and dicloxacillin are available in the
United States, with no serious hepatotoxicity listed for either
of these agents in the Epocrates database. Yet, recent


reports385,387 have indicated that IV oxacillin use in children

should be monitored for hepatotoxicity.

Amoxicillin-Clavulanic Acid
Amoxicillin-clavulanic acid is the most common antibiotic
reported to cause DILI in the U.S. DILIN Registry and the
Spanish Registry.105,106 Typical presenting symptoms are jaundice and pruritus with cholestatic DILI. Immunoallergic features, including rash and eosinophilia, may be present.
Resolution of liver test abnormities may take months and
chronic liver injury with ductopenia can occur.
Because the HLA complex is inherited and involved in
antigen presentation several studies have been performed on
the association between HLA polymorphisms and susceptibility to DILI (see Table 25-9).116,119,388-393 One of the best examples of an association of HLA and DILI is a study of 35 patients
with amoxicillin-clavulanate hepatotoxicity.116 This study is
unique because it includes a large number of patients with
DILI from a single drug that was biopsy proven and all of the
patients developed jaundice. HLA-A and HLA-B were typed
using lymphocytoxicity assays and HLA-DRB and HLA-DBQ
were typed by polymerase chain reaction (PCR)-line probe
assay. Cases were more likely to have HLA class II antigen
DRB1*1501-DRB5*0101-DQB1*0602 haplotype, p < 0.0002,

Table 25-14 Antibacterial Drugs and DILI

Reported to Cause Hepatotoxicity

Sulfisoxazole (Gantrisin)

Cholestatic > hepatitic



Cholestatic > hepatitic

Hepatitic > cholestatic

Cholestatic + sulbactam
(Unasyn) > hepatitic


Mitochondrial in high doses

Amoxicillin + clavulanic acid


Hepatitic > cholestatic

Cholestatic, granulomatous



Demeclocycline (Declomycin)

None reported


Cholestatic, granulomatous

Minocycline (Minocin,

Autoimmune hepatitis, hepatitic

Ticarcillin (Ticar) + clavulanic

acid (Timentin)
Piperacillin tazobactam

Hepatitic or mixed


Cefaclor (Ceclor)

Possibly cholestatic

Cefdinir (Omnicef)

Possibly hepatitic


Biliary sludge


Acute hepatitic and chronic


Nalidixic acid

Possible cholestasis (one case)


Possible cholestasis

Fosfomycin (Monurol)


Not Reported to Cause Significant Hepatotoxicity



Clarithromycin (Biaxin)


Azithromycin (Zithromax)


Telithromycin (Ketek)


Pen Vee K, ampicillin, nafcillin, mezlocillin (Mezlin)
Almost all first-, second-, and third-generation agents
Other Antimicrobials

Trovafloxacin (Trovan)

Immune-mediated FHF

Probably all others

Hepatitic or mixed


Other Antimicrobials

Immune hepatitic (especially


Chloramphenicol, aztreonam (Azactam, ALT), ertapenem

(Invanz, ALT), meropenem (Merrem), clindamycin,
metronidazole, tinidazole (Tindamax), furazolidone (Furoxone,
not available in U.S.), vancomycin, daptomycin (Cubicin,
ALT), imipenem/cilastin (Primaxin, ALT), linezolid (Zyvox),
iodoquinol (Yodoxin), rifaximin (Xifaxan)


Section IVToxinMediated Liver Injury

compared with controls, and they were more likely to have

cholestatic injury. Of interest is that the DRB5*0101 haplotype
has also been associated with primary sclerosing cholangitis,
a cholestatic disorder, and the injury from amoxicillinclavulanate is cholestatic.394 Others have speculated that neoantigens presented on bile duct epithelium are part of the
mechanism of liver injury from amoxicillin-clavulanate.394
Studies have demonstrated an association between HLA alleles
and DILI from flucloxacillin. In a genome-wide association
study the HLA allele HLA-B*5701 was associated with an
80-fold increased risk of DILI from flucloxacillin.121 A separate
proposed mechanism of action is as a pregnane X receptor
agonist. Subjects who developed DILI from flucloxacillin were
more likely to have the PXR polymorphism (rs3814055;C25385-T) compared with controls and were 3.37 times more
likely to have developed DILI.395
For the cephalosporins, most of the reports of hepatotoxicity are from the 1980s.260 Ceftriaxone, which is excreted into
bile, has been associated with the formation of biliary sludge
and stones.396 Up to 3% of patients treated with ceftriaxone
may develop elevations in the levels of aminotransferases.397
In general, the cephalosporins have only a minor risk of hepatotoxicity. Although cefaclor and cefdinir are listed in the
Epocrates database as causing cholestatic jaundice and hepatitis, no literature citations were found.

Hepatotoxicity from erythromycin has been known for
decades and can occur with either erythromycin base or
any of the salts.260 Erythromycin toxicity is predominantly
cholestatic, owing to an idiosyncratic immunoallergic reaction. Often the clinical presentation will occur well after
treatment has ended. Fever, jaundice, right upper quadrant
pain, and nausea can present like acute cholecystitis. Eosinophilia is often present. Fortunately the incidence is low
(1 in 30,000).398 Although recovery can take many weeks,
rarely is it fatal. Similar cholestatic presentations, including
occasional fatalities, have been reported recently for clarithromycin,399-410 azithromycin,402,403 and roxithromycin.404
However, the incidence of hepatotoxicity appears to be
lower with the newer macrolides.405 Telithromycin, a new
ketolide antibiotic that is a structural analogue of erythromycin, was FDA approved in April 2004 to treat resistant
Streptococcus pneumoniae respiratory tract infections and
sinusitis.406,407 No reports of hepatotoxicity have appeared,
although increased serum ALT levels and hepatic dysfunction are listed as adverse reactions in the Epocrates database,
and two instances have been entered into the U.S. DILIN
Erythromycin and troleandomycin, a related macrolide no
longer available, are well-known to be potent inhibitors of
CYP3A species and the P-glycoprotein transporter. Clarithromycin is also such an inhibitor.408,409 In fact, erythromycin and
clarithromycin cause adverse drug interactions much more
frequently than they cause cholestatic liver injury, especially
with immunosuppressive agents such as cyclosporin A410,411
and tacrolimus,412 which require CYP3A metabolism. Azithromycin, roxithromycin, and dirithromycin are much weaker
inhibitors of CYP3A.413 A potential link between CYP3A inhibition and cholestatic liver injury was identified when erythromycin and troleandomycin were found to block canalicular

bile acid efflux in human hepatocytes much more effectively

than the newer macrolides.414

The fluoroquinolones are considered to be relatively safe antibiotics,415 with only trovafloxacin identified as having an incidence of hepatotoxicity (1 in 7000)260 appreciable enough to
limit its use to serious infections in hospitalized patients. With
trovafloxacin, the patients who developed ALF appeared to
have a hypersensitivity reaction and were taking medication
for more than 14 days. However, case reports of hepatic failure
have been published for most of the fluoroquinolones,416-419
and the Epocrates database lists increased serum ALT levels as
occurring with all fluoroquinolones.

All the sulfonamides have been associated with reports of
hepatotoxicity, usually considered idiosyncratic with immunoallergic features.260 A cholestatic clinical presentation is
most common, usually with rash, fever, and eosinophilia. One
case of intrahepatic cholestasis with phospholipidosis has
been reported.420 Trimethoprim/sulfamethoxazole (TMP/
SMX) is one of the oldest and most widely prescribed antibiotic combinations. The incidence of hepatotoxicity in the
general population must be very low, because only occasional
reports of hepatitis, ALF, and cholestatic disease appeared in
the literature in the 1970s and 1980s.260 However, several
recent case reports of liver failure421-423 serve to remind us of
this potential. In the U.S. ALF study, sulfonamides were the
second largest class causing ALF.424
In HIV patients, the use of TMP/SMX has been noted to
lead to a much higher incidence of allergic reactions (20%)
than in non-HIV patients.260,425-427 Because TMP/SMX is considered the best therapy for the treatment and prevention
of Pneumocystis jiroveci pneumonia, desensitization protocols
were developed428 and efforts made to determine the cause
of hypersensitivity. A slow acetylator status may contribute429
by allowing more drug to be activated by CYPs to sulfamethoxazole hydroxylamine.260 Co-treatment with CYP3A
inducers leads to more measurable hydroxylamine, and
inhibitors decrease this metabolite.430 No consensus has yet
been reached to explain HIV-induced sensitivity. Interestingly,
TMP/SMX is widely used in developing countries as chronic
prophylaxis against opportunistic infections, with some
success,431-433 and no mention is made of severe allergic or
hepatotoxic reactions with the use of the drug in these

The original descriptions of hepatotoxicity attributable to
tetracyclines were in patients receiving high doses intravenously.260,305 The clinical presentation was similar to that seen
in Reyes syndrome, with ALF, renal failure, and acidosis.
Serum ALT levels were generally not very high (<1000 units/
ml), and histologic findings were of microvesicular steatosis
with minimal necrosis. The mechanism of the steatosis and
toxicity appeared to be inhibition of mitochrondrial fatty
acid oxidation434 and was probably dose related. Intravenous
tetracycline is rarely used today, and the incidence of

hepatotoxicity from oral low-dose tetracyclines is extremely
low.435 However, reversible hepatic failure436 and prolonged
cholestasis with paucity of bile ducts437 have been reported.
Minocycline, which has been widely used as chronic therapy
for acne in adolescents, was reported to cause both acute
hepatitis438 and chronic autoimmune hepatitis, with positive
ANA and antismooth muscle antibodies.97-99,439-441 No reports
of liver injury have been submitted for demeclocycline, used
mainly for treatment of syndrome of inappropriate antidiuretic hormone (SIADH), but the Epocrates database lists
hepatotoxicity as a serious reaction.

Other Antibiotics
Nitrofurantoin, still used as a chronic urinary tract infection
antimicrobial, was reported in 1980 to cause acute and chronic
liver disease.442 It is considered relatively safe to use as prophylaxis in children,443 but authors continue to report the occurrence in elderly women of DILI resembling autoimmune
hepatitis; DILI may or may not improve with drug withdrawal.444,445 It is still a common cause of increased serum ALT
level that prompts referral to hepatologists,446 and caution
with its use is warranted. Nalidixic acid is also used as a
chronic urinary tract infection antimicrobial and is listed as
possibly causing cholestatic hepatitis, based on one case report
from 1974.447 Whether it is safer than nitrofurantoin to use as
a chronic medication is unclear.
Quinupristin/dalfopristin is a relatively new streptogramin
antibiotic for vancomycin-resistant enterococci (VRE) and
resistant staphylococcal infections448 that caused hyperbilirubinemia when given to liver transplant recipients.449 Although
that study suggested that the cholestatic changes were not
drug related, another study450 suggested that elevated AP
values might be drug related. The drugs main side effect
appears to be a myalgia/arthralgia syndrome.
Fosfomycin, an epoxide low-molecular-weight antibiotic
introduced in the early 1990s also for VRE and methicillinresistant Staphylococcus aureus (MRSA),451 was noted to frequently cause increases in serum ALT levels and Clostridium
difficile colitis.452 One case of acute hepatotoxicity with
repeated use in a cystic fibrosis patient has been reported.453

Cardiovascular Agents
Thrombolytic Agents
A fixed dose of dipyridamole 200 mg and aspirin 25 mg
(Aggrenox) taken twice daily has been shown to be effective
in the secondary prevention of strokes,454,455 although there
is still controversy regarding its benefit over aspirin alone.
Hepatic dysfunction is listed as an adverse reaction in the
Epocrates database, but no literature citations could be found.
On the other hand, ticlopidine, a thienopyridine inhibitor
of platelet ADP-induced aggregation with thrombolytic
effects,456 is more effective than aspirin in preventing stroke.457
Ticlopidine was first reported in 1993458 to cause hepatitis,
and subsequent reports from many countries459-463 have confirmed that the drug causes a primarily cholestatic injury.
Presentation was between 2 and 13 weeks and was not correlated with the degree of platelet inhibition.463 The hepatotoxicity can be associated with red cell aplasia,460 and an

Chapter 25Drug-Induced Liver Injury


immune mechanism is therefore likely. Because of these side

effects, another antiplatelet drug, clopidogrel, has become
more popular464 and was used successfully in one patient
with ticlopidine hepatotoxicity.465 This was despite the fact
that clopidogrel is also a thienopyridine and has been reported
to cause fatal liver injury.466 However, clopidogrel requires
hepatic activation,467 and variable resistance to its efficacy
has been found because of lack of activation by CYP3A4.468
Besides monitoring for antiplatelet effects, it is important to
review medications that might inhibit CYP3A4 in patients
using clopidogrel therapy. So far, only one case report of a
mixed hepatocellular and cholestatic injury has appeared,
in 2000.469 Therefore clopidogrel probably has low hepatotoxicity (Table 25-15).
Hepatotoxicity attributable to warfarin is exceedingly rare,
with only two case reports in the past decade,470,471 and in both
cases the patients had been taking phenprocoumon before the
warfarin was administered. Cross-reactivity and rechallenge
confirmed the sensitivity. Phenprocoumon, not available in
the United States, led to at least eight cases of severe hepatitis
in Germany between 1992 and 2002, with one death and two
patients requiring liver transplantation.472
Although no significant hepatotoxicity is reported with
heparin, a number of the low-molecular-weight heparins are
listed in the Epocrates database as causing increased serum
ALT levels. For tinzaparin, cholestatic hepatitis is listed.
However, only one citation473 could be found that reported
increased ALT levels for tinzaparin, and a more recent report474
suggested that attribution of such increases is often erroneous
(e.g., more careful investigation of a reaction attributable to
dalteparin determined that it was instead attributable to ranitidine). Enoxaparin has been reported to cause elevated levels
of transaminases,475 including one recent case. Of presumed
hepatotoxicity.476 No literature citation for liver toxicity could
be found for the direct thrombin inhibitor lepirudin, and a
recent review including postmarketing surveillance did not
mention hepatotoxicity.477

Angiotensin-Converting Enzyme Inhibitors

All of these drugs have an excellent safety profile, although
hepatotoxicity and increased serum ALT levels are listed in
the Epocrates database. Many of the angiotensin-converting
enzyme (ACE) inhibitors have been shown to have a low
incidence of causing cholestatic hepatitis,155,241 including captopril,478,479 lisinopril,480 fosinopril,481 and ramipril.482 Patients
who developed cholestasis were generally middle-aged and
had been taking the drug for between 4 and 8 weeks. Most
cases displayed a long recovery time. The sole fatality was a
patient who had been continued on lisinopril for 3 weeks
after developing jaundice and whose death was attributed to
a perforated ulcer while his cholestasis was improving.480 Currently there are no known risk factors for developing

Angiotensin II Receptor Blockers

These agents, best characterized by losartan, can cause an
idiosyncratic hepatitic reaction,483,484 and candesartan,485 irbesartan,486 and valsartan487 have been reported to cause cholestatic hepatitis. Onset of clinical illness was always just a few
weeks after starting therapy and resolution was relatively rapid

Table 25-15 Cardiovascular Drugs and DILI

Reported to Cause Liver Injury
Dipyridamole/ASA (Aggrenox)

Hepatic dysfunction

Ticlopidine (Ticlid)

Definite cholestatic

Warfarin (Coumadin)

Hepatitis/cholestatic jaundice

Dalteparin (Fragmin)


Tinzaparin (Innohep)

Cholestatic hepatitis

Enoxaparin (Lovenox)


Lepirudin (Refludan)


ACE Inhibitors
All the -prils

Reports of cholestatic jaundice

Angiotensin Receptor Blockers

All the -sartans

Hepatotoxicity, ALT

Amiodarone (Cordarone, Pacerone)

ALT, phospholipidosis

Quinidine (Quinidex)

Immune mixed with granulomas


Immune cholestasis with granulomas

Propafenone (Rythmol)

Rare cholestasis

Labetatolol (Trandate, Normodyne)

ALT, hepatitic, nonimmune

Ca2 Channel Blockers


Rare hepatitic, immune

Diltiazem (Cardizem)

Rare hepatitic, rare granulomas


Rare hepatitic or cholestatic

Cholesterol Lowering
All statins

ALT, rare hepatitic, cholestatic


Rare autoimmune picture

Niacin (slow release > crystalline)

Rare acute hepatitic/cholestatic

Other Antihypertensives

Very rare immune hepatitic, granulomas

Bosentan (Tracleer)

ALT, too new to characterize

Not Reported to Cause Significant Liver Injury

Alteplase (Activase), clopidogrel (Plavix), anagrelide (Agrylin), dipyridamole (Persantine), eptifibatide (Integrilin), cilostazol (Pletal),
tirofiban (Aggrastat), abciximab (ReoPro), fondaparinux (Arixta), bivalirudin (Angiomax), argatroban, antithrombin III (ATnativ),
anistreplase (Eminase), streptokinase (Kabikinase), urokinase (Abbokinase), reteplase (Retevase), tenecteplase (TNKase)
Adenosine, bretylium, sotalol (Betapace), ibutilide (Corvert), moricizine (Ethmozine), mexiletine (Mexitil), disopyramide (Norpace),
flecanide (Tambocor), dofetilide (Tikosyn)
Almost all except labetolol appear without significant toxicity
Ca2+ Channel Blockers
All but verapamil and diltiazem appear safe
Cholesterol Lowering
Gemfibrazole (Lopid), ezetimibe (Zetia)
All loop and thiazide diuretics appear without significant hepatotoxicity
Other Antihypertensives
Minoxidil (Loniten), eplerenone (Inspra), treprostinil (Remodulin), epoprostenol (Flolan), fenoldopam (Corlopam), doxazosin
(Cardura), clonidine (Catapres), terazosin (Hytrin), guanabenz (Wytensin), prazosin (Minipress), nesiritide (Natrecor)
ALT, alanine aminotransferase.

after discontinuation of the drug. The incidence of this reaction appears to be low.

Antiarrhythmic Drugs
Amiodarone is a highly effective and widely used iodinated
benzofuran antiarrhythmic that has long been known to cause
liver injury.241 Its pulmonary toxicity is more serious, but
elevations in serum aminotransferase or AP levels are
common.488,489 Amiodarone was the drug most commonly
associated with liver injury in one tertiary hepatology referral
The spectrum of amiodarone liver injury is broad. An
acute hepatitis can occur within 24 hours of starting parenteral therapy,490 but the incidence of this is difficult to
assess because the drug is usually used during cardiac arrests
and the majority of patients do not survive. Asymptomatic
elevations of liver enzyme levels occur in about 25% of
patients using oral therapy, usually detected 10 months after
exposure, with the mean ALT level (104 units/ml) greater
than the mean AST level (89 units/ml) and generally normal
AP and bilirubin levels. Although adaptation may occur, with
normalization of values on continued use, the drug is often
stopped because of toxicities to other organs and death from
heart disease.488 Between 1% and 3% of patients develop
symptomatic hepatitis, with hepatomegaly that resolves relatively quickly on drug withdrawal. The drug and its metabolite
remain in liver and plasma for long periods and can cause
persistent abnormalities for many months after cessation of
The most ominous form of liver injury with amiodarone is
the development of cirrhosis that has been termed pseudoalcoholic based on the findings of Mallory bodies, polymorphonuclear leukocytes, and steatosis,491 and this can occur even
with low doses of the drug.494 Regular monitoring of serum
ALT level is recommended, especially if doses greater than
400mg/day are used. Decreasing the dose or discontinuing
the drug if ALT levels are more than three times the ULN and
performing a liver biopsy if elevations persist are also recommended. A recent prospective study of serum amiodarone
levels in 125 patients suggested that only 6% will have serum
ALT levels more than three times the ULN if amiodarone
levels are <2.5mg/L, and there should be no ALT level elevations if amiodarone levels are <1.5mg/L.493
Amiodarone is metabolized by CYP3A4 and CYP2C8494 to
N-desethylamiodarone.494 The drug and metabolite accumulate in the liver because they are amphiphilic, becoming
trapped in lysosomes and subsequently inhibiting phospholipases.241 Even in patients without liver injury, intralysosomal
inclusions are found with a characteristic lamellar structure
on electron microscopy that is the hallmark of phospholipidosis.495 Because of amiodarones iodine content, hepatic
accumulation can be demonstrated on noncontrast CT
scans.496 The drug can also accumulate in mitochondria and
cause lipid peroxidation and steatohepatitis in animal
models.497 However, the mechanism that amiodarone (or a
metabolite) employs to cause hepatic injury is still unclear.
The drug is also an inhibitor of the organic anion transporter
oatp2 in rats.498
Quinidine remains an important antiarrhythmic despite
many case reports from the 1970s describing idiosyncratic
hypersensitivity hepatotoxic reactions that occurred within a

Chapter 25Drug-Induced Liver Injury


month of therapy,241 often with granulomas on histologic

analysis.499 No recent case reports have appeared, and the incidence of hepatotoxicity is not really known. Another important effect of quinidine recently recognized is its ability to
heteroactivate CYP3A4 activity for other substrates.500,501
Therefore complex drug interactions should be expected
when using quinidine.
Although only mild abnormalities of liver tests are listed in
the Epocrates database for procainamide, the drug has been
reported to cause intrahepatic cholestasis in a number of
cases,241 often with granulomas. The drug is much more likely
to cause a systemic lupus-like reaction than hepatotoxicity.
Propafenone is not listed to have any hepatotoxicity, but seven
cases of cholestatic jaundice have been reported in the literature since 1980.502

All of these widely used agents have a very low incidence
of hepatotoxicity, with the possible exception of labetalol.503,504
Labetalol causes mild asymptomatic ALT level increases in
8% of patients, usually within the first few weeks of therapy.
Although ALT levels usually normalize with continued
therapy (a poorly understood phenomenon that has sometimes been dubbed adaptation), they may worsen in 2%
of patients, requiring drug withdrawal. Three fatalities have
been reported,503 and the RR-stereoisomer of labetalol, dilevalol, was withdrawn in postmarketing surveillance outside
the United States in 1990 because of hepatotoxicity (see
Table 25-1). The mechanism of injury appears to be idiosyncratic without immune features. Only one case report
(of an acute hepatitis) was found for DILI ascribed to
metoprolol.505 More recently, a case of severe cholestasis
was reported for carvedilol,506 which recurred 1 year later
when the patient began taking metoprolol. Considering the
wide use of these agents, it appears that hepatotoxicity is
very rare.

Ca2+ Channel Blockers

These agents appear to have a very low incidence of hepatotoxicity, with only verapamil and diltiazem listed in the
Epocrates database. Still, nifedipine has been reported to cause
acute hepatitis with immune features,507 with the last report
published in 1992.508 The cases of acute hepatic injury
described after diltiazem509 were both in patients who had
been taking nifedipine before their exposure to diltiazem. Diltiazem has been reported to cause granulomatous hepatitis.510
Verapamil has been reported to cause a few cases of both
hepatitic and cholestatic injury.511

Although rare hepatotoxicity is listed in the Epocrates database for hydrochlorothiazide, ethacrynic acid, and spironolactone, no citations could be found. Considering the
widespread use of these agents in relatively sick patients,
including those with liver disease, it is clear that they have very
little hepatotoxicity. The uricosuric diuretic tienilic acid was
withdrawn from the market in 1979 because of a large number
of cases of acute and chronic hepatitis, most likely the result
of an immune-mediated process.512


Section IVToxinMediated Liver Injury

Other Antihypertensive Agents,

Including Prescription Drugs
for Pulmonary Hypertension
Hydralazine is not listed in the Epocrates database to cause
any form of hepatotoxicity. However, its congener, dihydralazine (no longer available in the United States), is a classic
drug that causes immune-mediated drug-induced toxicity109
attributable to mechanism-based inactivation of CYPs 1A2
and 3A4,513 which then creates a neoantigen and the development of antimicrosomal antibodies. Most case reports of
hepatotoxicity from dihydralazine514 and hydralazine515 are
from the 1980s and show classic centrilobular necrosis. Granulomatous hepatitis attributable to hydralazine has also been
reported.516 Apparently, hydralazine must not inactivate CYPs
to the extent of dihydralazine, and the incidence of hepatotoxicity is low.
From a historical perspective, -methyldopa (Aldomet)
was one of the first drugs in widespread use that was noted to
have hepatotoxicity, but with a low enough incidence that it
was not withdrawn from the market. It was introduced in
1960, remains available in the United States, and continues to
cause serious DILI, even though there now are many more
effective and less risky antihypertensives. All forms of liver
injury, including acute hepatitis, chronic hepatitis, cholestatic
hepatitis, fulminant liver failure, and cirrhosis, have been associated with its use.241
Bosentan is an orally available benzenesulfonamide
designed to potently inhibit both endothelin receptor A and
endothelin receptor B.517 It has been FDA approved to treat
pulmonary hypertension518,519 but has significant hepatotoxicity that occurs in 2% to 18% of patients, is dose related, and
is reversible with drug withdrawal.520 It is interesting that
blocking endothelin receptors with the drug was initially
shown to protect the livers of experimental animals from
warm ischemia,521 and it was beneficial in portal-hypertensive
rats.522 When the drug was studied in humans, it became
apparent that it was extensively metabolized by CYPs 2C9 and
3A4, and its induction of these same enzymes caused a drop
in initial steady-state concentrations for as long as 3 to 5
days.519 It was also found to have important interactions with
3A4 and 2C9 substrates such as cyclosporin and warfarin.519
Although the mechanism of hepatotoxicity is still not certain,
bosentans ability to inhibit the canalicular bile salt export
pump may cause intracellular accumulation of cytotoxic bile
salts.520 Despite its potential for hepatotoxicity, it has been
used successfully for the treatment of portopulmonary
hypertension.523-525 Sildenafil has become more popular for
treatment of portopulmonary hypertension. It can rarely
cause cholestatic liver injury.526 Epoprostenol infusions, used
for pulmonary hypertension, do not appear to cause hepatotoxicity, but inhaled iloprost is listed in the Epocrates database
as causing LFT abnormalities.

Cholesterol-Lowering Agents
Hydroxymethylglutaryl-Coenzyme A
Reductase Inhibitors (Statins)
The introduction of the statins has made a major impact on
the therapy of hypercholesterolemia and heart disease, making
these agents among the most widely prescribed medications.

However, because these are long-term medications, there was

early concern about ocular, muscle, and liver toxicities that
had been seen with previous inhibitors of cholesterol synthesis.241,527 Ocular toxicity did not occur, but asymptomatic
increases in serum ALT levels more than twice the ULN were
found in 1% to 3% of subjects in early studies, which was 10
to 30 times more frequent than rhabdomyolysis.527 The
increases occurred within 3 months and there was a dose
dependence. There were also a number of severe cases of acute
hepatitis and cholestatic injury reported.155 Therefore recommendations were to avoid the use of statins in patients with
almost any liver disease. Unfortunately, following these recommendations would deny many patients with high cholesterol levels the benefit of these drugs, because these patients
often have increased levels of serum aminotransferases as part
of their metabolic syndrome.
Postmarketing surveillance studies of the statins have shown
that asymptomatic ALT level increases occur in 0.2% to 1.14%
of patients528,529 and that the majority of patients have adaptation and normalization of ALT levels with continued therapy.
Studies in specific groups, including children with familial
hypercholesterolemia,530 obese patients,531 elderly patients,532
and patients with increases before therapy,533 showed that all
tolerated statin therapy with a low incidence of side effects. It
is still recommended that liver tests and creatine kinase (CK)
levels be monitored at baseline, 3 months, and then every 6
months,534 although it has not been demonstrated that this
will identify those patients at risk of, nor reduce the occurrence of, severe liver or muscle toxicity.155 Serum ALT levels
more than three times the ULN should be monitored every 2
to 4 weeks, and the drug discontinued if adaptation fails to
occur or clinical symptoms develop. The dose should be
adjusted as low as possible to control cholesterol. When using
a statin that is metabolized by CYP3A4 (simvastatin, lovastatin, and atorvastatin), caution is necessary if prescribing
other medications that inhibit this CYP (e.g., ketoconazole,
erythromycin). Fluvastatin is metabolized by CYP2C9, and
pravastatin and rosuvastatin are not metabolized by the P450
system. There are also warnings concerning the combination
of statins with gemfibrozil, niacin, amiodarone, and verapamil.534 Cerivastatin was withdrawn from the market in 1991
because of a high frequency of rhabdomyolysis, not because
of liver injury.
Serious DILI from statins seems to be rare based upon their
widespread chronic use and results from large databases or
cohorts.104,107,108,535 In a retrospective study of DILI leading to
death or transplantation from the Swedish Adverse Drugs
Reaction Advisory Committee (SADRAC) database, there
were 151 cases with a fatal outcome and 17 patients who
underwent liver transplantation from 1966 to 2002.535 There
was one case each of DILI attributed to atorvastatin and simvastatin. Among 4690 suspected DILI cases reported from
1968 to 2003 to the WHO Collaborating Center for Drug
Monitoring, a statin was not one of the top 20 drugs associated
with fatality from DILI.104 A population-based study was conducted over a 3-year period in a region of France with a population of 81,301; 34 cases of DILI were reported.107 A statin
(atorvastatin) was the single implicated drug in two cases or
one of mutiple implicated drugs (both atorvastatin and ticlodipine). The Spanish drug-induced liver injury study is a
prospective study of DILI from centers in Spain.105 The investigators for the Spanish Registry reported 461 cases collected

over a 10-year period. Statins were incriminated in 11 cases
with a mean serum total bilirubin level of 6.1mg/dl, mean
ALT level of 15.8 times the ULN, and mean alkaline phosphatase level of 2.8 times the ULN.
In a systemic review of serious DILI from statins, 40 cases
of statin hepatotoxicity were identified.536 In 11 cases, autoantibodies were detected with or without DILI. Given the vast
number of prescriptions written for this class of drug, more
than 142 million in the United States in 2008 alone, the relatively small number of published case reports is a testament
to the hepatic safety of statins.537 The majority of these reports
have occurred with lovastatin, simvastatin, and atorvastatin,
probably reflecting their time on the market and numbers of
prescriptions written. Despite differences in pharmacokinetics, lipophilicity, and degree of hepatic metabolism,538 all
statins appear capable of causing rare but significant hepatotoxicity. Presenting symptoms have generally been consistent
with an acute hepatitis, including jaundice, anorexia, nausea,
abdominal pain, fatigue, and pruritus. Mortality secondary to
statin-induced DILI is exceedingly uncommon and identified
in only two of the case reports.539,540
Among the reported cases identified in the systematic
review the duration of statin therapy before the development
of symptomatic hepatotoxicity from statins is highly variable,
ranging from 5 days to 4 years.536 In more than half the cases,
DILI occurred within 4 months of instituting statin therapy.
The time from cessation of statin use until resolution of hepatotoxicity ranges from several weeks to 6 months. The most
common pattern of liver injury is hepatocellular, with peak
ALT levels varying from 39 to 8275 units/L, although a mixed
injury pattern with prolonged symptomatic cholestasis may
occur. In cases of mixed injury, the peak serum total bilirubin
level has been reported as high as 25mg/dl, but most cases
report total bilirubin levels of 5 to 10mg/dl.
On liver biopsy the most frequent histologic features of
DILI from statins are portal inflammation with mononuclear
cells with or without cholestasis. The portal inflammation
typically includes lymphocytes, and although eosinophils
were noted in a few cases, they are not commonly prominent. Changes on liver biopsy may not be due to statins,
however, because these patients may have preexisting underlying fatty liver disease and/or liver fibrosis. Statin-induced
liver injury may occasionally present with an autoimmune
phenotype.542 This pattern of liver injury on biopsy was
reported with atorvastatin, rosuvastatin, and simvastatin.
These cases could represent sporadic autoimmune hepatitis
(AIH) presenting in someone who happened to be prescribed
a statin, although the evidence for statins serving as a trigger
is strong. High titers of autoantibodies, suchs as ANA, anti
smooth muscle antibody, antihistone antibodies, and
acetylcholine-binding antibodies, may be seen in patients
with DILI from statins.
The pathogenesis of this type of DILI remains to be elucidated, but proposed mechanisms include the drug serving
as a hapten for cellular targets in genetically predisposed hosts
with specific HLA haplotypes (DR3,4) who are reexposed to
the same statin or another statin.541 The exact mechanism of
liver injury is not known, but studies in guinea pigs administered 125mg/kg/day of simvastatin suggest toxicity is a
result of inhibition of hydroxymethylglutaryl-coenzyme A
(HMG-CoA) reductase and mevalonate synthesis.540 The
mevalonate pathway is important for production of cell

Chapter 25Drug-Induced Liver Injury


membrane proteins, anchoring of proteins, and biosynthesis

of steroids.
As a drug class, statins are remarkably safe, including in
patients with chronic liver disease or a history of elevated liver
tests. A randomized, double-blind, placebo-controlled study
of 326 subjects with underlying liver disease treated with
80mg of pravastatin or placebo demonstrated no significant
difference in serum ALT level elevations between the 2
groups.543 The rate either of the serum ALT level elevation
exceeding two times the ULN or of doubling of the baseline
ALT level (if the baseline ALT level was already elevated) was
5% in the pravastatin group and 7% in the placebo group. No
statistical differences in ALT level doubling were demonstrated
in the pravastatin group or placebo group regardless of
whether the baseline ALT level was elevated. Most of the subjects in the study had chronic liver disease from nonalcoholic
fatty liver disease (NAFLD) (64.1%) or chronic hepatitis C
(24.8%). The U.S. DILIN Registry prospective study reported
the results of the first 300 enrolled cases in 2008.106 Lipidlowering agents were reported to be the causative agent in
3.4% of cases. One patient with cirrhosis treated with ezetimibe and simvastatin died and one patient with rheumatoid
arthritis treated with leflunomide and lovastatin underwent a
liver transplant.
The following are recommendations from The National
Lipid Association Safety Task Force regarding the safety of
statins with a focus on patients with chronic liver disease544:
(1) chronic liver disease is not a contraindication to statin
therapy; (2) compensated cirrhosis is not a contraindication
to statin therapy; (3) statins can be prescribed safely to patients
with nonalcoholic fatty liver disease (NAFLD). Based upon
expert opinion, the authors also concluded that statins should
not be used in patients with decompensated cirrhosis or acute
liver failure. Furthermore, patients should not reinitiate statin
therapy if they experienced prior liver test elevations presumably attributable to statin use.
Fenofibrate has been used for decades and is effective for
the management of hypertriglyceridemia. It has been reported
to rarely cause an autoimmune hepatitis with ductopenia and
fibrosis.155 Mild ALT level increases occur rarely, and routine
monitoring of liver tests is not considered necessary.545
Although the fibrates are potent peroxisomal proliferator
agents in rodents, this effect is not seen in humans based on
analysis of liver histologic findings.241 The fibrates can also
increase the lithogenicity of bile, but this effect does not
appear to be clinically significant.545
Niacin has also been shown to cause an acute hepatitis241
that occurs more frequently with the sustained-release form,
usually after a relatively short time (2 days to 7 weeks),546 and
often immediately after changing from the crystalline formulation that was well tolerated.547,548 A cholestatic picture has
also been described.549 Overall, the incidence of hepatotoxicity
must be low. There is some indication that toxicity may be
dose related,241 but the mechanism of liver injury has never
been clarified.

Nonsteroidal Antiinflammatory
Drugs and Acetaminophen
Nonsteroidal antiinflammatory drugs (NSAIDs) as a class are
important causative agents of hepatotoxicity. Although the
incidence of hepatotoxicity varies for different agents, the


Section IVToxinMediated Liver Injury

overall incidence of overt dysfunction is low (less than

0.1%).550 However, because of the large number of people who
use NSAIDs on a regular basis (approximately 20 million in
the United States alone), the actual number of cases that occur
is ultimately substantial.550 In the U.S. DILIN Registry, NSAIDs
and muscle relaxants accounted for 5% of serious DILI
cases.106 It is estimated, from Medicaid billing data, that acute
hepatitis, probably related to NSAID use, results in about 2.2
hospitalizations per 100,000 people.551 In a retrospective
Canadian study of 228 adult patients who contributed 645
person-years, the age- and gender-matched risk ratio for hospitalization for acute liver injury related to NSAID use was
1.7, or about 5 episodes per 100,000 patient-years.552 A systematic review of population-based studies reported the risk
of serious liver injury in NSAID users was 3.1 to 23.4 per
100,000 patient-years.553 Risk factors for the development of
hepatotoxicity from NSAIDs include advanced age, renal
insufficiency, multiple drug use, and high doses.554 Different
NSAIDs have different propensities to cause hepatotoxicity.
Benoxaprofen proved to be an agent that caused liver injury
with a high incidence and fatalities, prompting its withdrawal
from medical use. Other agents have minimal potential for
hepatotoxicity. NSAIDs that are capable of causing hepatotoxicity are listed in Table 25-16. In a systematic review of 67
articles and 65 studies from the FDA archives, diclofenac and

rofecoxib had the highest rates of elevelations of aminotransferase levelsmore than three times the upper limit of
normal.555 The most common mechanism of injury appears
to be idiosyncratic, probably as a result of metabolic abnormalities, and the most common type of injury appears to be
hepatocellular. Polymorphisms in glutathione S-transferase
have been reported to be associated with DILI from antibacterials and NSAIDs.556 Cross-reactivity between different
classes of NSAIDs may occur.557
The primary risk factor for aspirin-induced hepatotoxicity
appears to be the dose of the drug, and hence frequency correlates with the serum salicylate levels.550 Most patients with
hepatotoxicity, as evidenced by elevated aminotransferase
levels, are taking 2 to 6g of aspirin daily and have serum levels
of salicylates exceeding 25mg/dl, although toxicity has been
seen at levels as low as 10mg/dl.558 Predisposing conditions
have also been suggested as being risk factors. These include
the connective tissue disorders rheumatoid arthritis, systemic
lupus erythematosus (SLE), and juvenile rheumatoid arthritis.
However, the increased incidence in this subgroup is probably
explained largely by the higher doses used in treating these
conditions, rather than an intrinsic susceptibility, although the
cytokine milieu in systemic inflammatory diseases may predispose to hepatotoxicity.559 The same explanations are likely
for the increased incidence seen in cases of rheumatic fever.

Table 25-16 Nonsteroidal Antiinflammatory Drugs and DILI
















Acetic Acid Derivatives
















Fenclofenamic acid



Fenclozic acid





















Propionic Acid Derivatives










































Meclofenamic acid



Mefenamic acid



Niflumic acid



Tolfenamic acid


















In patients who develop Reyes syndrome, aspirin intake
appears to be one of the most commonif not
the most commontriggers for the development of its characteristic features, namely, a microvesicular hepatic steatosis
and acute encephalopathy. This occurs in the setting of a
febrile illness in children, most commonly induced by a viral
infection. The underlying predisposing condition is as yet
unclear, but may involve congenital mitochondrial enzyme
defects or deficiencies, the effect of which is exacerbated by
the use of aspirin.550,560 In experimental animals, salicylic acid
inhibits mitochondrial -oxidation of long-chain fatty acids,561
and up to one third of children who develop Reyes syndrome
have inborn errors of metabolism in this pathway.562 The incidence of Reyes syndrome is decreasing, mirroring the decline
in use of aspirin for childhood viral illnesses.550 In this dosedependent type of hepatotoxicity the mechanism is probably
related to an intrinsic ability to injure the hepatocyte. Based
on the ultrastructural histology, the site of injury appears to
be the mitochondria. Other mechanisms that have been postulated include lipid peroxidation, hydroxyl radical scavenging, and injury to the hepatocyte membrane.550
Apart from the features of the disease condition necessitating the use of aspirin, findings are minimal. Tender hepatomegaly may occur. Liver injury is most often recognized by
determining elevated serum AST and ALT levels, and, less
commonly, ammonia and bilirubin levels. Up to 50% of individuals with serum levels of salicylate greater than 15mg/dl
have elevated AST and ALT levels.558 Acute liver failure, characterized by coagulation abnormalities and hepatic encephalopathy, is rare.563 The classic histologic description of liver
injury from aspirin is a nonspecific focal hepatitis. Ballooning
degeneration that is more prominent in zone 3 is a typical
finding. Hepatocyte necrosis is also seen, and inflammatory
cell infiltration is minimal. Steatosis is unusual in the hepatotoxicity associated with high doses of aspirin. However, in
Reyes syndrome microvesicular steatosis is the hallmark.
Aspirin hepatotoxicity is rapidly reversible when the drug is
discontinued. Fatalities are very rare but have been reported.564
There is no conclusive evidence that aspirin can cause chronic
Aspirin overdose is managed by discontinuation of the
drug, with supportive care in the rare individual who has
severe hepatotoxicity. If aspirin is absolutely essential in the
individuals management, an attempt may be made to restart
the drug at a lower dose after the liver tests have returned to
normal. Close monitoring of the liver tests in this rechallenge
is necessary.
Diflunisal (Dolobid) is a difluorophenyl derivative of salicylic acid that has been reported to cause a cholestatic and
mixed hepatocellular type injury.565,566
Indomethacin (Indocin), an indole-containing acetic acid
derivative, is probably the most frequently used NSAID of this
class. There are relatively few reports of indomethacin-related
hepatic injury compared with other organ toxicities caused by
this drug.550,567 In one series, although indomethacin accounted
for relatively fewer instances of hepatotoxicity (compared with
other NSAIDs), the incidence of fatalities was higher.567 Case
fatalities have been reported.567-569 Children may be more susceptible to severe injury, and therefore the drug is not recommended for use in the pediatric age group.550
Based on the few case reports available, the mechanism of
toxicity appears to be metabolic idiosyncrasy. Features are

Chapter 25Drug-Induced Liver Injury


usually nonspecific, with laboratory values suggesting hepatocellular injury, and much less often concomitant cholestasis.
Massive hepatocellular necrosis, primarily centrally located,568
is typical. Microvesicular steatosis and cholestasis may occur.
Discontinuation of the drug and supportive measures should
be instituted. A good outcome is expected with early detection
and withdrawal. However, case fatalities have been reported.
Sulindac (Clinoril) is also an indole derivative of acetic acid
and therefore has some structural similarities to indomethacin. There are many reported cases of hepatotoxicity related
to this drug, which is a potent analgesic and has relatively
fewer gastrointestinal side effects than other NSAIDs. However,
it is still considered one of the most likely NSAIDs to produce
hepatic injury.550 In an analysis of 91 cases reported to the
FDA, the ratio of females to males was 3:5.570 Based on the
reported cases, the mechanism for most appeared to be a
generalized immunoallergic hypersensitivity reaction, which
included liver involvement. Metabolic idiosyncrasy may
account for a minor subset.570 Patients present with features
of a hypersensitivity reaction, including fever, skin rash, pruritus, and tender hepatomegaly. Stevens-Johnson syndrome
may occur. The onset is usually within 4 weeks of starting the
drug.571-573 Jaundice occurs in about two thirds of cases.570
Laboratory tests often reveal significant hepatocellular damage.
Eosinophilia tends to be more common when the pattern of
injury is cholestatic than when it is primarily hepatocellular.570
Pancreatitis may occur in some cases.574 Cholestasis is prominent in most cases, with only about 25% showing hepatocellular injury.570 Five percent (4 cases of 91) of patients with
sulindac-associated jaundice died.570 Although the cause of
death in most cases was attributable to systemic hypersensitivity, death from liver failure secondary to massive hepatocellular necrosis can occur.570 Rechallenge with the drug may
result in the reappearance of the hypersensitivity reaction after
only a few doses.572
Diclofenac (Arthrotec, Voltaren) is a phenylacetic acid
derivative that has been in use for some time. Although the
most common manifestation of hepatotoxicity is asymptomatic elevations in liver tests, there are numerous reports in the
literature of significant hepatotoxicity and even fatalities
attributable to the use of this drug.575,576 It is estimated that up
to 5 of 100,000 individuals have significant hepatotoxicity. The
onset is from 3 weeks to 12 months after starting the drug.575,576
Elderly women with osteoarthritis seem to be more susceptible.575 Among 17,829 patients treated with diclofenac for
arthritis over a mean of 18 months, 0.5% developed AST or
ALT levels more than 10 times the upper limit of normal,
0.023% of patients required liver-related hospitalization, and
none of the patients died or required liver transplant. Aminotransferase level elevations occurred primarily during the first
4 to 6 months of therapy.555 Data from the reports suggest that
in most cases the cause is immunologic idiosyncrasy. However,
metabolic idiosyncrasy has seemed to be the more logical
explanation in other cases. Polymorphisms in the genes
encoding UDPGT2B7, CYP2C8, and ABCC2 have been
reported to be associated with diclofenac DILI. The strongest
association was seen with the UDPGT2B7*2 allele, which was
8.5 times more common in individuals who developed DILI
from diclofenac compared with controls.577
Symptoms are nonspecific in most cases, with nausea, vomiting, abdominal discomfort, and jaundice being hallmarks of
more severe hepatitis. Rash and fever occur in a minority of


Section IVToxinMediated Liver Injury

cases. The liver test abnormalities favor hepatocellular damage.

In rare cases the ANA titers may be elevated and care should
be taken to rule out autoimmune chronic hepatitis.576,578 Zone
3 or spotty acute hepatocellular necrosis is the most common
histologic finding. Other features may include granulomas,
cholestasis, hepatic eosinophilia, and chronic hepatitis. Overdose is managed by withdrawal of the agent and supportive
care. With early withdrawal the prognosis is good, even with
severe hepatitis. Rarely, the use of diclofenac has been thought
to trigger development of autoimmune hepatitis.578 Similar
occurrences and features have been described also for meloxicam (Mobic), and likely occur with all drugs of this class.579
Although there have been cases of serious DILI from ibuprofen, both hepatocellular and cholestatic patterns of injury,
its rarity as an implicated cause of DILI and almost ubiquitous
use suggest ibuprofen rarely if ever causes serious DILI.580-582
Acetaminophen is a widely used analgesic, and compared
with other drugs that are associated with liver injury, acetaminophen is available over-the-counter. Of the 76% of
Americans who reported using nonprescription products in
the Third National Health and Nutrition Examination Survey
(NHANES III), 36% reported using acetaminophen.582 Annual
costs associated with acetaminophen toxicity are estimated at
$51.5 million.583 Acetaminophen is the most common cause of
drug-induced acute liver failure in the United States.584 Acetaminophen is the nonnarcotic analgesic of choice in patients
with significant co-morbidities, such as impaired renal function, gastrointestinal disease, and bleeding disorders.
Animal studies demonstrate acetaminophen-induced liver
injury is mediated through reactive oxygen species and hepatocyte apoptosis. During phase I metabolism acetaminophen
undergoes oxidation, reduction, or hydrolysis by cytochrome
P450 enzymes. During phase II metabolism acetaminophen
metabolites are conjugated with glucuronic acid, sulfates, or
glutathione. Acetaminophen is metabolized by the cytochrome CYPs and CYP2E1 is the major source of the toxic
metabolite N-acetyl-p-benzoquinone (NAPQI) that depletes
hepatic glutathione stores and leads to oxidative injury (see
Fig. 25-4). NAPQI covalently binds to hepatocyte proteins
and leads to cell death. Reactive oxygen species are associated
with mitochondrial damage and the activation of caspases.585
This sequence of events leads to premature apoptosis of hepatocytes. Further support of the role of the oxidative stress
response as an important mechanism in acetaminophen hepatotoxicity is demonstrated in a study of metallothionein
knockout mice (MT null mice).586 MT null mice were more
susceptible to acetaminophen liver injury as demonstrated by
markedly elevated liver enzyme levels and hepatic necrosis
compared with control mice. More lipid peroxidation was
present in MT null mice based upon immunohistochemical
localization of 4-hydroxynonenal and malondialdehyde
protein adducts. Other transcription factors that protect
against oxidative injury have been reported to be associated
with acetaminophen toxicity in mice. Other enzymes and
pathways associated with acetaminophen DILI include activation of the glycogen synthase kinase-3 and c-Jun-N-terminal
kinase (JNK) pathways.587 Increased mitochondrial-derived
reactive oxygen species as a result of GSH depletion in mitochondria was implicated in liver injury from acetaminophen.
The innate immune system and natural killer (NK) cell activation and increase in interferon- level have been shown to
play a role in progression and severity of acetaminophen

hepatotoxicity.588 Risk factors for acetaminophen hepatotoxicity include age, alcohol use, tobacco use, and nutritional
Novel methods for early detection of drug-induced liver
injury are needed to try to avoid serious DILI or the development of jaundice or high levels of aminotransferases. In a
study of healthy volunteers administered a single 4-g dose of
acetaminophen, changes in the blood transcriptome were seen
48 hours after the dose even though there were no significant
increases in serum liver chemistries.589 Genes in oxidative
phosphorylation and mitochondrial function are downregulated in subjects administered acetaminophen compared
with subjects administered placebo (p < 1.66 109). Corresponding changes were seen in the serum metabolome with
an increase in lactate concentration from 24 to 72 hours after

Antineoplastic and
These agents produce a large number of hepatic abnormalities
(Table 25-17). Causality assessment of hepatotoxicity in the
setting of cancer chemotherapy is often difficult for the following reasons:
1. Abnormal liver tests may result from metastasis or infiltration of the liver parenchyma or biliary tree by tumor. A
Budd-Chiarilike picture may resemble sinusoidal obstruction syndrome and may occur as a result of the procoagulant state caused by many tumors.
2. Immunosuppression may result in sepsis and shock, with
its attendant cytokine-induced effects on the liver, such as
cholestasis. Occasionally the liver itself may be opportunistically infected, or transfusion may result in viral
3. Multiple drugs are often used in overlapping schedules,
making it difficult to assign causality of DILI to a single
4. Other modalities of treatment (i.e., nonchemotherapy)
may also lead to hepatotoxicity. Examples include the direct
effects of radiation and graft-versus-host disease in patients
undergoing bone marrow or stem cell transplants.
5. Drugs that have minimal hepatotoxic potential when used
alone may produce severe liver disease when used in combination with other chemotherapeutic agents or with radiation therapy.
6. Liver biopsy, which might help in differential diagnosis, is
often contraindicated because of thrombocytopenia and
coagulation abnormalities caused by treatment.
7. Toxicity in other organ systems may result in abnormal
liver tests (e.g., adriamycin-induced cardiac failure may
result in hepatic congestion and its resultant liver test

Methotrexate (MTX), a derivative of aminopterin, is a folate
analogue that inhibits dihydrofolate reductase, which causes
the arrest of rapidly dividing cells in the S-phase of the cell

Chapter 25Drug-Induced Liver Injury

Table 25-17 Antineoplastic and

Immunosuppressive Agents and DILI


Sinusoidal obstruction

Combination chemotherapy
Radiation therapy plus
Mitomycin C
Other regimens

Hepatocellular necrosis

Methotrexate (high dose)
Vinca alkaloids

Hepatic steatosis






Sclerosing cholangitis


Peliosis hepatis


Nodular regenerative


Hepatic neoplasms


Actinomycin D
Mitomycin C

cycle. This property has been used in the treatment of leukemias and other neoplasms, and also as a disease-modifying
agent in several chronic inflammatory conditions, including
psoriasis, rheumatoid arthritis, and chronic idiopathic inflammatory bowel disease. Hepatotoxicity has been recognized as
a potential major adverse reaction that can occur with longterm use. Case reports describing cirrhosis as a result of MTX


use first appeared in the 1960s.590 The pathogenesis of MTX

hepatotoxicity is poorly understood. It has been hypothesized
that the drug can activate hepatic stellate (Ito) cells, which
leads to increased collagen deposition. Others have speculated
that the drug itself, and its metabolites (polyglutamates), may
accumulate, leading to prolonged folate inhibition with resultant impairment of nucleotide and methionine synthesis that
in turn leads to hepatocyte injury.590 Patients with preexisting
liver disease seem to be more susceptible to toxicity.591 Factors
associated with increased risk of MTX toxicity include heavy
alcohol use, preexisting liver disease (especially fatty liver),
daily dosing, duration of therapy more than 2 years, cumulative dose >1500mg, and obesity with diabetes mellitus.590
Acute symptoms are rare. With advanced toxicity and cirrhosis, clinical features will reflect these changes and are therefore
nonspecific. Minor elevations in liver tests may occur in many
who take methotrexate (20% to 50%), but this does not necessarily imply significant toxicity.592 Conversely, liver tests may
be normal in the setting of severe fibrosis. With advanced
disease, the laboratory findings reflect those associated with
cirrhosis and its complications.
In 1982 the Psoriasis Task Force (Roenigk and colleagues)
devised a classification scheme for the liver biopsy findings in
methotrexate hepatotoxicity (Table 25-18). This is probably
the most popular classification scheme, despite its subjective
nature. Ultrastructural changes precede microscopic changes
and include the deposition of fibrous tissue in the space of
Disse and an increase in the size and number of hepatic stellate (Ito) cells in the perisinusoidal space.590 Microscopic
changes include macrovesicular steatosis; nuclear variability;
infiltration with chronic inflammatory cells; focal liver cell
necrosis; fibrosis in the perivenular, pericellular, and portal
regions; and eventually cirrhosis. Many of these findings may
also be a result of other underlying conditions, many of which
have been identified as being risk factors for hepatotoxicity.
A systematic review of medical databases unearthed 426 references relevant to MTX use in rheumatoid or psoriatic arthritis, of which 47 were included.593 Among persons with
rheumatoid arthritis, the 3-year incidence rate of increased
liver tests was 13/100 patient-years with cumulative incidence
of 31%. After 4 years, liver biopsies show mild fibrosis in 15%
(vs. 9% at baseline), severe fibrosis in 1.3% (vs. 0.3%), and
cirrhosis in 0.5% (vs. 0.3%). The manner in which therapy
should be adjusted if liver tests or biopsies are abnormal is
There is no antidote for MTX toxicity. Patients with cirrhosis have sometimes required transplantation. Prevention of
significant toxicity requires close monitoring of patients who
are taking the drug long term. In cases where a preexisting
liver disease is strongly suspected, a baseline, pre-MTX liver
biopsy should be performed. In those with appreciable preexisting liver disease, liver tests should be monitored every 4 to
8 weeks for the first year and every 3 to 6 months thereafter
for as long as the patient is taking MTX. Subjects should avoid
alcohol and should take folic acid supplements. Patients with
diabetes mellitus should maintain strict control of glucose
levels and obese patients strongly advised to lose weight.
Patients with no history of liver disease but who develop
abnormal liver tests early after starting MTX (within a few
months) should have a liver biopsy before continuing with
further treatment. Otherwise, when the patient has received a
predetermined cumulative dose (the American College of


Section IVToxinMediated Liver Injury

Table 25-18 Roenigk Histopathologic Classification of Methotrexate Hepatotoxicity





Grade I

Mild or none

Mild or none

Mild or none


Grade II

Moderate to severe

Moderate to severe

Moderate to severe


Grade IIIa

May or may not be present

May or may not be present

May or may not be present


Grade IIIb

May or may not be present

May or may not be present

May or may not be present

Moderate to severe

Grade IV

May or may not be present

May or may not be present

May or may not be present


Rheumatology recommends after 1.5g initially, and thereafter

every 1 to 1.5g), liver biopsies should be performed. If the
Roenigk classification is used (see Table 25-18), the finding of
grade IIIb or grade IV fibrosis is grounds to discontinue the
Leflunomide is a pyrimidine synthesis inhibitor that was
approved for treatment of rheumatoid arthritis in 1998 and
has also been prescribed for a small number of psoriasis
patients. At the time of this drugs approval, it was known that
mild transient aminotransferase level elevations commonly
occurred. However, in 2001, when the European EMEA
reported 129 liver-related ADRs with 15 cases of ALF, subsequent careful transaminase monitoring was mandated.594 In a
recent large U.S. study,595 elevated levels of transaminases
more than twice the ULN were found in 1% to 2% of patients
prescribed leflunomide or MTX monotherapy, and in 5% of
patients prescribed both agents. However, no cases of ALF
were mentioned and several other series have found little evidence of significant DILI.594,596 Therefore DILI attributable to
leflunomide appears to be very low.
Similar to MTX, 6-mercaptopurine (6-MP) and azathioprine are probably used more frequently as immunosuppressive agents in the treatment of chronic inflammatory disorders
and in the posttransplant setting than as antineoplastic agents.
6-MP has been in use for the last 60 years. It is a thiopurine
analogue of the natural purine bases. Its potential to cause
hepatotoxicity is well recognized. Cholestatic liver injury
appears to be the most common manifestation of this toxicity
and may occur in 6% to 40% of recipients.597-599 The effect
appears to be dose dependent. Doses exceeding 2.5mg/kg
have the highest likelihood of toxicity.598,600,601 The latent
period between commencement of the drug and the onset of
toxicity is anywhere from 1 to 18 months. Adults appear to be
more susceptible to injury than children.602 6-MP is metabolized extensively in the liver, and this probably relates to its
hepatotoxic potential. The mechanism of toxicity appears to
be intrinsic. Evidence in support of this conclusion includes
the paucity of evidence that would suggest a hypersensitivity
mechanism (i.e., the long lag time before the onset of symptoms, the lack of hypersensitivity features such as rash and
eosinophilia). Other supporting facts include the relatively
high incidence and dose dependence. Jaundice and pruritus
are the main presenting features. The laboratory studies reflect
a mixed hepatocellular and cholestatic injury with moderate
elevations in serum AST, ALT, AP, and bilirubin levels.600,601
Hepatic histopathology shows a mixed picture, with features
of both cholestasis and hepatocellular necrosis. Management
consists of discontinuing the agent. Cases of fatal hepatic
necrosis, in the setting of continued use despite evidence of

toxicity, have been described. Rechallenge has led to recurrent

hepatotoxicity in some cases.601
Azathioprine is a prodrug of 6-MP and appears to be less
hepatotoxic than its metabolite. This notwithstanding, it is
capable of causing DILI with a spectrum of toxicity that is
wider than that of 6-MP. In addition to the cholestatic injury
seen with 6-MP,603,604 other patterns have been recognized.
Predominant cholestasis, with evidence of a hypersensitivity
reaction, has been reported,605 as has a primarily hepatocellular type of injury, especially in postrenal transplant
patients.606 More recently, several other lesions with a common
pathogenesis, in that they involve an insult to the vascular
endothelium, have been appreciated. These conditions include
striking sinusoidal dilation, peliosis hepatis,607 nodular regenerative hyperplasia,608,609 hepatoportal sclerosis,608 and sinusoidal obstruction syndrome (SOS).610-612 These observations
were all made in the postrenal transplant setting, and in one
report about such patients the incidence of SOS was estimated
to be 2.5%.612 The onset of SOS occurs from 2 months to as
long as 9 months after transplantation. There is a male preponderance. In one series co-infection with a hepatotrophic
virus was suggested as a probable contributing factor in the
pathogenesis of SOS.612 Clinically, signs of portal hypertension
with minimal elevations of the liver tests in a nonspecific
pattern are noted. Portal hypertension may progress, which
may have an effect on future morbidity and mortality.612 The
hepatotoxicity appears to be primarily an idiosyncratic reaction, although azathioprine is converted to 6-MP in vivo and
direct toxicity may also play a role. As alluded to previously,
patients may display features of a hypersensitivity reaction in
some instances of toxicity attributable to azathioprine. Histologic features are usually classic for SOS or the other pathologies described.
6-Thioguanine is also a purine analogue, used primarily
in the treatment of acute and chronic leukemia. As with
azathioprine, this agent also appears to result in endothelial
dysfunction leading to manifestations of SOS, nodular regenerative hyperplasia, and hepatoportal sclerosis.598,613,614 In one
study the incidence of portal hypertension in patients with
chronic myeloid leukemia who were treated with busulfan
alone or busulfan with 6-thioguanine was determined. In
the latter group, 18 of 675 patients, compared with none in
the busulfan-only group, developed portal hypertension. Histologically, idiopathic portal hypertension with minimal
morphologic abnormalities or nodular regenerative hyperplasia was the major finding; three patients developed cirrhosis and its attendant complications.613 Other studies have
described SOS in patients treated with 6-thioguanine and
cytosine arabinoside.615,616

5-Fluorouracil (5-FU) is used in the treatment of malignancies of the digestive system, breast, and ovary. It is a
pyrimidine-based analogue that is metabolized by the liver
with little hepatotoxicity when used orally. Floxuridine, a
derivative of 5-FU, is administered by continuous intravenous
infusion or by direct infusion into the hepatic artery for the
treatment of hepatic metastasis from colon cancer.617,618 This
leads to higher remission rates and improved survival, but at
the cost of increased hepatic injury. Damage appears to be
more common with direct hepatic artery infusions,598 which
cause a chemical hepatitis in more than half of the patients
treated.619 Liver tenderness and elevations in serum AST, ALT,
AP, and bilirubin levels characterize the reaction. In a smaller
subset of patients sclerosing cholangitis may develop.619-622
This is usually heralded by the onset of jaundice and marked
elevations in serum AP level. In one study of intraarterial
infusion all 35 patients developed a predominantly cholestatic
pattern of liver tests. Seven patients receiving intraarterial
therapy were studied with cholangiography, which in all cases
demonstrated sclerosis of the intrahepatic or extrahepatic bile
ducts. In addition, liver biopsies showed cholestasis and pericholangitis, with minimal hepatocytic damage. It was suggested that biliary sclerosis is probably more common than
the often-described chemical hepatitis.619 Chemical hepatitis
usually resolves after therapy is complete or discontinued.
Fatal cirrhosis has been reported to result from the more
serious sclerosing cholangitis.623 Cases with sclerosing cholangitis are managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting versus surgical therapy if
complications develop or are impending. The biliary tree is
highly dependent on the hepatic arterial supply for oxygenation and delivery of nutrients, and it is thought that damage
or dysfunction of the arteries caused by the chemotherapeutic
agent leads to the biliary sclerosis.
Cytosine arabinoside is also a pyrimidine analogue. Hepatotoxicity appears to be dose related and ranges from mild
increases in serum AST, ALT, and AP levels to more significant
elevations with frank jaundice.624-627 These changes are usually
L-Asparaginase is an enzyme that catalyzes the hydrolysis
of l-asparagine to aspartic acid and ammonia. Because leukemic cells cannot produce l-asparagine, whereas normal cells
can, l-asparaginase is used to treat acute lymphocytic leukemia and T-cell lymphoblastic lymphoma. Abnormal liver
tests have been reported in up to 75% of recipients.628
Hypersensitivity-type reactions, especially after repeated
doses, are common and have been reported in 43% of recipients, although anaphylactic-like reactions occur in only about
10% of recipients.629,630 Steatosis, a finding more typical of a
metabolic aberration, is common, occurring in 50% to 90%
of recipients.631 This is probably a result of impaired mitochondrial protein synthesis. Given the frequency of its occurrence, DILI attributable to l-asparaginase is likely to be a
direct toxic effect of the drug itself (rather than metabolic
idiosyncrasy). The clinical features of reactions to
l-asparaginase usually develop within 1 hour after administration and include pruritus, dyspnea, urticaria, swelling at
the injection site, angioedema, rash, abdominal pain, laryngospasm, nasal stuffiness, bronchospasm, and hypotension.629
The liver test abnormalities include modestly elevated serum
AST, ALT, bilirubin, and AP levels. The serum albumin levels
and also levels of several other proteins that are synthesized

Chapter 25Drug-Induced Liver Injury


by the liver are decreased. These proteins include factors I, II,

VII, IX, and X; ceruloplasmin; haptoglobin; transferrin; and
lipoproteins.628 Coagulopathy may be a prominent feature.
Elevated ammonia levels may, abnormal liver tests are
common, and it is often difficult to differentiate hepatotoxicity from other toxic effects of the drug. Fatal outcomes can
occur. A less immunogenic form of the drug (pegaspargase)
has been developed and is reportedly less likely to result in
hypersensitivity reactions.629
Mithramycin (plicamycin) is an antibiotic that can intercalate with DNA and thus inhibit RNA synthesis. In addition
to its use as an anticancer agent, it is sometimes used in the
treatment of hypercalcemia and Paget disease. Abnormal liver
tests occur in almost all patients treated.632,633 Levels of serum
aminotransferases may be quite elevated, and correlate with
dose. Depression of coagulation factor production and thrombocytopenia may result in a bleeding diathesis. Hepatocellular
necrosis (zone 3) and steatosis have been observed in liver
biopsies.633 The lower doses used to treat hypercalcemia and
Paget disease are reportedly associated with less frequent hepatotoxicity.607 All of these features imply that mithramycin is
an intrinsic hepatotoxin.
Adriamycin (doxorubicin) is also an antibiotic. It has rarely
been implicated as the cause of hepatic injury. In six cases of
acute lymphoblastic leukemia it was thought to have caused
acute or chronic hepatitis.634 It has also been postulated that
adriamycin potentiates the hepatotoxicity of 6-MP. It may
increase the incidence of radiation-induced injury when used
before radiation therapy.635 Adriamycin has a high propensity
to produce cardiomyopathy that can result in congestive heart
failure. The resultant liver congestion can sometimes be misleading, but reverses with appropriate treatment of the heart
Dactinomycin (actinomycin D) has been used for many
years without much evidence of hepatotoxicity. A few cases of
severe hepatic injury have been described when the agent is
used alone or with vincristine.636-638 Cases of SOS have also
been described, especially in the setting of concomitant irradiation for treatment of Wilms tumor.639-642
Vinca alkaloids are derived from the periwinkle plant.
Their antitumor effects are dependent on their ability to
disrupt cellular microtubule function. Vincristine appears to
increase liver toxicity when used with radiation therapy.598
Rarely it may result in a mild increase in serum aminotransferase levels outside the setting of radiation.643 Otherwise,
these agents do not appear to be significant hepatotoxins.
The alkaloid etoposide (VP-16) is a derivative of podophyllotoxin. The drug disrupts the formation of the mitotic
spindle. Acute hepatocellular necrosis has been reported.644 In
combination with ifosfamide severe hepatotoxicity has been

Alkylating Agents
Cyclophosphamide is commonly used in treatment regimens
for leukemia, lymphoma, and solid tumors. It is also used in
the treatment of a few chronic inflammatory conditions, such
as Wegeners granulomatosis and systemic lupus erythematosus (SLE). It is metabolized to its active form by CYPs. The
alkylating species usually are formed only in cells with high
turnover rates. However, hepatotoxicity may result from a
metabolic idiosyncrasy in some individuals who form toxic


Section IVToxinMediated Liver Injury

amounts of these species in the hepatocytes. Hepatotoxicity

appears to be a rare complication of therapy. There are case
reports of hepatocellular necrosis that were possibly related to
the use of cyclophosphamide.646 In patients with collagen vascular diseases cyclophosphamide rarely has caused hepatic
injury, including mild hepatitis to massive hepatocellular
necrosis.647 A convincing case of toxicity with resolution after
withdrawal and recurrence on rechallenge was seen in a
patient with SLE, who exhibited jaundice and marked elevation in serum ALT levels.648 There are increasing reports of
SOS in patients undergoing bone marrow transplantation
who receive a conditioning regimen containing cyclophosphamide and busulfan.649-652 There is a report of SOS in the nontransplant setting related to the use of cyclophosphamide.653
Busulfan appears to be a contributing factor in the causation
of SOS, as described previously. Ifosfamide has been reported
to cause cholestasis when this agent is used in combination
with etoposide (VP-16).645 Chlorambucil rarely causes hepatotoxicity, but there is a recent report of an acute cholestatic
hepatitis with its use. Older, sparse reports focus more on
hepatocellular injury.654

Nitrosoureas (Carmustine [BCNU],

Lomustine, Semustine, Streptozocin)
These compounds can all cause what appears to be reversible
hepatic dysfunction, with jaundice and an elevated AST level
in up to 25% of cases. Higher doses have been noted to
increase the AST levels in up to 40% of patients.655,656 With
high doses of BCNU, fatal hepatic necrosis can occur. Pericholangitis and intrahepatic cholestasis accompany mild
hepatic necrosis in most cases. Recent animal studies provide
evidence that lipid peroxidation and alterations in the antioxidant system may significantly contribute to BCNU-induced
hepatotoxicity, and some antioxidant agents may be of benefit
in reducing the incidence of cholestasis.657 Dacarbazine is
used primarily to treat malignant melanoma and some lymphomas. Recent case reports implicate this drug in the causation of acute hepatocellular necrosis secondary to SOS.658-660
This seems to occur within a few days of the second dose, and
eosinophilia may be a feature, raising the possibility of an
immunologically mediated process. Massive elevations in AST
and ALT levels occur, and histologic results are consistent with
those of SOS. There tends to be minimal inflammatory infiltration.658 Management is supportive. It has been recommended that if eosinophilia develops after the first dose of
dacarbazine, subsequent doses should be avoided.658

Immunosuppressives for Solid

Organ Transplantation
Cyclosporin A, a calcineurin inhibitor extracted from Tolypocladium inflatum, revolutionized solid organ transplantation
in the 1980s by effectively controlling organ rejection. It has a
narrow therapeutic window that requires monitoring of
trough serum levels, and because it is metabolized by CYP3A4,
care must be taken with regard to drug interactions. Problems
with erratic bioavailability led to the need for microemulsion
preparations and careful twicedaily dosing. With regard to
DILI, cyclosporin has been reported to cause a mild, dosedependent cholestatic injury594,661,662 with a highly variable
frequency, and most of these cases were reported before there

were reliable assays available for monitoring cyclosporin levels.

In many patients hepatotoxicity is subclinical, with liver tests
revealing mild, often transient increases in AP levels, occasionally accompanied by slight elevations in serum bilirubin and
aminotransferase levels. In the setting of liver transplantation,
there are often multiple other potential causes of liver dysfunction (e.g., infection, organ rejection, hepatic artery
thrombosis), confounding conditions that must be ruled out
with imaging studies and liver biopsy. Nephrotoxicity, hypertension, dyslipidemia, and neurotoxicity are much more
common problems.
Tacrolimus, formerly known as FK-506, is another calcineurin inhibitor and has become more popular than cyclosporin A because of better bioavailability and fewer cases of
ADRs such as hypertension and dyslipidemia. However, it is
also metabolized by CYP3A4 and requires therapeutic monitoring, and compared to cyclosporin, it causes just as much
nephrotoxicity and may cause more diabetes and neurotoxicity. DILI is extremely rare, but has been reported.594,663
Sirolimus (rapamycin) and the related drug everolimus
(also used in higher doses for advanced renal cell cancer) are
macrocyclic lactone compounds that cause immunosuppression by binding to m-TOR (mammalian target of rapamycin).
They cause less nephrotoxicity than the calcineurin inhibitors
and can be used when transplant patients develop kidney
injury. However, they are not used initially after transplantation because they inhibit wound healing and sirolimus may
promote hepatic artery thrombosis in liver transplant
patients.594 A few cases of cholestatic DILI have been
reported663,664 but these appear to be rare events.
Mycophenolate mofetil is an antimetabolite that inhibits
inosine monophosphate and has largely replaced azathioprine
in solid organ transplantation because of fewer side effects.
Although elevated levels of aminotransferases were reported
in 14% of Turkish renal transplant patients,665 no other significant reports of DILI from mycophenolate have been found.
It appears to be unlike the thiopurines (see Antimetabolites)
that can cause cholestatic, mixed cholestatic-hepatocellular,
and sinusoidal obstruction syndrome.

Tyrosine Kinase Inhibitors

Imatinib (Gleevec) was the first of this class of drugs, which
includes busutinib, dasatinib, INNO-406, lapatinib, and nitotinib, to be used for the treatment of leukemia. There have
been major advances in long-term management of Philadelphia chromosome-positive acute lymphoblastic or chronic
myelogenous leukemia, gastrointestinal stromal tumors, and
others. Unfortunately, imatinib may cause DILI. About 5% of
subjects develop moderate to marked increases in serum ALT
levels, which rarely progresses to acute massive hepatic necrosis and fulminant liver failure.666 Cholestatic hepatitis has also
been reported.667

Biologic Response Modulators

Alpha-interferons (IFN-) are used in the treatment of
chronic viral hepatitis (C and B), some solid tumors (e.g.,
Kaposi sarcomas in patients with HIV disease), melanoma,
and certain leukemias. Hepatotoxicity is extremely rare with
the low percutaneous doses used to treat hepatitis. However,
a few cases that probably represent induction of autoimmune

hepatitis by IFN-induced enhancement of the immune
system have been described.668 In addition, a small subset
of patients being treated for chronic hepatitis C often have
mild elevations in AST and ALT levels, despite a good virologic response. These return to normal levels when the
interferon is discontinued, suggesting that IFN- plays a
role in their elevation. The incidence of liver enzyme abnormalities seems somewhat more common with the pegylated
than with the standard interferons.669 Elevations of serum
aminotransferase levels are more frequent with administration of the higher doses of IFN- used in therapy of malignancies.670,671 Rare cases of jaundice and hepatic failure have
been reported with interferon alfa-2b.671 Beta-Interferons are
used increasingly in the treatment of multiple sclerosis and
may cause DILI of varying severity, ranging from asymptomatic elevation of liver tests to fatal DILI.672 A populationbased review of 844 Canadian patients with multiple sclerosis
who were prescribed beta-interferon showed 40% developed
new elevations of serum ALT levels.673 Tumor necrosis
factor- (TNF-) is a biologic agent that is produced in
response to several types of injury, such as alcoholic liver
disease and chronic inflammatory bowel disease. It has been
implicated in the pathogenesis of cholestasis,674 and therefore
it is not surprising that it has been found to cause profound
cholestasis when it is used as treatment in advanced colorectal
cancer.675 AntiTNF- drugs, including infliximab and etanercept, have been found to reactivate latent infections, such
as chronic hepatitis B or tuberculosis, and to lead to enhanced
rates of replication of the hepatitis C virus. Infliximab use
has been associated with severe hepatotoxicity, leading to
death or the need for liver transplant. Clinical features have
been variable, ranging from severe, prolonged cholestatic
hepatitis (that sometimes progresses to hepatic failure and
need for liver transplant676,677) to autoimmune hepatitis (that
improved with cessation of infliximab and initiation of
therapy with prednisone plus azathioprine).677 The mechanism of injury is uncertain, but an immunoallergic reaction
may be involved.
Interleukin-2 (IL-2) immunotherapy is associated with the
development of profound reversible cholestasis and hyperbilirubinemia in a large proportion of patients (up to 85%) who
receive it.678-684 There is evidence to suggest that this reversible
cholestasis is a direct result of IL-2dependent reduced excretion of bile.678 Clinical features include jaundice, right upper
quadrant pain and tenderness, nausea, pruritus, and hepatomegaly. Surprisingly, the administration of total parenteral
nutrition has been noted to reduce the incidence of this phenomenon.679 Several other biologic response modifiers, including lenalidomide (Revlimid)680 and leflunomide (Arava),681,682
have been reported to cause severe DILI.

Summary and Conclusions

Drug-induced liver injury is underdiagnosed and underappreciated as a cause or contributor to liver injury. Drugs and
toxins should be considered in virtually all types of liver injury
occurring in subjects of all ages, although the risks are higher
in older subjects (and probably increase progressively with age
[it is not clear whether this is due to increased intrinsic risk
or to the fact that older people take more drugs and therefore
have more opportunities to experience ADRs]).

Chapter 25Drug-Induced Liver Injury


A goal that now appears attainable within the next generation is to define the environmental and host factors that
underlie the development of idiosyncratic DILI. However, this
will require the establishment of a national registry of subjects
with bona fide, well-characterized DILI and the discovery of
the genetic polymorphisms and other factors that distinguish
these subjects from those with similar demographics and drug
exposure who do not develop DILI. Such an effort has begun
in the United States, thanks to funding provided by the
NIDDK of the National Institutes of Health (NIH). There is
a National DILI Network comprising eight clinical centers and
regional consortia. More information is available at http:// Healthcare providers are encouraged to
contact one of these centers for advice or to refer subjects to
the National DILIN Registry of patients. It is only through
careful phenotype-genotype correlation in DILI subjects
versus suitable controls that we will realize the promise implicit
in the sequencing of the human genome and the analytical
advances that have made metabolomics and metabonomics
emerging fields of science.

This work was supported by the following grants and contracts from the U.S. Public Health Service (USPHS) of the
NIH: DK38825 and DK065201. The opinions expressed herein
are those of the authors. They do not necessarily reflect the
official views of the USPHS or the Universities of Connecticut,
Iowa, or Kentucky, nor of Emory University. We thank Melanie
McDermid for much help in preparing the manuscript.

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Chapter 25Drug-Induced Liver Injury


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