Drugs associated with liver injury

Up to 20% of drug-induced liver injury cases are associated with herbal and dietary supplements. Paracetamol is the most common cause of severe drug-induced liver injury (see the Toxicology and Toxinology guidelines for management of paracetamol poisoning). Examples of drugs that have been reported to cause liver injury are listed in Examples of drugs associated with liver injury; this list is not exhaustive. Comprehensive information is available from the LiverTox website.

Drug interactions may significantly contribute to liver injury when the interaction between medications (including herbal and dietary supplements) alters their usual metabolic pathways. A drug that on its own would not cause clinically important liver injury can become hepatotoxic when it interacts with another drug.

Table 1. Examples of drugs associated with liver injury
[NB1]
Drug class	Examples
analgesics	NSAIDs (celecoxib, diclofenac, ibuprofen, naproxen), paracetamol
antiepileptics	carbamazepine, lamotrigine, phenytoin, valproate
antimicrobials	amoxicillin+clavulanate, azithromycin, ceftriaxone, ciprofloxacin, erythromycin, flucloxacillin, fluconazole, isoniazid, levofloxacin, minocycline, moxifloxacin, nitrofurantoin, pyrazinamide, rifampicin, roxithromycin, terbinafine, trimethoprim, trimethoprim+sulfamethoxazole
antineoplastic drugs	bortezomib, cyproterone, flutamide, imatinib, ipilimumab
antiretrovirals	darunavir, rilpivirine, ritonavir
cardiovascular drugs	amiodarone, hydralazine, methyldopa
herbal and dietary supplements	black cohosh, body-building supplements (may contain androgenic steroids), various Chinese herbs, echinacea, green tea extract, kava, kombucha tea, valerian, weight-loss supplements
illicit drugs	cocaine, MDMA (ecstasy)
immunomodulatory drugs	azathioprine, interferon-beta, leflunomide, mercaptopurine, methotrexate, TNF inhibitors
psychotropic drugs	agomelatine, chlorpromazine, duloxetine
other	allopurinol, androgenic steroids, disulfiram, propylthiouracil, DOACs (rivaroxaban, dabigatran)
Note: MDMA = methylenedioxymethamphetamine; DOACs = direct-acting oral anticoagulants; NSAIDs = nonsteroidal anti-inflammatory drugs; TNF = tumour necrosis factor NB1: Many drugs can cause liver injury. The drugs listed in this table are examples of recognised causes of drug-induced liver injury.