Management of suspected drug-induced liver injury

If drug-induced liver injury is suspected:

• check for reports of liver injury caused by any of the patient’s medications; for example, on the LiverTox website. Keep in mind that drug interactions may be a contributory factor, and that newly recognised or uncommon adverse reactions may not have been reported
• stop suspected drugs if possible
• exclude other causes of liver dysfunction (eg biliary disease, excessive alcohol consumption, viral hepatitis, autoimmune disease)
• monitor until there is clinical and biochemical evidence of resolution
• do not rechallenge with a suspected drug because the recurrent injury may be more severe.

Refer the patient for specialist assessment if liver enzymes or bilirubin concentrations are significantly elevated, especially if they remain elevated or increase further. Urgent discussion with a liver transplant team is required for patients with severe liver injury indicated by jaundice, an elevated international normalised ratio (INR) or hepatic encephalopathy.

Liver abnormalities usually resolve when the patient stops taking the causative drug. Treatment with prednisolone can be considered for drug-induced autoimmune hepatitis. This usually requires a liver biopsy for diagnosis—seek specialist advice.

Specific therapies to treat drug-induced liver injury are used in a specialist setting for some drugs; for example, acetylcysteine is effective for the treatment of paracetamol-induced liver injury (see the Toxicology and Toxinology guidelines for more information about paracetamol poisoning). Evidence is limited for use of other specific therapies (eg colestyramine for leflunomide-induced liver injury, carnitine for sodium valproate–induced liver injury).

For management of severe itch, see Cholestatic itch in patients with liver disease.