Drug-induced liver injury: Do we know everything?

Table 1 Summary of drug-induced liver injury guidelines by the American College of Gastroenterology[7,69]

Elements necessary for the diagnostic evaluation of DILI

Known duration of exposure

Concomitant medications and diseases

Response to dechallenge (and rechallenge if performed)

Presence or absence of symptoms, rash, eosinophilia

Performing sufficient exclusionary tests (viral serology, imaging, etc.) to reflect the injury pattern and acuteness of liver function tests (e.g., acute viral serology for A, B and C and autoimmune hepatitis when presenting with acute hepatocellular injury; routine testing for hepatitis E virus not recommended because of the problems with current commercial assays; Epstein-Barr virus, cytomegalovirus, and other viral serology if lymphadenopathy, atypical lymphocytosis present)

Sufficient time to determine clinical outcome - did the event resolve or become chronic?

Use of liver biopsy

Often not required if the acute injury resolves

Helpful in confirming clinical suspicion of DILI but rarely pathognomonic

Useful to differentiate between Drug-Induced autoimmune hepatitis and idiopathic autoimmune hepatitis

Useful to rule out underlying chronic viral hepatitis, non-alcoholic fatty liver disease, alcoholic liver disease, or other chronic liver disease

Used to exclude DILI where re-exposure or ongoing use of an agent is expected

Rechallenge: Generally best avoided, unless there is no alternative treatment

Use of Causality Assessment Methods

Roussel Uclaf Causality Assessment Method is best considered an adjunct to expert opinion (it should not be the sole diagnostic method)

Consensus opinion

Expert consultation

For patients with chronic viral hepatitis, DILI requires a high index of suspicion, knowledge of a stable clinical course before the new medication, and monitoring of viral loads to rule out flares of the underlying disease

Assigning causality to herbal compounds and dietary supplements can be especially difficult; require knowledge of all ingredients and their purity

DILI: Drug-induced liver injury.