Published online Dec 14, 2014. doi: 10.3748/wjg.v20.i46.17352
Revised: April 14, 2014
Accepted: July 24, 2014
Published online: December 14, 2014
Abnormalities in liver function tests, including transient and self-limiting hypertransaminasemia, cholestatic disease and hepatitis, can develop during treatment with anti-tumour-necrosis-factor (TNF) therapy. The optimal management of liver injury related to anti-TNF therapy is still a matter of debate. Although some authors recommend discontinuing treatment in case of both a rise of alanine aminotransferase more than 5 times the upper limit of normal, or the occurrence of jaundice, there are no standard guidelines for the management of anti-TNF-related liver injury. Bibliographical searches were performed in PubMed, using the following key words: inflammatory bowel disease (IBD); TNF inhibitors; hypertransaminasemia; drug-related liver injury; infliximab. According to published data, elevation of transaminases in patients with IBD treated with anti-TNF is a common finding, but resolution appears to be the usual outcome. Anti-TNF agents seem to be safe with a low risk of causing severe drug-related liver injury. According to our centre experience, we found that hypertransaminasemia was a common, mainly self-limiting finding in our IBD cohort and was not correlated to infliximab treatment on both univariate and multivariate analyses. An algorithm for the management of liver impairment occurring during anti-TNF treatment is also proposed and this highlights the need of a multidisciplinary approach and suggests liver biopsy as a key-point in the management decision in case of severe rise of transaminases. However, hepatic injury is generally self-limiting and drug withdrawal seems to be an exception.
Core tip: Anti-tumour-necrosis-factor (TNF) agents appear to be safe with a low risk of causing severe liver injury. Standard guidelines for the management of anti-TNF-related liver injury are lacking. Our approach, based on evidence from literature and our centre experience, highlights the need of a multidisciplinary approach and suggests liver biopsy as a key-point in the management decision. We particularly highlight that continuation of the anti-TNF treatment is usually possible, in view of the rarity of severe liver injury and the lack of alternative medical options in case of severe active inflammatory bowel disease.