Hepatotoxic Medication

Aka: Hepatotoxic Medication, Hepatotoxic Supplement, Hepatotoxin

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II. Causes: Medications associated with Cirrhosis

  1. Alpha-Methyldopa
  2. Amiodarone
  3. Isoniazid
  4. Methotrexate
  5. Troglitazone (no longer available in United States)
  6. Vitamin A

III. Causes: Most common drug causes of Acute Hepatitis

  1. Amoxicillin-Clavulanic Acid (Augmentin, most common cause)
  2. Acetaminophen (AST often rises above 5000, most common cause of Acute Liver Failure in U.S.)
  3. Anti-Tuberculosis medications
  4. Trimethoprim-sulfamethoxazole
  5. Minocycline (mimics Autoimmune Hepatitis)
  6. Nitrofurantoin (mimics Autoimmune Hepatitis)
  7. Valproic Acid
  8. Niacin

IV. Causes: Hepatotoxic Medications (including mild transaminase elevations)

  1. Analgesics
    1. NSAIDs
      1. Avoid in patients with Chronic Liver Disease
    2. Acetaminophen (>4 grams in 24 hours in adults)
      1. Limit to 2 grams/day in Chronic Liver Disease
    3. Allopurinol
    4. Baclofen
    5. Methotrexate
  2. Medications used in Diabetes Mellitus
    1. Acarbose (Precose)
    2. Pioglitazone (Actos)
    3. Sulfonylureas (e.g. Glyburide)
  3. Lipid-lowering Medications
    1. HMG-CoA Reductase Inhibitors (Statins)
    2. Nicotinic Acid (Niacin)
  4. Antihypertensives
    1. Labetolol
    2. Hydralazine
    3. Lisinopril
    4. Losartan (Cozaar)
  5. Antiarrhythmics
    1. Amiodarone
    2. Procainamide
  6. Antibiotics
    1. Augmentin
    2. Ciprofloxacin
    3. Erythromycin
    4. Isoniazid (INH)
    5. Nitrofurantoin (Macrobid)
    6. Penicillin
    7. Sulfonamides
    8. Tetracycline
    9. Rifampin
    10. Pyrazinamide
  7. Chemotherapy
    1. Imatinib (Gleevec)
    2. Methotrexate
  8. Antifungal Medications
    1. Fluconazole (Diflucan)
    2. Itraconazole (Sporanox)
    3. Ketoconazole (Nizoral)
  9. Anticonvulsant Medications
    1. Phenytoin (Dilantin)
    2. Valproic Acid
    3. Carbamazepine
  10. Psychotropic Medications
    1. Bupropion (Wellbutrin, Zyban)
    2. Tricyclic Antidepressants
    3. Chlorpromazine (Thorazine)
    4. Risperidone (Risperdal)
    5. Selective Serotonin Reuptake Inhibitors
    6. Trazodone
  11. Hormonal Medications
    1. Tamoxifen
    2. Testosterone
  12. Miscellaneous Medications
    1. Halothane
    2. Etretinate
    3. Protease Inhibitors
    4. Heparin
    5. Omeprazole

V. Causes: Hepatotoxic Supplements

  1. Amanita Species (Mushrooms)
  2. Asafetida
  3. Chaparral leaf
  4. Comfrey
  5. Colloidal Silver
  6. Echinacea
  7. Ephedra
  8. Gentian
  9. Germander
  10. Green Tea Extract (but standard Green Tea is safe)
  11. Iron
  12. Jin bu huan
  13. Kalms tablets
  14. Kava
  15. Mistletoe
  16. Nicotinic Acid (Niacin)
  17. Pennyroyal oil
  18. Ragwort
  19. Senna fruit extract
  20. Scutellaria (skullcap)
  21. Shark Cartilage
  22. Valerian Root
  23. Vitamin A
  24. Kava Kava

VI. Managment: Monitoring for Hepatotoxicity in Chronic Liver Disease

  1. See mild Liver Function Test Abnormality
  2. Indications
    1. Potential Hepatotoxin use in Chronic Liver Disease
  3. Labs
    1. Aspartate Aminotransferase
    2. Alanine Aminotransferase
    3. Total Serum Bilirubin
    4. Alkaline Phosphatase
  4. Lab Timing
    1. Baseline
    2. Every 2 weeks for first month
    3. Every month for next three months
    4. Every three months until medication stopped
  5. Indications to stop medication
    1. Liver Function Tests increase >2x baseline
    2. Liver related symptoms develop

VII. Resources

  1. NIDDK/NLM Liver Tox
    1. http://www.livertox.nih.gov

VIII. References

  1. Lee (1995) N Engl J Med 333:1118-27 [PubMed]
  2. Navarro (2006) N Engl J Med 354(7): 731-739 [PubMed]
  3. Oh (2017) Am Fam Physician 96(11): 709-15 [PubMed]
  4. Riley (2001) Am Fam Physician 64(9):1555-60 [PubMed]
  5. Speeg (1995) Gastroenterol Clin North Am 24:1047-64 [PubMed]

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Related Studies

Ontology: hepatotoxin (C0596691)

Definition (CSP) poisonous substance that damages or destroys liver cells.
Concepts Hazardous or Poisonous Substance (T131)
English hepatotoxin, hepatotoxins
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Pharmacology

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