Gastroenterology Book

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Hepatotoxic Medication

Aka: Hepatotoxic Medication, Hepatotoxic Supplement, Hepatotoxin
  1. See Also
    1. Toxic Hepatitis
    2. Chronic Liver Disease
    3. Medication Causes of Jaundice
  2. 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
  3. Causes: Most common drug causes of Acute Hepatitis
    1. Amoxicillin-Clavulanic Acid (Augmentin, most common cause)
    2. Acetaminophen Overdose (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
  4. 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 or Statins (transient transaminase increase and severe injury is rare)
      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)
      4. Terbinafine (transient transaminase increase and severe injury is rare)
    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
      6. Isoretinoin (transient transaminase increase and severe injury is rare)
  5. Causes: Hepatotoxic Supplements
    1. Precautions
      1. Supplements often have unlabeled ingredients as well as risk of contaminants (unregulated in U.S.)
    2. Amanita Species (Mushrooms)
    3. Asafetida
    4. Black Cohosh
    5. Chaparral leaf
    6. Comfrey
    7. Colloidal Silver
    8. Echinacea
    9. Ephedra
    10. Gentian
    11. Germander
    12. Green Tea Extract (but standard Green Tea is safe)
    13. Iron
    14. Jin bu huan
    15. Kalms tablets
    16. Kava Kava
    17. Mistletoe
    18. Nicotinic Acid (Niacin)
    19. Pennyroyal oil
    20. Ragwort
    21. Senna fruit extract
    22. Scutellaria (skullcap)
    23. Shark Cartilage
    24. Turmeric
    25. Valerian Root
    26. Vitamin A
  6. Managment: Monitoring for Hepatotoxicity in Chronic Liver Disease
    1. Precautions
      1. See mild Liver Function Test Abnormality
      2. Be alert for even mild transaminase elevations and consider medication causes
    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
  7. Resources
    1. NIDDK/NLM Liver Tox
      1. http://www.livertox.nih.gov
  8. References
    1. (2022) Presc Lett 29(5): 26-7
    2. Lee (1995) N Engl J Med 333:1118-27 [PubMed]
    3. Navarro (2006) N Engl J Med 354(7): 731-739 [PubMed]
    4. Oh (2017) Am Fam Physician 96(11): 709-15 [PubMed]
    5. Riley (2001) Am Fam Physician 64(9):1555-60 [PubMed]
    6. Speeg (1995) Gastroenterol Clin North Am 24:1047-64 [PubMed]

hepatotoxin (C0596691)

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


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