Can doxycycline cause transaminitis?

Doxycycline Can Cause Transaminitis

Yes, doxycycline can cause transaminitis (elevated liver enzymes), though it is an uncommon adverse effect compared to other tetracyclines like minocycline. 1, 2 This hepatotoxicity can range from mild, asymptomatic elevation of liver enzymes to more severe presentations including drug-induced autoimmune hepatitis.

Evidence for Doxycycline-Induced Liver Injury

• Doxycycline has been documented to cause hepatotoxicity in clinical guidelines and case reports 2, 1
• The British Thoracic Society guidelines specifically list hepatotoxicity as a known adverse effect of doxycycline 2
• A 2024 case report documented a healthy 28-year-old male who developed significant transaminitis with a hepatocellular pattern of liver injury after just five days of doxycycline therapy for Lyme disease 1
• Another study reported that 63.6% of infants treated with doxycycline for scrub typhus developed transaminitis 3

Clinical Presentation of Doxycycline-Induced Liver Injury

Patients with doxycycline-induced liver injury may present with:

• Nausea and vomiting
• Fatigue
• Elevated liver enzymes (transaminitis)
• Hepatocellular pattern of liver injury
• Short latency period (can occur within days of starting treatment) 1

Risk Factors and Monitoring

While specific risk factors for doxycycline-induced liver injury aren't well-established, general precautions include:

• Monitoring liver function tests in patients on long-term therapy
• The British Thoracic Society recommends routine toxicity monitoring tests including liver function tests (LFTs) intermittently throughout treatment 2
• Patients with pre-existing liver disease or hepatitis may require additional caution, though specific guidelines for doxycycline use in hepatitis B/C patients are limited 4

Severe Manifestations

In rare cases, doxycycline can cause more severe hepatic reactions:

• Doxycycline-induced autoimmune hepatitis (DIAH) has been reported, characterized by elevated liver enzymes >5x normal upper limit, elevated immunoglobulin G, and high titers of autoantibodies 5
• Doxycycline has been implicated in Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome, which can include transaminitis as part of its presentation 6

Management of Doxycycline-Induced Liver Injury

When transaminitis is detected in a patient taking doxycycline:

1. Discontinue doxycycline immediately
2. Monitor liver enzymes until normalization
3. Consider alternative antibiotics if treatment must continue
4. In cases of DIAH, liver enzymes typically normalize and autoantibody titers downtrend after discontinuation 5

Prevention

To minimize risk of hepatotoxicity:

• Consider baseline liver function testing before initiating therapy in high-risk patients
• Avoid concomitant hepatotoxic medications when possible
• Educate patients about symptoms of liver injury (jaundice, abdominal pain, nausea)
• Follow monitoring recommendations for patients on long-term therapy

Clinical Perspective

While doxycycline-induced liver injury is uncommon compared to other tetracyclines like minocycline, clinicians should maintain awareness of this potential adverse effect, particularly when prescribing for extended periods as is common in acne treatment or malaria prophylaxis 4, 2.