Does corticosteroid therapy work for drug-induced hepatitis?

From the Guidelines

Corticosteroid therapy is recommended for drug-induced hepatitis only in severe cases with significant inflammation and evidence of autoimmune features, as supported by the 2020 practice guidance from the American Association for the Study of Liver Diseases 1. The management of drug-induced hepatitis primarily involves discontinuing the offending medication and providing supportive care while the liver heals. In most cases, the liver will recover once the harmful drug is removed from the system. Some key points to consider in the management of drug-induced hepatitis include:

• Discontinuation of the offending agent with close monitoring until complete and sustained resolution of clinical and laboratory findings 1
• Institution of glucocorticoid therapy in cases where there is a clear indication, such as satisfaction of criteria for Hy’s law, which includes serum aminotransferase levels >3-fold ULN and total serum bilirubin level >2-fold ULN 1
• Consideration of glucocorticoid management in cases where laboratory tests fail to improve after discontinuation of the medication or worsening of symptoms or laboratory tests at any time during the observation period 1
• The use of an algorithm based on serum ALT level, total serum bilirubin level, and AST:ALT ratio to predict the risk of drug-induced acute liver failure, with a sensitivity of 80% and specificity of 82% 1
• The potential for idiosyncratic drug reactions to have a mortality of 5% and need for liver transplantation in 4.5% 1 In terms of the specific use of corticosteroids, they may be considered for a short course of 1-2 weeks with gradual tapering in severe cases of drug-induced liver injury with significant inflammation and evidence of autoimmune features, as mentioned in the guidance from the American Association for the Study of Liver Diseases 1. It is essential to note that corticosteroid therapy should only be implemented under specialist guidance, as it comes with significant side effects, including increased infection risk, metabolic disturbances, and potential worsening of certain types of liver injury. Regular liver function tests and monitoring by hepatologists or gastroenterologists experienced in managing liver disease are crucial in making treatment decisions for patients with drug-induced hepatitis.

From the Research

Corticosteroid Therapy for Drug-Induced Hepatitis

• The effectiveness of corticosteroid therapy in treating drug-induced hepatitis is supported by several studies 2, 3.
• A systematic review of the role of corticosteroids in drug-induced liver injury (DILI) found that most studies suggested beneficial effects of steroid treatment in moderate/severe DILI 3.
• In cases of drug-induced autoimmune hepatitis (DI-AIH), corticosteroids have been shown to be effective, with rapid and long-lasting effects after discontinuation of corticosteroids and without evidence of relapse 2, 3.
• However, the efficacy of corticosteroids in DILI is still unclear, and more research is needed to fully understand their role in treatment 3.

Specific Cases and Studies

• A case report of a patient with steroid-refractory immune-related hepatitis found that ursodeoxycholic acid and bezafibrate were useful in treating the condition 4.
• A study on the role of corticosteroids in chronic type B hepatitis found that a short course of prednisolone had no beneficial effects and may even be harmful 5.
• Another study discussed the various pathogenetic mechanisms and risk factors involved in drug-induced liver disease, and noted that therapy with ursodeoxycholic acid or steroids may be helpful in some cases 6.

Treatment Outcomes

• The majority of studies analyzing the effects of corticosteroids in moderate/severe DILI have demonstrated beneficial effects, with improvement in liver function and symptoms 3.
• However, patients with drug-induced fulminant acute liver failure did not show improved overall survival with steroid therapy 3.
• In cases of CPIs-induced liver injury, corticosteroids were found to be effective in improving liver function, but some patients recovered spontaneously without treatment 3.