Can streptomycin cause liver injury?

Streptomycin and Liver Injury

Streptomycin does not cause liver injury and no precautions are necessary when using it in patients with hepatic disease. 1

Streptomycin's Safety Profile in Liver Disease

• According to the CDC and American Thoracic Society guidelines on tuberculosis treatment, streptomycin requires no precautions when used in patients with hepatic disease 1
• Unlike other anti-tuberculosis medications such as isoniazid, rifampin, and pyrazinamide that can cause hepatotoxicity, streptomycin has no documented hepatotoxic effects 1
• Streptomycin is primarily eliminated by the kidneys rather than metabolized by the liver, which explains its lack of hepatotoxicity 1

Primary Adverse Effects of Streptomycin

• Ototoxicity is the most important adverse reaction, including vestibular and hearing disturbances, with increased risk in elderly patients and those using loop diuretics 1
• Nephrotoxicity occurs in approximately 2% of patients, though less commonly than with other aminoglycosides like amikacin or kanamycin 1
• Neurotoxicity can manifest as circumoral paresthesias after injection and rarely as interactions with muscle relaxants causing respiratory muscle weakness 1

Monitoring Recommendations

• No liver function monitoring is required when using streptomycin 1
• Baseline and periodic monitoring should focus on:
  • Audiogram and vestibular testing at baseline 1
  • Romberg testing at baseline 1
  • Serum creatinine measurement at baseline and monthly 1
  • Regular assessment for auditory or vestibular symptoms 1

Clinical Considerations for Streptomycin Use

• Streptomycin is contraindicated in pregnancy due to risk of fetal hearing loss 1
• Dosage adjustments are essential in patients with renal insufficiency but not in those with liver disease 1
• For adults, the standard dose is 15 mg/kg per day (maximum 1g/day), reduced to 10 mg/kg for patients over 59 years of age 1
• In patients with renal insufficiency, dosing frequency should be reduced to 2-3 times weekly while maintaining the 12-15 mg/kg per dose 1

Antibiotics Associated with Hepatotoxicity

• While streptomycin does not cause liver injury, other commonly used antibiotics do carry hepatotoxicity risks:
  • Amoxicillin-clavulanate is the leading cause of drug-induced liver injury among antibiotics 2
  • Macrolides like erythromycin can cause cholestatic liver injury 2
  • Tetracyclines may cause microvesicular steatosis, particularly at high intravenous doses 2
  • Fluoroquinolones have been shown to be safe alternatives in patients who develop hepatotoxicity from first-line anti-tuberculosis medications 3

Clinical Application

• When treating tuberculosis in patients with underlying liver disease, streptomycin can be safely used without concern for worsening hepatic function 1
• For patients who develop hepatotoxicity from first-line anti-TB drugs, a regimen containing streptomycin can be considered as it does not add hepatotoxic burden 3
• Monitoring should focus on renal function and ototoxicity rather than hepatic parameters when using streptomycin 1