From the Guidelines
The management of drug-induced hepatitis involves immediate withdrawal of the offending agent and close monitoring until complete and sustained resolution of clinical and laboratory findings.
Key Considerations
- The diagnosis of drug-induced hepatitis is supported by an acute onset, features of hypersensitivity, published literature on the implicated drug, latency period from drug exposure to liver injury, and absence of advanced fibrosis or cirrhosis at presentation 1.
- Liver tissue examination is warranted if the diagnosis is uncertain, laboratory findings indicate severe injury, or the institution of glucocorticoid therapy is being considered 1.
- Treatment with glucocorticoids may be necessary in cases where laboratory tests do not improve after discontinuation of the medication or worsening of symptoms or laboratory tests at any time during the observation period 1.
Management Strategies
- Withdrawal of the offending agent: This is the primary management strategy for drug-induced hepatitis, with resolution typically occurring within 1 month (rarely 3 months) 1.
- Glucocorticoid therapy: May be considered in cases where laboratory tests do not improve after discontinuation of the medication or worsening of symptoms or laboratory tests at any time during the observation period 1.
- Monitoring: Close monitoring of clinical and laboratory findings is essential to ensure complete and sustained resolution of the disease 1.
Special Considerations
- Hy's law: Serum aminotransferase levels >3-fold ULN and total serum bilirubin level >2-fold ULN increase the risk of death or need for liver transplantation in 9%-12% of patients, and satisfaction of these criteria supports the institution of glucocorticoid therapy 1.
- Cholestatic liver diseases: Patients with underlying cholestatic liver diseases may require different approaches to the assessment and management of suspected drug-induced liver injury, compared to patients with normal livers or parenchymal liver diseases 1.
From the Research
Management of Drug-Induced Hepatitis
The management of drug-induced hepatitis typically involves the withdrawal of the suspected medication and supportive care.
- Early diagnosis and withdrawal of the suspected medication is the mainstay of treatment of DILI 2.
- In patients who show no clinical improvement, or there is progressive liver injury despite cessation of the suspected drug, a liver biopsy should be considered 3.
- Empirical treatment with corticosteroids may be required in patients with non-resolving liver injury 3.
- For acetaminophen and Amanita mushroom poisoning, there are specific therapies in use 2.
- Other possible management modalities for DILI include ursodeoxycholic acid 2.
- Novel therapies such as magnesium isoglycyrrhizinate (MgIG), bicyclol, and S-adenosylmethionine have shown promise in improving laboratory markers, but more research is needed to confirm their efficacy 4.
Treatment Approaches
Different treatment approaches may be considered depending on the severity and type of drug-induced hepatitis.
- For cytolytic hepatitis, the prognosis is more severe, and the treatment involves removing the noxious agent, which can lead to disease resolution in one or two weeks 5.
- For chronic hepatitis, evolution towards cirrhosis is possible, and treatment involves interruption of the drugs generating them 5.
- In some cases, plasma exchange, radix Paeoniae Rubra, and livina-polyherbal preparation may be considered, but the certainty of the evidence for these interventions is very low 4.