Drug-Induced Liver Injury

Question 1

Suspect hepatocellular or mixed DILI

Answer 1

a. acute viral hepatitis A, B, and C and autoimmune hepatitis should be excluded w/ serology and HCV RNA - strong, very low evidence
b. anti-HEV IgM may be considered if higher suspicion - conditional, very low evidence
c. recommend testing for acute CMV, EBV, HSV if viral hepatitis excluded - strong, low evidence
d. recommend evaluation for Wilson disease and Budd-Chiari when clinically appropriate - strong, very low evidence

Question 2

Suspect cholestatic DILI

Answer 2

a. recommend abdominal imaging to exclude biliary tract pathology and infiltrative processes - strong, low evidence
b. recommend limiting serological testing for PBC to those w/ no evidence of obvious biliary tract pathology on imaging - strong, low evidence
c. suggest limiting ERCP to instance where routine MRI or EUS is unable to exclude impacted CBD stones, PSC, or pancreaticobiliary malignancy - conditional, very low evidence

Question 3

When to consider biopsy

Answer 3

a. recommend biopsy if autoimmune hepatitis remains an etiology and immunosuppressive therapy is contemplated - strong, low evidence
b. suggest biopsy if unrelenting rise in LFTs despite stopping the suspected agent - conditional, very low evidence
c. peak ALT not fallen by >50% at 30-60 d after onset of hepatocellular DILI or if peak ALP has not fallen by >50% at 180 d in cases of cholestatic DILI despite stopping offending agent - conditional, very low evidence
d. DILI where continued use or re-exposure to the agent is contemplated - conditional, very low evidence
e. LFT abnormalities persist beyond 180 d, especially if associated symptoms - conditional, very low evidence

Question 4

Suggest using a prognostic model consisting of MELD, Charlton comorbidity index, and serum albumin for predicting 6-month mortality in DILI patients

Answer 4

conditional, low evidence

Question 5

Suggest NAC in early stage of ALF, given its good safety profile and some evidence for efficacy one early coma stage patients

Answer 5

conditional, low evidence

Question 6

Suggest against using NAC for CHILDREN

Answer 6

conditional, low evidence

Question 7

No good studies of steroids but they can be considered if concern for AIH

Answer 7

conditional, low evidence

Question 8

Recommend encouraging reporting use of herbs and supplements

Answer 8

strong, low evidence

Question 9

Recommend stopping all herbs and supplements in patients w/ suspected hepatoxicity

Answer 9

strong, low evidence

Question 10

Consider transplant eval in patient w/ ALF and severe cholestatic injury from HDS-DILI

Answer 10

strong, low evidence