Did you know that most acute liver failure is caused by drugs?[1] While rare, drug-induced liver injury (DILI) is the leading reason for a medication approved by the US Food and Drug Administration to subsequently be withdrawn from the market.[2,3] This frightening complication can result from both prescribed and over-the-counter agents, including some herbal and dietary supplements.
DILI is both difficult to predict and challenging to recognize. Considering that the range of presentations can also be bewildering—from mild asymptomatic liver test abnormalities to acute hepatic failure—here are five issues to be aware of related to DILI.
1. Some patterns are safer than others; recognize Hy's Law.
Although hepatocellular or cholestatic injuries alone rarely lead to transplantation or death, jaundice (bilirubin > 2 times upper limit of normal) in combination with elevated serum aminotransferase levels (> 3 times upper limit of normal) has the worst prognosis. These findings in a patient with a hepatocellular pattern of injury are associated with mortality rates as high as 10%-50% without transplantation.[4,5] This pattern was first identified by Hyman Zimmerman and is now called Hy's Law.
Categorizing DILI into one of its three basic injury patterns—hepatocellular, cholestatic, and mixed hepatocellular-cholestatic—may not be granular enough to fully characterize the injury, though. Therefore, a clinical phenotype is also used and is based on multiple elements.
