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KEY CONCEPTS
Through its normally functioning enzymes and processes the liver often causes a drug to become toxic through a process known as bioactivation.
Drug-induced liver injury (DILI) can have many different clinical presentations: idiosyncratic reactions, allergic hepatitis, toxic hepatitis, chronic active toxic hepatitis, toxic cirrhosis, and liver vascular disorders.
The mechanisms of DILI are diverse, representing many phases of biotransformation, and are susceptible to genetic polymorphism.
The assessment of a possible liver injury caused by drugs should include what is known in the literature, the timing involved, the clinical course, and, always, an exploration for preexisting conditions that may have encouraged the lesion’s development.
Liver enzyme assays in serum can help to determine if a particular type of liver damage is present.
Monitoring for DILI must be tailored to the drug and the patient’s potential risk factors.
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Patient Care Process for Drug-Induced Liver Injury
The image shows the five fundamental steps included in The Pharmacist’s Care Process endorsed by the Joint Commission for Pharmacy Practitioners (2014). The tagline of this process reads collaborate, communicate, and document. The five fundamental steps listed here are collect, assess, plan, implement, and follow-up: monitor and evaluate. All these steps are listed in a circular block diagram.
Collect
Patient demographics listing, age, and pregnancy status are very important
Patient medical history including any possible previous liver injury and illness that may indicate an alternative cause or a predisposition; and type 2 diabetes mellitus that may indicate a nonalcoholic fatty liver
History of present illness that carefully documents each symptom with a time of onset
Social history comprising a detailed assessment of alcohol use; intravenous drug use and other recreational substance use; along with a careful work history (see Table e56-3)
Current medication history that prioritizes those initiated within the last 90 days and includes prescription, nonprescription, herbal, and other complementary medicines. If possible, determine exact time the medication was started prior to patient presentation
Objective data should include
Liver enzyme values, Total Bilirubin, Direct and Indirect Bilirubin
Liver function tests, such as INR, transferrin and ammonia
Hepatitis A, B, C assessments
Objective confirmation of liver injury via biopsy, CT, MRI, or sonogram
A literature search for reports of the patient’s medications, herbs used and other substances, and liver injury
A search of liver injury reports on LiverTox
Assess
The pattern of liver enzyme elevation (see Table e56-4)
The probability of each likely agent as a causative agent using RUCAM (see Table e56-2)
The severity of the reaction
Determine through consultation with the medical team and patient if a rechallenge with the probable causative agent is worthwhile
Plan*
Drug therapy regimen to replace the drug or herb that must be discontinued
Monitoring parameters to determine liver recovery, note that there will be short-term and long-term needs
Patient education on drug or herbs to avoid in the future and any long-term ...