Internal Medicine

P1: RLJ/OZN P2: KUF

0521779407-D-01 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:41

Drug and Toxin-Induced Liver Diseases 501

about 48 hours of well-being and then rising LFTs; FHF in up to 30%;

renal failure in up to 20%

■nonsteroidal anti-inflammatory (NSAIDS): mild to severe; usually

idiosyncratic

■antibiotics: usually self-limited and idiosyncratic: carbenicillin

(necroinflammatory), oxacillin (cholestatic), Augmentin (chol-

estatic) ceftriaxone (biliary sludge), erythromycin (cholestasis), sul-

fonamide (mixed)

■antifungals: ketoconazole, fluconazole (necroinflammatory): mild

to fulminant

■antituberculous agents: isoniazid (INH): jaundice in 1% of all

patients; affects 2% of patients older than 50; female and alcoholics:

greatest risk; FHF associated with high mortality. Rifampin: rarely

hepatotoxic when taken alone; clinical hepatitis in 5–8% when taken

with INH

■antiviral agents: zidovudine (AZT): sporadic cases of biochemical

hepatitis, can lead to fatal syndrome of hepatomegaly, lactic acidosis,

and steatosis in AIDS patients; didanosine (DDI)

■oral contraceptives: cholestasis, hepatic adenoma, Budd-Chiari

syndrome; HCC and focal nodular hyperplasia

■anabolic, androgenic steroids: cholestasis, hepatic adenoma, HCC

■antilipids: niacin – infrequent injury (cholestatic and hepatocellu-

lar) at doses >3 g/day; mild to FHF; 50–75% dose reduction required

for sustained-release form. HMG-CoA reductase inhibitors – asymp-

tomatic elevated AST and ALT, usually in the first year of therapy

■neurologic/antipsychotic agents: chlorpromazine (cholestasis), car-

bamazepine, phenytoin, valproic acid

■cardiovascular agents: amiodarone (acute liver failure and chronic

hepatitis/steatosis/fibrosis), alpha-methyldopa (chronic hepatitis

to FHF), ACE-inhibitors-captopril (cholestatic), enalapril (hepa-

tocellular), lisinopril (mixed pattern), calcium channel blockers-

verapamil (hepatocellular), diltiazem (cholestatic), nifedipine

(mixed)

■chemotherapeutic/immunosuppressive agents: methotrexate (stea-

tosis, fibrosis, cirrhosis), 5-FU, azathioprine (asymptomatic ele-

vated AST/ALT, cholestasis, peliosis hepatitis, venoocclusive disease,

nodular regenerative hyperplasia), cyclosporine (cholestasis)

■total parenteral nutrition (TPN): steatosis, steatohepatitis,

cholestasis-usually reversible with cessation of TPN

■herbal medicine/remedies: many hepatotoxic, should be part of his-

tory in evaluation of abnormal LFTs