Drug Induced Liver Injury - Symptoms, Treatment & Recovery

1. Drug induced liver injury (DILI) is an adverse reaction that occurs in response to drugs (medicines) or xenobiotics.
2. Drug induced liver injury is otherwise also known as drug-induced hepatotoxicity. It can be caused by prescription, over-the-counter (OTC), and herbal and dietary supplements.
3. Drug induced liver injury or hepatotoxicity may be acute or chronic, and it is responsible for causing frequent acute liver failure.

Drug-induced liver injury is usually classified into two types. These two types include:

1. Intrinsic drug induced liver disease: Intrinsic drug induced liver injury or illness usually depends on the dose of the drug and is predictable—for example, acetaminophen toxicity.
2. Idiosyncratic drug induced liver disease: Idiosyncratic drug induced liver injury or disease is not predictable and does not depend only on the dose. It is accountable for most drug-related hepatotoxicity.

Besides the dose and total drug exposure time, idiosyncratic drug-induced liver injury also depends on the uncommon response of the patient receiving it. Examples of medicines (drugs) that can cause idiosyncratic drug induced liver injury include using antimicrobial treatments, Amoxicillin-clavulanate. 

The occurrence of drug induced liver disease is usually dependent on the interactions between the drug (medicine), the patient (host) and the environmental risk factors. This includes the following:  

1. The factors related to drugs (medication) that increase the risk of drug-induced liver injury include:
   1. The dose of the drug
   2. The route of drug administration
   3. The duration of administration of the drug
2. People who are at an increased risk of developing drug-induced liver injury include the following:
   1. Female sex 
   2. Children 
   3. Elderly people
   4. Genetic factor
   5. People with compromised immunity 
   6. People with acute liver damage 
   7. Patient with a history of previous drug-induced liver injury 
   8. People having Non-alcoholic fatty liver disease (NAFLD) 
3. Environmental risk factors that increase or put an individual at risk of developing drug induced liver injury (DILI):
   1. People who are obese or have obesity 
   2. Dietary habits of the person 
   3. Alcohol consumption 
   4. Tobacco usage 
   5. People who are on multiple drug therapy 
   6. Excessive consumption of caffeinated drinks 

Many drugs are known to cause liver injury. These drugs include over-the-counter (OTC) medicines, prescription medicines and even herbal and dietary supplements. Examples of some drugs inducing hepatotoxicity or causing liver injury include the following:

1. Antibiotics: Drugs like Amoxicillin-Clavulanate, Ciprofloxacin, Isoniazid (INH), Erythromycin, and Ciprofloxacin are some antibiotics that are known to cause drug-induced liver injury. Antibiotics are responsible for causing 45.4% of idiosyncratic drug-induced liver injuries. 
2. Nonsteroidal anti-inflammatory drugs (NSAIDs): Diclofenac, Ibuprofen, Mefenamic acid, etc., are NSAIDs known for inducing liver injury or hepatotoxicity. 
3. Cardiovascular drugs: Drugs like statins (atorvastatin, pentostatin) or amiodarone are examples of cardiovascular drugs that cause hepatotoxicity or liver injury.  
4. Herbal and dietary supplements (HDS): HDS are responsible for about 16.1% of hepatotoxicity or liver injury. Examples of Herbal and nutritional supplements (HDS) that induce liver injury include green tea extract, multi-ingredient dietary supplements and anabolic steroids.
5. Central nervous system (CNS) drugs: Drugs acting on the CNS, like valproate and phenytoin, are responsible for causing liver injury. 
6. Anticancer agents or antineoplastic medicines:
   1. Methotrexate: It is an immunosuppressant that slows the immune system and aids in the reduction of inflammation.
   2. Tyrosine kinases inhibitors: They inhibit the proliferation or multiplication of tumour cells, hence used to treat cancer. Examples include Erlotinib and Gefitinib.
   3. Tumour necrosis factor inhibitors inhibit the body's response to tumour necrosis factor (TNF- helps the body fight infections), which is part of the inflammatory response, resulting in stopping inflammation. Examples include Infliximab, Adalimumab.
   4. Alpha inhibitors: ( which lower blood pressure) like Doxazosin, Prazosin, and Terazosin are some anticancer or antineoplastic drugs known for producing hepatotoxicity or liver injury. 

Usually, drug induced liver disease symptoms appear about 3 to 6 months after the drug administration. They may vary from person to person. Where the symptoms are mild or chronic in some instances, some people don’t experience any liver injury symptoms at all. 

However, the symptoms indicating drug-induced liver injury include the following:

1. Jaundice 
2. Dark urine 
3. Abdominal pain
4. Nausea or vomiting
5. Diarrhoea 
6. Fatigue
7. Fever
8. Itching on the skin (pruritis)
9. Headache 
10. Loss of appetite

Diagnosing drug induced liver injury is difficult. This is because most of the patients don’t experience any symptoms at all. And the ones who share it may not know that it is caused due to liver injury as the symptoms they experience are similar to other conditions. 

However, depending on the symptoms being experienced by the patient, the healthcare provider may suggest some of the following tests:

1. A complete medical history examination
2. Blood tests to check the level of liver enzymes
3. Imaging tests like ultrasound and Computed tomography (CT) scans to get a detailed view of the liver.
4. Liver biopsy

The first treatment approach used to treat drug-induced hepatotoxicity is to stop the consumption of the drug causing it and avoid its exposure. A doctor may also use other treatment approaches to treat drug induced hepatotoxicity. These treatment approaches are as follows: 

1. Using N-acetyl-cysteine (NAC) to treat the intrinsic drug-induced liver injury caused by acetaminophen toxicity.
2. Using L-carnitine to treat the drug-induced liver injury caused by an overdose of valproic acid.
3. Glucocorticoid therapy to treat liver damage due to autoimmune hepatitis.
4. Bile acid sequestrants for cholestatic drug-induced liver disease.
5. Antihistamines for treating itching (pruritus).
6. Hospitalisation in patients showing signs of progression of drug-induced liver injury.
7. Liver transplant in severe conditions where the liver is extensively damaged.

However, consult the doctor if you are facing any symptoms associated with drug induced hepatotoxicity to get the proper treatment at the right time. Do not self-treat yourself, as it can further worsen your condition.

The time taken to recover from drug induced hepatotoxicity typically depends on the drug that has caused it. Usually, the patient with drug-induced liver injury starts recovering in a few days to a week after cessation of the drug therapy.

However, the recovery might also be quick in some instances, whereas it may take a few weeks to months to recover entirely in others. 

Drug induced liver injury (DILI) is an adverse reaction that usually depends on the interactions between the drug (medicine), the patient (host) and the environmental risk factors. It is highly prevalent, and almost all medications may cause drug-induced liver diseases. In most instances, the drug-induced liver injury is not severe and improves once the medicine causing it is discontinued. 

If you or your loved ones have doubts or symptoms associated with drug-induced liver injury, contact our team of experts at HexaHealth. Our expert team of doctors can consult you and provide you with the proper treatment. Get in touch with us TODAY!