Practical guidelines for diagnosis and early management of drug-induced liver injury

Abstract

The spectrum of drug-induced liver injury (DILI) is both diverse and complex. The first step in diagnosis is a suspicion of DILI based on careful consideration of recent comprehensive reports on the disease. There are some situations in which the suspicion of DILI is particularly strong. Exclusion of other possible etiologies according to the pattern of liver injury is essential for the diagnosis. In patients with suspected DILI, diagnostic scales, such as the Councils for International Organizations of Medical Sciences/Roussel Uclaf Causality Assessment Method (CIOMS/RUCAM) scale, may be helpful for the final diagnosis. Early management of DILI involves prompt withdrawal of the drug suspected of being responsible, according to serum levels of alanine aminotransferase (ALT), alkaline phosphatase (ALP), and total bilirubin (T-Bil). However, as DILI patients may show resolution of liver injury without discontinuation of the drug, it should be carefully evaluated whether the suspected drug should be discontinued immediately with adequate consideration of the importance of the medication.

Figure 1

Percentages of methods for causality assessment utilized for diagnosis of DILI, reported during the last decade.

Figure 2

Algorithm for management of DILI. A: When new drugs are started; B: When liver dysfunction is recognized. The type, severity, and causes of liver injury should be assessed promptly. ¹Imaging studies such as ultrasonography should be performed in cases with suspected bile duct disorders.