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ACG releases guidelines for drug-induced liver injury

The American College of Gastroenterology has released guidelines and recommendations for physicians and health care providers to diagnosis and manage idiosyncratic drug-induced liver injury.

Although rare, drug-induced liver injury (DILI) is one of the most challenging disorders faced by gastroenterologists. According to researchers, the growing use of herbal and dietary supplements (HDS) has coincided with an increase in DILI incidence.

“A lot of consumers have a preconceived notion that if it’s a natural product, it must be safe. But that is not necessarily the case,” Herbert L. Bonkovsky, MD, FACG, Carolinas HealthCare System, and one of the researchers who drafted the guidelines, said in a press release. “Most of these products are not well-regulated and have very little oversight. We encourage patients to talk to their doctor about the medications they are taking, and herbal and dietary supplements [HDS] should be no exception.”

Herbert L. Bonkovsky

The guidelines strongly recommend that patients notify physicians of any HDS they are taking, and providers should conduct a liver biopsy, discourage re-exposure of a drug that may have caused hepatotoxicity in a patient, discontinue the drug if there is evidence of liver dysfunction, and discuss medication history.

Other guideline recommendations:

For patients with suspected cholestatic DILI:

• Ultrasound or CT scans should be conducted.
• Serological testing for primary biliary cirrhosis should be limited to patients without evidence of biliary tract pathology on abdominal imaging tests.
• Endoscopic retrograde cholangiography should be limited when routine imaging cannot exclude affected common bile duct stones, pancreatico-biliary malignancy or primary sclerosing cholangitis.

 For patients with suspected hepatocellular or mixed DILI:

• Anti-hepatitis E virus IgM testing should be avoided unless there is clinical suspicion.
• Acute cytomegalovirus, Epstein-Barr virus or herpes simplex virus infection tests should be conducted per clinical features and if viral hepatitis is excluded.
• Acute viral hepatitis A, B, C and autoimmune hepatitis should be excluded with HCV RNA testing and standard serologies.

Because DILI is often misdiagnosed, researchers said, the guidelines strongly recommend that patients give providers a full history of medication and supplemental usage.

Naga P. Chalasani

“Accurate history of medication exposure and onset and course of liver biochemistry abnormalities is crucial,” Naga P. Chalasani, MD, FACG, chief, division of gastroenterology and hepatology at Indiana University School of Medicine, said in a press release.

Disclosure: See the study for a full list of relevant financial disclosures.