II. Causes: Medications associated with Cirrhosis

  1. Alpha-Methyldopa
  2. Amiodarone
  3. Isoniazid
  4. Methotrexate
  5. Troglitazone (no longer available in United States)
  6. Vitamin A

III. Causes: Most common drug causes of Acute Hepatitis

  1. Amoxicillin-Clavulanic Acid (Augmentin, most common cause)
  2. Acetaminophen Overdose (AST often rises above 5000, most common cause of Acute Liver Failure in U.S.)
  3. Anti-Tuberculosis medications
  4. Trimethoprim-sulfamethoxazole
  5. Minocycline (mimics Autoimmune Hepatitis)
  6. Nitrofurantoin (mimics Autoimmune Hepatitis)
  7. Valproic Acid
  8. Niacin

IV. Causes: Hepatotoxic Medications (including mild transaminase elevations)

V. Causes: Hepatotoxic Supplements

  1. Precautions
    1. Supplements often have unlabeled ingredients as well as risk of contaminants (unregulated in U.S.)
  2. Amanita Species (Mushrooms)
  3. Asafetida
  4. Black Cohosh
  5. Chaparral leaf
  6. Comfrey
  7. Colloidal Silver
  8. Echinacea
  9. Ephedra
  10. Gentian
  11. Germander
  12. Green Tea Extract (but standard Green Tea is safe)
  13. Iron
  14. Jin bu huan
  15. Kalms tablets
  16. Kava Kava
  17. Mistletoe
  18. Nicotinic Acid (Niacin)
  19. Pennyroyal oil
  20. Ragwort
  21. Senna fruit extract
  22. Scutellaria (skullcap)
  23. Shark Cartilage
  24. Turmeric
  25. Valerian Root
  26. Vitamin A

VI. Managment: Monitoring for Hepatotoxicity in Chronic Liver Disease

  1. Precautions
    1. See mild Liver Function Test Abnormality
    2. Be alert for even mild transaminase elevations and consider medication causes
  2. Indications
    1. Potential Hepatotoxin use in Chronic Liver Disease
  3. Labs
    1. Aspartate Aminotransferase
    2. Alanine Aminotransferase
    3. Total Serum Bilirubin
    4. Alkaline Phosphatase
  4. Lab Timing
    1. Baseline
    2. Every 2 weeks for first month
    3. Every month for next three months
    4. Every three months until medication stopped
  5. Indications to stop medication
    1. Liver Function Tests increase >2x baseline
    2. Liver related symptoms develop

VII. Resources

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