Raised liver enzymes

Hepatotoxicity Itraconazole has been associated with rare cases of serious hepatotoxicity, including liver failure and death. Some of these cases had neither pre-existing liver disease, nor a serious underlying medical condition. If liver function tests are abnormal, discontinue treatment. In patients with raised liver enzymes or an active liver disease or who have experienced liver toxicity with other drugs, do not start treatment unless the expected benefit exceeds the risk of hepatic injury. In such cases, liver enzyme monitoring is necessary. 

Adverse effects include elevation of cholesterol and triglycerides levels hepatotoxicity and raised liver enzyme levels has also been reported. 

Three children developed hepatomegaly and raised liver enzymes after receiving high-dose dexamethasone therapy (0.66-1.09 mg/kg/day) (158). 

In a 78-week double-blind single center study 139 patients with type 2 diabetes were randomized to acarbose or placebo in addition to their usual therapy (63). The mean dose of acarbose at the end of the study was 680 mg. Two patients taking 600 mg or more developed raised liver enzymes, to more than three times the upper limit of normal. 

A 37-year-old HIV-infected woman receiving stavudine, lamivudine, and indinavir developed epigastric pain, anorexia, and vomiting. She had lactic acidosis (serum lactate 4.9 mmol/1), raised liver enzymes, and an increased prothrombin time. She had hepatomegaly and tachypnea and required mechanical ventilation. Her progress was complicated by pancreatitis and acute respiratory distress syndrome. Antiviral medication was stopped and she was treated with co-enzyme Q, carnitine, and vitamin C. The serum lactic acid and transaminases returned to normal over 4 weeks and she was weaned off the ventilator after 4 months. 

A 46-year-old woman developed fatigue and jaundice about 20 weeks after she started to take nefazodone (300 mg/day). She had raised liver enzymes and bilirubin concentrations. There was no evidence of infectious hepatitis or immune disorders. Liver biopsy showed ballooning degeneration and necrosis of... 

Raised liver enzymes have been rarely found in patients taking venlafaxine, and it appears that hepatitis may also be rare adverse effect (21). 

An 18-year-old man was found collapsed outside the nightclub. He had taken five ecstasy tablets and some powder that was later confirmed as ecstasy. He was vomiting and agitated, had a tachycardia and hyperthermia, and needed mechanical ventilation. He later developed rhabdomyolysis and renal impairment with raised liver enzymes. He went on to develop pneumonia and a urinary tract infection. He was discharged after 32 days with a mildly ataxic gait and dysphonia secondary to vocal cord damage. 

Adverse effects. A variety of effects has been associated with these agents, including gastrointestinal disturbance, headache, dizziness, sleep disturbance, raised liver enzymes, neutropenia, pancreatitis, and rashes. 

Tcpotccan Nausea and vomiting Bone marrow depression alopecia rash dyspnoea headache paraesthesia transient raised liver enzymes... 

The safety profile of angiotensin II receptor antagonists is so far remarkably good. Except for hypotension, virtually no dose-related adverse effects have been reported. Headache, dizziness, weakness, and fatigue are the most common adverse effects. There have been reports of raised liver enzymes (9), cholestatic hepatitis (10), and pancreatitis (11) with losartan. Several cases of angio-edema have been reported but no other obvious hypersensitivity reactions. 

Hepatotoxicity has been described, but the disease itself may play an overriding role. In 16 patients with mucosal leishmaniasis treated with meglumine antimoniate 20 mg/ kg intravenously for 28 days, there were raised liver enzyme in conjunction with electrocardiographic abnormalities and/or musculoskeletal complaints in three subjects (SEDA-16, 311). 

Fatal liver damage was observed particularly in the UK and tended to occur in elderly subjects. The complication initially presented as jaundice or raised liver enzymes (including alkaline phosphatase). Surprisingly, biochemical and histological liver changes were not consistent with major hepatocellular damage. There were three reports of primary biliary cirrhosis, but a causal relation was not proven (SEDA-12, 84). 

Cholestatic hepatitis occurred in a 61-year-old man with chronic myelocytic leukemia who had taken busulfan for 8 years (27). He presented with fever, abdominal pain, and raised liver enzymes. A liver biopsy showed cellular cholestasis with focal liver cell necrosis accompanied by a mild inflammatory infiltrate. When busulfan was withdrawn, his Uver enzymes normalized and his fever resolved. 

Both patients also had raised liver enzymes, peripheral eosinophilia, and eosinophils in the colonic infiltrate. Persistent recovery occurred after carbamazepine was withdrawn. 

A 51-year-old woman consumed 20 pieces of the lower stem and root of B. officinalis to treat dermatitis. She developed nausea, vomiting, and dizziness, and had raised liver enzymes. Her liver function recovered 1 month after withdrawal of B. officinalis. 

Raised liver enzyme activities have been reported in most studies. In some articles this effect was described as transient, in others as disappearing after withdrawal. The incidence varies from a few percent of cases to 35 5%, but occasionally the effect has been recorded in aU cases treated. A temporal relation between these hver function changes and fluconazole treatment has been shown in many cases. Severe liver toxicity has not been reported (SED-12, 681) (21). While asymptomatic rises in transaminases were noted in some children with neoplastic disease who were treated concomitantly with fluconazole in a small study (48), there were no significant changes in a larger study in cancer patients treated with placebo or fluconazole 400 mg (42). 

The efficacy and safety of fluconazole in neonates with Candida fungemia has been evaluated in a multicenter prospective study (65). Fluconazole was safe and effective even in complicated cases, including infants of very low birth weights. Two of 50 neonates developed raised liver enzymes during fluconazole therapy and two others had raised serum creatinine concentrations. In none of them did these abnormalities necessitate discontinuation of antifungal therapy. 

Hepatotoxicity is exceedingly rare. The role of gabapentin in one patient with markedly raised liver enzymes after 12 weeks of treatment was unclear (SEDA-22, 88). 

A 56-year-old woman developed the signs and symptoms of lead poisoning after taking an Indian herbal medicine for many years (147). Her blood and urine lead concentrations were 1530 ng/ml and 4785 gg/day. She also had raised liver enzymes. After withdrawal of the remedy and treatment with penicillamine, she made a full recovery. 

A 49-year-old black woman was admitted with jaundice and raised liver enzymes 4 months after starting to take... 

Liver damage usually appears 1-2 months after the start of therapy. In children, raised liver enzymes are common during the first few months of treatment, but withdrawal is seldom necessary. A careful watch should be kept for early symptoms of isoniazid-induced hepatitis, such as malaise, fatigue, nausea, and epigastric distress. The dangers of continuing isoniazid after the onset of symptoms of toxicity have been highlighted (30). The earhest symptoms of isoniazid toxicity should be clearly described to the patient, particularly to hepatitis B carriers, who may be more susceptible to hepatotoxicity (26). 

In most clinical reports, there were some cases of raised liver enzyme activities the changes were transient or disappeared after withdrawal of itraconazole (36). More serious hepatotoxicity was not reported. 

A 49-year-old man with bipolar disorder inadvertently took four daily doses of lamotrigine 2700 mg each. He developed a low-grade fever, a skin rash, and periorbital edema. He had a leukocytosis, raised liver enzymes, and acute renal insufficiency. He recovered fully after lamotrigine withdrawal and steroid therapy. 

In 3325 patients who took leflunomide, the rate of drug withdrawal was 42% within 33 months after approval by the US Food and Drugs Administration, and was more likely in patients who received a loading dose. The most common causes of discontinuation were inefficacy (30%), gastrointestinal symptoms (29%), non-adherence to therapy or loss to follow-up (14%), and raised liver enzymes (5%) (50). 

A 67-year-old woman with rheumatoid arthritis developed diarrhea and raised liver enzymes after taking leflunomide for 15 days. Histologically, the liver showed acute hepatitis. She was homozygous for the CYP2C9 3 allele. The liver damage subsided within a few weeks. 

Of 17 individuals with suspected latent multidrug-resistant tuberculosis treated with pyrazinamide and levofloxacin, 11 developed musculoskeletal adverse effects related to therapy, 5 had nervous system effects, and 15 had raised liver enzymes, uric acid, or creatinine kinase (4). 

Of 42 patients, 19 of whom received methyl tert-butyl-ether alone and 23 with bile acid-ethylenediaminetetra-acetate, there were mild complications in 40 vomiting in 12, pain at the start of treatment in 32, raised liver enzymes in six, and fever and leukocytosis in five (5). In those given methyl tert-butylether alone, there were two serious complications (gallbladder wall necrosis with... 

Immunoallergic reactions have been reported with minocycline and include lupus-like syndrome, autoimmune hepatitis, eosinophilic pneumonia, hypersensitivity syndrome, a serum sickness-like illness (29), and Sweet s syndrome (SEDA-21, 262) (SEDA-22, 271). Over 60 minocycline-induced cases of lupus-like syndrome and 24 cases of minocycline-induced autoimmune hepatitis were found in a review of the literature (30). In 13 patients, both disorders co-existed. These patients had symmetrical polyarthralgia/polyarthritis, raised liver enzymes, and positive antinuclear antibodies they were also generally antihistone-negative, and only two patients had p-ANCA antibodies. Minocycline-related lupus can also occur in adolescents (31). 

A 47-year-old woman took an extract of C. racemosa for 1 week to treat menopausal symptoms she developed jaundice and raised liver enzymes (5). No other causes of liver damage were found. She required liver... 

A 59-year-old woman with mantle-cell lymphoma and no hepatic involvement took a range of unconventional medicines (8). During a routine check-up she had raised liver enzymes, and self-medication with cat s claw was deemed the most likely cause. Cat s claw was withdrawn and her liver tests normalized within 60 days. 

Trop M, Novak M, Rodl S, Hellbom B, Kroell W, Goessler W. Silver-coated dressing acticoat caused raised liver enzymes and argyria-like symptoms in burn patient. J Trauma 2006 60(3) 648-52. 

Raised liver enzymes due to tolcapone were often associated with diarrhea and occurred within 6 weeks to 6 months of the start of tolcapone therapy. Diarrhea... 

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