Early ALT response to corticosteroid treatment distinguishes idiosyncratic drug‐induced liver injury from autoimmune hepatitis

Abstract

Background Drug‐induced liver injury (DILI) and idiopathic autoimmune hepatitis (AIH) are competing diagnoses in patients with acute liver injury (ALI) and drug intake. In absence of unequivocal markers, scores like RUCAM and AIH are used to distinguish both entities. However, in some cases the diagnosis remains ambiguous. Our aim was to identify a simple parameter to discriminate DILI and AIH shortly after starting corticosteroid treatment. Methods For the current analysis, 44 patients with ALI who took at least one drug and who received corticosteroids were included and comprised 22 DILI and 22 AIH cases. Scores of AIH and RUCAM were calculated at initial presentation, the final diagnosis was made from analysing the course of disease. Changes in the serum alanine aminotransferase (ALT) concentrations after starting corticosteroid treatment were determined and compared between the DILI and AIH groups. Results Fifty‐nine per cent of patients (n = 26) were correctly classified at presentation by AIH score and RUCAM respectively. However, in one‐third (n = 13) of the 44 patients, results were inconclusive and five other patients were misclassified. The decrease in ALT levels 1 week after the initiation of steroid therapy was significantly more pronounced in patients with the final diagnosis of DILI than in AIH patients (accuracy 77%). This difference was also observed in the 18 initially misclassified or inconclusive cases (accuracy 83%). Conclusion Short‐term response of ALT to corticosteroid therapy helps to differentiate DILI and AIH. This finding may be helpful in treatment decision for patients with inconclusive diagnostic scores.

Recent updates on the management of autoimmune hepatitis

“…Remarkably, the short-term (1 week) response to corticosteroids was demonstrated to be more pronounced in the patients with AIH-mimic DILI compared to those with pure AIH. 38 AIH-mimic DILI and pathogenically DIAIH are difficult to differentiate by liver pathology, including the intensity of inflammatory infiltrates, the type of the predominant inflammatory cells, and the grade of fibrosis. In the 2019 AASLD practice guidance and guidelines, the term "DIAIH-like injury" was introduced as an alternative to DIAIH.…”

Worldwide Use of RUCAM for Causality Assessment in 81,856 Idiosyncratic DILI and 14,029 HILI Cases Published 1993–Mid 2020: A Comprehensive Analysis

“…In the current analysis, authors from 31 countries worldwide reported on cases of idiosyncratic DILI caused by multiple drugs published from 1993 up to mid 2020 and applied in all cases RUCAM to assess causality ( Table 1 ) [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , …”

A Case of Vanishing Bile Duct Syndrome after Drug-Induced Liver Injury Caused by Pelubiprofen

“…19 Although corticosteroid use is controversial, corticosteroid was administered for 28 days, starting with a dose of methylprednisolone 30 mg which was tapered in half every week until it was tapered out since the patient had a skin lesion suspected to be Stevens-Johnson syndrome. 20 Intractable severe cholestasis for over 4 months did not improve; therefore, liver transplantation was the only treatment option.…”