To examine the available literature and summarize what is known about
chronic drug-induced liver injury. We reviewed PubMed/MEDLINE through March 2015. We developed a MEDLINE search strategy using PubMed medical subject heading terms chronic liver injury, hepatotoxicity,
drug-induced liver injury,
cirrhosis and chronic
liver disease. We reviewed the reference list of included articles to identify articles missed in the database search. Chronic liver injury from drugs is more common than once thought with prevalence as high as 18% based on large national registries. Patients with cholestatic injury, age ≤65 years, and a long latency period (>365 days) are at increased risk. Of the most common drugs associated with
drug-induced liver injury,
antibiotics (
amoxicillin-clavulanic acid,
trimethoprim-sulfamethoxazole,
azithromycin) are most likely to cause chronic injury. The presence of
autoantibodies is common with chronic DILI, however, it is not diagnostic nor is it specific to autoimmune-like
drug-induced liver injury. Immunosuppressive therapy may be necessary for individual cases of autoimmune-like
drug-induced liver injury where cessation of the
drug alone does not result in resolution of injury, however, the lowest dose should be used for the shortest duration with careful attention to the development of side effects. The effectiveness of treament of cholestatic liver injury with
corticosteroids or
ursodiol remains unclear. Cases of
drug-induced
fatty liver, nodular regenerative
hyperplasia and peliosis
hepatitis are less common subtypes of
chronic drug-induced liver injury that deserve special consideration. A high degree of clinical suspicion is required for the diagnosis of
chronic drug-induced liver injury and should be suspected in any patient with liver associated
enzyme abnormalities that persist out past 6 months of initial presentation. Treatment with
drug removal and/or immunosuppressive therapy appears to be effective for the majority of cases. More study into pharmacogenomics and
personalized medicine may aid in predicting which patients will go on to develop
chronic drug-induced liver injury.