Reactions 1285 - 23 Jan 2010

ursodeoxycholic acid and insulin for his hyperglycaemia.Over the following month, his ALP level continued to SAtorvastatin/fluvastatinexceed the upper normal limit by 2- to 3-fold and his totalbilirubin peaked at 30 mg/dL. He also received rifampicinLiver injury and autoimmune hepatitis: 2 casefor severe pruritus. One month later, his pruritus hadreportsimproved and after a further 2 months his ALT, AST, ALPA 52-year-old woman and a 54-year-old man developedand total bilirubin levels had returned to normal.liver injury after receiving fluvastatin [Lescol] andMetformin was restarted without recurrence of hisatorvastatin [Lipitor], respectively, for dyslipidaemia. Thehepatitis.woman later developed autoimmune hepatitis after

commencing therapy with atorvastatin [Lipitor]. Russo MW, et al. Drug-induced liver injury associated with statins. Seminars inLiver Disease 29: 412-422, No. 4, 2009. Available from: URL: http://Three months after being diagnosed with type IIdx.doi.org/10.1055/s-0029-1240010 - USA 803004497hyperlipidaemia, the woman started treatment with

fluvastatin 20 mg/day; her baseline liver function testresults were normal. During week 12 of therapy sheexperienced anorexia and fatigue. Laboratory investigationsrevealed increased ALT, AST and ALP levels (850, 880 and215 U/L, respectively). Fluvastatin was stopped. Testing forautoantibodies was negative as were the results ofserological tests for hepatitis A, B and C. Moderate lobularand portal hepatitis was evident on liver biopsy, along withmild portal fibrosis and moderate hepatocytic apoptosisand necrosis. One month later, her anorexia and fatiguehad improved and her liver function tests eventuallyreturned to normal.

Around 2 years later, the woman started treatment withatorvastatin 20 mg/day for persistenthypercholesterolaemia. She reported fatigue andgeneralised pruritus within 3 weeks of starting statintherapy and then right upper quadrant pain 8 weeks later;she also experienced extreme fatigue and hypersomnia.Laboratory investigations revealed ALT, AST and ALP levelsof 1750, 1800 and 285 U/L, respectively, and total bilirubinand globulin levels of 14 mg/dL and 3.6 g/dL, respectively.Testing was negative for viral hepatitis but positive forantinuclear antibody (1:160) and anti-smooth muscleantibody (1:80). Eight weeks after stopping atorvastatin herALT, AST and ALP levels remained elevated and herantinuclear and anti-smooth muscle antibody titres wereunchanged. A liver biopsy showed marked lobular andinterface hepatitis, severe fibrosis and signs indicative ofcirrhosis. Chronic acute autoimmune hepatitis precipitatedby atorvastatin was suspected. Her symptoms improvedfollowing 3 weeks’ therapy with prednisone. Azathioprinewas then added and her prednisone dosage was graduallydecreased over a 3-month period. After a further 3 monthsher liver function test results returned to normal,prednisone was tapered off and azathioprine wasdiscontinued 3 months later. However, she experienced amodest rise in her ALT level 2 months later. Prednisone andazathioprine were restarted; after 1 year prednisone wasgradually tapered off while azathioprine was continued.Her antinuclear and anti-smooth muscle antibody titresdeclined to 1:40 and 1:20, respectively.

The man started treatment with atorvastatin 10 mg/dayfor hypercholesterolaemia. He was also receivingmetformin for type II diabetes mellitus. Seventy days afterstarting atorvastatin he experienced a gradual onset ofnausea, anorexia and abdominal discomfort. He was thenadmitted with jaundice. On examination he was febrilewith right upper quadrant tenderness and a firm palpableliver. Laboratory investigations revealed markedly elevatedALT, AST and ALP levels (6200, 5500 and 280 U/L,respectively). All drugs were immediately stopped and hereceived intravenous fluid therapy. Testing forautoantibodies was negative as were the results of tests forhepatitis A, B, C and E, Epstein-Barr virus, cytomegalovirusand herpes simplex. Marked portal inflammation wasevident on liver biopsy as well as fibrosis (1+), endotheliitisof portal veins and signs of injury to the epithelium ofinterlobular bile ducts. He was treated with

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Reactions 23 Jan 2010 No. 12850114-9954/10/1285-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved