Drug-Induced Liver Injury 

What is drug-induced liver injury?

Drug-induced liver injury (DILI) can happen if your liver is damaged by a reaction to a medication, supplement or other substance. Your liver processes most drugs, which means it’s at risk for injury from them.

DILI can be caused by prescription drugs, over-the-counter (OTC) medicines, herbal products or dietary supplements.

Some drug-induced liver injuries are predictable, since it’s known that certain doses could cause damage. Others are unexpected and can happen at usually prescribed doses in some people.

Causes and risk factors

Many substances can cause drug-induced liver injury. They may harm the liver directly or trigger the immune system.

Common causes include:

• Prescription medications, including, in rare cases, steroids, birth control pills and statins
• OTC medications, including pain relievers like acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Aleve), although these medications are generally safe
• Herbal products and dietary supplements
• Certain antibiotics, antifungals or seizure medications

Not everyone exposed to these substances develops liver injury and serious drug-induced liver injury is uncommon compared with how often these medicines are used. These risk factors make it more likely:

• The specific drug you are taking
• Taking high doses
• Taking multiple medications
• Using medication for a long period of time
• Repeat exposure to the same drug, for certain immune reactions
• Underlying liver disease such as viral hepatitis (B or C) or fatty liver disease 
• HIV infection
• Heavy alcohol use
• Genetic differences in how the body processes drugs

Most OTC products and supplements are not regulated by the U.S. Food and Drug Administration (FDA) Therefore, it is important to always tell your provider about all the medicines, OTC products and supplements you use.

Signs and symptoms

Symptoms of drug-induced liver injury can range from mild to severe. Mild and early symptoms can get worse if the liver gets more inflamed. Contact a health care provider if you notice symptoms.

Common symptoms include:

• Fatigue
• Nausea or vomiting
• Abdominal pain, especially on the right side
• Loss of appetite
• Dark urine
• Pale stools

In some cases, you may also notice:

• Fever
• Headache
• Diarrhea
• Rash

More serious symptoms may include:

• Yellowing of the skin or eyes (jaundice)
• Severe itching
• Confusion or changes in mental status
• Easy bruising or bleeding

You should be evaluated right away for jaundice that happens suddenly, confusion or severe abdominal pain.

How it’s diagnosed

To diagnose drug-induced liver injury, your health care provider will ask about your medical history and perform a physical exam. 

They will note when symptoms started. Drugs that harm the liver directly usually trigger symptoms within hours to a few days. With drugs that cause an immune response, symptoms may not start for weeks. Sometimes, changes will show up on blood tests before symptoms appear.

There are no specific blood tests, biomarkers or biopsy findings that prove DILI. Your provider will review your history and laboratory test results to make a diagnosis and rule out other causes of liver disease, like viral hepatitis, autoimmune disease or cholestatic (bile-related) disease, and/or genetic/metabolic liver diseases.

They may order tests and conduct assessments such as:

• Detailed review of all the medications and supplements you take
• Blood tests to check your liver enzymes and function
• Imaging tests such as ultrasound,  CT or MRI scans
• Liver biopsy, in some cases

If you stop taking the medication and your symptoms improve, that helps support a DILI diagnosis. Experts usually don’t recommend re-starting the medication to watch for symptoms because of the risk of liver damage.

Treatment and care

The main treatment for drug-induced liver injury is stopping the medication or substance that’s causing the damage. Many people with mild to moderate liver injury recover fully once they aren’t taking the drug but close follow-up is important.

Care may include:

• Monitoring liver enzymes and liver blood tests until you recover, to make sure your liver is healing
• Managing symptoms with supportive care like fluids, rest, avoiding strenuous exercise, anti-nausea medicines and anti-itch treatments
• Avoiding alcohol and liver-damaging substances

If you have an acetaminophen overdose, getting treatment right away is especially important because there are specific medications and antidotes that reduce the risk of severe liver damage.

Complications and advanced disease

Spotting signs of DILI early and getting treatment lowers the risk of complications. In rare cases, drug-induced liver injury can lead to:

• Acute liver failure, which is a life-threatening condition that may require liver transplant 
• Ongoing liver damage, including cirrhosis 
• The need for specialized liver care

When to talk to a specialist

Your provider may refer you to a gastroenterologist (digestive system specialist) or hepatologist (liver specialist) if:

• Your liver enzymes stay abnormal or get worse
• Your symptoms are severe or progressing
• They think you may have acute liver failure
• You have underlying liver disease

Early evaluation by a specialist can help prevent complications and guide safe medication choices going forward.

Find care at Banner Health

At Banner Health, our multidisciplinary team offers expert evaluation and care for drug-induced liver injury and other liver conditions. Our specialists help identify what’s causing your symptoms, treat the condition, coordinate ongoing care and protect your liver function.

Schedule an appointment with a Banner Health liver specialist near you.