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Identifying Drug-Induced Autoimmune-Like Hepatitis, with Lily Dara, MD
Dara describes similarities between drug-induced autoimmune-like hepatitis and idiopathic autoimmune hepatitis, as well as how to differentiate them.
Autoimmune hepatitis (AIH) often demands lifelong immunosuppression, but what happens when a patient presents with AIH-like features—only for the culprit to be a medication?
Drug-induced autoimmune-like hepatitis (DI-ALH) is a rare subtype of idiosyncratic drug-induced liver injury (DILI) that closely mimics AIH. Distinguishing between the 2 is essential but complicated by the fact that both DI-ALH and idiopathic AIH share nearly identical serological markers and histological features.
“What's really interesting here is that drug-induced autoimmune-like hepatitis seems to be associated with some specific drugs that can trigger this autoimmune-like reaction,” Lily Dara, MD, a physician-scientist, hepatologist, and assistant professor of medicine at the University of Southern California, explained to HCPLive. “Of course, it needs to be differentiated from autoimmune hepatitis because if you have a diagnosis of autoimmune hepatitis, that basically says you need lifelong immunosuppression… but this is self-limiting.”
Dara goes on to describe how liver biopsy can help differentiate between the two, calling attention to differences in the amount of fibrosis in patients with AIH versus those with DI-ALH. In DI-ALH, she says the short course of exposure to drugs that can cause it, most commonly nitrofurantoin, minocycline, alpha methyldopa, and hydralazine, does not allow enough time to develop significant fibrosis.
“While it's not a foolproof mechanism, the presence of fibrosis underlying chronicity points to classic or de novo autoimmune-like hepatitis,” she explained. “When you run across these cases, make sure you have a very good liver pathologist review it and maybe consult some experts in the disease.”
Dara also notes that anti-tumor necrosis factor (TNF) drugs like infliximab, adalimumab, and etanercept have been associated with DI-ALH, as have statins. Additionally, cases of DI-ALH have been observed with use of khat, or Bushman’s tea, a flowering plant native to eastern and southeastern Africa used as a stimulant.
Editors’ note: Dara has no relevant disclosures.
