Drug-Induced Liver Disease

A 54-year-old woman presents with jaundice shortly after being discharged from hospital. Liver function tests are reported as follows:
Albumin = 49 g/l, Bilirubin = 89 mmol/l, Alanine transferase (ALT) = 66 iu/l,
Alkaline phosphatase (ALP) = 245 mmol/l, Gamma glutamyl transferase (yGT) = 529 u/l.
Which of the following antibiotics is she most likely to have received?
A. Co-amoxiclav
B. Gentamicin
C. Ciprofloxacin
D. Trimethoprim
E. Ceftazidime

Answer:
A. Co-amoxiclav.

Discussion: Co-amoxiclav is a well recognised cause of cholestasis

Drug-induced liver disease:
Drug-induced liver disease is generally divided into:

• hepatocellular, 
• cholestatic or 
• mixed. 

There is however considerable overlap, with some drugs causing a range of changes to the liver.

The following drugs tend to cause a hepatocellular picture:
 paracetamol
 sodium valproate,
 phenytoin
 MAOIs
 halothane
 anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
 statins
 alcohol
 amiodarone
 methyldopa
 nitrofurantoin

The following drugs tend to cause cholestasis (+/- hepatitis):
 oral contraceptive pill
 antibiotics: flucloxacillin, co-amoxiclav, erythromycin
 anabolic steroids, testosterones
 phenothiazines: chlorpromazine, prochlorperazine
 sulphonylureas
 fibrates
 rare reported causes: nifedipine

The following drugs can cause Liver cirrhosis:
 methotrexate
 methyldopa
 amiodarone