The bulk of hepatotoxicity (drug induced liver injury, DILI) cases in clinical practice is idiosyncratic in nature. This assumption is based on the apparent absence of dose dependency and the unpredictability of the reaction, which presents after a relatively long latency period of drug exposure in susceptible individuals. Recent evidence suggests that the administration of high oral daily dose of drugs that undergo extensive hepatic metabolism does influence the risk of developing idiosyncratic DILI (IDILI) [1,2]. We report a patient safely treated with atorvastatin at a standard therapeutic dose for more than a year who developed acute liver failure and rhabdomyolysis after doubling the daily dose of the drug ( Supplementary Fig. 1).An 85-year-old woman was admitted in February 2014 because of a 4-day history of worsening drowsiness, anorexia, jaundice, dark-yellow-coloured urine, and vomiting. Since early January, she had complained of fatigue, decreasing ability to walk, and sleepiness. Eighteen months prior to the episode six intracoronary stents were placed. Past medical history included diabetes mellitus, hypercholesterolemia, arterial hypertension, and essential tremor. She had been receiving atorvastatin (40 mg daily) since June 2012, along with furosemide, ramipril, omeprazole, aspirin, metformin, and phenobarbital for more than 3 years. She had no toxic habits and denied taking over-the-counter drugs, herbal remedies, dietary supplements, or grapefruit. Five months before admission, the atorvastatin dose was increased to 80 mg daily due to deficient lipaemic control. Liver and renal biochemistry at the time of starting atorvastatin and repeatedly checked thereafter up to September 2013 (prior to atorvastatin dose escalation), had remained within the normal range. On admission, blood pressure was 131/68 mmHg and heart rate 78/min. Physical examination revealed jaundice, confusion, and pronounced asterixis. Her body mass index was 29.5 kg/m 2 . Diagnostic work-up showed elevated alanine aminotransferase (