FRI0438 Toxic Hepatitis in Patients with Systemic Lupus Erythematosus:

Abstract

Background Although subclinical liver disease is common in SLE, strikingly high levels of liver enzymes are rare. Liver enzyme abnormalities in lupus are multifactorial and can be drug induced or caused by disease activity. Objectives Our aim was to determine the cause of high levels of liver enzymes in lupus patients, particularly in patients diagnosed with toxic hepatitis. Methods We performed a retrospective chart review of SLE patients treated at the Inje University Hospital between 2001 and 2013. We defined liver enzyme abnormality as a ≥2 fold increase in 2 or more of the 4 components: bilirubin, AST, ALT and LDH or ALP. Toxic hepatitis was diagnosed by a score 5 in the Roussel Uclaf Causality Assessment Method (RUCAM) and classified according to their pattern of liver enzyme: cholestatic, hepatocellular and mixed. Results Clinical and laboratory findings of liver disease was reviewed in 301 SLE patients who met ≥4 ACR criteria. Of 301 SLE patients, 74 (24.6%) met strict criteria for the liver enzyme abnormality and had the following diagnoses: toxic hepatitis (n=20), viral hepatitis (n=3), autoimmune hepatitis (n=5), liver enzyme elevation associated with infection (n=4) and an indeterminate clinical diagnosis, presumably associated with lupus activity (n=42). In total, 20 patients (6.6%) had presumed toxic hepatitis associated with either herbal medicines (n=8), anti-tuberculosis (Tb) drug (n=4), antibiotics (n=5), NSAIDS (n=1), or anticonvulsant drug (n=2). There were striking abnormalities in patients with toxic hepatitis (mean peak values: AST 610±551 U/L, ALT 369±352 U/L, ALP 598±387 U/L, LDH1,128±761 U/L). 5 had a cholestatic pattern, 9 had a hepatocellular pattern, 3 had a mixed pattern and 3 were undeterminated. Among the 20 patients with toxic hepatitis, 17 were found to have active lupus (SLEDAI≥4). After cessation of the suspected causative medication and subsequent steroids treatment, liver enzymes were improved. Number Age Cause RUCAM SLEDAI bilirubin AST ALT ALP LDH 1 47 Herb 6 3 0.5 87 352 2 23 Herb 6 10 4.9 659 130 995 1407 3 25 Herb 5 16 0.8 625 135 1268 1049 4 71 Herb 7 17 1.6 695 195 1046 1227 5 30 Herb 5 10 0.3 79 100 144 563 6 32 Herb 6 24 1.9 1144 275 699 1681 7 41 Herb 6 14 0.7 764 1545 922 1832 8 21 Herb 7 8 0.4 114 217 268 204 9 28 Ceftriaxone 6 4 0.5 186 228 177 10 39 Ceftazidime 6 18 0.2 123 182 182 11 27 Pip/TZ 5 4 0.2 66 52 599 637 12 20 Ceftazidime 5 10 0.8 1267 369 1001 3422 13 26 Pip/TZ 8 16 243 413 518 14 20 Anti-Tb 5 3 1.2 260 105 178 1249 15 23 Anti-Tb 8 2 11 1729 915 438 16 48 Anti-Tb 7 25 0.4 590 201 1095 1190 17 22 Anti-Tb 9 4 0.3 1942 726 536 862 18 36 Phenytoin 5 14 0.5 584 542 505 380 19 21 Valproic acid 8 13 0.9 835 449 329 1547 C, cholestatic; H, hepatocellular; M, mixed Pip/Tz; Piperacillin/Tazobactam. Conclusions In our study, herbal medicines was the most common cause of toxic hepatitis in Korean lupus patients. Antibiotics and anti-Tb drugs also could lead to toxic hepatitis in lupus patients. Since...

Liver Abnormalities in Systemic Lupus Erythematosus: A Prospective Observational Study

“…None of our patients were on native or herbal medicines and none had chronic viral hepatitis. In contrast, a study from Korea has reported a significantly large number of patients having transaminitis due to herbal medication use [18]. Another observation we made was the relative elevation of AST over ALT in patients with lupus hepatitis.…”