Many drugs can affect the way the liver functions, damage the liver, or do both. (See also Drugs and the Liver.)
Some drugs, such as statins (used to treat high cholesterol), can increase the levels of liver enzymes and cause liver damage (usually minor) without symptoms. However, doctors may continue to prescribe statins for people with chronic liver disease, for example metabolic dysfunction–associated steatotic liver disease (MASLD) (formerly nonalcoholic fatty liver disease [NAFLD]), metabolic dysfunction–associated steatohepatitis (MASH) (formerly nonalcoholic steatohepatitis [NASH]), and MASH due to cirrhosis, because:
Taking statins is no riskier for people with chronic liver disease than for those who do not have chronic liver disease.
Using statins to treat high cholesterol in people with MASLD and MASH has benefits.
Statins are not, however, prescribed, or are prescribed at lower doses, for many people who have decompensated cirrhosis (an advanced stage of cirrhosis in which the liver can no longer function properly).
Very few drugs damage the liver enough to cause symptoms, such as a yellow color of the skin and eyes (jaundice), abdominal pain, itching, and a tendency to bruise and bleed.
Doctors use the term drug-induced liver injury (DILI) to refer to any liver damage caused by medications, whether it results in symptoms or not. The term also includes damage caused by illicit drugs, medicinal herbs, plants, and nutritional supplements, energy drinks, hormones, or antibiotics.
For some drugs, liver damage is predictable. It occurs shortly after the drug is taken and is related to the drug's dose. In the United States, such damage (often caused by ) is one of the most common causes of the sudden appearance of jaundice, liver failure, or both. For other drugs, damage is unpredictable. It is detected some time after the drug is taken and is not related to the dose. Rarely, such damage results in a severe liver disorder.
Medicinal herbs and the liver
Some medicinal herbs (parts of plants used for health benefits) contain substances that can damage the liver. The liver is a prime target for damage because it processes everything that enters the mouth and is swallowed.
Pyrrolizidine alkaloids: Hundreds of herbs contain pyrrolizidine alkaloids, which may damage the liver. These herbs include borage, comfrey, and certain Chinese herbs, such as zi cao (groomwell), kuan dong hua (coltsfoot), qian li guang (liferoot), and pei lan (Eupatorium). Some herbs used to make teas contain pyrrolizidine alkaloids. Sometimes milk, honey, and cereals are contaminated with pyrrolizidine alkaloids, which are then consumed unknowingly.
Pyrrolizidine alkaloids can damage the liver gradually if small amounts are consumed for a long time. Damage can occur more quickly if a large amount is consumed. Pyrrolizidine alkaloids can damage the walls of the hepatic veins, blocking blood flow out of the liver.
Affected people have abdominal pain and may vomit. Fluid accumulates in the abdomen and legs. Eventually, scar tissue in the liver (cirrhosis), liver failure, and even death may result.
Other herbs: Liver damage may also result from herbs such as Atractylis gummifera, Camellia sinensis (used to make green and black teas), celandine (in the poppy family), chaparral, Garcinia cambogiajin bu huan, kava, ma huang (Ephedra), mistletoe, pennyroyal oil (used to make teas), and syo-saiko-to (a mixture of herbs).
In general, liver doctors recommend avoiding all herbal supplements because of the lack of safety testing by the U.S. Food and Drug Administration (FDA) and the fact that many of these substances can cause liver damage and sometimes liver failure, even in people who do not have any preexisting liver disease.
Risk factors
Generally, the risk of liver damage by drugs is thought to be increased by the following:
Age (18 years or over)
Obesity and diabetes
Preexisting liver disease
A genetic makeup that makes people more susceptible to a drug's effects
The effect of alcohol consumption and tobacco use on DILI is not fully understood.
Classification
Doctors categorize drug-induced liver damage in various ways, such as by how the drug damages the liver, how liver cells are affected, and which liver enzyme abnormalities are detected by blood tests. For example, drugs may damage the liver by directly damaging liver cells (hepatocellular), by blocking the flow of bile out of the liver (cholestatic), or by doing both.
Some Medications and Substances That Can Damage the Liver
Type of Drug | Examples |
|---|---|
Antibiotics | Sulfonamides Tetracyclines |
Anticonvulsants | Valproate |
Antidepressants | |
Antifungals | |
Antihypertensives (used to treat high blood pressure or sometimes kidney or heart disorders) | |
Antipsychotics | |
Heart medications | |
Hormones and related medications | Anabolic steroids Birth control pills (oral contraceptives) Estrogens |
Pain relievers | NSAIDs |
Other medications | Antiretroviral drugs (used to treat HIV infection) PD-1/PD-L1 inhibitors (anticancer drugs) Statins (used to treat high cholesterol levels) Many types of chemotherapy, including immune checkpoint inhibitors |
Medicinal herbs | Germander Kava Some energy drinks |
NSAID = nonsteroidal anti-inflammatory drug. | |
Symptoms of Drug-Related Liver Injury
Symptoms of liver disease vary from the general (such as fatigue, a general feeling of being unwell, nausea, itching, and loss of appetite) to the more severe (such as jaundice, an enlarged liver, pain in the upper right part of the abdomen, confusion, disorientation, and reduced alertness).
Diagnosis of Drug-Related Liver Injury
A doctor's evaluation
Liver blood tests
After stopping the drug suspected of causing damage, doctors repeat liver tests. A significant decrease in liver enzyme levels further supports the diagnosis of drug-induced liver damage.
Liver damage caused by drugs
If liver damage caused by drugs is identified quickly, people have a better prognosis.
Doctors ask which drugs are being taken to determine whether any can cause liver damage. Doctors also do blood tests to measure levels of specific liver enzymes and to evaluate how well the liver is functioning and whether it is damaged (liver tests). Drug-induced liver injury (DILI) is likely when results of liver tests are typical of the liver damage usually caused by a drug that the person is taking. Drugs sometimes cause damage after they are stopped, even when the dose was not high, and sometimes it can take several months for DILI to improve. Thus, determining that a drug is the cause is sometimes difficult or impossible.
Liver damage from other causes
Because no test can confirm the diagnosis, doctors also check for other causes of liver damage. Blood tests to check for hepatitis, autoimmune disorders, and other causes are done. Pressing on the upper abdomen to determine the size of the liver and doing imaging tests, such as ultrasonography or computed tomography (CT), can also help doctors identify other causes of liver damage.
Treatment of Drug-Related Liver Injury
Stopping the drug
Administration of antidote if available
Sometimes corticosteroids
Sometimes liver transplantation
Usually, stopping the drug results in recovery. Drugs to relieve symptoms such as itching can be used.
Only a few drugs have antidotes. For example, N. Corticosteroids may be appropriate in some cases.
If the damage is severe, people may be referred to a specialist. Liver transplantation may be required.
Prevention of Drug-Related Liver Injury
When some medications that can damage the liver (such as statins) are used, doctors sometimes regularly do blood tests to monitor liver enzyme levels. Such monitoring may detect problems early and may help prevent liver damage. For most medications, liver enzyme levels are not monitored.
More Information
The following English-language resource may be useful. Please note that The Manual is not responsible for the content of this resource.
U.S. Food and Drug Administration: Sometimes Drugs and the Liver Don't Mix: Consumer-friendly information on how to prevent the potentially toxic effects of drug use on the liver.
