My stunningly attractive and sophisticated wife happens to be a brilliant
GI and liver pathologist (yes, I married up). From time to time, she’ll try to
educate me by sharing an article from her field with me. Such was the case
about a week ago when she handed me an article titled, Hepatic Histological
Findings in Suspected Drug-Induced Liver Injury: Systematic Evaluation and
Clinical Associations. Now, this stuff
is typically way over my little pediatrician head, so I told her I’d read it…
later. But she wouldn’t relent. “Look at Table 1,” she said. “You need to know
this.” Boy, did Table 1 get my attention.
The article was written by members of the
Drug-Induced Liver Injury Network (or DILIN) which is an effort involving some
of the most prestigious medical centers in the country to better categorize and
understand liver injury caused by exposure to drugs. If you had asked me, last
week, what drugs are most commonly associated with liver injury, I would have
guessed some big-gun, heavy-duty medications such as steroids, immune
suppressants such as those used after organ transplantation, chemotherapy
drugs, and perhaps some of the anti-fungals. I was only partly right.
Table 1 of the article listed the characteristics of
the 249 consecutive patients who were included in the study. The age range of
the patients was 7 to 87 years of age. What got my attention were the 8 most
common drugs implicated in liver injury.
Turns out I was right only about the steroids. The
heading, “Anabolic Agents” was number 6 on the list. They also happened to be
the only drug class listed that was not an antibiotic. Here’s the complete list of the top 8
culprits:
1. Amoxicillin/clavulanate
2. Nitrofurantoin
3. Sulfamethoxazole/trimethoprim
4. Minocycline
5. Ciprofloxacin
6. Anabolic
agents
7. Azithromycin
8. Levofloxacin
This list should give every physician pause because
they are all medications that are prescribed quite frequently. In fact, I
suspect that it is the very frequency with which we prescribe them that
explains their presence on this list. The likelihood that any one of these
medications result in liver injury in an individual patient is extremely low,
but when you consider how many courses of antibiotics are prescribed, it’s not
surprising that this very small percentage ends up accounting for the majority
of incidents. To make an analogy, many more people die in automobile accidents
than aviation accidents. Yet more people have a fear of flying than a fear of
driving.
Of course, this does not mean we should stop using
antibiotics altogether: they are a necessary and useful tool when indications
call for their use. But this is yet another warning that the injudicious,
indiscriminate use of antibiotics is fraught with danger. No patient should
suffer complications from a medication or surgical procedure that was not
needed in the first place.
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