Chronic Liver Disease

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TABLE 1

Selected Potentially Hepatotoxic Medications

All nonsteroidal anti-inflammatory drugs Lipid-lowering agents: statins,

nicotinic acid (niacin; Nicolar)

Antidiabetic agents: acarbose (Precose), pioglitazone (Actos), sulfonylureas

Antibiotics: amoxicillin­clavulanate potassium (Augmentin), erythromycin,

isoniazid (INH), nitrofurantoin (Furadantin), tetracycline

Antifungal agents: fluconazole (Diflucan), itraconazole (Sporanox), ketoconazole

(Nizoral) (THese may be needed if you have a fungal infection!.then you would

take)

Retinoids: etretinate (Tegison)

Anticonvulsant agents: phenytoin (Dilantin), valproic acid (Depakene)

Psychotropic agents: bupropion (Wellbutrin), chlorpromazine (Thorazine),

tricyclic antidepressants

Hormones: tamoxifen (Nolvadex), testosterone

Others: halothane (Fluothane), methotrexate (Rheumatrex)

EVALUATION OF DRUG TOXICITY

Most ingested substances are metabolized and chemically altered as they pass

through the liver. In particular, the liver is the central site for the

clearance, detoxification, excretion and activation of most medications. The

liver is vulnerable to injury from some medications, vitamins and herbal

remedies.23

Medications. Patients with chronic liver disease can have variably affected

liver function. In recommended dosages, most medications are safe in these

patients despite their altered metabolism and hepatic function. However,

patients with chronic liver disease may be at increased risk for idiosyncratic

drug reactions and less able to tolerate hepatotoxicity when it occurs.

Acetaminophen (Tylenol) has predictable hepatotoxicity and affects the liver in

a dose-dependent manner. In patients with chronic liver disease who have pain

symptoms, acetaminophen CAN BE USED SAFELYin a dosage of no more than 2000MG)

(2 g) per day. However, acetaminophen hepatotoxicity has been reported with

dosages of less than 4 g per day, usually IN ASSOCIATION WITH starvation or

alcohol ingestion.27

As many as 30 percent of patients with liver disease have high serum iron

levels, and 10 percent have excessive amounts of iron in their liver

tissue.30,31 The reason for the iron excess is not known, but postulated

mechanisms include the release of iron from injured hepatocytes and their uptake

by Kupffer cells, acute-phase reactions associated with chronic inflammatory

states, increased uptake of iron through the gastrointestinal tract, and

ineffective erythropoiesis with redistribution of iron from sites of utilization

to sites of storage. The most likely mechanisms of liver injury from excess iron

are increased generation of free radicals and increased peroxidation of lipids,

which, in turn, lead to mitochondrial dysfunction, lysosomal fragility and cell

death.

TABLE 2

Selected Potentially Hepatotoxic Supplements

Amanita species

Asafetida

" Bush " herbal teas

Chaparral

Comfrey

Echinacea Gentian

Germander

Iron

Jin bu huan

Kalms tablets

Mistletoe Nicotinic acid (niacin; Nicolar)

Pennyroyal oil

Senna fruit extracts

Valerian

Vitamin A ( TAKE Beta Carotene form of A instead)