Psychotropic: Drug Induced Liver Injury

 Mood Stabilizers

• Among mood stabilizers, carbamazepine and VPA are associated with the highest incidence of hepatotoxicity.
• Although there are case reports of hepatotoxicity with oxcarbaze­pine, it may have a better liver safety profile than carbamazepine.
• Hepatotoxicity with lamotrigine is rare, although fatal cases have been reported

Antipsychotics

• When initiating an antipsychotic, a tem­porary, benign increase in liver enzymes can be expected, but typically discontinuation is unnecessary.
• Phenothiazines in particular can cause increases in liver enzymes in 20% of patients.
• Hepatotoxicity with benzodi­azepines is infrequent, with a few cases of cholestatic injury reported with diazepam, chlordiazepoxide, and flurazepam

SSRI

• are relatively safe; incidents of hepatic injury are rare.
• Among SSRIs, parox­etine is most frequently associated with hep­atotoxicity.
• Abnormal liver function tests have been observed with fluoxetine (0.5% of long-term recipients) and other SSRIs

Antidepressants

• Antidepressants with dual norepinephrine and serotonin reuptake inhibitor properties carry a higher risk of liver injury, especially duloxetine.
• Hepatocellular, cholestatic, and mixed types of hepatotoxicity are associated with duloxetine-induced hepatotoxicity

Monitoring recommendations

• Before prescribing potentially hepatotoxic medications, order baseline liver function tests.
• During therapy, periodic liver func­tion monitoring is recommended. Elevated transaminase concentrations (>3 × the upper limit of normal), bilirubin (>2 × the upper limit of normal), and prolonged pro­thrombin times are indicators of hepatic injury.
• Caution should be taken to prevent polypharmacy with multiple hepatotoxic medications and over-the-counter use of hepatotoxic drugs and supplements.
• When choosing a psychotropic, take into account patient-specific factors, such as underlying liver disease and alcohol con­sumption.
• Patients on potentially hepato­toxic medications should be counseled to recognize and report symptoms of liver dysfunction, including nausea, vomiting, jaundice, and lower-extremity edema

References:

1.      How to modify psychotropic therapy for patients who have liver dysfunction, Current Psychiatry Vol. 13, No. 12

2.      Antipsychotic Drugs – Prescribing & Monitoring in Adults Information for Primary Care

3.      MANAGEMENT OF MARKED LIVER ENZYME INCREASE DURING OLANZAPINE TREATMENT:A CASE REPORT AND REVIEW OF THE LITERATURE. Psychiatria Danubina, 2011; Vol. 23, Suppl. 1, pp 15–17