Herbal supplements and cancer drugs are a growing share of drug-induced liver injury

Design

Prospective multicentre registry, analysed over time

Population

1,983 high-causality cases of idiosyncratic drug-induced liver injury, US, 2004–2024

Primary outcome

Causative agents, severity and six-month outcomes

Effect

Antibiotics 41% overall and falling; supplements and anticancer drugs rising; oncology six-month mortality 30%

The US Drug-Induced Liver Injury Network has followed consecutive cases for six months since 2004. This analysis covers 1,983 cases judged highly likely to be drug-induced over twenty years. The median age was 52, 59% were women and 54% had hepatocellular injury.

Antibiotics were the leading cause overall (41%), but their share fell over time, including isoniazid and nitrofurantoin, as did central nervous system drugs. The share caused by herbal and dietary supplements and by anticancer drugs, including checkpoint inhibitors, rose significantly. Severity at presentation — peak bilirubin, INR and severity scores — declined over the period.

Patients with pre-existing chronic liver disease had higher mortality, as did those over 65 and oncology patients, whose six-month mortality was 30%, mostly from non-liver causes. Children more often had hepatocellular injury but lower mortality than adults.

This is US registry data. Supplement use, antituberculous therapy and access to checkpoint inhibitors differ in India, so the proportions may not transfer. But the shift toward supplements is a reminder that a standard medication history misses much of what patients take.

• Ask specifically about herbal, ayurvedic and dietary supplements when liver tests are abnormal.
• Consider checkpoint-inhibitor hepatitis in any patient on immunotherapy with new liver test abnormalities.
• Take extra care with hepatotoxic drugs in patients with existing chronic liver disease, who had higher mortality.
• Antibiotics remain the commonest single cause; review recent courses, including nitrofurantoin and antituberculous drugs.

Why it matters

Supplements rarely appear on a medication list, yet they are a rising cause of liver injury.

Don't overread it

Trends in a US referral registry may not reflect the causes of drug-induced liver injury in India.

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