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30 Shah et al. | Journal of Clinical and Translational Research 2024; 10(1): 25-32
patients without autoimmune features [21]. Contrary to these
findings, two studies reported that corticosteroid administration
was not found to be beneficial, but instead, was harmful to patients
with severe DILI [22] and DILI-related acute liver failure [23].
A recent report from prospective DILI registries concluded that
corticosteroid therapy did not worsen outcomes in DILI patients,
and its administration led to a greater rate of normalization of liver
enzymes in patients with severe DILI [24]. Amidst these mixed
results on the role of corticosteroids in DILI/HILI, a recent open-
label randomized controlled study concluded that steroids may
accelerate the recovery of patients with severe DILI [25].
Despite a very limited number of patients, the present study
demonstrates the beneficial role of corticosteroids in the treatment
of DILI. In the present study, four patients had mixed patterns
of liver injury with predominant cholestasis, leading to severe
pruritus that significantly hampered quality of life in three
patients (cases 1, 2a, and 4). The severity of pruritus in Case 1 was
characterized by intense itching, which led to skin excoriations
and bleeding. Case 2b had a hepatocellular pattern of liver injury
(R-value = 7) with cholestatic symptoms, which can be explained
by cholestatic pattern of liver injury by histopathologic means.
Most patients with DILI recovered following the cessation of
culprit agents, without showing signs of progression. Typically,
patients with progressive liver injury may have severe DILI or end
Figure 3. Histopathological micrographs of the liver (hematoxylin and up with liver failure, in which secondary infections play a major
eosin staining) of all patients. role, and may face a very high mortality risk if liver transplantation
is not implemented. Treatment with steroids in the setting of liver
most common adverse events [11] and contributes to 2.9% of all failure may increase the risk of secondary infections, posing a
cases of DILI [12]. negative impact on the overall outcome. None of our patients
Identification and discontinuation of the culprit agents and had features of liver failure. Severe coagulopathy in Case 4 due
avoidance of re-exposure are the mainstays of DILI management. to itraconazole-induced DILI can be explained by cholestasis
In most patients, spontaneous recovery occurs after the culprit leading to Vitamin K malabsorption. This patient had features of
drug is discontinued [13]. DILI, in its natural course, may fat-soluble Vitamin A deficiency; therefore, he responded well to
develop acute or sub-acute liver failure and may prove fatal if Vitamin A supplements in addition to corticosteroids.
liver transplantation is not implemented [14]. Pruritus hampers Discontinuation of culprit medications along with supportive
the quality of life to a great extent, and in severe cases, patients management was not sufficient to keep the patient’s liver parameters
may develop suicidal tendencies. For severe pruritus, drugs and symptoms under control. Thus, steroids were prescribed as a
rescue therapy for the patients, and all of them responded well
like antihistaminics, namely, hydroxyzine or diphenhydramine, to steroids without exhibiting any adverse effects. The beneficial
topical emollients, and soothing agents like lactocalamine can effects of steroids in DILI may be attributed to its anti-inflammatory
be attempted. Cholestyramine provides symptomatic relief in action. However, therapeutic effect of steroids in pruritus is
patients with pruritus. conditional on the improvement in liver function and cholestasis.
At present, there is no specific therapy for changing the natural In the present study, improvement in pruritus was observed in a
course of DILI [15,16]. Steroids have been recommended in mean duration of 3.2 weeks and complete normalization of LFTs
patients with drug-induced autoimmune hepatitis, DILI secondary was achieved in a mean period of 11.2 weeks.
to immune checkpoint inhibitors and biologicals, and DILI with Several limitations of this study should be acknowledged.
features of hypersensitivity [17,18]. The role of steroids in other A small number of patients and the absence of a control group are
causes of DILI has been studied with mixed results presented in significant limitations of this study, which prevent us from drawing
uncontrolled studies. A retrospective study showed that 15 patients a firm conclusion about the role of steroids in such scenarios.
treated with a combination of prednisolone and ursodeoxycholic Furthermore, we did not perform tests for atypical viruses like
acid exhibited a rapid reduction in bilirubin, liver enzymes, and herpes simplex virus, Epstein bar virus, varicella-zoster virus, and
INR [19]. Another retrospective study with a larger number of cytomegalovirus that can cause liver injury. Three patients had
patients described a beneficial effect of corticosteroid therapy in KF ring, as confirmed during slit lamp examination, but a genetic
terms of mortality benefit and rapid recovery in severe DILI [20]. analysis for the ATP7B gene was not performed to completely rule
In addition, budesonide has been reported to be beneficial in two out Wilson’s disease in these cases.
DOI: https://doi.org/10.36922/jctr.00104