Hepatotoxicity of antirheumatic drugs

The central role of the liver in drug metabolism makes it vulnerable to toxic injury. Drug induced liver injury may mimic any of the naturally occurring liver diseases. The rheumatic diseases themselves may have liver disease associated with them, making it especially difficult to recognize hepatotoxicity. Nevertheless, hepatotoxicity has been reported with most of the drugs used to treat the rheumatic diseases. Because the reactions may be fatal, it is important to recognize hepatotoxicity. The current drug development process does not and cannot identify drugs with a low incidence of hepatotoxicity. Therefore, it is necessary for physicians to be aware of the potential of any drug to cause liver injury. Serious hepatotoxicity, however, can usually be prevented by awareness and appropriate monitoring. Most of the nonsteroidal antiinflammatory drugs, azathioprine and dantrolene should be monitored at monthly intervals for the first 6 months of therapy. Methotrexate should be monitored indefinitely. It remains unrealistic to expect premarketing studies to identify hepatotoxicity and, thus, surveillance is needed for all newly marketed drugs.