Disulfiram-induced fulminating hepatitis: guidelines for liver-panel monitoring

Although psychiatrists have medical responsibility for many alcoholic patients, the psychiatric literature, in contrast with the general medical literature, contains few reports of disulfiram-induced hepatotoxicity. For that reason, the authors review the literature on disulfiram hepatitis and report a case of severe fulminating hepatitis associated with disulfiram use, despite careful and currently accepted standard-of-care clinical and biochemical monitoring. All but two of the 17 disulfiram-associated hepatotoxic cases reviewed developed symptoms after 2 weeks to 2 months of use. Six patients died. This article discusses strategies for avoiding that rare but life-threatening side effect. The strategies include more frequent initial measurements of liver enzymes than is now accepted. Currently, only two reports recommend liver-function studies on a regular schedule for patients taking disulfiram. The authors believe that liver-function tests should be administered before treatment, at 2-week intervals for 2 months, and at 3- to 6-month intervals thereafter. The authors emphasize that the hepatotoxicity reaction is rare and do not discourage the use of disulfiram in appropriate patients; rather, they wish to heighten the index of suspicion to disulfiram-induced hepatotoxicity.