Severe liver injury due to infliximab therapy and adalimumab

Drug-induced liver injury (DILI) due to infliximab has been well documented. In the vast majority of patients, the liver injury is mild or moderate and some of these patients will require corticosteroids for a faster recovery. However, more than 10 cases in the literature have been reported where infliximab has led to a very severe liver injury, requiring emergency liver transplantation. The nature of this type of DILI due to infliximab has not been well characterized. The current article highlights the cases where the use of infliximab has been associated with severe and life-threatening liver failure and potential predictors of severe outcomes. The clinical, biochemical, immunological and histological characteristics of patients who have suffered from severe consequences of DILI due to infliximab are described. Infliximab can cause acute liver failure and vanishing bile duct syndrome which can require liver transplantation. Overall 12 patients have been reported in the literature with severe liver injury associated with acute liver failure due to infliximab. Concomitant treatment with immunomodulators seems to reduce the risk of infliximab DILI and should always be considered in patients starting infliximab. In contrast with the severe liver injury described in patients treated with infliximab, no cases of acute liver failure due to adalimumab requiring liver transplantation have been reported. However, subacute liver failure due to hepatitis B reactivation have been reported associated with adalimumab therapy and one case of subacute liver failure with adalimumab has been described in a patient without concomitant hepatitis B.