Common Causes of Drug-Induced Liver Injury in 2025

Drug-induced liver injury (DILI) is an important clinical condition and should be considered in the differential diagnosis of patients with elevated liver enzymes and normal hepatobiliary imaging. In previous studies of DILI, antibiotics were the most commonly implicated class of drugs. A newly recognized phenotype of cefazolin has been described in several studies. After an ultra-short duration of cefazolin, with 1 or 2 doses, a prominent cholestatic or mixed reaction develops 2-3 weeks later. This phenotype was originally described in the United States and has recently been reproduced in a study from Iceland. In a recent and important report from Türkiye, hepatocellular jaundice associated with the antibiotic ornidazole was described; 8% of affected patients required liver transplantation. In recent years, several new agents have been associated with other idiosyncratic DILI associated with prescription drugs, suggesting that the clinical landscape of DILI may be evolving. Liver injury resulting from the biological effects of drugs that modulate the immune system appears to be increasing. In a recent study from Barcelona, anticancer drugs, mainly checkpoint inhibitors, were the most frequent causes of DILI, followed by antibiotics, analgesics, and recreational drugs. Furthermore, several newly recognized hepatotoxic herbal and dietary supplements (HDSs) have been reported. These are Polygonum multiflorum, ashwagandha, green tea extract, turmeric, Tinospora cordifolia, Garcinia cambogia, and kratom. Most patients recover after discontinuation of the HDS, but acute liver failure (ALF), death from ALF, or liver transplantation has been reported in some cases.