Kathleen A. Prendergast, MD; Carl L. Berg, MD; Ralph Wisniewski, MD
Prendergast K., Berg C., Wisniewski R.; Troglitazone-Associated Hepatotoxicity Treated Successfully with Steroids. Ann Intern Med. 2000;133:751. doi: 10.7326/0003-4819-133-9-200011070-00034
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Published: Ann Intern Med. 2000;133(9):751.
TO THE EDITOR:
A 59-year-old diabetic man was referred to a transplantation clinic with progressive liver dysfunction. He had begun feeling increasingly fatigued 5 months earlier. Liver enzyme levels were elevated (alanine aminotransferase [ALT] level, 8350 nkat/L; aspartate aminotransferase [AST] level, 4.98 µkat/L), and troglitazone and simvastatin therapies were stopped. During the next 8 weeks, aminotransferase levels continued to increase to 21 667 nkat/L, and the bilirubin level increased from normal to 308 µmol/L (18 mg/dL) (Figure).
The patient had initiated troglitazone therapy 1 year before presentation. At baseline and periodic checks, liver enzyme levels were within normal limits. Other medications included ramipril, diltiazem, furosemide, insulin, and glyburide. Alcohol intake was insignificant. On evaluation at our center, total bilirubin level was 444 µmol/L (26.0 mg/dL), alkaline phosphatase level was 7.36 µkat/L, ALT level was 10 583 nkat/L, and AST level was 5.26 µkat/L. Prothrombin time was normal. Laboratory investigation included negative results on viral serologic testing, normal immunoglobulin levels, and mild positivity for antinuclear and anti–smooth-muscle antibodies (both at a titer of 1:80). Ultrasonography and computed tomography were unremarkable. Liver biopsy showed submassive necrosis. The overall presentation was considered consistent with troglitazone-induced hepatotoxicity.
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