• Always bear in mind the possibility. Take a careful drug history, including over-the-counter and alternative complementary medicine remedies.
• In patients with hepatitis a viral aetiology should be excluded.
• Cholestatic lesions, which may resolve only slowly on drug withdrawal, have to be differentiated from other causes of obstructive jaundice, both intrahepatic and extrahepatic.
• Underlying liver disease can cause diagnostic confusion, e.g. the alcoholic patient receiving antituberculosis drugs. It is wise to measure liver function tests before starting treatment with any drug which has documented hepatotoxic potential.
• Liver biopsy is of only limited use in diagnosis, although certain features, e.g. eosinophil infiltration, may provide a pointer to drug-induced liver disease.
• Diagnostic challenge is extremely dangerous for hepatic reactions because it may precipitate fulminant hepatic failure; the procedure is safer for cholestatic reactions.
• Monitoring liver function tests in the early weeks of therapy is useful in detecting an impending reaction to some drugs e.g. isoniazid. Minor abnormalities (serum transaminases less than twice normal) are often self-limiting and progress can be monitored. Elevations greater than three-fold should be an indication for drug withdrawal, even if the patient is asymptomatic.
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