Clinical presentation of terbinafine-induced severe liver injury and the value of laboratory monitoring: a critically appraised topic

Abstract

Context

Many physicians monitor liver function tests during terbinafine therapy.

Objective

Evaluate the symptoms of published cases of terbinafine associated severe DILI (Drug Induced Liver Injury) to assess the utility of laboratory monitoring.

Data sources

We based our search on the Liver Tox database of the National Institute of Health, but searched PUBMED as well as EMBASE. In addition, we hand-searched the references of the papers we found.

Study selection

All reports of patients with DILI on terbinafine and reported clinical symptoms, or absence thereof, were evaluated.

Data extraction

Two independent reviewers (J.A. and O.K.) assessed articles for eligibility of inclusion, and collected and evaluated the data.

Data synthesis

38 papers fulfilled the inclusion criteria with reports of 69 symptomatic patients. Mean duration of terbinafine treatment until onset of symptoms was 30.20 days (range 5 – 84). Symptoms in order of frequency were jaundice, flu-like symptoms, dark urine, and pruritus. Patients experienced symptoms for a mean and median of 14.78 and 16 days, respectively, (range of 0 – 42) until seeking medical attention.

Conclusions

Patients who had DILI were symptomatic, usually with jaundice, abdominal pain, general malaise, but also with severe pruritus. No asymptomatic patient was identified through laboratory screening. The timeline of DILI onset varies significantly, but most cases occur between 4 and 6 weeks. There was no timepoint at which monitoring is meaningful, and we do not recommend monitoring of LFTS on terbinafine, however, patients should be advised to discontinue treatment and search medical care when symptoms of DILI occur.

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