Case Presentation:
We first described herein a case of long-term drug-induced liver injury attributable to kedaling tablets. A patient was a 64-year-old man with more than 30 years hypertension and more than 1 year coronary disease. The patient has an alcohol history of 25 ml of white spirit per day, on average, but there was no known family history of liver disease. He was referred to our outpatient clinic on May 24, 2017 due to hypertension and coronary disease, and he treated with amlodipine/ diltiazem/rabeprazole sodium/heart-protecting musk pill/simvastatin/clopidogrel/ irbesartan and his liver enzymes have been stable. Until August 20, 2018, he add flunarizine/betahistine/kedaling tablets, his liver enzymes were start changed. Over the next 1 month, his alanine transaminase (ALT), aspartate transaminase (AST), gamma-glutamyltransferase (GGT) and alkaline phosphatase (ALP) significantly increased to 382, 178, 90 and 57 IU/L, respectively. An abdominal CT scan did demonstrate fatty liver. On further testing, a viral serology screen was negative for hepatitis A (HAV) IgM, hepatitis C (HCV) IgM and HBc IgM, however, anti-HBs was noted to be weakly positive. Moreover, Anti-liver-kidney-microsomal, antimitochondrial, anti-smooth muscle and anti-centromere antibodies were all negative. After two week of liver protection treatment, his liver enzymes decreased to returned to baseline and he was discharged. His anti-hypertension and anti-coronary heart disease were continued with amlodipine/diltiazem/rabeprazole sodium/ heart-protecting musk pill/simvastatin /clopidogrel/irbesartan/kedaling tablets, however, his ALT, AST, GGT and ALP rebounded to 864, 440, 389 and 93 IU/L for 1 month later. He was re-admission, kedaling tablets was discontinued on the first day, while other drugs were continued. The results of viral serology screen are similar to those of last time. After around one year of follow-up without kedaling tablets, liver enzymes remained normal. Unfortunately, On October 29, 2019, he switched to kedaling tablets, and his ALT, AST, GGT and ALP elevated at 716, 277, 148 and 93 IU/L 1 month later, which suggested that kedaling tablets probably account for DILI. The patient was instructed never to re-challenge himself with kedaling tablets and to report it as a medication adverse reaction in the future. Thus, kedaling tablets was discontinued and liver enzymes returned to baseline and have remained stable until now.