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.