Hepatic manifestations of non-steroidal inflammatory bowel disease therapy

Table 2 Summary of medication side effects and management options

Medication	Prevalence of liver injury	Manifestation	Management1
Sulfasalazine	0.4%-2.9%	Mild liver test abnormalities
		Severe systemic hypersensitivity
		Granulomatous hepatitis
		DRESS syndrome
5-ASA	Approximately 2.6%	Mild liver test abnormalities
		Drug induced autoimmune hepatitis
		Systemic hypersensitivity reaction
AZA/6-MP	1.4%-7.1%	Hypersensitivity reaction	Slight liver test elevation →
		Cholestasis	Monitor
		Peliosis hepatitis
		Disse space fibrosis	Persistent elevation →
		Veno-occlussive disease	Consider stopping medication/reducing dose
		Nodular regenerative hyperplasia	Marked elevation →
		Hepatosplenic T-cell lymphoma	Stop medication
Methotrexate	Approximately 10.2%	Elevated liver tests
		Fibrosis
Anti-TNF-α agents	0.37%-6.7%	Hepatocellular injury
		Cholestasis
		Hepatosplenic T-cell lymphoma
		Autoimmune hepatitis
Anti-integrin therapy	< 5%	Hepatocellular injury
		Cholestasis
		Autoimmune hepatitis
		Liver failure
Ustekinumab	1.4%	Elevated liver tests
Cyclosporine	1%-4%	Increased bile acids
		Cholestasis
		Hepatocellular injury

¹For general management of elevated liver tests. For specific recommendations see text. ASA: Aminosalicylic acid; AZA: Azathioprine; 6-MP: 6-Mercaptopurine; TNF: Tumor necrosis factor; DRESS: Drug reaction with eosinophilia and systemic symptoms.