Severe cholestasis due to adalimumab in a Crohn’s disease patient

Abstract

Elevation of liver biochemistry has been reported with anti-tumor necrosis factor agents, but overt liver failure rarely reported. Autoimmune hepatitis has been more commonly reported with infliximab than adalimumab (ADA). Our case, however, describes the first reported case of ADA-associated severe cholestatic injury. A 39-year-old female with Crohn’s disease developed severe jaundice after initiation of ADA. All serologic tests and imaging studies were normal. Liver biopsy showed prominent pericentral canalicular cholestasis, without features of steatosis or sclerosing cholangitis, consistent with drug-induced cholestasis. The serum total bilirubin peaked at 280 μmol/L, and improvement was seen after 5 wk with eventual normalization of liver enzymes at 10 wk. Our case describes the first reported case of ADA-associated severe cholestatic liver disease and the first histopathologic examination of this adverse drug effect. Clinicians need to be aware of this potential drug-induced liver injury when prescribing this commonly used biologic medication.

Keywords: Crohn’s disease; Cholestasis; Adalimumab; Anti-tumor necrosis factor agents; Drug-induced liver injury

Core tip: Anti-tumor necrosis factor agents are commonly used in the treatment of inflammatory bowel disease and other inflammatory conditions. Drug-induced injury to the liver induced by the agents includes autoimmune hepatitis, direct hepatocellular necrosis and cholestasis. Our patient, a 39-year-old female with Crohn’s disease, developed severe jaundice after initiation of adalimumab. We present the first report of adalimumab-associated severe cholestatic injury and the first histopathologic examination of this adverse drug effect. Clinicians need to be aware of this potential severe drug-induced liver injury when prescribing this commonly used biologic medication.