Synopsis
Recognise drug-induced liver injury, manage paracetamol exposure through the current toxicology pathway, and prevent delayed antidote, rechallenge and acute liver failure.
- Drug-induced liver injury is a diagnosis of careful exclusion based on exposure, latency, biochemical pattern, dechallenge and competing causes; there is no single confirmatory blood test.
- Record prescription, non-prescription, herbal, bodybuilding, weight-loss, recreational and recently stopped products, with start dates, dose changes and last doses.
- Use the R ratio at first recognition to describe hepatocellular, cholestatic or mixed injury, but interpret laboratory upper limits and clinical context rather than relying on the label alone.
Key red flags
ALT predominates relative to alkaline phosphatase and symptoms may include malaise, nausea, right upper-quadrant discomfort and jaundice. Severe cases can progress rapidly to coagulopathy and encephalopathy.
Investigation priorities
Guide treatment after a single acute ingestion with reliable timing.
Management branches
One ingestion event with a reliable time and presentation before established hepatotoxicity.
- Establish exact time, amount, formulation, co-ingestants and body weight; assess self-harm risk and obtain a plasma concentration at or after four hours with baseline liver, renal and coagulation tests.
- If presentation is beyond eight hours after a potentially toxic dose, start acetylcysteine immediately while results are pending; otherwise use the current UK nomogram and TOXBASE treatment line.
Key medicines
Intravenous acetylcysteineUse the current TOXBASE-approved weight table and locally adopted infusion regimen.
Activated charcoalGive only within the time window and dose advised by TOXBASE.