P2581 - Eltrombopag-Induced Autoimmune Hepatitis

Hassnain R. Syed, MD, Fady Salama, MD
University of Kentucky, Lexington, KY

Introduction: Autoimmune hepatitis (AIH) is an immunological disorder of the liver characterized by hepatic necroimflammation due to the break in self-tolerance to autoantigens. The most common medications associated with a definite cause of drug-induced autoimmune hepatitis (DIAH) are: Minocycline, Nitrofurantoin, and Infliximab. A review of the literature reveals no documented association between eltrombopag and AIH. Here, we present a case of a 59-year old female with refractory thrombocytopenia who was started on eltrombopag treatment, and later found to have AIH.

Case Description/Methods: 59 year old female with significant history of morbid obesity and compensated NASH cirrhosis-diagnosed in 2/2020 via imaging as workup for thrombocytopenia. Multidisciplinary team consensus came to a conclusion of a combination of cirrhosis and immune mediated thrombocytopenia as the etiology of her low platelet count. Patient was ultimately started on eltrombopag 50 mg PO daily on 3/6/2020.


Two years after starting eltrombopag, patient had a significant elevation in her liver function tests: AST 1132 U/L, ALT 393 U/L, total bilirubin 4.4 mg/dL, alkaline phosphatase 460 U/L, and INR 1.3. Immunological workup was significant for normal ANA, normal antimitochondrial antibody level, and strongly positive antismooth muscle antibody level at 1:2560. Ig G level was elevated at 1835 mg/dL . Patient was instructed to immediately stop the eltrombopag.


A liver biopsy was performed with histology showing stage 3-4 fibrosis, interface hepatitis with predominant lobular involvement and the portal areas showing lymphocytic infiltration with occasional plasma cells.

Patient was diagnosed with DIAIH from eltrombopag. She required a prednisone taper. There was significant improvement in her LFTs within 2 weeks post cessation of the drug. The patient’s labs showed near normal LFTS: AST 75 U/L, ALT 33 U/L, TB 1.2 mg/dL, ALP 133 U/L, and INR 1.

Discussion: DIAH resembles classic idiopathic AIH, but usually resolves upon cessation of the offending agent. Any drug induced liver injury is largely a diagnosis of exclusion. DIAH onset is usually more than six months, and in many cases up to several years, after starting the medication. A review of the literature, including a review of major guidelines, does not reveal any cases of DIAH caused by eltrombopag. This case highlights a potentially major sequela of eltrombopag that should be considered in the event of elevated transaminases seen in a patient taking eltrombopag.


Disclosures:


Hassnain R. Syed, MD, Fady Salama, MD. P2581 - Eltrombopag-Induced Autoimmune Hepatitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.