I face a lot of difficulty in treating viral hepatitis (HAV) with superimposed toxic or herbal medicine toxicity. There is insufficient clinical or research work in management of toxic hepatitis.
You need to check out the information on fulminant hepatic failure-
http://emedicine.medscape.com/article/177354-overview
There are also review articles. For drug toxicity the treatment is generally supportive with referral for liver transplantation if the patients condition is inexorably worsening.
There are two types of toxic hepatitis: acute or chronic. Acute hepatitis produces cytotoxicity and is best treated withdrawing the offensive agent (frequently a drug) and if necessary giving hepatic support and transplantation only in indicated cases. Use of steroids is controversial or unusual.
In the other side, chronic toxicity may be treated similarly nevertheless in some patients immunologic mechanisms are triggered by drugs (autoimmune hepatitis). This is confirmed by the presence of antinuclear antibodies, smooth muscle antibodies and liver biopsy (cytotoxicity or cholestasis) only in these cases there is no question the use of steroids may be useful.
In hepatitis A, may be front with a form of cholestatic type hepatitis which have response to steroids.
In toxic or herbal remedies hepatitis as a general rule there is no place for steroids, however in patients with hypersensitivity reaction, the steroid can be used as a short course.
In conditions which we could not differentiate between toxic and autoimmune hepatitis, and after exclusion of viral and bacterial infection, steroid therapy also could used.
Best
Dr Saberifiroozi
I agree with you. In my experience autoimmune hepatitis(AH) triggered by drugs may be difficult to differentiate from those (AH) non associated with toxics. Nevertheless a careful clinical history may help for diagnosis. Unfortunatelly no biological marker is available for this differentiation. In liver biopsy small-droplet steatosis may be seen. Many of them are solved just with withdrawal of toxic agent, nevertheless some (a minority in my experience) are severe and in those cases steroids use is required. I suggest initial monitoring of these patiens and only use of steroids in required cases.
The majority of toxic hepatitis improve with the withdrawal of the responsible agent ; nevertheless, in some cases need special liver support and the role of steroids is very controversial
Dear Dr Luis Rodrigo
I completely agree with you.
Therefore for answering the question of Amitava: The role of steroids in toxic hepatitis is quite limited.
Best regards
alot of cases in our locality presented by toxic drug induced hepatitis not needed steroid and passed safely with withdrawal of causative drug and supportive ttt,
i also fully agree with the opportune comment from Dr. Sedeek
Best regards
I agree with all of you the use of steroids in such cases is very restricted to resistant cases non responsive to offending agent withdrawal
I think that all of you are coincident about the restricted use os steroids in only a small proportion of difficult cases
I don't think steroids woiuld be useful in this case with the exception of autoimmune hepatitis (AIH) following HAV hepatitis, Accordingly, However, if you could diagnose AIH, its treatment including low doses steroids is a reasonable option. Moreover, early after hospital admission, IV N-acetylcysteine was certainly indicated for 2 or 3 days (see WM Lee, Gastroenterolgy).
Dr Bernuau
I agree with you. Just I precise. Steroids are not useful for toxic hepatitis en general. Only those cases in which the toxic agent or drug triggers an autoimmune hepatitis, steroids may have a role. I say "may have" because even autoimmune hepatitis triggered by drugs may be solved without steroids. Only those that do not improve after downloading the toxic agent or worsens should receive steroids.
Best regards.
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