A comprehensive review of hepatotoxicity – liver damage – caused by alcohol, illicit drugs and complementary and alternative medicines has given an insight into epidemiology, risk factors, clinical manifestations, pathogenesis, investigations, management and prognostic factors.
The study could now be used as a reference for treating patients in acute settings such as emergency departments, as well as ongoing treatment during hospitalisation, according to one of its authors. Dr Puraskar Pateria from the WA Liver Transplant Service at Sir Charles Gairdner Hospital says the research formed one of the most practical documents about hepatotoxicity.
"The potential of illicit substances to cause hepatotoxicity has been widely studied and published in the past, especially alcohol," he says.
"But some things surprised me such as the prevalence of illicit drug use being far more than I expected."
Cannabis is the most commonly used illicit substance worldwide with an estimated 200 million users, followed by amphetamine-type stimulants (excluding ecstasy).
"Some of the illicit drugs can cause acute liver failure even with a single overdose," Dr Pateria says.
"Amphetamine-type stimulants can lead to exhaustive dancing at hot nightclub raves, leading to a heatstroke-like syndrome causing hyperthermia, shock, ischaemia and hepatic necrosis. These patients have a high risk of dying in hospital.
"Complementary and alternative medicines, which are considered innocuous by many people, can also cause hepatotoxicity.
"Paracetamol is more hepatotoxic with chronic alcohol consumption and older patients are more susceptible to hepatotoxicity compared to younger patients."
Researching already available statistics and information based on their relevance, accuracy, source and authenticity, Dr Pateria drew on a range of research papers, meta-analysis, textbook chapters, World Health Organization annual reports and case series from reputed journals.
"With my co-authors [Dr Bastiaan de Boer and Dr Gerry MacQuillan], we tried to focus on epidemiology, clinical manifestations, pathogenesis, diagnosis and management of hepatotoxicity caused by the most commonly used illicit substances such as alcohol, cannabis, amphetamines, khat chewing and cocaine," he says.
"The greatest concerns with illicit substances are their easy availability, widespread use, the strong association between alcohol and their use, a lack of education and awareness among users regarding their ill-effects and the high prevalence of illicit substance abuse in people with mental health issues.
"But it's important to recognise that managing addiction and use of illicit drugs is a complex and challenging process.
"It involves a multidisciplinary approach involving doctors, counsellors, psychiatrists, clinical psychologists, social workers and drug and alcohol services.
"Unfortunately, it was beyond the scope of my research to discuss these equally important issues."
"Liver abnormalities in drug and substance abusers." Pateria P, de Boer B, MacQuillan G. Best Pract Res Clin Gastroenterol. 2013 Aug;27(4):577-96. DOI: 10.1016/j.bpg.2013.08.001. Epub 2013 Aug 22.