Oral Azole Antifungal Medications and Risk of Acute Liver Injury, Overall and by Chronic Liver Disease Status

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• 作者：Vincent Lo Re III ; MD ; MSCE^a ; ^b ; ^c ; ^{vincentl@mail.med.upenn.edu" class="auth_mail" title="E-mail the corresponding author} ; Dena M. Carbonari ; MS^b ; ^c ; James D. Lewis ; MD ; MSCE^b ; ^c ; ^d ; Kimberly A. Forde ; MD ; MHS^b ; ^c ; ^d ; David S. Goldberg ; MD ; MSCE^b ; ^c ; K. Rajender Reddy ; MD^c ; ^d ; Kevin Haynes ; PharmD ; MSCE^b ; ^c ; Jason A. Roy ; PhD^b ; ^c ; Daohang Sha ; PhD^b ; Amy R. Marks ; MPH^e ; Jennifer L. Schneider ; MPH^e ; Brian L. Strom ; MD ; MPH^b ; ^c ; ^f ; Douglas A. Corley ; MD ; PhD^e
• 关键词：Acute liver failure ; Azole ; Drug-induced liver injury ; Hepatotoxicity
• 刊名：The American Journal of Medicine
• 出版年：2016
• 出版时间：March 2016
• 年：2016
• 卷：129
• 期：3
• 页码：283-291.e5
• 全文大小：412 K

文摘

Reports on associations between azole antifungal medications and acute liver injury are inconsistent and have not been based on liver-related laboratory tests. We evaluated incidence rates of acute liver injury associated with oral azole antifungals.

Methods

We conducted a cohort study among Kaiser Permanente Northern California members who initiated an oral azole antifungal in an outpatient setting during 2004-2010. We determined development of: (1) liver aminotransferases >200 U/L, (2) severe acute liver injury (coagulopathy with hyperbilirubinemia), and (3) acute liver failure. We calculated incidence rates of endpoints. Cox regression was used to determine whether chronic liver disease was a risk factor for outcomes.

Results

Among 195,334 azole initiators (178,879 fluconazole; 14,296 ketoconazole; 1653 itraconazole; 478 voriconazole; 28 posaconazole), incidence rates (events/1000 person-years [95% confidence intervals (CIs)]) of liver aminotransferases >200 U/L were similarly low with fluconazole (13.0 [11.4-14.6]), ketoconazole (19.3 [13.8-26.3]), and itraconazole (24.5 [10.6-48.2]). Rates were higher with voriconazole (181.9 [112.6-278.0]) and posaconazole (191.1 [23.1-690.4]), but comparable. Severe acute liver injury was uncommon with fluconazole (2.0 [1.4-2.7]), ketoconazole (2.9 [1.1-6.3]), and itraconazole (0.0 [0.0-11.2]), but more frequent with voriconazole (16.7 [2.0-60.2]) and posaconazole (93.4 [2.4-520.6]). One patient developed acute liver failure due to ketoconazole. Pre-existing chronic liver disease increased risks of aminotransferases >200 U/L (hazard ratio 4.68 [95% CI, 3.68-5.94]) and severe acute liver injury (hazard ratio 5.62 [95% CI, 2.56-12.35]).

Conclusions

Rates of acute liver injury were similarly low for fluconazole, ketoconazole, and itraconazole. Events were more common among voriconazole and posaconazole users but were comparable. Pre-existing chronic liver disease increased risk of azole-induced liver injury.