SHM Converge Scientific Abstract ePoster Gallery-Topical Diclofenac-Induced Hepatotoxicity

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A 94-year-old man with Paget’s disease and osteoarthritis was found down after an unwitnessed fall. He had no prodromal symptoms, palpitations, or loss of consciousness, but his family noted poor oral intake and decreased appetite. On exam he was mildly hypotensive with positive orthostatics and had left hip tenderness. Imaging of the abdomen was unremarkable, and hepatitis testing was negative.<br /><br />Laboratory studies showed marked hepatocellular injury and cholestasis, including AST 426, ALT 239, total bilirubin 4.9, direct bilirubin 3.84, INR 1.8, and ALP 368, along with thrombocytopenia and elevated creatine phosphokinase. His acetaminophen level was low, and other potential causes such as viral hepatitis, stable long-term atorvastatin use, stable ibuprofen use, and muscle injury from statin toxicity were considered unlikely.<br /><br />The case was attributed to topical diclofenac-induced hepatotoxicity. Diclofenac is known to cause idiosyncratic liver injury, but this is typically reported with oral formulations; evidence for topical diclofenac causing clinically significant liver injury is limited. The authors propose that topical diclofenac can still lead to acute hepatotoxicity in predisposed individuals through an idiosyncratic mechanism involving altered metabolism, toxic metabolite accumulation, and immune-mediated hepatocyte injury.<br /><br />Management included IV fluids and stopping atorvastatin, acetaminophen, ibuprofen, and topical diclofenac. Liver tests improved, and by three weeks after discharge they had normalized except for chronic alkaline phosphatase elevation. The report concludes that patients using higher doses or prolonged courses of topical diclofenac may benefit from liver function monitoring, with FDA labeling recommending transaminase checks within 4 to 8 weeks after initiation.

Asset Subtitle

Thilini Delungahawatta

Meta Tag

Author List Ashik Pokharel, Christopher J Haas, Robert Paz, Thilini Delungahawatta

Category Clinical Vignettes

Concept Diclofenac

Concept Drug-Induced Liver Injury

Concept Hepatotoxicity

Concept ALT

Concept AST

Distinguished Non-Finalist

Presenter Organization MedStar Health Internal Medicine Residency Program

Presenting Author Thilini Delungahawatta

Track Adult

Keywords

topical diclofenac

hepatotoxicity

acute liver injury

cholestasis

idiosyncratic drug reaction

elevated transaminases

Paget disease

orthostatic hypotension

drug-induced liver injury

liver function monitoring

Diclofenac

Drug-Induced Liver Injury

Hepatotoxicity

ALT

AST