1. Drug Induced Liver Disease Tutoring
By Alaina Darby

2. Chronic hepatocellular damage Acute hepatocellular damage
JD is a 24 yo WM who presents complaining of RUQ pain. He has been taking isoniazid due to his PPD coming back positive. Which of the following types of liver disease does he likely have?
Chronic hepatocellular damage
Acute hepatocellular damage
Chronic cholestatic jaundice
Acute cholestatic jaundice b

3. JD is a 24 yo WM who presents complaining of RUQ pain
JD is a 24 yo WM who presents complaining of RUQ pain. He has been taking isoniazid due to his PPD coming back positive. Which of his values would be least likely to be elevated?
AST
ALT
Alkaline phosphatase
INR c

4. Which of the following would be elevated in liver disease due to use of sulfonamides?
AST
ALT
Alkaline phosphatase
All of the above d

5. Which of the following is chlorpromazine most likely to cause?
Chronic hepatocellular damage
Acute hepatocellular damage
Chronic cholestatic jaundice
Acute cholestatic jaundice d

6. Which would most likely be elevated with chlorpromazine-induced liver disease?
AST
ALT
Alkaline phosphatase
All of the above c

7. Which of the following medications causes the accumulation of fat in the liver?
Nitrofurantoin
Acetaminophen
Sulfasalazine
Amiodarone d

8. Elevated alkaline phosphatase Presence of rash
FK is a 32 yo WF who has been taking Bactrim for a UTI. Which of the following might be the earliest indication of the potential for liver failure based on mechanism of DILI?
Elevated AST
Elevated ALT
Elevated alkaline phosphatase
Presence of rash d

9. Elevated alkaline phosphatase Elevated INR
JD is a 22 yo AAM who wants to increase his basketball skills. His friend was able to get him anabolic steroids, which he started taking 3 months ago. Which of the following would be most indicative of DILI due to the steroids?
Elevated AST
Elevated ALT
Elevated alkaline phosphatase
Elevated INR c

10. Discontinue chlorpromazine Biopsy the liver
HR is a 45 yo WF with HIV who is taking Truvada, isoniazid, chlorpromazine, APAP, and prophylactic Bactrim. Her AST is 3x ULN and bilirubin is 1.5x ULN. Which of the following should be done first?
Discontinue Truvada
Discontinue Bactrim
Discontinue chlorpromazine
Biopsy the liver b

11. HR is a 45 yo WF with HIV who is taking Truvada, isoniazid, chlorpromazine, APAP, and prophylactic Bactrim. Her AST is 3x ULN and bilirubin is 1.5x ULN. Which of the following medications is least likely to cause her elevated labs?
Truvada
Isoniazid
Chlorpromazine
APAP a

12. All but Truvada and chlorpromazine None of them
HR is a 45 yo WF with HIV who is taking Truvada, isoniazid, chlorpromazine, APAP, and prophylactic Bactrim. Her AST is 3x ULN and bilirubin is 1.5x ULN. Which medications should be discontinued?
All of them
All but Truvada
All but Truvada and chlorpromazine
None of them b

13. At lower doses all at the same time
HR is a 45 yo WF with HIV who is taking Truvada, isoniazid, chlorpromazine, APAP, and prophylactic Bactrim. Her AST is 3x ULN and bilirubin is 1.5x ULN. How should the medications be reinstated?
At lower doses all at the same time
At the same dose all at the same time
At lower doses one at a time
At the same dose one at a time
d… probably

14. HR is a 45 yo WF with HIV who is taking Truvada, isoniazid, chlorpromazine, APAP, and prophylactic Bactrim. Her AST is 3x ULN and bilirubin is 1.5x ULN. Which medication should be reinstated first?
Chlorpormazine
Bactrim
APAP
Isoniazid d

15. HR is a 45 yo WF with HIV who is taking Truvada, isoniazid, chlorpromazine, APAP, and prophylactic Bactrim. Her AST is 3x ULN and bilirubin is 1.5x ULN. Which medication should be reinstated first?
Chlorpormazine
Bactrim
APAP
Isoniazid a

16. ST is taking allopurinol. When should you monitor for DILI?
First weeks
First month
First 6 months
First year
All of the above a

17. ST is taking allopurinol. How do you minimize risk of DILI?
Hepatic dosing
Renal dosing
Frequent LFT monitoring
Watch for clinical symptoms b

18. JR is taking isoniazid. When should you monitor for DILI? First weeks
First month
First 6 months
First year
All of the above c

19. Which of the following baseline characteristics puts JR at risk for isoniazid-induced DILI?
Age 49
Bilirubin 3x ULN
AST 1.5x ULN
ALT 2x ULN c

20. OF is taking nitrofurantoin. When should you monitor for DILI?
First weeks
First month
First 6 months
First year
All of the above e

21. Which patient is most at risk for APAP toxicity?
Patient who had 2 drinks 8 hours ago
Patient who had 8 drinks 2 days ago
Patient who is a chronic alcoholic who has not recently consumed alcohol
Patient who is a chronic alcoholic who had 8 drinks 2 days ago a

22. Why would the patient who had 2 drinks 8 hours ago be at higher risk?
Increase of CYP2E1
Decrease of CYP2E1
Increase of glucuronidated APAP
Decrease of glucuronidated APAP a

23. PA is an alcoholic who has not recently consumed alcohol
PA is an alcoholic who has not recently consumed alcohol. He has cirrhosis and is currently taking propranolol to prevent variceal hemorrhage. Which of the following should you monitor if he is taking APAP for headaches?
AST
ALT
INR
Alk phos a

24. PA is an alcoholic who has not recently consumed alcohol
PA is an alcoholic who has not recently consumed alcohol. He has cirrhosis and is currently taking propranolol to prevent variceal hemorrhage. Which of the following values would you expect for AST if he weren’t taking APAP? 20
200
2,000
20,000 b

25. PA is an alcoholic who has not recently consumed alcohol
PA is an alcoholic who has not recently consumed alcohol. He has cirrhosis and is currently taking propranolol to prevent variceal hemorrhage. Which of the following values would most concern you in this patient if he starts taking APAP? 20
200
2,000
20,000 d

26. PA is an alcoholic who has not recently consumed alcohol
PA is an alcoholic who has not recently consumed alcohol. He has cirrhosis and is currently taking propranolol to prevent variceal hemorrhage and APAP for headaches. Which of the following would increase his risk?
Obesity
Not eating
Anorexia
High fat meal b

27. Maximum of 2 g/day of APAP Maximum of 3 g/day of APAP
PA is an alcoholic who has not recently consumed alcohol. He has cirrhosis and is currently taking propranolol to prevent variceal hemorrhage and APAP for headaches. Which of the following would you recommend?
Maximum of 2 g/day of APAP
Maximum of 3 g/day of APAP
Maximum of 4 g/day of APAP
Maximum of 5 g/day of APAP b

28. PA is an alcoholic who has not recently consumed alcohol
PA is an alcoholic who has not recently consumed alcohol. He has cirrhosis and is currently taking propranolol to prevent variceal hemorrhage and APAP for headaches. Which of the following do you expect to be elevated in this patient?
AST/ALT
CYP2E1
NAPQI
INR d

29. Give N-acetylcysteine A&B All of the above
PA is an alcoholic who has not recently consumed alcohol. He has cirrhosis and is currently taking propranolol to prevent variceal hemorrhage and APAP for headaches. He accidentally takes too much APAP and presents to you approximately 36 hours after OD. What should you do?
Monitor vitals
Get an APAP level
Give N-acetylcysteine
A&B
All of the above d

30. Acute hepatocellular damage Acute cholestatic jaundice
Which of the following is usually the cause of DILI by herbal medications?
Acute hepatocellular damage
Acute cholestatic jaundice
Chronic hepatocellular damage
Chronic cholestatic jaundice
A&B
C&D
All of the above e

31. PMH: CKD, HTN, and gouty arthritis.
RT is a 25 yo AAM who complains of RUQ pain, fever, a rash, and yellow eyes. Symptoms reportedly began 3 days ago.
PMH: CKD, HTN, and gouty arthritis.
Medications: iron supplement (x1 year), lisinopril (x6 months), APAP (x1 year), and allopurinol (x1 week)
Labs: CrCl 55, BP 130/79, HR 89, RR 22, AST 150, ALT 100, bilirubin 9.1
Which of the following would be a likely culprit for his symptoms?
Iron
Lisinopril
APAP
Allopurinol d

32. PMH: CKD, HTN, and gouty arthritis.
RT is a 25 yo AAM who complains of RUQ pain, fever, a rash, and yellow eyes. Symptoms reportedly began 3 days ago.
PMH: CKD, HTN, and gouty arthritis.
Medications: iron supplement (x1 year), lisinopril (x6 months), APAP (x1 year), and allopurinol (x1 week)
Labs: CrCl 55, BP 130/79, HR 89, RR 22, AST 150, ALT 100, bilirubin 9.1
How should he be treated?
Discontinue allopurinol
Supportive care
Discontinue APAP
A&B
All of the above d

33. PMH: CKD, HTN, and gouty arthritis.
RT is a 25 yo AAM who complains of RUQ pain, fever, a rash, and yellow eyes. Symptoms reportedly began 3 days ago.
PMH: CKD, HTN, and gouty arthritis.
Medications: iron supplement (x1 year), lisinopril (x6 months), APAP (x1 year), and allopurinol (x1 week)
Labs: CrCl 55, BP 130/79, HR 89, RR 22, AST 150, ALT 100, bilirubin 9.1
Should allopurinol be restarted? If so, how?
Absolutely not
Yes, start back at a dose that is calculated on CrCl
Yes, start at a low dose and titrate up
Yes, start back at the same dose b