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Oral Azole Antifungal Medications and Risk of Acute Liver Injury, Overall and by Chronic Liver Disease Status.
Am J Med. 2015 Nov 17;
Authors: Lo Re V, Carbonari DM, Lewis JD, Forde KA, Goldberg DS, Reddy KR, Haynes K, Roy JA, Sha D, Marks AR, Schneider JL, Strom BL, Corley DA
Abstract
BACKGROUND: 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 from 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 if chronic liver disease was a risk factor for outcomes.
RESULTS: Among 195,334 azole initiators (178,879 fluconazole; 14,296 ketoconazole; 1,653 itraconazole; 478 voriconazole; 28 posaconazole), incidence rates (events/1,000 person-years [95% 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 (HR, 4.68 [95% CI, 3.68-5.94]) and severe acute liver injury (HR, 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.
PMID: 26597673 [PubMed - as supplied by publisher]