Apixaban Induced Hepatotoxicity in a Chronic Kidney Disease Patient with Left Ventricular Apical Clot

Drug induced liver injury (DILI) is a common occurrence in clinical practice mostly seen with anti-tubercular drugs. Drug cessation is crucial part of management. But DILI secondary to direct oral anticoagulant (DOAC) is rare. Especially risk of hepatotoxicity with apixaban is lower than other DOACs. A 78 years old diabetic and hypertensive female with coronary artery disease admitted with acute on CKD stage-3 (serum creatinine 1.7) underwent echocardiography revealing left ventricular apical clot. Cardiology team added apixaban following which patient developed anorexia, nausea and abdominal discomfort. Liver function test revealed transaminitis with liver enzymes suggestive DILI. Patient was neither on any concomitant hepatotoxic drugs nor had a history of liver disease. Apixaban was discontinued and enoxaparin was started following which transaminitis improved and patient became better.