S5447 Acute Liver Failure Secondary to Risperidone Drug Induced Liver Injury

Introduction: According to AASLD, the estimated annual incidence of idiosyncratic drug-induced liver injury (DILI) in the general population is 14–19/100,000. Given its relatively infrequent nature, DILI is considered to be a diagnosis of exclusion when assessing liver injury. When accounting for the overall causes of acute liver failure (ALF) though, DILI is the leading cause. This is mainly secondary to acetaminophen toxicity, but additionally due to idiosyncratic DILI. Early recognition of idiosyncratic DILI-related ALF is important, as there is only a 25% likelihood of spontaneous survival. Due to the wide number of drugs associated with idiosyncratic DILI, databases like LiverTox have been developed to help assess the likelihood of any given drug to cause DILI. In this case presentation, we demonstrate what we believe to be a novel presentation of an idiosyncratic DILI caused by Risperidone leading to acute liver failure. Case Description/Methods: An 80-year-old woman with a prior medical history of end-stage renal disease on hemodialysis, renal cell carcinoma s/p L nephrectomy, and dementia presented to us in the setting of altered mental status. On presentation, she was found to meet criteria for acute liver failure. Her only pertinent history was the recent initiation of risperidone for agitation in the setting of her dementia. GI was promptly consulted, and, as she was not a good transplant candidate, she was not transferred to a transplant facility. She was empirically treated with N-acetylcysteine, and liver function tests were monitored for 10 days until they returned near baseline. Work-up was ultimately negative for an alternate cause, including acetaminophen, and DILI from risperidone was determined to be the underlying cause. Discussion: Risperidone is a widely used antipsychotic with multiple treatment indications, including schizophrenia, bipolar disorder, and often agitation. Risperidone has been associated with liver test abnormalities in up to 30% of patients, usually within the first 8 weeks of treatment, earning it a Likelihood score B on LiverTox. Unfortunately, the mechanism by which risperidone causes a DILI is still unknown. Positively, DILI from risperidone is usually mild and often does not even require dose adjustment or cessation for resolution of injury. To our knowledge, there have been no apparent previously recorded cases of acute liver failure caused by risperidone drug-induced liver injury. We believe this case represents a novel presentation of risperidone’s ability to cause drug-induced liver injury leading to acute liver failure.