S5747 Deer Antler Extract Pre-Workout Ensues Supplement-Induced Liver Injury

Introduction: Acute liver injury (ALI) is a rapid onset of hepatic dysfunction, characterized by severe acute hepatocellular necrosis, and manifested by markedly elevated aminotransferases without mental status changes. While acetaminophen is a well-known hepatotoxin, increasing reports implicate over-the-counter (OTC) supplements as up-and-coming etiologies. Pre-workout supplements, including those containing deer antler extract (DAE), may be unacknowledged contributors to supplement-induced liver injury (SILI). Case Description/Methods: A 33-year-old previously healthy man who developed acute hepatocellular injury after presenting with intermittent fevers, myalgia, fatigue, and vomiting for the prior 10 days. He reported consuming high doses of acetaminophen (6–8 extra strength tablets daily), Nyquil, and Dayquil, in addition to DAE pre-workout supplement 5 days prior to presentation. Chemistry showed aspartate aminotransferase 871 U/L, alanine aminotransferase 1,691 U/L, alkaline phosphatase 263 U/L, and total bilirubin 1.6 mg/dL. Acute and chronic liver disease workup including, acetaminophen level, viral hepatitis panel, autoimmune serologies, tick-borne illnesses screen, and mononucleosis panel were all negative. Imaging was unremarkable. Given the negative workup and recent supplement use, a diagnosis of SILI was made. Interestingly, the DAE supplements contain insulin-like growth factors—known to have hepatotoxic capability. The patient improved clinically with discontinuation of hepatotoxic agents and upon discharge was advised to abstain from DAE supplements. Discussion: There is a need to consider dietary and workout supplements as potential causes of SILI. Patients unknowingly taking widely available pre-workout supplements, particularly when taking over the counter medications for fever, cold, and flu when ill, may inadvertently produce ALI. Obtaining a detailed history of supplement use is essential for early identification and management. Providers should counsel patients on the hepatotoxic risks of supplements and urge for greater regulatory oversight.