Adderall® Induced Acute Liver Injury: A Rare Cause

Abstract

Purpose: Introduction: Toxin induced liver injury contributes to 30% of acute liver injury. Amphetamines and their derivatives are among the rarer causes of drug induced liver injury. Although both amphetamine and dextroamphetamine have been reported to individually cause liver injury, to our knowledge, Adderall®, a combination of both dextroamphetamine and amphetamine has not been associated with liver injury. We report a case of Adderall induced acute liver injury. To our knowledge this is the first case reported in the English medical literature. Case report: A 55 y.o. African American female presented with a 3 day history of malaise, anorexia, nausea, vomiting, and jaundice. The patient had a history of partial hepatic resection secondary to liver metastasis from colon cancer in 2006. She had been in remission since that time. She denied any risk factors for acute liver injury including complementary and alternative medications. She had been on Adderall XR 30mg twice a day for 11 months. The patient developed encephalopathy with worsening of liver enzymes and acute kidney injury by the second hospital day. In 72hrs, the patient's encephalopathy improved with lactulose. Renal function responded to aggressive intravenous hydration. The patient was discharged on the seventh hospital day with normal liver and kidney function. We arrived at a diagnosis of Adderall induced acute liver injury after excluding common etiologies of acute hepatic failure. Discussion: Amphetamine and its derivatives causing liver injury have been mentioned in the literature. Since amphetamines are rare causes of acute liver injury, physicians should first exclude common etiologies of acute hepatic failure. However, drug induced acute liver failure is considered to have a worse prognosis than viral causes of liver injury. Patients should be considered for emergency liver transplantation on an individual basis if conservative measures fail. However, data on the survival rate after liver transplantation in amphetamine induced fulminant hepatic failure is limited. Conclusion: Although few cases of amphetamine induced acute liver injury have been reported in the medical literature, no case of Adderall induced acute liver injury has been reported to our knowledge. In our patient, hepatic resection may have resulted in compromised functional reserve which, in turn, might have aggravated the Adderall induced hepatic insult. Meticulous supportive care was crucial for our patient with compromised liver function. Our case suggests that amphetamine like medications might need to be used with caution in patients with compromised liver function. Clinicians need to be alert to possible liver injury when using Adderall.