S2475 The Buck Stops Here: A Case of Deer Antler Extract-Induced Liver Injury

Abstract

INTRODUCTION: Liver injury secondary to prescription or over the counter drugs and supplements is an ongoing public health concern, especially with the growing marketplace of unregulated supplements. Drug induced liver injury (DILI) has been reported as the most common reason for regulatory actions instituted by the US FDA against medications and supplements. Deer antlers are the only mammalian organs that can entirely grow back once lost and their extract contains insulin-like growth factor. Many athletes admit using deer antler extract as a performance-enhancing supplement, but its safety is unknown. The following is the first reported case of a deer antler supplement induced liver injury. CASE DESCRIPTION/METHODS: A 38 YO male presented with fatigue and elevated liver chemistry tests: AST 360, ALT 1297, ALP 78 (U/L) and bilirubin 2.9 mg/dL. He was not on any medications but did note recent use of a supplement called “Bucked Up” consisting of deer antler velvet extracts, ginseng, caffeine, taurine and Himalayan rock salt. He denied any concurrent supplement, herb, drug, or alcohol use, and noted improved symptoms following stopping using the supplement 5 days prior to presentation. The patient underwent a thorough work-up which ruled out infectious causes such as viral hepatitis, CMV, HSV, EBV, biliary obstruction, genetic diseases and autoimmune hepatitis. Liver biopsy showed moderate acute lobular cholestatic hepatitis. Patient was followed for total of 150 days after the liver injury. Figure 1 shows the peaks of Alk Phos, T bili, AST and ALT throughout the follow-up period. Alk Phos and T bili peaked around day 25 after the injury, while ALT and AST peaked at the first day and decreased to normal level at day 10. Another peak in AST and ALT was noted at around day 30. At day 50, all the labs started to return to the normal level. DILI resolved spontaneously without any treatment. DISCUSSION: The updated RUCAM Causality Assessment was used to evaluate the probability of DILI secondary to the deer antler velvet blend. The R ratio was consistent with hepatocellular type injury. It showed a probable correlation with a 7-point score, which along with the patient’s clinical course confirms the diagnosis of DILI secondary to the supplement. This report represents the first case of a deer antler-based supplement leading to hepatotoxicity, highlighting the need for public awareness regarding the hepatotoxicity of deer antler extract containing supplements.Figure 1.: Lab measurements from day 0 to day 150.Table 1.: The R ratio score