Drug-induced liver injury (DILI) from leflunomide and terbinafine-related chronic cholestasis represent two distinct hepatotoxic presentations, each with a specific therapeutic approach beyond simple drug withdrawal.
Acute liver injury due to leflunomide is usually self-limited once therapy is stopped, but severe and fatal cases have been reported. Separately, terbinafine can induce chronic cholestasis that may persist even after the offending drug is discontinued, requiring active intervention.
For leflunomide-related DILI, a bile acid resin is used to accelerate drug elimination — a strategy driven by leflunomide's enterohepatic circulation and extended half-life. For terbinafine-induced chronic cholestasis, a combined regimen involving a bile acid resin together with antihistamines has been reported to improve outcomes. The complete protocol — including agent selection, sequencing, and all dosing details — is available in the full structured regimen.
DOI: 10.1016/j.jhep.2019.02.014
Acute liver injury due to leflunomide is usually self-limited once therapy is stopped, but severe and fatal cases have been reported.
Because of the enterohepatic circulation and long half-life of leflunomide, therapy with a bile acid resin such as cholestyramine has been recommended to speed up drug clearance.
Cholestyramine in association with antihistamines has been reported to accelerate the improvement of chronic cholestasis induced by terbinafine.
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