Liver Injury Following Intravenous Methylprednisolone Pulse Therapy in Multiple Sclerosis: The Experience from a Single Academic Liver Center
Dimitris Kounatidis,
Natalia G. Vallianou,
Georgios Kontos,
Hariklia Kranidioti,
Nikolaos Papadopoulos,
Alexandros Panagiotopoulos,
Krystalia Dimitriou,
Vasileios Papadimitropoulos,
Melanie Deutsch,
Spilios Manolakopoulos,
Dimitrios Vassilopoulos,
John Koskinas
Affiliations
Dimitris Kounatidis
Second Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece
Natalia G. Vallianou
First Department of Internal Medicine, Sismanogleio General Hospital, 15126 Athens, Greece
Georgios Kontos
Second Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece
Hariklia Kranidioti
Second Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece
Nikolaos Papadopoulos
Second Department of Internal Medicine, 401 General Army Hospital of Athens, 15561 Athens, Greece
Alexandros Panagiotopoulos
Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, National & Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
Krystalia Dimitriou
Second Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece
Vasileios Papadimitropoulos
Second Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece
Melanie Deutsch
Second Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece
Spilios Manolakopoulos
Second Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece
Dimitrios Vassilopoulos
Second Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece
John Koskinas
Second Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 11527 Athens, Greece
Intravenous methylprednisolone (IVMP) pulses, widely used for managing multiple sclerosis (MS) exacerbations, can lead to acute liver injury, presenting a diagnostic challenge in distinguishing between drug-induced autoimmune-like hepatitis (DI-ALH) and idiopathic autoimmune hepatitis (AIH). This study aimed to delineate the clinical and biochemical features of IVMP-induced liver injury, discern its etiology, and evaluate the efficacy of glucocorticoid (GC) therapy in treatment. A retrospective analysis of 13 relapsing MS patients with IVMP-induced liver injury was conducted. Liver injury was classified as hepatocellular, cholestatic, or mixed, with severity assessment guiding liver biopsy in selected cases. Causality was assessed using the Roussel Uclaf Causality Assessment Method (RUCAM) and the Simplified Diagnostic Criteria for AIH. All patients were initially monitored for a minimum of six months, with a mean follow-up period of 4.30 years. The median onset of liver injury was 37.46 days post-IVMP, with a mean peak alanine transaminase (ALT) level of 618.46 U/L. antinuclear antibody (ANA) positivity was observed in 61.53% of cases, with elevated serum immunoglobulin G (IgG) at 15.38%. Hepatocellular injury was universal among patients, and causality assessment predominantly supported DI-ALH. GC therapy was administered in six cases, achieving favorable outcomes in all but one, which necessitated rituximab. Biochemical normalization occurred within a mean of 55.41 days, with GC-treated patients recovering faster (48 days). These findings support the hypothesis that IVMP can induce hepatocellular injury, likely DI-ALH, during MS exacerbations. A tapering GC regimen proved effective in promoting recovery, particularly in severe cases. Additionally, this study introduced a diagnostic and therapeutic algorithm for managing IVMP-induced liver injury, offering a practical framework for clinical application.
