A 47-year-old woman diagnosed with rheumatoid arthritis was seen in outpatient clinics due to changes in liver parameters.
In April 2003, she received 25 mg of subcutaneous etanercept twice a week in addition to previous methotrexate therapy, meloxicam and folic acid.
At the time of initiation of etanercept therapy, aminotransferase levels were within the normal range.
Two years later he was well, but ALT exceeded 13.2 times the upper limit of normal (xULN), AST 10.1 xULN and FA 1.7 xULN.
Physical examination was normal.
Viral antigens and antibodies to hepatitis A, C, B and cytomegalovirus were negative.
The rest of the study did not identify any specific cause for liver dysfunction.
Laboratory findings returned to normal after discontinuation of etanercept within 80 days.
However, liver function tests were increased again when adalimumab 40 mg every two months was administered (ALT xULN, AST 3.5 xULN and FA 1 xULN).
Adalimumab was interposed and although the patient developed positive antinuclear antibody titers (1/320), two months later liver tests had normalized.
Treatment was then started with anakinra (100 subcutaneous mg per day) and infliximab (300 mg per month).
Currently, the patient is being treated with infliximab without recurrence of hepatotoxicity despite the fact that ANA continue to be positive two years later.
