Bessone F, Bjornsson ES. Autoimmune-like hepatitis induced by drugs: Still many unanswered questions. World J Hepatol 2025; 17(11): 110946 [DOI: 10.4254/wjh.v17.i11.110946]
Corresponding Author of This Article
Fernando Bessone, Professor, Department of Gastroenterology and Hepatology, Facultad de Ciencias Médicas, Hospital Provincial del Centenario, University of Rosario School of Medicine, Urquiza 3101, Rosario 2000, Santa Fe, Argentina. bessonefernando@gmail.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Hepatol. Nov 27, 2025; 17(11): 110946 Published online Nov 27, 2025. doi: 10.4254/wjh.v17.i11.110946
Autoimmune-like hepatitis induced by drugs: Still many unanswered questions
Fernando Bessone, Einar S Bjornsson
Fernando Bessone, Department of Gastroenterology and Hepatology, Facultad de Ciencias Médicas, Hospital Provincial del Centenario, University of Rosario School of Medicine, Rosario 2000, Santa Fe, Argentina
Einar S Bjornsson, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik 101, Iceland
Author contributions: Bessone F and Bjornsson ES designed the topics to be covered, reconstructed the manuscript, made revisions, wrote small comments and organized the references; and all authors thoroughly reviewed and endorsed the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Fernando Bessone, Professor, Department of Gastroenterology and Hepatology, Facultad de Ciencias Médicas, Hospital Provincial del Centenario, University of Rosario School of Medicine, Urquiza 3101, Rosario 2000, Santa Fe, Argentina. bessonefernando@gmail.com
Received: June 19, 2025 Revised: July 6, 2025 Accepted: October 23, 2025 Published online: November 27, 2025 Processing time: 161 Days and 18.4 Hours
Abstract
Drug-induced autoimmune-like hepatitis (DI-ALH) is an increasingly recognized phenotype within the spectrum of drug-induced liver injury. Several drugs, including nitrofurantoin, minocycline, hydralazine, methyldopa and infliximab, have a well-documented capacity to induce DI-ALH. Distinguishing DI-ALH from classic de novo autoimmune hepatitis (AIH) can be challenging due to overlapping clinical, biochemical, and serological features. Accurate distinction from classic AIH is crucial, as management and prognosis differ. While some DI-ALH cases resolve spontaneously after drug withdrawal, others show persistent or worsening liver injury. Histological studies have shown that fibrosis and cirrhosis are more prevalent in classic AH. Unfortunately, there are no pathognomic clinical, biochemical or immunological features that reliably distinguish DI-ALH from classic AIH. However, most patients with DI-ALH do not relapse after corticosteroid withdrawal, in contrast to the high relapse rate observed in classic AIH. Most patients respond well to corticosteroids, and once liver tests normalize, biochemical parameters should be monitored, and long-term immunosuppression should not be indicated. However, DI-ALH is not exempt from risk of relapse, underscoring the need for long-term follow-up. Most patients with DI-ALH have a favorable prognosis; however, although rare, cases of cirrhosis and, in exceptional instances, acute liver failure have been reported. International collaborative studies are needed to further characterize DI-ALH. In this review, we update current controversies, present emerging concepts, and outline future challenges in the diagnosis and management of this complex condition learned so far.
Core Tip: Drug-induced autoimmune-like hepatitis is a challenging issue in clinical practice. Although some parts of the puzzle have been put in place, there are still several events to be solved. These include the lack of a clear classification of the disease, the role of liver pathology and how treatment should be approached in terms of corticosteroid dosage, for how long it should be prescribed and when to stop therapy.
