Paracetamol‐induced hepatotoxicity at recommended dosage

. Kurtovic J, Riordan SM (The Prince of Wales Hospital and University of New South Wales, Sydney, Australia). Paracetamol‐induced hepatotoxicity at recommended dosage (Case report). J Intern Med 2003; 253: 240–243. In patients who develop liver damage following moderate paracetamol overdose in the order of 5–10 g daily, recent fasting and nutritional impairment have been identified as key precipitants. Hepatotoxicity caused by paracetamol at recommended dosage, in the absence of exposure to enzyme‐inducing drugs, has recently been described as an idiosyncratic phenomenon. The possible importance of fasting and malnutrition in this setting is uncertain. We report a severely malnourished 53‐year‐old woman who developed severe hepatotoxicity whilst receiving paracetamol at recommended dosage (4 g daily) following a period of fasting, in the absence of enzyme‐inducing agents. Subsequent paracetamol exposure up to 2.6 g daily thrice weekly, in the setting of ongoing malnutrition and fasting as before, did not lead to recurrent liver damage. These findings indicate that paracetamol‐related liver damage occurring within recommended dosage guidelines can be a dose‐dependent rather than necessarily idiosyncratic phenomenon, at least in the setting of recent fasting and severe malnutrition.