Drug Safety

, Volume 39, Issue 3, pp 199–208 | Cite as

Hepatotoxicity Associated with the Use of Anti-TNF-α Agents

  • Joshua B. French
  • Maurizio Bonacini
  • Marwan Ghabril
  • David Foureau
  • Herbert L. Bonkovsky
Review Article


Medications to inhibit the actions of tumour necrosis factor alpha have revolutionized the treatment of several pro-inflammatory autoimmune conditions. Despite their many benefits, several serious side effects exist and adverse reactions do occur from these medications. While many of the medications’ potential adverse effects were anticipated and recognized in clinical trials prior to drug approval, several more rare adverse reactions were recorded in the literature as the popularity, availability and distribution of these medications grew. Of these potential adverse reactions, liver injury, although uncommon, has been observed in some patients. As case reports accrued over time and ultimately case series developed, the link became better established between this family of medicines and various patterns of liver injury. Interestingly, it appears that the majority of cases exhibit an autoimmune hepatitis profile both in serological markers of autoimmune liver disease and in classic autoimmune features seen on hepatic histopathology. Despite the growing evidence of this relationship, the pathogenesis of this reaction remains incompletely understood, but it appears to depend on characteristics of the medications and the genetic composition of the patients; it is likely more complicated than a simple medication class effect. Because of this still incomplete understanding and the infrequency of the occurrence, treatments have also been limited, although it is clear that most patients improve with cessation of the offending agent and, in certain cases, glucocorticoid use. However, more needs to be done in the future to unveil the underlying mechanisms of this adverse reaction.


Infliximab Liver Injury Etanercept Adalimumab Primary Sclerosing Cholangitis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Compliance with Ethical Standards


This work was supported by U01 cooperative agreements between the National Institutes of Health/National Institute for Diabetes and Digestive and Kidney Diseases and the University of North Carolina Chapel Hill/Wake Forest University Health Sciences (DK065201) and Indiana University (DK065211); by a U54 award from the National Institutes of Health/National Institute for Diabetes and Digestive and Kidney Diseases (DK083909) to Wake Forest [HLB, PI]; and by a grant from the National Institutes of Health/National Heart, Lung, and Blood Institute (R15 HL117199) to HLB.

Conflicts of interest

The authors (Joshua B. French, Maurizio Bonacini, Marwan Ghabril, David Foureau and Herbert L. Bonkovsky) have no conflicts of interest that are directly relevant to the content of this review.


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Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Joshua B. French
    • 1
  • Maurizio Bonacini
    • 2
  • Marwan Ghabril
    • 3
  • David Foureau
    • 4
  • Herbert L. Bonkovsky
    • 1
    • 5
    • 6
  1. 1.Section on Gastroenterology and Hepatology, Department of Internal MedicineWake Forest Health SciencesWinston-SalemUSA
  2. 2.Liver Center, Sutter HealthSan FranciscoUSA
  3. 3.Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisUSA
  4. 4.Department of ResearchCarolinas HealthCare SystemCharlotteUSA
  5. 5.Department of MedicineUniversity of Connecticut Health Science CenterFarmingtonUSA
  6. 6.Department of MedicineUniversity of North Carolina School of MedicineChapel HillUSA

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