Ticlopidine-induced acute cholestatic hepatitis

History and admission findings: A 52-year-old man who had sustained a cerebellar infarct was given the platelet inhibitor ticlopidine (2 x 250 mg/d) to prevent further thromboses. 28 days after starting the medication he complained of itchings, feeling unwell and diarrhoea. He had also noted darkened urine and faecal discoloration, Physical examination revealed marked jaundice and multiple scratch marks over the entire body. Investigations: The activities in serum of alkaline phosphatase (420 U/I) and of gamma-GT (470 U/I) were markedly elevated and total bilirubin concentration was maximally 26.4 mg/dl. Activities of GPT (197 U/I) and GOT (44 U/I) were slightly increased. No cause was found for any extra-or intrahepatic cholestasis with or without mechanical obstruction (e. g. viral or autoimmune hepatitis). A biopsy, which showed centro-acinar cholestasis also suggested drug-induced liver damage. Treatment and course: Despite discontinuing ticlopidine, the signs of cholestatic hepatitis had only disappeared 2 1/2 months after the onset of symptoms. Conclusion: Changes in the blood picture, allergic skin reactions and gastrointestinal disorders are among the significant clinical side effects of ticlopidine. As this drug is increasingly being prescribed world-wide, the possibility of toxic liver damage should be taken into account.