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Drug-induced liver injury (DILI) can mimic almost all other liver disorders. A phenotype increasingly ascribed to drugs is autoimmune-like hepatitis (ALH). This article summarizes the major topics discussed at a joint International Conference held between Drug-Induced Liver Injury consortium and the International Autoimmune Hepatitis Group. DI-ALH is a liver injury with laboratory and/or histological features that may be indistinguishable from those of autoimmune hepatitis (AIH). Previous studies have revealed that patients with DI-ALH and those with idiopathic AIH have very similar clinical, biochemical, immunological and histological features. Differentiating DI-ALH from AIH is important as patients with DI-ALH rarely require long-term immunosuppression and often resolve spontaneously after stopping the culprit drug whereas patients with AIH mostly need long-term immunosuppression. Therefore, revision of the diagnosis on long-term follow up may be necessary in some cases. More than 40 different drugs including nitrofurantoin, methyldopa, hydralazine, minocycline, infliximab, herbal and dietary supplements such as Khat and Tinospora cordifolia have been implicated in DI-ALH. Understanding of DI-ALH is limited by the lack of specific markers of the disease that could allow a precise diagnosis and similarly, there is no single feature which is diagnostic of AIH. A management algorithm is proposed. There is an urgent need to prospectively evaluate patients with DI-ALH systematically to enable definitive characterization of this condition.

In general, if a patient survives idiosyncratic DILI, then no long-term consequences on liver function are to be expected. However, severe DILI associated with jaundice may induce progressive liver disease in a small proportion of individuals despite drug withdrawal. A number of drugs have been shown to induce autoimmune hepatitis. In addition, the development of liver cirrhosis has been reported for several different drugs. Some drugs with a cholestatic type of injury have been associated with the development of vanishing bile duct syndrome, with long-term persistent liver injury. Although it seems well documented that chronic liver injury can occur after DILI and discontinuation of drug therapy, the long-term consequences in terms of liver-related morbidity and mortality are unclear. It has been shown that chronic liver disease including cirrhosis is very rare but chronic liver disease due to drugs can occur and may contribute to cases of cryptogenic cirrhosis.