Preface
The 2024 Chinese Society of Clinical Oncology (CSCO) Guidelines Congress was held in Jinan on April 26-27. In this guideline conference, CSCO released 32 guidelines for the diagnosis and treatment of tumors, among which the "CSCO Guidelines for the Diagnosis and Treatment of Liver Injury Associated with Tumor Drugs" was released for the first time, which aims to deal with the risk of drug-induced liver injury (DILI) caused by the single use and combination of drugs in the current cancer treatment, and improve the awareness and diagnosis and treatment level of DILI among oncologists in mainland China. In the special session on tumor-related thrombosis, anemia and liver injury, Professor Tang Qinghua of Harbin Institute of Hematology and Oncology interpreted the content of the "CSCO Guidelines for the Diagnosis and Treatment of Liver Injury Associated with Tumor Drugs".
Professor Tang Qinghua
DILI refers to liver damage caused by chemicals and biological products, Chinese patent medicines and other drugs managed as prescription drugs or over-the-counter drugs, as well as Chinese herbal medicines, natural medicines, health products, dietary supplements and other products, or their metabolites, as well as their excipients, pollutants and impurities.
The annual incidence of DILI in the general population in Chinese mainland is at least 23.80/100,000 people, which is higher than that in other countries, of which antitumor drugs and immunomodulators cause DILI to account for 8.34%. With the continuous progress of targeted therapy and immunotherapy in tumor and its wide clinical application, monotherapy and various combination therapy regimens have been included in the diagnosis and treatment guidelines of different tumors, and the reports of liver injury caused by these new treatment methods have gradually increased, making liver injury caused by anti-tumor drugs a major challenge in the current clinical practice of cancer.
In recent years, a number of clinical specialties at home and abroad have published DILI-related guidelines in their respective fields, but there are no specific guidelines for the diagnosis and treatment of antineoplastic drug-related liver injury worldwide. In order to improve the understanding of mainland clinicians on the prevention of oncology drug-related liver injury and avoid confusion in diagnosis and treatment practice, CSCO specially organized domestic experts in related fields to compile this guideline.
Clinical phenotype
- Acute DILI: the main phenotype of patients with antineoplastic drug-related liver injury, most patients present with this phenotype, liver enzymes are significantly elevated in a short period of time, and DILI events are acute.
- Chronic DII: Some cancer patients have this phenotype, with long-term, recurrent mild to moderate elevations of liver enzymes, similar to chronic hepatitis or chronic liver disease, and overlapping with the specific phenotype of some DILI.
- Specific phenotype DILI: The specific phenotype is complex and covers common or relatively rare types of liver injury. Patients exposed to specific antineoplastic agents may present with different classical specific phenotypes, with varying clinical symptoms, liver enzymes, and/or imaging manifestations.
Patients with tumors who require focused screening and surveillance
Those who have known risk factors for liver injury with specific antineoplastic drugs and need to be treated with such drugs; Those who have had liver damage below CTCAE grade 3 due to previous exposure and who need to be treated with the drug subsequently; Patients who require a combination anti-tumor regimen containing ICIs; Patients with cirrhosis with underlying liver disease, especially those with severely impaired liver function; HCC patients; Patients treated with multi-drug combination therapy where drug interactions may occur; Patients who have had DILI in the past, especially those with immune-mediated DILI.
diagnosis
To diagnose acute DILI, liver biochemistry must be met on one of three criteria:
- ALT≥5×ULN
- ALP≥2×ULN (especially if ALP levels are elevated with elevated GGT and excludes skeletal disorders)
- ALT≥3×ULN and TBil≥2×ULN
The diagnosis of DILI lacks specific diagnostic biomarkers and remains an exclusive strategy based on a detailed history, clinical symptoms and signs, serum biochemistry, imaging, and histology. According to the principle of adverse drug reaction/event correlation evaluation, the establishment of a diagnosis ultimately depends largely on:
- There is a clear and reasonable time-sensitive relationship between drug exposure or discontinuation and changes in liver biochemistry;
- The clinical and/or pathologic manifestations (type) of liver injury are consistent with the known hepatotoxicity of the suspected drug;
- Significant improvement or return to normal liver damage after discontinuation or dose reduction;
- recurrence of liver damage after re-administration;
- Other causes of liver injury and the activity or recurrence of underlying liver disease were excluded and could not be explained by other concomitant medications/treatments, or progression of the primary disease.
grading
treat
Timely discontinuation of drugs suspected of liver injury and avoiding the use of suspected or similar drugs as much as possible is the most important measure for the cause of liver injury, and it is also the most basic treatment principle of DILI.
For hepatocell-damaged and mixed DILI, magnesium isoglycyrrhizinate and bicyclol can be used. For cholestatic DILI, treatment with ursodeoxycholic acid, S-adenosylmethionine, etc., may be considered. Glucocorticoids should be used for immune-mediated DILI with hypersensitivity and autoimmune features, as well as immune checkpoint inhibitor hepatotoxicity.
Editor: Faline
审校:Faline
Typesetting: Faline
Execution: Ryland
This platform aims to deliver more medical information to healthcare professionals. The content published on this platform should not be used as a substitute for professional medical guidance in any way, nor should it be regarded as diagnosis and treatment advice. If such information is used for purposes other than understanding medical information, the platform does not assume relevant responsibilities. This platform does not mean that it agrees with its descriptions and views on the published content. If copyright issues are involved, please contact us, and we will deal with it as soon as possible.