Nimesulide-induced hepatitis and acute liver failure

Background: Nimesulide is a relatively new non-steroidal anti-inflammatory drug that is gaining popularity in many countries because it is a selective cyclooxygenase 2 inhibitor. Occasionally, treatment is associated with mil d elevation of liver enzymes, which return to normal upon discontinuation o f the drug. Several cases of nimesulide-induced symptomatic hepatitis were also recently reported, but these patients all recovered. Objectives: To report the characteristics of liver injury induced by nimesu lide. Patients and Methods: We report retrospectively six patients, five of them females with a median age of 59 years, whose aminotransferase levels rose a fter they took nimesulide for joint pains. In all. patients nimesulide was discontinued, laboratory tests for viral and autoimmune causes of hepatitis were performed, and sufficient followup was available. Results: One patient remained asymptomatic. Four patients presented with sy mptoms, including fatigue, nausea and vomiting, which had developed several weeks after they began taking nimesulide (median 10 weeks, range 2-13). He patocellular injury was observed with median peak serum alanine aminotransf erase 15 rimes the upper limit of normal (range 4-35), reversing to normal 2-4 months after discontinuation of the drug. The remaining patient develop ed symptoms, but continued taking the drug for another 2 weeks. She subsequ ently developed acute hepatic failure with encephalopathy and hepatorenal s yndrome and died 6 weeks after hospitalization. In none of the cases did se rological tests for hepatitis A, B and C, Epstein-Barr virus and cytomegalo virus, as well as autoimmune hepatitis reveal findings. Conclusions: Nimesulide may cause liver damage. The clinical presentation m ay vary from abnormal liver enzyme levels with no symptoms, to fatal hepati c failure. Therefore, monitoring liver enzymes after initiating therapy wit h nimesulide seems prudent.