Fulminant chemical hepatitis possibly associated with donepezil and sertraline therapy

OBJECTIVE: To describe a case of fulminant hepatitis possibly related to co ncomitant donepezil and seratriline therapy. PATIENT AND SETTING: An 83-year-old woman treated in a dementia care facili ty and later ill a tertiary medical center. INTERVENTION AND MANAGEMENT: Discontinuation of donepezil and sertraline th erapy with subsequent improvement evidenced by liver biopsy and liver funct ion tests. RESULTS: An older woman with Alzheimer's disease was admitted to a dementia care facility because of aggressive behavior. Treatment with sertraline wa s initiated in February 1998. Sertraline doses were increased gradually to 200 mg daily by May 1998, and some improvement in behavior was seen. Concom itant therapy with donepezil 5 mg qhs was initiated June 26, 1998. Ten days later, confusion and jaundice were noted. Total bilirubin was 5.6 mg/dL, G GTP was 1208 IU/L, and alkaline phosphatase was 369 IU/L. Computed tumograp hy revealed cholelithiasis without ductal dilation. Liver, spleen, and panc reas seemed normal. Donepezil and sertraline were discontinued. The patient was admitted to our institution and treated fur dehydration, A liver biops y revealed scattered portal eosinophils and prominent cholestasis consisten t with acute chemical hepatitis. The GGTP and total bilirubin of this patie nt peaked at 2235 IU/L and 22.6 mg/dL, respectively. The patient improved, and her liver function tests normalized over the next 2 months.