Adderall (dextroamphetamine/amphetamine) is a widely prescribed medicine for the treatment of attention-deficit/hyperactivity disorder (ADHD) and is considered safe with due precautions. Use of prescribed Adderall without intention to overdose as a cause of acute liver injury is extremely rare, and to our knowledge no cases have been reported in the English literature. Amphetamine is an ingredient of recreational drugs such as Ecstacy and is known to cause hepatotoxicity. We describe here the case of a 55-year-old woman who developed acute liver failure during the treatment of ADHD with Adderall. She presented to the emergency room with worsening abdominal pain, malaise, and jaundice requiring hospitalization. She had a past history of partial hepatic resection secondary to metastasis from colon cancer which was under remission at the time of presentation. She recovered after intensive monitoring and conservative management. Adderall should be used carefully in individuals with underlying liver conditions.
Acute hepatitis can result from wide variety of causes, among which viral and toxin induced injuries are the most common. Toxin induced liver injury contributes to 30% of acute liver injury [
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A 55-year-old female presented to Washington Hospital Center with three days history of malaise, anorexia, nausea, vomiting, jaundice, intense pruritus, and upper abdominal pain. She denied fever, chills, weight loss, and diarrhea. She also denied alcohol abuse, illicit drug use, and use of herbal supplementation. Her past medical history consisted of hypertension, hypothyroidism, Roux-En-Y Gastric bypass, ADHD, and colorectal cancer. Patient was diagnosed with stage IV (T3, M1, N1) malignant neoplasm of the ascending colon in 2002 for which she underwent right hemicolectomy. She had a partial hepatic resection (segments 4 and 7) in 2005 secondary to liver metastasis from colon cancer. Her colon cancer was in remission at the time of presentation. She has been on Adderall 30 mg twice a day for about eleven months. Patient took twice the recommended dose by herself (due to worsening of ADHD) for 5 days before she presented to the hospital. Her other medications included aspirin 81 mg, carvedilol 12.5 mg, and synthroid 50 mcg. Family history was negative for chronic liver disease including Wilson’s disease,
Patient remained hemodynamically stable for first 24 hours. Her hepatocellular injury was confirmed with biochemical markers. Additional investigation included serologic testing for cytomegalovirus, Epstein-Barr virus, and hepatitis A, B, and C viruses; results of all the serologies were negative for current or past infection. Her condition deteriorated by worsening encephalopathy, worsening of liver enzymes, and acute kidney injury by second day. Further evaluation also included testing her levels of acetaminophen, ceruloplasmin,
Biochemical markers of hepatocellular injury.
We arrived at a diagnosis of Adderall induced acute liver injury after an extensive evaluation for viral, metabolic, and autoimmune conditions that failed to reveal a cause for hepatitis in this patient. Her clinical presentation, with symptoms emerging after administration of the drug and cessation of symptoms shortly after withdrawing the drug, led to our conclusion that the hepatitis resulted from a reaction to Adderall. According to the Naranjo scale, it is probable (score = 5) that this case of acute liver failure was a result of an adverse drug reaction [
Our case is the first case in the medical literature that has resulted in enormous elevation of transaminases due to amphetamine toxicity. Various mechanisms of amphetamine and its derivatives causing liver injury have been mentioned in the literature [
Since amphetamines are the rare cause of acute liver injury, physicians should first exclude common etiology of acute hepatic failure which includes acetaminophen overdose, viral hepatitis, autoimmune causes, Wilson’s disease, hemochromatosis, and portal and hepatic vein thrombosis. The ingestion/presentation interval and short half-life of the drug frequently lead to a negative result in blood or urine. It is crucial to monitor the serial prothrombin time estimations, serum bilirubin, transaminases, and albumin levels. Liver biopsy should be considered if the extent of liver damage or the etiology is in doubt (should be carried out by transjugular route if PT is significantly prolonged). Accurate clinical assessment of renal function and adequate hydration is also required. Hyperthermia should be treated aggressively. Drug induced acute liver failure is considered to have worse clinical outcomes [
Although few cases of Ecstasy and Amphetamine induced acute liver injury have been reported in the medical literature, no case of Adderall induced acute liver injury has been reported. In our patient, hepatic resection may have resulted in compromised functional reserve which, in turn, might have led to Adderall induced hepatic insult. Meticulous supportive care was crucial for our patient with compromised liver function. Clinicians need to be alert to possible liver injury when using Adderall especially in a similar setting.
The authors of this publication disclose no conflict of interests relevant to this submission.