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Medicines That Can Harm the Liver
The liver processes most medicines, and some can inflame or injure it. This list collects the 54 medicines in our Drug Guide whose liver toxicity is well established. Most liver injury from medicines is uncommon and settles once the medicine is reviewed, but it can occasionally be serious — which is why knowing the warning signs matters.
Some entries are everyday medicines: acetaminophen (paracetamol) is the standout example, especially when several products containing it are combined. Others are specialist medicines whose liver effects are monitored with regular blood tests.
Safety first: Never stop a prescribed medicine on your own because it appears on this list. Many of these medicines are essential, and stopping suddenly can be far more dangerous than the kidney or liver risk. If you notice a warning sign, contact your doctor or pharmacist promptly and ask whether the medicine should be reviewed.
For patients and families — in plain language
Antibiotics & Infection Medicines
- Albendazole (Albenza) — On longer courses it can affect liver blood tests, so they are checked. Warning signs: yellowing of the skin or eyes or unusual tiredness.
- Amoxicillin-clavulanate (Augmentin) — Occasionally inflames the liver, sometimes even after the course has finished. Warning signs: yellowing of the skin or eyes, itching, or dark urine.
- Caspofungin (Cancidas) — Given in hospital, it can affect liver blood tests, so they are checked during treatment. Warning signs: yellowing of the skin or eyes or dark urine.
- Ciprofloxacin (Cipro) — Rarely inflames the liver. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or unusual tiredness.
- Clarithromycin (Biaxin) — Rarely inflames the liver. Warning signs: yellowing of the skin or eyes, itching, or dark urine.
- Erythromycin (Ery-Tab, E.E.S.) — Occasionally causes liver inflammation with jaundice. Warning signs: yellowing of the skin or eyes, itching, or dark urine.
- Fluconazole (Diflucan) — Can affect liver blood tests and, rarely, inflame the liver. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Isoniazid (INH) — A TB medicine that can inflame the liver. Warning signs: yellowing of the skin or eyes, dark urine, nausea, loss of appetite, or unusual tiredness — and avoid alcohol while taking it.
- Itraconazole (Sporanox) — Can inflame the liver. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or unusual tiredness.
- Ketoconazole (Nizoral) — The tablet form can seriously injure the liver, which is why it is now rarely used. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or severe tiredness.
- Levofloxacin (Levaquin) — Rarely inflames the liver. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or unusual tiredness.
- Micafungin (Mycamine) — Given in hospital, it can affect liver blood tests, so they are checked during treatment. Warning signs: yellowing of the skin or eyes or dark urine.
- Nitrofurantoin (Macrobid, Macrodantin) — Used long-term it can inflame the liver (and also the lungs and nerves). Warning signs: yellowing of the skin or eyes, dark urine, unusual tiredness, or new breathlessness.
- Posaconazole (Noxafil) — Can affect the liver. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness; levels and liver tests are followed during treatment.
- Pyrazinamide () — A TB medicine that can inflame the liver. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or unusual tiredness.
- Remdesivir (Veklury) — Given in hospital, it commonly raises liver blood-test numbers, so liver tests are checked during treatment. Warning signs: yellowing of the skin or eyes or dark urine.
- Rifampin (Rifadin) — A TB medicine that can inflame the liver and can also turn urine, sweat, and tears orange — that color change is expected and harmless. Warning signs of liver trouble: yellowing skin, dark urine, or unusual tiredness.
- Terbinafine (Lamisil) — The tablets can rarely inflame the liver. Warning signs: yellowing of the skin or eyes, itching, dark urine, or loss of appetite.
- Voriconazole (Vfend) — Can inflame the liver. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness; blood levels and liver tests are followed during treatment.
Heart & Blood Pressure Medicines
- Amiodarone (Pacerone, Cordarone) — Over months to years it can slowly damage the liver, so regular monitoring tests — including liver tests — are essential. Warning signs: unusual tiredness, nausea, or yellowing of the skin.
- Atorvastatin (Lipitor) — Statins can raise liver blood-test numbers slightly, but serious liver injury is rare. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Dronedarone (Multaq) — Rarely injures the liver. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or unusual tiredness; liver tests are checked in the first months.
- Fenofibrate (Tricor, Antara) — Can affect liver blood tests and, rarely, inflame the liver. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Fluvastatin (Lescol) — Can raise liver blood-test numbers slightly, but serious liver injury is rare. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Gemfibrozil (Lopid) — Can affect liver blood tests and, rarely, inflame the liver. Warning signs: yellowing of the skin or eyes, itching, or dark urine.
- Lovastatin (Mevacor, Altoprev) — Can raise liver blood-test numbers slightly, but serious liver injury is rare. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Niacin (Niaspan) — At high amounts, especially the slow-release kind, it can injure the liver. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or unusual tiredness.
- Pitavastatin (Livalo) — Can raise liver blood-test numbers slightly, but serious liver injury is rare. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Pravastatin (Pravachol) — Can raise liver blood-test numbers slightly, but serious liver injury is rare. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Rosuvastatin (Crestor) — Can raise liver blood-test numbers slightly, but serious liver injury is rare. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Simvastatin (Zocor) — Can raise liver blood-test numbers slightly, but serious liver injury is rare. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
Digestive (GI) Medicines
- Orlistat (Xenical, Alli) — Rare cases of liver injury have been reported. Warning signs: yellowing of the skin, dark urine, itching, or loss of appetite.
- Sulfasalazine (Azulfidine) — Can injure the liver, usually in the first weeks and sometimes with a rash. Warning signs: yellowing of the skin, dark urine, or a new rash with fever.
Hormone & Endocrine Medicines
- Methimazole (Tapazole) — Rarely affects the liver, usually causing bile-flow problems rather than deep liver damage. Warning signs: yellowing of the skin, itching, or dark urine.
- Propylthiouracil (PTU) — Can cause severe, sometimes fatal, liver injury. Warning signs: yellowing of the skin, dark urine, severe tiredness, loss of appetite, or upper belly pain — report these promptly.
Mental Health Medicines
- Amitriptyline (Elavil) — Rarely affects the liver. Warning signs: yellowing of the skin or eyes, itching, or dark urine.
- Atomoxetine (Strattera) — Very rarely injures the liver. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Chlorpromazine (Thorazine) — A classic cause of liver inflammation with bile-flow blockage, usually in the first weeks. Warning signs: yellowing of the skin or eyes, itching, dark urine, or fever.
- Duloxetine (Cymbalta) — Can injure the liver in rare cases, so it is generally avoided in people with significant liver disease or heavy alcohol use. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Fluvoxamine (Luvox) — Rarely affects the liver. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Phenelzine (Nardil) — Rarely affects the liver. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
Neurology Medicines
- Carbamazepine (Tegretol) — Can injure the liver, usually together with a serious rash reaction. Warning signs: yellowing of the skin, dark urine, or a new rash with fever — get checked urgently.
- Dimethyl fumarate (Tecfidera) — Can injure the liver, usually early in treatment, so liver tests are checked at the start. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Fingolimod (Gilenya) — Can raise liver blood-test numbers, so liver tests are part of its routine monitoring. Warning signs: yellowing of the skin or eyes, dark urine, or unusual tiredness.
- Lamotrigine (Lamictal) — Rarely injures the liver, usually together with a serious rash reaction. Warning signs: yellowing of the skin or a new rash with fever — get checked urgently.
- Phenytoin (Dilantin) — Can injure the liver as part of a serious allergic-type reaction. Warning signs: yellowing of the skin, a new rash with fever, or swollen glands — get checked urgently.
- Valproic acid (Depakene, Depakote (divalproex form)) — Can seriously injure the liver, rarely fatally, especially in young children. Warning signs: unusual sleepiness, vomiting, loss of appetite, confusion, or yellowing of the skin — seek care promptly.
Other Medicines
- Febuxostat (Uloric) — Can affect liver blood-test numbers, so they are checked from time to time. Warning signs: yellowing of the skin or eyes or unusual tiredness.
- Isotretinoin (Accutane, Claravis) — Can raise liver blood-test numbers, so blood tests — including liver tests and blood fats — are part of treatment monitoring. Warning signs: yellowing of the skin or unusual tiredness.
- Leflunomide (Arava) — Can injure the liver, so liver blood tests are checked regularly, especially at the start. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or unusual tiredness.
- Methotrexate (Trexall, Otrexup, Rasuvo) — Used over a long time it can cause fatty changes and scarring of the liver, which is why regular blood tests are part of treatment and alcohol is best avoided. Warning signs: unusual tiredness, nausea, or yellowing of the skin.
Pain Relief & Fever Medicines
- Acetaminophen (Tylenol) — Taking more than the label maximum — including extra amounts hidden in cold, flu, and combination pain products — can severely damage the liver. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or pain in the upper right belly.
- Tizanidine (Zanaflex) — Can injure the liver in some people, so liver tests are monitored, especially early on. Warning signs: yellowing of the skin or eyes, dark urine, nausea, or unusual tiredness.
Transplant & Immune Medicines
- Azathioprine (Imuran) — Can irritate or injure the liver in several ways. Warning signs: yellowing of the skin or eyes, itching, dark urine, or unusual tiredness; blood tests are followed during treatment.
For health professionals — clinical summary
The same medicines in clinical terms: pattern or mechanism of injury, key risk factors, and monitoring in general terms. No doses, dose adjustments or treatment protocols are given.
Antibiotics & Infection Medicines
| Medicine (brands) | Pattern / mechanism of injury | Key risk factors | Monitoring (general) |
|---|---|---|---|
| Albendazole Albenza | Mild hepatocellular enzyme elevations, usually reversible, on longer courses | Prolonged courses, pre-existing liver disease | Liver tests and blood counts on long courses |
| Amoxicillin-clavulanate Augmentin | Cholestatic (or mixed) hepatitis — the most common single cause of idiosyncratic drug-induced liver injury in many registries; onset may be after the course finishes; linked to HLA risk types | Older men somewhat more often, repeated courses, prolonged courses | No routine monitoring; liver tests if jaundice, itching, or dark urine appear during or after the course |
| Caspofungin Cancidas | Usually mild hepatocellular enzyme elevations; clinically significant injury is uncommon | Pre-existing liver disease, concurrent hepatotoxic medicines | Liver tests during hospital therapy |
| Ciprofloxacin Cipro | Hepatocellular injury — rare idiosyncratic hepatitis, occasionally severe | Prior drug-induced liver injury; prolonged courses | No routine monitoring; liver tests if symptoms appear |
| Clarithromycin Biaxin | Cholestatic/mixed hepatitis — rare, usually self-limited | Older age, prolonged courses, pre-existing liver disease | No routine monitoring; liver tests if symptoms appear |
| Erythromycin Ery-Tab, E.E.S. | Cholestatic hepatitis — a classic cause, especially the older estolate form (no longer common); usually self-limited | Prior reaction to macrolides; prolonged courses | No routine monitoring; liver tests if jaundice or itching appears |
| Fluconazole Diflucan | Usually asymptomatic hepatocellular enzyme elevations; rare clinically significant hepatitis (mixed pattern reported) | Prolonged or high-amount therapy, pre-existing liver disease, concurrent hepatotoxic medicines | Liver tests during prolonged therapy |
| Isoniazid INH | Hepatocellular injury — idiosyncratic hepatitis that can progress to liver failure; risk increases with age | Older age (risk rises after 35), alcohol use, pre-existing liver disease, slow acetylators, concurrent rifampin or pyrazinamide, pregnancy/postpartum | Baseline liver tests in at-risk patients and symptom-triggered testing; monthly symptom review |
| Itraconazole Sporanox | Hepatocellular injury — idiosyncratic hepatitis reported; enzyme elevations with continued use | Prolonged therapy, pre-existing liver disease, concurrent hepatotoxic medicines | Liver tests at baseline and during prolonged therapy |
| Ketoconazole Nizoral | Hepatocellular injury — boxed warning for hepatotoxicity including liver failure; oral form restricted for this reason | Pre-existing liver disease, alcohol use, prolonged therapy, concurrent hepatotoxic medicines | Baseline and periodic liver tests when the tablet form is used |
| Levofloxacin Levaquin | Hepatocellular injury — rare idiosyncratic hepatitis, occasionally severe | Prior drug-induced liver injury; prolonged courses | No routine monitoring; liver tests if symptoms appear |
| Micafungin Mycamine | Usually mild hepatocellular enzyme elevations; clinically significant injury is uncommon | Pre-existing liver disease, concurrent hepatotoxic medicines | Liver tests during hospital therapy |
| Nitrofurantoin Macrobid, Macrodantin | Both acute (hepatocellular or cholestatic, sometimes with allergic features) and chronic injury resembling autoimmune hepatitis, mainly with long-term use | Long-term prophylactic use, older women most often in reports | Liver tests periodically during long-term use; symptom review |
| Posaconazole Noxafil | Hepatocellular/cholestatic enzyme elevations; hepatitis reported | Prolonged therapy, pre-existing liver disease, high levels | Liver tests and drug levels during therapy |
| Pyrazinamide | Hepatocellular injury — among the more hepatotoxic standard TB medicines | Pre-existing liver disease, alcohol use, concurrent isoniazid/rifampin, gout | Baseline and periodic liver tests and symptom review during TB treatment |
| Remdesivir Veklury | Hepatocellular enzyme elevations — common during therapy and usually transient; discontinuation thresholds are part of hospital protocols | Pre-existing liver disease, critical illness | Liver tests before and during hospital treatment |
| Rifampin Rifadin | Mixed hepatocellular/cholestatic injury; commonly causes transient enzyme rises and competes with bilirubin excretion (jaundice without true injury can occur early) | Pre-existing liver disease, alcohol use, concurrent isoniazid/pyrazinamide | Baseline liver tests; symptom-triggered testing during therapy |
| Terbinafine Lamisil | Cholestatic hepatitis — rare but well documented with the tablet form; taste disturbance is a separate common effect | Pre-existing liver disease; prolonged therapy | Baseline liver tests for tablet courses; symptom-triggered testing |
| Voriconazole Vfend | Hepatocellular injury — exposure-related enzyme elevations and hepatitis; levels guide safety | High drug levels, prolonged therapy, pre-existing liver disease, CYP2C19 poor metabolizers | Liver tests and drug levels during therapy |
Heart & Blood Pressure Medicines
| Medicine (brands) | Pattern / mechanism of injury | Key risk factors | Monitoring (general) |
|---|---|---|---|
| Amiodarone Pacerone, Cordarone | Chronic cumulative injury resembling alcohol-related liver disease (steatohepatitis/phospholipidosis), which can progress to cirrhosis; also causes mild enzyme elevations in many patients | Long duration and high cumulative exposure, pre-existing liver disease, alcohol use | Liver tests every 6 months during long-term therapy, alongside thyroid, lung, and eye monitoring |
| Atorvastatin Lipitor | Mild asymptomatic enzyme elevations are dose-related and usually transient; clinically significant hepatocellular injury is rare and idiosyncratic | Pre-existing liver disease, heavy alcohol use, concurrent hepatotoxic medicines | Liver tests if liver symptoms appear; no routine scheduled monitoring needed for most patients |
| Dronedarone Multaq | Hepatocellular injury — rare cases of liver failure reported after marketing, prompting scheduled early monitoring | Pre-existing liver disease; first months of therapy | Liver tests during the first 6 months of therapy and if symptoms appear |
| Fenofibrate Tricor, Antara | Mild enzyme elevations; rare hepatocellular injury reported with long-term use | Pre-existing liver disease, long-term use | Liver tests periodically during long-term use |
| Fluvastatin Lescol | Mild asymptomatic enzyme elevations, usually transient; clinically significant injury is rare | Pre-existing liver disease, heavy alcohol use | Liver tests if liver symptoms appear |
| Gemfibrozil Lopid | Mild enzyme elevations; rare cholestatic hepatitis reported | Pre-existing liver disease, concurrent statin use (mainly a muscle concern) | Liver tests if symptoms appear; periodic tests during long-term use |
| Lovastatin Mevacor, Altoprev | Mild asymptomatic enzyme elevations, usually transient; clinically significant injury is rare | Pre-existing liver disease, heavy alcohol use | Liver tests if liver symptoms appear |
| Niacin Niaspan | Hepatocellular injury — risk is highest with sustained-release forms and high amounts; can progress to liver failure | Sustained-release preparations, high amounts, pre-existing liver disease, alcohol use | Liver tests at baseline and periodically with high-amount use |
| Pitavastatin Livalo | Mild asymptomatic enzyme elevations, usually transient; clinically significant injury is rare | Pre-existing liver disease, heavy alcohol use | Liver tests if liver symptoms appear |
| Pravastatin Pravachol | Mild asymptomatic enzyme elevations, usually transient; clinically significant injury is rare | Pre-existing liver disease, heavy alcohol use | Liver tests if liver symptoms appear |
| Rosuvastatin Crestor | Mild asymptomatic enzyme elevations, usually transient; clinically significant injury is rare | Pre-existing liver disease, heavy alcohol use | Liver tests if liver symptoms appear |
| Simvastatin Zocor | Mild asymptomatic enzyme elevations, usually transient; clinically significant injury is rare | Pre-existing liver disease, heavy alcohol use | Liver tests if liver symptoms appear |
Digestive (GI) Medicines
| Medicine (brands) | Pattern / mechanism of injury | Key risk factors | Monitoring (general) |
|---|---|---|---|
| Orlistat Xenical, Alli | Rare hepatocellular injury — isolated reports of severe liver injury prompted a label warning | Pre-existing liver disease | No routine monitoring; liver tests if symptoms appear |
| Sulfasalazine Azulfidine | Hepatocellular/mixed injury, often within a hypersensitivity reaction in the first weeks | Hypersensitivity history; slow acetylators; first weeks of therapy | Liver tests and blood counts early in therapy; immediate review for rash with fever |
Hormone & Endocrine Medicines
| Medicine (brands) | Pattern / mechanism of injury | Key risk factors | Monitoring (general) |
|---|---|---|---|
| Methimazole Tapazole | Cholestatic injury — typically milder and more cholestatic than propylthiouracil's hepatocellular pattern | Pre-existing liver disease; prolonged therapy | Liver tests if jaundice, itching, or dark urine appears |
| Propylthiouracil PTU | Hepatocellular necrosis — carries a boxed warning for severe, sometimes fatal, liver injury including liver failure requiring transplant | Children/adolescents (risk prominent enough that it is not first-line in children), pre-existing liver disease | Symptom-triggered liver tests; patient education on warning symptoms is the core safeguard |
Mental Health Medicines
| Medicine (brands) | Pattern / mechanism of injury | Key risk factors | Monitoring (general) |
|---|---|---|---|
| Amitriptyline Elavil | Rare cholestatic/mixed injury reported with tricyclics | Pre-existing liver disease, older age | Liver tests if symptoms appear |
| Atomoxetine Strattera | Rare hepatocellular injury — isolated cases of liver failure reported after marketing | Pre-existing liver disease | No routine monitoring; liver tests if jaundice or dark urine appears |
| Chlorpromazine Thorazine | Cholestatic hepatitis — the classic phenothiazine pattern, usually within the first weeks, often with allergic features (fever, rash, eosinophilia) | First weeks of therapy; prior cholestatic reaction to phenothiazines | Liver tests if jaundice or itching appears early in therapy |
| Duloxetine Cymbalta | Hepatocellular injury — increased risk in patients with substantial alcohol use or pre-existing liver disease, where it is generally avoided | Heavy alcohol use, pre-existing liver disease | Liver tests if symptoms appear; avoidance in significant liver disease |
| Fluvoxamine Luvox | Rare hepatocellular enzyme elevations/injury reported | Pre-existing liver disease, concurrent hepatotoxic medicines | Liver tests if symptoms appear |
| Phenelzine Nardil | Rare hepatocellular injury reported with the hydrazine MAOI class | Pre-existing liver disease, alcohol use | Liver tests if symptoms appear |
Neurology Medicines
| Medicine (brands) | Pattern / mechanism of injury | Key risk factors | Monitoring (general) |
|---|---|---|---|
| Carbamazepine Tegretol | Mixed hepatocellular/cholestatic injury, often as part of a hypersensitivity reaction (DRESS) with rash and fever | Hypersensitivity history; HLA risk types for skin reactions; concurrent interacting medicines | Baseline and periodic liver tests and blood counts; immediate review for rash with fever |
| Dimethyl fumarate Tecfidera | Hepatocellular injury — clinically significant cases reported, typically in the first months | Pre-existing liver disease; first months of therapy | Liver tests before starting and during the first months of therapy |
| Fingolimod Gilenya | Hepatocellular enzyme elevations — scheduled monitoring is part of its safety program; rare significant injury | Pre-existing liver disease, concurrent hepatotoxic medicines | Liver tests at baseline and periodically during therapy per its monitoring program |
| Lamotrigine Lamictal | Rare hepatocellular injury, usually within a hypersensitivity reaction (DRESS) | Hypersensitivity history; rapid amount increases; concurrent valproate | Immediate review for rash with fever; liver tests if symptoms appear |
| Phenytoin Dilantin | Hepatocellular injury, classically within a hypersensitivity reaction (DRESS) with rash, fever, and swollen glands | Hypersensitivity history; slow metabolizers | Liver tests if rash/fever or liver symptoms appear; drug levels for its seizure treatment |
| Valproic acid Depakene, Depakote (divalproex form) | Hepatocellular injury up to fulminant liver failure (microvesicular steatosis/mitochondrial injury); risk highest in young children on multiple antiseizure medicines and in mitochondrial disease; hyperammonemia can occur with normal liver tests | Age under 2 years, multiple antiseizure medicines, mitochondrial (POLG) disorders, metabolic disease, pre-existing liver disease | Liver tests and clinical review especially in the first 6 months; ammonia if confusion occurs |
Other Medicines
| Medicine (brands) | Pattern / mechanism of injury | Key risk factors | Monitoring (general) |
|---|---|---|---|
| Febuxostat Uloric | Mild hepatocellular enzyme elevations; clinically significant injury is rare | Pre-existing liver disease | Liver tests periodically during therapy |
| Isotretinoin Accutane, Claravis | Mild, usually transient hepatocellular enzyme elevations; clinically significant injury is uncommon | Pre-existing liver disease, alcohol use, concurrent hepatotoxic medicines | Liver tests and blood fats monitored during therapy as part of its safety program |
| Leflunomide Arava | Hepatocellular injury — enzyme elevations common enough that scheduled monitoring is standard; rare liver failure, risk higher combined with methotrexate | Pre-existing liver disease, alcohol use, concurrent methotrexate or other hepatotoxic medicines | Liver tests monthly during the first months, then periodically |
| Methotrexate Trexall, Otrexup, Rasuvo | Chronic steatosis and hepatic fibrosis with long-term cumulative exposure (the classic methotrexate liver concern); acute hepatocellular enzyme flares after high amounts or early in weekly therapy | Alcohol use, obesity, diabetes, pre-existing liver disease/viral hepatitis, high cumulative exposure, inadequate folate supplementation | Liver tests regularly during therapy; fibrosis risk review with long-term use; alcohol avoidance counseling |
Pain Relief & Fever Medicines
| Medicine (brands) | Pattern / mechanism of injury | Key risk factors | Monitoring (general) |
|---|---|---|---|
| Acetaminophen Tylenol | Hepatocellular necrosis — centrilobular (zone 3) injury from the toxic metabolite NAPQI when glutathione is overwhelmed; the leading cause of acute liver failure in the US/UK | Taking more than the label maximum, combining several acetaminophen-containing products, heavy alcohol use, liver disease, fasting/malnutrition | No routine monitoring at label amounts; liver tests and acetaminophen level urgently in suspected overdose |
| Tizanidine Zanaflex | Hepatocellular injury — enzyme elevations in trials; rare liver failure reported after marketing | Pre-existing liver disease, concurrent hepatotoxic medicines | Liver tests at baseline and during the first months of therapy |
Transplant & Immune Medicines
| Medicine (brands) | Pattern / mechanism of injury | Key risk factors | Monitoring (general) |
|---|---|---|---|
| Azathioprine Imuran | Several patterns: cholestatic hepatitis, hepatocellular injury, and with long use, vascular injury (nodular regenerative hyperplasia, sinusoidal obstruction) — usually enzyme or platelet signals first | TPMT deficiency (marrow rather than liver), pre-existing liver disease, long duration of use | Liver tests and blood counts during therapy; closer monitoring early on |
Frequently asked questions
What are the warning signs that a medicine is harming my liver?
Possible signs include yellowing of the skin or the whites of the eyes (jaundice), dark urine, pale stools, severe itching, pain in the upper right of the abdomen, nausea and unusual tiredness. These need prompt medical attention, especially in the weeks after starting a new medicine.
Can painkillers and cold remedies damage my liver without me realising?
Acetaminophen (paracetamol) is in a large number of pain, cold, flu and sleep products, so it is easy to take it in several products at once without realising. Always check whether your other products contain acetaminophen or paracetamol, and never take more than the label maximum.
Can herbal remedies and supplements harm the liver?
Yes — some herbal and dietary supplements, such as high-dose green tea extract, kava and anabolic steroids, have been linked to liver injury. Supplements are outside this guide’s list of medicines, but “natural” does not mean safe for the liver; tell your doctor about any supplements you take.
Should I stop a medicine on this list?
Never on your own. Many of these medicines are essential, and stopping suddenly can be far more dangerous than the liver risk. If you notice a warning sign, contact your doctor or pharmacist promptly and ask whether the medicine should be reviewed.
Please note: This page is a patient-education summary, not medical advice, and it deliberately contains no doses. Medicines affect everyone differently — always follow your own prescription and talk to your doctor or pharmacist before starting, stopping or changing any medicine.