A 34-year-old male patient was diagnosed with adult-onset Still's disease. After treatment with methylprednisolone and tocilizumab, the levels of aminotransferase and bilirubin increased significantly, and decreased to normal levels after drug withdrawal and liver protective treatment. After the patient was treated with methylprednisolone again, the aminotransferase and bilirubin levels significantly increased. The treatment was changed from methylprednisolone to prednisolone, the levels of aminotransferase and bilirubin decreased significantly, the patient's condition improved and was discharged. Using the Naranjo Assessment Scale score of 9 points, the causal relationship between severe liver injury and methylprednisolone in this patient can be judged as "very likely". Clinical pharmacists conducted a comprehensive analysis of patients' medication usage and provided evidence-based recommendations for subsequent treatment regimens, thereby serving as a valuable reference for promoting rational drug use in clinical practice.

1.Björnsson HK, Björnsson ES. Drug-induced liver injury: pathogenesis, epidemiology, clinical features, and practical management[J]. Eur J Intern Med, 2022, 97: 26-31. DOI: 10.1016/j.ejim.2021.10.035.

2.Hoofnagle JH, Björnsson ES. Drug-induced liver injury-types and phenotypes[J]. N Engl J Med, 2019, 381(3): 264-273. DOI: 10.1056/NEJMra1816149.

3.Björnsson ES, Bergmann OM, Björnsson HK, et al. Incidence, presentation, and outcomes in patients with drug-induced liver injury in the general population of Iceland[J]. Gastroenterology, 2013, 144(7): 1419-1425, 1425.e1-e3. DOI: 10.1053/j.gastro.2013.02.006.

4.Chalasani N, Bonkovsky HL, Fontana R, et al. Features and outcomes of 899 patients with drug-induced liver injury: the DILIN prospective study[J]. Gastroenterology, 2015, 148(7): 1340-1352. e7.DOI: 10.1053/j.gastro.2015.03.006.

5.Rockey DC, Seeff LB, Rochon J, et al. Causality assessment in drug-induced liver injury using a structured expert opinion process: comparison to the Roussel-Uclaf causality assessment method[J]. Hepatology, 2010, 51(6): 2117-2126. DOI: 10.1002/hep.23577.

6.Björnsson ES, Hoofnagle JH. Categorization of drugs implicated in causing liver injury: critical assessment based on published case reports[J]. Hepatology, 2016, 63(2): 590-603. DOI: 10.1002/hep.28323.

7.Feist E, Mitrovic S, Fautrel B. Mechanisms, biomarkers and targets for adult-onset Still's disease[J] .Nat Rev Rheumatol, 2018, 14(10): 603-618. DOI: 10.1038/s41584-018-0081-x.

8.Efthimiou P, Apostolos K, Hur P, et al. Adult-onset Still's disease in focus: clinical manifestations, diagnosis, treatment, and unmet needs in the era of targeted therapies[J]. Semin Arthritis Rheum, 2021, 51(4): 858-874. DOI: 10.1016/j.semarthrit.2021.06.004.

9.史玉媛. 成人斯蒂尔病合并肝脏损害23例临床分析[J]. 中国药物与临床, 2011, 11(3): 320-321. DOI: 10.3969/j.issn.1671- 2560.2011.03.034.

10.Cottin J, Pierre S, Pizzoglio V, et al. Methylprednisolone-related liver injury: a descriptive study using the French pharmacovigilance database[J]. Clin Res Hepatol Gastroenterol, 2020, 44: 662-673. DOI: 10.1016/j.clinre.2019.12.008.

11.Zoubek ME, Pinazo-Bandera J, Ortega-Alonso A, et al. Liver injury after methylprednisolone pulses: a disputable cause of hepatotoxicity. A case series and literature review[J]. United European Gastroenterol J, 2019, 7(6): 825-837. DOI: 10.1177/2050640619840147.

12.Allgeier J, Weber S, Todorova R, et al. Acute liver injury following methylprednisolone pulse therapy: 13 cases from a prospectively collected cohort[J]. Eur J Gastroenterol Hepatol, 2022, 34(4): 457-461. DOI: 10.1097/MEG.0000000000002334.

13.Kimura H, Takeda A, Kikukawa T, et al. Liver injury after methylprednisolone pulse therapy in multiple sclerosis is usually due to idiosyncratic drug-induced toxicity rather than autoimmune hepatitis[J]. Mult Scler Relat Disord, 2020, 42: 102065. DOI: 10.1016/j.msard.2020.102065.

14.Bahn R. High-dose intravenous glucocorticoid therapy for Graves' ophthalmopathy: where are we now?[J]. Thyroid, 2012, 22(1): 1-2. DOI: 10.1089/thy.2012.2201.ed.

15.Wichary H, Gasińska T. Methylprednisolone and hepatotoxicity in Graves' ophthalmopathy[J]. Thyroid, 2012, 22(1): 64-69. DOI: 10.1089/thy.2010.0158.

16.Le Moli R, Baldeschi L, Saeed P, et al. Determinants of liver damage associated with intravenous methylprednisolone pulse therapy in Graves' ophthalmopathy[J]. Thyroid, 2007, 17(4): 357-362. DOI: 10.1089/thy.2006.0267.

17.高靓. 儿童静脉注射大剂量甲泼尼龙致肝损伤的临床特点及危险因素分析[D]. 济南: 山东大学, 2023. DOI: 10.27272/d.cnki.gshdu.2023.006777.

18.Pachkoria K, Lucena MI, Molokhia M, et al. Genetic and molecular factors in drug-induced liver injury: a review[J]. Curr Drug Saf, 2007, 2(2): 97-112. DOI: 10.2174/157488607780598287.

19.Dara L, Liu ZX, Kaplowitz N. Mechanisms of adaptation and progression in idiosyncratic drug induced liver injury, clinical implications[J]. Liver Int, 2016, 36(2): 158-165. DOI: 10.1111/liv.12988.

20.European Association for the Study of the Liver, Andrade RJ, Aithal GR. EASL Clinical Practice Guidelines: drug-induced liver injury[J]. J Hepatol, 2019, 70(6): 1222-1261. DOI: 10.1016/j.jhep.2019.02.014.

21.Yokoi T, Oda S. Models of idiosyncratic drug-induced liver injury[J]. Annu Rev Pharmacol Toxicol, 2021, 61: 247-268. DOI: 10.1146/annurev-pharmtox-030220-015007.

22.Andrade RJ, Aithal GP, de Boer YS, et al. Nomenclature, diagnosis and management of drug-induced autoimmune-like hepatitis (DI-ALH): an expert opinion meeting report[J]. J Hepatol, 2023, 79(3): 853-866. DOI: 10.1016/j.jhep.2023.04.033.