title: A cohort study on the risk of acute liver injury among users of ketoconazole and other antifungal drugs.
abstract: OBJECTIVE
  The aim of this cohort study was to estimate the risk of clinical acute liver injury among users of oral antifungals identified in the general population of the General Practice Research Database in UK.
  
  
  METHODS
  The cohort included 69 830 patients, 20-79 years old, free of liver and systemic disease, who had received at least one prescription for either oral fluconazole, griseofulvin, itraconazole, ketoconazole, or terbinafine between 1991 and 1996.
  
  
  RESULTS
  Sixteen cases of acute liver injury were identified and validated. Ten cases occurred during nonuse of oral antifungals with a background rate of 0.6 per 100,000 person-months (95% confidence interval 0.3,1.1). Five cases occurred during current use of oral antifungals. Two were using ketoconazole, another two itraconazole, and one terbinafine. Incidence rates of acute liver injury were 134.1 per 100 000 person-months (36.8,488.0) for ketoconazole, 10.4 (2.9-38.1) for itraconazole, and 2.5 (0.4,13. 9) for terbinafine. The remaining case was associated with past use of fluconazole. Ketoconazole was the antifungal associated with the highest relative risk, 228.0 (95% confidence interval 33.9,933.0), when compared with the risk among nonusers, followed by itraconazole and terbinafine with relative risks of 17.7 (2.6,72.6) and 4.2 (0.2, 24.9), respectively.
  
  
  CONCLUSIONS
  Ketoconazole and itraconazole were the two oral antifungal associated with a marked increase of clinical acute liver injury. The risk associated with ketoconazole should be taken into account when prescribing it as initial treatment for uncomplicated fungal infections.
authors.affiliation: Centro Español de Investigación Farmacoepidemiológica (CEIFE), Madrid, Spain.
authors.forename: L A
authors.initials: LA
authors.lastname: García Rodríguez
authors.forename: A
authors.initials: A
authors.lastname: Duque
authors.forename: J
authors.initials: J
authors.lastname: Castellsague
authors.forename: S
authors.initials: S
authors.lastname: Pérez-Gutthann
authors.forename: B H
authors.initials: BH
authors.lastname: Stricker
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000009:adverse effects*; D056486:Chemical and Drug Induced Liver Injury / Q000453:epidemiology / Q000209:etiology*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007654:Ketoconazole / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D012306:Risk; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D000935:Antifungal Agents; D007654:Ketoconazole