Gemcitabine is a chemotherapeutic agent used in the treatment of a variety of cancers. It exerts its effects by inhibiting DNA synthesis and is considered to be a drug with a good safety profile.
Common side effects include mild gastrointestinal disturbance, influenza-like symptoms, and rashes. In post-marketing surveillance, abnormal liver function tests including raised concentrations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) have been rarely reported and are considered to be transient, asymptomatic and reversible.1
Serious hepatotoxicity including liver failure and death has been reported very rarely in patients receiving gemcitabine alone or in combination with other potentially hepatotoxic drugs. We describe a case of fulminant hepatic failure attributed to gemcitabine from which the patient made a full recovery.
A middle-aged man with relapsed refractory stage 4B Hodgkin’s lymphoma had been receiving palliative single agent gemcitabine therapy for 5 months at a dose of 1 g/m2. He was first diagnosed 4 years previously with stage 4B Hodgkin’s lymphoma with bone marrow involvement and received six cycles of ABVD (Adriamycin, bleomycin, vinblastine and dacarabazine). After achieving complete remission his course was complicated by further relapses which responded to both ESHAP (etoposide, cytarabine, cisplatin and methylprednislone) and BEAM (carmustine, etoposide, cytarabine and melphalan) with an autograft, each treatment achieving complete remission. Three years after diagnosis he relapsed and went on to have 10 cycles of radiotherapy for progressive cervical and mediastinal lymphadenopathy. He was also taking sodium valproate and lamotrigine long term for his epilepsy. His only other medication was occasional paracetamol for pain. He did not drink alcohol. Before starting the gemcitabine treatment, his ALT and bilirubin were normal (ALT 26 iu/l, bilirubin 7 μmol/l) and alkaline phosphatase was 379 iu/l.
He presented to hospital with a few days history of malaise and vomiting. On examination he was apyrexial, heart rate 90 beats/min, blood pressure 140/83 mm Hg, icteric with a liver flap, drowsy and had grade 3 hepatic encephalopathy.