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In conjunction with BMJ Case Reports, DTB will feature occasional drug-related cases that are likely to be of interest to readers. These will include cases that involve recently marketed drugs for which there is limited knowledge of adverse effects and cases that highlight unusual reactions to drugs that have been marketed for several years.
Summary
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of cardiovascular and renal disease. Rarely, ACE inhibitors have been associated with cholestatic jaundice and hepatitis, with potential risk of fulminant hepatic failure if continued. There is limited information available regarding the risk of hepatic failure secondary to lisinopril use, with a handful of case reports demonstrating drug-induced liver injury at varying time scales from drug initiation. In this case, we present a man with symptoms of cholestatic jaundice, a blistering skin rash and flare of chronic plaque psoriasis, 27 months after lisinopril initiation for hypertension. Biochemical, serological and radiological investigations of an alternative cause for his jaundice were unremarkable. Cessation of lisinopril led to a rapid and sustained improvement in liver biochemistry and a significant improvement in his chronic plaque psoriasis.
Background
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used in the treatment of hypertension, heart failure and renal disease. Given ACE inhibitors’ cardiovascular-protective profile, they are frequently prescribed in primary care, with ramipril the sixth most commonly dispensed medication in England in 2021/2022.1 Although generally well tolerated, in very rare cases, ACE inhibitors have been associated with cholestatic jaundice and hepatitis with risk of progression to fulminant hepatic necrosis and hepatic failure.2 Limited previous case reports have varied in time from lisinopril initiation to drug-induced liver injury (DILI), from 12 days to 8 months.3 ACE inhibitors have also been associated with first presentation and exacerbation of psoriasis.4
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Footnotes
Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content—GLJ and GJW. The following authors gave final approval of the manuscript—GLJ and GJW.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.