ACG Case Reports Journal

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Tirzepatide has been also reported to be beneficial in reducing liver fat content. Although its efficacy is well described in the literature, no cases of tirzepatide-induced hepatotoxicity have been reported. 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id="ga_a2fc1a71-2cd1-4cc8-8e88-90f7db002574" class="ad-slot-container ad-slot-container-ga_a2fc1a71-2cd1-4cc8-8e88-90f7db002574" data-sizemap="[[[730, 500], [[728, 90]]], [[0, 0], [[300, 50]]]]" data-adpath="/15726702761/Desktop/acgcr/Article/Top" data-autoload="yes" data-outofpage="no" data-sticky="no" data-slottargeting='' data-displayslug="yes" data-sticky-duration="5" data-name="Top"></div> </div> </div> </div> </div> </div> <div class="main-wrapper"> <div id="main-container">  <header class="header"> <div class="header__holder"> <div class="header__layout-top wk-grid-page-container"> <script type="text/javascript" src="https://lww.com/_layouts/15/1033/Scripts/wk/UserToolbarDropdown.js?v=05.24.00.023" defer="true"> </script> <section class="user-action-toolbar"> <ul class="user-menu user-info" role="tablist"> <li id="ctl00_ctl51_Header_UserActionTools_liLogin" class="user-menu__item user-menu__item--popup-container user-menu__item--login-popup-container dib"> <button class="user-menu__link user-menu__link--login js-ejp-login-btn" type="button" data-config="{"eventName":"login","eventDetail":{"source":"Masthead Dropdown"},"isNull":false}"> <i class="fa fa-sign-in"></i> <span>Log in</span> </button> </li> <li id="ctl00_ctl51_Header_UserActionTools_liOr" class="dib or-spacing"><span>or</span></li> <li id="ctl00_ctl51_Header_UserActionTools_liRegister2" class="user-menu__item dib"> <a id="ctl00_ctl51_Header_UserActionTools_RegisterUserPopupLnk" class="user-menu__link js-register-link" data-config="{"eventName":"Register","eventDetail":{"source":"Masthead Dropdown"},"isNull":false}" href="https://journals.lww.com/acgcr/pages/register.aspx?ContextUrl=%2facgcr%2ffulltext%2f2024%2f10000%2fa_rare_case_of_tirzepatide_induced_hepatotoxicity.14.aspx">Register</a> </li> <li id="ctl00_ctl51_Header_UserActionTools_liIssueAlerts" class="user-menu__item dib"> <i class="fa fa-envelope"></i> <a rel="nofollow" title href="javascript:javascript: alerts_ShowSubscribeeTOCPopup('ACG Case Reports Journal','acgcr','eTOC', 'eTOC');;" onclick="javascript: alerts_ShowSubscribeeTOCPopup('ACG Case Reports Journal','acgcr','eTOC', 'eTOC');" class="user-menu__link"><span id="ctl00_ctl51_Header_UserActionTools_SubscribeToAlertsActionToolLink_defaultText" class="hideOnFixed">Get new issue alerts</span><span id="ctl00_ctl51_Header_UserActionTools_SubscribeToAlertsActionToolLink_stickyText" class="showOnFixed">Get alerts</span></a> </li> </ul> </section> <span id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_dummyTargetControl"></span> <div id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pnlunSubscribeToAlerts" style="display: none;"> <div tabindex="-1" role="dialog" class="wk-modal horizontally-centered small wk-modal-with-overlay wk-modal-small ejp-modal"> <div id="ej-box-modal-style-1"> <div id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pnlMain"> <div id="tocUnsubscribeModal" > <section class="wk-modal-content"> <header class="wk-modal-header ejp-modal-header"> <div class="wk-modal-title ejp-modal-title"></div> <button aria-label="close dialog" class="js-close primary-button wk-button-icon wk-modal-close ejp-modal-close "><i class="fa fa-times"></i></button> </header> <div class="wk-modal-body"> <div class="wk-field-item"> <p> <span id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage"></span> </p> <div class="wk-button-bar"> <div class="wk-button-group-left"> <p id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons" Style="display: none;"> <input type="submit" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$btnContinue" value="Yes" onclick="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$btnContinue", "", true, "", "", false, false))" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_btnContinue" class="primary-button" /> <input type="button" value="No" id="btnCancel" aria-label="close dialog" class="js-close secondary-button" /> </p> </div> </div> </div> </div> </section> </div> </div> </div> </div> </div> <div id="ej-clear-float"> </div> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenUnSubscribeAlertType" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenUnsubscribeJournalId" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeJournalId" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenUnsubscribeMessage" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenTopicalCollectionId" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenTopicalCollectionId" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenOvidId" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenOvidId" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenJournalId" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId" /> <script type="text/javascript"> function alerts_ShowUnSubscribeeTOCPopup(title, alertType, journalId) { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); var lblUnsubscribeMessage = document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage'); lblUnsubscribeMessage.innerHTML = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType').value = alertType; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage').value = title; $('#' + 'ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons').show(); if (document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value == null || document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value == '') { document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value = journalId; } if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } function alerts_ShowUnSubscribeeTOCPopup_Root(title, journalId, alertType) { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); var lblUnsubscribeMessage = document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage'); lblUnsubscribeMessage.innerHTML = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage').value = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType').value = alertType; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeJournalId').value = journalId; $('#' + 'ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons').show(); if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } function alerts_ShowUnSubscribeeTOCPopup_Citation(title, journalId, ovidId) { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); var lblUnsubscribeMessage = document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage'); lblUnsubscribeMessage.innerHTML = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage').value = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType').value = 'Citation'; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeJournalId').value = journalId; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenOvidId').value = ovidId; $('#' + 'ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons').show(); if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } function alerts_ShowUnSubscribeeTOCPopup_Topical(title, journalId, topicalCollectionId) { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); var lblUnsubscribeMessage = document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage'); lblUnsubscribeMessage.innerHTML = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage').value = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType').value = 'Topical'; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeJournalId').value = journalId; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenTopicalCollectionId').value = topicalCollectionId; $('#' + 'ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons').show(); if (document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value == null || document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value == '') { document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value = journalId; } if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } function alerts_ShowUnSubscribeeTOCSuccessPopup() { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } $('.js-close').on('click', function() { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.hide(); } return false; }); </script> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_dummyTargetControl"></span> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$hiddenSubscribeToEtocPopupState" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscribeToEtocPopupState" value="showemail" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$hiddenConfirmSubscriptionPageUrl" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenConfirmSubscriptionPageUrl" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$hiddenJournalId" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenJournalId" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$hiddenSubscriptionType" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscriptionType" /> <div id="divPopupOverLay" class="Popup-Overlay" style="display: none; position: fixed; left: 0; top: 0; z-index: 3800; width: 1920px; height: 4517px;"></div> <div id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlSubscribeToEtoc" class="etoc-popup ej-box-modal-drop-shadow" style="display: none;"> <div tabindex="-1" role="dialog" class="wk-modal horizontally-centered small wk-modal-with-overlay wk-modal-small ejp-modal"> <div id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlMain" onkeypress="javascript:return WebForm_FireDefaultButton(event, 'ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_btnContinue')"> <section class="wk-modal-content"> <header class="wk-modal-header ejp-modal-header"> <div class="wk-modal-title ejp-modal-title"> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblTitle"></span> </div> <button aria-label="close dialog" class="js-close primary-button wk-button-icon wk-modal-close ejp-modal-close "> <i class="fa fa-times"></i> </button> </header> <div class="wk-modal-body"> <div class="wk-field-item"> <div class="wk-field-body"> <strong> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblThankYouMessage"></span></strong> </div> <div class="wk-field-body"> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_cvEmailError" style="color:Black;display:none;"> <div class="ej-error-message"> <p class="ej-error-message-icon error-red"> </p> </div> </span> <label for="Email input">Enter your Email address:</label> <div class="wk-field-body"> <input name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$txtEmailAddress" type="text" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_txtEmailAddress" class="ej-box-modal-style-1-input" /> </div> </div> <div class="wk-button-bar"> <div class="wk-button-group-left"> <input type="submit" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$btnContinue" value="Continue" onclick="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$btnContinue", "", true, "", "", false, false))" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_btnContinue" class="primary-button" /> <input type="button" value="Cancel" id="btnCancel" class="js-close secondary-button" /> </div> </div> </div> <div class="wk-field-item"> <div class="wk-field-body"> <a id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hypPrivacy" href="https://journals.lww.com/acgcr/_layouts/oaks.journals/privacy.aspx" target="_blank">Privacy Policy</a> </div> </div> </div> </section> </div> <div id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlAuthenticatedUser" style="display: none;"> <section class="wk-modal-content"> <header class="wk-modal-header ejp-modal-header"> <div class="wk-modal-title ejp-modal-title"></div> <button aria-label="close dialog" class="js-close primary-button wk-button-icon wk-modal-close ejp-modal-close "><i class="fa fa-times"></i></button> </header> <div class="wk-modal-body"> <div class="wk-field-item"> <p> <strong> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblAuthenticatedUserTitle"></span> </strong> </p> </div> <p id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pAuthenticatedUserMessage"> </p> </div> </section> </div> </div> </div> <div id="ej-clear-float"> </div> <script type="text/javascript"> function alerts_SaveSubscriptionTypeInHiddenField(url, subscriptionType, journalId, yearId, issueId, articleId) { if (journalId && yearId && issueId && articleId) { logCounterDataAlertWhenCitedSynchronously(journalId, yearId, issueId, articleId); } $('#' + 'ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscriptionType').val(subscriptionType); $('#' + 'ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenJournalId').val(journalId); if (url) window.location = url; else __doPostBack('hypSubscribeToAlerts'); return false; } function alerts_ShowSubscribeeTOCPopup(journalTitle, journalId, subscriptionType, displaySubscriptionType) { $('#' + 'ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscriptionType').val(subscriptionType); var subscribeToEtocPopup = $find('subscribeToEtoc'); subscribeToEtocPopup.show(); document.getElementsByTagName( 'html' )[0].classList.add('no-scroll'); var modelPopupState = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscribeToEtocPopupState'); var emailTextBox = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_txtEmailAddress'); var thanksPanel = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlAuthenticatedUser'); var mainPanel = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlMain'); var thankYouMessageUnAuthenticated = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblThankYouMessage'); var thankYouMessageAuthenticated = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblAuthenticatedUserTitle'); if (!displaySubscriptionType) { displaySubscriptionType = subscriptionType; } if (modelPopupState.value == 'showthanksmessage') { thanksPanel.style.display = "block"; mainPanel.style.display = "none"; thankYouMessageAuthenticated.innerHTML = "Thank you for subscribing to the " + displaySubscriptionType + " for " + journalTitle + "."; } if (modelPopupState.value == 'showemail') { thanksPanel.style.display = "none"; mainPanel.style.display = "block"; thankYouMessageUnAuthenticated.innerHTML = "Thank you for choosing to subscribe to the " + displaySubscriptionType + " for " + journalTitle + "."; } if ($('.etoc-popup') != null) { document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenJournalId').value = journalId; if (modelPopupState.value == 'showemail') emailTextBox.focus(); } } $('.js-close').on('click', function () { document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_txtEmailAddress').value = ""; document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_cvEmailError').style.display = "none"; var pageUrl = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenConfirmSubscriptionPageUrl'); var subscribeeTocPopup = $find('subscribeToEtoc'); if (subscribeeTocPopup != null) { subscribeeTocPopup.hide(); document.getElementsByTagName( 'html' )[0].classList.remove('no-scroll'); if (pageUrl.value !== '' && pageUrl.value !== window.location.pathname) window.location = pageUrl.value; } return false; }); </script> <div id="ctl00_ctl51_Header_UserActionTools_eTocTopContainer"> <div id="eTocTop" style="display: none;"> <a rel="nofollow" title href="javascript:javascript: alerts_ShowSubscribeeTOCPopup('ACG Case Reports Journal','acgcr','eTOC', 'eTOC');;" onclick="javascript: alerts_ShowSubscribeeTOCPopup('ACG Case Reports Journal','acgcr','eTOC', 'eTOC');"><span id="ctl00_ctl51_Header_UserActionTools_alertLinkControlTop_defaultText" class="hideOnFixed">Subscribe to eTOC</span></a> </div> </div> <script> $(function () { //find recent searches link and move container var recentSearchesControl = $("a[id$='RecentSearches']"); if (recentSearchesControl.length) { recentSearchesControl.click(function (e) { e.stopPropagation(); if ($("#ResentSearchContainer").is(":hidden")) { $("#ResentSearchContainer").slideDown("slow"); recentSearchesControl.addClass('open'); } else { $("#ResentSearchContainer").hide(); recentSearchesControl.removeClass('open'); } }); } var eTocAccountLink = $("ul.js-user-action-toolbar__dropdown>li>a[id='SubscribeToEToc']"); if (eTocAccountLink.length) { eTocAccountLink.parent().html($("#eTocTop>a")); } }); </script> <a class="logo-secondary black" href="http://wolterskluwer.com/" target="_blank"> <h3 class="logo-secondary-text">Secondary Logo</h3> </a> <a href="#" class="sticky-search"><i class="fa fa-search"></i></a> </div> <div class="header__layout-bottom wk-grid-page-container"> <a id="hypJournals" class="logo-main" href="https://journals.lww.com/acgcr/pages/default.aspx"> <h3 class="logo-main-text">Journal Logo </h3> </a> <div class="search-v2"> <div class="search-wrapper"> <select name="ctl00$ctl51$Header$SearchTopBoxControl$ddlContentScope" id="ctl00_ctl51_Header_SearchTopBoxControl_ddlContentScope"> <option value="All">All</option> <option selected="selected" value="Articles">Articles</option> <option value="Images">Images</option> <option value="Videos">Videos</option> <option value="Podcasts">Podcasts</option> <option value="Blogs">Blogs</option> </select> <div class="input-group" id="globalSearch"> <input name="ctl00$ctl51$Header$SearchTopBoxControl$txtKeywords" type="text" value="Search" id="ctl00_ctl51_Header_SearchTopBoxControl_txtKeywords" class="form-control searchText" /> <span class="input-group-btn"> <button id="ctl00_ctl51_Header_SearchTopBoxControl_btnGlobalSearchMagnifier" type="submit" class="btn btn-default"><i class="fa fa-search"></i></button> </span> <input type="hidden" name="ctl00$ctl51$Header$SearchTopBoxControl$IsAutoCompleteEnabled" id="ctl00_ctl51_Header_SearchTopBoxControl_IsAutoCompleteEnabled" value="false" /> <input type="hidden" name="ctl00$ctl51$Header$SearchTopBoxControl$AutocompleteApiUrl" id="ctl00_ctl51_Header_SearchTopBoxControl_AutocompleteApiUrl" value="https://platformservices.wolterskluwerhealth.com/autocomplete/ACGCRJ/shingle/" /> </div> </div> <div class="advance-search" style=""> <a id="ctl00_ctl51_Header_SearchTopBoxControl_lnkAdvanceSearch" href="https://journals.lww.com/acgcr/pages/advancedsearch.aspx">Advanced 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of Tirzepatide-Induced Hepatotoxicity', '10042024', 'Aalam Sohal, Luis Casanova, and Kris V. Kowdley', '11', '10', '\u00A9 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.', '02075970-202410000-00014', '', true, 'CCBY-NC-ND'); } </script> <div id="ArticleContainer"> <article id="ej-article-view" class="js-article-view ej-article-view" xmlns:ssr="http://ssr-eus-go-csi.cloudapp.net/v1/assets" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xhtml="http://www.w3.org/1999/xhtml"><section class="ejp-r-article-subsection"><div class="ejp-r-article-subsection__text">CASE REPORT: LIVER</div></section><header class="ejp-article-header"><h1 class="ejp-article-title">A Rare Case of Tirzepatide-Induced Hepatotoxicity</h1></header><section id="ejp-article-authors"><p id="P7">Sohal, Aalam MD<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1</sup>; Casanova, Luis BSc<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1</sup>; Kowdley, Kris V. MD, FACG<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1,2</sup></p><section><a href="#" id="ejp-article-authors-link"> Author Information <i class="wk-icon-arrow-down-r"></i></a></section></section><section id="ejp-article-authors-info" class="ejp-article-authors-info ejp-article-authors-info--hidden"><div class="ejp-article-authors-info-holder"> <p id=""><sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1</sup>Department of Hepatology, Liver Institute Northwest, Seattle, WA</p> <p id=""><sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">2</sup>Department of Gastroenterology and Hepatology, Elson Floyd College of Medicine, Spokane, WA</p> <p id="cor1"><strong xmlns:mrws="http://webservices.ovid.com/mrws/1.0">Correspondence:</strong> Kris V. Kowdley, MD, FACG (<span><a href="/cdn-cgi/l/email-protection#a5c8c4ccc9d1ca9fcececad2c1c9c0dce5c9ccd3c0d7cccbd6d1ccd0d1c0cbd28bcad7c2" onclick="javascript:window.open('mailto:mailto:kkowdley@liverinstiutenw.org');return false"><span class="__cf_email__" data-cfemail="5e353531293a323b271e3237283b2c37302d2a372b2a3b302970312c39">[email protected]</span></a></span>).</p> <p id="">This is an open access article distributed under the terms of the <span><a href="http://creativecommons.org/licenses/by-nc-nd/4.0/" onclick="javascript:window.open('http://creativecommons.org/licenses/by-nc-nd/4.0/');return false">Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND)</a></span>, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.</p> </div></section><section id="article-journal-info"><div class="ej-journal-info"><span class="ej-journal-name">ACG Case Reports Journal </span><span id="ej-journal-date-volume-issue-pg"><a href="/acgcr/pages/currenttoc.aspx">11(10):p e01484, October 2024.</a></span><span> | </span><span class="ej-journal-doi">DOI: </span>10.14309/crj.0000000000001484<a id="ej-article-indicators-ccl" onmouseover="javascript:Tooltip_CCL('This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.')" onmouseout="javascript:Tooltip_MouseOut()" href="http://creativecommons.org/licenses/by-nc-nd/4.0/" target="_blank"><span class="ejp-article-indicators__ccl"></span></a></div></section><section id="ejp-article-indicators" class="ejp-article-indicators"><ul class="ejp-article-indicators__list"> <li id="ej-article-indicators-open" class="ejp-article-indicators__list-item" onmouseover="javascript:Tooltip_Open()" onmouseout="javascript:Tooltip_MouseOut()"><span class="ejp-indicator">Open</span></li> </ul><button id="openArticleMetricsPopupButton" type="button" class="wk-button wk-button-ghost wk-button-icon-left ejp-article-metrics-btn" data-articleMetricsEndpoint="//services.journals.lww.com/IntegrationServices/ArticleMetricsService.svc" data-articleMetricsDetailsUrl="https://wolterskluwer.altmetric.com/details/" data-doi="10.14309/crj.0000000000001484" data-suiteId="vrs_woltere_journalsglobalvrs" data-articlePublicationDate="2024-10-04" data-articlePublicationDateString="October 4, 2024" data-receivedDate="2024-04-14" data-revisionReceivedDate="" data-acceptedDate="2024-07-26" data-crossrefRefLinkRoot="https://doi.org/" data-medlineRefLinkRoot="http://www.ncbi.nlm.nih.gov/pubmed/" data-pubMedId=""><i class="wk-icon-filled-chart-r"></i><i class="wk-icon-filled-chart-white-r"></i> Metrics </button></section><section class="ejp-article-tabs" id="abstractWrap"><h2 class="ejp-article-tabs-heading">Abstract</h2> <div class="ejp-article-tabs__tabpanel" id="panel1" role="tabpanel" aria-labelledby="tab1"> <div id="article-abstract-content1"> <div class="ejp-article-text-abstract"> <p>Tirzepatide is the first dual incretin glucose-dependent insulinotropic polypeptide/glucagon-like peptide 1 receptor activator approved for the management of type II diabetes mellitus. This drug was also recently approved by the Food and Drug Administration as a management option for patients with obesity. Tirzepatide has been also reported to be beneficial in reducing liver fat content. Although its efficacy is well described in the literature, no cases of tirzepatide-induced hepatotoxicity have been reported. We report a case of a 37-year-old woman with metabolic syndrome who was noted to have elevated liver enzymes secondary to tirzepatide use.</p> </div> </div> </div></section><div class="ejp-fulltext-content js-ejp-fulltext-content"><section id="ArticleBody"><h2 class="ejp-article-outline-heading" data-level="1" id="s1">INTRODUCTION</h2> <p id="JCL-P-1">There has been a rapid increase in the incidence and prevalence of diabetes mellitus (DM) and obesity in the last few decades. Recent studies have reported that the prevalence of DM doubled from 3.2% in 1990 to 6.5% in 2021, and that of obesity has increased from 4.6% in 1990 to 14% in 2019.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R1 R2">1,2</a></sup></sup> The treatment landscape for type II DM and obesity has significantly changed over the last 2 decades, with the introduction of incretin mimetics.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R3">3</a></sup></sup> Recently, tirzepatide, a combined glucose-dependent insulinotropic polypeptide/glucagon-like peptide 1 (GLP-1) agonist, was approved as a treatment option for diabetes in May 2022.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R4">4</a></sup></sup> This drug has been shown to improve glycemic control by stimulating insulin release from the pancreas and has been reported to be superior to GLP-1 agonists in improving hemoglobin A1C levels.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R5">5</a></sup></sup> It has also been reported that tirzepatide injection once a week results in significant weight loss in obese patients.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R6">6</a></sup></sup> Tirzepatide has also been shown to have beneficial effects on the liver, and its use has been associated with significant reduction in liver fat content.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R7">7</a></sup></sup> However, as of this report, there have been no reports of liver-related adverse events. We present a rare case of tirzepatide-induced liver injury in a 37-year-old woman.</p> <h2 class="ejp-article-outline-heading" data-level="1" id="s2">CASE REPORT</h2> <p id="JCL-P-2">A 37-year-old woman with a medical history of obesity, hypertension, and hypercholesterolemia was referred to our clinic for elevated liver enzymes. The patient denied any symptoms such as nausea, vomiting, abdominal distension, jaundice, or episodes of confusion. Physical examination was normal. She denied any supplement use, excessive alcohol use, or family history of autoimmune disease. Her medications included ethinyl estradiol 0.15 mg/levonorgestrel 30 mg for birth control and tirzepatide. She was initiated on tirzepatide 2.5 months before presentation and was on birth control medication for more than 10 years. She also reported losing 30 pounds since starting tirzepatide. Her blood tests on presentation revealed an alanine transaminase (ALT) level of 500 U/L and aspartate transaminase (AST) level of 261 U/L.</p> <p id="JCL-P-3">Further laboratory workup including hepatitis serologies, antinuclear antibody level, antimitochondrial antibody level, and ceruloplasmin and alpha-1 antitrypsin levels were unremarkable. Anti-smooth muscle antibody level was 37 (normal < 20). Abdominal ultrasound revealed normal hepatic echotexture, without any evidence of portal hypertension. Tirzepatide was considered a possible cause of the liver injury, and she was recommended to discontinue the medication. Three weeks later, her ALT and AST levels had decreased to 110 U/L and 57 U/L, respectively.</p> <p id="JCL-P-4">The patient decided to resume tirzepatide after noticing an improvement in the liver enzyme levels. Three weeks later, an increase in both ALT and AST levels to 184 U/L and 104 U/L, respectively (<a href="javascript:void(0)" onclick="javascript:showSlideShowByImageID('F1', '02075970-202410000-00014');">Figure 1</a>), was noted. At that point, a liver biopsy was performed, which revealed benign hepatic tissue with lymphocytic infiltration within the lobules and macrophage infiltration in portal tracts and sinusoidal spaces. There was no evidence of steatosis, bile duct injury, bile duct proliferation, interface hepatitis, steatosis, or necrosis on the liver biopsy (<a href="javascript:void(0)" onclick="javascript:showSlideShowByImageID('F2', '02075970-202410000-00014');">Figure 2</a>). Her Roussel Uclaf Causality Assessment Method (RUCAM) score was 5 (<a href="#T1">Table 1</a>). Based on her overall presentation, a diagnosis of drug-induced liver injury (DILI) from tirzepatide was made. She was recommended not to reinitiate tirzepatide. Her blood work 2 months later revealed an ALT level of 36 U/L and AST level of 24 U/L. The patient was switched to semaglutide at that time and continued to have normal liver enzyme levels on follow-up (3 months after initiating semaglutide).</p><section class="ejp-r-article-images"><figure class="ejp-r-article-images__figure"><a href="javascript:void(0)" class="ejp-r-article-images__image-link" onclick="showSlideShowByImageID('F1', '02075970-202410000-00014')"><img class="ejp-r-article-images__img js-lazy-load lazy-load" src="javascript:void(0);" data-src="https://images.journals.lww.com/acgcr/ArticleViewerPreview.02075970-202410000-00014.F1.jpeg" data-srcset="https://images.journals.lww.com/acgcr/ArticleViewerPreview@2.02075970-202410000-00014.F1.jpeg 2x" srcset="" alt="F1"></a><figcaption class="ejp-r-article-images__figcaption"><a href="javascript:void(0)" class="ejp-r-article-images__figcaption-link" onclick="showSlideShowByImageID('F1', '02075970-202410000-00014')">Figure 1.: </a><div class="ejp-r-article-images__figcaption-text">Temporal relation of tirzepatide use and ALT and AST patterns. ALT, alanine transaminase; AST, aspartate transaminase.</div></figcaption></figure><figure class="ejp-r-article-images__figure"><a href="javascript:void(0)" class="ejp-r-article-images__image-link" onclick="showSlideShowByImageID('F2', '02075970-202410000-00014')"><img class="ejp-r-article-images__img js-lazy-load lazy-load" src="javascript:void(0);" data-src="https://images.journals.lww.com/acgcr/ArticleViewerPreview.02075970-202410000-00014.F2.jpeg" data-srcset="https://images.journals.lww.com/acgcr/ArticleViewerPreview@2.02075970-202410000-00014.F2.jpeg 2x" srcset="" alt="F2"></a><figcaption class="ejp-r-article-images__figcaption"><a href="javascript:void(0)" class="ejp-r-article-images__figcaption-link" onclick="showSlideShowByImageID('F2', '02075970-202410000-00014')">Figure 2.: </a><div class="ejp-r-article-images__figcaption-text">(A) Liver biopsy showing no evidence of fibrosis (10×). (B) Presence of macrophages on liver biopsy (40×). (C) No evidence of steatosis or inflammation on liver biopsy (10×).</div></figcaption></figure></section><div class="wk-clearfix-article-table"></div> <div class="article-table"><a id="T1"></a><div class="article-table-title"><span>Table 1. - </span> RUCAM score<em class="fa fa-arrows-alt expand-button js-expand-table-event" aria-label="expand table"></em><div class="clearfix"></div> </div> <div class="scroll-message"></div> <div class="dummy-scroll"> <div></div> </div> <div class="article-table-body"> <div class="article-table-container"> <table> <thead xmlns="http://www.w3.org/1999/xhtml"> <tr> <td rowspan="1" colspan="1">Factors</td> <td rowspan="1" colspan="1">Case</td> <td rowspan="1" colspan="1">Score</td> </tr> </thead> <tbody xmlns="http://www.w3.org/1999/xhtml"> <tr> <td rowspan="1" colspan="1">Time of onset from the beginning of drug use</td> <td rowspan="1" colspan="1"><90 d</td> <td rowspan="1" colspan="1">2</td> </tr> <tr> <td rowspan="1" colspan="1">Change in ALT levels between peak and stopping of the drug use</td> <td rowspan="1" colspan="1">>50% improvement in 30 d after withdrawal</td> <td rowspan="1" colspan="1">2</td> </tr> <tr> <td rowspan="1" colspan="1">Risk factors</td> <td rowspan="1" colspan="1" /> <td rowspan="1" colspan="1" /> </tr> <tr> <td rowspan="1" colspan="1"> 1. Age > 55</td> <td rowspan="1" colspan="1">Yes</td> <td rowspan="1" colspan="1">0</td> </tr> <tr> <td rowspan="1" colspan="1"> 2. Alcohol/pregnancy</td> <td rowspan="1" colspan="1">No</td> <td rowspan="1" colspan="1">0</td> </tr> <tr> <td rowspan="1" colspan="1">Concomitant drug use</td> <td rowspan="1" colspan="1">Unknown hepatotoxicity</td> <td rowspan="1" colspan="1">0</td> </tr> <tr> <td rowspan="1" colspan="1">Exclusion of other causes</td> <td rowspan="1" colspan="1">Ruled out all 6 causes of group 1</td> <td rowspan="1" colspan="1">1</td> </tr> <tr> <td rowspan="1" colspan="1">Previous information on hepatotoxicity</td> <td rowspan="1" colspan="1">Unknown</td> <td rowspan="1" colspan="1">0</td> </tr> <tr> <td rowspan="1" colspan="1">Response to readministration</td> <td rowspan="1" colspan="1">No doubling of ALT levels with the drug readministration</td> <td rowspan="1" colspan="1">0</td> </tr> <tr> <td rowspan="1" colspan="1">Total score</td> <td rowspan="1" colspan="1">Possible</td> <td rowspan="1" colspan="1">5</td> </tr> </tbody> </table> <div class="article-table-descriptions"> <div class="article-table-descriptions-content"><span id=""><div class="dib">ALT, alanine transaminase; RUCAM, Roussel Uclaf Causality Assessment Method.</div></span></div> </div> </div> </div> </div><br><h2 class="ejp-article-outline-heading" data-level="1" id="s3">DISCUSSION</h2> <p id="JCL-P-5">To the best of our knowledge, this is the first reported case of tirzepatide-induced liver injury. In our patient, the diagnosis of tirzepatide-induced liver injury was based on the history of recent initiation of tirzepatide before presentation, improvement in liver enzyme levels after discontinuation, and an increase in liver enzyme levels after reinitiation.</p> <p id="JCL-P-6">The RUCAM scale used to identify if the liver injury is secondary to drug use was noted to be 5, which classified it as possible DILI.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R8">8</a></sup></sup> We propose that the prompt recognition of the repeat elevation in liver enzyme levels and subsequent discontinuation of tirzepatide limited any further elevation in enzyme levels. As such, their levels were not allowed to rise to the threshold of doubling, which in and of itself would have resulted in a RUCAM score of 7 and pushed the likelihood of DILI into the probable range. Our patient also had mildly elevated anti-smooth muscle antibody levels. Studies have reported that it is difficult to distinguish DILI from AIH because of significant overlap in the clinical features and presence of antibodies in both the conditions. A limitation of this report is that we did not measure tirzepatide-induced or immunoglobulin G (IgG) antibodies; however, considering the lack of interface hepatitis on biopsy, the diagnosis was considered less likely.</p> <p id="JCL-P-7">The underlying mechanism responsible for hepatotoxicity from this drug continues to be unclear. As of this report, 3 cases of liver injury from GLP-1 agonists have been reported.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R9 R10 R11">9–11</a></sup></sup> Kern et al<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R9">9</a></sup></sup> reported a case of liraglutide-induced autoimmune hepatitis. They hypothesized that liraglutide induced immune-mediated liver injury due to the formation of anti-liraglutide antibodies. Patel et al<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R10">10</a></sup></sup> and Neahusan et al<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R11">11</a></sup></sup> each reported a case of dulaglutide-induced liver injury. However, they did not comment on the mechanism of hepatotoxicity. Our patient had no steatosis on liver biopsy, despite having multiple risk factors of steatotic liver disease. We hypothesize that in our patient, tirzepatide use resulted in rapid mobilization of fat from the liver and was responsible for the elevation in liver enzyme levels. This phenomenon has also been noted in an investigational drug miricorilant, a selective glucocorticoid receptor modulator that is currently under development for metabolic dysfunction-associated steatotic liver disease.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R12">12</a></sup></sup> In their phase 2a study, 4 of 5 patients on the drug were noted to have elevation in liver enzyme levels greater than 250 IU/mL, which was associated with a rapid and marked reduction in liver fat content.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R12">12</a></sup></sup> It was speculated that the perturbation in liver enzyme levels was related to rapid defatting of the liver.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R12">12</a></sup></sup></p> <p id="JCL-P-8">In conclusion, we report the first case of tirzepatide-induced liver injury. It is possible that as the use of this drug increases, we will note more postmarketing adverse events in the next decade. Physicians should be aware of this rare side effect, and regular monitoring of liver function tests will be beneficial in identifying patients with hepatotoxicity earlier during the course.</p> <h2 class="ejp-article-outline-heading" data-level="1" id="s4">DISCLOSURES</h2> <p id="JCL-P-9">Author contributions: A. Sohal and L. Casanova: writing the draft; KV Kowdley: patient evaluation, critical revisions, and is the article guarantor.</p> <p id="JCL-P-10">Financial disclosure: A. Sohal and L. Casanova have no conflicts of interest or financial disclosures. KV Kowdley declares research support from CymaBay Therapeutics; grants and/or contracts from 89Bio, Genfit, Gilead, GlaxoSmithKline, Hanmi, HighTide, Intercept, Madrigal, Mirum, NGM, Pfizer, Pliant, and Viking; royalties/licenses from UpToDate; consulting fees from 89Bio, Calliditas Therapeutics, CymaBay Therapeutics, Genfit, Gilead, Inipharm, Intercept, Madrigal, Mirum, NGM, and Pliant; payment/honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from AbbVie, Gilead, and Intercept; participation in a data safety monitoring board or advisory board for CTI, Medpace and Labcorp; stock or stock options for Inipharm; and receipt of equipment, materials, drugs, medical writing, gifts, or other services from Sonic Insight.</p> <p id="JCL-P-11">Informed consent was obtained for this case report.</p></section><section id="article-references" class="article-references js-article-references"><h2 class="ejp-article-outline-heading" data-level="1" id="JCL-L-0">REFERENCES</h2> <div id="R1" class="article-references__item js-article-reference">1. 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A selective GR modulator, induced a rapid and significant reduction in liver fat content in a randomized, placebo-controlled phase 2a study in patients with non-alcoholic steatohepatitis. Hepatology (Baltimore, Md). 2021;74(6):1412A.<div> <ul class="article-references__item-links"> <li class="internal-links"><a href="#JCL-P-7"> Cited Here</a> | </li> <li><a href="https://scholar.google.com/scholar_lookup?title=A+selective+GR+modulator%2c+induced+a+rapid+and+significant+reduction+in+liver+fat+content+in+a+randomized%2c+placebo-controlled+phase+2a+study+in+patients+with+non-alcoholic+steatohepatitis&publication_year=2021&author=KV+Kowdley&author=P+Butler&author=S+Cubberley" onclick="javascript:window.open('https://scholar.google.com/scholar_lookup?title=A+selective+GR+modulator%2c+induced+a+rapid+and+significant+reduction+in+liver+fat+content+in+a+randomized%2c+placebo-controlled+phase+2a+study+in+patients+with+non-alcoholic+steatohepatitis&publication_year=2021&author=KV+Kowdley&author=P+Butler&author=S+Cubberley');return false">Google Scholar</a></li> </ul> </div> </div> <div class="article-references__button-container"></div></section><div><strong>Keywords:</strong><p id="">tirzepatide; hepatotoxicity; liver injury</p> </div><section class="ej-article-copyright">© 2024 The Author(s). 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