2338 Drug-Induced Liver Injury From Prolonged Kava Kava and Kratom Use

INTRODUCTION: Several herbal supplements carry the risk of drug-induced liver injury (DILI).Kava Kava is a herbal compound derived from the root of the Piper methysticum plant that is indigenous to the South and Western Pacific. Kratom is a herbal extract derived from the leaves of Mitragyna speciosa, a evergreen tree indigenous to Southeast Asia. Here we report a case of Kava and Kratom induced hepatocellular hepatitis in a male with complex regional pain syndrome (CRPS). CASE DESCRIPTION/METHODS: A 48-year-old male with history of CRPS and rheumatoid arthritis presented with a 7-day history of nausea, vomiting, dark urine, and jaundice. He denied alcohol, tobacco, or IV drug abuse. Denied use of medications. On exam, he was jaundiced. His labs on admission were- WBC 10.8, HGB 17.2, INR 1.4, creatinine 0.97, Total Bilirubin 21.8, Conjugated Bilirubin 16.7, ALP 293, ALT 1805, AST 1539. Viral hepatitis, HIV, HSV, EBV, and CMV were ruled out. Autoimmune serologies and ceruloplasmin were negative. Abdominal ultrasound showed a dilated common bile duct measuring 9.6mm. MRCP ruled out biliary ductal abnormality. Patient refused liver biopsy. Further questioning revealed prior use of opioids for pain, but in the last 9 months he had been substituting with a combination of Kava Kava and Kratom tea. DISCUSSION: Herbal supplementation use is increasing, and often, not discussed with medical providers. Kava Kava is comprised of kavalactones, which have similar effects to alcohol with regards to relaxation, sociability and euphoria. Kratom is used for its opioid-like ability to increase stamina and treat chronic pain. Its highly potent agonist activity on the mu, kappa and delta opioid-receptors have led to its popularity as a recreational drug. Formulations of Kava Kava and Kratom can be found for sale in herbal supplement stores and on the internet. Although a few case reports exist of these supplements leading to hepatocellular damage, the exact mechanism of injury is still not well understood and more research is necessary. Health care professionals should be aware of the hepatotoxic potential associated with Kratom and Kava Kava use and should be vigilant in identifying patients who would benefit from education regarding supplement use and discontinuation. Although these herbal supplements can cause hepatotoxicity, it’s important to exclude other possible causes of hepatic injury, including infection, vascular, autoimmune, and biliary etiologies.