Early detection of nebivolol-induced hepatotoxicity

Introduction: Nebivolol, a third-generation selective β1-adrenergic receptor antagonist possessing vasodilatory properties, is characterised by a favourable safety profile. However, isolated cases of drug-induced liver injury (DILI) associated with its use have been documented in the literature. Case description: We present a case of hepatotoxicity in a 58-year-old female patient with a history of arterial hypertension, obesity and impaired glucose tolerance. Eight weeks after initiating nebivolol therapy (2.5 mg daily), a significant elevation in liver enzymes was observed: alanine aminotransferase (134.5 U/l), aspartate aminotransferase (118.1 U/l) and alkaline phosphatase (182.1 U/l), compared to previously normal baseline values. After excluding other potential causes (viral hepatitis, alcohol consumption, biliary obstruction), nebivolol was discontinued. Subsequent clinical and laboratory improvement was noted: transaminase levels decreased significantly within two weeks, and biochemical parameters had almost completely normalised after two months. The Naranjo Adverse Drug Reaction Probability Scale score was 7, indicating a probable causal relationship. Subsequent replacement of nebivolol with metoprolol did not result in recurrent hepatic dysfunction. Conclusion: This case substantiates the potential for idiosyncratic mixed-type hepatotoxicity associated with nebivolol administration. Although rare, this report underscores the importance of clinical vigilance and the consideration of DILI in cases of unexplained liver enzyme elevations in patients receiving this agent. Monitoring of liver function during the initial months of therapy is advisable, particularly in patients with underlying comorbidities. LEARNING POINTS: Nebivolol, despite its favourable safety profile can, rarely, cause significant mixed-type (hepatocellular-cholestatic) liver injury.Early recognition of drug-induced liver injury and prompt discontinuation of the offending agent are crucial for complete recovery.Monitoring of liver enzymes during the initial weeks of nebivolol therapy should be considered, especially in patients with metabolic risk factors.