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Are certain populations (e.g., elderly, hepatic disease, polypharmacy) at higher risk for ivermectin liver injury?
Executive Summary
A small but consistent body of reports and pharmacovigilance data indicates certain groups—older adults, people with pre-existing liver disease, and patients on multiple potentially hepatotoxic drugs—are more likely to experience liver enzyme elevations or rare clinically apparent liver injury after ivermectin exposure. Signals come from case reports, national pharmacovigilance analyses and reviews during the COVID-19 era, but the overall absolute risk remains low and evidence is limited by small numbers, variable doses and confounding by illness and co-medication [1] [2] [3] [4].
1. A troubling cluster of case reports that forces attention
Case reports and small series first raised the possibility that elderly patients can develop prolonged or clinically apparent liver dysfunction after ivermectin. A 2011 report described an 85-year-old with liver dysfunction after ivermectin for scabies and noted one event among 30 treated elderly patients, framing the elderly as a potential higher‑risk group [5] [1]. During the COVID-19 period, case series documented small numbers of hepatic disorders after self‑medication with higher-than‑label ivermectin doses, again with older age and higher doses appearing in several reports [6] [4]. These reports do not establish causality but establish repeated real‑world signals that merit caution and monitoring, especially when doses exceed recommendations or when patients have comorbidities [1] [4].
2. Pharmacovigilance databases show a signal but limited resolution
Analyses of VigiBase and other spontaneous‑report systems identified a handful of serious hepatic events reported with ivermectin, including reports linked to COVID‑19 use, with mean ages in the 50s and co‑reports of preexisting liver disease or concomitant hepatotoxic drugs (2020–2024) [2] [7]. Pharmacovigilance data capture signals across populations but cannot reliably quantify incidence or prove causation because reporting is biased by media attention, dosing heterogeneity, and concurrent illnesses. Still, the presence of reports clustered in patients with liver comorbidity or polypharmacy strengthens the plausibility that these subgroups could face elevated risk, even if the absolute frequency remains low [2] [7].
3. Clinical reviews and drug safety resources temper alarm with perspective
Authoritative summaries such as LiverTox and medication guides describe ivermectin associations with minor, self‑limiting aminotransferase elevations and very rare clinically apparent liver injury, emphasizing that severe outcomes are uncommon in controlled use but advising caution in patients with liver disease or age‑related organ impairment [8] [9] [3] [10]. Reviews of drug‑induced liver injury during COVID‑19 highlight that polypharmacy and the systemic effects of severe infection complicate attribution and increase risk for DILI overall, reinforcing the need for liver function monitoring and careful medication reconciliation when ivermectin is used off‑label or alongside other hepatotoxins [6] [11].
4. Dose, self‑medication and COVID‑era use amplify risk signals
Several reports link hepatic events to higher-than-prescribed doses or self‑medication during the COVID‑19 pandemic, contexts that also involve other hepatotoxic therapies and systemic illness, making it difficult to isolate ivermectin’s role [6] [4] [7]. The pharmacokinetic profile of ivermectin and its hepatic metabolism means preexisting hepatic impairment or drug interactions can plausibly increase exposure and toxicity. Regulatory medication guides explicitly state elderly patients and those with liver or kidney impairment may require dose adjustment or increased vigilance, a practical risk‑mitigation measure when off‑label use occurs [9] [8] [10] [3].
5. What the evidence implies for clinicians and patients right now
Taken together, the data justify targeted caution rather than blanket prohibition: screen for preexisting liver disease, review concomitant hepatotoxic medications, avoid supratherapeutic dosing and monitor liver enzymes in elderly or polypharmacy patients when ivermectin is used. The evidence is limited and observational—case reports and pharmacovigilance signals support increased vigilance but do not define precise risk rates—so decisions should weigh baseline liver function, indication strength, and alternative therapies. If liver enzymes rise, stop the drug and investigate other causes; severe cases are rare but documented, especially in complex clinical contexts [1] [3] [11].