RUCAM

The updated RUCAM scores how likely a drug or herbal product caused a liver injury. Choose the pattern first, using the R factor from the first abnormal results: hepatocellular if R is 5 or more, cholestatic if 2 or less, and mixed in between. Score each suspected product separately.

Pattern of injuryHepatocellular (R 5 or more)Cholestatic or mixed (R below 5)

Time to onset5 to 90 days after starting(+2)Hepatocellular: on re-exposure, 1 to 15 days. Cholestatic or mixed: on re-exposure, 1 to 90 daysUnder 5 days or over 90 days after starting(+1)Hepatocellular: on re-exposure, over 15 days. Cholestatic or mixed: on re-exposure, over 90 daysAfter stopping the product(+1)Hepatocellular: within 15 days of stopping (except slowly metabolised products). Cholestatic or mixed: within 30 days of stoppingBefore starting, or later than 15 days (hepatocellular) or 30 days (cholestatic) after stoppingThe product is considered unrelated and RUCAM is not applicable.

Course after stopping the product

Hepatocellular: follow the ALT. Cholestatic or mixed: follow the ALP or bilirubin.

Hepatocellular: ALT falls by 50% or more within 8 days(+3)Hepatocellular: ALT falls by 50% or more within 30 days(+2)Hepatocellular: ALT falls by 50% or more, but after day 30(0)Hepatocellular: ALT falls by less than 50% after day 30, or rises again(−2)Cholestatic: ALP or bilirubin falls by 50% or more within 180 days(+2)Cholestatic: ALP or bilirubin falls by less than 50% within 180 days(+1)No information, product continued, or (cholestatic) persistence or rise(0)

Risk factorsAlcohol: more than 2 drinks a day for women or 3 for men (cholestatic: alcohol or pregnancy)(+1)Age 55 or over(+1)

Other products taken at the same timeNone, or no information(0)Another product, but its timing does not fit(0)Another product with timing that fits(−1)A known hepatotoxin with timing that fits(−2)Another product with evidence it caused the injury (positive rechallenge or validated test)(−3)

Search for alternative causes

Group I (7): hepatitis A, B, C and E; hepatobiliary imaging; alcohol use disorder (AST to ALT ratio 2 or more); recent hypotension, particularly with heart disease. Group II: complications of underlying disease such as sepsis, metastatic cancer, autoimmune hepatitis, chronic hepatitis B or C, PBC or PSC, genetic liver disease; and CMV, EBV, HSV or VZV infection.

All causes in groups I and II reasonably ruled out(+2)The 7 causes in group I ruled out(+1)5 or 6 causes in group I ruled out(0)Fewer than 5 causes in group I ruled out(−2)Alternative cause highly probable(−3)

Previous reports of liver injury with this productListed in the product information(+2)Published but not listed(+1)Not known(0)

Response to unintentional re-exposure

Hepatocellular: ALT, with ALT below 5 times the upper limit before re-exposure. Cholestatic: ALP, with ALP below 2 times the upper limit before re-exposure.

Doubling with the product alone(+3)Doubling with the product and the others taken at the time of the first reaction(+1)A rise, but staying below the upper limit, in the same conditions as the first exposure(−2)Other situations, or no re-exposure(0)

Enter the values above.

Interpretation

Score	Causality
0 or less	Excluded
1 to 2	Unlikely
3 to 5	Possible
6 to 8	Probable
9 or more	Highly probable

Reporting

Report suspected drug-induced liver injury to the TGA through the adverse event reporting page. LiverTox summarises the known hepatotoxicity of individual drugs.

Reference

Danan G, Teschke R. RUCAM in drug and herb induced liver injury: the update. Int J Mol Sci. 2016;17(1):14.