Background & Aims: Ezetimibe was introduced recently as a new class of cholesterol-lowering drugs. Until now only limited increases of transaminase levels were reported. Methods: We studied 2 patients with severe hepatic side effects of ezetimibe in a general community hospital. Results: Ezetimibe may lead to 2 distinct types of severe hepatic side effects. Conclusions: Ezetimibe may rarely cause hepatotoxicity, severe cholestatic hepatitis, or acute autoimmune hepatitis.