What is the clinical significance of elevated ferritin and liver enzymes in a 65-year-old male with a history of coronary artery disease, taking lisinopril (angiotensin-converting enzyme inhibitor), rosuvastatin (HMG-CoA reductase inhibitor), clopidogrel (antiplatelet), tizanidine (muscle relaxant), gabapentin (anticonvulsant), and meloxicam (nonsteroidal anti-inflammatory drug), who consumes excessive alcohol, approximately two 6-packs of beer daily?

From the Guidelines

The patient's excessive alcohol consumption of two 6-packs of beer daily is likely contributing to his abnormal liver function tests and elevated ferritin, suggesting possible alcohol-related liver damage or early hemochromatosis, and therefore, immediate action should be taken to reduce or stop his alcohol intake. The patient has a significant medical history of coronary artery disease with heart stents, left hip pain, and inguinal hernia. His current medications include lisinopril 10 mg, rosuvastatin, clopidogrel, tizanidine, gabapentin, and meloxicam. Laboratory results show elevated ferritin levels, which is concerning given his reported alcohol consumption. The patient is already established with cardiology and plans to attend his yearly check-up. He is also in the process of re-establishing care with gastroenterology for evaluation of elevated liver enzymes, elevated ferritin, and to schedule a repeat colonoscopy.

According to the EASL clinical practice guidelines: management of alcohol-related liver disease 1, excessive alcohol consumption may induce a wide spectrum of lesions that include pure alcoholic steatosis, steatohepatitis, progressive liver fibrosis, cirrhosis, and HCC. The guidelines also state that above a daily consumption of 30 g/day, or a weekly consumption above seven units in women and 14 units in men, the risk of developing ALD is increased 1.

The patient's cardiac history necessitates continued monitoring, particularly with his current medication regimen which includes antiplatelet therapy and antihypertensive medication. The patient's excessive alcohol intake is a significant concern and should be addressed promptly to prevent further liver damage and other complications.

Key points to consider in the patient's management include:

• Reducing or stopping alcohol intake to prevent further liver damage
• Continued monitoring of liver function tests and ferritin levels
• Evaluation of the patient's cardiac history and medication regimen to ensure optimal management
• Scheduling a repeat colonoscopy as part of the patient's gastrointestinal evaluation
• Considering the patient's overall health and well-being, including his nutritional status and potential for malnutrition due to excessive alcohol consumption.

The EASL clinical practice guidelines: management of alcohol-related liver disease 1 and other studies 1 emphasize the importance of addressing excessive alcohol consumption in patients with ALD to prevent further liver damage and other complications.

From the FDA Drug Label

Patients who consume substantial quantities of alcohol and/or have a history of liver disease may be at increased risk for hepatic injury The patient's elevated liver enzymes and ferritin levels, combined with a history of consuming two 6-packs of beer a day, may indicate a risk for hepatic injury.

• The patient's alcohol consumption and elevated liver enzymes should be further evaluated.
• Consider liver enzyme testing and monitoring.
• The patient is already scheduled for a GI evaluation, which is appropriate given the elevated liver enzymes and ferritin levels 2.

From the Research

History of Present Illness

The patient is a 65-year-old male with a past medical history significant for coronary artery disease with heart stents, left hip pain, and inguinal hernia. He presents to the clinic for baseline laboratory tests and to obtain refills for his current medications, which include lisinopril 10 mg, rosuvastatin, clopidogrel, tizanidine, gabapentin, and meloxicam.

Chief Complaints and Symptoms

• The patient's ferritin levels are elevated, which may be related to his alcohol consumption, as he reports drinking two 6-packs of beer per day 3, 4.
• He has elevated liver enzymes, which can be caused by various factors, including alcohol use, non-alcoholic fatty liver disease, and other liver conditions 5.
• The patient is established with cardiology and will return for his yearly check-up.

Relevant Medical History

• Coronary artery disease with heart stents
• Left hip pain
• Inguinal hernia
• Elevated liver enzymes
• Elevated ferritin levels

Social History

• The patient consumes two 6-packs of beer per day, which is a significant risk factor for liver disease, particularly cirrhosis 3, 4.
• His alcohol consumption may be contributing to his elevated liver enzymes and ferritin levels.

Follow-up and Management

• The patient is in the process of being re-established with GI for evaluation of his elevated liver enzymes, ferritin levels, and to undergo a repeat colonoscopy.
• His alcohol consumption should be addressed, and he should be encouraged to reduce or abstain from alcohol to minimize the risk of liver disease progression 4, 6.
• Further testing and management will depend on the results of his GI evaluation and laboratory tests.