What are the methods to reduce elevated liver enzymes, specifically hypertransaminasemia (elevated alanine transaminase (ALT) and aspartate transaminase (AST))?

From the Guidelines

To reduce elevated liver enzymes, it is essential to focus on lifestyle changes, particularly dietary modifications, as evidenced by the most recent and highest quality study 1. The key to reducing elevated liver enzymes lies in addressing the underlying causes, which can include nonalcoholic fatty liver disease (NAFLD), alcohol-induced liver disease, and other conditions.

Lifestyle Changes

• Maintaining a healthy weight through regular exercise and a balanced diet is crucial, as it helps reduce inflammation and fat accumulation in the liver.
• A daily intake of 1,500–1,800 kcal in men and 1,200–1,500 kcal in women can help reduce total energy intake by more than 500 kcal/day, as recommended by the Kasl clinical practice guidelines 1.
• Limiting carbohydrate intake, particularly fructose, can also help reduce liver fat content and elevated liver enzymes, as suggested by studies on the association between macronutrient ratios and NAFLD 1.

Addressing Underlying Causes

• For NAFLD, reducing the intake of total energy and controlling food intake are crucial aspects of treatment, as emphasized by the Kasl clinical practice guidelines 1.
• For alcohol-induced liver disease, limiting or avoiding alcohol consumption is essential, as alcohol is a common cause of liver damage.
• Regular monitoring of liver enzymes through blood tests is important to track improvement, and referral to gastroenterology should be considered for persistently elevated or worsening transaminases, as recommended by the standards of medical care in diabetes-2022 1 and standards of care in diabetes-2024 1.

Medical Evaluation and Treatment

• If liver enzymes remain elevated despite lifestyle changes and addressing underlying causes, further medical evaluation is necessary to identify and treat the underlying cause, which may involve medications such as vitamin E for fatty liver disease, prednisone or azathioprine for autoimmune hepatitis, or antiviral medications for viral hepatitis.
• Certain supplements like milk thistle may support liver health, though evidence is limited, as noted in the example answers. By prioritizing lifestyle changes, addressing underlying causes, and seeking medical evaluation and treatment when necessary, individuals can effectively reduce elevated liver enzymes and improve their overall liver health, as supported by the most recent and highest quality study 1.

From the FDA Drug Label

Hepatic Effects: ... Liver function tests should also be obtained for patients if symptoms suggestive of hepatic dysfunction occur, e.g., nausea, vomiting, abdominal pain, fatigue, anorexia, or dark urine. The decision whether to continue the patient on therapy with ACTOS should be guided by clinical judgment pending laboratory evaluations. If jaundice is observed, drug therapy should be discontinued Therapy with ACTOS should not be initiated if the patient exhibits clinical evidence of active liver disease or the ALT levels exceed 2.5 times the upper limit of normal. Patients with mildly elevated liver enzymes (ALT levels at 1 to 2. 5 times the upper limit of normal) at baseline or any time during therapy with ACTOS should be evaluated to determine the cause of the liver enzyme elevation. Initiation or continuation of therapy with ACTOS in patients with mildly elevated liver enzymes should proceed with caution and include appropriate clinical follow-up which may include more frequent liver enzyme monitoring. If serum transaminase levels are increased (ALT > 2. 5 times the upper limit of normal), liver function tests should be evaluated more frequently until the levels return to normal or pretreatment values. If ALT levels exceed 3 times the upper limit of normal, the test should be repeated as soon as possible. If ALT levels remain > 3 times the upper limit of normal or if the patient is jaundiced, ACTOS therapy should be discontinued

To reduce elevated liver enzymes, the following steps can be taken:

• Evaluate the cause of the liver enzyme elevation
• Monitor liver enzymes more frequently until the levels return to normal or pretreatment values
• Discontinue ACTOS therapy if ALT levels exceed 3 times the upper limit of normal or if the patient is jaundiced
• Proceed with caution and clinical follow-up in patients with mildly elevated liver enzymes (ALT levels at 1 to 2.5 times the upper limit of normal) 2

From the Research

Reducing Elevated Liver Enzymes

To reduce elevated liver enzymes, it is essential to understand the underlying cause of the elevation. According to 3, elevated liver enzymes can be caused by various factors, including viral hepatitis, genetic liver diseases, drug-induced liver diseases, and non-alcoholic fatty liver disease.

Lifestyle Changes

• Maintaining a healthy lifestyle and weight reduction are crucial to the prevention and treatment of non-alcoholic fatty liver disease (NAFLD) 4.
• Overweight and obese individuals with chronic hepatitis B (CHB) have an increased risk of NAFLD, highlighting the importance of weight management 5.

Managing Underlying Conditions

• Type 2 diabetes mellitus (DM) is associated with an increased risk of NAFLD, emphasizing the need for proper management of concurrent conditions 5.
• Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections can impact liver enzyme levels and fibrosis markers in patients with NAFLD 6.

Monitoring and Follow-up

• Regular monitoring of liver enzymes and fibrosis markers is necessary to assess the progression of liver disease and the effectiveness of treatment 3, 6.
• Asymptomatic patients with elevated transaminases should be controlled, as more than 30% of elevated transaminases spontaneously normalize during follow-up 3.