Is it safe to start metronidazole and Diloxanide (Furamide) in a patient with elevated Serum Glutamic-Pyruvic Transaminase (SGPT), also known as Alanine Transaminase (ALT) elevation?

From the Guidelines

Starting metronidazole and diloxanide in a patient with elevated SGPT is not recommended due to the potential risk of further liver injury. When considering the use of metronidazole in patients with elevated SGPT, it is essential to weigh the benefits of treatment against the potential risks. Metronidazole undergoes hepatic metabolism, and its use in patients with pre-existing liver dysfunction may lead to further liver injury 1. The degree of SGPT elevation is a critical factor in determining the safety of metronidazole use. Mild elevations may permit cautious use with monitoring, while significant elevations (>3 times upper limit of normal) warrant consideration of alternative treatments 1. Some key points to consider when making a decision include:

• The potential for metronidazole to cause further liver injury in patients with pre-existing liver dysfunction 1
• The importance of investigating the underlying cause of the elevated SGPT, as it may influence treatment decisions 1
• The need to monitor liver function tests closely during therapy if metronidazole is used 1
• The potential benefits of consulting with a gastroenterologist or infectious disease specialist in complex cases 1
• The fact that diloxanide furoate has less hepatic metabolism and is generally safer in liver impairment, though data is limited 1. In the context of real-life clinical medicine, it is crucial to prioritize caution and consider alternative treatments or reduced doses of metronidazole to minimize the risk of worsening liver function 1.

From the FDA Drug Label

Metronidazole may interfere with certain types of determinations of serum chemistry values, such as aspartate aminotransferase (AST, SGOT), alanine aminotransferase (ALT, SGPT), lactate dehydrogenase (LDH), triglycerides, and hexokinase glucose. The FDA drug label does not answer the question.

From the Research

Liver Function and Medication

• The decision to start metronidazole and diloxanide in a patient with elevated SGPT should be made with caution, as elevated liver enzymes can indicate liver injury or disease 2.
• However, it is essential to note that liver function tests (LFTs) are not specific to the liver and can be affected by various factors unrelated to liver disease 3, 4.
• A study found that elevation of serum levels of SGOT and SGPT is a marker for intra-abdominal injury, and levels in excess of 130 IU/L are relative indicators of abdominal computed tomography scan 2.
• Another study suggested that metformin, a different medication, does not appear to cause or exacerbate liver injury and can be beneficial in patients with nonalcoholic fatty liver disease 5.
• The correlation between routine LFTs and stages of hepatic fibrosis is limited, and normal or near-normal laboratory findings may be seen in asymptomatic patients with liver disease 6.

Medication Considerations

• There is no direct evidence in the provided studies regarding the safety of starting metronidazole and diloxanide in patients with elevated SGPT.
• However, it is crucial to consider the potential risks and benefits of initiating any medication in patients with elevated liver enzymes, and careful monitoring of liver function may be necessary 5, 6.
• A thorough evaluation of the patient's medical history, clinical examination, and interpretation of liver test abnormalities can help identify the type and etiology of liver disease, allowing for a targeted investigation approach 3.