From the Guidelines
For patients with elevated liver function tests (LFTs) and low risk of fibrosis, I recommend rechecking LFTs in 2-4 weeks after initial detection, as suggested by the guidelines 1. This approach is based on the joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies, which recommend repeating LFTs in 2-4 weeks for elevations less than 3-fold the upper limit of normal 1. The guidelines also emphasize the importance of monitoring for hepatotoxicity in patients on methotrexate with risk factors for hepatotoxicity, and provide a framework for assessing the likelihood of liver fibrosis using non-invasive blood serology tests such as FIB-4, Fibrosure, Fibrometer, and Hepascore 1. In contrast, the guidelines on the management of abnormal liver blood tests published in Gut in 2018 suggest a more conservative approach, with repeat testing at 3-6 month intervals for patients with mild elevations and low risk of fibrosis 1. However, the more recent guidelines from the American Academy of Dermatology-National Psoriasis Foundation 1 take precedence, and their recommendation for rechecking LFTs in 2-4 weeks is the most appropriate course of action. Key factors to consider when determining the timing of repeat testing include the degree of elevation, suspected underlying cause, and patient-specific factors, such as the presence of risk factors for hepatotoxicity or underlying liver disease. By following this approach, clinicians can balance the need for monitoring against unnecessary testing in low-risk patients, while ensuring timely detection of any progression or hepatotoxicity. It is also important to note that lifestyle modifications, such as alcohol cessation and weight management, should be implemented during this period, and further testing should be adjusted based on the patient's response to these interventions. Ultimately, the goal is to prioritize the patient's morbidity, mortality, and quality of life, and to make decisions based on the most recent and highest-quality evidence available 1.
From the Research
Rechecking LFT Levels with Low Risk of Fibrosis
- When liver function tests (LFTs) are elevated, it is essential to determine the underlying cause and assess the risk of fibrosis 2, 3.
- Studies have shown that LFTs may not accurately predict the presence or absence of fibrosis, and normal or near-normal laboratory findings may be seen in asymptomatic patients with liver disease 3.
- The pattern of elevated LFTs can provide valuable information about the risk of fibrosis and metabolic-associated comorbidities in patients with nonalcoholic fatty liver disease (NAFLD) 4.
- Non-invasive imaging modalities such as ultrasound and magnetic resonance elastography can be used to assess liver fibrosis and provide a more accurate diagnosis than LFTs alone 5, 6.
Timing of Rechecking LFT Levels
- There is no specific guideline on when to recheck LFT levels in patients with elevated LFTs and low risk of fibrosis.
- However, it is recommended to recheck LFT levels in patients with NAFLD who have a high risk of advanced fibrosis or metabolic-associated comorbidities, as identified by the pattern of elevated LFTs 4.
- Rechecking LFT levels may also be necessary in patients who have undergone treatment for liver disease or who have experienced changes in their clinical status 2, 3.
Factors to Consider
- The presence of metabolic-associated comorbidities such as diabetes, hypertension, and hypertriglyceridemia may increase the risk of advanced fibrosis in patients with NAFLD 4.
- The use of non-invasive imaging modalities such as ultrasound and magnetic resonance elastography can provide a more accurate diagnosis of liver fibrosis than LFTs alone 5, 6.
- The clinical context and individual patient characteristics should be taken into account when determining the timing and frequency of rechecking LFT levels 2, 3.