What is the management approach for a patient with elevated liver enzymes?

From the Guidelines

The management of a patient with elevated liver enzymes, such as the patient with AST of 53 IU/L and ALT of 57 IU/L, begins with a thorough evaluation to determine the underlying cause before initiating specific treatment. Initial steps include obtaining a detailed history focusing on alcohol use, medications, supplements, and risk factors for viral hepatitis, followed by a comprehensive physical examination looking for signs of chronic liver disease. Laboratory testing should include a complete liver panel (ALT, AST, alkaline phosphatase, bilirubin, albumin), complete blood count, coagulation studies, and targeted tests based on clinical suspicion such as viral hepatitis serologies, autoimmune markers, iron studies, and ceruloplasmin levels. Imaging with ultrasound is typically the first-line study to assess liver structure and rule out biliary obstruction, as recommended by the American College of Radiology 1.

Some key considerations in the management of elevated liver enzymes include:

• Discontinuation of hepatotoxic medications or alcohol
• Antiviral therapy for viral hepatitis (such as entecavir or tenofovir for hepatitis B, or direct-acting antivirals for hepatitis C)
• Weight loss and lifestyle modifications for non-alcoholic fatty liver disease, with consideration of the Fibrosis 4 Index (FIB-4) and other non-invasive tests to assess fibrosis risk 1
• Ursodeoxycholic acid for primary biliary cholangitis
• Immunosuppressive therapy for autoimmune hepatitis

Regular monitoring of liver enzymes is essential to assess treatment response, with frequency determined by the severity of elevation and underlying condition. Severe cases with signs of liver failure require prompt referral to a hepatologist for specialized care. The rationale for this approach is that liver enzyme elevations are not diseases themselves but indicators of underlying hepatic injury, and successful management depends on addressing the specific cause rather than treating the laboratory abnormality in isolation. In cases where drug-induced liver injury is suspected, treatment should be interrupted and referral to gastroenterology should be considered, as advised by the International Eczema Council 1. Additionally, guidelines from the US FDA and other organizations emphasize the importance of careful evaluation and management of patients with elevated liver enzymes, particularly in the context of clinical trials or suspected drug-induced liver injury 1.

From the FDA Drug Label

Abnormalities in liver enzymes have not been associated with Ursodiol therapy and, in fact, Ursodiol has been shown to decrease liver enzyme levels in liver disease. However, patients given Ursodiol should have SGOT (AST) and SGPT (ALT) measured at the initiation of therapy and thereafter as indicated by the particular clinical circumstances

For a patient with elevated liver enzymes, the management approach may include:

• Monitoring liver enzymes, such as AST (SGOT) and ALT (SGPT), at the initiation of therapy and as indicated by clinical circumstances 2
• Considering the use of Ursodiol, which has been shown to decrease liver enzyme levels in liver disease
• Being aware of potential drug interactions, such as with bile acid sequestering agents, aluminum-based antacids, estrogens, oral contraceptives, and clofibrate, which may counteract the effectiveness of Ursodiol 2

From the Research

Management Approach for Elevated Liver Enzymes

The patient's lab results show elevated liver enzymes, including Alkaline Phosphatase (162 IU/L), AST (53 IU/L), and ALT (57 IU/L). To manage this condition, the following steps can be taken:

• Evaluate the patient's medical history and perform a physical exam to identify potential causes of elevated liver enzymes 3
• Order additional lab tests to determine the underlying cause of the elevated liver enzymes, such as viral hepatitis, genetic liver diseases, or drug-induced liver diseases 3
• Consider an ultrasound study to discern intra- from extrahepatic cholestasis if the patient has high serum alkaline phosphatase and γ-glutamyltranspeptidase activities 3

Treatment Options

• Vitamin E has shown beneficial effects on oxidative stress, which plays a major role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD) 4, 5
• Vitamin E may slightly reduce serum ALT and AST levels compared to placebo or no intervention 4
• However, the effects of vitamin E on liver-related mortality, liver-related morbidity, and serious adverse events are very uncertain 4
• Lifestyle and diet changes, such as weight loss and low-calorie diet interventions, are also recommended for patients with NAFLD 4, 5

Diagnostic Approach

• An algorithmic approach can be taken to help narrow the spectrum of a differential diagnosis based on the patient's clinical presentation and lab results 6
• Focused testing, which involves directing testing based on the patient's history and physical exam, may be the most cost-effective strategy in certain situations 7
• However, extensive testing, which involves testing for all diseases at once, may be necessary in some cases to rule out rare or uncommon causes of elevated liver enzymes 7