How to manage elevated Alanine Transaminase (ALT) levels?

From the Guidelines

Managing elevated Alanine Transaminase (ALT) levels requires a comprehensive approach that includes identifying and addressing the underlying cause, making lifestyle modifications, and closely monitoring liver function. The most recent and highest quality study, 1, provides guidance on the detection, assessment, and management of suspected drug-induced liver injury during clinical trials in oncology patients.

Key Considerations

• Determine the source of liver inflammation through comprehensive testing, as elevated ALT indicates liver cell damage.
• Common causes of elevated ALT include viral hepatitis, alcohol consumption, non-alcoholic fatty liver disease (NAFLD), certain medications, and autoimmune conditions.
• If alcohol is contributing, complete cessation is recommended.
• For NAFLD, weight loss of 7-10% through a balanced diet low in processed foods and regular exercise (150 minutes weekly of moderate activity) can significantly reduce ALT levels.
• Avoid hepatotoxic medications and supplements when possible.
• Specific treatments depend on the underlying cause: antiviral medications for viral hepatitis, corticosteroids for autoimmune hepatitis, or discontinuation of offending medications.
• Maintain good metabolic control if you have diabetes or metabolic syndrome, as these conditions can worsen liver inflammation.
• Regular monitoring of ALT levels every 3-6 months is important to track improvement.
• Liver-supportive nutrients like coffee (2-3 cups daily) and vitamin E (800 IU daily for non-diabetic NAFLD patients) may provide additional benefits.

Monitoring and Management

• Routine monitoring of liver tests should include ALT, AST, ALP, and TBIL, with a certain threshold of elevation triggering additional testing for detection of potential DILI.
• The frequency of liver test monitoring may be reduced in Phase 2/3 studies guided by the risk of hepatotoxicity and liver status.
• The goal is to reduce inflammation and prevent progression to more serious liver conditions like cirrhosis or liver failure, as emphasized in 1.

Classification of Abnormal Aminotransferase

• Mild: <5 times the upper reference limit
• Moderate: 5 to 10 times the upper reference limit
• Severe: >10 times the upper reference limit By following these guidelines and considering the most recent evidence, healthcare providers can effectively manage elevated ALT levels and improve patient outcomes.

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

To manage elevated Alanine Transaminase (ALT) levels, Ursodiol may be beneficial as it has been shown to decrease liver enzyme levels in liver disease. However, it is essential to monitor SGOT (AST) and SGPT (ALT) levels at the initiation of therapy and as indicated by the clinical circumstances 2.

• Key points:
  • Ursodiol may help decrease elevated ALT levels
  • Monitor liver enzymes during therapy
  • Clinical circumstances should guide the frequency of monitoring

From the Research

Managing Elevated Alanine Transaminase (ALT) Levels

Elevated ALT levels can be a sign of liver damage or disease. To manage elevated ALT levels, it is essential to identify and address the underlying cause.

• Nonalcoholic fatty liver disease (NAFLD) is a common cause of elevated ALT levels, and treatment options include lifestyle modifications and medication.
• Ursodeoxycholic acid (UDCA) has been shown to be effective in reducing ALT levels in patients with NAFLD 3, 4, 5, 6.
• Combination therapy with UDCA and other medications, such as alpha-lipoic acid or vitamin E, may also be effective in reducing ALT levels and improving liver function 4, 5.
• Lifestyle modifications, such as weight loss and a hypocaloric diet, can also help to reduce ALT levels and improve liver function 4.

Diagnostic Evaluation

If the cause of elevated ALT levels is unclear, a stepwise evaluation should be initiated to identify the underlying cause.

• Initial testing should include a fasting lipid profile, measurement of glucose, serum iron, and ferritin, total iron-binding capacity, and hepatitis B surface antigen and hepatitis C virus antibody testing 7.
• Additional testing may include ultrasonography, measurement of α(1)-antitrypsin and ceruloplasmin, serum protein electrophoresis, and antinuclear antibody, smooth muscle antibody, and liver/kidney microsomal antibody type 1 testing 7.
• Referral for further evaluation and possible liver biopsy is recommended if transaminase levels remain elevated for six months or more 7.