How can I stabilize a patient with elevated liver enzymes and experiencing extreme dizziness after taking naltrexone (opioid receptor antagonist)?

From the Guidelines

Discontinue naltrexone immediately and provide supportive care to address the patient's symptoms, as the medication may be causing hepatotoxicity and exacerbating the patient's condition. For a patient with elevated liver enzymes and extreme dizziness after taking naltrexone, immediate medical attention is necessary. The patient's symptoms suggest naltrexone-induced hepatotoxicity, which can occur in patients taking this medication, particularly at higher doses 1.

The patient should be positioned lying down with legs elevated to reduce dizziness, and vital signs, liver function tests, and electrolytes should be monitored closely. Administering antiemetics such as ondansetron 4-8 mg IV or oral may be necessary if nausea is present. For severe dizziness, consider meclizine 25 mg every 6 hours as needed. It is essential to avoid medications metabolized by the liver, as they may exacerbate the patient's condition 1.

Some key points to consider when managing this patient include:

• Monitoring liver function tests at baseline and every three to six months, as recommended 1
• Being aware of the potential for naltrexone to cause hepatic injury at supratherapeutic doses 1
• Considering alternative treatments for the patient's underlying condition that required naltrexone, once the patient is stabilized
• Providing supportive care, including IV fluids, to address potential dehydration and maintain blood pressure.

The patient's extreme dizziness may result from autonomic effects of naltrexone or from liver dysfunction affecting metabolism of other substances. The plasma half-life of naltrexone is 4 hours, and the half-life of the active metabolite, 6-b-naltrexol, is 13 hours, which may persist for 2 to 3 days after stopping 1.

From the FDA Drug Label

Patients should be warned of the risk of hepatic injury and advised to seek medical attention if they experience symptoms of acute hepatitis Use of naltrexone hydrochloride should be discontinued in the event of symptoms and/or signs of acute hepatitis. Advise patients that naltrexone hydrochloride may cause liver injury. Dizziness may occur with naltrexone hydrochloride treatment, and they should avoid driving or operating heavy machinery until they have determined how naltrexone hydrochloride affects them

The patient is experiencing elevated liver enzymes and extreme dizziness after taking naltrexone.

• The FDA drug label warns of the risk of hepatic injury and advises patients to seek medical attention if they experience symptoms of acute hepatitis.
• The label also advises that use of naltrexone hydrochloride should be discontinued in the event of symptoms and/or signs of acute hepatitis.
• Additionally, the label notes that dizziness may occur with naltrexone hydrochloride treatment. To stabilize the patient, it is recommended to:
• Discontinue use of naltrexone hydrochloride due to the risk of hepatic injury and the patient's elevated liver enzymes.
• Monitor the patient's liver function and adjust treatment as needed.
• Assess the patient's overall health and consider alternative treatments for their condition. 2

From the Research

Patient Stabilization on Naltrexone with Elevated Liver Enzymes

To stabilize a patient with elevated liver enzymes who is experiencing extreme dizziness after taking naltrexone, consider the following:

• Monitor liver enzyme levels closely, as naltrexone has been shown to be safe in patients with underlying liver disease, including those with compensated cirrhosis 3.
• The patient's extreme dizziness may be a side effect of naltrexone, and it is essential to weigh the benefits and risks of continuing the medication.
• Studies have found that naltrexone can actually decrease liver enzyme levels in some patients, particularly those with pretreatment hepatic enzyme levels exceeding the normal range 4.
• High-dose naltrexone has been used in some studies without adverse effects on liver function 5.

Management of Elevated Liver Enzymes

When managing a patient with elevated liver enzymes, consider the following:

• Evaluate the patient's clinical presentation and the pattern of injury to guide the diagnostic work-up and management 6.
• Investigate possible causes of elevated liver enzymes, such as alcohol-related liver disease or paracetamol hepatotoxicity 7.
• Consider alternative treatments or adjustments to the patient's medication regimen to minimize the risk of further liver damage.

Naltrexone Administration

When administering naltrexone to a patient with elevated liver enzymes, consider the following:

• Start with a low dose and gradually increase as needed and tolerated, monitoring liver enzyme levels closely 3.
• Be aware of the potential for naltrexone to cause dizziness and other side effects, and adjust the treatment plan accordingly.
• Consider consulting with a specialist, such as a hepatologist or an addiction medicine specialist, for guidance on managing the patient's care 3, 4, 5.