From the Guidelines
Management of a patient with ulcerative colitis (UC) and mildly elevated liver enzymes (AST 43, ALT 83) should prioritize careful monitoring and adjustment of medications to minimize liver-related complications while effectively treating UC, as recommended by the most recent guidelines 1.
Key Considerations
- Evaluate potential causes of liver enzyme elevation, including medication-induced hepatotoxicity from UC treatments like azathioprine, 6-mercaptopurine, or methotrexate, and consider primary sclerosing cholangitis (PSC) which occurs in 2-10% of UC patients.
- Order additional liver tests including alkaline phosphatase, bilirubin, gamma-glutamyl transferase, and prothrombin time to assess liver function comprehensively.
- Ultrasound or magnetic resonance cholangiopancreatography (MRCP) may be indicated to evaluate biliary structures.
UC Management
- Continue appropriate therapy based on disease severity while monitoring liver enzymes every 1-3 months.
- If using potentially hepatotoxic medications, consider dose adjustment or alternative therapies such as mesalamine (2-4g daily), biologics like infliximab (5mg/kg at weeks 0,2,6, then every 8 weeks), or vedolizumab, as suggested by guidelines for moderate to severe UC management 1.
- Avoid alcohol consumption and hepatotoxic medications when possible.
Monitoring and Consultation
- If liver enzymes continue to rise or exceed three times the upper limit of normal, consult with hepatology for specialized management.
- Follow the guidelines for managing immune checkpoint inhibitor-related liver toxicity, which include holding or discontinuing the offending agent and initiating glucocorticoids in cases of grade 2 or higher hepatitis 1. This approach ensures that the management of UC and elevated liver enzymes prioritizes both the effective control of UC and the minimization of liver-related complications, in line with the most recent and highest quality evidence available.
From the Research
Management of Ulcerative Colitis with Elevated Liver Enzymes
- The patient has ulcerative colitis (UC) with elevated liver enzymes, specifically aspartate aminotransferase (AST)/alanine aminotransferase (ALT) of 43/83.
- A study from 1983 2 found that patients with UC and persistently abnormal liver function tests are likely to have primary sclerosing cholangitis (PSC), and cholangiography is necessary for a reliable diagnosis.
Treatment Options for UC
- Aminosalicylates, such as 5-ASA, sulfasalazine, and mesalazine, play a central role in the treatment of UC, and are effective for acute and maintenance treatment 3.
- Infliximab is effective for treatment of moderate-to-severe UC and is recommended for patients who have had an inadequate response to medical therapy or who are intolerant of or do not desire to take certain agents 4.
Management of Elevated Liver Enzymes in UC
- There is no direct evidence on the management of elevated liver enzymes in UC patients.
- However, a study from 2022 5 found that maintaining infliximab-induced clinical remission with azathioprine and 5-aminosalicylates in acute severe steroid-refractory UC has lower cost and high efficacy.
- Another study from 2008 6 found that infliximab is a viable rescue therapy for patients with steroid-refractory severe UC, and the majority of patients were discharged without surgery.