What is the next step for a patient with hypertransaminasemia on Epuris?

From the Guidelines

For a patient with hypertransaminasemia on Epuris, the next step should be to review medications and supplements that may cause hepatotoxicity and rule out abnormal liver enzymes from development or progression of liver metastases, as well as workup for other causes of elevated liver enzymes, such as viral hepatitis, alcohol history, iron studies, thromboembolic event, or potential liver metastasis from primary malignancy, as recommended by the ASCO guideline update 1. Given the patient's elevated ALT 92 and AST 68, which can be classified as grade 1 or 2 LFT elevations depending on the upper limit of normal, it is crucial to monitor the patient for abnormal liver blood tests and consider weekly monitoring if the elevations persist.

• The patient's current medication, Epuris 20 mg qD, should be evaluated for potential hepatotoxicity, and other causes of liver enzyme elevation should be investigated.
• A workup for other causes of elevated liver enzymes, including blood work and imaging (ultrasound and cross-sectional imaging), should be considered to rule out conditions such as viral hepatitis, alcohol-related liver injury, or potential liver metastasis from primary malignancy.
• If the suspicion for primary autoimmune hepatitis is high, additional tests such as ANA/ASMA/ANCA may be considered, and if the patient has isolated elevation of transaminases, checking CK for other etiologies may be necessary, as suggested by the ASCO guideline update 1.
• The decision to temporarily discontinue Epuris or adjust the dose should be based on the severity of the liver enzyme elevations and the patient's overall clinical condition, with careful monitoring and follow-up to ensure the patient's safety and minimize the risk of liver injury.

From the Research

Patient with Hypertransaminasemia on Epuris

The patient is a 20-year-old female on Epuris 20 mg qD with elevated ALT 92 and AST 68.

• The next step for this patient would involve careful evaluation of the cause of the elevated liver enzymes.
• According to the provided studies, elevated liver enzymes can be caused by various factors, including drug-induced liver injury 2, 3, 4.
• It is essential to monitor liver function tests regularly in patients on medications that can cause liver injury, such as Epuris.
• If liver injury is suspected, rechallenge with the offending drug is not recommended to avoid severe hepatotoxicity 2.
• The patient's clinical presentation, including the pattern of liver enzyme elevation, should be evaluated to determine the best course of action.
• In some cases, discontinuation of the offending drug may lead to rapid resolution of clinical symptoms and liver enzymes 4.
• The patient's condition should be closely monitored, and liver function tests should be performed regularly to assess the severity of the liver injury and guide further management.

Possible Causes of Elevated Liver Enzymes

• Drug-induced liver injury: Epuris or other medications the patient is taking may be causing the elevated liver enzymes 2, 3, 4.
• Viral hepatitis: Although not directly related to Epuris, viral hepatitis can cause elevated liver enzymes 5, 6.
• Other factors: Insulin resistance, autoimmune hepatitis, and other conditions may also contribute to elevated liver enzymes 5, 6.

Management of Elevated Liver Enzymes

• Regular monitoring of liver function tests to assess the severity of the liver injury and guide further management.
• Discontinuation of the offending drug, if suspected to be the cause of the liver injury 2, 4.
• Close monitoring of the patient's clinical presentation and adjustment of the treatment plan as needed.