How do you treat transaminitis?

From the Guidelines

Treatment of transaminitis should focus on addressing the underlying cause while supporting liver health, with the most recent and highest quality study suggesting that for autoimmune hepatitis, initial treatment should be prednisolone plus azathioprine 1.

Key Considerations

• Identify and treat the primary condition causing elevated liver enzymes, which could include stopping hepatotoxic medications, managing viral hepatitis, treating alcohol use disorder, or controlling autoimmune conditions.
• Supportive measures include avoiding alcohol, maintaining hydration, and limiting use of over-the-counter medications that may stress the liver, particularly acetaminophen (which should be limited to less than 2 grams daily if used at all).
• No specific medications directly treat transaminitis itself, as it's a symptom rather than a disease.
• In cases of non-alcoholic fatty liver disease, lifestyle modifications including weight loss, regular exercise, and dietary changes are recommended.
• For viral hepatitis, specific antiviral treatments may be prescribed based on the type.
• Autoimmune hepatitis typically requires immunosuppressive therapy such as prednisone or azathioprine, with a recommended initial dose of prednisolone 60 mg/day and azathioprine 1 mg/kg/day, tapering down as liver enzymes improve 1.

Specific Treatment Approaches

• For medication-induced transaminitis, discontinuing the offending drug often resolves the issue.
• Patients with celiac disease and NAFLD/NASH should follow a gluten-free diet to improve liver enzymes and histology, and to prevent progression to cirrhosis 1.
• Regular monitoring of liver enzymes is essential to track improvement, and the liver has remarkable regenerative capacity, with transaminitis often improving once the underlying cause is addressed, though the timeline varies depending on the severity and cause of liver injury.

Important Considerations for Patient Care

• Addressing comorbidities such as diabetes and hypertension is crucial in patients with NAFLD, as they are at increased risk of cardiovascular disease and liver disease progression 1.
• Patients with NAFLD should be screened for diabetes, and those with type 2 diabetes should be evaluated for the presence of NAFLD, regardless of serum transaminases 1.

From the Research

Treatment of Transaminitis

To treat transaminitis, the underlying cause of the condition must be identified and addressed. The following are some possible causes and their corresponding treatments:

• Nonalcoholic fatty liver disease (NAFLD): Treatment typically involves lifestyle modifications, such as weight loss, exercise, and a healthy diet 2, 3.
• Alcoholic liver disease: Treatment involves abstaining from alcohol and may include medications to reduce cravings and support liver health 2, 3.
• Drug-induced liver injury: Treatment typically involves discontinuing the offending medication and monitoring liver function 4.
• Viral hepatitis: Treatment depends on the type of hepatitis and may include antiviral medications and lifestyle modifications 2, 3.
• Other causes: Treatment will depend on the underlying cause of the transaminitis, such as thyroid disorders, celiac disease, or muscle disorders 2, 3.

Diagnostic Evaluation

The diagnostic evaluation for transaminitis typically involves a combination of laboratory tests and imaging studies, including:

• Liver function tests (LFTs), such as alanine transaminase (ALT) and aspartate transaminase (AST) 2, 3.
• Complete blood count (CBC) with platelets 2.
• Measurement of serum albumin, iron, total iron-binding capacity, and ferritin 2.
• Hepatitis C antibody and hepatitis B surface antigen testing 2, 3.
• Imaging studies, such as ultrasonography, may be used to evaluate the liver and bile ducts 2, 3.

Management of Transaminitis

The management of transaminitis typically involves a stepwise approach, with the following steps:

• Initial evaluation to identify the underlying cause of the transaminitis 2, 3.
• Treatment of the underlying cause, as described above.
• Monitoring of liver function and adjustment of treatment as needed 2, 3.
• Referral to a specialist, such as a gastroenterologist or hepatologist, if the transaminitis is severe or persistent 2, 3.