What is the management approach for elevated bilirubin (hyperbilirubinemia)?

From the Guidelines

The management of elevated bilirubin, or hyperbilirubinemia, should prioritize phototherapy as the first-line treatment for mild unconjugated cases in newborns, with exchange transfusion considered for severe cases to prevent kernicterus, as supported by the most recent guidelines 1.

Causes and Severity

The approach to managing hyperbilirubinemia depends on its cause, severity, and whether it is unconjugated or conjugated.

• For mild unconjugated hyperbilirubinemia in newborns, phototherapy is typically administered when bilirubin levels exceed 12-15 mg/dL in term infants.
• In adults with Gilbert's syndrome, no treatment is typically required.
• For hemolytic causes, treating the underlying condition is essential.
• In cases of conjugated hyperbilirubinemia, management focuses on addressing the underlying liver disease, biliary obstruction, or infection.

Treatment Options

• Phototherapy is an essential intervention for severe hyperbilirubinemia, especially in neonates at high risk, as it reduces the risk of bilirubin neurotoxicity and the need for exchange transfusions 1.
• Exchange transfusion may be necessary for severe cases (>20 mg/dL) to prevent kernicterus.
• Ursodeoxycholic acid (10-15 mg/kg/day) may help in cholestatic conditions by improving bile flow.
• For obstructive jaundice, endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) may be needed to relieve the blockage.
• Supportive care includes maintaining hydration, proper nutrition, and monitoring for complications.
• In drug-induced hyperbilirubinemia, discontinuation of the offending agent is crucial.

Monitoring and Adjustment

• The effectiveness of treatment is monitored through serial bilirubin measurements, with the goal of preventing complications such as kernicterus in newborns or progressive liver damage in adults with chronic conditions.
• The decision to discontinue phototherapy should be individualized, considering the TSB level at which phototherapy was initiated, the cause of the hyperbilirubinemia, and the risk of rebound hyperbilirubinemia 1.
• Follow-up TSB measurements are crucial after phototherapy discontinuation to ensure that bilirubin levels do not rebound to dangerous levels.

From the Research

Management Approach for Elevated Bilirubin (Hyperbilirubinemia)

The management of elevated bilirubin levels, or hyperbilirubinemia, can vary depending on the underlying cause and severity of the condition. Some key considerations include:

• Phototherapy: This is a common treatment for neonatal hyperbilirubinemia, where the infant is exposed to special lights that help break down bilirubin in the skin 2.
• Ursodeoxycholic acid (UDCA): This medication has been shown to have an additive effect with phototherapy in reducing indirect hyperbilirubinemia in neonates, and may also reduce the duration of phototherapy 2, 3.
• Obeticholic acid (OCA): This is another therapeutic bile acid that has been investigated as a potential treatment for neonatal hyperbilirubinemia, and has been shown to reduce plasma and brain bilirubin levels in animal models 3.
• Extracorporeal bilirubin elimination: This is a treatment option for severe hyperbilirubinemia, where the patient's blood is filtered outside the body to remove excess bilirubin 4.
• Modification of antiviral therapy: In cases where hyperbilirubinemia is a side effect of antiviral medication, modification of the treatment regimen may be necessary to reduce the risk of liver injury or hemolysis 5.

Diagnostic Considerations

It is essential to determine the underlying cause of hyperbilirubinemia, as this will guide the management approach. Some possible causes include:

• Gilbert's syndrome: A benign condition characterized by mildly elevated unconjugated bilirubin levels, which may be associated with a reduced risk of certain chronic diseases 6.
• Hemolysis: A condition where red blood cells are broken down, leading to increased bilirubin production 5.
• Liver disease: Conditions such as hepatitis, cirrhosis, or liver cancer can cause hyperbilirubinemia due to impaired liver function 5, 6.
• Biliary obstruction: Blockage of the bile ducts can cause conjugated hyperbilirubinemia, which may require surgical intervention 5.