How to manage a mildly elevated total bilirubin level?

From the Guidelines

Managing a mildly elevated total bilirubin level of 1.6 typically involves identifying and addressing the underlying cause while monitoring levels over time, with a focus on lifestyle modifications and potentially discontinuing offending medications, as outlined in the 2018 guidelines on the management of abnormal liver blood tests 1. To approach this, it's crucial to first determine if the elevation is due to unconjugated (indirect) or conjugated (direct) bilirubin, as this helps narrow down potential causes. For unconjugated hyperbilirubinemia, common causes include Gilbert's syndrome, hemolysis, or certain medications, while conjugated elevations may indicate liver disease or biliary obstruction. Some key points to consider in management include:

• Lifestyle modifications can help manage mild elevations, particularly in Gilbert's syndrome, including maintaining adequate hydration, eating regular meals, avoiding prolonged fasting, and limiting alcohol consumption, as these measures can help reduce bilirubin levels without necessitating medication.
• Certain medications like phenobarbital (30-60 mg daily) may reduce bilirubin levels in some cases, though they're rarely necessary for mild elevations, and their use should be considered on a case-by-case basis.
• If the elevation is medication-related, discontinuing the offending drug under medical supervision may resolve the issue, highlighting the importance of reviewing a patient's medication list.
• Regular follow-up with healthcare providers is important to monitor bilirubin levels and ensure they don't progressively increase, as this allows for the early detection of any worsening liver function or the development of complications. Bilirubin elevations occur when there's increased production (as in hemolysis), decreased liver uptake or conjugation, or impaired excretion of bilirubin, so identifying which process is affected guides appropriate management strategies, and this approach is supported by the most recent and highest quality evidence available, including the 2020 consensus guidelines on the detection, assessment, and management of suspected acute drug-induced liver injury 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Managing Mildly Elevated Total Bilirubin Level

To manage a mildly elevated total bilirubin level of 1.6, consider the following:

• The cause of the elevated bilirubin level should be assessed, as it can be due to various factors such as hemolysis, decreased hepatic bilirubin clearance, or genetic disorders 2.
• In cases of antiviral therapy, modification of the drug choice or dose may be required if liver injury or significant anemia occurs 2.
• For patients with acute-on-chronic liver failure, high levels of bilirubin can predict short-term mortality, and bilirubin can be used as a biochemical marker to improve triage 3.
• In individuals with Nonalcoholic Fatty Liver Disease (NAFLD), higher bilirubin levels are associated with a lower risk of all-cause mortality, which may be derived from a lower risk of cardiovascular/cancer-related mortality 4.

Diagnostic Tests

• The overnight rifampin test can be used to diagnose Gilbert's syndrome, with elevation of total serum bilirubin above 2.4 mg/dL being 93.8% sensitive and 93.3% specific for the diagnosis 5.
• Bilirubin levels can be used to predict short-term mortality in patients with acute-on-chronic liver failure, with conjugated and total bilirubin levels being significant predictors 3.

Treatment and Outcomes

• Treatment of high total serum bilirubin levels in newborns with phototherapy or exchange transfusion is not associated with adverse neurodevelopmental outcomes 6.
• In adults, higher bilirubin levels are associated with a lower risk of all-cause mortality in individuals with NAFLD, but not in those without NAFLD 4.