What are the implications of Hepatitis (inflammation of the liver) with elevated Liver Function Tests (LFTs)?

From the Guidelines

Elevated liver function tests (LFTs) in hepatitis require prompt evaluation and management to prevent progression to cirrhosis and liver failure, with the goal of reducing inflammation and normalizing liver enzymes, as indicated by the most recent study 1. The approach depends on the type of hepatitis (A, B, C, D, or E) and severity of liver dysfunction.

• For viral hepatitis, specific treatments include entecavir 0.5mg daily or tenofovir 300mg daily for chronic hepatitis B, and direct-acting antivirals like sofosbuvir/velpatasvir 400/100mg daily for 12 weeks for hepatitis C, as recommended by 1 and 1.
• Supportive care is essential for all types, including adequate hydration, rest, and avoiding hepatotoxic substances like alcohol and acetaminophen.
• Patients with markedly elevated LFTs (ALT/AST >1000 IU/L) may require hospitalization for monitoring, as suggested by 1.
• For autoimmune hepatitis, prednisone 40-60mg daily with azathioprine 50-150mg daily is typically used, as indicated by 1.
• Regular monitoring of LFTs every 2-4 weeks initially is recommended to assess treatment response, with adjustments made as necessary to prevent liver damage and promote recovery, as emphasized by 1 and 1.
• Severe cases with signs of liver failure (encephalopathy, coagulopathy, jaundice) require immediate specialist referral, highlighting the importance of timely intervention in preventing long-term complications, as noted by 1 and 1.

From the FDA Drug Label

Severe acute exacerbations of hepatitis B have been reported in patients who have discontinued anti-hepatitis B therapy, including entecavir Hepatic function should be monitored closely with both clinical and laboratory follow-up for at least several months in patients who discontinue anti-hepatitis B therapy. Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogue inhibitors alone or in combination with antiretrovirals

The implications of Hepatitis (inflammation of the liver) with elevated Liver Function Tests (LFTs) are:

• Severe acute exacerbations of hepatitis B can occur, especially when discontinuing anti-hepatitis B therapy
• Close monitoring of hepatic function is necessary for at least several months after discontinuing therapy
• Lactic acidosis and severe hepatomegaly are potential risks, including fatal cases, associated with the use of nucleoside analogue inhibitors 2

From the Research

Implications of Hepatitis with Elevated Liver Function Tests (LFTs)

The implications of hepatitis with elevated LFTs can be understood by examining the various biochemical tests and their underlying biological basis.

• Hepatitis, or inflammation of the liver, can be indicated by abnormal LFTs, which are a common problem faced by physicians 3.
• The liver is a complex organ with multiple roles, and key biochemical markers of hepatic function can be organized into groupings of hepatocellular, cholestatic, or functioning liver, based on underlying enzymatic roles 3.
• Pathologic alterations to these markers can be algorithmically assessed by separating disease processes of these groupings, followed by assessment of the magnitude of enzymatic elevation 3.

Prescribing Considerations

When prescribing medications to patients with abnormal LFTs, it is essential to establish the cause of the abnormal liver function and determine if the patient has cirrhosis, as this will have broad-reaching implications for prescribing 4.

• Idiosyncratic drug reactions are equally common in patients with normal or abnormal liver function, and drugs with predominant hepatic metabolism and/or excretion should be used with caution in advanced liver disease 4.
• In the presence of decompensated cirrhosis, prescribing practices are likely to need altering 4.

Laboratory Evaluation

Laboratory evaluation of patients with suspected or established liver disease involves a broad array of biochemical tests, referred to collectively as "liver function tests" (LFTs) 5.

• LFTs are used to screen people for the presence of liver disease, suggest the underlying cause, estimate the severity, assess prognosis, and monitor the efficacy of therapy 5.
• Abnormal LFTs may be the first indication of subclinical liver disease and may guide further diagnostic evaluation 5.

Testing Strategies

The usefulness of LFTs in patients with no pre-existing or self-evident liver disease has been assessed in studies, and various testing strategies for viral hepatitis have been compared 6.

• A cost-minimization analysis has been used to define a base case and calculate the incremental cost per case detected to inform a strategy for identification of patients with chronic viral hepatitis 6.
• A "fast and frugal" heuristic has been produced to guide general practitioners with respect to diagnosing cases of viral hepatitis in asymptomatic patients with abnormal LFTs 6.

Hospitalized Patients

Evaluation of abnormal LFTs in hospitalized patients is typically more urgent than in the outpatient setting and should be organized into four steps: determining the association with the illness, determining the etiology of the underlying liver disease, evaluating the severity of liver dysfunction, and looking for associated complications 7.

• The presence of acute liver failure (ALF) or acute decompensation of chronic liver failure should be determined, and associated complications should be identified 7.