What are the aids for managing elevated bilirubin?

Management of Elevated Bilirubin

The primary management of elevated bilirubin depends on the cause, with phototherapy and exchange transfusion being the mainstays of treatment for severe hyperbilirubinemia in newborns, while in adults, treatment should focus on addressing the underlying etiology after determining whether the hyperbilirubinemia is predominantly conjugated or unconjugated. 1, 2

Assessment and Diagnosis

• Determine whether hyperbilirubinemia is predominantly conjugated (direct) or unconjugated (indirect) by calculating the proportion of conjugated bilirubin to narrow down potential causes 2
• For newborns, perform systematic risk assessment for severe hyperbilirubinemia through ongoing clinical evaluation 1
• Check maternal blood type (ABO and Rh) and screen for unusual isoimmune antibodies in pregnant women to identify risk of hemolytic disease 1
• For infants with jaundice, assess bilirubin levels whenever vital signs are measured (at least every 8-12 hours) 1
• In adults with unconjugated hyperbilirubinemia, evaluate for Gilbert's syndrome, hemolysis, or medication-induced causes 2, 3
• For conjugated hyperbilirubinemia, assess for biliary obstruction, parenchymal liver disease, or cholestatic disorders 2, 4

Laboratory Evaluation

• Measure total serum bilirubin (TSB) and direct bilirubin levels 1
• Check blood type (ABO, Rh) and direct antibody test (Coombs') in newborns with elevated bilirubin 1
• Measure serum albumin level, as low albumin (<3.0 g/dL) is a risk factor for bilirubin toxicity 1
• Evaluate complete blood count with differential and smear for red cell morphology 1
• Check reticulocyte count to assess for hemolysis 1
• Consider G6PD testing if suggested by ethnic or geographic origin or if poor response to phototherapy 1
• For adults, evaluate liver enzyme patterns (hepatocellular, cholestatic, mixed) and synthetic function (albumin, prothrombin time/INR) 2

Treatment for Neonatal Hyperbilirubinemia

• For breastfed infants, encourage nursing 8-12 times per day to prevent inadequate intake and dehydration that may contribute to hyperbilirubinemia 1
• Avoid routine supplementation with water or dextrose water in non-dehydrated breastfed infants as it does not prevent hyperbilirubinemia 1
• Use phototherapy according to gestational age and risk factor-based thresholds (see AAP guidelines) 1
• For infants receiving intensive phototherapy:
  • Continue breastfeeding or bottle-feeding every 2-3 hours 1
  • Monitor TSB levels at intervals based on the severity of hyperbilirubinemia 1
  • Consider exchange transfusion if TSB is not decreasing or approaches exchange level 1
• For infants with isoimmune hemolytic disease and rising TSB despite intensive phototherapy, administer intravenous immunoglobulin 0.5-1 g/kg over 2 hours 1
• Perform immediate exchange transfusion for any infant showing signs of acute bilirubin encephalopathy, even if TSB is falling 1

Treatment for Adult Hyperbilirubinemia

• For Gilbert's syndrome, no specific treatment is needed as this is a benign condition 2, 3, 5
• For drug-induced liver injury, discontinue the suspected hepatotoxic agent immediately 2
• For autoimmune hepatitis, administer high-dose corticosteroids (prednisone 40-60 mg/day) with gradual taper 2
• For primary sclerosing cholangitis, consider ursodeoxycholic acid 2
• For Wilson's disease, initiate chelation therapy with D-penicillamine, trientine, or zinc 2
• For hepatitis B infection/reactivation, treat with nucleos(t)ide analogues for elevated HBV DNA 2

Monitoring and Follow-up

• For newborns, discontinue phototherapy when TSB is <13-14 mg/dL 1
• Consider measuring TSB 24 hours after discharge to check for rebound, depending on the cause of hyperbilirubinemia 1
• For adults with mild elevations (<5× upper limit of normal) without symptoms, monitor liver tests periodically while investigating the underlying cause 2
• For moderate-severe elevations or symptomatic patients, monitor more frequently (every 3-7 days) 2

Special Considerations

• Avoid medications that can displace bilirubin from albumin in jaundiced newborns, including certain antibiotics (sulfisoxazole, sulfamethoxazole, dicloxacillin, cefoperazone, and ceftriaxone) 6
• In breastfed infants requiring phototherapy, continue breastfeeding if possible, but temporary interruption with formula substitution is an option to reduce bilirubin levels 1
• Provide supplementation with expressed breast milk or formula if the infant's intake seems inadequate, weight loss is excessive, or the infant appears dehydrated 1
• Consider pharmacologic therapy with tin-mesoporphyrin (if approved) to prevent the need for exchange transfusion in infants not responding to phototherapy 1