What is the treatment for high bilirubin levels?

Treatment for High Bilirubin Levels

The treatment for high bilirubin levels depends primarily on the patient population, with phototherapy being the first-line treatment for neonatal hyperbilirubinemia, while adults require management of the underlying cause after determining whether the hyperbilirubinemia is predominantly conjugated or unconjugated. 1, 2

Neonatal Hyperbilirubinemia Treatment

Phototherapy

• Phototherapy is the primary treatment for neonatal hyperbilirubinemia and should be initiated based on the infant's age, total serum bilirubin (TSB) level, and risk factors 1
• For infants 25-48 hours old, phototherapy should be initiated when TSB reaches 15 mg/dL (257 μmol/L); for those 49-72 hours old, at 18 mg/dL (308 μmol/L); and for those older than 72 hours, at 20 mg/dL (342 μmol/L) 3
• Intensive phototherapy can produce a 30-40% reduction in initial bilirubin levels within 24 hours, with the most significant decline occurring in the first 4-6 hours 1
• For maximum effectiveness, expose as much of the infant's surface area as possible to phototherapy; consider removing the diaper when bilirubin levels approach exchange transfusion range 1

Monitoring During Phototherapy

• TSB should be measured to verify efficacy after starting phototherapy, with timing guided by the TSB trajectory and infant age 1
• For hospitalized infants requiring "escalation of care" (TSB at or approaching exchange transfusion threshold), measure TSB at least every 2 hours 1
• Discontinue phototherapy when TSB has declined by 2-4 mg/dL below the hour-specific threshold at which phototherapy was initiated 1

Exchange Transfusion

• Exchange transfusion is reserved for extreme hyperbilirubinemia not responding to intensive phototherapy 1, 2
• It is a medical emergency when TSB reaches 25 mg/dL or higher at any time 2
• Should only be performed by trained personnel in a neonatal intensive care unit with full monitoring and resuscitation capabilities 2
• Carries risks including death (approximately 3 in 1000 procedures) and significant morbidity such as apnea, bradycardia, cyanosis, vasospasm, thrombosis, and necrotizing enterocolitis 1

Additional Treatments for Neonatal Hyperbilirubinemia

• For isoimmune hemolytic disease, intravenous immunoglobulin (0.5-1 g/kg over 2 hours) is recommended if TSB continues to rise despite intensive phototherapy 2
• Maintain adequate hydration and good urine output to improve phototherapy efficacy, but routine IV fluid supplementation is not necessary unless there is evidence of dehydration 1
• For infants not responding to phototherapy, tin-mesoporphyrin (not yet FDA approved) could potentially prevent the need for exchange transfusion 1

Adult Hyperbilirubinemia Treatment

Diagnostic Approach

• First determine whether hyperbilirubinemia is predominantly conjugated or unconjugated by obtaining fractionated bilirubin levels 2
• Order complete liver function tests including ALT, AST, ALP, GGT, and albumin to assess for liver injury and synthetic function 2
• Measure prothrombin time (PT) and INR to evaluate liver synthetic capacity 2

Treatment Based on Bilirubin Type

• For unconjugated hyperbilirubinemia: Evaluate for hemolysis with reticulocyte count, haptoglobin, and LDH 2
• For conjugated hyperbilirubinemia: Perform ultrasound of the abdomen as the initial imaging study to evaluate for biliary obstruction 2

Management of Specific Causes

• For biliary obstruction: Consider preoperative biliary drainage if total bilirubin exceeds 12.8 mg/dL, especially if major hepatic resection is planned 2
• For hemolytic disorders: Address the underlying cause of red blood cell destruction 4
• For Gilbert syndrome (impaired bilirubin conjugation): Usually requires no treatment as it's a benign condition 4
• For viral or alcoholic hepatitis: Provide supportive care and treat the underlying cause 4

Pitfalls to Avoid

• Do not subtract direct (conjugated) bilirubin from total bilirubin when making treatment decisions in neonates 2
• Avoid delaying appropriate imaging in patients with conjugated hyperbilirubinemia, as early identification of biliary obstruction is critical for timely intervention 2
• Be aware that standard laboratory tests for hemolysis have poor specificity and sensitivity 1
• Remember that in neonates with hemolysis, G6PD levels can be elevated, potentially obscuring the diagnosis in the newborn period 1, 2

Special Considerations

• For infants with G6PD deficiency, intervention is required at lower TSB levels due to risk of sudden increases in bilirubin 1
• The bilirubin/albumin ratio can be used as an additional factor in determining the need for exchange transfusion in neonates 2
• For infants with conjugated bilirubin >25 μmol/L, urgent referral to a pediatrician is essential to assess for possible liver disease 2