What are the treatments for elevated bilirubin levels?

Treatment of Elevated Bilirubin Levels

Phototherapy is the primary treatment for elevated bilirubin levels, with exchange transfusion reserved for severe cases that don't respond to phototherapy. 1

Treatment Approach Based on Patient Population

For Neonates (35+ weeks gestation)

• Intensive phototherapy is the first-line treatment for neonatal hyperbilirubinemia and should be initiated immediately when total serum bilirubin (TSB) reaches treatment thresholds based on age and risk factors 2
• Exchange transfusion should be performed only by trained personnel in a neonatal intensive care unit when TSB is ≥25 mg/dL or fails to respond to intensive phototherapy 1
• Intravenous immunoglobulin (0.5-1 g/kg over 2 hours) is recommended for isoimmune hemolytic disease when TSB continues to rise despite intensive phototherapy 1

For Adults with Elevated Bilirubin

• Treatment depends on whether hyperbilirubinemia is predominantly conjugated or unconjugated, which should be determined through fractionated bilirubin levels 1
• For unconjugated hyperbilirubinemia, evaluate for hemolysis with reticulocyte count, haptoglobin, and LDH 1
• For conjugated hyperbilirubinemia, ultrasound of the abdomen should be performed to evaluate for biliary obstruction 1
• Preoperative biliary drainage should be considered if total bilirubin is >12.8 mg/dL, especially if major hepatic resection is planned 1

Phototherapy Implementation

Optimizing Phototherapy Effectiveness

• Use light sources that deliver irradiance in the blue-green spectrum (430-490 nm) for maximum bilirubin isomerization 2
• Expose maximum body surface area by removing diapers when bilirubin levels approach exchange transfusion range 2
• Position light sources to achieve optimal irradiance (typically 8-10 μW/cm²/nm) 2
• Change infant's position every 2-3 hours to maximize skin exposure 2
• Continue phototherapy until bilirubin levels fall below treatment thresholds (typically 13-14 mg/dL for readmitted infants) 2

Expected Response to Phototherapy

• Clinical impact should be evident within 4-6 hours with an anticipated decrease of >2 mg/dL in serum bilirubin 2
• With intensive phototherapy, expect a 30-40% reduction in initial bilirubin level within 24 hours 2
• The most significant decline typically occurs in the first 4-6 hours of treatment 2
• With standard phototherapy systems, expect a 6-20% decrease in the initial bilirubin level in the first 24 hours 2

Hydration and Nutritional Support During Treatment

• Maintain adequate hydration as photo-products are excreted in urine and bile 2
• For breastfed infants with high bilirubin levels who are mildly dehydrated, supplementation with milk-based formula may help lower serum bilirubin by inhibiting enterohepatic circulation 2
• Routine intravenous fluid supplementation is not necessary unless there is evidence of dehydration 2
• Continue breastfeeding during phototherapy to avoid early discontinuation of breastfeeding 3

Monitoring During Treatment

• Serial measurements of bilirubin concentration should be used to monitor treatment effectiveness 2
• For infants with hemolytic disease or those discharged early after phototherapy (before 3-4 days old), follow-up bilirubin measurement within 24 hours is recommended 2
• Monitor for signs of early bilirubin encephalopathy such as changes in sleeping pattern, deteriorating feeding pattern, or inconsolability 2

Special Considerations and Pitfalls

• Do not subtract direct (conjugated) bilirubin from total bilirubin when making treatment decisions 1
• Home phototherapy should only be used for infants with bilirubin levels in the "optional phototherapy" range, not for higher concentrations 2
• Despite historical recommendations, exposure to sunlight is not recommended as a reliable therapeutic tool due to practical difficulties and risk of sunburn 2
• Be aware that phototherapy in infants with cholestatic jaundice may lead to bronze infant syndrome (dark, grayish-brown discoloration of skin, serum, and urine) 2
• Exchange transfusion should be considered in infants with direct hyperbilirubinemia who develop bronze infant syndrome if TSB remains in the intensive phototherapy range despite treatment 2

By following these evidence-based guidelines for the treatment of elevated bilirubin, clinicians can effectively manage hyperbilirubinemia while minimizing the risk of complications such as kernicterus and bilirubin encephalopathy.