Is Chymoral (lysozyme) safe to use in patients with deranged liver function tests (LFTs)?

Chymoral Safety in Deranged Liver Function Tests

Chymoral (trypsin-chymotrypsin enzyme combination) can be used cautiously in patients with deranged LFTs, as there is no specific evidence of hepatotoxicity with this agent, but close monitoring is warranted given the general principles of prescribing in liver dysfunction.

Clinical Context and Evidence Gap

The available evidence does not specifically address Chymoral (trypsin-chymotrypsin) use in patients with abnormal liver function tests. However, general principles for prescribing in hepatic dysfunction provide guidance:

General Prescribing Principles in Deranged LFTs

Step 1: Establish the Cause of Liver Dysfunction

• Perform standard investigations including viral hepatitis serology (HBV, HCV), metabolic workup, and imaging to identify the underlying etiology 1
• Investigation should be tailored to clinical presentation and pattern of liver injury 2
• Monitor LFTs twice weekly if the patient is on potentially hepatotoxic medications 1

Step 2: Assess Severity of Liver Dysfunction

• Grade hepatotoxicity severity: mild (<5× ULN), moderate (5-10× ULN), severe (>10× ULN) 3
• Determine if cirrhosis is present, as this has broad implications for drug prescribing 4
• In decompensated cirrhosis, prescribing practices require significant modification 4

Step 3: Risk-Benefit Assessment for Chymoral

• Idiosyncratic drug reactions occur equally in patients with normal or abnormal liver function 4
• Drugs with predominant hepatic metabolism and narrow therapeutic index require caution in advanced liver disease 4
• Chymoral is primarily a proteolytic enzyme with minimal hepatic metabolism, suggesting lower risk compared to drugs requiring extensive hepatic processing

Practical Management Algorithm

For Mild LFT Elevations (ALT/AST <5× ULN):

• Continue Chymoral with close monitoring 5
• Investigate alternative causes of LFT derangement 5
• Monitor LFTs every 2 weeks initially 1

For Moderate-to-Severe LFT Elevations (≥5× ULN):

• Consider withholding Chymoral temporarily 2
• Evaluate for other causes including drug-induced liver injury, viral hepatitis, or underlying chronic liver disease 5
• Reassess need for Chymoral versus alternative anti-inflammatory approaches

For Patients with Established Cirrhosis:

• Use Chymoral with heightened caution 4
• Monitor for signs of hepatic decompensation (encephalopathy, coagulopathy, ascites) 1
• Consider referral if liver function deteriorates despite medication review 1

Critical Pitfalls to Avoid

• Do not attribute all LFT abnormalities to medications - the underlying disease process may be responsible 5
• Do not delay investigation of persistent LFT abnormalities - if tests fail to normalize within 8-12 weeks, investigate for chronic liver diseases 2
• Do not overlook drug-drug interactions - review all concomitant medications for potential hepatotoxic effects 5
• Do not ignore signs of hepatic decompensation - urgent referral is needed for progressive deterioration, acute liver failure signs, or severe elevation with bilirubin >2× ULN 3

Monitoring Strategy

• Baseline LFTs before initiating Chymoral if liver disease is suspected 1
• Repeat LFTs at 2-4 weeks after starting therapy 3
• If LFTs remain stable, extend monitoring interval to monthly for 3 months 3
• Increase monitoring frequency if any elevation occurs 1