From the Guidelines
Elevated liver enzymes indicate potential liver damage or inflammation, and it is crucial to consult with a healthcare provider for proper evaluation and management, as most causes can be effectively treated, especially when identified early 1.
Causes of Elevated Liver Enzymes
Elevated liver enzymes can be caused by various factors, including:
- Medications (like statins, antibiotics, or pain relievers)
- Alcohol consumption
- Viral hepatitis
- Fatty liver disease
- Autoimmune conditions
Evaluation and Management
The healthcare provider will likely recommend:
- Lifestyle modifications, such as limiting alcohol intake, maintaining a healthy weight, eating a balanced diet, and regular exercise
- Discontinuing certain medications temporarily
- Further testing, including a complete metabolic panel, hepatitis screening, ultrasound, or in some cases, a liver biopsy
- Treatment depends on the underlying cause, such as antiviral medications for hepatitis, weight loss for fatty liver disease, or medication adjustments if drug-induced
Importance of Monitoring
Monitoring liver enzymes through follow-up blood tests is essential to track improvement, as liver enzymes (ALT, AST, ALP, GGT) are released into the bloodstream when liver cells are damaged, serving as important biomarkers for liver health assessment 1.
Key Considerations
It is essential to consider other liver disorders and conduct testing as appropriate, such as evaluating for genetic/metabolic liver disease, autoimmune hepatitis, Wilson’s disease, coinfection with hepatitis C virus (HCV), hepatitis D virus (HDV), or human immunodeficiency virus (HIV), heavy alcohol usage, or drug hepatotoxicity, depending on the patient’s history 1.
From the FDA Drug Label
Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogue inhibitors, including entecavir, alone or in combination with antiretrovirals. Increased transaminases.
Elevated liver enzymes can occur with entecavir use, as evidenced by reports of lactic acidosis and increased transaminases 2, 2, and 2.
- Lactic acidosis has been reported, often in association with hepatic decompensation, other serious medical conditions, or drug exposures.
- Increased transaminases have been reported during postmarketing use of entecavir. It is essential to monitor hepatic function closely with both clinical and laboratory follow-up for at least several months in patients who discontinue anti-hepatitis B therapy, including entecavir.
From the Research
Causes of Elevated Liver Enzymes
- Elevated liver enzymes can be caused by various factors, including hepatocellular liver injury, cholestasis, and isolated hyperbilirubinemia 3
- Hepatocellular liver injury is characterized by elevations in serum alanine (ALT) and aspartate (AST) aminotransferases, while cholestasis is associated with elevated serum alkaline phosphatase (ALP) levels 4
- The most common causes of abnormal liver testing include alcohol-use disorder, suspected liver disease, and medication adverse effects 5
Evaluation and Management
- Evaluation of elevated liver enzymes should be guided by both the clinical presentation and the pattern of injury 5
- A step-wise algorithm can be used to interpret abnormal elevation of liver enzymes in asymptomatic patients, classifying enzyme alterations on the basis of pattern (hepatocellular, cholestatic, and isolated hyperbilirubinemia) 3
- Initial investigations should include liver function tests, such as ALT, AST, and ALP, as well as tests for hepatitis B and C infections 6
Special Considerations
- Patients with pre-existing liver disease, such as hepatitis B and C infections, are at increased risk of liver toxicity when taking antiretroviral therapy 6
- Alcohol drinking and viral hepatitis can synergistically cause liver injury in patients with chronic liver disease, and several mechanisms have been implicated in exacerbation of liver injury in these patients 7
- Minor enzyme elevations (< 5-fold upper normal limit) are generally safe to tolerate and usually resolve, but patients must be closely observed with regular liver function tests 6