From the Guidelines
Management for elevated AST (209 IU/L) and ALT (114 IU/L) should begin with identifying and addressing the underlying cause, and the most recent guidelines from the American College of Radiology 1 suggest that the first step is to discontinue any potentially hepatotoxic medications and avoid alcohol consumption. The pattern of elevation (AST>ALT) may suggest alcoholic liver disease, muscle injury, or certain other conditions, as noted in a study on alcoholic liver disease 1. Additional testing should include hepatitis serologies, autoimmune markers, iron studies, and abdominal ultrasound to evaluate for liver disease, as recommended by the Journal of Autoimmunity 1. While awaiting diagnosis, supportive care includes maintaining adequate hydration and nutrition, and no specific medications are routinely recommended to lower transaminases directly. Some key points to consider in the management of elevated liver enzymes include:
- Discontinuing potentially hepatotoxic medications and avoiding alcohol consumption
- Performing additional testing, such as hepatitis serologies and abdominal ultrasound
- Maintaining adequate hydration and nutrition
- Monitoring liver function tests every 2-4 weeks until values normalize
- Considering lifestyle modifications, such as weight loss, regular exercise, and a balanced diet, to improve liver health. The normal alkaline phosphatase, bilirubin, and albumin levels suggest preserved liver function despite the inflammation indicated by elevated transaminases, as noted in a study on glycogen storage disease type I 1. If transaminases continue to rise or symptoms develop (jaundice, abdominal pain, fatigue), prompt medical evaluation is necessary, and the patient should be evaluated for other possible causes of liver injury, as recommended by the Journal of Autoimmunity 1. It is also important to note that the AST/ALT ratio can be helpful in diagnosing the underlying cause of liver injury, with a ratio of >1.5 suggesting alcoholic liver disease, as noted in a study on alcoholic hepatitis 1. Overall, the management of elevated AST and ALT should be focused on identifying and addressing the underlying cause, and providing supportive care to manage symptoms and prevent further liver damage.
From the Research
Management of Elevated AST and ALT
The management of elevated AST and ALT levels involves a series of steps to determine the underlying cause of the elevation.
- The first step is to obtain a complete history regarding risk factors for viral hepatitis, substance abuse, and other potential causes of liver damage 2.
- The patient's history of alcohol intake, clinical examination, sonography of the abdomen, serum ALT and bilirubin levels should be evaluated 3.
- Laboratory tests such as AST, ALT, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT) should be performed to determine the pattern of liver enzyme elevation 4, 3.
- The ratio of AST to ALT (De Ritis ratio) can help differentiate between alcoholic liver disease (ALD) and non-alcoholic liver disease (NALD), with a ratio greater than 2 suggesting ALD 3.
- Further investigations such as viral hepatitis serology, autoimmune markers, and imaging studies may be necessary to determine the underlying cause of the elevation 2, 5.
- Referral to a hepatologist may be necessary for suspected chronic viral hepatitis and liver cirrhosis 2.
- The patient should be advised to abstain from alcohol and potentially hepatotoxic drugs, and weight reduction may be recommended if the patient is overweight or obese 4.
Differential Diagnosis
The differential diagnosis of elevated AST and ALT levels includes:
- Alcoholic liver disease (ALD) 3
- Non-alcoholic steatohepatitis (NASH) 3, 6
- Chronic viral hepatitis 4, 2
- Drug-induced liver disease 4
- Non-alcoholic fatty liver disease (NAFLD) 6
- Polymyositis, acute muscle injury, acute myocardial infarction, and hypothyroidism as non-hepatic causes of elevated AST and ALT levels 2, 5