When to recheck elevated liver enzymes (transaminases)?

From the Guidelines

If you have raised liver enzymes, you should typically recheck them within 2-4 weeks after the initial abnormal result, as recommended by the most recent and highest quality study 1. This timeframe allows enough time to see if the elevation is transient or persistent. The evaluation of patients with alanine aminotransferase (ALT) and aspartate aminotransferase (AST) elevations should be based on the clinical scenario, and common hepatic diseases should be excluded with noninvasive serologic tests 1. If your liver enzymes are only mildly elevated (less than 2-3 times the upper limit of normal), and you have no symptoms, this follow-up timeline is appropriate. However, if your liver enzymes are significantly elevated (more than 3 times the upper limit of normal) or you have symptoms like jaundice, abdominal pain, or fatigue, you should seek medical attention immediately rather than waiting. Some key points to consider when evaluating raised liver enzymes include:

• The interpretation of all abnormal liver chemistries must be taken in the clinical context of a given patient 1
• The initial evaluation of abnormal liver tests includes a detailed history, inventory of medications, and a physical examination 1
• If one elects observation, close clinical follow-up and serial serum liver chemistry testing is essential 1
• Chronic ALT or AST elevations (6 or more months) usually warrant additional serologic and radiologic evaluations and potentially a liver biopsy 1 During the waiting period, it's advisable to avoid alcohol, review your medications with your doctor as some can affect liver function, and maintain a healthy diet. If the repeat test still shows elevated enzymes, your doctor may recommend additional testing such as ultrasound, more specific blood tests, or possibly a liver biopsy to determine the underlying cause. Liver enzymes can be temporarily elevated due to many factors including medication use, alcohol consumption, viral infections, or fatty liver disease, which is why monitoring over time provides valuable diagnostic information. In patients receiving methotrexate, repeat measurements of serum creatinine, complete blood cell count, and liver enzymes were recommended approximately every 3 to 4 months for patients receiving a stable dose of methotrexate with no recent history of abnormal laboratory monitoring results 1. The frequency of monitoring liver enzymes may vary depending on the clinical scenario and the presence of risk factors for liver disease. For example, when starting methotrexate or increasing the dose, ALT with or without AST, creatinine and CBC should be performed every 1–1.5 months until a stable dose is reached and every 1–3 months thereafter 1. Overall, the management of raised liver enzymes should be individualized based on the clinical context and the presence of risk factors for liver disease.

From the Research

Evaluation of Raised Liver Enzymes

• The evaluation of raised liver enzymes in asymptomatic patients can be challenging due to the lack of a standardized approach 2.
• Studies suggest that extensive evaluation of all abnormal test results would expose many patients to undue risks and expenses, while failure to evaluate minor liver enzyme elevations could mean missing the early diagnosis of potentially treatable disorders 3, 4.

Timing of Recheck

• There is no specific guideline on when to recheck raised liver enzymes, but it is recommended to adopt a step-wise algorithm that classifies enzyme alterations on the basis of pattern (hepatocellular, cholestatic and isolated hyperbilirubinemia) 2.
• The decision to recheck liver enzymes should be based on the patient's clinical presentation, medical history, and the results of initial investigations 5.
• Focused testing becomes the most cost-effective strategy when accounting for pre-test probabilities and prior evaluations performed, especially in the referral setting where assessments for viral hepatitis, alcoholic and non-alcoholic fatty liver disease have already been performed 5.

Factors to Consider

• The magnitude of aminotransferase elevation can be used to categorize abnormalities in liver biochemical tests, with mild, moderate, and severe elevations having different implications for patient management 6.
• The pattern of liver enzyme elevation (hepatocellular or cholestatic) can help guide further investigation and treatment 6.
• Clinicians should consider the patient's history, physical exam, and pre-test probabilities when deciding which tests to order and when to recheck liver enzymes 5.