From the Guidelines
Transaminitis should be treated by addressing the underlying cause, with the most recent and highest quality study recommending a step-wise approach based on the grade of serum ALT elevation 1. The treatment of transaminitis involves identifying potential triggers such as medications, alcohol, viral infections, or fatty liver disease.
Key Steps in Management
- Stop any hepatotoxic medications and avoid alcohol completely.
- For medication-induced transaminitis, discontinuation often resolves the issue within weeks.
- For alcoholic liver disease, abstinence is essential.
- In non-alcoholic fatty liver disease (NAFLD), weight loss of 5-10% through diet and exercise is recommended.
- Viral hepatitis may require specific antiviral treatments.
Grade-Based Approach
- Grade 1 ALT elevation: closer monitoring (e.g., weekly or bi-weekly) for signs and symptoms of liver injury and hepatic biochemical tests, without treatment interruption 1.
- Grade 2 serum ALT elevation: withholding ICI treatment and initiating close monitoring, with oral corticosteroid therapy (prednisolone, methylprednisolone or equivalent) at a dose of 0.5–1 mg/kg/day if ALT returns to baseline values within 1–2 weeks 1.
- Grade 3 or 4 serum ALT elevation: withholding of ICI therapy and initiating corticosteroid therapy (prednisolone, methylprednisolone or equivalent) at 1–2 mg/kg/day, with consideration of a liver biopsy and addition of mycophenolate mofetil if no response to corticosteroids within 2–3 days 1.
Additional Considerations
- Regular monitoring of liver enzymes (ALT, AST) every 2-4 weeks is important to assess improvement.
- Supportive care includes adequate hydration and a balanced diet low in processed foods.
- Severe cases with signs of liver failure (jaundice, coagulopathy, encephalopathy) require immediate hospitalization.
- A recent guideline update also emphasizes the importance of workup and evaluation for other causes of elevated liver enzymes, including viral hepatitis, alcohol history, and potential liver metastasis from primary malignancy 1.
From the Research
Treatment of Transaminitis
- The treatment of transaminitis is not explicitly stated in the provided studies, but the causes and associations of transaminitis are discussed in various contexts, such as chronic cholecystitis 2, pancreatic islet transplantation 3, hepatitis B virus resistance to nucleos(t)ide analogue therapy 4, irritable bowel syndrome 5, and anorexia nervosa 6.
- In the context of chronic cholecystitis, the study suggests that further research is needed to understand the pathology behind chronic cholecystitis and its impact on liver damage 2.
- For pancreatic islet transplantation, the study found that transaminitis is common and self-limited, and does not signal acute rejection or serious procedure-related complications 3.
- In the case of irritable bowel syndrome, the study proposes a potential relation between elevated ALT levels, metabolic system, and IBS, but further trials are needed to confirm these results 5.
- For anorexia nervosa, the study highlights malnutrition as an important cause of aminotransferase elevations and underscores the need for judicious early weight restoration in patients with anorexia and abnormal liver chemistry 6.
Associations and Causes of Transaminitis
- Transaminitis has been associated with various conditions, including chronic cholecystitis 2, pancreatic islet transplantation 3, irritable bowel syndrome 5, and anorexia nervosa 6.
- The studies suggest that transaminitis can be caused by ischemic, toxic, or inflammatory injury to the liver, leading to the release of biochemical markers such as AST and ALT into the circulation 2.
- In the context of hepatitis B virus resistance to nucleos(t)ide analogue therapy, the study discusses the risk of drug resistance as a threat to treatment outcomes, but does not directly address the treatment of transaminitis 4.
Monitoring and Surveillance
- The study on hepatitis B virus resistance to nucleos(t)ide analogue therapy highlights the need to develop appropriate prevention, monitoring, and surveillance approaches for HBV drug resistance 4.
- In the context of pancreatic islet transplantation, the study suggests that monitoring of ALT levels and other liver enzymes is necessary to assess the severity of transaminitis 3.