From the Guidelines
Dilantin (phenytoin) is the most likely medication to cause elevated liver enzymes among the listed medications. The medications listed include lacosamide, Dilantin (phenytoin), levothyroxine, metoprolol ER, Protonix, ondansetron, trazodone, and sevelamer. According to the guidelines on the management of abnormal liver blood tests 1, Dilantin (phenytoin) is one of the drugs most commonly implicated in liver disease. Some key points to consider:
- Dilantin can cause hepatotoxicity, which may present as asymptomatic elevation of liver enzymes or, rarely, as severe hepatitis.
- Lacosamide and trazodone may also occasionally cause liver enzyme elevations, though less frequently than Dilantin.
- The mechanism of Dilantin-induced liver injury typically involves the production of toxic metabolites during drug metabolism, which can directly damage hepatocytes.
- Patients on Dilantin should have periodic liver function tests to monitor for hepatotoxicity, especially during the first few months of treatment.
- If significant elevations in liver enzymes occur, dose adjustment or medication change may be necessary. Other medications in the list, such as levothyroxine, metoprolol ER, Protonix, ondansetron, and sevelamer, are not commonly associated with significant liver enzyme elevations, though any medication can potentially affect liver function in susceptible individuals 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Drugs Causing Elevated Liver Enzymes
The patient is taking several medications, and some of them have been associated with elevated liver enzymes. The following drugs may cause elevated liver enzymes:
- Lacosamide: A case report describes a patient who developed symptomatic hepatotoxicity after lacosamide administration, with markedly increased liver enzymes 2.
- Phenytoin (Dilantin): This medication has a well-recognized association with liver toxicity, and liver function tests should be monitored in patients taking this drug 3.
- Other medications: There is no direct evidence in the provided studies that the other medications the patient is taking (levothyroxine, metoprolol ER, Protonix, ondansetron, trazodone, and sevelamer) cause elevated liver enzymes.
Mechanism of Liver Enzyme Elevation
The mechanism of liver enzyme elevation varies depending on the medication. For example, lacosamide has been reported to cause hepatotoxicity, which may lead to elevated liver enzymes 2. Phenytoin, on the other hand, has a well-established association with liver toxicity, which may be related to its metabolism in the liver 3.
Monitoring and Management
It is essential to monitor liver function tests in patients taking medications that may cause elevated liver enzymes. If liver enzyme elevation occurs, the medication may need to be discontinued or adjusted, and further investigation may be necessary to determine the cause of the elevation 2, 3.