From the Guidelines
Dilantin (phenytoin) is the most likely medication to cause elevated liver enzymes in this patient, due to its extensive metabolism by the liver's cytochrome P450 enzyme system, which can lead to hepatocellular injury in some patients. Lacosamide and levetiracetam (anti-seizure medications) can occasionally cause liver enzyme elevations but less frequently than Dilantin 1. Metoprolol and Protonix (pantoprazole) rarely cause liver enzyme abnormalities. Levothyroxine, ondansetron, trazodone, and sevelamer are not typically associated with significant liver enzyme elevations.
Some key points to consider:
- The patient's medication regimen includes multiple drugs that can potentially affect liver function, but Dilantin is the most likely culprit due to its well-documented association with liver enzyme elevations 1.
- Regular liver function monitoring is recommended for patients on Dilantin and other antiepileptic medications, especially during the first few months of treatment 1.
- If liver enzyme elevations are detected in this patient, Dilantin would be the first medication to consider as the potential cause, though the other antiepileptic drugs should also be considered.
- Clinical judgement is necessary to determine the relative contribution of a drug or drugs alongside possible concomitant liver disease, taking into account the pattern of liver blood tests, the timing of medication use, and the clinical setting 1.
From the FDA Drug Label
The following adverse events have been identified during post-approval use of levetiracetam ... abnormal liver function test, hepatic failure, hepatitis
- Levitiracetam can cause elevated liver enzymes, as evidenced by reports of abnormal liver function test, hepatic failure, and hepatitis in the postmarketing experience section of the drug label 2.
From the Research
Drugs Causing Elevated Liver Enzymes
The patient is taking several medications, including lacosamide, levetiracetam, Dilantin (phenytoin), levothyroxine, metoprolol ER, Protonix, odansetron, trazodone, and sevelamer. To determine which of these drugs may cause elevated liver enzymes, we can look at the available evidence.
- Lacosamide: There is no direct evidence in the provided studies that lacosamide causes elevated liver enzymes. Studies 3, 4, and 5 compared the efficacy and safety of lacosamide with phenytoin, but they did not specifically mention liver enzyme elevation as a side effect of lacosamide.
- Levetiracetam: Similarly, there is no direct evidence in the provided studies that levetiracetam causes elevated liver enzymes. Studies 3, 5, and 6 compared the efficacy and safety of levetiracetam with phenytoin, but they did not specifically mention liver enzyme elevation as a side effect of levetiracetam.
- Dilantin (Phenytoin): Study 7 does not directly relate to phenytoin, but studies 3, 4, and 5 compared the efficacy and safety of phenytoin with lacosamide. While these studies did not specifically mention liver enzyme elevation as a side effect of phenytoin, study 7 discusses the elevation of liver enzymes in general, but in the context of statins, not phenytoin.
- Other medications: The provided studies do not mention the other medications (levothyroxine, metoprolol ER, Protonix, odansetron, trazodone, and sevelamer) in relation to elevated liver enzymes.
Conclusion Not Provided as per Request
As per the request, no conclusion will be provided, and the response will only include the analysis of the available evidence.
However, it can be noted that:
- There are no research papers provided that directly assist in answering which of the patient's medications cause elevated liver enzymes.
- The studies provided primarily compare the efficacy and safety of lacosamide and levetiracetam with phenytoin, but do not specifically address the issue of elevated liver enzymes in relation to the patient's medications.