From the Guidelines
The most effective intervention to treat elevated liver enzymes is to address the underlying cause, with a focus on lifestyle modifications and management of comorbidities, as evidenced by the 2021 standards of medical care in diabetes 1. When considering the treatment of elevated liver enzymes, it's crucial to evaluate the patient for the presence of nonalcoholic steatohepatitis and liver fibrosis, especially in patients with type 2 diabetes or prediabetes 1. Key interventions include:
- Weight loss, which can improve metabolic abnormalities and is beneficial for fatty liver disease 1
- Glycemic control, which is essential for managing diabetes and its associated liver conditions 1
- Treatment with specific drugs for hyperglycemia or dyslipidemia, which can also improve liver health 1
- Discontinuation of medications causing liver injury when possible
- Consideration of treatments like pioglitazone, vitamin E, or liraglutide for biopsy-proven nonalcoholic steatohepatitis, as these have been shown to improve liver histology 1. It's also important to note that noninvasive tests, such as elastography or fibrosis biomarkers, may be used to assess the risk of fibrosis, but referral to a liver specialist and liver biopsy may be required for a definitive diagnosis 1. Regular monitoring of liver enzymes during treatment is vital to assess the response to the intervention and make necessary adjustments 1.
From the Research
Treatment Options for Elevated Liver Enzymes
- The treatment for elevated liver enzymes depends on the underlying cause of the elevation, which can be determined by evaluating the pattern of liver enzyme elevation and the patient's clinical presentation 2.
- For non-alcoholic fatty liver disease (NAFLD), pioglitazone and vitamin E have been shown to be effective in reducing liver inflammation and fibrosis, and are currently recommended by European and American guidelines 3, 4.
- Vitamin E has been found to slightly reduce serum alanine transaminase (ALT) and aspartate aminotransferase (AST) levels in patients with NAFLD, although the evidence is not conclusive 5.
- Pioglitazone has been shown to decrease triglycerides and increase high-density lipoproteins, and may have superior efficacy to vitamin E in fibrosis reduction 4.
- The combination of vitamin E and pioglitazone may have superior efficacy than pioglitazone alone for NASH resolution, although further research is needed to confirm this 4.
Diagnostic Approach
- The diagnostic approach to elevated liver enzymes should be guided by the clinical presentation and the pattern of liver enzyme elevation 2, 6.
- The pattern of liver enzyme elevation can be used to determine the underlying cause of the elevation, with different patterns suggesting different causes such as hepatocellular injury, cholestatic liver disease, or infiltrating liver disease 2.
- Imaging studies such as ultrasound and liver biopsy may be necessary to further evaluate the cause of elevated liver enzymes and to assess the extent of liver damage 2, 6.
Management
- The management of elevated liver enzymes depends on the underlying cause of the elevation and may involve lifestyle modifications, medication, or other interventions 6.
- For patients with NAFLD, lifestyle modifications such as weight loss and dietary changes are recommended as first-line treatment, with medication such as pioglitazone or vitamin E added as needed 3, 4.
- For patients with other causes of elevated liver enzymes, treatment should be targeted at the underlying cause, such as discontinuing a offending medication or treating an underlying infection 6.