From the Guidelines
You should contact your healthcare provider immediately about your increasing liver function tests, as this is a serious concern that requires prompt medical attention. You're currently taking multiple medications that could potentially affect your liver, including cyclobenzaprine (10mg three times daily), duloxetine (30mg twice daily for 30 days), gabapentin (600mg three times daily), ibuprofen (600mg three times daily as needed), olanzapine (5mg, frequency not specified), and pregabalin (100mg three times daily). Several of these medications, particularly duloxetine, olanzapine, and the combination of multiple drugs, can impact liver function, as noted in the guidelines on the management of abnormal liver blood tests 1.
Key Considerations
- The combination of multiple medications can increase the risk of liver damage, and it's essential to assess the relative contribution of each drug to the rising LFT levels.
- Duloxetine and olanzapine have been associated with liver injury, and their use should be carefully evaluated in the context of rising LFT levels.
- The severity of abnormal aminotransferase can be classified as mild, moderate, or severe, and moderate and severe elevations are considered significant clinical overlap 1.
- Regular monitoring of liver function will likely be necessary to ensure safety, and your doctor may need to adjust your medication regimen, reduce dosages, or substitute certain medications.
Recommendations
- Avoid alcohol completely and don't take any additional over-the-counter medications without consulting your doctor.
- Do not stop any of these medications suddenly without medical supervision, as this could cause withdrawal symptoms or worsen your underlying conditions.
- Your healthcare provider should be consulted immediately to determine the best course of action, considering the potential risks and benefits of each medication, as well as the underlying conditions being treated.
From the FDA Drug Label
In a pharmacokinetic study of sixteen subjects with hepatic impairment (15 mild, 1 moderate per Child-Pugh score), both AUC and Cmax were approximately double the values seen in the healthy control group The plasma concentration of cyclobenzaprine is increased in patients with hepatic impairment Due to the lack of data in subjects with more severe hepatic insufficiency, the use of cyclobenzaprine hydrochloride tablets in subjects with moderate to severe impairment is not recommended Cyclobenzaprine hydrochloride tablets should be used with caution in subjects with mild hepatic impairment starting with a 5 mg dose and titrating slowly upward
The patient is taking cyclobenzaprine, DULoxetine, gabapentin, ibuprofen, OLANZapine, and pregabalin.
- Liver function tests (LFTs) are going up, which may indicate hepatic impairment.
- The cyclobenzaprine label warns about the increased plasma concentration of the drug in patients with hepatic impairment.
- The label recommends using cyclobenzaprine with caution in patients with mild hepatic impairment, starting with a 5 mg dose and titrating slowly upward.
- The label also recommends avoiding the use of cyclobenzaprine in patients with moderate to severe hepatic impairment due to the lack of data. Given the patient's increasing LFTs, it is recommended to exercise caution when using cyclobenzaprine and consider reducing the dose or monitoring LFTs closely. However, the best course of action would be to consult the prescribing doctor for further guidance. 2 2 2
From the Research
Medications and Liver Function
The patient is taking several medications, including:
- Cyclobenzaprine 10 mg tablet, taken 3 times a day
- Duloxetine 30 mg capsule, delayed release, taken twice a day for 30 days
- Gabapentin 600 mg tablet, taken 3 times a day
- Ibuprofen 600 mg tablet, taken 3 times a day as needed
- Olanzapine 5 mg tablet
- Pregabalin 100 mg capsule, taken 3 times a day
Potential Causes of Elevated LFTs
Elevated liver function tests (LFTs) can be caused by various factors, including medications. According to 3, antipsychotics, such as olanzapine, can be associated with abnormal LFTs. The study found that all groups receiving regular antipsychotics had a prevalence of LFT abnormalities greater than chance.
Evaluation of Abnormal LFTs
The evaluation of abnormal LFTs should be organized into several steps, including:
- Determining whether the abnormal LFTs are associated with the underlying illness or preceded the present illness 4
- Determining the etiology of the underlying liver disease
- Evaluating the severity of the liver dysfunction and determining if acute liver failure (ALF) or acute decompensation of chronic liver failure is present
- Looking for the presence of associated complications, either those of ALF or chronic liver failure as appropriate
Diagnostic Approach
A systematic, stepwise approach to the evaluation and management of abnormal liver test results is recommended to optimize high-value care 5. This approach should include:
- Review of previous laboratory test results, medical and family histories, substance use, and drugs, including over-the-counter drugs and herbal supplements
- Physical examination results
- Tests, such as complete blood cell count, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, and albumin levels
- Additional tests and imaging should be based on patient-specific risk factors and the pattern of abnormal liver test results 6
Management of Abnormal LFTs
The management of abnormal LFTs should be based on the underlying cause and severity of the liver dysfunction. According to 7, an algorithmic approach can be taken to help narrow the spectrum of a differential diagnosis and ensure appropriate management and evaluation of the patient with elevated LFTs.