From the Guidelines
Elevated liver function tests (LFTs) are a common occurrence in patients with rheumatoid arthritis (RA), particularly during disease flares, with studies suggesting that up to 48.9% of patients on methotrexate may experience abnormal ALT/AST levels above the upper limit of normal 1.
Background
During an RA flare, the inflammatory processes can affect the liver, leading to mild to moderate elevations in liver enzymes such as ALT, AST, and alkaline phosphatase. Many medications used to treat RA, including methotrexate, leflunomide, and NSAIDs, can also cause liver enzyme elevations.
Monitoring and Management
The systemic inflammation characteristic of RA flares can directly impact liver function through the release of pro-inflammatory cytokines like TNF-alpha and IL-6, which affect hepatocyte function. Patients with RA should have regular monitoring of their LFTs, especially when starting new medications or during disease flares.
- If LFT elevations are noted during a flare, it's essential to determine whether they're related to the inflammatory process itself or to medication effects.
- Mild elevations (less than 2-3 times the upper limit of normal) are often transient and may resolve as the flare subsides or with adjustment of medications.
- However, significant elevations warrant further investigation and potential modification of the treatment regimen, as suggested by the 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1.
Recommendations
Regular monitoring of LFTs is crucial for patients with RA, especially during disease flares or when starting new medications, to promptly identify and manage any potential liver enzyme elevations 1.
- The frequency of monitoring should be based on the specific medication used and the patient's individual risk factors, with more frequent monitoring recommended within the first 3 months of therapy or after increasing the dose 1.
- In cases where LFT elevations are noted, a comprehensive plan should be implemented to monitor disease activity and address possible flares, with consideration given to adjusting or discontinuing medications as needed 1.
From the Research
Elevated LFTs in RA Flare
- Elevated liver function tests (LFTs) can be a concern in patients with rheumatoid arthritis (RA), particularly during flares 2, 3, 4, 5.
- Studies have shown that abnormal liver function can occur in patients with RA, with one study finding that 21.6% of patients had abnormal liver function 2.
- Another study found that increased liver enzymes were more frequent in patients taking leflunomide compared to methotrexate 3.
- However, it's worth noting that not all patients with elevated LFTs have underlying pathology, and emergency physicians can use an algorithmic approach to interpret abnormalities and manage patients accordingly 6.
- In the context of RA, elevated LFTs may be related to the disease itself or to the medications used to treat it, such as leflunomide or methotrexate 2, 3, 4, 5.
Management of Elevated LFTs in RA
- The management of elevated LFTs in patients with RA depends on the underlying cause and severity of the elevation 6.
- In some cases, elevated LFTs may be a sign of a more serious condition, such as liver damage or disease, and require prompt medical attention 6.
- In other cases, elevated LFTs may be a side effect of medication, and adjusting the medication or dosage may be necessary 2, 3, 4, 5.
- Patients with RA should be monitored regularly for signs of liver damage or disease, and any concerns should be discussed with their healthcare provider 2, 3, 4, 5.