From the Guidelines
Evaluation of transaminitis should begin with monitoring patient for abnormal liver blood tests, including AST, ALT, and bilirubin, and reviewing medications and supplements that may cause hepatotoxicity, as recommended by the ASCO guideline update 1. The initial workup should include a thorough history and physical examination, followed by laboratory testing to determine the underlying cause.
- Initial tests should include a complete metabolic panel, complete blood count, and coagulation studies.
- Additional first-line tests include hepatitis serologies (A, B, and C), iron studies, ceruloplasmin level, alpha-1 antitrypsin level, and autoimmune markers such as antinuclear antibody, anti-smooth muscle antibody, and anti-mitochondrial antibody, as suggested by the AGA clinical practice update 1.
- Imaging with ultrasound or CT scan of the liver should be performed to assess for structural abnormalities, and liver biopsy should be considered if the patient is steroid-refractory or if concern for other differential diagnoses that would alter medical management, as recommended by the ASCO guideline update 1. The management of transaminitis depends on the underlying cause, but generally involves treating the primary condition, discontinuing hepatotoxic medications, limiting alcohol consumption, and implementing lifestyle modifications such as weight loss and dietary changes for metabolic causes.
- Common causes of transaminitis include viral hepatitis, alcohol-related liver disease, non-alcoholic fatty liver disease, drug-induced liver injury, autoimmune hepatitis, and hemochromatosis.
- For patients with grade 2 or higher hepatitis, consideration of liver biopsy and potential discontinuation of immune checkpoint inhibitors (ICIs) is necessary, as outlined in the AGA clinical practice update 1. It is crucial to evaluate transaminitis promptly and thoroughly, as persistent elevation of liver enzymes can indicate ongoing liver damage, which if left untreated, may progress to cirrhosis, liver failure, or hepatocellular carcinoma, highlighting the importance of evidence-based management strategies, such as those recommended by the ASCO guideline update 1 and the AGA clinical practice update 1.
From the Research
Evaluation of Transaminitis
- Transaminitis is a condition characterized by elevated liver transaminase levels, which can be caused by various factors, including drug-induced hepatotoxicity 2, 3, 4.
- Studies have shown that certain medications, such as anticonvulsant drugs and nonsteroidal anti-inflammatory drugs (NSAIDs), can cause transaminitis 2, 3.
- Ursodeoxycholic acid (UDCA) has been found to be effective in improving liver transaminase levels in children with anticonvulsant drug-induced hepatotoxicity 2.
- UDCA has also been shown to have a positive effect on serum transaminases and cholestasis indexes in acute viral hepatitis 5.
- In cases of autoimmune-associated chronic hepatitis C, UDCA has been found to improve liver function tests and immunoserological markers 6.
- Monitoring of liver function enzymes is necessary during therapy with potentially hepatotoxic medications, such as NSAIDs, to detect transaminitis early on 3.
- In severe cases of transaminitis, such as fulminant hepatic failure, liver transplantation may be a feasible treatment option 4.