OpenHealth Q&A

Evaluating Fluctuating Liver Function Test Results

A 50-year-old female patient with a history of systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD), and several additional rheumatological issues is currently on a medication regimen that includes Benlysta infusions every four weeks, Diclofenac 75 mg twice daily, Gabapentin 200 mg three times a day, and low-dose Aspirin 81 mg daily. She is also taking Estradiol (0.1 mg biweekly, new over the last three months), Cyclobenzaprine 10 mg three times a day, Lunesta 2 mg as needed (approximately four nights a week), Morphine 10 mg as needed with a maximum of three times daily, along with probiotics, vitamins A and D (2000 IU daily), and magnesium every other day. The patient uses acetaminophen very rarely and depends on Docusate depending on her Morphine intake. Recently, Tirzepatide was gradually increased to 10 mg weekly. Routine laboratory tests are conducted every three months to monitor her biologic therapy. In January 2024, her liver function tests revealed an ALT of 72 and an AST of 41, leading to her rheumatologist discontinuing methotrexate. A follow-up assessment two weeks later showed a return to normal liver function. Stability lasted until July 10 when abnormal levels surfaced again, with ALT at 142 and AST at 69. By August 7, hepatitis panels for types A, B, and C returned negative, while GGT was 19 and ALT/AST levels dropped to 13/19. Some intermittent right upper quadrant discomfort prompted an ultrasound, revealing gallstones, which led to a scheduled laparoscopic cholecystectomy in mid-December. Both preoperative and postoperative laboratory results were normal, and liver function tests in February also remained steady. However, on March 5, another set of lab results indicated elevated liver enzymes, with ALT at 192 and AST at 175. Throughout this period, both bilirubin and alkaline phosphatase levels have consistently stayed within normal limits. The patient has not undergone a comprehensive metabolic panel (CMP) since early March, and she abstains from alcohol due to exacerbation of her condition even with minimal consumption. Medications remained unchanged, aside from the introduction of Tirzepatide. It is unclear when exactly she began this medication, but she noted some weight loss that coincided with each elevation in liver enzymes, suggesting she might have been on Tirzepatide during the lab tests. She is certain she took the medication just prior to her March visit—either the day before or the morning of her blood draw. While she has experienced mild discomfort near her liver, she attributed this to the surgical healing process, although it has now been three months since her cholecystectomy. The patient has a gastrointestinal appointment scheduled in two weeks to discuss her liver functions further. However, she is concerned about potentially worrying over health issues during her upcoming trip to Europe next week. Consequently, she has paused the use of Tirzepatide until further consultation occurs. Any insights would be greatly appreciated!

Answers (1)

3/18/2025, 2:20:43 AM

OpenHealth AI

Based on the information provided, it appears that the patient's liver function tests have been fluctuating, with elevated enzymes that are concerning but not uncommon in patients with a complex medical history like hers. Understanding these results, especially in context with her medications and recent surgical history, is essential to interpreting her overall health and managing her concerns.

Key Points:

1. Fluctuating Liver Enzymes: Elevated ALT and AST can indicate liver irritation or damage but monitoring trends is crucial, especially given the negative viral hepatitis panels and consistent bilirubin and alkaline phosphatase levels.
2. Recent Medications: The initiation of Tirzepatide could be contributing to liver enzyme changes, as this medication has known side effects related to liver function.
3. Gallbladder Surgery: Her recent cholecystectomy could have impacted her liver function temporarily, but the timing of enzyme fluctuations must be evaluated.
4. Concerns and Stress: Considering her upcoming trip, it’s understandable that she feels anxious about her health status, especially with ongoing fluctuations in liver tests.

Next Steps:

1. Continue Monitoring: Keep an eye on any symptoms (e.g., abdominal pain, jaundice, fatigue) and document any changes leading up to her gastrointestinal appointment.
2. Pause Tirzepatide: It's prudent to pause Tirzepatide until further evaluation, as this could be a suspect contributor to the liver enzyme elevations. This decision may also help alleviate some anxiety.
3. Review All Medications: Discuss with her healthcare provider the potential implications of her current medication regimen—especially the impact of ongoing medications like Diclofenac and Morphine on liver function.
4. Follow-Up Lab Tests: Ensure that a comprehensive metabolic panel (CMP) is performed soon to provide a clearer picture of liver function. This will help the healthcare team address possible causes of fluctuations.
5. Supportive Measures: Encourage hydration, maintain a balanced diet, and consider stress-reducing techniques, especially before her trip to Europe.

Reassurance:

It’s important for her to remember that fluctuations in liver enzymes can occur for various reasons—many of which are manageable with proper monitoring and adjustments. Regular communication with her healthcare team will provide guidance and reassurance. Enjoying her upcoming trip while focusing on her health will be much easier with these proactive measures in place.