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Drug-Induced Hepatitis?? Bili 29.5

Dear Dr. Schiano,

My 60-year old, non-drinking, non-smoking and otherwise healthy mom got sick 3 weeks ago with jaundice, loss of appetite, darker urine and fatigue.  She had been on Lipitor for 4 years.  Her doctor took her off Lipitor 6 months ago due to elevated AST/ALT levels (160/200).  Four months of no lipitor lowered her numbers to 20/24.  He put her back on Lipitor (cholesterol was up to 236). Within one month being back on Lipitor, mom started having the symptoms listed above.  She was admitted at the hospital where CT scan (normal), biopsy (inconclusive, inflammation present), ultrasounds of the entire abdominal area (normal) were done.

First, they suspected Autoimmune Hepatitis, now they think it may be drug-duced because Prednisone (40mg) should have lowered her numbers in the last 3 weeks.  Except for looking very yellow and needing insulin from the effects of the Prednisone, she feels good.  They lowered her Prednisone last week to 30 and today to 20.  Her numbers today were:

Bilirubin total:  29.5  (25 last week)
AST:  1448  (2500 last week)
ALT:  2572 (3500 last week)
INR: 1.2  (1.4 last week)
ALK:  207
Albumin: 3.1
Hgb:  14.5
Platelet count:  214
Creatimine:  0.6
WBC:  17 (most likely from the Prednisone)

The team of specialists have asked us to be patient and hope that her numbers will go down.  They are concerned about her albumin but think that her liver is still functioning and what works for her are the biopsy results.  They've already done all the needed tests to prep her for a possible transplant but they don't think she's at the accepted level.  It's all so confusing and so new for us.

How many weeks or months would it take for the numbers to possibly go down to normal levels for a patient in her situation?  Could this be 100% drug-induced and later turn into a chronic hepatitis?  Have you seen a case with her numbers before? Any hope that her liver will regenerate completely and be back to normal after these numbers?

Thank you.
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Avatar universal
I forgot to add today's numbers:

INR:  1
Albumin:  3.6
Protein:  7.5
ALK: 486  (was 335 two weeks ago)
MPV:  8.70
MCH: 33.6
Bilirubin: 4
ALT/AST: 704/1036  (was 265/336 two weeks ago)
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Avatar universal
Dr. Schiano,

Sorry to bother you with another question.  Mom's doctors are puzzled by her case.  An ultrasound showed little scaring but they say that it is possible that her liver is trying to regenerate itself after the acute problem she went through.  They reduced her Prednisone to 2.5 for the last 2 weeks.  Her Biliburin is down to 4 but her ALT/AST went up quite a bit 704/1036. They were 265/336 two weeks ago.

She was hospitalized with the flu two weeks ago and was given antibiotics.  We noticed a hike since then but the doctor thinks that the hike is from lowering the Prednisone to 2.5 so they are now suspecting autoimmune hepatitis but at the same time have their doubts because of the blood test numbers.  Everyone is intrigued!  She will have a biopsy this week and they raised her prednisone to 20 again.

Can you think of any possibilities from the pattern that I've been posting?  Her doctors are wonderful but why are they not getting to the bottom of this? They said they've never seen a case like this  ????

Thanks,
Zola
Helpful - 0
517301 tn?1229797785
MEDICAL PROFESSIONAL
i really do not think this is concerning.  the blood tests are the bottom line.  URSO has no side effects really.  people can definitely have less appetite when taking less Prednisone as well as less energy.
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Avatar universal
Last week, they reduced mom's Prednisone to 5mg and added Ursodiol 300mg.  The last few days, I'm noticing that the color of her face/eyes has turned a little more greenish yellow.  Also, she has a little less appetite.

Could this be the effect of reduced Prednisone level OR her liver is reacting negatively to Ursodiol?  Is this concerning?

Thanks,
Zola
Helpful - 0
517301 tn?1229797785
MEDICAL PROFESSIONAL
i think getting the MRI is reasonable.  as long as the bilirubin is going down I think things are OK.
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Avatar universal
Dr. Schiano,

Mom had a blood test done again today.  Her Bilirubin is down to 12.5 now and her ALT/AST are 262/326.  The only concerning numbers are the Alkaline Phosphate (ALK) that's gone up to 489 and her Albumin has dropped even more to 2.8.

They want her to have an MRI to rule out obstruction of bile ducts because of her ALK level.

Her liver numbers seem to go down.  Prednisone was reduced to 5mg.

Any feedback on the Alkaline level?  Is this concerning?

Thanks again,
Zola
Helpful - 0
517301 tn?1229797785
MEDICAL PROFESSIONAL
i am not too concerned ablout the albumin level as it decreases typically when people get sick.  Not sure of the significance of the platelets.  Everything else is trending down which is a good sign.
Helpful - 0
Avatar universal
Dr. Schiano,

Just an update to you.  Mom's liver enzyme levels are dropping as you said they would...

(Blood test result:  Today / 1 week ago / 2 weeks ago)
======================================
Bilirubin total: 23.6 / 30.2/ 29.5
AST:  624/ 830/ 1448
ALT:  660 /1167/ 2572
INR:  1 / 1.1 / 1.2
Albumin:2.9 / 3.1 / 3.1  CONCERNING?
Platelets count: 115/154  CONCERNING?
Phosphate: 2.6 / 2.9  Concerning?

Should we be concerned about her Albumin level being low and platelets count? Is this from the Prednisone?  She's not eating too much protein.

Thanks again,
zola
Helpful - 0
517301 tn?1229797785
MEDICAL PROFESSIONAL
i think that hopefully she will get better as the INR is normal.  the bilirubin always lags behind so hopefully it will eventually come down.  I am hoping that she will not need a transplant.
Helpful - 0
Avatar universal
Dr. Schiano,

Mom had another blood test done today.  The specialist said that she was happy with some of the numbers that got lower (AST/ALT), but is still very much concerned about her Bilirubin which continues to be high at 30 and Albumin at 3.1.  

(Blood test result:  Today / 1 week ago / 2 weeks ago)
======================================
Bilirubin total: 30.2/ 29.5 / 25
ALK: 235 / 207
AST:  830/ 1448/ 2500
ALT:  1167/ 2572/ 3500
INR:  1.1/  1.2 / 1.4
Albumin: 3.1/ 3.1
Creatimine:  0.6 / 0.6


Could there be a hidden or missed cause for bilirubin to continue to go up THIS high at this point?  or is it simply like you said earlier that it would lag and take time to get lower? Why are the doctors concerned and are discussing the possibility of putting her on the transplant list? I calculated her MELD score online and it's 20.

Thanks again,
Zola
Helpful - 0
517301 tn?1229797785
MEDICAL PROFESSIONAL
prednisone can improve a drug-induced liver injury as well as an inducted AIH.  The drug-induced AIH may occur in the absence of a (+) ANA.  The biopsy is the way to make the diagnosis.
Helpful - 0
Avatar universal
Dr. Schiano,

1) Does Prednisone (20mg) help with the drug-induced? Her numbers seem to go lower when they reduce  the dosage.

2) At what point and how can doctors determine if her DILI has or will cause Autoimmune Hepatitis? Her ANA so far is negative.

Thanks again,
Zola
Helpful - 0
Avatar universal
Thank you so much for your opinion Dr. Schiano.  I have two other questions if I may:

1) Does Prednisone (20mg) help with the drug-induced? Her numbers seem to go lower when they reduce  the dosage.

2) At what point and how can doctors determine if her DILI has or will cause Autoimmune Hepatitis? Her ANA so far is negative.

Thanks again,
Zola
Helpful - 0
517301 tn?1229797785
MEDICAL PROFESSIONAL
this sounds like a drug-induced hepatitis (DILI) triggered by the statin.  These can cause an autoimmune-hepatitis and almost always should get better as long as the offending agent is discontinued.  the ALT is getting better which is a good prognostic sign--the bilirubin always lags behind. it can sometimes take several months for total resolution. the INR is OK so I think she should fare well. I have seen similar cases.
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Avatar universal
Sorry, I forgot to mention that her ANA is negative.
Helpful - 0

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