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Avatar universal

ALT/AST normal questions

I have decided to go ahead with treatment in January and my tx is covered to 80%.  I applied for coverage for the remaining 20% to our federal drug plan here and their response is that because my ALT/AST is normal, no treatment is required.

Subsequent reading tells me that some people have normal ALT/AST and yet can have progressed stages of liver damage and high viral load....and that the reverse has also been found, that you can have elevated levels of ALT/AST and yet have none to minimal liver damage.

If you have been / are either of these scenarios, can you weigh in please?  And also, can you weigh in on whether what I've stated is true or false?

First of all, I want to be sure I have my facts right.  Second of all, I'll likely proceed with tx regardless but it's going to be tight.  Third of all, my GI is really, really upset with their position as it's from their "medical expert".  He's written them a really nasty note as he has to include his treatment recommendation along with my application and their expertise trumps his apparently.  

What I'm MOSTLY concerned about ... is that if they're only basing it on ALT/AST levels and this is their expert, there are others who will also be applying who don't have any coverage at all or worse coverage than me who will be turned away for this.  I don't want to let this slide and I want to make sure of my facts before I decide what I want to do about this, both for myself and others with HCV as a whole.

Any info you can share that clarifies the picture here will be greatly appreciated.  Thanks.


135 Responses
Avatar universal
ALANINE AMINOTRANSFERASE (ALT; formerly SGPT): an enzyme (also called alanine transaminase) produced in the liver when the membranes of liver cells break down. ALT levels are measured to help assess the degree of liver damage and determine how well HCV treatment is working. A normal level is below 48 IU/L.

ASPARTATE AMINOTRANSFERASE (AST, formerly SGOT): an enzyme (also called aspartate transaminase) produced in the liver. When liver cells are damaged, AST is released. Elevated levels may indicate liver disease, but are also seen in people with muscle damage. A normal level is below 42 IU/L.

Wasn't sure if I had my terms right.  So have added them here for other "challenged" individuals like me.  The rest of you could explain this in your sleep.
Avatar universal
Yes, everything you say is true, and then some. In fact, you can have stage 4 (cirrhosis) with normal liver enzymes. Whoever is making these decisions is outdated.

One of many articles on the subject. Free Medscape registration may be required for the one below.

Conclusions: A treatment approach that considers host and virus-related variables and optimizes patient and cost benefits may therefore provide more effective management of patients with chronic hepatitis C and normal alanine aminotransferase activity.
206807 tn?1331939784
I know you are in Canada and I am not familiar with procedure there (and the more I am into this, the more I realize that I don’t understand how decisions are made in the U.S) but, does the Federal Drug Plan have the Right to second-guess what the Medical Profession has decided?

BTW I got your email and it looks like I got "turded" to. I have 1 more venue to try and if that fails, I guess I will take a loan out and get started ASAP. I only have a 6-month treatment and really want it get it over with before the South Louisiana Summer is in full force.
86075 tn?1238118691
youre right, this info is so outdated...you should tell them that if you wanna treat...first of all, what they call "normal," for a women particularly, is still elevated...up to 45? I'm in the low 30s 31 ( I think alt), then 28 for ast, and I'm still slightly elevated...most people without hep under normal conditions test out in the teens or lower...and yes, many people with cirrhosis test out "normal" I've read because there isn't a lot cell damage leakage registering like this once your very cirrhotic anyway, in many people...HR would know a great deal more then I would on this...course, it's always better to have these values lower then higher, but it's not a great indication of ongoing liver damage for the most part...any hepatologist will tell you this, what is your grade/stage btw?

People can be symptomatic with (low liver damage) affecting their quality of life, (having an ongoing virus that your body is trying to fight off tends to do that)...

and can have no symptoms with a lot of damage and normal enzymes, this disease is all over the place...they need to factor these issues into their treatment criterion...best of luck with this...
Avatar universal

Thanks for your lending your opinion here.  I registered so I could read that article.  I'm partway through and it's just what I'm after.  I've found a couple others too and each one I read says pretty much the same thing.  In approximately 30% of the cases, ALT/AST does not correspond with the progression of the disease.  

R Glass, that's the question, isn't it.  And if their medical expert trumps all the other physicians/specialists in this province then he/she better be pretty damn good and an expert at everything.  As I said, my GI was very upset and fired off a letter apparently outlining his own experience treating HCV patients.  He's the only GI in my area specializing in HCV.  Unfortunately, I don't like how he talks, or doesn't talk, to me.  When I called initially to ask for specific figures on my viral load, his nurse said "why do you want to know?"  Huh?  And when I talked to her yesterday to get information on when their support group meets, I asked her if she'd heard from the drug plan yet and she actually got this information two weeks ago and decided not to tell me because she didn't have any good news.  So I let her know...less information is not a good thing with me and I can take the bad news as well as the good news and that to me, being more informed is more comforting than being ill-informed.  No wonder I'm going for a second opinion on Dec. 6th.  I need to have faith in what my doc is telling me.

Forseegood....you have always been so supportive in your own ways and I'm thankful for that.  Thanks for your comments also.  I needed to know I was on the right track before I start "makin' some noise". :)  I'm Stage 1, Grade 1.  My ALT is 36 and my AST is 26.  I'm geno 1a/1b. I'm 46 going on 47.  I don't want to get any further along than this and I can fit tx into my life right now so I'm wanting to treat now.  I feel things happening in my body and I feel myself getting more fatigued and I want this done.

First my own family doc told me I had nothing to worry about because my enzymes were normal...then the "expert" at the Health Unit told me the same sort of thing....and now this.  It has upset me every time I hear this sort of logic applied by the medical profession because, to me, it means more people get sicker than they need to and some people die.  To be denied coverage based on ALT/AST levels is just one too much because I know that a number of the people applying won't have ANY coverage and will get turned down and won't have any recourse and possibly not the same..uh..feistiness ... that I might have.  it already upsets me to know that people aren't screened for HCV yet, despite the numbers in Canada being 1 in 100 people that have HCV.  Thank goodness my own doc threw in the HCV test when I asked him to verify what strand of HBV I have.  I'm very lucky that, even though he didn't think I have anything to worry about, he sent me to the GI anyway.  I want other people to be lucky like me.  

Anyway...rant done.  Means nothing without action.
151263 tn?1243377877
Maybe you should lift some weights for a few days and then top it off with several Molsons (or Seagrams). Then go in the very next morning to have your blood sampled and measured for liver enzymes. I suspect they'll be higher (as long as you pumped enough iron and drank enough Molsons, that is). Eh??

In the meantime I would suggest you stop telling stories about nationalized healthcare that are unflattering. Some of our "the grass is always greener/socialized healthcare is what americans need most!" crew will get upset. Please don't burst their bubble. ;-)
338734 tn?1377163768
Amen to what jmjm530 says, "In fact, you can have stage 4 (cirrhosis) with normal liver enzymes. Whoever is making these decisions is outdated."

Apparently livers can be amazing in their ability to compensate even while disease progresses.

This may not persuade the fed mds, but I would sure try to press the issue for more current treatment SOC. Maybe your GI doc can help somehow?

Best of luck whichever way you decide to go.

- Walrus
338734 tn?1377163768
I don't mean to alarm you, but my personal story is perfect example of why not to rely on ALT to detect liver disease or use it as an excuse not to take an opportunity to TX. I share your grief with getting information from the GI. I get much more information here in a couple of days that my GIs have given me for the last 1.5 years. Sounds like you are hanging tough and taking charge of your treatment. I think that is a good thing. Keep it up :)
- W
288609 tn?1240100356
I wish you luck with getting the proper coverage you need. My GI told me the levels can be very deceiving and a biopsy was a better indicator of liver damage. I have low #'s but at 47 for the last year and 1/2 I have had increased jt. pain w/RA showing up, I'm hypothyroid, my visions going and I don't seem to heal anymore. I am now waiting results of my biopsy and I will begin TX in Jan. even if it's a low grade. I just need to do whatever I can to feel better even if it means getting worse.

288609 tn?1240100356
I wish you luck with getting the proper coverage you need. My GI told me the levels can be very deceiving and a biopsy was a better indicator of liver damage. I have low #'s but at 47 for the last year and 1/2 I have had increased jt. pain w/RA showing up, I'm hypothyroid, my visions going and I don't seem to heal anymore. I am now waiting results of my biopsy and I will begin TX in Jan. even if it's a low grade. I just need to do whatever I can to feel better even if it means getting worse.

Have you had a biopsy? The Ins. Co. should start to figure out it is a lot more cost effective to TX earlier than getting on a waiting list for a donor.
338734 tn?1377163768
Biopsy is the gold standard for grading liver disease, short of post TP pathology report!

CmcH - hope your biopsy shows good results and your TX goes well
Avatar universal
In the meantime I would suggest you stop telling stories about nationalized healthcare that are unflattering. Some of our "the grass is always greener/socialized healthcare is what americans need most!" crew will get upset. Please don't burst their bubble. ;-)

Just to be clear, the drug plan "medical expert" is provincial only, not federal so when I say govt it isn't federal I'm referring to in this instance.  And really, so is the situation with testing.  It varies from province to province.  And I have no idea what happens in the other provinces.  I think I'll be finding out though.  Does it vary from state to state in the U.S.?

Overall, I would still take our socialized healthcare over what you have in the U.S. - and I'm not slagging the U.S., just saying.  Our system comes with it's issues, that's for sure and it's probably near or top of the list for most Canadians of the issues of most concern.  However, all things considered, I'd still take this system over being at the whim of various insurance companies.  I don't envy what some of you have to go through.
Avatar universal
Maybe you should lift some weights for a few days and then top it off with several Molsons (or Seagrams). Then go in the very next morning to have your blood sampled and measured for liver enzymes. I suspect they'll be higher (as long as you pumped enough iron and drank enough Molsons, that is). Eh??

Seagrams whiskey you're thinking perhaps - not around anymore!  Or perhaps Sleemans beer.  Maybe that's it, eh?  Cute, Mr. Meet...very cute. :)  I actually do use that little phrase...ALOT. :)  It's very versatile....sort of a multi-purpose word like the venerable word "sh**". ;->
254544 tn?1310779332
this really scares the heck out of me.  My AST/ALT were always normal to just slighly elevated, my liver CT scan was beautiful (except for  hernia I didn't know I had), I had zero Hep C symptoms and had a VERY low viral load of 90,000 (it's still low at 111,000).  My biopsy came back with Stage 3, Grade 3/4 liver damage.

In my humble opinion (as Willy50 says) the only way to determine the true amount of liver damage is with a biopsy.

144210 tn?1273092382
Socialized health care is the only fair alternative! If some people fall through the cracks and die, well too bad, the sacrifice of the few for the welfare of the whole!  Good luck comrades!
86075 tn?1238118691
hey kiddo...didn't know if you were talking about our own medical care here in the US (because indeed, many people DO fall through the cracks and die, I'm sure you'll admit that yourself)...these are always heated issues, but some people felt the need to chime in, so I will too...really like the anti-socialized medicine (or universal health care, as that is what it is ... to make the people who will say "socialized" more comfortable, and not think we're all going communist, which is patently ridiculous I should say)....posters who post on this board, no hard feelings:) but it makes things lively and more informative if we can disagree and debate these issues...

I think here in the US, it's come down to basically this, if you make more money in the workplace, or you got your money from some other means, and you can afford good health insurance, your life is worth more in this society...then someone who is of the working poor, or just plain poor...your life is valued more, that's the long and short of it.

Now some people really don't have much problem with that fact, if they were honest with themselves and everybody else, but no one dares admit it...the politicians would rather say (to not sound like an uncivilized, cruel pragmatist) that they are "working" on these issues, but it's been like this for a long time now, and unless someone comes up with a better plan than *people who have good insurance get care, and those who don't have good insurance get the worst care, or no care at all*...

Unless someone comes up with a better plan than this, and can implement it against the insurance lobbyists, who have most politicians (dems and repubs) in their pockets...this is the way of the land in medical care here in the US, and I don't see any way out of it...

Now many Americans, most if the last presidential elections proved anything, feel the need to be THE BEST in the world....we are "the best" COUNTRY in the world...we have "the best" medical care..."the best" educational system...and on and on and on...problem is, we are not "the best" in everything, far from it in some cases, but if you say this publically, you're somehow "unpatriotic" and/or ungrateful to live here....and you should go elsewhere to live...don't dare to critisize the best country in the world. Criticizing might mean change, and who wants that? This is a great country, and I'm grateful to live here, but we are far from perfect in all areas.

Because truth be known and not to bag on anybody, most Americans have never been any friggin place else, for them to say this without reservation. A 5 day vacation to Hawaii is not really what I'm talking about here. REALLY, WHY CAN'T THE AMERICANS, WHO HAVE A NEED TO SAY WE ARE THE BEST IN THE WORLD IN THIS OR THAT, JUST SAY, WE ARE THE BEST "FOR ME."

To me, this falls in line with our current pres...who is making gravely important decisions on foreign policy issues, and had never been out of the US before he took up residency in the White house. Does that make any sense to anybody? I guess so.

My sister went to England to die basically, she had been suffering from self-medicating with alcohol and drugs, for her chronic bi-polar and severe depression issues. I know some people have read this before so forgive me. She was a gorgeous, highly intelligent woman who could just not get a handle on her alcoholism. Her boyfriend calls my mother to tell her that she had been "talking gibberish" for a few days, to which my mother exclaimed, get her in a hospital!!!! She was in Liverpool, England and they took her in there, with liver and kidney failure. They called us up to make funeral arrangements with the American Counsel there, cause she had a 5% chance of pulling though. Each night they called us, she miraculously pulled through. She was in the intensive care there for 4 months. She was incubated for the first few.

She had a 24-hour nurse with her "at all times". Physical therapists moving her arms and legs for her circulation. Top specialists there consulting on her case. They knew she was an alcoholic with no money, but they gave her the best care possible, ANYWAY. I have no idea what she cost the English heath care system, one can only speculate. She was there for 5 months. Once they thought she could fly, they put her in a limo with 2 nurses to the airport, flew her first class (they needed the room with her two nurses) flew her to LAX, rented a medical vehicle here, took her to my mothers, and dropped her off.

It's about 5 years later now, and even though she has advanced cirrhosis and will probably need a tp in the coming years, no one knows, she is walking a few miles a day and living a good, sober life, at least in comparison to her previous life.

If this would of happened to her here, and she was in a county hospital in any major American city, what do you think her chances would of been of pulling through? Of getting this type of medical care? They would of let her die and we all know it. Being a poor alcoholic, her life just wasn't worth saving in this society, as we now have it. I think it's terrible that human beings can make that call, and not some "higher deity." But that's how we have it set up now. Yes, we do have great medical care here, as long as you're making money and have good medical insurance.
144210 tn?1273092382
New I'd get a rise out of you!  This needs to be debated because I think we are headed for socialized hc and it scares the he!! out of me. The costs keep going up and the hard working people who play by the rules are getting screwed!  When a political party continues to make people dependant on the government in order to secure power, and then that party raises the taxes on hard working folks to pay for it, well there comes a time to say enough! Help the poor by getting them off the dole and getting them in the game for crying out loud! And quit importing illegal poor for political advantage! Sheesh, enough already! I like you 4c and glad your sis got help, but something has to change for the better and it's not universal healthcare.  
86075 tn?1238118691
uhhh...what political party are you talking about that are making people dependent on the government, in order to secure power? the one that is in power now? The repubs make the government bigger (when they are not paying big money to defense contractors) then anybody else, look at the stats on that, but that's their rallying cry to get at the dems. I guess that's who you mean.

The conservatives are *in* power now Gauf. We have a medical system that costs more then anybody else's medical system in the entire world, faaar more, yet it covers far less people. For all the money we put into it, it's the least efficient medical system than any developed country. Look at the stats on that too. It's a mess. The sky is falling, yet no one wants to touch it for fear of not getting elected. Till a person gets sick, then they are "empowered" to do something about it. That is going around with your eyes open?

You really think the conservatives are helping out the middle class? They are helping the top percentile in the country, most of all, billionaires have never been so rich. The illegal question is a whole different question, the most lax regs on that were done by the conservatives, to help out big business, now that that's out of fashion, they are crying foul now to get people on their bandwagon. It's been the conservatives in power for almost the last decade and we are far worse off, in soooo many areas, with giant deficits- then any prior time in recent history. Even the repubs are saying this pres is probably the worst in recent history, yet he was only following conservative policy. They are scapegoating Bush now, and won't mention his name, and calling up dead presidents for god's sake.

This no-holds-barred free market policy of the conservatives - of letting loan companies give mortgages to people who clearly can't afford to buy a house, is on the verge of taking down the whole economy with it. But never fear, those people at the top of the loan companies got rich.

It's not just people "on the dole" who can't get decent medical care in this country, but many middle class people "who work" can't afford medical insurance. In fact, MILLIONS of them.

When a society deems that only people that are making good money are worth saving once a medical crisis befalls them, and a poorER person is not worth saving, and they let them DIE BECAUSE OF IT....that is what scares the he** out of me.

Because I don't know if you've noticed, but there are plenty of WORKING middle class and poor people who are good, kind, decent people, and plenty of rich people who are sons of you know what's...(not to say all moneyed people are a-holes, I know plenty of them, and there are good and bad like all the sects of society) but we have it set up that the moneyed people are the ones whose skins will be saved? That make a lot of sense to you or anybody else? You think we have a bad reputation in the rest of the world for this - for nothing? Other countries take care of their people when they get sick, the developed ones anyway. How can you build a society that does anything else?

And this is coming from a person who does make decent money, and has great medical insurance. But I'm just not on this planet to look out for my own best interests. If a society falls, we all fall.

144210 tn?1273092382
I was talking primarily of liberal democrats, however I am nearly as disgusted with the republicans. I am a conservative, but vote independent.  I am hard working and my wife is disabled. I spent 5 hrs sitting in the ER of our local hospital on Tuesday before we saw a doctor. My wife had emergency angioplasty on an arterial blood clot. People were lined up with no where to sit. We all felt like cattle! Believe me, I know the system needs help. My health insurance and med co-pay has bankrupted me. I have to float a loan just to get some Alinia. And I am pissed at the government for the reasons stated before, and pissed at tort lawyers, and pissed at the large pharmaceutical lobbyists, and on and on... There is plenty of blame to go around all sides. I just know that socialized health care is not gonna fix it. Gonna make it worse. And my opinion has nothing to do with who or who does not deserve to have medical care. The care I receive for my family is sub par and getting worse.  Conservatism is NOT necessarily republican. These fat cat corporations are a huge problem and I support no one who unfairly supports them. I am a christian as well, and when I see liberal leaders attacking my faith, I fight back. We agree there is a problem, and looking around to see who is to blame, well I think honestly it is power hungry politicians on both sides.
86075 tn?1238118691
I could debate more, but I'll leave it as a agree to not agree, although I think your last post had some salient points...I like you too much, and I think you deserve a break today, practically and metaphorically...best of luck to you and your family, your wife has a really good husband...
144210 tn?1273092382
We probably are not that far apart on our views, or maybe we are, but I do like you 4C and know you have a big heart. God Bless.
151263 tn?1243377877
Actually my comments may have seemed like a joke when I referred to working out and drinking alcohol for a few days just prior to getting your blood sampled for liver enzymes. But I'm not kidding. If I were in your shoes, and I wanted treatment and some a-hole/idiot was standing in my way based on "normal enzymes", then I'd produce some elevated enzymes for him. I'm not sure if you're aware of this but physical exertion that strains muscles causes them to release enzymes that are similar to liver enzymes. This could make your liver enzymes appear higher than they actually are. Also, obviously drinking a six pack of beer (or several shots of whiskey) the night prior to getting your blood sampled again should elevate your enzymes at least some. And yes it's unfortunate that you might have to resort to such shenanigans to get access to treatment, but if that's the "one obstruction", then I'd work around it by demonstrating elevated enzymes (more than once if necessary).

As far as socialized healthcare, the story you describe is the thing I hate and fear most about govt run healthcare. Some lazy, stupid, largely unaccountable and completely incompetent bureaucrat sitting up in an unreachable ivory tower “somewhere” making life and death decisions for people like you and me. Rationing potentially lifesaving healthcare as HE sees fit as opposed to how you see fit and as opposed to what you actually need for your well being and possibly even for your very *survival*. And as you can see, he’s not making very good decisions at all, and according to your story, not even listening to reason when his utter and complete incompetence is specifically brought to his attention. Any asshat clown could go online and within 5 minutes determine that normal liver enzymes have no bearing on the determination of HCV disease progression or status (much less a “medical expert” like this idiot is supposed to be). Here in the states, the only place I've heard of something like this happening is in prisons. I remember reading that if an HCV prisoner was found to have normal enzymes, they were not considered to be in need of treatment. And do prisoners have insurance and are they being denied healthcare access as a result of that lack of insurance? No. Their healthcare is provided by either state or federal agencies. Funny how these similarities crop up in two separate countries that utilize similar state run healthcare strategies. But as you’ve described yourself, it’s anything but funny. That incompetent government bureaucrat you’re fighting could cost you your life. Imagine how many other people’s lives he may already have either directly or indirectly ended or otherwise put into perilous situations.

In the meantime, hope you get it worked out. If you want treatment, don’t give up. When there’s a will, there’s a way.
Avatar universal
"Some lazy, stupid, largely unaccountable and completely incompetent bureaucrat sitting up in an unreachable ivory tower “somewhere” making life and death decisions for people like you and me."

How is that any different than what we get from the insurance companies right now?
151263 tn?1243377877
pigeoncaquote: "How is that any different than what we get from the insurance companies right now?"

Well for one it means we still get to treat for HCV even if our enzymes are normal (unless you're in prison where the govt is calling "the shots" for you (as it is in Canada for everyone)). That's why you may have seen so many people on this forum (from the US) that have low to normal enzymes and yet they still are able to treat anyway. For another, blatant incompetence or outright unlawful denial of coverage for a legitimate illness (like HCV for instance) exposes a private corporation (i.e. the insurance co) to SUBSTANTIAL legal penalties (and perhaps even criminal charges depending on the situation). It may not necessarily be easy for a sole private citizen to take an insurance co to court, but as everyone knows in the US there's a whole "ecosystem" of lawyers who feed off of our medical system (via both legitimate and frivolous lawsuits). Especially when it comes to class action suits where the profit from a successful case could be stupendous. These class action suits can and are waged against the medical providers, the pharmaceutical industry and against insurance companies ALL THE TIME. There's also the constant threat of more overt governmental regulation (including the implementation of socialized healthcare!) that will diminish insurance company profits if insurance companies are too heavy handed with patients. This is also why pharmaceutical companies have implemented programs like "Committment to Care", where *very* expensive (and patented) drugs are provided free of charge to those who do not have insurance/coverage and cannot easily afford them. All of these factors are amongst the various checks and balances that work in the favor of the sole citizen and against insurance companies should they misbehave. On the other hand, if the incompetent governmental bureaucrat replaces the private corporation's counterpart, the possible legal remedies and the "accessibility" (from a disgruntled patient's perspective) to that bureaucrat decreases. I'm not familiar with Canadian law or the intricasies of its healthcare system, but I would imagine the aforementioned "medical expert" that's making these awful denial of care decisions for trish, is essentially untouchable - as is the Canadian government, his employer.

Another primary factor that goes against the patient in socialized healthcare, is that the patient is no longer a customer that either directly or indirectly vectors money from themselves into the insurance co and into their chosen healhcare provider. In socialized healthcare, the patient is a number in the purest sense. There is no financial reward for the healthcare provider that may be withdrawn in the event the patient is unhappy with the service or care they're being provided. The patient has been financially emasculated (via excessive taxation), the money for the medical services they are provided do not come (directly) from them. The money comes from the government (which of course comes from the citzens as a group), and it will not be curtailed simply because a single patient decides to go elsewhere for treatment (should they even have that option without paying out of their own pocket). Furthermore, with private healhcare insurance, they will lose customers if an excess of them decides they're not being treated properly. That's why healthcare insurers compete for customers, because they want to make money like any corporation. If they mistreat their customer base too badly, people will switch en masse. In the socialized system, the government is the "insurer". If you're not happy with the way they're providing your healthcare and you wish to switch providers, you basically have two immediate options: (1) leave the country, and (2) organize a revolution (which may lead to serious health related issues in and of itself).

In short, turning the keys of your life over to the government is a MISTAKE. Generally speaking, socialism sucks.
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