Using a DMARD in an RA Patient With Elevated Liver Enzymes

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Using a DMARD in an RA Patient With Elevated Liver Enzymes



Question

A female with recently diagnosed rheumatoid arthritis (RA) presents

with a 4-year history of abnormal liver enzymes with no obvious

clinical cause. Her SGOT and SGPT are double the normal levels.

Ultrasound abdomen is normal. She has no other medical conditions.

She has to be started on a disease-modifying antirheumatic drug

(DMARD). Which DMARD drugs would be safe in her case?

Anil Arora, MD



Response from Arthur Kavanaugh, MD

University of California at San Diego, Division of Rheumatology,

Allergy, and Immunology, La Jolla, California.



The presence of abnormal liver functions represents a common

therapeutic challenge in rheumatology patients. In this case, we will

assume that by " no obvious clinical cause " it is implied that other

medications (eg, nonsteroidal anti-inflammatory drugs, analgesics),

toxins (eg, ethanol) infections (eg, hepatitis B/C/A), and other

comorbid conditions (eg, congestive heart failure) have been

excluded, and that the normal ultrasound argues against structural

abnormalities. In this instance, I think that nonalcoholic

steatohepatitis (NASH) should be considered. NASH seems to be a

health problem that is growing in frequency and appreciation, and is

a subject of growing investigation.[1]

For the rheumatologist, the most common clinical dilemma with NASH

relates to clinical management and therapeutic options. Although

there is no evidence of which I am aware that rheumatic therapies

worsen NASH, the fluctuating transaminase levels commonly seen in

patients with NASH, the lack of a highly effective therapy for NASH,

and the potential for hepatotoxicity with DMARDs make therapeutic

choices difficult. Depending on the patient's therapeutic and

clinical history, it might be appropriate to initiate DMARDs that

have a very low association with hepatic disease, such as

cyclosporine, hydroxychloroquine, or sulfasalazine. However, it

certainly would be possible to initiate DMARDs that have been

associated with liver toxicity, including methotrexate, leflunomide,

and tumor necrosis factor (TNF) inhibitors, provided that the patient

is monitored regularly.



Posted 10/20/2005

http://www.medscape.com/viewarticle/513939