December 21, 2016
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New ACG guideline on liver chemistries lowers normal ALT level

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The American College of Gastroenterology has published the first new guideline in over 10 years on the evaluation of abnormal liver chemistries, which provides a framework for physicians to approach this common problem, and notably sets new lower thresholds defining normal serum alanine aminotransferase levels.

“What is unique about the ACG guideline is that for the first time in a liver test guideline, a normal healthy [alanine aminotransferase (ALT)] level is defined for women and men (19-25 IU/L [for women], 29-33 IU/L [for men]), and levels above this should be assessed by physicians,” Paul Y. Kwo, MD, FACG, FAASLD, of the division of gastroenterology/hepatology in the department of medicine at Stanford University School of Medicine, Palo Alto, Calif., told Healio.com/Hepatology. “This decision was based on the emerging data over the past decade demonstrating that ALT levels above our defined thresholds are associated with higher liver related mortality rates across a broad range of populations world-wide including populations from the U.S., Europe, and Asia that is driven in part by the obesity epidemic.”

Paul Y. Kwo
Paul Y. Kwo

Kwo and his co-authors — Stanley M. Cohen, MD, FACG, FAASLD, of the Digestive Health Institute at University Hospitals Cleveland Medical Center, and the division of gastroenterology and liver disease, department of medicine at Case Western Reserve University School of Medicine in Cleveland, and Joseph K. Lim, MD, FACG, FAASLD, of the Yale Viral Hepatitis Program at Yale University School of Medicine in New Haven, Conn. — acknowledged that others have argued against lowering ALT thresholds as it would lead to higher health care costs, unnecessary evaluations, mental anguish and anxiety, and a reduced blood donation pool. However, the guideline authors maintained that the emerging data mentioned above warrant educating clinicians about “the adverse long-term outcomes of these historically non-elevated levels,” and standardizing ALT levels across populations.

“We recognize that it will take time for clinicians to recognize the newer lower limits of ALT levels that should now be considered normal,” Kwo said.

The guideline also provides management algorithms to help clinicians evaluate elevated ALT levels.

“We have devised algorithms that allow a graded approach to those with elevated aminotransferase elevations by categorizing these elevations as minimal, mild, moderate and severe, as well as giving specific guidelines as to when immediate evaluation is required and when a more limited evaluation can be performed with subsequent evaluation if liver chemistries fail to normalize,” Kwo said.

Moreover, the guideline authors provide additional algorithms for evaluating abnormal alkaline phosphate levels and bilirubin levels, “to help clinicians efficiently evaluate these abnormalities including suggested serologic and radiologic evaluations as well as when liver biopsy should be considered,” Kwo added.

This practice guideline is intended to be flexible and adjusted for individual patients, and the quality of evidence used to develop it was classified using a modified grading of recommendation assessment, development and evaluation workup. – by Adam Leitenberger

Disclosures: The researchers report no relevant financial disclosures.