elevated ALT - questions

[hotpuppy]

I'm concerned about elevated ALT/AST numbers in my bloodwork. 

3 months ago my ALT was 155 and my AST was I think 65.
2 months before that the ALT was 88, don't recall the AST.

I do not believe that I am HCV+.  Although everything I'm reading suggests that we should test for it.

I am in a drug study.  Vicriviroc + Reyataz + Norvir.

I suspect this is a reaction over time to the Reyataz and Norvir.

I've had high bilirubin the whole time.... which suggests drug impaired liver function, which was somewhat expected. 

I am of course free to stop the study at any time, however, it would leave me in a bind for my HIV meds because my insurance won't cover them until Dec 1st and I make too much this year for Ryan White coverage.

The study has worked well for me other than the liver enzymes being elevated.

They did draw blood Friday.  We'll have the results back Tue/Wed. (This is normal).

They said that if the ALT is at grade 3 that I'm out of the study regardless.  What would grade 3 be?  I forgot to ask.

My own position is that I'm out of there if it is causing permanent damage.   

Apparently they are dead set on using reyataz because my study doc and I have both asked about switching to a different PI.  So apparently failing a patient out over the PI choice is preferable to keeping them on the investigational drug.....

Anyhow, I have no history of drinking, drug use, or hepatitis. 

It appears that some elevation of liver enzymes is normal for HIV patients, but I'm not sure what is acceptable and where the danger areas are.

[markaj]

Hey hotpuppy,

All ARV classes can cause elevated liver numbers.  Abnormal liver function tests are graded from 1 (ALT 2-3x upper limit of normal, to 4 (ALT >10x upper limit of normal.  Grade 3 is when the number are greater than 5x the upper limit of normal.  If your numbers are high enough for grade 4 then you would normally have to stop the offending drugs.  All labs have different ranges but a rough guide would be ALT 0-63 and AST 15-37.

I was on the same Reyataz, Norvir combo with Truvada, and a routine liver test came back as abnormal - my ALT was 540 and bilirubin 113. I can't remember the AST.  When the test was repeated the ALT was 394 and bilirubin 153.  My ALT numbers were classed as grade 4 and I was pulled off all my drugs.

They ran a HCV test, which should be done as routine in these circumstances and it unfortunately came back positive.  I could only have caught this from unprotected sex with my HIV+ partner at that time.  Like you I had no history of drinking, drug use or hepatitis.

They should definitely test for HCV to be on the safe side.  As for permanent damage I had an ultrasound and even with my high numbers there was no sign of damage to the liver, all looked fine. 

Fingers crossed for the Hep C test.

Mark

[Inchlingblue]

 
I've had high bilirubin the whole time.... which suggests drug impaired liver function, which was somewhat expected. 

acoording to aidsmeds.com elevated bilirubin levels due to Reyataz does not suggest impaired liver function:

Increased bilirubin can also be a sign of liver damage. However, in people who have taken Reyataz in clinical trials, an increase in bilirubin has not been associated with any other signs of liver damage.

LINK:

http://www.aidsmeds.com/archive/Reyataz_1563.shtml

[Ann]

Pup,

ANYONE who has hiv should be tested for hcv as a matter of routine. Get tested.

Ann

[hotpuppy]

All very good responses... .thank you Markaj.  Sorry to hear about your HCV result.  There is conflicting information about HCV out there.  The CDC officially says it isn't transmitted sexually, but a UK study of HIV+ men found that it can be transmitted through unprotected sex.  On the bright side, there are some promising drugs in the pipeline for treating HCV.  The UK study also found that a significant percentage of men were able to clear the HCV with no treatment and another big chunk cleared the HCV with treatment for 1 year. 

I'm changing around when I take my meds for the interim.  I've been taking them in the morning which means that my blood draw is coming an hour after dosing.  If nothing else, taking my vitamins in the morning and my HIV drugs at night will spread out the work that my body has to do.

I'm also going to ask my primary care provider to check for HCV and see if HSV is under control.  I ran across an obscure type of liver impairment caused by HSV (Herpes) that occurs mostly in immune impaired folks (read HIV+).  I doubt that is the case, but in any event it's easier to check then to have issues.  The treatment, incidentally is Acyclovir, which I alread take.  Strangely, hepes is like some scarlet H more so than HIV.  Anyhow, 80%+ of the population has HSV1 and a big enough chunk has HSV2. 

I'd like to add to Ann's comment, I think you are right.... but anyone who is poz and sexually active (safe or not) should also be routinely tested for STIs like Syphillis, Clamydia, and Ghonorrea.  It's too easy to pick up and too easy to treat for anyone to have them. 

[hotpuppy]

Just an update.  got preliminary lab numbers back today and while there was some rise in ALT/AST numbers they are acceptable. 

One benefit of being a study subject is fast lab results. 

[newt]

Normal range for ALT is about 10-50 IU [international units] per litre. Grade 3 would be 5-7.5 times the upper limit of normal ie 250+. Grade 1 or 2, ie under 5 times the upper limit oif nomal is usually not cause for major concern unless it goes on and on being high. There's no special reason why Reyataz should be worse than other PIs for ALT, indeed, if used with the normal 100mg Norvir boost, it could well be better (it's bilirubin this drug usually affects).

Hope this helps.

- matt