POZ Community Forums
Meds, Mind, Body & Benefits => Questions About Treatment & Side Effects => Topic started by: atlq on August 11, 2008, 10:46:08 pm
-
I just got some lab results in today. I had started a Intelence, Isentress, Truvada combo on the 25th. So today we were checking my liver function (ALT and AST). In all the years I have been positive, they have always been in the normal range..until today. Got this back:
Component Your Value Standard Range Flag
ALT 152 9-33 IU/L H
AST 68 12-41 IU/L H
ALKALINE PHOSPHATASE 53 42-121 IU/L
BILIRUBIN, TOTAL 0.9 0.1-1.0 mg/dL
BILIRUBIN, DIRECT 0.1 0.0-0.2 mg/dL
TOTAL PROTEIN 7.1 6.0-8.3 g/dl
ALBUMIN 4.0 3.5-4.8 g/dl
ALBUMIN/GLOBULIN RATIO, SERUM/PLASMA 1.3 -
It must be one of the new meds (I have been on Truvada with no issues) . I know we have some knowledgeable folks out there...anyone care to offer a theory? ...and that ALT number-cause to panic or just something to watch? How high can an ALT number go before it indicates serious liver damage?.....Thanks!...
-
One test is unreliable.
The ALT is kinda high, on the edge of the top of Grade 2 (out of 4) seriousness.
ALT 7.5-10+ times top of normal limit consistently = serious worry, but it can go much, much higher than this. AST flaky indicator of liver damage, ignore.
I am inclined to suspect the NNRTI but, Truvada aside, the drugs is new and there ain't a lot of data on them, so who knows eh?
- matt
-
Yeah, I'd suspect the Intelence but like matt says it's new. I can't even think of anyone on aidsmeds that's on it, and I don't think anyone in my local LTS support group is either. I know many people, however, on Isentress - and of course myself - and nobody has spoken to results like this.
So what did your doctor say?
-
On reflection, it could be both/either new drugs
The reported rate of liver enzyme abnormalities (Grade 2 or higher) is about 5% for Intelence and and 8% for Isentress. El nurso who has popped in for a glass of wine sez she would expect bilirubin to be high if it was the Isentress, but also agrees with who knows? etc.
-
The nurse drinks wine while working? Fascinating :)
-
Matt, Philly,
Thanks. I had a battery of various tests yesterday ( VL,metabolic panel...), so my doc is waiting for all the results to roll in before we talk about it.
I suspect the Intelence also may be the "culprit", but as you guys said, with these drugs being so new, who knows? Being a pioneer!-what fun!
And yeah, Matt one test is not reliable I guess....maybe the bod will adjust a bit to the new meds...I'm just a little unclear on how high these numbers have to consistently be before we have to stop and look at each drug....
-
The nurse drinks wine while working?
natch! we wish...a friend n a social visit to return tent borrowed for a festival
On the liver enzymes, 5-10 times top of normal range long term, like 3-6 months+ is prob cause for concern
- matt
-
Thanks...I'll let ya'll know the outcome of our discussion.....
-
oops...just read my subject line header...yes, I realize there is no such thing as a "Blod Test"!....I really need to wear my glasses when typing...
-
Doctor wanted to retest my liver numbers. He had me eliminate alcohol. These results are in today, 6 days after the original results I posted earlier:
Component Your Value Standard Range Flag
ALT 131 9-33 IU/L H
AST 62 12-41 IU/L H
ALKALINE PHOSPHATASE 52 4 2-121 IU/L
BILIRUBIN, TOTAL 1.2 0.1-1.0 mg/dL H
BILIRUBIN, DIRECT 0.2 0.0-0.2 mg/dL
TOTAL PROTEIN 7.4 6.0-8.3 g/dl
ALBUMIN 4.4 3.5-4.8 g/dl
O.K. Obviously treatment is going to have to modified....my question: would it be wise to remove one med for a week, test, then reintroduce it if it is not the culprit? Or should I stop everything,and go back to square one in drawing up a regimen?
I can't have any resistance to the Isentress or Intelence at this point, but would removing the Truvada short term increase the risk of developing resistance to those drugs?
-
I would be inclined to simplify/change 1 of the I drugs but leave the nuke backbone. Depends on whether you are undetectable. If not I would wait til undetectable then simplify or change one drug, one of the I drugs obviously, but which?
The resistance mechanisms for each is different. Perhaps start with the NNRTI. This is sheer empirical prejudice, though, cos pre-marketing studies suggest a lower rate of Grade 2 ALT abnormality for Intelence v Isentress, but as a class NNRTIs are notorious etc. I don't know what other options you have, eg Prezista or another older PI to go with the Isentress.
The two Is are very strong, and if you're feeling like exploring a new frontier, perhaps strong enough. Certainly strong enough on paper as a maintenance regimen. This is, of course, completely untested.
Since either of the I drugs + Truvada = a full-strength combo, it is perhaps an option to try one and see if the ALT level normalises, and if not, try the other. Depends if there's a reason why you need both + 2 nukes.
The trade here is an ALT about 5 x normal v possible risk of slightly weak combo. 5 x normal ALT would do for me short-term, like a few months, but not long-term.
Maybe give it a month and see?
- matt
-
Matt,
Thanks for the insight. Liver abnormalities are something I have yet to deal with on meds, so I am a little behind the curve here.
Just talked to my doc and we are going to do a liver scan to see if there is any fat accumulation-doubtful but..
as well as a hep screen-again doubtful again as I have been vaccinated (A/B) and have not been at risk for C..
We did discuss the swapping strategy and he pretty much laid out the options you presented for me (getting a VL back today, so all depends on that)...Yeah, I suspect the Intelence too, but the clinical evidence appears to be slight...just a gut reaction (no pun intended)..One drug plus Truvada wouldn't be strong enough I think, since i have the 184 mutation.... As for the two drug I/I combo option, I'm not really in a gambling mood with these drugs, particularly the Isentress, since I don't want to close off any future Integrase inhibitor options...
So it probably looks like I will be riding as is for a while longer until tests are returned. My main concern was that I wasn't doing any irreparable harm to my liver in the interim....
Does ALT output decrease, if the body adjusts to the regimen...or is it the case that the damage tends to only get worse if left alone?....
-
And Matt,
if I haven't said it already...thanks for your insight, it has been extremely helpful...
-
It could also not be the meds at all, too. The liver is a funny organ in the body. Other things that could be affecting your liver are potential bone fractures/bone disease, metabloic state (hyperthyroid), underlying hepatitis infection, diabetes, oral contraceptives, parasites, congestive heart failure, and/or the lack of vitamin D.
It is natural for your liver enzymes to fluctuate, but if you have any of the above that could be doing it too. Your numbers are pretty elevated. I'm not trying to make you worry by any means, but you may want to get tested for hepatitis, lack of vitamin d, diabetes, and get a thyroid test.
I know a little too much about the liver because I had a couple of friends that were alcoholics and I did a lot of research and papers on the liver when I was in med school wanting to become a Pediatrician, but went into Human Resources instead, lol...I still finished Med school, however :)
-Aris
-
Aris,
Thanks for the tips.
I have been up to date on my hep screens and am vaccinated aganst A/B, but we are checking again. My blood glucose numbers have always been fine also....I'll bring up the other issues you mentioned next time I consult with the doc....
Thanks agian...I am always amazed at the amount of good advice I get here.... ;D
-
You're welcome! ;D
-
Unfortunately, or perhaps fortunately, there is no cast-iron correlation between elevated ALT and AST levels and liver damage per se. Elevated liver enzymes is always an indication of something else.
It's good the doc is doing all the work-up, for tis true many, many things result in elevated liver enzymes, esp. the non-liver specific ones like AST, injury/infection and/or treatment for injury/infection being big factors -- this includes using OTC doses of painkillers, especially paracetamol, and many antibiotics. But, if you ain't had an injury/infection, taken painkillers/antibiotics, and the hep tests etc come back as expected and the ++ALT appeared after starting the new drugs, it kinda points to the drugs.
- matt
-
The adventure continues....I'll post any updates... Thanks :)
-
Well I didn't say he has liver damage. It's just something that I'd recommend he get checked out just to be safe. The liver is a hokey organ and can be very sensitive at times. It could very well be the meds but most doctors will do various tests to see if anything that I listed is around. At least that's what they do here in Boston. It's standard practice here.
-
Well, my abdominal CT scan is in...no sign of fatty liver (and hardly any visceral fat, just a bit of the subcutaneous (read "eat to much) kind). My latest ALT number is 113, down from 156 (ish) on the 11th...we are gonna hold fast and see if the liver numbers continue to drop...if not, I guess we will burn that bridge if we get to it...thanks for all the advice!...
-
Update....Just got my latest liver function tests in (on the 6th) and things seems to have calmed down with an ALT just above normal (52) and AST levels returning to normal levels.
Other than that all is normal and the hardest thing to adjust to is having a stomach that feels normal (quite a change from the Kaletra days)...