Managing abnormal LFTs in Primary care

Summary guideline, April 2015 Sally Hull, Lucy Carter

Managing abnormal LFTs in Primary care

Draft guideline written by Dr Sally Hull and Dr Lucy Carter at

CEG, with advice from

• Susannah Solaimain TH CCG Clinical lead

• Prof G. Foster, Dr W. Alazawi Hepatology, BartsHealth

• Somen Banerjee Public Health TH LA

• Identify patients at risk of chronic liver disease.

• Increase testing for treatable liver disease among those

with abnormal tests.

• Identify those with NAFLD and stratify by risk of fibrosis

• Audit prevalence of major liver disease in east London, and audit investigation of abnormal LFTs.

Main objectives for LFT guidance

Sally Davies, CMO for England.

Growing numbers of people are dying from liver disease caused by heavy drinking and unhealthy eating, the CMO says “The three major causes of liver disease – obesity, undiagnosed infection and harmful drinking – are preventable,"

Non-Alcoholic Fatty Liver Disease

Condition Number % UK Predicted*

Alcoholic Liver Disease

1,407

0.19%

0.3%

Hepatitis B 2,737 0.37% 0.3%

Hepatitis C 2,060 0.28% 0.4%

NAFLD 5,430 0.74% 17-33%

East London GP recorded prevalence of major liver diseases (adults >18 years). .

*Figures from the Lancet commission on liver disease, HSCIC and ONS

Audit of managing abnormal LFTs across east London (ALT >35iu/L on two occasions)

Two Abnormal LFTs in the past 2 years

11,235 Cases

Had Audit C 7010 60.7%

Had Virology 3228 31.8%

Had Ultrasound 438 3.5%

Had All 3 tests 139 1.1%

Which patients do we request Liver function tests?

1) Patients with vague, non specific symptoms

Other groups who might benefit from testing :

2) Diagnosing NAFLD

3) Check for alcoholic liver disease (ALD)

4) Viral hepatitis

5) Those requiring drug monitoring-on new medicines

6) High risk drugs e.g.methotrexate

7) STATINS*

Choose ALT

• Highly sensitive marker of hepatic dysfunction

• (more than AST)

• The local lab ranges for ALT are 5-40Iu/l

• The cut off is a grey area as there will be some patients who have no liver disease (raised ALT)

STATIN monitoring

• CEG 2015 guidance on statin monitoring proposes only ALT is used -at baseline only*

• NICE 2014 recommends repeat ALT at 3 and 12 months.

• CEG recommend only to do this if liver disease suspected*

• If ALT normal- no need to repeat

• No need to stop STATIN unless ALT >3x ULN

• cost saving for the CCG: 462 000K/yr

If ALT is raised in an patient without other liver symptoms

• CHECK. Careful medical history/medications/travel

• RECORD BMI Alcohol consumption

• REPEAT- ALT-within 3 months

If ALT is still raised add full liver screen

Liver screen

• Full LFT panel- including ALP, GGT and AST

• FBC • Lipids & HbA1c • Viral hepatitis • Autoantibody screen • Immunoglobulins- • TFT • Ferritin

Purpose of liver screen

• To find treatable causes of liver disease that is as cost efficient as possible

• To improve our diagnosis of NAFLD and viral hepatitis

• Differentiate cholestatic from hepatic liver disease

Which patients need an ultrasound?

• 1. Those with cholestasis or jaundice where intra /extra hepatic obstruction is suspected.

• 2. Clinical hepatomegaly

•

• 3. Where there is a suspicion of cirrhosis.

• 4. Risk of metastatic or primary liver cancer

• Consider discussion with local Hepatologist

if unusual results,

rare diseases suspected

if ALT >3x ULN

Diagnosing NAFLD-do we need ultrasound?

Hepatologists remind us that ultrasound

or( liver biopsy) is required for definitive diagnosis

BUT in

– Obese patients BMI >35 ( >28 if SE Asian)

– Metabolic syndrome

– Who may have T2diabetes-

– AND No evidence of other liver disease and without alcohol excess consumption

– AST:ALT ratio <0.8 (PPV only 44%)

– If all above- probability of NAFLD is high

Staging of NAFLD

• NAFLD-steatosis prevalence* is 17-33%.

• 75%*do NOT progress to NASH and is reversible

• NASH(non alcoholic steatohepatitis is 15% of NAFLD

• Cirrhosis 10-15% of NASH

• Liver Failure and HCC

NAFLD –risk stratification in primary care

• GPs can assess presence or absence of fibrosis using a well validated score

• www.NAFLDscore.com • • 7 indicators- from your liver screen

T2DM/IGT, AGE platelets, albumin, BMI, AST, ALT

• Read code for the NAFLD fibrosis score EMIS -

EMISNQ107

NAFLD fibrosis score

Management of NAFLD

GPs

Secondary care

GPs

Local resources for primary care

• Healthwise exercise on prescription-requires bloods/ BP /pulse and a diagnosis

• Health trainers- Newham and Tower Hamlets

• Hackney iCARE http://www.hackneyicare.org.uk/

• National Organizations- Weight watchers /Slimming world (small cost to the patient)

• Parkrun every Saturday morning FREE- Becton /hackney marshes/Mile end

• Social prescribing

Managing abnormal LFTs in Primary care

Summary guideline, April 2015 Sally Hull, Lucy Carter

references

• Lancet commission on liver disease Nov 2014

• Alazawi W, Mathur R, Hull S, R. Foster GR. et al. Population-based study of ethnicity and the diagnosis gap in liver disease. Br J Gen Pract, 2014

• Angulo P, Hui JM, Marchesini G et al. The NAFLD

fibrosis score. A noninvasive system that identifies liver fibrosis in

patients with NAFLD Hepatology 2007;45(4):846-854

Alcohol liver disease

Alcohol is the main cause of liver disease in the UK (>60% of cases) England is one of the few countries where alcohol consumption is rising • 3 stages -steatosis hepatitis and cirrhosis • 50% mortality with alcoholic hepatitis • Not all patients will develop hepatitis • Steatosis IS reversible with abstinence of alcohol • AuditC /alcohol consumption is key to identifying

patients at risk of alcohol liver disease ALD

Less common disorders

• Drug induced -

• Obstetric- cholestasis

• Haemachromatosis

• alpha1 antitrypsin deficiency

• Wilsons disease

• Autoimmune hepatitis

• Non hepatic causes- hyper/hypothyroidism, heart failure,coeliac