Transcript Managing abnormal liver tests in primary care

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
• Prof G. Foster, Dr W. Alazawi
• Somen Banerjee
TH CCG Clinical lead
Hepatology, BartsHealth
Public Health TH LA
Main objectives for LFT guidance
• 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.
Non-Alcoholic Fatty Liver Disease
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,"
East London GP recorded prevalence of major
liver diseases (adults >18 years).
.
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%
*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 T2diabetesAND 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
Secondary care
GPs
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
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•
•
•
•
•
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Drug induced Obstetric- cholestasis
Haemachromatosis
alpha1 antitrypsin deficiency
Wilsons disease
Autoimmune hepatitis
Non hepatic causes- hyper/hypothyroidism,
heart failure,coeliac