MTX - Relafen & Elevated Liver Enzymes | Arthritis Information
Hey all. I've been being treated for Sero-positive RA for a little over two years now. I've been on injectable MTX @ 15 mg for over a year and up until recently all of my liver labs have came back good. I went for a follow up visit and physically, everything looked good as far as swelling, etc.,. However, my liver panel came back with my liver enzymes being elevated (2) times the upper limit of normal. I know this can happen with MTX but I'm wondering if any of you have experienced elevated liver tests with the use of NSAIDS. The reason that I ask is that up until now, all of my liver tests always came back normal until we added Relafen to the mix. These are the first labs that I've had taken since using both the MTX and Relafen together and now my labs are out of whack. I was searching the net and info states that NSAIDS often do produce elevated liver enzymes and those with known liver disease and liver problems should avoid them. I called my Rheumy back after reading the info on Relafen and elevated liver tests and asked her if this could be the cause and the nurse said that Relafen being the cause was unlikely and that it was most probably due to the MTX.
My Rheumy seemed concerned by the tests and told me to hold the MTX and not take it for a week and then told me to have my liver panel ran again next Friday. I know MTX can be the likely culprit for these elevated tests but based on what I've read with regards to elevated liver enzymes and NSAIDS (Relafen) I'm seriously considering stopping both the Relafen and the MTX together for the week before I have the test ran again.
My rheumy did state that after week of holding the MTX, if the liver enzymes come back at the same elevated levels that these last tests were or at higher levels that he believes we should do a liver biopsy. This is not a test that I want to have done if at all possible. My next question is has anybody on here had to have a liver biopsy done due to elevated liver enzymes and if so was the test procedure bad?
Regards,
Ta2d
hi Ta2d.. sorry to hear that you're having this issue.
what did you use as an NSAID for the first two years of DX?
Babs,
I used Relafen for the first couple weeks after being diagnosed with RA. However, during those couple weeks I had major stomach issues and when reported them to the doc he took me off the Relafen. That said, I don't have any previous labs showing the results of a combo of NSAIDS and MTX to compare to. Due to my stomach issues with the Relafen I continued all of this time with my only meds being MTX, Plaquenil and an occasional Prednisone DosePak and I did "OK". However, in November of last year ('08) I began having major swelling and pain in my elbows that I couldn't keep under control once my Pred. DosePak was finished so I asked to try the Relafen again. That is when I began using MTX and Relafen together on a steady basis even though I had to fight through some stomach issues during this period. Again, this is now my first and only set of labs showing the results of MTX and Relafen together. I do know that MTX can cause elevated liver enzymes at "any" time. However, since I'm on a relatively low dose of MTX and since I've never had any lab issues up until this point I find it somewhat suspicious that they shot up only after adding Relafen to the mix.
Ta2d
Ta2d2009-04-08 07:59:32wow.
I can't take relafen ...... I lose my peripheral vision.... weird.
I would bet it's the MTX.. but that is just my uneducated guess.
My brother, who has end-stage liver disease (alcohol-induced), has had several biopsies. He's a big baby, but even he said it hurts for a second (more like an inside "pinch") and then it's over. Far worse for him is the repeated large-volume paracentesis they have to do to drain off the ascites.
Another question - Do you think a week of no MTX is even enough time to allow liver enzymes to come back down or normalize? Ta2d-
I'm just curious because I know that I drink more than I should while on MTX. Do you drink alcohol at all?
No, I do not drink alchohol at all. Also, I'm a health nut and follow a good diet, have a normal bodyweight and I stay fairly fit and active when I'm not in a flare. NSAIDs can definitely cause elevated liver problems. From the official prescribing information for Relafen:
Hepatic Function: As with other NSAIDs, borderline elevations of 1 or more liver function
tests may occur in up to 15% of patients. These abnormalities may progress, may remain essentially
unchanged, or may return to normal with continued therapy. The ALT (SGPT) test is probably the
most sensitive indicator of liver dysfunction. Meaningful (3 times the upper limit of normal) elevations
of ALT (SGPT) or AST (SGOT) have occurred in controlled clinical trials of RELAFEN in less than
1% of patients. A patient with symptoms and/or signs suggesting liver dysfunction, or in whom an
abnormal liver test has occurred, should be evaluated for evidence of the development of a more severe
hepatic reaction while on therapy with RELAFEN. Severe hepatic reactions, including jaundice and
fatal hepatitis, have been reported with RELAFEN and other NSAIDs. Although such reactions are
rare, if abnormal liver tests persist or worsen, if clinical signs and symptoms consistent with liver
disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, etc.), RELAFEN should
be discontinued. Because nabumetone’s biotransformation to 6MNA is dependent upon hepatic
function, the biotransformation could be decreased in patients with severe hepatic dysfunction;
therefore, RELAFEN should be used with caution in patients with severe hepatic impairment (see
Pharmacokinetics: Hepatic Impairment).
http://www.fda.gov/medwatch/SAFETY/2005/aug_PI/Relafen_PI.pdf
JasmineRain,
Thanks for the info. The info you provided definately mirrors most of the info that I've recently found on the net with regards to NSAIDS such as Relafen and hepatic (liver) issues. I've also used the search function on here (duh, I should have tried that before) and found another member that said that her NSAIDS that she took for RA caused her liver enzymes to elevate way up above normal. That said, I've decided to discontinue both the MTX and Relafen (Dr. said only discontinue the MTX) for the next week leading up to the blood test. I really want these #'s to come back down so I can avoid any further evaluation such as a liver biopsy. However, even with the discontinuation of both meds I have my doubts that a week is going to be a long enough period for my liver to detox enough to bring the levels back down. After that period he wants me to reduce my MTX to 10 mg.
The worst part about this whole thing is that for the past (3) months I've felt the best I've felt in two years. My rhuemy found no visible inflamation and I had no new flares to report since my last visit. I tell you, if it weren't for bad luck I wouldn't have any.......lol. It seems there always has to be something wrong..................
Ta2d2009-04-08 09:56:21I skipped all the replies here so forgive me if this has already been said; I'm short on time right now.
MTX is likely the culprit. I was on MTX for more than 5 years at the max dose before mine read high. We lowered MTX a couple times with no help. It took being off of it for at least a month before they came down. My GP did an ultrasound and saw nothing and then sent me to a Gastro (doctor for stomach stuff) and he ran the blood work again and it had FIANLLY returned to almost normal. Mine were well over 120 and normal is close to 25 if I'm not mistaken. It's been a while since I've dealt with it so I can't remember the numbers right off.
My advice on the liver biopsy would be to encourage your doctor to hold off. That's pretty invasive and it's likely un-nesssesary. I sometimes think these doctors jump the gun on some of these test. Chances are after a week or two your blood test might not change much. MTX stays in your blood system a long time. Give it a chance to come down and then see.
After my blood test came back fine with the gastro doctor his nurse called me and said that he still wanted to do a liver biopsy. I said "WHAT?!?! Why on earth would I want to do that....and better yet, whey would he need to? I'm no doctor but it would make sense to me that if it was suspected that the MTX was the cause of the elevated panels and I stopped the MTX and it went down then the MTX was obviosly the cause. No, Tell him I won't be doing that." The nurse just sat there like she didn't know what to say. It blew my mind though that they would subject me to an unessesary test for no reason. I told my RD about the situation and he said he absolutely agreed it was un-nessesary. Money; it's all about money with some of these doctors. Kills me!
If you drink alcohol with MTX and NSAIDS; that could be contribution to your problem. I'm sure it did for me. I continued to drink several times a week through out all that time.....no doubt it caught up to me. I'm more selective about my cocktails now-a-days MTX or not.
I WOULD ALSO ADD MILK THISTLE AND LEICHTIN TO YOUR DIET
Copyright ArthritisInsight.com