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
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 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 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 Drug induced - Obstetric- cholestasis Haemachromatosis alpha1 antitrypsin deficiency Wilsons disease Autoimmune hepatitis Non hepatic causes- hyper/hypothyroidism, heart failure,coeliac