Ask the Doctors

Dear Doctor: I recently had blood work done, and now my doctor says my liver enzymes are too high. How can I lower them? I have no symptoms, so I was surprised. I have never consumed alcoholic beverages, nor smoked. I am trying to lose some weight. I do frequently take ibuprofen for arthritis.

Dear Reader: I am not certain which of your liver enzymes are elevated, but the ones most often tested are AST (aspartate aminotransferase) and ALT (alanine aminotransferase). These enzymes are important for enzymatic reactions in the liver, but they are also a marker for liver inflammation and injury. We'll start with those.

An obvious cause for liver enzyme elevation is alcohol, which directly damages the cells of the liver. In such circumstances, AST is more elevated than ALT. But, as you said, you don't drink. Other possible causes include chronic infection with hepatitis B or C, or a genetic disorder called hemochromatosis, which leads to iron deposits in the liver. Tests for hepatitis infection and for iron and ferritin (a protein containing iron) levels can help diagnose or rule out these conditions.

Many medications can inflame the liver, such as statins for lowering cholesterol. Stopping the statin is often necessary to see if the liver enzymes come back down to normal. As for ibuprofen, it and other nonsteroidal anti-inflammatory drugs, or NSAIDs, rarely cause liver inflammation, but acetaminophen (Tylenol) does, especially at high doses (more than 4,000 milligrams per day). But again, the only way to determine a connection is to stop the medication and see if the enzymes return to normal.

Heart failure can be linked to liver enzyme elevation, as can cancers of the liver and cancers that metastasize to the liver. These conditions can be diagnosed through imaging procedures such as ultrasound and CT. Autoimmune conditions are a possibility as well; these are better diagnosed with specific blood tests.

But after ruling out these conditions, the most likely cause of liver enzyme elevation is non-alcoholic fatty liver disease, the most common liver disorder in the United States. A 2017 study of 6,000 adult men and women estimated the prevalence of fatty liver in the United States around 30 percent. The rise of this disease correlates with the rise of obesity and diabetes.

To diagnose fatty liver, you must rule out other causes for liver disease, with the first being alcohol consumption. After that, an ultrasound of the liver is a sensitive and simple way to diagnose the condition. An MRI, although costlier, is also a good test to diagnose the disease. Rarely, a liver biopsy is necessary to diagnose and evaluate the extent of fatty liver.

The best treatment for this condition is weight loss. Studies have shown significant improvements due to weight loss among those with fatty liver. To decrease both blood sugar and the storage of fat, choose a diet that is low in sugars and simple carbohydrates.

Eliminating sweets, sodas and juices would be a good start. If you're overweight or obese, try for a gradual weight loss of 1 to 2 pounds per week. Although you don't drink alcohol, those who do -- and who have elevated liver enzymes or fatty liver -- should give it up.

With a good diet and exercise, your liver enzymes should start to decline. But make sure to monitor them to ensure that's the case.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

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