Why are my liver function tests elevated?

[MyDoorsAreOpen]

I dare not ask any of my colleagues in the medical field, nor any healthcare provider I go to as a patient under my real name. An answer to this question is not worth the potential harm of people outside of this site knowing the full extent of my recent (and now ended) polypharmacy.

I recently went apeshit at work and got thrown in the loony bin for a week, due in no small part to the numerous drugs and supplements I'd been taking, combined with some major life stressors. In addition to the urine drug screen I got in the emergency department that was positive for THC (d'oh!), I had bloodwork drawn, which showed the following abnormalities:

* Serum potassium: 3.3 (normal range 3.5-5.1 mEq/L)
* Aspartate transaminase (AST), a.k.a. serum glutamic oxaloacetic transaminase (SGOT): 147 (normal range 7-40 units/L)
* Alanine transaminase (ALT), a.k.a. serum glutamate-pyruvate transaminase (SGPT): 158 (normal range 7-40 units/L)

In the week preceding this labwork, I'd been taking, approximately:

* dextromethorphan HBr 30-60mg by mouth daily, as Indian manufactured dollar-store cough gels
* ketamine ~50mg intranasal daily -- almost certainly cut with something, would not dissolve in water without a white residue
* racemic amphetamine salts 15-30mg by mouth twice daily -- as pharmaceutical-grade Adderall™
* sertraline 50mg by mouth daily -- as pharmaceutical-grade Zoloft™
* magnesium citrate 1500mg by mouth daily -- pharmaceutical grade Solgar™ brand
* fish oil 1g by mouth daily -- purified Norwegian
* ginseng 1.5g by mouth daily, as 3 pills of dollar-store Nature's Measure™ brand
* vitamin B complex time release, containing 50mg niacin and 50mg of most other B vitamins each, 1 tablet by mouth daily
* l-tyrosine 1-1.5g by mouth twice daily on an empty stomach -- pharmaceutical grade Solgar™ brand
* melatonin 3mg by mouth every other day at bedtime -- as 15 pills of dollar-store Nature's Measure™ Relax & Sleep
* valerian root extract 1.125g by mouth every other day at bedtime -- as 15 pills of Relax & Sleep
* chamomile extract 375mg by mouth every other day at bedtime -- as 15 pills of Relax & Sleep
* caffeine, at least 6-8 cups of coffee daily
* acetaminophen 1g by mouth about every 2-3 days as needed for headache -- as pharmaceutical-grade Tylenol Extra Strength
* cannabis ~500mg inhaled by water pipe twice daily -- known source, high grade

Wow. Yeah. Don't do this at home, kids. During this week, I drank no alcohol, slept 4-6h per night, and got about 30min of cardiovascular exercise every other day. I was under intense pressure at work. I am an otherwise [physically] healthy 30-something male of mostly Celtic ancestry. My only physical health problem is psoriasis, which I do not treat. My mental health is another story. I've always been a thin man, with a BMI of about 19. My liver function tests have never been elevated in the past.

I snapped when I received a critical-to-mediocre performance evaluation that I was in too fragile a mental state to take. I was put in the emergency department under one-to-one supervision, then put in an insane asylum for 1 week, since I have a job where an angry outburst is considered a matter of public safety. All of the above drugs and supplements were abruptly stopped, except for the Zoloft, which was quickly tapered off over the course of 4 days. Repeat urine drug screening in the asylum was negative for everything, and repeat liver function tests were in the low 40s, just above normal limits. Clearly something, or some combination of things, was making my liver work overtime.

It was probably a combination of everything, really. I mean, that's some serious polypharmacy, in retrospect, which I have no intention of repeating. Still, does any particular item in my list jump out at anyone as being pretty hepatotoxic?

 

[PriestTheyCalledHim]

I'm not a medical professional but it could have been from the acetaminophen, DXM, and the supplements you were taking. Take care of yourself.

Have you ever eaten wild mushrooms? A friend of mine ate some that his wife had picked, and those turned out to make a liver test he took decades later elevated. The mushrooms were apparently mildly toxic but they didn't kill my friend or his wife, and they did not even have to seek medical attention.

 

[Shimmer.Fade]

I wouldn't say your AST/ALT is that worrying with a De Ritis Quotient (AST/ALT) of <1. Have you checked your yGT? Do you have values for coagulation? Have you checked whether your liver is enlarged (I prefer the scratch method)? Do you bruise abnormally easy in recent times? Hard to get a subjective impression of how you feel if you are no longer taking all that shit. Do you have all your Hep vaccines? Any grounds to think you may have Hep A/C? How is your right heart/lung function? Too many things to put together with such little infos, you should know this .

Anyhow, something good you can do is stop taking all that stuff together (I don't have the time to go through all CYP interactions, only the Sertraline stands out to me as a light to moderate CYP2D6 inhibitor, Dextromethorphan also uses CYP2D6, maybe read further in depth with regards to the substances you use and their CYP interactions), and get your liver values tested more extensively in the near future. If the values don't sink or you notice symptomatic then maybe it is time to bring out the big guns. 1g paracetamol shouldn't be enough to cause problems (we say anything under 4g is able to be cleared by bio-transformation in a healthy person), but your 6-8 cups coffee could be quite a bit of caffeine depending on how you make it.

Take it easy on yourself MDAO. We need people like you, and you can't help people if you can't work. If you want to bounce ideas off me feel free.

 

[ebola?]

I'd like to get back to you on this, but. . .it's quite a bit beyond my knowledge, and even with the appropriate facts about these compounds' activities, any explanation yielded would remain quite speculative.

I will PM you about this though, just in case by some stroke of luck I actually clean some insight on the matter. I'd also like to see how you've been lately overall.

ebola

 

[Foreigner]

Valerian, ginseng and chamomile are not supposed to be taken long term. Chamomile is a specific agent for the liver in herbal medicine. Taken as a tea every night shouldn't be a problem, but as a daily extract it could prove detrimental to an already-burdened liver. Ginseng (assuming it's real, i.e. American or Chinese Ginseng), is not supposed to be taken for longer than 2 week stints. Most people exhibit some liver signs beyond that.

Added to that, the slew of other things you've been taking surely didn't help.

I wouldn't recommend anymore supplements for your liver recovery, except for maybe milk thistle or burdock root. Both are nutritive and safe for long term use. However, the best thing to aid liver recovery is nutrition, especially glutathione. Don't take it in pill form though -- stay away from supplements! Just eat a wide range of veggies each day, especially dark leafy greens and beets, and their juices. Raw juices would help a lot in this case. Valerian definitely has a 14 day limit. You can also consider eating liver itself. Calf liver is better... less chance of toxins accumulated in the tissue. Liver pate is mostly useless... it's so processed that the nutrition is gone. I know that liver and onions is gross to most people but if you can even have some twice a month, you'd probably feel some good restoration.

Your liver enzymes aren't that high anymore, but most liver tests only look for liver function by proxy of the enzyme levels in the blood. Up to 70% of your liver could be non-functional but the remaining 30% could meet the enzyme test requirements. The only way to know a liver's true state is through biopsy, which no one ever does. The reason why we know conclusively that things like acetaminophen + alcohol damage the liver is because of post-mortem analysis. Not good for detecting serious problems, but it does speak to the over all resiliency of the human liver. If you back off of the chemical bombardments and stick to eating a nutritive, organic diet for a while, you should be in good shape.

 

[Joeof1]

* caffeine, at least 6-8 cups of coffee daily
* acetaminophen 1g by mouth about every 2-3 days as needed for headache -- as pharmaceutical-grade Tylenol Extra Strength

These two in combination with minor dehydration can elevate liver values.

Also, how is you scalp? Is it really flaky, or does it have a good shine to it?

 

[ebola?]

I'm not particularly familiar with the hepatic load of many of these substances. . .but otherwise, I see overkill on the monoamine transporters. You have DXM acting as an SNRI, zoloft acting as an SSRI, and amphetamine interacting with NE and DA transporters. The points of overlap include varying binding affinities and efficacies, so points of synergy and inhibitory interaction should prove unpredictable. Your dosage of DXM is quite low, so the above might be slightly alarmist. Ketamine and caffeine both impose renal strain, at least at that high a dose of caffeine (which I've been told is typical for physicians ). You are taking what appear to be very high doses of supplements / herb extracts / etc., many with poorly known mechanisms, little known levels of danger to the liver and/or kidneys, etc.

Unfortunately, I'm too ignorant to give further useful answers, but a good thing to look at would be how the various compounds are metabolized (for those metabolized hepatically). This might be a good first step in assessing hepatic risk due to interaction effects between multiple compounds undergoing metabolism (in particular for cases where metabolic pathways with overlap).

As for the recent mental health issues, I would guess that there's some complex interaction between the three drugs mentioned that interact with monoamines at the root of the problem, and it could also be that there's some key interaction between nmda-antagonism and modulation of monoamines. Because the chains of mechanisms underlying the efficacy of SSRIs and NMDA antagonists as anti-depressants likely converge downstream (eg, in promoting neuroplasticity, with BDNF playing a key mediating role). I'm guessing that your 'off-kilter' monoamine function interacted with stress to promote an unpleasant and non-functional state.

Stay well,
ebola

 

[Shimmer.Fade]

Valerian definitely has a 14 day limit.

This is definitely false. I agree that it is probably not the best thing to take chronically, however there are many, many people that have taken it all their lives, and show no specific signs of pathology as a result. It is a very popular phytopharmica here.

Up to 70% of your liver could be non-functional but the remaining 30% could meet the enzyme test requirements.

False. The enzymes show damage to the liver AST is not liver specific. AST is useful in that it comes from the mitochondria, which can indicate more severe damage (De Ritis >1). ALT is liver specific, but does not give us a very exact level of damage done. However, If 70% of the liver were non-functional the damage would be likely shown through clinical symptomatic as well as elevated liver values with a De Ritis >1.

The only way to know a liver's true state is through biopsy, which no one ever does.

Wrong. Biopsies are usually only taken after a HCC or CCC has been confirmed through a CT/MRT. Through a combination of clinical symptoms, physical exam results, lab values, sono, and CT/MRT it is possible to know how a liver is doing.

The reason why we know conclusively that things like acetaminophen + alcohol damage the liver is because of post-mortem analysis.

This is also wrong. Through observing the changes in a liver from healthy, to fatty, to cirrhotic we are able to follow the life of a liver, and determine what is happening to said liver. On a micro/molecular biological scale the mechanisms for liver destruction are known.

but it does speak to the over all resiliency of the human liver.

The liver is very resilient. One can have large parts removed, and still live a fairly good life.

Hope things are going better!

 

[MyDoorsAreOpen]

Guys, I really appreciate your input. To answer some of your questions:

Have you ever eaten wild mushrooms?

I have never once, and probably never will, eat a wild mushroom. I've seen patients come in through the emergency department after eating wild mushrooms or plants, and yeah, their transaminases are often mildly elevated. But they're usually quite ill, in a way that I was not.

I wouldn't say your AST/ALT is that worrying with a De Ritis Quotient (AST/ALT) of <1. Have you checked your yGT? Do you have values for coagulation? Have you checked whether your liver is enlarged (I prefer the scratch method)? Do you bruise abnormally easy in recent times? Hard to get a subjective impression of how you feel if you are no longer taking all that shit. Do you have all your Hep vaccines? Any grounds to think you may have Hep A/C? How is your right heart/lung function? Too many things to put together with such little infos, you should know this .

Good point about the DeRitis Quotient. I'm ashamed to say that's a concept I haven't thought about since med school. AST is indeed produced in quite a number of different tissues, and is a better marker for global toxicity. I have my hepatitis vaccines up to date. I was once spat at in the face by a nursing home patient with open sores who was Hep C positive, but I always followed standard precautions (gloves, gown, mask) when working with him, and from what I've learned you really need blood-to-blood contact to have a high chance of contracting this disease.

I didn't (and still don't) feel "polluted" the way people with seriously compromised livers tend to. My liver is not enlarged or tender. Some odd things happened with my skin tone when I started taking turmeric and l-tyrosine -- I swear it darkened a touch. But at no point were my eyes yellow. I haven't noticed a problem digesting fatty foods either. You make a good point, which I think a lot of us clinicians miss from time to time -- treat patients and symptoms, not lab values. Lab values are just supporting evidence. It's feeling like shit that warrants attention, and right now, especially from a GI perspective, I don't feel that bad at all.

As for my heart and lungs, I think they're in pretty good shape. I've never smoked tobacco. I can run my heart at 170 BPM for >30min every day no problem when exercising. Never had chest pain, shortness of breath, palpitations, or fainting spells. My EKGs have always shown an incomplete right bundle branch block and a slight rightward deviation. One of the cardiologists who taught me looked at my EKG and flat out asked me, "You don't smoke pot, do you?" Of course I denied that. I could also have very well been born with this defect. My cholesterol profile couldn't be better -- LDL 85, HDL 55.

I agree with you that it's probably a combination of everything in my not-as-healthy-as-I-thought lifestyle. I plan to do a visit to a primary care doctor just to recheck my LFTs, and probably a Hep C DNA for good measure. Hopefully no need for imaging. Not looking forward to this though; I'm kind of like the barber with a bad haircut, or the bare-footed cobbler. I hate being a patient, and have done things to my body I would never dare recommend to one of my patients.

caffeine

Wanna know something funny? Since quitting all that crap I listed, caffeine has, for the first time in my life, not sat well with me. I do not find it euphoric or motivating the way I used to, and what's more, I feel its unpleasant side effects very acutely even at low doses. So I've quit it, for the first time since I was 15. And I haven't felt any withdrawal symptoms, like I expected to. It reminds me of long term amphetamine abusers who often talk about quitting the drug, but then finding it revolting when they try it again months to years later, and not missing it at all. I never thought the day would come when I didn't enjoy coffee anymore. I have a hunch this has something to do with the messy induction and inhibition of liver enzymes I had going on, but no longer do. I think it may also have had to do with the hard-to-shake droopiness that tends to come with long term marijuana abuse, which mostly overpowers any dose of caffeine you throw at it.

I'll let you all know when I get my LFTs checked again, or hear anything new. Might do a detox regimen, as you suggested, Foreigner.

 

[Shimmer.Fade]

Hep C has a ~3% transmission rate for an accidental used needle stick (not IV use!), and is not fecal/oral. Hep A is fecal/oral. We have a nice rule of thumb here to keep people from freaking out (although all prophylactic measures are followed through), 30%/3%/.3% chance of transmission by accidental used needle sticks for HBV/HCV/HIV !!!NOT IV USE, percents there are much higher!!!

Sounds like you are in decent shape for now (as far as I can tell without you sitting in front of me), but it would be nice to verify a return to normal liver values =)

Turmeric is known to have quite a bit of pigment, and from a cursory reading seems to be used by women sometimes to even out skin tone. Pretty interesting, lol.

I'm kind of like the barber with a bad haircut, or the bare-footed cobbler. I hate being a patient, and have done things to my body I would never dare recommend to one of my patients.

Tell me about it lol. I have an issue that has been bothering me awhile, but I still haven't made an appointment cause I'm pretty sure some of my worse habits may be causing it. Sometimes being a human can suck.

 

[flyhighk]

Are you guys nurses/doctors?

 

[MyDoorsAreOpen]

I'm a family doctor in my last year of training.

Shimmer.Fade is a much more experienced clinician than myself, which is why I'll defer to him when it comes to medical know-how.