Management of Abnormal Liver Enzyme Tests in Adult Patients on Anti
Tuberculosis Treatment
Department of Internal Medicine, PMHC
Abnormal liver enzyme tests are not uncommon in patients starting anti-TB treatment, they may be caused
by a variety of factors such as hepatitis, alcohol and TB itself. Treatment can usually still be given but
careful monitoring is required. Some patients may develop abnormal liver or worsening liver enzyme levels
whilst Anti-TB treatment this may result in treatment having to be interrupted. Below is a scheme to
manage abnormal liver enzyme levels. It should be emphasised that all patients should have their liver
enzymes checked prior to starting anti-TB treatment. The protocols below assume a patient is taking
standard combination therapy so all drugs will be stopped together.
1.
Management of patients with pre-treatment liver enzyme abnormality – raised ALT
a. ALT >2x normal – repeat weekly – if increase to >5x normal stop drugs
b. ALT <2x normal – repeat after two weeks – if it has fallen repeat only if patient
symptomatic (fever, vomiting, jaundice, malaise, deterioration) - If ALT remains stabl
repeat every 2 weeks – if ALT rises to >2x normal repeat weekly – if ALT rises to >5x
normal stop anti-TB treatment
2.
3.
Management of patients where anti-TB drugs were stopped as ALT>5x normal or bilirubin
elevated
a. If the patient is clinically unwell or sputum is AFB positive start ethambutol 15mg/kg
daily po and streptomycin 0.5g (30-37kg) / 0.75g (38-54kg) / 1g (>55kg) daily im
b. If the patient is well and AFB –ve monitor liver enzymes weekly until they return to pretreatment levels
Order of reintroduction of anti-TB drugs following drug induced hepatotoxicity
Check liver enzyme tests daily and only proceed to the next step if they are not deteriorating
a. Start ethambutol 15mg/kg and isoniazid 50mg daily for 3 days
b. Then increase isoniazid to 150mg daily for 3 days
c. Then increase isoniazid to 300mg daily for 3 days and continue
d. If no reaction continue ethambutol 15mg/kg and isoniazid 300mg and add rifampicin
75mg daily for 3 days
e. Then increase rifampicin to 300mg daily for 3 days
f. Then increase rifampicin to 450mg daily (<50kg) or 600mg (>50kg) daily for 3 days and
continue
g. If there is no reaction continue ethambutol 15mg/kg daily, isoniazid 300mg daily and
rifampicin 450/600mg daily and add pyrizinamide 250mg daily for 3 days
h. Than increase pyrizinamide to 1g daily for 3 days
i. Then increase pyrizinamide to 1.5g (<50kg) or 2g (>50kg) daily for 3 days
j. If there is no reaction change the patient to the appropriate dose of RHZE (combination
tablets R150, H75, Z400, E275)
i. 30 – 37Kg
2 tablets daily
ii. 38 - 54Kg
3 tablets daily
iii. 54 – 70Kg
4 tablets daily
iv. >71Kg
5 tablets daily
Reference
Ormerod PL. In Infectious Diseases. 2nd Edition. Ed Cohen J, Powderly WG. Mosby London 2004