TOPIC: High AST and Alt

I recently complete 8 weeks of Mavyret . My HepC is gone. However my last labs showed that my AST went from 35 to 276, my ALT went from 32 to 390, my BILI went from .4 to 1.3 my glucose went from 97 to
152. I have had HepB in the past but my doctor assured me that because my Hep B surface Ab was reactive (consistent with immunity) and my HBsAg screen was negative I had zero chance of HepB reactivation. The only HepB test that came back positive was the Hep B core Ab, Tot. All these changes happened within a span of 18 days. Does anyone have another explanation?

Hello Howard,

When did you finish the Maviret?

It certainly needs looking into. We do see some bilirubin rise with both Viekira and Maviret and this we ignore because it happens to most patients and goes away after treatment.

Both AST and ALT are released by damaged muscle as well as liver so we do see this happen occasionally in athletes.

Any drug can cause some liver toxicity (including Maviret) in rare individuals.

The list of causes of liver enzyme increases is quite long - here's the Mayo version:

www.mayoclinic.org/symptoms/elevated-liv.../causes/sym-20050830

You and your doctor are going to need to work through that list.

If you have a positive surface antibody then you should be immune to Hep B. Your positive core antibody shows this is from past infection. This surface antibody wipes out the surface antigen that Hep B produces (in excess) in patients with chronic Hep B. So it's really unlikely to be Hep B - the virus can't assemble without the surface antigen (this is actually part of the stucture of it).

I have seen CMV reactivation do this, but as you can see from the Mayo list there are lots of causes that need to be excluded.

Diabetes is 3x more common in patients with Hep C and it is common full stop. Your 152 suggests you are probably going to be diabetic but should just be checked a few times before doing anything. High blood sugar causes damage over decades and 152 would be pretty good for a diabetic (on treatment) so there is no need to panic about this.

By any chance did you give a urine sample? I had similar results last year and the results freaked me out. I have prostate issues and some symptoms mask urinary infection symptoms. The subsequent urine test confirmed e-coli infection in my urinary tract,aka, UTI (urinary tract infection).

Follow Dr J's advise as I have elevated glucose readings, also. An A1c test might
help. Hopefully, it is only a minor infection of some sort. Good luck!

Dr. James,
Thank you for your response. I finished my treatment about 10 days ago. I have looked at the possible causes of my high Labs. I'm thinking this may be alcohol related. I have always been a moderate drinker but I have never had any issues even though I had HepC for decades. I have reviewed all of my labs and they all are good even though I was drinking. I abstained from drinking beginning in January when I learned I had HepC. I started drinking again after my treatment ended not heavily and not often. Then my labs came back bad. I do not understand how I could drink without any problems for so long then quit and then start having problems when I went back. I guess my question would be, does the Maviret sensitize the liver to alcohol?

Hello Howard,

It would be useful to see your full tests, but that said...

With alcohol, we normally see an isolated rise in the GGT liver enzyme with the AST and ALT enzymes typically being normal. In some patients who drink a lot we may see all of these rise but typically we are not talking moderate drinking, we're talking bottle of scotch, 2-3 bottles of wine, case of beer a day level consumption.

One of the first things I do when presented with unexpected abnormal test results, somewhat as a knee-jerk reaction, is simply to order them again. It's surprising how often the repeat bloods come back normal. If they do I just shrug, make a note to keep an eye on it for a while, and we move on with a "dunno what it was but it seems to be gone now". If on the other hand the repeat comes back abnormal it depends on whether a) things are getting better in which case I would typically just monitor it to see it normalise or b) things are getting worse in which case I would start looking for the cause.

re_roll has suggested an HbA1c which is the 60 day rolling average of your blood sugar levels. This is probably less useful to you right this second because if your blood sugar has not been up for long this won't be up yet - it needs a solid 60 days delay.

Repeating the blood sugar, and CMP nowish would be a useful first step. There are lots of other tests we could add in but if the repeat is normal(ish) a watching brief is probably on the cards.

Besides alcohol there are literally thousands of other things patients take that can impact the liver. "Healthy" supplements can be the cause, for example green tea extract is known to cause liver failure when taken in excessive supplement level quantities, so a key question would be

Besides starting to drink again have you added in any other "drugs" where this would include prescription, non-prescription and supplements - anything that goes through your mouth that is not routine food.

There have been outbreaks of Hepatitis A all around the world, often associated with frozen berries, so it could be you've got a dose of that from a berry smoothie...

Anyway, step 1 is repeat the CMP +/- the BSL so we can see if things are trending better, or trending worse.

Dr James,
Thanks again for your help. I went to my doctor yesterday and we went over my labs. He seems to believe that my bad results may be alcohol related. I didn't know that ALT and AST would remain at normal levels when consuming alcohol and only the GGT would elevate. My doctor did not mention this to me. The reason I'm so concerned, is that having had HepB in the past, I've seen numbers like this when the infection was active. However, the opinions I am getting are that reactivation of my HepB is remote and I show no physical symptoms. OK, that being said, I do not take any medications. The only supplements I take are a multivitamin and fish oil, which I have been doing for many months. I have not been exposed to any environmental toxins that I am aware of. My diet has remained unchanged etc. As for HepA, I was vaccinated for it before I started treatment for HepC. I have not had the six month booster but I don't know if that makes any difference. You can see why I'm a bit perplexed by my bad labs. The bad labs may well be a one off as you suggest, I can hope so. No matter, as you noted, the next step is to do new tests. These are already in work. My doctor scheduled me for new labs in three weeks. He told me to abstain from alcohol for that time to test the theory of alcohol causing the bad labs and to see what changes occur. Hopefully all will be well. Meanwhile, I can only wait. Thanks again.

Hi Howard,

The alternative to waiting would be to do a CMP privately. It's pretty inexpensive. Here's a link to a number of lab providers in the USA

fixhepc.com/link2labs

These ones don't need a doctors order:

• www.directlabs.com
• www.discountedlabs.com
• www.econolabs.com
• www.ultalabtests.com
• www.walkinlab.com