Raised AST and ALT levels and methotrexate

[MelB71]

Hi,

I was diagnosed with RA in December 23 and I have been on 15mg methotrexate weekly and 5mg folic acid once a week.

I have just got to my final monthly mxt monitoring and my alt level was raised. As advised by rheumy nurses I stopped mxt for two weeks and have just had repeat monitoring. Alt level has decreased slightly although still raised and the ast level is now raised too.

I know that you can't give medical advice and I need to talk to my team but would just like to know of others with similar experiences and what the next steps may be.

Thank you 😍

Mel

[Runrig01]

I had a similar issue with Azathioprine, after being on it several year. They increased to the max dose, and my enzymes were raised. I’d to stay off till I had an ultrasound of my liver. Thankfully that came back normal and I was switched to MTX. Been on it 8urs now at 25mg with no issues. I take folic acid 6 days a week to minimise side effects. Low folate can cause liver problems. It seems most on MTX take it 6 days a week, perhaps this is contributing to the problem

[Hightower62 in reply to Runrig01]

Hi, I was taking Prednisolone for 28months before tapering off completely around a year a year ago. I have been taking 20mg MTX for almost all of that time and have only had raised (out of range) ALS and ALT levels three times and each time it has resolved by the next blood test.

So I have learned not to worry too much but every case is different so you’re right to say that your Rheumy team will advise you accordingly. Good luck.

[YorkieBard]

Hi MelB71

I was diagnosed in Jan 24 & like you was put on methotrexate & folic acid, until 6 weeks later when my ALT levels were high. Consultant phoned me on a Saturday & said stop at once. Unfortunately, I had taken my weekly dose 2 hours before the phone call!

My ALT levels went back to normal 4 weeks after stopping MTX.

I saw him a month later & was put on Leflunomide. 4 weeks after that appointment, I got a second Saturday phone call & told that my ALT levels were even higher than when I was on MTX & to stop Leflunomide!

I now have an appointment in June to discuss what happens next.

Consultant told me that while most people are fine on MTX or Leflunomide (that act in a similar way - according to him) - there are a small percentage of patients who react badly re high ALT with both drugs.

Meanwhile my symptoms continue to worsen as the months go on...........

My point is here that if your consultant suggests trying Leflunomide - please do question if it is wise - given your history with MTX & high ALT.

I wish I had!

[BastinH]

Hi, have been on methotrexate for many years and the only time my liver enzymes rise is if I have alcohol, (and it doesn't have to be much) which I do very rarely now, usually at celebrations. I'm not suggesting for a minute that you drink 🤦‍♀️😂 I'm just saying that's my experience. I'm not worried about the occasional blip as the enzymes appear to return to normal very quickly. I know methotrexate doesn't suit all but the drug changed my life, combined with a biologic I am now in remission and have been for about 10 years. I give myself a 20mg mxt injection once per week, and the biologic once every other week. I take 20mg of folic acid once per week. The injections lessen the impact on the stomach I believe.

I think in the first few years it's a bit hit and miss what is suited to you personally. I know I was put on numerous regimes before they found the right combination that suits me. I'm also under no illusion that the body can get used to the drugs resulting in more flare ups. At that time the drugs need to be changed or tweeked.

I hope you find your combination soon to alleviate the symptoms of this horrible disease.

[MelB71]

Thank you everyone. Just an update - I have spoken to the rhuemy nurse, who is lovely by the way. She has asked me to go down to 10mg for two weeks then repeat bloods. She is also requesting an appointment at clinic so that we can discuss a back up plan as she doesn't think mtx is doing all it should for me.

I also contacted my doctors as no one had been in touch even though I can see phone consultation with doctor is needed due to results. They offered me an appointment on June 11th! I'm now trying to get a blood form from them (if I use rheumy one my docs can't see results apparently) which needs a phone consultation.

All I can say is thank goodness for such a great rheumatology team.

[Nodule in reply to MelB71]

HI Mel,

I have been on MTX for 2 years now, the one time my ALT and AST were elevated we figured out it was due to vitamin supplements I was taking that interacted with the MTX. Do you take any supplements? And if so, let your Rheumatologist know so they can check interactions. Mine was specifically Black Cohash that I was taking for menopause symptoms! I had no idea it would interact!

[MelB71 in reply to Nodule]

The only vitamin supplement I'm taking is vit D ampoules prescribed by doctor due to very low vit d levels. I hadn't mentioned these to the nurses as I've only taken them once a week I'd forgotten about them.