Erhöhte Leberwerte bei einem Rheumapatienten. Was nun?

Zusammenfassung

Regelmäßige Kontrollen der Leberwerte sind ein fester Bestandteil der rheumatologischen Routine. Erhöhte Transaminasen sind dabei ein häufiger Befund, für den viele verschiedene Gründe in Frage kommen. Als Erstes muss die Möglichkeit einer unerwünschten Wirkung eines der rheumatologischen Medikamente erwogen werden. Am häufigsten sind dies NSAR, vor allem Diclofenac, gefolgt von den DMARD Methotrexat oder Leflunomid. Die Kombination der letztere beiden verursacht besonders häufig Transaminasenanstiege. Der aktive Metabolit von Leflunomid muss dann unter Umständen mit Colestyramin aus dem enterohepatischen Kreislauf ausgewaschen werden. Leberwerterhöhungen durch Sulfasalazin sind selten, schwere nekrotisierende Hepatitiden als Teil einer systemischen Medikamentenreaktion können jedoch auftreten. Unter den biologischen DMARD sind es v. a. die TNF-alpha-Hemmer Infliximab und Adalimumab welche Hepatitiden verursachen können. Bei Patienten mit ankylosierender Spondylitis waren aber auch unter Etanercept Leberwertanstiege beobachtet worden. Als weitere Substanz kann der Interleukin-6-Rezeptor Antikörper Tocilizumab zu einem Anstieg der Transaminasen führen, selten auch zu schweren Leberreaktionen. Schließlich gibt es noch eine ganze Reihe von anderen Ursachen für Anstiege der Leberwerte bei Rheumapatienten, die von einer Reaktivierung oder Neuinfektion einer Virushepatitis, dem Auftreten einer Autoimmunhepatitis bis zu Begleiterkrankungen der Leber reichen. Dies alles macht ein systematisches differentialdiagnostisches Vorgehen notwendig.

Abstract

The monitoring of liver enzymes in blood on a regular basis is an established part of routine care in rheumatology. Elevated transaminases are a frequent finding, which may be attributed to various causes. Firstly, the possibility of an adverse event of a rheumatologic drug should be considered. The most common drugs causing elevated liver enzymes are NSAIDs, especially diclofenac, followed by the DMARDs methotrexate and leflunomide. The combination of the latter two causes elevated transaminase levels more frequently than the same drugs given in monotherapy. When there are strong signs of liver damage, the active metabolite of leflunomide has to be eliminated from the enterohepatic circulation by colestyramin. Elevations of liver enzymes caused by sulfasalazine are rare, but there is a possibility of severe necrotising hepatitis occurring as part of a systemic drug reaction. Biologic DMARDs may induce increased liver enzymes as well: Most commonly, it is the TNF-alpha inhibitors infliximab and adalimumab that have been reported to cause drug-induced hepatitis. However, in patients with ankylosing spondylitis, etanercept has also been reported to induce elevated transaminases. Further on, the interleukin-6 receptor antibody tocilizumab may induce elevated transaminases and, rarely, it may cause severe liver reactions. Finally, there are a number of other causes for elevated transaminases in patients with rheumatic diseases, e. g. reactivated or new viral hepatitis infection, autoimmune hepatitis or comorbid disorders of the liver. All of this requires a systematic differential diagnostic procedure in this clinical situation.

Schlüsselwörter

Hepatitis - Transaminasen - Rheumatoide Arthritis - NSAR - DMARD - Biologika

Key words

hepatitis - transaminases - rheumatoid arthritis - NSAID - DMARD - biologics

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