Initial management of abnormal liver function tests in patients on chronic low-dose MTX*^¶

MTX: methotrexate; AST: aspartate aminotransferase; ALT: alanine aminotransferase; ULN: upper limit of normal; NSAIDs: nonsteroidal antiinflammatory drugs.
* Refer to UpToDate topic review on hepatotoxicity of chronic low-dose MTX for nonmalignant disease for further details.
¶ Management of patients with serum albumin levels that decrease approximately 0.3 g/L while otherwise clinically stable on MTX uses the same general approach as is used for patients with aminotransferase levels ≥3 to 5 times the ULN.
Δ Some experts prefer that blood for laboratory testing should be drawn in the days just prior to MTX dosing rather than in the day or 2 following drug administration.
◊ Elevations ≥3 to 5 times the ULN are infrequent and usually associated with exposure to an additional hepatotoxin (eg, alcohol).
§ May consider subsequent resumption of MTX on an individualized basis depending upon an assessment for other potentially reversible causes of the hepatic abnormalities (eg, alcohol, medications, comorbidities such as resolving or treatable infections).