Elevated ALT (liver enzyme)

[Pangolin]

Son is 11 and currently on EEN and a rather high dose of infliximab 400mg (which is about 14 mg/kg now) every 6 weeks. Obvious Crohn's symptoms have been minimal lately and improving over time, but blood tests have been trending in the wrong direction:

Sed rate up. Last three measurements (reference range 0-15): 14, 19, 28
ALT (reference range 10-30): 31, 36, 48
CRP (reference range 0-10): 2, 2.5, 4.9

6 weeks ago, fecal calprotectin was 282. 12 weeks before that, it was around 290.

Sed rate increase might be related to some fevers he had last week which were apparently due to a respiratory infection. Last time he may also have been sick, but these numbers could actually be attributable to the Crohn's inflammation.

In general, he's continuously sniffly on infliximab.

The doctor thinks the elevated ALT and sed rate are probably related to the Crohn's inflammation, but without obvious Crohn's symptoms I don't know what to attribute it to. I wonder if the elevated ALT could be a direct side effect of the infliximab. The doctor is also suggesting methotrexate to boost the infliximab, but I'm worried about the liver effects.

I suppose the answer is that it's time for a colonoscopy (it's been almost a year and a half). If a colonoscopy shows significant inflammation, I wonder if it's time for a different biologic.

 

[DanceMom]

Honestly, our GI would consider that ALT to be normal. Anything under 60 and he's pleased. The SED rate would definitely prompt more testing though (because my girl is never high).

 

[Jenn]

Crohn's inflammation while on Remicade means Remicade isn't working right? I'd say it's time to try something else. Most times the symptoms are not obvious, which is why blood work is monitored. Ask the doc to run a blood level antibodies test too.
I hear you on your concerns about adding methotrexate, I did the same and it works out ok. You could try adding that first, and/or while waiting for insurance to approve a change. Because a combo is often needed anyway.
Good luck!

 

[Pangolin]

Thanks for the responses. Remicade levels were taken a few months ago and were ok but could be higher (I think the level was in the 4-ish range, before a dose increase). No antibodies.

I'm not sure whether or how much Crohn's-related inflammation there is right now. The current sed rate is really uncoupled from symptoms and could possibly be because of a respiratory infection the week before. I also wonder if there's an abscess or fistula forming without any obvious signs. The doctor says it's time for an MRE (MRI) to see what's going on, and that sounds great to me.

The doctor is not at all worried about the ALT number at the moment.

If there's still inflammation we can see in the MRE despite the relatively high doses of remicade, the doctor suggests either adding methotrexate or going to Humira.

 

[my little penguin]

Understand not wanting mtx
But adding something works faster than switching to humira and waiting 3-5 months for results to see if your child is a responder
Did he require abx for the upper respiratory infection(cold)?
Or was it simply a bad cold ?
Most colds don’t increase the sed rate ?
And you are seeing an increasing trend over a longer period of time
Sed rate is the past two weeks

MRE is a good idea

 

[Pangolin]

He had a fever with it for a few nights, so it was a little more than the usual cold. These test results definitely could be the Crohn's, but I think it's strange that his symptoms are lower than ever if that's the case. We'll see what the MRE shows soon though--hopefully that will give us a lot more info.

 

[Pangolin]

Update:

ALT back to normal (21)
Sed rate down a bit to 23
CRP down to 3.3

So, everything normal or improving in the blood except one thing.

B12: 1373 pg/ml (reference range goes up to about 900)

Looking up causes of high B12, I see that can be caused by liver damage among other things. Maybe the previous high ALT levels are related, and with lower ALT now indicating that the liver is better, the B12 can come down?

 

[Maya142]

My kiddo has had high B12 levels. I panicked after reading up on them online and so called her GI. Her GI was not concerned at all but said we would recheck in 6 weeks or so, I think. Next time we checked, they were within the normal range.

 

[crohnsinct]

^ same with O