75-Year-Old Woman With Elevated Liver Enzymes

PATIENT OUTCOME
Gladys’s ALT and AST levels were mildly elevated. One of the more common causes for this pattern is medication. In addition, her ALP level of more than twice the upper limit of normal further pointed to a viral, alcohol-related, or drug toxicity cause. Since her hepatitis panel was negative and she did not use alcohol, it was determined that elevated liver enzymes were related to the recent addition of quetiapine, which was discontinued. In addition, in light of Gladys’s hypotension (which is also a potential adverse effect of quetiapine⁸), her dose of lisinopril/hydrochlorothiazide was decreased by half.

One week later, liver enzyme levels were returning to normal. Gladys, however, began having more difficulty sleeping and more trouble remaining focused and getting things done, despite taking methylphenidate. In place of quetiapine, risperidone (0.5 mg at bedtime) was initiated. At first, Gladys was concerned with her continuing dry mouth symptoms, but when she skipped doses of risperidone, she noticed that she functioned less well. Further, her liver enzyme levels were being closely monitored and were normal. With this reassurance, Gladys remained adherent to risperidone for mood stabilization.

CONCLUSION
Atypical antipsychotic drugs such as quetiapine can cause elevated liver enzyme levels, especially in the elderly, patients with hepatic impairment, or patients on polypharmacotherapy. Rarely, quetiapine has been reported to cause serious hepatotoxicity and even death. Patients taking these drugs should be informed of possible symptoms of liver toxicity, including fatigue, nausea, vomiting, abdominal pain, and change in color of urine or stools. Particularly in more vulnerable patients, liver enzyme levels should be monitored carefully to confirm the continued safety of antipsychotic treatment.

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