Raised Alt & Infection

[Eve]

My last lot of methotrexate blood screening showed a raised ALT of 80. I'm on self injected 25mg per week.

I'm waiting for a call back from rheumatology (GP faxed results over) but could this be anything to worry about?

My GP had a look at my toe (looks like ingrowing toenail) and said there are signs of infection setting in so was given 500mg flucloxocillin 4 x a day. The pharmacist queried it with the Methotrexate and asked how my bloods were and queried whether to wait until I hear back from rheumatology so now not sure whether to start them tonight but if I don't I could risk a bad infection (seem to be prone to bad skin infections) which would also be bad doesn't help some of the skin seems broken as it's been bleeding a bit on and off.

Arghhh!

[Sqad]

From my point of view an ALT of 80 is nothing to be concerned about, possibly to be repeated in 3 months.
LazyGun/slaney will give your their opinions.

[Eve]

Thanks Sqad, that's a relief. I don't know much about the figures but them saying it was double to usual high end of the normal range and faxing them over and such I was worried that after all this time getting through the side effects and such it might affect me taking the methotrexate.

My inflammatory markers are back down (ESR 17, woohoo!) and kidneys (GFR 69) and white count seem to be behaving so hopefully this is just a blip. I have bloods every month anyway so would have it done again in 3 weeks or so as part of the usual screening.

Can I ask another quick question, they have my MCH flagged at 32.8 but it's only just above the end of range, I googled and I noticed a folate thing so could this just be the affect of the methotrexate and why I have to take folic acid?

[Sqad]

Folic acid reduces the side effects of methotrexate in Rheumatoid arthritis.

[Eve]

Thanks, as always, much appreciated.

[LazyGun]

Normal range for ALT is 5-60, so at 80 it is not hugely elevated. Typically, you would tend to worry if the value is a multiple of the normal, like 2x normal or more, so like Sqad I would not say it a cause for serious concern. Have you a recollection of a previous result?

Methotrexate is known as a folate- antagonist; it competes with folic acid and reduces functionality of folic acid within the body in consequence.

The MCH is a crude index, and is usually not taken in isolation. Normal range is 27-31 ish, so a reading of 32 is only slightly elevated. It is likely a reflection of the fact you are on methotrexate, which is inhibiting folic acid activity in the body - so not unexpected, and not alarmingly high.

The reason why you pharmacist raised concerns over flucloxicillin is that it tends to inhibit the natural removal of methotrexate from the body, which in turn might tend to impair the folic acid activity of the body still further. It is a legitimate concern, and you should raise it with your GP for confirmation, but I think the treatment of the infection outweighs the theoretical risk of interaction with methotrexate in this instance...

[Eve]

Thank you so much. I'm trying to learn more about how things work :) I'll always be restricted by my scientific lack of understanding, I'm not dense but I've never gone above GCSE level and a lot of stuff on the net is very sciency (or doom-mongering if not read in the right way).

My last ALT (about a month ago) was 36 then before that, going backwards, 32, 51, 51, 39, 38, 44...few weeks similar, then down to 23 then 18 a few weeks before that (mtx lowered that week), 21, 23 then was in the 40s and 50s again - sorry if it's confusing going backwards. So it's jumped about a bit though one benefit of a blood monitoring book is that I can see how much figures do change within just a couple of weeks, trying to learn as things go on what is ok and not ok. Fair dos, that usually comes from my GP/hospital though but it helps me feel more informed :)

[slaney]

Hi Eve - sorry that you seem to be going through something of a bad patch at the moment.
Methotrexate is usually stopped if there is a greater than X2 increase of liver enzymes over baseline. In this case it depends what the normal range is for your local laboratory. Very likely you will need an early repeat of the test to ensure it indeed just a blip.
As regards the flucloxacillin I wouldn't worry too much - there is a theoretical risk but in practice this does not seem to be significant. There are other antibiotics which interfere more.
http://www.ncbi.nlm.nih.gov/pubmed/8866922

Good luck - I will be interested to know what advice you are given.

[Eve]

Thanks Slaney. My nurse rang today and said to stop the methotrexate, repeat bloods in 2 weeks and to ring her then. She said I won't be able to go back on it until my liver results are back to normal.

The flucloxocillin is fine (also checked out omeprazole as read a few things online which say it shouldn't be taken with methotrexate) but she said that is fine too, just as well as I've been taking up to 80mg some days due to the side effects as well (I was on it anyway).

So, will see how it goes. Just frustrated to think about being off meds and flaring and maybe not being allowed back on and having to start again or reaccustom to them. I'm just tired of it all. Managed to get through 5 hours of work before giving up and coming home today as I felt so crap, feel bad for taking time off.

[slaney]

Hopefully this is just a blip Eve, and you will be back on the methotrexate soon.
I would be interested to know what happens to your rash while you are off it though.