COMMENTARY

Morning Report: Liver Tests, Young Adults With Dyslipidemia, Prioritizing Preventive Services

Arefa Cassoobhoy, MD, MPH

Disclosures

January 20, 2017

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Hello. I'm Dr Arefa Cassoobhoy, a practicing internist and a medical editor for Medscape and WebMD. Welcome to our weekly brief on recent medical news and findings.

New Liver Test Guidelines

First, we learn that the American College of Gastroenterology (ACG) has issued new guidelines that should make it easier to recognize abnormal liver chemistries.

The updated recommendation is the first to provide specific ranges classifying the upper limit of a "normal" serum alanine aminotransferase (ALT) level as 19-25 IU/L for women and 29-33 IU/L for men. This represents a major change from previous guidelines. Some critics have suggested that this could result in chasing elevated ALT levels in many patients. However, the guideline authors emphasize that even slight increases that don't normalize over time increase the risk for liver-related death and require investigation.

The guidelines address diagnostic testing for specific liver diseases, including viral hepatitis A, B, and C; nonalcoholic fatty liver disease; alcoholic liver disease; and screening for celiac disease.

Also, the guidelines provide step-by-step algorithms to evaluate abnormal levels of ALT, aspartate aminotransferase (AST), alkaline phosphatase, and bilirubin. This includes questions to assess your patient's history, recommendations for lab and imaging tests, and guidance on when to consider a liver biopsy.

And just a note: ACG suggests that the name "liver function tests" be retired, because these are not true measures of hepatic function. From now on, the authors urge us to refer to "liver chemistries" or "liver tests."

Statins Underused in Young Adults With Severe Dyslipidemia

Younger patients with severe dyslipidemia, defined as a low-density lipoprotein (LDL) cholesterol level above 190 mg/dL, seem to be undertreated.

Researchers analyzed data from 2.8 million inpatient and outpatient encounters in all 50 states and found that patients under age 40 years with high LDL cholesterol received fewer statin prescriptions than older patients, even though a statin was indicated. In fact, only 45% of patients under the age of 40 were treated. And only 32% of patients in their 30s with this degree of hyperlipidemia were getting treatment.

The strongest predictor of statin use was age over 40 years, which could speak to the misconception that patients who appear active, young, and healthy can be treated with lifestyle change. The researchers say that this degree of hyperlipidemia, generally genetic in origin, is unlikely to be controlled through diet and exercise alone. Consider this the next time you're taking care of a younger patient with severe dyslipidemia.

Updated Rankings for Preventive Services

And finally, for the first time since 2006, there is an updated list that clinicians can use to prioritize implementation of preventive health services. The evidence-based ranking takes into account a service's impact and cost-effectiveness.

Not surprisingly, the intervention considered to be most effective and the highest priority—in adults—is screening for tobacco use and tobacco cessation counseling. The next two highest ranked interventions are screening for alcohol misuse with a brief intervention, and aspirin use for adults at high risk for cardiovascular disease.

In all, 28 services are included in the rankings, which can be viewed online. This prioritized list of value-based services should help decision-makers select which services to emphasize in quality-improvement initiatives.

For Medscape and WebMD, I'm Dr Arefa Cassoobhoy.

Follow Dr Cassoobhoy on Twitter at @ArefaMD

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