Management of Elevated Liver Function Tests in Patients Taking Hydroxychloroquine

Assessment and Monitoring

The American College of Rheumatology conditionally recommends annual monitoring of CBC and LFTs for patients on hydroxychloroquine without liver abnormalities 1, 2
Classify the severity of liver enzyme elevations using a standardized grading system: mild (1-3× ULN), moderate (>3-5× ULN), severe (>5-20× ULN), or life-threatening (>20× ULN) 3
Determine the pattern of liver injury by measuring both aminotransferases (ALT, AST) and cholestatic markers (ALP, GGT, bilirubin) 3
Check for signs of hepatic dysfunction such as increased bilirubin, decreased albumin, or prolonged clotting times 3
Evaluate for other potential causes of liver enzyme elevation, including viral hepatitis, alcohol use, and other hepatotoxic medications 3

For patients with mild elevation (1-3× ULN), continue hydroxychloroquine with increased monitoring frequency 3
For patients with moderate elevation (>3-5× ULN), monitor liver enzymes every 2-3 days until stable or improving 3
For patients with severe elevation (>5-20× ULN), monitor liver enzymes every 1-2 days until stable or improving 3
For patients with life-threatening elevation (>20× ULN), hospitalize for intensive monitoring and supportive care 3
If hydroxychloroquine is restarted after normalization of liver enzymes, monitor LFTs more frequently (every 2-4 weeks) for at least 3 months 3

For patients with known chronic liver disease, the American Thoracic Society recommends monitoring liver function every 1-3 months rather than annually 4
The American Thoracic Society suggests screening for alcohol use and chronic viral hepatitis before initiating therapy in patients with baseline liver abnormalities 4