Table 3 Summary of ETD for Recommendation # 18

Original Recommendation

Liver function and hepatocellular integrity should be assessed in patients taking MMI or PTU who experience pruritic rash, jaundice, light-colored stool or dark urine, joint pain, abdominal pain or bloating, anorexia, nausea, or fatigue (Strong Recommendation; Low Quality Evidence).

Modified Recommendation

Liver function tests and hepatocellular integrity should be assessed in patients taking MMI or PTU who experience specific symptoms (pruritic rash, jaundice, light-colored stool or dark urine, abdominal pain) or multiple non-specific symptoms (joint pain, bloating, anorexia, nausea, or fatigue) using only ALT instead of a full LFT panel (alanine transaminase, aspartate transaminase, alkaline phosphatase, gamma-glutamyl transferase; total, conjugated and unconjugated bilirubin) routinely (Strong Recommendation; Low Quality Evidence).

Overall Conclusion

☒Strong recommendation for Modified Recommendation

☐Conditional recommendation for Modified Recommendation

☐Conditional recommendation for either Original Recommendation or Modified Recommendation

☐Conditional recommendation for Original Recommendation

☐Strong recommendation for Original Recommendation

Additional Suggestions:

• Remain wary that checking ALT only may lead to missed diagnosis of cholestasis.

• In patients with prior history of liver disease or high suspicion of liver damage (multiple specific symptoms), then baseline full LFTs should be performed.

• Following drug withdrawal, LFTs need to be repeated after 1–2 weeks

Justification:

• The magnitude of liver dysfunction with ATDs in clinical practice is limited, usually occurring with intercurrent illness.