What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?

This is an important concept because anyone using tocilizumab will eventually wrestle with this question. The question, though, does not tell you whether this is the first time a practitioner sees the liver enzyme elevation, or how high the liver enzymes rose.

Since everyone should have had a lipid panel before starting tocilizumab, I always review the medication list when I see liver enzymes go up and specifically look for the ‘statin that might have been ordered. Tocilizumab is not the only drug that causes transaminase elevations.

First and foremost, it must be an AST and ALT elevation, as an isolated AST elevation or AST >> ALT should suggest a muscle disorder and should be repeated with a CPK and aldolase, as this will confirm unrelate...