Review Question - QID 103596

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Generalized Anxiety Disorder Treatment Medical QID: 103596 (M3.PY.15.106)

QID 103596 (Type "103596" in App Search)

A 46-year-old woman presents to her family physician for a general wellness checkup with a chief complaint of high levels of anxiety over the past year. Her anxiety has started to affect her performance at work, making her even more anxious and concerned that she will lose her job. She started psychotherapy several months ago and has experienced minimal improvement in her symptoms from this treatment. The patient is vehemently opposed to beginning any pharmacologic treatment for anxiety; however, she is interested in potential herbal remedies and has started taking kava. She also takes vitamin D, a multivitamin, fish oil, protein powder, and drinks goat milk regularly. The patient works as a commercial sex worker and has a history of IV drug abuse and alcohol abuse which she states she has not used in over a year. She has chronic tension headaches for which she self-administers acetaminophen usually multiple times per day. Her last wellness appointment was unremarkable and these problems are new. Laboratory values are ordered as seen below.

Hemoglobin: 13 g/dL
Hematocrit: 38%
Leukocyte count: 6,870/mm^3 with normal differential
Platelet count: 227,000/mm^3

Serum:
Na+: 138 mEq/L
Cl-: 102 mEq/L
K+: 4.1 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 111 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: 10.2 mg/dL
AST: 82 U/L
ALT: 90 U/L

Which of the following is the most likely cause of this patient's lab derangements?

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Acetaminophen

50%

3/6

Acute hepatitis B infection

0/6

Alcoholic hepatitis

0/6

Chronic hepatitis C infection

17%

1/6

Dietary supplement

33%

2/6

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Kava is a popular herbal supplement used for the treatment of mild-to-moderate generalized anxiety disorder (GAD). Kava has been shown to cause hepatitis, cirrhosis, and liver failure and can elevate liver enzymes.

Kava is a popular herbal supplement that originated in the Pacific Islands and has purported benefits in treating anxiety, insomnia, depression, stress, and menopausal symptoms. Kavalactones, the active ingredient in kava supplements, interacts with numerous liver enzymes and also may cause direct hepatotoxicity. The FDA recommends that patients with pre-existing liver disease or patients who are taking medications that are predominantly metabolized by the liver should consult their physician before initiating kava supplementation due to the risk of hepatotoxicity.

Incorrect Answers:
Answer 1: Acetaminophen overdose would present with nausea, vomiting, abdominal pain, and liver enzyme elevation into the 1000's (often > 5,000). The treatment involves the administration of N-acetylcysteine.

Answer 2: Acute hepatitis B infection would present in a high-risk patient (just like this patient) with a liver enzyme elevation at least > 500. Hepatitis B core and surface antigen would be positive and surface antibody would be negative (a marker of resolved infection or vaccination).

Answer 3: Alcoholic hepatitis would present with a liver enzyme elevation into the hundreds (usually > 200) with AST and ALT elevated in a 2:1 (AST:ALT) fashion.

Answer 4: Chronic hepatitis C infection would present with a low-grade liver enzyme elevation with other possible signs/symptoms of liver injury/failure. It is possible in this high-risk patient; however, her recent use of kava and current elevation in liver enzymes offers a temporal relationship for her lab changes.

Bullet Summary:
Kava is a supplement used for anxiety that can be hepatotoxic.

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