LabSense

ALT & AST High (Elevated Liver Enzymes): Causes, Patterns, and Next Steps

8/21/2025

ALT and AST (transaminases) rise when liver cells leak enzymes. Common searches include “ALT 2x normal”, “AST ALT ratio”, “elevated liver enzymes after workout”. Magnitude, trend, and pattern with other liver tests (ALP, GGT, bilirubin) matter.

Common causes of elevated ALT/AST

  • Metabolic dysfunction–associated steatotic liver disease (MASLD/NAFLD): weight, insulin resistance, triglycerides.
  • Alcohol: AST may exceed ALT (often AST:ALT > 2), GGT can be high.
  • Medications/supplements: acetaminophen, statins, antibiotics, herbals (kava, green tea extract).
  • Viral hepatitis (A, B, C), autoimmune hepatitis, hemochromatosis, Wilson disease (less common).
  • Muscle injury: heavy exercise, rhabdomyolysis — check CK if the clinical picture fits.

Pattern recognition

  • Hepatocellular pattern: ALT/AST high with relatively normal ALP → consider viral, metabolic, drugs, autoimmune.
  • Cholestatic pattern: ALP and GGT high (ALT/AST mild) → consider obstruction, cholestasis (see our “Alkaline Phosphatase High” guide).
  • AST:ALT ratio: > 2 suggests alcohol-related injury; < 1 common in metabolic disease — not diagnostic alone.

Educational next steps

  1. Confirm fasting, alcohol intake, new meds/supplements, exercise; repeat in 2–4 weeks if mild and asymptomatic.
  2. Discuss targeted labs/imaging with a clinician: viral hepatitis panel, iron studies, autoimmune markers, ultrasound if persistent.
  3. Lifestyle education: weight management, limit alcohol, manage diabetes and triglycerides; avoid unnecessary hepatotoxic medicines.

When to seek urgent care

  • Yellowing of skin/eyes, severe abdominal pain, confusion, or bleeding.
  • Very high ALT/AST with rising bilirubin and INR — emergency evaluation is needed.

FAQs

Can exercise raise ALT/AST?
Yes — intense workouts and muscle injury can raise AST (and sometimes ALT). A CK test can help distinguish liver vs muscle sources.
Do statins always harm the liver?
True liver injury from statins is uncommon. Mild ALT/AST bumps are often observed and monitored; decisions are individualized by a clinician.

Educational use only. Not medical advice or a prescription.

Educational information only — not a diagnosis, treatment, or prescription.