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08-31-2017, 04:09 PM   #1
Tesscorm
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How important is AST?

Hi all,

Have a question for you re AST bloodwork.

S went to his infusion today and he takes labwork requisition each time. We use the same form that was given to us by his GI and just print a copy for each infusion.

Today, he was told that Ontario health coverage no longer covers AST. The charge will be $35 per test. Of course I'll pay but I'm wondering how necessary this test is?? Is there a comparable test that can replace AST?

Does everyone on biologics have their AST tested?

And, has anyone else in Ontario been told the same thing?

I'm going to send an email to his GI but just wondering what your thoughts are??

Thanks
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08-31-2017, 04:26 PM   #2
DanceMom
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A always gets a CMP which covers ALT and AST. Her numbers are pretty comparable...meaning if one is high the other usually is too.
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08-31-2017, 04:37 PM   #3
Maya142
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We always get it done - here, like DanceMom said, it's part of the Comprehensive Metabolic Panel (both AST and ALT are). Both my girls have that done at least every 3 months, usually more often for the younger one, since she is on so many medications.

Honestly, I'd ask your GI. They are usually done together here - in the 8 years or so my girls have been on biologics they've always had AST and ALT checked.
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08-31-2017, 06:14 PM   #4
my little penguin
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They always Check ast and alt for ds every 3 months sometimes sooner
One may go up before the other
They watch it closely since Crohns has a higher risk of liver issues
And
Biologics put you at higher risk
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08-31-2017, 08:47 PM   #5
Tesscorm
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Thanks everyone. I was fairly certain AST was a necessary test given possible liver issues but, wanted to see what everyone else thought as well.

I'm surprised they're not covering it anymore?? Here, vitamin D testing is not covered for the 'general public' but, if a doctor determines that vitamin D levels are relevant for a patient, the cost is then covered by Ontario health (ie in the past it's been covered when tested for S but I've paid just to know where things stand for my daughter). I'm surprised it wouldn't be the same for something like AST, given Crohn's dx and biologic treatment.

Maybe there is some 'code' that needs to be shown on the requisition under these circumstances?? But, considering it's an infusion centre, I would've thought they would've told S if that was the case.

Well, I'll be emailing GI and will probably hear back next week... I'll update just for anyone else's reference.

Thanks
08-31-2017, 10:05 PM   #6
kimmidwife
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I agree with the others Tess. It is not a test I would want him to forgo. That is just crazy. Keep us posted what the GI says.
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08-31-2017, 10:17 PM   #7
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Agree with others. S' GI always looks for it because there is a FDA warning on liver issues related to anti TNFs.
09-01-2017, 12:45 AM   #8
Farmwife
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Grace also had hers checked every four weeks.
That's just crazy they won't cover it.
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09-01-2017, 09:42 PM   #9
lisadc1
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It is important. Along with so many issues I have, recently I was diagnosed with liver disease as well. They have monitored my liver all along, but it continuously has gotten worse. I would definitely continue to keep those tests monitored.
09-04-2017, 05:09 AM   #10
DustyKat
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AST is a less specific test for liver disorders than ALT, and so has limited utility in the community setting. OHTAC recommended that AST testing be restricted to ordering by or on the advice of physicians with experience treating liver disorders.
http://www.health.gov.on.ca/en/pro/p...00/bul4584.pdf

ALT is primarily an enzyme of the liver. AST, whilst liver a enzyme, is also found elsewhere in the body, particularly the heart and other muscles.
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09-04-2017, 01:49 PM   #11
Tesscorm
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Paragraph #35: L222 SGOT (AST) is only insured for insured persons when ordered by or on
the advice of a physician with expertise in hepatic disorders.
Amazing Dusty! Thanks so much for finding that link!!

Above quote from same link. From reading above, my understanding is that the testing should have been covered as it was ordered by an appropriate physician.

Seems like it was an error on the part of the lab?? I'll be following up tomorrow (today is a holiday here).

So great to hear from you! Hope all is well with you, Sarah and Matt! Spring must be in the air for you ; hopefully, you will have a better summer then we've just had!
09-04-2017, 05:09 PM   #12
DustyKat
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Hey Tess,

I think it is a lab error for two reasons:

Firstly, if it was ordered by a Gastroenterologist or Hepatologist then that is your physician with expertise in hepatic disorders. Also if your health system is similar to ours then specialists refer back to GP's to continue care between specialist visits. That being the case then the GP would be ordering tests under the direction of the specialist so you are covered by that area of the statement too.

Secondly, this has been in effect since 1st of January 2013. As you haven't been charged for this test before you have four and half years of precedence. lol

Things have been a bit up and down here and time has been my enemy on many fronts, hey ho.

Yes! Spring has sprung, sort of. Winter was milder than normal, dry as hell (hate to think what summer will bring), and the worst on record for flu. Thankfully we all had our vaccinations and have avoided it thus far, fingers crossed! lol

Hoping that all is well at your end.
09-05-2017, 11:42 AM   #13
Tesscorm
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Apparently, not a lab error.

There must have been a more recent change to policy because now it is only urologists who can order the test.

When I spoke with GI's office, they told me they have updated the requisitions but because we take our own copy, ours was out of date. And they are no longer requiring AST.

I offered to continue the testing and offered to pay but GI office said it's not necessary as they have sufficient info without AST for the 'routine' testing. I suppose they will track ALT.

I'm not happy with this (because, with testing, as far as I'm concerned, the more the better!) but not much more I can do now... I can speak to his GI at next follow up but that won't be for a year as he just had his follow-up. I'm going to be moving S to a new GP in a few months to one that will be more conveniently located for S (plus, hubby and S have same GP and neither have been happy with him lately). We can ask new GP to test and we'll just pay???


As far as whether this info is of relevance to any one else, keep in mind, the policy may be different for pediatrics??
09-05-2017, 12:12 PM   #14
my little penguin
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He is only seen by the GI once a year .
Wow
We were told 4 months is the max between visits allowed for Crohns patients regardless of age (including adults )
09-05-2017, 12:24 PM   #15
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What labs do they run then if they don't track AST? ALT and AST are both part of CMP. My son (unusual case, I know) has CMP run once/3 months. I expect that insurance will eventually push back on his quarterly FCP but hopefully AST isn't up on chopping block.
09-05-2017, 01:12 PM   #16
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This is the first time his follow-up has been extended to one year. So far, it's been every six months. But, perhaps because he's been stable for so long and maybe he takes into account that I keep them informed of everything (ie abx prescriptions for infections, I've sent copies of reports when S has gone to school ER for respiratory, kept him informed of shoulder surgery, etc.), that he thought it would be ok to schedule next one in one year. I think he's pretty confident I would let them know if anything was off.

Really, S's follow ups are very short... GI asks crohns and remi symptom related questions and S's responses are always 'all ok'... I have way more interaction with GI office throughout the year due to updates re infections, etc. When there has been a concern (ie chest xray that indicated a 'spot', GI had him come in to redo xray at his hospital).

So, I was okay with the one year wait.

Given the above, what else could be done in more frequent appointments?
09-05-2017, 01:18 PM   #17
Tesscorm
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This is what's included at every infusion:

Creatinine
Sodium
Potassium
Chloride
ALT
Alk. Phosphatase
Bilirubin
Albumin
Vit B12
Ferritin

CBC

AST (which will be cancelled)
GGT
Amylase
CRP

And, periodically, Vit D is added.


Are you in U.S.? Asking because our labs aren't covered by insurance. It's all covered through Ontario Health (except for when they 'no longer cover' like AST and Vit D)
09-05-2017, 01:33 PM   #18
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In a general/indirect sense, this is why I want to move S to a new GP. Given the time periods between GI apptmts, I haven't been at all comfortable with the follow-up/care given by his GP.

Annual physicals were always recommended and paid for by Ontario health. Last year, when I tried to book S's physical, his doctor's office said that Ontario Health was no longer 'recommending' annual check-ups as those same tests could be done at any apptmt without an apptmt being booked specifically for a 'physical'. But, dr's office said they would do a 'physical' if a patient requested it. I told the office that given that S has crohns and remi, I didn't want it left to 'some random' apptmt (because, seriously, is the dr going to remember?!?). So, S went to his physical but, when he came home and I questioned the apptmt, S told me they didn't even do bloodwork! S said he told GP that he had bloodwork done every six weeks, so I imagine GP thought all was covered! Totally irresponsible, I think. Because, of course, routine bloodwork for remi/crohns doesn't cover all that should be done for a physical! (Really, this pissed me off huge! But, because S is an adult, I can't really complain to dr! ) And, anyone who deals with a teen/young adult knows the chances of me getting S to go to another apptmt was nil!

So, I'm just waiting for S to finish school (Dec) and, very likely, start working downtown. At that time, I'm going to move him to a dr in my own doctor's clinic - which is minutes away from any job downtown and, they happen to have an infusion centre in the same clinic.

(This is why I have so much interaction with GI's office... I know he's a GI but, really, I run most issue sby him and then follow his instructions...)


BTW, it really does get tricky when your 'kid' becomes an adult! When I was going to S's GP apptmts, I asked lots of questions, requested certain tests, asked questions as to what tests could be ordered to look for this or that, etc. and, at that time, I liked his GP. He was always accommodating, etc. But, since I stopped going to S's GP apptmts, it seems the care has really slacked off.
09-05-2017, 02:26 PM   #19
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We've just moved to once a year with GI, his numbers have been about the same for the last year. He also just got the first doctor bill in his name since turning 18, it was pretty funny when he looked scared and asked us if he had to pay it. We will be moving to labs every 3rd infusion after this next one which will be his first at college but he is under strict instructions from his GI to email him if there is even the slightest twinge of anything even if he doesn't think it's Crohn's related.
But definitely, does AST/ALT at labs and I would be likely to pay and ask for it but then his father was diagnosed with liver disease about a year ago liver numbers were bad and we were in discussions for the liver transplant list. They pulled him off Imuran and don't want to put him on anything until we have issues. Within several months of being off Imuran his numbers have dropped significantly and are only slightly elevated and do not have to currently pursue a liver transplant. So now I watch those numbers with an eagle eye, as hubbies numbers would be high he'd rerun in 2 weeks and they would be fine so I'm guessing damage was being done all that time.
Jack's infusions will be done in his dorm so they won't pull labs but he will have to go to the lab on campus (thank you for being a medical oriented school) and have those done the day before. But I'm with you Tess, I want to be there to make sure everything runs smoothly and I can ask all the questions, he won't even think of asking as he will just assume if it's needed it's being done.
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09-05-2017, 04:38 PM   #20
Optimistic
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This is what's included at every infusion:

Creatinine
Sodium
Potassium
Chloride
ALT
Alk. Phosphatase
Bilirubin
Albumin
Vit B12
Ferritin

CBC

AST (which will be cancelled)
GGT
Amylase
CRP

And, periodically, Vit D is added.


Are you in U.S.? Asking because our labs aren't covered by insurance. It's all covered through Ontario Health (except for when they 'no longer cover' like AST and Vit D)
Thank you! I am in US, but my husband works some in Canada. I like to read about Ontario Health just to see what is going on. Trends for care and coverage generally go in same direction, eventually. I did get some push back on vitamin d test recently from what had been a robust insurance coverage plan.

I'm dreading a few years when he has to manage this himself. I hope a big blast of maturity sweeps in... I lose access to his med records unless he requests an ID for me at age 18.
09-05-2017, 05:59 PM   #21
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Urologist?? Are you sure that is what they said Tess? It makes no sense that a Urologist is the only specialist that can order it but that they are ordering at all in the vast majority of cases.

ALT is more specific to the liver than AST, a little bit like CRP/ESR versus FC. That said the ratio of ALT/AST can be useful determining what type of liver damage may be present when they are elevated. IIRC I think AST also responds more quickly to damage but also stays elevated for longer periods.

This is the latest bulletin I could find, March 2017:

https://www.dynacare.ca/DYN/media/DY...17_website.pdf

The information provided is a tad ambiguous:

In their January 2013 Bulletin (OHIP restriction notice), OHIP stipulated that AST is an insured service only when ordered by physicians with experience in treating liver disorders, or on the advice of physicians with such experience.

If applicable, please indicate OHIP eligibility for your patients by writing in the “Other Tests” section of the OHIP laboratory requisition: “AST ordered/advised by hepatologist” (see Page 2, on reverse).
They are still saying the same as they did in 2013 but have now they are saying a Hepatologist has to order it. But on page 2 it states:

To qualify as an insured service:
AST – State that testing was ordered/advised by a physician (provide name) with expertise in hepatic disorders
It could easily be argued that all gastroenterologists have expertise in hepatic disorders.

Perhaps this part of the form wasn't correctly completed??

Sarah has only ever been on annual visits to the specialist, once stabilised, and Matt 6 monthly. He will remain on 6 monthly due to the need for Humira approval. I have never had an issue with this schedule as the GP is the centre of care. The GP receives a letter from the GI after each consult outlining his treatment requirements, the GP orders all the tests, does scripts, etc and the GI is cc'd into all results. If needed the IBD nurse and GI are just a phone call away.
09-06-2017, 09:28 AM   #22
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Jacqui, that must have been so scary for you and your husband!! I'm glad things are settling! And, his crohns has been okay with no meds? Hope it stays stable for a long while so his liver can settle back to normal levels.

Dusty, yes, I'm certain it is a 'urologist'. I spoke with both the nurse that acts as the liaison between the GI's office and treatments (handles infusions centres, insurance issues, etc.) and the GI office directly. Liaison nurse is the one who told me urologist and she said she would be updating S's req to delete AST. To confirm that she was correct in changing S's req, I then called his GI's office and they told me the same thing - GI's office didn't specify urologist but confirmed the cancellation of AST going forward.

As ALT, GGT, Alk. Phosphatase, Bilirubin, Albumin are all related to liver testing, you don't think these would indicate the beginnings of a liver problem? At least enough to warrant further investigation?
09-07-2017, 07:34 AM   #23
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Vitamin D is technically not covered here. It not covered for Sarah. But it is covered for Kerry and myself. We both have a history of very low vitamin D.

Sarah hadn't seen a GI in the 2 years she had been away but had 3 visits in the 7 weeks she was home. Due to a flare and increase in meds.
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09-07-2017, 03:39 PM   #24
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Only a urologist can order AST? That seems pretty strange.

My son (24) has had blood work and appointments every 6 months while on Remicade and (knock on wood) doing well. The frequency of lab testing and visits most likely varies depending on doctor and clinical situation.
09-07-2017, 05:25 PM   #25
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I still can't get my head around the urologist bit Tess. I believe what you are saying but I think the nurse has her specialties mixed up.

TBH I don't think that AST is required in the vast majority of cases of those with IBD and yes, the other liver enzymes and markers would indicate the beginnings of a liver problem.To satisfy myself I would look over previous results and look to the correlation of AST to ALT. If both have remained within normal limits or risen and fallen together without large disparities in their numbers then I would be satisfied with that.

I imagine in those in which liver issues do arise then there would be justification within the guidelines for AST to be again be covered in routine monitoring bloods.

Catherine, the doctor ordering the Vit D testing for Sarah should be using item number 66833 as IBD is a descpritor for approval under this number:

(d) is suffering from malabsorption (for example, because the patient has cystic fibrosis, short bowel syndrome, inflammatory bowel disease or untreated coeliac disease, or has had bariatric surgery);
https://www.nps.org.au/radar/article...itamin-d-tests
09-07-2017, 06:13 PM   #26
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For what it's worth, L's AST and ALT always rise and fall together. She has liver disease as well as IBD, so I realize the two cases are not parallel.
09-07-2017, 09:36 PM   #27
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Good point re the correlation. I've just checked his past records and there is a very tight correlation when both are normal and in the occasions when they have risen.
09-09-2017, 12:48 AM   #28
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Fwiw, in NZ AST is not part of the standard blood tests I get. ALT, Alk. Phosphatase, Bilirubin, Albumin yes but no AST.

Vit D is only free when the hospital orders it I think, I've had to pay for the one time I got the GP to order it.
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