Prescribing in Liver Disease

Question 1

Name some causes of abnormal liver tests

Answer 1

Obesity
Alcohol
Drugs 
Fatty foods 
Fizzy drinks

Question 2

What is cirrhosis?

Answer 2

Cirrhosis is scarring of the liver as a result of continuous, long-term liver damage. Scar tissue replaces healthy tissue in the liver and prevents the liver from working properly.

Question 3

Name 3 major factors contributing to cirrhosis?

Answer 3

Reduced liver blood flow as it is hard for the blood to get through from the portal system
Reduced metabolic function
Reduced plasma proteins

Question 4

Describe a standard case of cirrhosis

Answer 4

Middle aged man, alcoholic, complaining of severe chest pain due to many fractured ribs from falling over drunk

Increased creatinine, decreased Na and K+
Low blood pressure

Question 5

How can we treat cirrhosis?

Answer 5

NSAID
Paracetamol
Opiate

Question 6

What is a clue of first pass metabolism

Answer 6

Oral dose is greater than the IV dose

Question 7

What type of blood does not go through the liver?

Answer 7

Blood that is shunted

Question 8

What is the result of 70-90% metabolism

Answer 8

Increased plasma levels

Question 9

What has to happen to pro drugs to become active? Give an example of a pro drug

Answer 9

They need to be metabolised first

Codeine

Question 10

What happens to the plasma volume if albumin is low

Answer 10

The plasma level is low

Question 11

What is aldosterone?

Answer 11

A steroid with a complex structure

No steroid is well metabolised in the liver

Question 12

What do patients with aldosteronism require and why

Answer 12

IV vitamins all the time to prevent brain damage

Question 13

What happens to the plasma concentration of hormones

Answer 13

It increases as the liver cannot metabolise them very well

Question 14

Why can male alcoholics get female characteristics?

Answer 14

Because they dont metabolise oestrogen so it builds up in their body

Question 15

What happens to a patient with hepato-renal syndrome>

Answer 15

It is very hard to reverse and there is a high mortality rate as the kidney is basically falling apart

Question 16

What type of drugs can induce renal failure?

Answer 16

NSAID as they get rid of protoglandins

Question 17

describe 3 signs of moderate hepatic impairment

Answer 17

Decrease renal clearance
effect on unbound drug masked by decrease protein binding
renal function reduced

Question 18

describe 3 consequences of moderate hepatic impairment

Answer 18

Gut oedema
Liver and kidney congestion
Gross oedema and ascites
CHF

Question 19

Name 8 adverse affects of NSAIDs

Answer 19

UGI ulcer complications
CV toxicity
Hypertension
CHF
Sodium Retention
Asthma
Diarrhoea / Colitis
Renal Failure

Question 20

What should always be co-prescribed with a proton pump inhibitor (PPI)

Answer 20

NSAID or COX2 inhibitor

Question 21

Describe the prescribing cascade

Answer 21

One drug that is prescribed may give unwanted side effects which have to be treated with another drug. This is not cost effective

Question 22

Why might the diaphragm not be able to be pushed down in breathing?

Answer 22

Ascities - fluid blocks it

Question 23

What are the phases of drug metabolism

Answer 23

Phase 1 (early) and phase 2 (late)

Question 24

What drugs are are best for treating early stages of lvier disease?

Answer 24

Phase 2 metabolised drugs so that they will be properly metabolised

Question 25

Name some drugs which have reduced metabolism

Answer 25

``` Opiates (codeine) Benzodiazepines Chlormethiazole Cyclosporin Metronidazole Calcium blockers ```

Question 26

How long does it take for symptoms of a paracetamol overdose to appear?

Answer 26

Around 4 days

Question 27

What does alcohol do to the receptors

Answer 27

It blocks the receptors if it is on board which is good

Question 28

What happens for chronic alcoholics and paracteramol

Answer 28

It gets metabolised faster which is worse for the patient

Question 29

Name 4 effects of Paracetamol in liver disease

Answer 29

reduced glutathione stores longer half-life increased P450 in acloholics Toxicity with normal doses

Question 30

Name 2 other drugs which cause liver disease

Answer 30

Flucloxiclav and Amoxicillin

Question 31

Is drug induced liver injury more common in men or women

Answer 31

Women

Question 32

What is the best diuretic to give in liver disease?

Answer 32

Spironolactone

Question 33

What are the requirements for patients to be on spironolactone?

Answer 33

``` Fluid restriction (1L) Use at high doses 1kg/day weight loss (aim) ```

Question 34

Are antibiotics safe to give in liver disease?

Answer 34

Yes

Question 35

What are the worst hepatic disorders?

Answer 35

Fulminant hepatic failure Decompensated cirrhosis severe acute or chronic hepatitis severe congestive heart failure

Question 36

What is the main message of drugs and liver disease

Answer 36

Dose reduction regardless of the route of elimination of drug or metabolite

Question 37

Name some general principles in presribing in liver disease

Answer 37

``` Avoid pro drugs Use drugs with renal excretion Be wary of sedatives, CNS drugs, anticoagulants, NSAIDs, theophyllines, aminoglycosides high inter-inividual variability Liver tests not predictive Start low, go slow ```