Prescribing in Liver Impairment

Question 1

What are the different types of liver disease?

Answer 1

Hepatitis
Alcohol-associated liver disease
Alcohol-associated fatty liver
Alcohol-associated hepatitis
Alcohol-associated cirrhosis
Non-alcoholic fatty liver disease (NAFLD)
Non-alcoholic steatohepatitis (NASH) –

Question 2

What is hepatitis?

Answer 2

inflammation of the liver caused by viruses (A, B, C) or autoimmune.

Question 3

What are the stages of alcohol-associated liver disease?

Answer 3

1. Alcohol-associated fatty liver – early stages of alcoholic liver disease caused by extensive damage to liver cells by excessive alcohol intake.
2. Alcohol-associated hepatitis – further damage of liver cells and inflammation of tissue caused by continuing to drink.
3. Alcohol-associated cirrhosis – most
   serious form where the extent of damage to the liver by alcohol causes development of scar tissue, which significantly impacts hepatic function.

Question 4

What is NAFLD?

Answer 4

Liver disease caused by excess fat in the liver which leads to inflammation.

Question 5

What is non-alcoholic steatohepatitis?

Answer 5

A form of NALD where there is inflammation and cell damage in the liver as well as fat. This can develop into cirrhosis.

Question 6

What is used to assess the severity of liver cirrhosis?

Answer 6

Child-Pugh score

Question 7

What does the Child-Pugh score consider?

Answer 7

Ascites
Bilirubin
Albumin
Prothrombin time or INR
Encephalopathy

Question 8

What is ascites?

Answer 8

Collection of fluid in the abdomen caused by liver cirrhosis due to high pressure in certain veins of the liver (portal hypertension) and low serum albumin.

Question 9

What does the Child-Pugh score indicate?

Answer 9

Cirrhosis classification:
5-6: Class A – well-compensated disease, 100% 1-year survival, 85% 2 year survival

7-9: Class B – significant functional compromise. 80% 1-year survival, 60% 2-year survival.

10-15: Class C – decompensated disease. 45% 1-year survival, 35% 2-year survival

Question 10

What do ALT and AST tests indicate?

Answer 10

They are intracellular enzymes which care released from hepatocytes when they become damaged. Therefore, high serum levels indicate hepatocellular injury.

Question 11

What does the AST:ALT ratio indicate and why?

Answer 11

The AST: ALT ratio can indicate the progression of liver disease. ALT is more specific to the liver with small concentrations in other organs, AST is found highly in the liver, heart, pancreas, lungs, muscles and RBC.
A high ALT alone indicates acute injury, but if long-term liver disease/damage occurs, it will affect other organs and raise AST also. An AST:ALT of 1:2 indicates non-alcoholic liver disease, but 2:1 indicates alcoholic liver disease.

Question 12

What do ALP tests indicate?

Answer 12

Detects cholestasis – if the flow of bile is obstructed (e.g., by a gallstone), serum ALP will increase.

Question 13

Why must ALP be used in conjunction with other LFTs?

Answer 13

Any condition affecting bone growth or causes increased activity of bone cells can affect ALP, so not specific.

Question 14

What does raised GGT with raised ALP or bilirubin suggest?

Answer 14

Cholestatic damage

Question 15

What does isolated raised GGT indicate?

Answer 15

Hepatic damage caused by:
Alcohol abuse
Enzyme inducing drugs

Question 16

What does raised GGT in patients with chronic liver disease indicate?

Answer 16

Bile duct damage
FIbrosis

Question 17

Why can GGT only be used in conjunction with other LFTs?

Answer 17

Released in all types of liver dysfunction.

Question 18

What do bilirubin levels incidicate in LFTs?

Answer 18

Bilirubin is a pigment produced by the destruction of red blood cells. Hepatocytes transform unconjugated bilirubin into water-soluble conjugated form which is excreted via bile into the intestine. High levels of bilirubin (50micromol/L serum) can produce jaundice. This may be due to hepatic damage reducing metabolism of unconjugated to conjugated bilirubin, causing hyperbilirubinaemia.

Question 19

Why should bilirubin levels be assessed in conjunction with other LFTs?

Answer 19

High bilirubin can be caused by excess release due to haemolytic anaemia. Consult other LFTs and whether or not the bilirubin is conjugated (HA) or unconjugated (LD).

Question 20

What do albumin levels indicate in LFTs?

Answer 20

Albumin is a plasma protein produced by the liver which governs oncotic pressure. Albumin is a hepatocellular marker as low levels can indicate reduced liver function. Its long half-life means it is an indicator of chronic rather than acute liver disease.

Question 21

Other than impaired liver function, what else can decrease albumin levels?

Answer 21

Reduced production - malnutrition, malignancy
Increase loss - IBD, nephoritic syndrome

Question 22

Why is a clotting screen (INR and PT) performed in LFTs?

Answer 22

The liver is responsible for production of vitamin-K dependent clotting factors. If a patient is given a dose of vitamin K and the INR doesn’t decrease, this may indicates the synthetic function of the liver has decreased.

Question 23

Why is a clotting screen used in conjunction with other LFTs?

Answer 23

It is non-specific as low INR following vitamin K may also indicate vitamin K absorption is impaired, the patient has a coagulopathy disorder, or is on warfarin.

Question 24

What are some key medicines which can result in acute liver damage or cholestasis? (12)

Answer 24

• Amiodarone
• Azathioprine
• Carbamazepine
• Isoniazid
• Methotrexate
• NSAIDs
• Antibiotics such as co-amoxiclav and flucloxacillin
• Paracetamol
• Rifampicin
• Sodium valproate
• Statins