Therapeutics Exam 4 (Hepatology) Flashcards by TheOneandOnly Ash

What are the functions of the liver?

-Bile production

-Drug/food/toxin metabolism

-Protein synthesis (albumin + coagulation factors)

-Storage/Adjustment of vitamins/gluconeogenesis

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What do liver enzymes (AST, ALT, Alk phos) tell us?

These are markers of acute injury

-not true markers of liver function

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What 3 proteins does chronic liver disease affect and what effects does it have?

Decreases albumin

Increases INR

Increases bilirubin

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What is the main drug that can cause Drug-induced liver injury (DILI)?

Acetaminophen

-high doses (>8g)

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How do high doses of acetaminophen cause drug-induced liver injury?

Results in toxic levels of N-acetyl-p-benzoquinone imine (NAPQI)

-this causes direct hepatotoxicity

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What is the normal AST range?

0-50 IU/L

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What is the normal ALT range?

0-50 IU/L

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What is the normal Alk phos range?

30-120 IU/L

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What drug can we use to reverse the toxic metabolite (NAPQI) produced by high doses of acetaminophen?

N-acetylcysteine +/- activated charcoal

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To give activated charcoal, it must be within what amount of time to the time that the patient ingested acetaminophen?

<1 hour
-only prevents absorption if taken immediately after ingestion

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How do we determine if we need to give a patient N-acetylcysteine?

Use the Rumack-Matthew Nomogram

-Hours post-ingestion vs plasma concentration

-Dark grey area= give med

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What is the dosage form of N-acetylcysteine?

Oral or IV depending on what they tolerate

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What is cirrhosis?

Severe, chronic, irreversible fibrosis of the liver

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what are the S/S of cirrhosis?

Fatigue
Weight Loss
Ascites (fluid buildup in abdomen)
Jaundice
Hepatomegaly or Splenomegaly
Encephalopathy (confusion)

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What are the causes of cirrhosis?

Alcohol use
Viral hepatitis
Liver disease
Drugs (amiodarone, methotrexate)

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What is ascites?

Fluid accumulation in the peritoneal space

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What are the non-pharmacologic treatments for ascites?

Sodium Restriction

Assess for liver transplant

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What is the first-line therapy for ascites?

Aldosterone antagonist (spironolactone)
+
Loop diuretic (furosemide)

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What is the second-line therapy for ascites?

Paracentesis
TIPS (surgery)

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If a patient can only tolerate one of the first-line therapies for ascites, which drug class is preferred?

Aldosterone antagonist (spironolactone)

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Which drug class should be avoided in patients with cirrhosis due to its ability to increase the risk of ascites and bleeding?

NSAIDs

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At what ratio should the diuretics for ascites be initiated?

spiro 100:40 furo

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What is the maximum daily dose of diuretics for ascites?

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400mg spiro/ 160mg furo

When is a paracentesis indicated for ascites?

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Refractory/resistant ascites

Cases of AKI

How much fluid needs to be removed via paracentesis for us to replace albumin?

>5L

How much albumin should be given to paracentesis patients who need it?

25% IV albumin Give 6-8g albumin per liter removed*

How does cirrhosis result in esophageal varices?

Portal hypertension causes hepatic/splanchnic vasodilation -results in decreased perfusion -compensatory varices (small offshoots) form

Why are esophageal varices dangerous?

Dilation of EV can occur and result in variceal bleeding -this can be severe

What are the risk factors for variceal bleeding?

-Larger size varices -Cirrhosis severity -Red color markings seen on endoscopy -Active alcohol use

What are the 2 options for variceal bleeding prophylaxis (prevention)?

Non-selective beta-blockers (moderate disease) Endoscopic variceal ligation *NOTE that neither of these have mortality benefits

What are the beta-blockers that can be used for variceal bleeding prophylaxis?

Nadolol Propranolol Carvedilol

What is the HR goal with beta blockers?

55-60 bpm

Immediately upon presentation of a patient with variceal bleeding, what needs to be done?

-Blood transfusion (Hg>7) -Give octreotide -Antibiotic prophylaxis

What is the second thing we do after a patient presents with variceal bleeding?

Endoscopic variceal ligation

After an EVL, what is the third thing we do after a patient presents with variceal bleeding?

Secondary prophylaxis (indefinitely until compensated)

What is the moa of octreotide?

Inhibits release of vasodilatory peptides -results in splanchnic vasoconstriction and decreased blood flow

What do we use octreotide for?

Acute variceal bleeds

How long should octreotide be used for?

2-5 days -or until EVL, then stop 1 day after

What is the gold standard for variceal bleeding cessation?

Endoscopic variceal ligation

What is the goal for how quickly we want patients to have an endoscopic variceal ligation after they appear with variceal bleeding?

Within 12 hours

What is the downside to variceal ligation?

It is not a long-term solution -bands can break -new varices can form

What other type of prophylaxis do patients with active variceal bleeding need?

Primary Antibiotic Prophylaxis -due to increased infection risk

What antibiotic is recommended for primary antibiotic prophylaxis?

Ceftriaxone -use until the hemorrhage resolves (max 7 days)

What therapy is not recommended in variceal bleeding despite elevated INR?

Vitamin K -do not give

What therapy do we use as secondary prophylaxis for varices?

Endoscopic variceal ligation (every 1-4 weeks) Non-selective beta-blockers indefinitely (nadolol, propranolol, carvedilol)

How does cirrhosis cause spontaneous bacterial peritonitis (SBP)?

-Due to bacterial translocation -bacteria cross the intestinal barrier

What is the clinical presentation of spontaneous bacterial peritonitis?

-Fever -Abdominal pain/Tenderness -Leukocytosis -Encephalopathy *can be asymptomatic

How do we diagnose spontaneous bacterial peritonitis?

Therapeutic Paracentesis -If the fluid has >/= 250 cells/mm^3 polymorphonuclear leukocytes (PMN) then diagnose Note: PMNs= WBC from fluid x % Neutrophils

What is the treatment for spontaneous bacterial peritonitis?

Ceftriaxone

How long do we treat with ceftriaxone for spontaneous bacterial peritonitis?

5-7days

What other drug is used in treatment of spontaneous bacterial peritonitis?

albumin

What is the dosing of albumin for spontaneous bacterial peritonitis?

IV: Day1: 1.5 g/kg once Day 3: 1 g/kg once *use ABW

What agents can be used for secondary prophylaxis of spontaneous bacterial peritonitis?

Sulfamethoxazole/Trimethoprim (Bactrim) Ciprofloxacin -not used as much

How long should secondary antibiotic prophylaxis be used in patients with SBP?

Indefinitely!

What is the estimated incidence of drug-induced liver injury (DILI)?

0.02%

Therapeutics Exam 4 (Hepatology) Flashcards

(55 cards)