6: Prescribing for liver disease

Question 1

What is a common sign of liver disease?

Answer 1

Jaundice

Question 2

What liver disease is associated with obesity?

Answer 2

NAFLD

non-alcoholic fatty liver disease, or hepatic steatosis

Question 3

What are some causes of liver disease?

Answer 3

Obesity

Alcohol

Viruses

Drugs

Autoimmune

Question 4

What is cirrhosis?

Answer 4

Small shrunken liver which cannot regenerate

Question 5

What are three major factors of cirrhosis?

Answer 5

Reduced liver blood flow

Reduced metabolic function

Reduced plasma proteins

Question 6

If an alcoholic patient presents with lots of fractured ribs, what could have caused this?

Answer 6

Alcoholism - lots of falling over, bumps and bruises

Question 7

What is portal hypertension?

Answer 7

High blood pressure in the portal venous system, caused by cirrhosis

Question 8

Where do varices appear in cirrhosis?

What is a major complication of these varices?

Answer 8

Oesophagus

Umbilicus

Rectum

Haemorrhage

Question 9

What is a sign of liver disease in which a patient becomes confused and disorientated?

Answer 9

Encephalopathy

Question 10

What is a sign of portal hypertension seen at the umbilicus?

Answer 10

Caput medusae

Question 11

What happens to some of the blood in cirrhosis?

Answer 11

Portal system bypassed

“shunting” of blood past the liver, metabolism doesn’t occur so more of a drug needs to be administered to see the same effect

Question 12

In cirrhosis, the liver has (increased/reduced) metabolic capacity.

Answer 12

reduced

Question 13

High portal pressure and low albumin causes ___ in the abdomen.

Answer 13

ascites

Question 14

If the oral dose of a drug is greater than the IV dose, what organ is important in its metabolism?

Answer 14

Liver

Question 15

Which drug is administered sublingually to treat angina?

Why is it administered this way?

Answer 15

GTN

Sublingual administration bypasses the liver

Question 16

The liver has a limit of metabolism - small doses of a drug can be metabolised but increasing the rate of administration may suddenly cause the plasma concentration to increase. What drug is this prominently seen in?

Answer 16

Alcohol

Question 17

Which plasma protein is lowered in liver disease?

Answer 17

Albumin

marker of liver disease

can carry less protein in blood, leading to ascites

Question 18

Low albumin levels causes a low ___ volume.

Answer 18

plasma

Question 19

Why may plasma volume decrease, prompting the kidneys to secrete renin?

Answer 19

Low albumin in liver disease

Question 20

Which system produces aldosterone as a response to low albumin (low plasma volume)?

Answer 20

RAAS

Question 21

Which product of the RAAS system cannot be metabolised by diseased livers?

Answer 21

Aldosterone

Question 22

What name is given to accumulation of aldosterone in patients with liver disease?

Answer 22

Secondary hyperaldosteronism

Question 23

Why do people with liver disease develop gynaecomastia?

Answer 23

Liver cannot metabolise hormones like oestrogen and endothelin

Question 24

In liver disease, hormones aren’t metabolised and go on to act on the kidneys. What are some consequences of this?

Answer 24

Potassium loss - HYPOKALAEMIA

Sodium retention - HYPERNATREMIA & WATER RETENTION

Question 25

**Aldosterone** also causes ___ in the kidney. What condition does this cause?

Answer 25

**Vasoconstriction** **Hepato-renal syndrome**

Question 26

The failure of the liver to metabolise drugs, which then travel to the kidneys, leads to what?

Answer 26

**Reduced renal clearance** **Reduced renal function**

Question 27

What signs are seen in patients with reduced hepatic and renal function?

Answer 27

**Oedema** **Ascites** **Spider naevi**, **gynaecomastia** (lots of oestrogen) **Congestive heart failure**

Question 28

Which class of drug would further impair renal function by inhibiting prostaglandin production?

Answer 28

**NSAIDs**

Question 29

What is a major GI side-effect of NSAIDs?

Answer 29

**Peptic ulcers**

Question 30

Would you give an NSAID as analgesia to someone suffering liver disease?

Answer 30

**No**

Question 31

In other conditions which require NSAIDs e.g arthritis, what is co-prescribed to prevent peptic ulcer disease?

Answer 31

**PPIs** to reduce the risk of peptic ulcers

Question 32

If a patient is suffering encephalopathy and you give them opiates, what will happen?

Answer 32

**Further confusion** **Respiratory depression** make neuro symptoms worse basically

Question 33

Which over-the-counter analgesic drug is the most common cause of fulminant liver failure, often leading to liver transplant surgery?

Answer 33

**Paracetamol**

Question 34

Metabolism of paracetamol produces a ___ which causes liver ___ in people who can't metabolise it quickly.

Answer 34

**toxin** **necrosis**

Question 35

Which molecule detoxifies the toxin produced by paracetamol metabolism?

Answer 35

**Glutathione**

Question 36

When glutathione levels are decreased, what happens when you take paracetamol?

Answer 36

**Toxicity** **Liver necrosis** **Liver failure**

Question 37

Which drug, when taken in conjunction with paracetamol, worsens its toxic effects on the liver?

Answer 37

**Alcohol**

Question 38

Which liver disease is caused by paracetamol overdose?

Answer 38

**Fulminant liver failure**

Question 39

Liver disease can be induced by \_\_\_.

Answer 39

**drugs**

Question 40

**NSAIDs** and **morphine** worsen the symptoms of someone who already has liver disease. Which drugs can **induce** liver disease?

Answer 40

**Paracetamol** **Antibiotics**

Question 41

Which class of drug is used to treat **oedema**, **ascites** and general fluid overload caused by liver failure?

Answer 41

**Diuretics**

Question 42

Which diuretic drug is **best** for treating fluid overload caused by liver --\> renal disease?

Answer 42

**Spironolactone** loop diuretics (e.g furosemide) and thiazide diuretics make it worse

Question 43

Which class of drug is used to calm down patients who have encephalopathy secondary to liver disease?

Answer 43

**Sedatives** lorazepam, diazepam etc