Hepatology: Prescribing

Question 1

Alcohol withdrawal sydrome serverity is determined using a scoring system from which chart? [1]

Answer 1

CIWA-Ar Chart

Question 2

If a patient is scoring > [] on a CIWA-Ar then they are given a [] to help control symptoms

Answer 2

If a patient is scoring > 10 on a CIWA-Ar then they are given a benzodiazapene to help control symptoms

Question 3

State the first and second line benzodiazepenes used to treat AWS [2]

Answer 3

1st line: Chlordiazepoxide

2nd line: Lorazepam - First line if cirrhotic.

Question 4

Which drugs are used if seizures [1] and pyschotic symptoms [1] develop from AWS?

Answer 4

Seizures: IV Lorazepam

Pyschotic symptoms: Haloperidol (blocks D2 receptors)

Question 5

Which drug is used to prevent Wernicke’s encephalopathy or Korsakoffs? [1]

What is given as continuing supplementation after ^? [1]

Answer 5

Prevent WE & Korsakoffs: Pabrinex: high strength Vit B & C

After completin pabrinex: Thiamine 100mg 3XD}

Question 6

Describe MoA of benzodiazapenes [1]

Name some important AEs [4]

Answer 6

Enhance GABA: sedative effect

AEs: confusion; drowsiness; respiratory depression; hallucinations; risk of addiction; risk of suicide ideation; falls and fractures in elderly}

Question 7

Why is Lorazepam prescribed for AWS in Ptx w cirrhosis? [2]

Answer 7

Short acting: liver function is already impaired, so if give long acting chlordiazepoxide then could get accumulation & cause toxicity (like resp. depression)

Question 8

What is the treatment dose for pabrinex in treating AWS? [1]
What is the prophylatic dose for pabrinex in treating AWS? [1]

Answer 8

TD: 2 pairs IV pabrinex 3xday for 3-5 days
Prophylatic dose: 1 pair 3xD}

Question 9

Name an AE of pabrinex [2]

Answer 9

• Risk of anaphylaxis
• Risk of glucose infusions in diabetic or low blood sugars: may deplete thiamine stores and precipate Wernickes

Question 10

What is target for encephalopathy treatment? [1]
Which substance are you trying to eliminate the build up of in encephalopathy? [1]

Answer 10

2-4 soft stools per day
Ammonia

Question 11

Describe and explain treatment plan for hepatic encephalopathy [3]

Answer 11

1. Lactulose:
- Increases faecal bulk & peristalsis
- Also reduces colonic pH: reduces absorption of NH3
- dose varies from 15-50ml TDS

2. Phosphate enemas:
- fast acting osmotic laxative
- STAT if Ptx encephalopathic; after passing stools PRN BD

3. Rifaximin
- antibiotic: diminishes deaminating enteric bacteria to decrease production of nitrogenous compounds
- 550mg BD

Question 12

When is rifaximin prescribed in HE? [1]

Answer 12

Only in recurrent HE

Question 13

Treatment of ascites? [2]

Answer 13

Fuoresemide:
- loop diuretic: binds to Na-K-2Cl; inhibits Na+ reabsorption
- 40mg OM
- IV in ascitic patients due to risk of AKI

Spironolactone:
- aldosterone antagonist at DCT
- 100mg OM; increased to 400mg if need

Question 14

AEs of using furosemide and spironolactone for treating ascites? [2]

Answer 14

Fuoresemide: hypokalaemia
Spironolactone: hyperkalaemia
Therefore used in combination to complement each other}

Question 15

Which patients does terlipressin prescription need to be cautious with? [2]

Answer 15

Cardiac conditions:
Causes increase in BP; atherosclerosis; cardiac dysrythmia or coronary insufficiency

Question 15

Tx for gastro-oesophageal varices? [2]

Answer 15

Terlipressin:
- contracts smooth oesophageal muscles; compression of the varices
- 1-2 mg for 4-6hrs until bleeding controlled
- Continue for 5day

Carvedilol:
- preffered due to mild anti-alpha 1 adrenergic activity (historically propanolol)
- used as prophylaxis

Question 16

What dose of paracetamol can cause acute liver toxicity? [1]

How long after OD does paracetamol ingestion are:
- ALT & AST increased? [1]
- Symptoms? [1]

Answer 16

7.5g dose

OD:
- 24-72 hrs: AST & ALT raised
- 48-96 hrs: symptoms (jaundice, confusion, hepatic failure, death)

Question 17

Tx for paracetamol OD? [1]
Describe MoA [1]

Answer 17

N-acytlcysteine (NAC) IV infusion:
- restores gluthathione levels or acts as alternate substrate for conjugation
- antioxidant
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Question 18

Describe IV NAC infusion regime in paracetamol OD [3]

Answer 18

First infusion:
- 150mg/kg: one hour

Second infusion:
- 50mg/kg: 4 hours

Third infusion (can repeat if need)
- 100mg/kg: 16 hours

Question 19

Tx for Hep B? [2]

Answer 19

Tenofocir
- competitive inhibition: replaces the deoxyribonucleitde substrate in HBV DNA
- faster acting than entecavir
- safe in pregancy

Entecavir
- inhibits RT of Hep B DNA
- toxicity in pregnancy

Question 20

Describe the aim of Hep B treatment? [1]

Describe treatment aim of HCV? [1]

Answer 20

HBV: Suppress but DO NOT cure virus: undetectable viral load
HCV: CURE of virus

Question 21

What monitoring should be given for HBV treatment? [1]

Why? [2]

Answer 21

Renal monitoring: nephrotoxicity due to lactic acidosis and may decrease bone mineral density

• Monitor phosphate and creatinine levels

Question 22

HCV treatment? [1]

Answer 22