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CDM 2 Exam 3 > Lecture 1 - Drug Induced Liver Disease > Flashcards

Lecture 1 - Drug Induced Liver Disease Flashcards

1
Q

Direct Bilirubin is….

A

conjugated bilirubin

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2
Q

Indirect Bilirubin is…

A

free unconjugated

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3
Q

Markers of Liver injury

A 
ALT
AST
ALP
GGT
GDH
LDH
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4
Q

Markers of hepatocellular function

A

Bilirubin
Albumin
PT

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5
Q

Risk factors for DILI

A

Adult > children
Women > men
Racial differences (W>B)
Comorbidites

** Highest risk of liver injury within 1st 90 days of med exposure **

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6
Q

Asymptomatic Signs & Symptoms

A
  1. Minor elevations in liver enzymes

2. Transient injury

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7
Q

Symptomatic Signs & Symptoms

A
  1. Elevations in liver enzymes & bilirubin

2. Jaundice

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8
Q

Acute liver failure Signs & Symptoms

A
  1. Symptomatic + Signs of encephalopathy or coagulopathy

** maybe considered life-treating and require liver transplant**

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9
Q

Chronic Liver Disease Signs & Symptoms

A
  1. Cirrhosis

2. Hepatic decompensation

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10
Q

5 Steps of DILI

A
  1. Is pt presenting w/ clinical features consistent with liver injury
  2. What is the pattern/type of DILI based on clinical markers
  3. What is the severity of the injury
  4. What are the potential drug and/or non-drug causes of liver injury
  5. What literature exists regarding the cause of injury due to this med
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11
Q

Liver injury is defined as..

A 
1. increase in ALT > 3 X ULN
or
2. ALP > 2X ULN
or 
3. total bilirubin > 2 X ULN and any ALT or ALP elevation
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12
Q

ULN =

A

Upper limit of normal

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13
Q

Hepatocellular pattern/type of injury

A

ALT > 3X ULN

Ratio >5

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14
Q

Cholestatic pattern/type of injury

A

ALP > 2X ULN

Ratio < 2

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15
Q

Mixed pattern/type of injury

A

ALT > 3X ULN
ALP > 2X ULN

Ratio 2 - 5

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16
Q

Ratio Calculation

A

(ALT/ALT baseline or ULN) / ( ALP/ALP baseline or ULN)

17
Q

Severity of Injury Nonspecific signs/symptoms

A

Fatigue & Malase
Jaundice
Abdominal pain
Fever and Chills

18
Q

Hepatocellular symptoms

A

Nausea + Vomiting

Anorexia

19
Q

Cholestatic Symptoms

A

Pale Stools
Tea-colored dark urine
Pruritus

20
Q

Mixed symptoms

A

Nause + vomiting
Pale stools
Dark urine

21
Q

Hy’s Law

A

Applies to hepatocellular injury only

Jaundice (total bilirubin > 2 X ULN) + elevation in transaminase ( ALT or AST > 3X ULN)

Mortality can be as high as 14% w/ these features

22
Q

Meds that met Hy’s Law

A

Bromfenac
troglitazone
ximelagatran
dilevalol

23
Q

Coagulopathy assesment

A

INR
Albumin or pre-albumin
Transport proteins for bilirubin excretion

24
Q

Encephalopathy assessment

A

Bilirubin

Ammonia

25
Q

What goes into Child-Pugh Score

A 
Ascites (round belly full of fluid)
Bilirubin
Albumin
INR
Encephalopathy
26
Q

Grade A Child-Pugh

A

5-6

1/2 yr survival = 100,85%

27
Q

Grade B Child-Pugh

A

7-9

1/2 yr survival = 80/60%

28
Q

Grade C Child-Pugh

A

10-15

1/2 yr survival 45,35%

29
Q

If Direct < Indirect Bilirubin then that means that….

A

can conjugate your bilirubin

30
Q

Stuff related to Hepatocellular pattern

A 
Alcohol
Fatty liver
Viruses - Hep, EBV, CMV
Hepatic infarction or congesstion
Autoimmune
31
Q

Stuff related to Cholestatic pattern

A

Gall stones
Pregnancy
Alcohol
Primary sclerosing cholangitis

32
Q

Max acetaminophen for healthy people

A

3-4g, probs closer to 3g for older adults

33
Q

Max of 2g/day acetaminophen if…

A

Heavy alcohol use
Malnutrition
DI
Advanced age

34
Q

When to hold Atorvastatin in potential DILI?

A

ALt > 10 X ULN or persistent over 5 X or associated w/ symptoms of liver injury

35
Q

Managing Statins in liver injury

A

Monitor liver enzymes

36
Q

Treatment Approach DILI

A
  1. D/x suspected Drug
  2. Admin antidotes if available
  3. Consider Steroids if hypersensitivity reaction…prednisone
  4. supportive care for N/V/ itching
  5. Treat encephalopathy
  6. follow serial enzyme test and consult hematologist
  7. consider transplant for acute liver failure
37
Q

Antidote for Acetaminophen

A

N-acetylcysteine

38
Q

Antidote for valproic acid

A

Carnitine

39
Q

DILI prevention strategies

A
  1. Dont ignore danger symptoms
  2. Take careful history
  3. pay attention to Hy’s Law and prognosis
  4. Report injury to MedWatch

CDM 2 Exam 3 (13 decks)

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