Liver Disease Flashcards
Variables in Child Pugh Score
Encephalopathy
Ascites
Bilirubin
Albumin
Prothrombin time
Child Pugh A, B, C
A= 5-6 points
B = 7-9 points
C >10 points
Ascites treatment
1) Treat cause of cirrhosis
2) Na restriction <2000mg/day; fluid restriction <1.5L/day
3) Spironolactone 100mg (initial)
4) Add furosemide 40mg for subsequent. Titrate q3 days to max of 400/160mg
5) Large volume paracentesis with albumin replacement
Meds to avoid with ascites
NSAIDs
ARB
ACE
Hepatic encephalopathy classical physical finding
asterixis “hand flap”
If present = Grade II (overt) on West Haven
Lactulose
Converts ammonia to ammonium in gut which cannot be absorbed
DOC for overt hepatic encephalopathy
May be given as an enema
Antibiotcs for hepatic encephalopathy
Neomycin = as effective as lactulose, caution renal insufficiency
Metronidazole = caution, long term use can cause peripheral neuropathy
Rifaximin = as effective as lactulose; better tolerated than neomycin but expensive. May add on to lactulose therapy if subsequent episode.
Flumazenil concern
lowering seizure threshold if benzo overdose
Esophageal varices bleed management
1) Fluid resuscitation. FFP or platelets if needed to maintain Hgb >8
2) Endoscopy +/- sclerotherapy
3) Ocretotide preferred over vasopressin + nitroglycerin
4) Ceftriaxone 1g x7d or FQ = reduces short term mortality
Endoscope + Octreotide is preferred medical management option
Primary prophylaxis for varices
-Only if medium to large varices and no history of bleeding
Nonselective beta blockers (propranolol, nadolol, carvedilol)
Blocks B1 (reduce cardiac output) and B2 (prevent splanchnic vasodilation). Unopposed alpha1 constriction of splanchnic circulation leads to reduction in portal pressure
**Goal: resting HR 55-60bpm for 25% reduction
do not use long acting nitrates
Secondary prophylaxis for varices
ALL PATIENTS WITH HISTORY OF VARICEAL BLEED SHOULD RECEIVE SECONDARY PPX
Combination of:
1) endoscopic variceal band ligation
2) nonselective B blocker (carvedilol, propranolol, nadolol)
May combine BB with long acting nitrate, but increased risk of side effects; no mortality benefit
shunt is reserved for medically unresponsive pts
Antibiotic for CA-SBP
Ceftriaxone or cefotaxime x5-7 days
Antibiotic for Nosocomial SBP or risk for MDRO
Zosyn +/- Daptomycin (if prior infection or VRE-+)
OR
Meropenem (if recent Zosyn exposure or known MDRO) +/- Vanco or teicoplanin (if MRSA risk)
5-7 days
Lab values in SBP
Elevated SCr or leukocytosis
MUST PEROFRM PARACENTESIS PRIOR TO FIRST ANTIBIOTIC DOSE
> 250 PMNs = diagnostic for SBP
Albumin replacement for SBP
SBP exacerbates intravascular hypovolemia & organ hypoperfusion that is present with cirrhosis
Albumin 1.5g/kg on admission & 1g/kg on day 3 improves survival, especially if jaundiced or AKI
RECOMMENDED IN THESE PTS:
SCr >1 or
BUN>30 or
Total bili >5
SBP Prophylaxis
Cipro 500mg daily
Bactrim DS daily
Continue indefinitely
Hepatorenal Syndrome
Cirrhosis + ascities + AKI
SCr increase 0.3 in 48 hours or 50% inc in SCr in 7 days
No response to diuretic withdrawal and albumin infusion
AKI cannot be due to structural kidney issue or nephrotoxic meds
Give Vasoconstrictor therapy (norepi) + albumin
Maddrey discriminant function score
4.6 * (PT - control PT) + total bili
> 32 = poor prognosis
Alcoholic liver disease therapy
If Maddrey score >32 or MELD >20 =
Prednisolone 40mg/day for 4 weeks, then 2 week taper
30% decrease in short-term death
IV acetylcysteine plus steroids should be considered
Lille score
Measures change in bilirubin after 7 days of steroid therapy in alcoholic cirrhosis patients
Determines if prednisolone should continue for full 28 days
Hepatitis A transmission
Fecal oral
self limiting disease; supportive care; vaccine >1 y/o or high risk groups
Hepatitis A Immune Globulin
Required for traveling to endemic countries or <1 y/o
Hepatitis A post exposure prophylaxis
Vaccine ASAP, but within 2 weeks exposure
Immune globulin 0.1ml/kg if cannot receive vaccine
Serologic assay for Hepatitis B screening
HBV Surface Antigen (HBsAg)
this is the first detectable serum antigen in acute infection but is also present in chronic infection
HBeAg
E antigen – serologic marker that most patients have
demonstrates active viral replication
Chronic Hepatitis B clinical definition
HBsAg + > 6 mo
Serum HBV DNA >20,000
AST/ALT elevation
Biopsy demonstrates chronic hepatitis
treat these patients right away. all other cases, can wait to see if spontaneously resolves
Goal of Hepatitis B therapy
LFTs back to normal
HBV DNA to undetectable
loss of HBeAg if positive
If nonresponse then change therapy
HBV therapy first line
Entecavir (Baraclutde) 0.5mg
TAF (Vemlidy) 25mg
TDF (Viread) 300mg
If lamivudine resistant, entecavir should be 1mg
Use for 1 year
Pegylated interferon
Not as effective in HBeAg negative
Pegasys 180mcg SC weekly x48 weeks
WILL increase ALT. This is expected and not an ADR.
May need filgrastim for leukopenia
CNS effects, thyroid
Typical Hep B vaccine schedule
Three doses (0, 1, 6 mo)
Exception: Heplisav-B (0, 1 mo) and Engerix B if on HD (0,1,2,6 mo)
Hep B immune globulin
Give within 7 days of exposure (0.06mL/kg)
If perinatal transmission, administer first dose within 12 hours of birth (HBsAG+ mom)
Hepatitis C goal of therapy
Sustained Virologic Response (SVR) = undetectable HCV RNA 12 weeks after completion of therapy. Considered cured
Pre/post exposure prophylaxis for hepatitis C
None recommended
HCV preferred treatment for patient without cirrhosis
Glecaprevir + pibrentasvir x8 weeks
Sofosbuvir + velpatasvir x12 weeks
HCV preferred treatment with compensated cirrhosis (class A)
Glecaprevir + pibrentasvir x8 weeks
Sofoxbuvir + velpatasvir x12 weeks for genotypes 1,2,4,5,6
Genotype 3 requires NS5A RAS testing
Genotype Ia & Ib HCV treatment
glecaprevir + pibrentasvir (Mavyret) x8week
lamivudine/sofosbuvir x12 week
velpatasvir + sofosbuvir (Epclusa) x12 weeks
Ib also has elbasvir + grazoprevir (zepatier) x 12 weeks
Ribavirin ADRs
hemolytic anemia
teratogenicity
pancreatitis
depression (riba rage)
pulmonary issues
Sofosbuvir notable drug interactions
Statins (combo not recommended)
anticonvulsants (carbamazepine, phenytoin, phenobarbital, oxcarbazepine)
amiodarone (symptomtic bradycardia)
antacids
Mavyret (glecaprevir/pibrentasvir) notable drug interactions
pgp 3a4 inducers (carbaamzepine, efavirenz, st johns wort)
Atazanavir, rifampin
antacids
statins
Zepatier (grazoprevir/elbasvir) notable drug interactions
OATP1B1/3 inhibitor
strong 3A4 inducers
efavirenz
antacids
statins
Monitoring for HCV treatment
Baseline: HCV RNA, genotype, CBC, LFT, GFR, HIV, Hepatitis B, pregnancy test
While on therapy: adherence, interactions
After: HCV RNA 12 weeks after
