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Pharm II Exam 4 > Liver Disease Agents > Flashcards

Liver Disease Agents Flashcards

1
Q

What is liver cirrhosis?

A

Chronic degenerative disease characterized by replacement of normal liver tissue w/ diffuse fibrosis that disrupts structure & function of liver

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2
Q

Types of Cirrhosis?

A

Alcoholic (MC): from chronic alcoholism
Post-necrotic: from previous infection (acute viral hepatitis)
Biliary: from chronic biliary obstruction/infection (LC)

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3
Q

Precipitating factors/predisposition of cirrhosis?

A

Malnutrition, Excess alcohol, bile excretion impairment (obstructed liver/bile duct, gallstones), necrosis (toxins, hepatitis), CHF

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4
Q

Pathophysiology of cirrhosis?

A

Liver cell damage –> inflammation & hepatomegaly –> slow hepatic impairment –> obstructed venous b/f –> portal HTN –> regeneration attempts –> fibrosis/small nodular liver

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5
Q

Complications of cirrhosis?

A

Spider angioma, Hepatomegaly, Splenomegaly, Fingernail changes, Bruising/bleeding, Asterixis, Hepatic enceph, Portal HTN, Esophageal varices, ascites, Bacterial peritonitis, Hepato-renal synd.

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6
Q

What is Asterixis?

A

Flapping tremor

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7
Q

How does Child-Turcotte-Pugh (CTP) Classify liver disease?

A

Grades degree of disease based on labs & clinical manifestations
(encephalopathy, ascites, bilirubin, albumin, PTT)

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8
Q

Encephalopathy CTP points?

A

(+1) none, (+2) mild-mod grade 1/2, (+3) severe grade 3/4

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9
Q

Ascites CTP points?

A

(+1) none
(+2) mild-mod diuretic response
(+3) severe diuretic refractory

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10
Q

Bilirubin CTP points?

A

(+1) <2
(+2) 2-3
(+3) >3

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11
Q

Albumin CTP points?

A

(+1) >3.5
(+2) 2.8-3.5
(+3) <2.8

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12
Q

PTT (seconds prolonged) CTP points?

A

(+1) <4
(+2) 4-6
(+3) >6

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13
Q

PTT (normalized ratio) CTP points?

A

(+1) <1.7
(+2) 1.7-2.3
(+3) >2.3

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14
Q

Class A CTP?

A

5-6 points (least severe)

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15
Q

Class B CTP?

A

7-9 points (mod-severe)

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16
Q

Class C CTP?

A

10-15 points (most severe)

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17
Q

1 and 2 year survival of Class A CTP?

A

1 yr: 100%
2 yr: 85%

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18
Q

1 and 2 year survival of Class B CTP?

A

1 yr: 80%
2 yr: 60%

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19
Q

1 and 2 year survival of Class C CTP?

A

1 yr: 45%
2 yr: 35%

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20
Q

What is hepatic encephalopathy?

A

Protein rich foods (meat) absorbed involving normal flora, unable to metabolize urea in liver –> ammonia (NH3) build-up in blood & crosses BBB causing s/sx of encephalopathy

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21
Q

S/sx of encephalopathy?

A

Confusion, Inverted sleep cycle, Jerking limbs, Personality changes

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22
Q

What is a common admission to acute care?

A

Episodic overt encephalopathy

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23
Q

Tx for 1st acute encephalopathy episode & outpatient prevention of 2nd event?

A

Lactulose

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24
Q

Combo Tx for 2nd encephalopathy event in hospital & outpatient prevention for future events?

A

Lactulose & Rifaximin

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25
Primary prevention pharm agents for encephalopathy?
None (no data)
26
What is portal HTN?
Diseased liver doesn't allow venous flow --> backup flow increases BP in portal vein --> esophageal area creates collateral veins (varices) that enlarge as dz progresses/cause frank bleeding in stomach
27
What can portal HTN cause?
Esophageal varices & ascites (can lead to bacterial peritonitis
28
Importance of maintaining hepatic portal HTN?
Development/progression of varices, minimizes risk of varices rupture & risk of ascites
29
Goal of treatment w/ portal HTN?
Slow progression of cirrhosis (cure/reversal not possible)
30
Cornerstone of tx for portal HTN?
BB (propanolol, nadolol)
31
Primary goal of BB tx for portal HTN?
Prevent varices
32
Use of BB with portal HTN is dependent on what?
Varices status
33
Window hypothesis for early cirrhosis BB use?
Use not indicated Cardiac reserve, SNS/RAAS @ baseline Low risk for bacterial translocation/death
34
Window hypothesis for decomp cirrhosis BB use?
Use indicated for prophylaxis (primary & secondary for variceal bleeds) SNS/RAAS inc. to compensate for low arterial BP Inc. risk for bacterial translocation/death
35
Window hypothesis for end-stage cirrhosis BB use?
Stop BB if: ascites, SBP >400, MAP
36
What is ascites?
Dec. intravascular volume stimulates RAAS to increase intravascular volume --> don't stay in vessels d/t albumin shortage (from diseased liver) & high aldosterone (inc. SNS/RAAS holds onto Na+/H2O)
37
1 yr mortality w/ ascites?
15%
38
5 yr mortality w/ ascites?
45%
39
Non-pharmaceutical tx of ascites?
Sodium/H2O restriction (no added table salt, <1L of free water/day)
40
Med tx for ascites?
Diuretics (Spironolactone, Furosemide)
41
What is bacterial peritonitis?
Infection of ascitic fluid w/o definitive intra-abdominal source
42
What is the most common life-threatening infection with cirrhosis?
Bacterial peritonitis
43
Most common bacteria that cause bacterial peritonitis?
E. coli (*MC), Klebsiella pneumo, Pneumococci, Strep. viridans, S. aureus, misc gram (-) and (+)
44
3 implicated factors of bacterial peritonitis?
-Altered gut microbiota -Inc. gut permeability -Impaired immunity
45
How is gut microbiota altered in bacterial peritonitis?
Increased enterobacteria & SI bacterial overgrowth
46
Increased gut permeability with bacterial peritonitis?
Impaired GI motility w/ flora disturbance --> dec. immunity --> flow of pathogens/endotoxins to mesenteric nodes
47
Impaired immunity with bacterial peritonitis?
Inadequate bacterial activity in ascitic fluid, compromised defense mechanisms
48
Active bacterial peritonitis tx?
3rd gen cephalosporin: Cefotaxime & Albumin (to dec. risk of renal failure/hepato-renal synd.)
49
Alternate med for bacterial peritonitis if Cefotaxime allergy?
Oxofloxacin
50
Consider discontinuing what med w/ bacterial peritonitis?
BB (may improve life expectancy)
51
Med for prevention of bacterial peritonitis w/ severe liver disease (2+ events of ascites, bili >3mg/dL, several encephalopathy events)?
Ceftriaxone daily
52
Med for prevention of bacterial peritonitis for less severe liver disease?
Norfloxacin
53
Prescriber trends for cirrhosis?
-Pain management -PPI's -Sedatives -Statins (pravachol)
54
Avoid which meds w/ cirrhosis?
NSAIDs (high risk of GI bleed, renal failure, worsened ascites)
55
MOA of Lactulose w/ hepatic encephalopathy?
Antidiarrheal: -increases peristalsis to dec. ability to absorb ammonia/proteins from foods -May absorb some existing ammonia/protein from the blood
56
ADRs of Lactulose?
Diarrhea (given 3-4x/day and monitored for loose stools daily), Non-compliance
57
Rifaximin MOA?
ABx w/ little systemic absorption, decreases flora in intestines/prevents conversion of food to ammonia type chemicals
58
ADRs of Rifaximin?
Chronic use: abx resistance
59
Protein restriction in tx for hepatic encephalopathy?
1g/kg/day
60
How do propanolol and nadolol lower portal vein HTN?
Have vasoconstricting action limiting blood to the liver (decreases portal vein pressure)
61
Why are propanolol and nadolol used specifically for portal HTN?
Non-specific BB: lower HR (B1 action) Goal HR: 55-65bpm
62
ADRs of propanolol and nadolol?
Dec. HR --> indirectly dec. BP Also have B2 activity: asthma/COPD exacerbations
63
Ratio of Spironolactone:Furosemide for ascites?
2.5:1
64
How do diuretics counteract pathology of ascites?
Counteract high levels of aldosterone
65
ADRs of diuretics for ascites?
BP changes Furosemide: dec. in Na+, K+, Ca Spironolactone: inc. in K+
66
Method for pain management in cirrhosis?
Start low, go slow
67
Risk w/ PPIs?
Increased SBP
68
Risk w/ sedatives?
Fall risk

Pharm II Exam 4 (3 decks)

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