Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

3034PHM Evidence Based Prac > Liver Disease = Drug selection/dosing > Flashcards

Liver Disease = Drug selection/dosing Flashcards

1
Q

What does the liver do?

A

Production of plasma proteins

synthesis of clotting factors

Production of bile = req for absorption of fat, fat soluble vitamins, lipophilic drugs

Enterohepatic (re)circulation of bile salts and some drugs

Conjugation and excretion of bilirubin

Hormone inactivation

Metabolism and excretion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Do LFTs always indicate liver disease?

A

No, some liver disease can present in the presence or absence of abnormal LFT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is Alanine transferase used to measure?

A

ALT = Cell death

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is aspartate transferase used to measure?

A

AST = cell death

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is alkaline phosphatase used to measure?

A

Alk phos or ALP = biliary problems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is gamma GT/GGT used to measure?

A

Biliary problems

Helps clarify if raised alk phos is from liver

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What do altered liver aminotransferase levels indicate about liver health?

(GENERALLY)

A

Indicate inflammation and necrosis (hepatocyte damage and death)

NOT RELIABLE MEASURE OF DYSFUNCTION

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Explain the De Ritis Ratio

A

Ratio of AST:ALT

> 1 = damage is probably alcohol related

<1 = probably non alcoholic liver disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What do altered liver ALT levels indicate?

A

Inc = hepatocellular damage

Also = muscle damage, acute MI, renal infarction

Haemolysis = falsely elevated levels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What do altered liver AST levels indicate?

A

Found in: liver, heart, kidney, pancreas

Raised = hepatocellular damage, acute MI, musculoskeletal disease, intestinal injury, haemolysis, hypothyroidism, pulmonary embolism, necrotic tumours

Dec = Vit B6 def, preg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What do altered liver Alk phos levels indicate?

A

Found in: liver, bone, placenta, biliary tract

Raised = hepatobiliary obstruction (+ other liver disease, associated w/ cholestasis), bone disease, children, preg, over 50

Dec = Vit D tox, milk-alkali syndrome, scurvy, hypophosphatasemia, hypothyroidism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What do altered liver GGT/gammaGT levels indicate?

A

One of the only LIVER SPECIFIC LFT!

Clarify if inc ALT is liver origin

Raised in = Cholestasis, diabetes, alcohol abuse, enz inducing meds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What do altered bilirubin levels indicate?

A

Raised = intravascular haemolysis, failure of conjugation in hepatocytes, biliary obstruction

- direct hyperbilirubinemia = biliary obstruction, cholestasis, hepatocellular injury 
- indirect hyperbilirubinemia = inc bilirubin production --> haemolysis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is total bilirubin?

A

Conjugates + unconjugated + delta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is direct bilirubin?

A

conjugated + delta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Explain the movement/breakdown of bilirubin in the liver

A

Bilirubin is bound to albumin in blood, taken up by hepatocytes

In hepatocytes = bilirubin conjugated with glucuronic acid

Conjugated (direct) bilirubin = secreted into bile (allows plasma albumin to stay low)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Cumulatively, what does bilirubin, ALP, and aminotransferases indicate?

A

Whether jaundice is pre-hepatic due to:
- intrahepatic damage
- intrahepatic cholestasis
- post-hepatic

18
Q

What do altered serum albumin levels indicate?

A

Dec (due to dec synth) = chronic hepatitis, severe acute hepatitis, cirrhosis, malnutrition

Dec (due to inc loss of albumin) = burns, crohn’s disease, nephrotic syndrome

Dec (Due to inc catabolism) = infection, trauma, thyrotoxicosis

19
Q

What are signs of severely low serum albumin?

A

Ascites (inc volume of dist, reduces absorption of water soluble meds)
Peripheral oedema
Pulmonary oedema
Reduced protein binding of drugs

20
Q

In what liver conditions can you seen jaundice in?

A

cholestasis
severe cirrhosis
end stage liver failure

21
Q

What are some clinical signs of compensated cirrhosis?

A

Xanthelasmas

Parotid enlargement

Spider naevi

Gynecomastia

Small/large liver

Splenomegaly

22
Q

What are some clinical signs of general cirrhosis?

A

Jaundice

Fever

Loss of body hair

23
Q

What are some clinical neurological signs of decompensated cirrhosis?

A

(neurological)

Disorientated

Drowsy

Hepatic flap

fetor hepaticus

24
Q

Generally, what is the appearance of someone with liver disease?

A

Jaundice

Thin/skinny

Muscle wasting

Ascites =portal HTN, low plasma albumin, enhanced renal retention of Na

Gynaecomastia

Spider naevi

easily bruised/bruising

25
Q

What are the general rules for drug choice in liver disease?

A

Avoid herbal medicines

Avoid medicines previously linked to liver ADRs (raised LFT)

Avoid hepatotoxic drugs

Use potentially hepatotoxic drugs w/ caution

26
Q

List some potentially hepatotoxic drugs

A

Abx = Amoxicillin/clavulanate, flucloxacillin

Analgesics = NSAIDs, paracetamol

Anticonvulsants = sodium valproate, phenytoin

Herbal/dietary supps = black cohos, echinacea, body-building, weight loss supplements

27
Q

Outline steatotic liver disease (diagnosis, risk factor, association, what is)

A

Diagnosis = histology or imaging, slightly abnormal LFTs
Accumulation of fat in the liver

Risk factors = over nutrition, insulin resistance, complicated by alcohol use

Associated w/ obesity, high chol/TG, T2DM

28
Q

What are some LFT characteristics of SLD/Fatty liver/mild disease?

A

ASL/ALT = 2x ULN

Some ongoing damage, no other LFT/clotting/albumin/cirrhosis/cholestasis

No change in drug characteristics

29
Q

What are some LFT/other characteristics of cholestasis?

A

Jaundice

Raised bilirubin, alk phos, GGT = 3x ULN

ALT, AST normal unless cirrhosis

Can be due to med

30
Q

How is ADME influenced in cholestasis?

A

Reduced absorption = lipid soluble drugs (inc vit K)

Impaired elimination = biliary excreted drugs

Protein bound drugs = high bilirubin displace protein bound drug –> inc free [serum]

metabolic function unchanged

31
Q

What drug types should be changed (dose, administration, avoided, etc.) in cholestasis?

A

Lipid soluble meds = will have reduce absorption

Medicines excreted in bile = impaired secretion

Protein bound medicines = high bilirubin can displace meds bound to plasma

Entero-hepatically recycled meds = dec/no excretion in bile

32
Q

What drugs should you be cautious of in cholestasis?

A

Co-amoxiclav, fluclox

oestrogen, NSAID, carbamazepine

33
Q

What is portal HTN and varices? (causes, effects)

A

Hepatocytes die, liver becomes scarred/fibroses –> blood cannot flow freely —> portal HTN

Reduces 1st pass metabolism –> blood from gut bypasses the liver

Minor bleed –> vomit blood or pass tarry stool

34
Q

What are general rules for drug choice in cirrhosis and acute liver failure?

A

Avoid pro-drug and drugs w/ active metabolites = conversion is unpredictable

Prefer with shorter half-life

No hepato-renal syndrome, prefer drugs that are renally excreted

Drug with high first pass effect = reduce dose

Drug only available in hepatically metabolised forms = dose intervals may/will need to be inc depending on degree of impairment

Varices = drug w/ high first-pass effect, reduce dose

35
Q

Discuss the symptoms of compensated cirrhosis?

A

portal hypertension

splenomegaly

Varices

spider naevi

36
Q

Discuss some LFT changes seen in compensated cirrhosis?

A

ALT/AST = normal or 3*ULN

Albumin, clotting = normal

Bilirubin = may be normal, may inc (restrictions associated w/ cholestasis apply

Metabolic function may be normal, can deteriorate to decompensated cirrhosis, reduced first pass metabolism

Portal HTN = reduce blood flow through liver and therefore reduced metabolism

37
Q

Discuss decompensated cirrhosis in drug treatment

A

Dose and freq adjustment of liver metabolised drugs

Varices dec 1st pass effect

Will need to dec drug freq/inc time between doses and avoid pro-drugs

38
Q

What are the LFT symptoms/signs of decompensated cirrhosis?

A

Bilirubin usually raised, therefore restrictions associated with cholestasis also apply

Reduced albumin, inc clotting time = avoid highly bound protein medicines

Ascites inc vol of dist, reduces the absorption of water soluble meds

39
Q

What are some drugs with high extraction/poor bioavailability?

A

Atorvastatin
Fluvastatin
Morphine
Pravastatin
Rosuvastatin
Simvastatin

40
Q

What drugs should be avoided in cirrhosis?

A

Sedating, constipating drugs = encephalopathy
- opiates, TCAs, antihistamines, benzos, barbiturates, hypnotics, antipsychotics
- CCB, antispasmodics (hyoscine), loperamide (constipation)

Antiplatelet/anticoagulant = bleeding
- NSAIDs, aspirin, clopidogrel, dipyridamole, warfarin, heparin

Nephrotoxic = hepatorenal
- NSAIDs, COX-2 inhibitors, aminoglycosides, ACE inhibitors

sodium = ascites

gastric ulcerations = bleeding
- NSAIDs, aspirin, corticosteroids, bisphosphonates

Seizures = risk of seizures
- tramadol, varenicline/buproprion
- phebothiazines, sedating antihistamines

41
Q

What are some LFT changes with acute liver failure?

A

Raised AST/ALT, bilirubin, clotting, encephalopathy

Albumin = normal, take time for it to be affected

Blood flow unaffected = no cirrhosis, portal HTN/varices –> take time to develop

Metabolism = severely affected

3034PHM Evidence Based Prac (15 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions