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Victor BNF Notes > Prescribing in Hepatic and Renal Impairment > Flashcards

Prescribing in Hepatic and Renal Impairment Flashcards

1
Q

What does reduced liver function mean to drug bioavailability/dose

A

reduced dose and therefore therapeutic effect

important for narrow therapeutic drugs

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2
Q

How does liver change as you age

A

reduced liver volume = liver impairment

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3
Q

What does hypoproteinanaemia cause

A

reduced protein binding as less protein binding sites in body

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4
Q

What does hypoproteinanaemia mean in terms of drugs and toxicity

A

it will increase level of free drug in blood, increasing toxicity

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5
Q

What does vitamin k deficiency lead to

A

increased risk of bleeding

  • give Menadiol (water soluble vitamin k) for vitamin k balance
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6
Q

What are the fat soluble vitamins

A

ADEK

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7
Q

What is Obstructive jaundice

A

blockage in bile ducks reducing or stopping bile flow from liver into small intestine

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8
Q

What is the difference between intrahepatic and extrahepatic jaundice

A

Intra- blockage is inside the liver

Extra- blockage is outside the liver

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9
Q

Why does obstructive jaundice affect fat soluble vitamin absorption

A

reduced bile into small intestine causes lowered emulsification and absorption of fat soluble vitamins

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10
Q

Fusidic acid and obstructive jaundice

A
  • impaired liver
  • causes lowered excretion of fusidic acid from liver
  • increased fusidic acid levels in blood
  • causing toxicity
  • impacting its effectiveness on biliary tract infections
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11
Q

Rifampicin and obstructive jaundice

A
  • impaired liver
  • causes lowered excretion of rifampicin
  • increasing its systemic levels
  • can increase liver impairment
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12
Q

What is hepatic encephalopathy

A
  • liver detoxifies ammonia into urea normally
  • impaired liver leads to build up of ammonia in blood
  • it passes BBB and builds up in brain
  • disrupting neurotransmission and brain function
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13
Q

What is Grade I hepatic encephalopathy

A

Grade I: Subtle cognitive changes, euphoria or depression, mild confusion, and slight tremor.

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14
Q

What is Grade II hepatic encephalopathy

A

Grade II: Increased drowsiness, lethargy, confusion, disorientation, and asterixis (flapping tremor).

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15
Q

What is Grade III hepatic encephalopathy

A

Grade III: Stupor, marked confusion, severe disorientation, and incoherent speech.

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16
Q

What is Grade IV hepatic encephalopathy

A

Grade IV: Coma, unresponsiveness to stimuli, and potential progression to death if untreated.

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17
Q

What drugs can exacerbate hepatic encephalopathy

A
  • Constipating drugs
    (opioids, TCAs)
  • Sedating drugs
    (opioids, antihistamine, benzodiazepines)
  • Hypokalaemic drug
    (Loop and thiazide like diuretics)
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18
Q

How to treat hepatic encephalopathy

A

Lactulose

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19
Q

What drugs can exacerbate Oedema and Ascities

A

drugs that cause fluid retention

(NSAIDs, Corticosteroids)

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20
Q

Main hepatoxocic drugs

A
  • Antipsychotics
  • Amiodarone
  • Carbamazepine
  • Co-Amoxiclav
  • Fluconazole
  • Flucloxacilin
  • Ketoconazole
  • Labetalol
  • Methotrexate
  • Paracetamol
  • Piolitazone
  • Rifampicin
  • Statins
  • Valproate
  • Tetracyclines
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21
Q

What are the Signs of liver toxicity

A
  • jaundice (yellow skin, eyes)
  • abdominal pain
  • nausea / vomiting
  • weight loss
  • dark urine
  • drowsiness or confusion
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22
Q

What does grapefruit do to cytochrome p450

A

enzyme inhibitor

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23
Q

What does enzyme inhibition cause

A

increased plasma concentration

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24
Q

What drugs will have increased plasma concentration with grapefruit

A
  • CVS drugs
  • CNS drugs
  • Immunosuppressants
  • Colchicine
  • Sildenafil
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25
Q

What CVS drugs interact with grapefruit juice

A
  • amiodarone
  • statins
  • verapamil
  • CCB (amlodipine)
  • dihydropyrdine
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26
Q

What CNS drugs interact with grapefruit juice

A
  • Quetiapine
  • Sertraline
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27
Q

What immunosuppressants drugs interact with grapefruit juice

A
  • Tacrolimus
  • Ciclosporin
28
Q

What factors are HIGH in liver function test in liver impairment

A
  • ALT
  • AST
  • ALP
  • GGT
  • Bilirubin
  • Prothrombin time / INR
29
Q

What factors are LOW in liver function test in liver impairment

A

Albumin

30
Q

When is ALT raised in a liver function test when there is liver impairment

A

raised transaminases in hepatocellular damage

31
Q

When are AST and ALP raised in a liver function test when there is liver impairment

A

raised in obstructive jaundice

(found mainly in bile duct)

32
Q

What is bilirubin

A

it is a pigment in the bile that causes jandice

33
Q

Why is Albumin LOW in liver function test when there is liver impairment

A

because the liver can’t make the protein as much in hepatic impairment

34
Q

What does reduced renal excretion of drugs cause

A

toxicity, as plasma concentration of the drug isn’t excreted

35
Q

How should you handle the dose of a narrow therapeutic drug in renal impairment

A

close monitoring of plasma concentration and clinical response

36
Q

What does renal impairment do to plasma half life of drugs

A

increases it

37
Q

Why is renal impairment a problem in half life drugs

A
  • some drugs require a loading dose before regular use
  • it will take longer to reach the drug steady state
38
Q

What are the signs of acute kidney injury

A
  • reduced urine output
  • fluid retention
  • dehydration
  • nausea / vomiting
  • fatigue
  • High BP
  • confusion
39
Q

What will lab results show for acute kidney injury

A
  • reduced eGFR
  • reduced creatinine clearance
  • high serum creatinine
40
Q

Examples of Nephrotoxic drugs

A
  • ACE inhibitors
  • Aciclovir
  • NSAIDs
    -Tetracyclines
  • Quinolones
  • Aminoglycosides
  • Aminosalicylates
  • Cephalosporins
41
Q

What is the most significant risk factor or AKI

A

Dehydration

42
Q

What are renal impairment sick day rules

A

when unwell, stop taking certain medications

43
Q

When should you restart sick day rule medications

A

24-48 hours after eating and drinking normally

44
Q

What medications should you stop taking when feeling unwell with AKI (sick day rule medication)

A
  • Diuretics
  • ACE Inhibitors
  • Metformin
  • NSAIDs
45
Q

Why should you stop taking Diuretics when feeling unwell with AKI

A

it exacerbates dehydration and electrolyte disturbances

46
Q

Why should you stop taking ACE Inhibitors when feeling unwell with AKI

A

they are nephrotoxic and they reduce eGFR

47
Q

Why should you stop taking Metformin when feeling unwell with AKI

A

increases risk of lactic acidosis in renal impairment

48
Q

Why should you stop taking NSAIDs when feeling unwell with AKI

A

they are nephrotoxic and they reduce eGFR, sodium and water retention

49
Q

Which equation do you use to calculate creatinine clearance

A

Cockcroft-Gault formula

50
Q

What is the Cockcroft-Gault formula

A

Serum creatinine

51
Q

What is the Cockcroft-Gault formula constant for men and women

A

Men: 1.23
Women: 1.04

52
Q

If BMI is less than 18 what weight should be used in the Cockcroft-Gault formula

A

actual body weight

53
Q

if major contributor to high body weight is fat, what weight should be used in the Cockcroft-Gault formula

A

ideal body weight

54
Q

how to calculate ideal body weight

A

Constant + 0.91(height -152.4)

55
Q

What is the constant for men and women for the ideal body weight formula

A

Men: 50
Women: 45.5

56
Q

If eGFR is above 60 and the ACR is below 3 than what is the status of the kidney

A

Normal

57
Q

What is urine ACR

A

the ration between the amount of albumin to the amount of creatinine in the urine

58
Q

What drugs colour urine and bodily secretions RED

A
  • Dantron
  • Doxorubicin
  • Levodopa
59
Q

What drugs colour urine and bodily secretions RED-ORANGE

A
  • Rifampicin
60
Q

What drugs colour urine and bodily secretions ORANGE

A
  • Sulfasalazine
61
Q

What drugs colour urine and bodily secretions YELLOW-BROWN

A
  • Nitrofurantoin
  • Senna
62
Q

What drugs colour urine and bodily secretions PINK O ORANGE

A
  • Phenindone
63
Q

What drugs colour urine and bodily secretions BLUE

A
  • Triamterene
64
Q

What drugs colour urine and bodily secretions BLACK/TARRY

A
  • Iron
  • Bismuth
65
Q

What drugs colour urine and bodily secretions BROWN

A
  • Prostoglandin Analogues
    (latanoprost eye drops)

Victor BNF Notes (25 decks)

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