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GI > Prescribing in liver disease > Flashcards

Prescribing in liver disease Flashcards

1
Q

What happens in cirrhosis?

A

= liver gets small and shrunken

  • reduced metabolic capacity
  • portal hypertension
  • high portal pressure & low albumin = ascites
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2
Q

what are risk factors for liver disease?

A
  • alcohol
  • obesity
  • drugs
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3
Q

what are 3 major factors involved in liver problems?

A
  • reduced liver blood flow
  • reduced metabolic function
  • reduced plasma proteins
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4
Q

what happens when highly metabolised drugs, e.g. GTN, phenytoin, calcium blockers, are taken when the liver is slightly messed up?

A

= they first-pass metabolism and result in portal-systemic shunting
= lead to high toxic levels

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5
Q

what circulatory changes happen in cirrhosis?

A
  • low albumin = low plasma volume
  • increasing renin levels
  • more aldosterone is produced
  • the liver cannot metabolise the aldosterone, therefore secondary aldosteronism arises
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6
Q

describe endothelia and oestrogen effect when there is cirrhosis/liver damage?

A
  • increased endothelin

- increased oestrogen

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7
Q

what are the consequences for the kidneys when the liver has increased angiotensin II, aldosterone, SNS and ADH?

A
  • potassium loss
  • sodium retention
  • water retention

= renal vasoconstriction
= fewer renal prostaglandins are produced

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8
Q

what is hepato-renal syndrome?

A

when you are unable to stop liver and renal failure

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9
Q

what does moderate hepatic impairment cause?

A
  • decreased renal clearance
  • effects on unbound drug masked by decreased protein binding
  • renal function is reduced
    (creatinine & Cr clearance misleading)
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10
Q

what are consequences of hepatic impairment?

A

1) gout oedema
= poor absorption

2) liver & kidney congestion
= reduced function

3) gross oedema & ascites
4) CHF

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11
Q

why would you NOT give NSAIDS?

A

= renal prostaglandin synthesises is decreased

  • worsen renal impairment
  • further sodium retention
  • risk of hepato-renal syndrome
  • worsening of CHF

= cirrhosis peptic ulcers increase
- risk of GI bleed or perforation

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12
Q

what other complications do NSAIDs do?

A
  • hypertension
  • sodium retention
  • asthma
  • diarrhoea/colitis
  • CHF
  • CV toxicity
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13
Q

how would you ideally treat liver diseases?

A
  • standard NSAID or COX-2 inhibitor

= both co-prescribed with a proton pump inhibitor

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14
Q

what are the affects of NSAIDs, diuretics and metoclopramide?

A

NSAIDS
= hypertension
- ant-hypertension

DIURETICS
= gout
- gout Rx

Metoclopramide (anti-emetic)
= parkinsons
- L-DOPA

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15
Q

what drugs would you use to treat reduced drug metabolism?

A

1) opiates
= codeine

2) benzodiazepines
3) chlormethiazole
4) cyclosporin
5) metrondiazole
6) calcium blockers

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16
Q

what does 8% of paracetamol get converted into?

A

= a highly reactive intermediate
N-acetyl-p-benzoquinonimine by P4502E1
= liver failure

17
Q

what happens if you have a loss of glutathione?

A

= failure to break down of N-acetyl-p-benzoquinomine

Resulting in
= cysteine and mercapturic acid conjugates

18
Q

describe paracetamol in liver disease?

A
  • reduced glutathione stores
  • longer half-life
  • increased P4502E1 in alcoholics
  • toxicity with ‘normal’ doses
19
Q

Describe Hy’s rule?

A

= used for drug induced liver failure

ALT/AS > 5 x ULN
AND
Bilirubin > 3mg/dI

20
Q

describe who is most likely to get drug induced liver injuries?

A
  • women
21
Q

what diuretics could you give to some with oedema and ascites?

A
  • Loop
  • thiazide
  • spironolactone
22
Q

why is sprinolactone the best drug of choice?

A

Frusemide
= reduced intra-vascular volume
= hypokalaemia, hypomagnesaemia

Thiazide
= hypokalaemia
= hypomagnesaemia

Spironolactone
= best drug
= with fluid restriction
= Aim at 1kg/day weight loss

23
Q

describe antibiotics use in disease?

A
  • mostly safe
  • amino-glycosides nephrotoxic
  • quinolone epileptogenic
  • metronidazole reduced metabolism
24
Q

what are 4 bad hepatic disorders?

A
  • fulminant hepatic failure
  • decompensated cirrhosis
  • severe or acute chronic hepatitis
  • severe congestive heart failure
25
Q

what are mild/moderate problems with the liver?

A
  • compensated cirrhosis
  • cholestatic jaundice
  • enzyme blockers:
    = non-specific: cimetidine, ketoconazole, grapefruit juice
    = specific: erythromycin, quinolones
  • hypothyroidism
  • old age

GI (43 decks)

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