Renal & Liver Disease Part 1 Flashcards
1
Q
Drugs that require ↓ dose or ↑ interval w/ low CrCl
Anti-Infectives
A
- Aminoglycoside - nephrotoxic
- Beta-lactams - seizures
- Fluconazole
- Quinolones (except moxifloxacin) - seizures
- Vancomycin - nephrotoxic
Exception: Ceftriaxone & antistaphylococcal PCN (eg, dicloxacillin, nafcillin, Oxacillin)
2
Q
Drugs that require ↓ dose or ↑ interval w/ low CrCl
Cardiovascular Drugs
A
Causes bleeding
* LMWHs (enoxaparin)
* Rivaroxaban (for Afib)
3
Q
Drugs that require ↓ dose or ↑ interval w/ low CrCl
Gastrointestinal Drugs
A
- H2RAs - CNS
- Metoclopramide - EPS
4
Q
Drugs that require ↓ dose or ↑ interval w/ low CrCl
Other
A
- Bisphosphonates
- Lithium
5
Q
Vancomycin Renal Dose Adjustment
A
CrCl 20-49: Q24H
CrCl < 20: give one dose, then dose per levels
6
Q
Enoxaparin (Lovenox) Renal Dose Adjustment
PPx of VTE
A
CrCl < 30: 30 mg SC QD
7
Q
Enoxaparin (Lovenox) Renal Dose Adjustment
Tx of VTE & UA/NSTEMI
A
CrCl < 30: 1 mg/kg SC QD
Use TOTAL body wt
8
Q
Enoxaparin (Lovenox) Renal Dose Adjustment
Tx of STEMI in pts < 75 y/o
A
CrCl < 30: 30 mg IV bolus + a 1 mg/kg SC dose,
followed by 1 mg/kg SC QD
Use TOTAL body wt
9
Q
Enoxaparin (Lovenox) Renal Dose Adjustment
Tx of STEMI in pts ≥ 75 y/o
A
CrCl < 30: 1 mg/kg SC QD
Use TOTAL body wt
10
Q
In general, what to do when
CrCl < 60
A
check for dose adjustments
11
Q
In general, what to do when
CrCl < 30
A
check for dose adjustments OR
CI
12
Q
CI Drugs
CrCl < 60
A
Nitrofurantoin
13
Q
CI Drugs
CrCl < 50
A
TDF-containing products
Voriconazole IV
14
Q
CI Drugs
CrCl < 30
A
TAF-containing products
NSAIDs
Dabigatran
Rivaroxaban
15
Q
CI Drugs
GFR < 30
A
SGLT2 inhibitors
Metformin
16
Q
CI Drugs: Renal
Other
A
Meperidine
17
Q
Which of the following natural products is used for liver disease?
A. Coenzyme Q10
B. Milk thistle
C. Feverfew
D. Magnesium
E. Soy
A
Milk thistle
Sometimes used by patients with liver disease. Efficacy data is limited, but it does not appear to be harmful.
18
Q
What meds are
NS3/4A protease inhibitors
A
Glecaprevir
Grazoprevir
Voxilaprevir
-previr
P for Protease Inhibitors
Generally taken w/ food
19
Q
What meds are
NS5A replication complex inhibitors
A
Elbasvir
Ledipasvir
Pibrentasvir
Velpatasvir
-asvir
A for NS5A
20
Q
What meds are
NS5B polymerase inhibitors
A
Sofosbuvir (Sovaldi)
-buvir
B for NS5B
21
Q
Treatment regimens for HCV
For All Genotypes
A
Glecaprevir/pibrentasvir (Mavyret)
OR
Sofosbuvirivelpatasvir (Epclusa)
Administer for 8-12 weeks
22
Q
Treatment regimens for HCV
For Genotype 1, 4, 5, 6
A
Ledipasvir/sofosbuvir (Harvoni)
Administer for 8-12 weeks
23
Q
Treatment regimens for HCV
For Genotype 1, 4
A
Elbasvir/grazoprevir (Zepatier)
Administer for 8-12 weeks
24
Q
Treatment regimens for HCV
For Genotype 3
A
Sofosbuvir/velpatasvir/voxilaprevir (Vosevi)
Administer for 8-12 weeks
25
Which of the following is correct regarding the need to test for HIV before starting HBV therapy? (Select ALL that apply.)
A. Antivirals used for HBV can have activity against HIV.
B. HBV treatment requires higher doses of antivirals than HIV treatment.
C. HIV resistance can occur if HIV is unrecognized.
D. A treatment regimen for HIV will require the addition of a direct-acting antiviral to treat HBV.
E. HIV and HBV share similar routes of transmission.
Antivirals used for HBV can have activity against HIV.
HIV resistance can occur if HIV is unrecognized.
HIV and HBV share similar routes of transmission.
## Footnote
It is critical to identify and correctly treat co-infection with HBV and HIV. The combination products approved for treating HIV are not currently approved for HBV. The direct-acting antivirals (DAAs) are used to treat HCV.
26
Hep B Tx
Interferon Alfa - monotherapy
NRTIs
27
NRTIs Boxed Warnings
Lactic acidosis and hepatomegaly with steatosis
Exacerbation of Hep B once discontinued
## Footnote
Staeatosis - fat buildup in an organ (usually your liver)
28
NRTIs Side Effects
Gl upset
Rash
↑ LFTs
29
NRTIs approved for HBV
Tenofovir disoproxil (Viread)
Tenofovir alafenamide (Vemlidy)
Entecavir (Baraclude)
Adefovir (Hepsera)
Lamivudine (Epivir HBV)
30
Te**NOF**ovir
| Side Effects
N - nephrotoxic
O- osteoporosis
F - Fanconi syndrome
31
Which of the following statements concerning bone metabolism abnormalities in chronic kidney disease (CKD) is correct?
A. Initially, bone metabolism abnormalities are caused by a rise in calcium.
B. Hyperphosphatemia causes an increase in the release of parathyroid hormone.
C. A benefit of hyperphosphatemia is improved bone health.
D. To counteract the increase in phosphate levels, it is necessary to give injectable phosphate binders.
E. Hyperphosphatemia can lead to anemia.
Hyperphosphatemia causes an increase in the release of parathyroid hormone.
## Footnote
High serum phosphorus and low serum calcium trigger release of parathyroid hormone.
32
Complications of CKD
↑ PO4
↓ Vitamin D & Calcium
↓ Erythropoietin
33
Hyperphosphatemia Tx
Restrict diet
Phosphate binders
* Aluminum-based
* **Calcium-based** first line
* Aluminum & calcium free
| Must take w/ food, skip if meal is skip
34
# Phosphate binders
Aluminum-based
Potent, use short-term
Toxic to bone and CNS
35
# Phosphate binders
Calcium-based
**First-line**
Hypercalcemia
Constipation
36
# Phosphate binders
Aluminum- and calcium-free
Iron-based products
Lanthanum carbonate (Fosrenal): chew thoroughly (Gl obstruction, ileus)
Sevelamer carbonate (Renvela): N/V/D, LDL Boxed Warnings
37
# Phosphate binders
Drug Intxn
Levothyroxine
Quinolones & Tetracyclines
PO Bisphophonates
| There are others
38
In a patient unable to tolerate lactulose for the prevention of hepatic encephalopathy, which of the following would be the best recommendation?
A. Start rifaximin
B. Start neomycin
C. Start metronidazole
D. Start nadolol
E. Start octreotide
Start rifaximin
| Cause by ↑ in ammonia
## Footnote
Lactulose is the preferred first-line therapy for the prevention of hepatic encephalopathy, followed by rifaximin.
This decision is mainly driven by cost.
The side effects associated with chronic neomycin or metronidazole treatment limit their use.
39
GK is a 68-year-old African American male with chronic kidney disease due to a long history of uncontrolled hypertension. He presents to his primary care provider for a routine check up and labs.
Urine Albumin to Creatinine Ratio (ACR) 180 (mg/g)
Which medication is best to initiate in this patient?
A. Hydrochlorothiazide
B. Verapamil
C. Ramipril
D. Amlodipine
E. Bumetanide
Ramipril
## Footnote
A normal urine albumin-to-creatinine ratio (ACR) is < 30 mg/g. All patients with albuminuria (ACR ≥ 30 mg/g) should receive treatment with an ACE inhibitor or an ARB to decrease the progression of kidney damage.
In patients with concurrent hypertension, an ACE inhibitor or an ARB is first line regardless of patient race.
40
MB is a 28-year-old female beginning therapy with ribavirin for the treatment of hepatitis C. What is an important warning about ribavirin the pharmacist should counsel her on?
A. It causes flu-like syndrome after administration.
B. It can decrease bone density and lead to osteoporosis.
C. It causes birth defects if she were to become pregnant.
D. It can cause neuropsychiatric disorders.
E. It can cause rebound hypertension if stopped abruptly.
It causes birth defects if she were to become pregnant.
## Footnote
If a female patient taking ribavirin wishes to become pregnant, she must wait for six months after stopping ribavirin before she attempts pregnancy; continue using two forms of contraception during this time.
41
Ribavirin (RBV) Indication
Only for HCV
| Oral
42
Ribavirin Boxed Warnings
Pregnancy Category X:
* Avoid pregnancy (females and female partners of male patients) during therapy and for 6 months after completion of therapy; use 2 forms of birth control
Must be used in combination with other agents
Hemolytic anemia
43
**RIBA**virin Effects
R - Renal (Cl when CrCl < 50 mL/min)*
I - In combination only
B - Birth Defects
A - Anemia: Hemolytic (primary toxicity)
44
Interferon Alfa (Inf-Alfa) Indications
HBV, HCV, & some cancers
45
Interferon Beta Indications
Multiple sclerosis (MS)
46
Pegintron, Pegasys
Polyethylene glycol (PEG) added to pegylated products to ↑ t½
| Added to Interferon Alfa (Inf-Alfa)
47
Interferon Alfa (Inf-Alfa) Boxed Warnings
Neuropsychiatric, autoimmune, ischemic and infectious
48
Interferon Alfa (Inf-Alfa) SE
CNS (depression, anxiety, fatigue)
GI, ↑ LFTs, myelosuppression
Flu-like syndrome 1-2 hours after administration (fever, chills, arthralgias)
49
# Interferon Alfa (Inf-Alfa)
Stop treatment or reduce dose based on:
ANC, platelets and CrCl
50
Which of the following is used to prevent and treat Wernicke-Korsakoff syndrome?
A. Vitamin A
B. Vitamin B6
C. Vitamin B1
D. Vitamin C
E. Vitamin D
Vitamin B1
| Wernicke-Korsakoff usually associated w/ alcohol abuse
51
Alcoholic Liver Disease Tx
Alcohol cessation
Thiamine
52
SH is beginning therapy with Pegasys (pegylated interferon-alfa-2a). The pharmacist will counsel him on possible side effects from Pegasys therapy. He should receive counseling on which of the following side effects? (Select ALL that apply.)
A. Depression
B. Hair growth
C. Flu-like syndrome
D. Fatigue
E. Liver damage
Depression
Flu-like syndrome
Fatigue
Liver damage
## Footnote
Interferons have numerous side effects (e.g., CNS effects, GI upset, increased LFTs), making treatment difficult for the patient.
53
HV is a 57-year-old male with chronic kidney disease due to long-term overuse of ibuprofen for osteoarthritis of the knee. He was recently started on candesartan and aspirin. On a routine follow-up of his labs, the following results were obtained.
4/3
Value (Normal)
Glucose 107 (65-99 mg/dL)
Sodium 140 (135-145 mEq/L)
Potassium 6.1 (3.5-5 mEq/L)
Chloride 100 (95-103 meq/L)
HCO3 24 (24-30 mEq)
BUN 28 (7-20 mg/dL)
Creatinine 3.4 (0.6-1.3 mg/dL)
Magnesium 1.8 (1.3-2.1 mEq/L)
Phosphate 5.1 (2.3-4.7 mg/dL)
Calcium 10.5 (8.5-10.5 g/dL)
AST 47 (10-40 units/L)
ALT 47 (10-40 units/L)
An ECG was ordered, which revealed abnormalities including peaked T-waves. He was admitted to the hospital to be treated for hyperkalemia.
Question: Which of the following medications should be given first?
A. Sodium polystyrene sulfonate
B. Albuterol
C. Insulin plus dextrose
D. Calcium gluconate
E. Sodium bicarbonate
Calcium gluconate
## Footnote
All of the answer choices are used in the treatment of hyperkalemia, but this patient is experiencing ECG changes due to hyperkalemia.
In this instance, calcium is given first to stabilize the cardiac tissue (to prevent arrhythmia)
54
Hyperkalemia Steps
Stabilize the heart
Move K intracellularly
Remove it
55
# Hyperkalemia Steps
Stabilize the heart
Calcium gluconate
## Footnote
Prevent arrhythmias
56
# Hyperkalemia Steps
Move K intracellularly
Insulin (regular) w/ dextrose
Sodium bicarbonate
Albuterol
## Footnote
Shift excess K intracellularly
57
# Hyperkalemia Steps
Remove it
Furosemide (Quick 5-10 mins)
Binding agents
Hemodialysis
58
# Hyperkalemia Steps
What are some binding agents?
Sodium polystyrene
Patiromer
59
Which of the following medications is/are nephrotoxic? (Select ALL that apply.)
A. Cisplatin
B. Ibuprofen
C. Metformin
D. Nitrofurantoin
E. Furosemide
F. Amikacin
Cisplatin
Ibuprofen
Furosemide
Amikacin
60
Select Drugs that Cause Kidney Disease
Aminoglycosides
Amphotericin B
Cisplatin
Cyclosporine
Loop diuretics
NSAIDs
Polymyxins
Radiographic contrast dye
Tacrolimus
Vancomycin
61
Which of the following treatments remove potassium from the body? (Select ALL that apply.)
A. Sodium polystyrene sulfonate
B. Sodium bicarbonate
C. Calcium gluconate
D. Regular insulin plus D50W
E. Furosemide
F. Hemodialysis
G. Albuterol
Sodium polystyrene sulfonate
Furosemide
Hemodialysis
62
DW has a history of alcohol abuse and cirrhosis secondary to alcohol. Which of the following could be considered to prevent alcohol relapse? (Select ALL that apply.)
A. Acamprosate
B. Disulfiram
C. Nadolol
D. Naltrexone
E. Rifaximin
Acamprosate
Disulfiram
Naltrexone
63
A medical resident is writing post-dialysis orders for a patient under his care. She asks the pharmacist what factors cause a drug to be removed during hemodialysis. Which of the following statements concerning drug removal is correct?
A. High-flux dialysis membranes (or filters) are less efficient at removing drugs.
B. Highly protein-bound drugs are easily removed by dialysis.
C. Drugs with a larger Vd are cleared more easily than drugs with a smaller Vd.
D. Smaller molecular compounds (smaller drugs) are more easily cleared by dialysis.
E. Dialysis is very effective for removing drugs that are largely cleared by the liver.
Smaller molecular compounds (smaller drugs) are more easily cleared by dialysis.
## Footnote
Smaller molecules are more easily cleared by dialysis.
High-flux membranes have larger pore sizes and are more efficient at drug removal.
Drugs with a larger Vd distribute out of the bloodstream into the tissues, so they are not available to be removed by dialysis.
Dialysis can only clear unbound drug in the bloodstream, which means highly protein-bound drugs are also NOT easily removed by dialysis.
64
Factors Affecting Drug Removal During Dialysis
Drug molecular wt, Vd, protein-binding
Will filter:
* Low MW
* Low Vd
* Not protein-bound
Dialysis membrane (low vs high flux)
* High flux membranes have the largest pore size
Blood flow rate (faster - more drug removed)
65
Medications:
Amlodipine 10 mg 1 tablet PO daily
Hydrochlorothiazide 25 mg 1 tablet PO daily
Sofosbuvir/velpatasvir/voxilaprevir 1 tablet PO daily
Loratadine 10 mg 1 tablet PO daily
Tadalafil 5 mg 1 tablet PO daily
Calcium carbonate 500 mg 1–2 tablets PO TID PRN heartburn
Which newly prescribed medication will decrease the effectiveness of the antiviral regimen on this patient's profile?
A. Bismuth subcitrate
B. Metronidazole
C. Pantoprazole
D. Potassium chloride
E. Tetracycline
Pantoprazole
## Footnote
Velpatasvir-containing direct-acting antiviral (DAA) regimens require an acidic gastric environment for optimal absorption and can reduce antiviral efficacy if used concurrently with acid-suppressive therapies (eg, pantoprazole).
66
# Direct-Acting Antivirals (DAAs)
Boxed warning
Hepatitis B virus (HBV) reactivation: test for HBV before starting a DAA
67
# Direct-Acting Antivirals (DAAs)
Drug interactions
Avoid strong CYP3A4 inducers1 (↓ DAA serum concentration & efficacy)
68
# Direct-Acting Antivirals (DAAs)
Dispensing & administration
Keep in the original manufacturer container
Glecaprevir/pibrentasvir: must be taken with food
69
Which DAA must be taken w/ food?
Glecaprevir/pibrentasvir (
70
# Direct-Acting Antivirals (DAAs): Sofosbuvir
Drug interactions
Avoid concurrent amiodarone (↑ risk of symptomatic bradycardia)
## Footnote
Includes carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifabutin & St. John’s wort.
71
# Direct-Acting Antivirals (DAAs): Ledipasvir & velpatasvir
Drug interactions
↓ Serum concentrations if used in combination with acid-suppressive drugs2
## Footnote
Administer antacids & H2RAs separately; avoid PPIs with velpatasvir-containing regimens.
72
# Mavyret
Which counseling points should the pharmacist provide to the patient regarding this new medication? (Select ALL that apply)
A. Keep this medication in its original container.
B. Take antacids at a separate time from this medication.
C. Take this medication with food.
D. This medication can cause a depressed mood.
E. This medication can cause a flu-like syndrome.
Keep this medication in its original container.
Take this medication with food.
## Footnote
Direct-acting antivirals should be kept in the original container to maintain stability.
Mavyret (glecaprevir/pibrentasvir) must be taken with food to maximize absorption and antiviral efficacy.
73
PW was prescribed lanthanum carbonate tablets. How should the daily dose be administered?
A. Swallow whole in the morning, half an hour before breakfast.
B. Chew and swallow the daily dose in the evening (at bedtime).
C. Divide the daily dose and chew before each meal.
D. Divide the daily dose and swallow whole after each meal.
E. Swallow whole in the evening (at bedtime).
Divide the daily dose and chew before each meal.
## Footnote
Phosphate binders work by binding phosphate in the gut to prevent absorption.
They need to be in the gut when the food is in the gut, or they are not useful.
Lanthanum carbonate (Fosrenol) tablets must be chewed thoroughly in order for the drug to work properly and to avoid a GI obstruction.
74
SC has lupus-related renal disease. Her serum creatinine today is 2.7 g/dL and the potassium is 6.2 mEq/L. In order to reduce the potassium, the physician has prescribed oral sodium polystyrene sulfonate. When can the physician expect the drug to take effect?
A. Immediately
B. Hours to days
C. Within 15 minutes
D. 30-45 minutes
E. 5-7 days
Hours to days
## Footnote
Sodium polystyrene sulfonate powder can be given orally or rectally.
The onset of action with oral administration may take hours to days.
This is why oral administration of sodium polystyrene sulfonate should not be used alone in acute emergencies.
75
Which of the following medications have a boxed warning for liver damage? (Select ALL that apply.)
A. Tylenol
B. Isoniazid
C. Depakote
D. Aleve
E. Nefazodone
Tylenol
Isoniazid
Depakote
Nefazodone
76
Select Drugs w/ Boxed Warnings for Liver Damage
APAP (high doses, acute or chronic)
Amiodarone
Isoniazid
Ketoconazole (oral)
Methotrexate
Nafazodone
Nevirapine
NRTIs
Propylthiouracil
Valproic acid
## Footnote
Watch for LFTs when > 3x Normal (10-40) or > 150
77
RH is an 81-year-old male who comes to the primary care clinic due to **fatigue and painful sores in his mouth**. Six months ago, he moved into an assisted living facility that manages his medications.
**Medications**:
Alendronate 70 mg PO weekly
Amlodipine 10 mg PO daily
Carbidopa/levodopa 25/100 mg PO TID
**Methotrexate** 10 mg PO weekly
Rosuvastatin 20 mg PO daily
Mean corpuscular volume 110 fL
Which treatment plan is most appropriate to manage this patient's signs and symptoms?
A. Discontinue carbidopa/levodopa
B. Initiate Aranesp
C. Initiate ferrous sulfate
D. Initiate folic acid
E. Initiate Venofer
Initiate folic acid
## Footnote
Folic acid supplementation is used to treat macrocytic anemia (ie, mean corpuscular volume > 100 fL) due to folate deficiency, which can be caused by drugs (eg, methotrexate), low intake, or decreased absorption (eg, celiac disease, gastric bypass surgery).
Folate deficiency can present with oral ulcers and altered skin or hair pigmentation in addition to typical anemia symptoms (eg, fatigue).
78
# Folate deficiency
Causes
Drug-induced (eg, methotrexate)
Low intake or ↓ absorption (eg, gastric bypass, Crohn's disease)
Alcohol use disorder
Pregnancy
79
# Folate deficiency
Signs & symptoms
Fatigue, weakness, shortness of breath, pallor
Oral ulcers
Skin, hair, nail pigmentation changes
80
# Folate deficiency
Laboratory findings
↓ Hgb, RBCs, reticulocyte count
↑ MCV (> 100 fL), homocysteine
↓ Serum folate
81
# Folate deficiency
Treatment
Folic acid 0.4–5 mg PO daily
82
Which of the following statements is correct regarding vitamin D?
A. Calcitriol is used to decrease dietary phosphate absorption.
B. Cholecalciferol is synthesized in the skin with ultraviolet light exposure.
C. Vitamin D3 is the primary dietary source of vitamin D.
D. Calcitriol is the active form of vitamin D2.
E. Paricalcitol and doxercalciferol cause more hypercalcemia than calcitriol.
Cholecalciferol is synthesized in the skin with ultraviolet light exposure.
## Footnote
Calcitriol increases calcium absorption which helps inhibit PTH secretion.
Cholecalciferol (vitamin D3) is synthesized in the skin.
Remember cholecalciferol and calcitriol start with "C" which rhymes with "3" (for D3) and you can also "see" sunlight on the skin.
Ergocalciferol is vitamin D2 which is produced in plants.
The newer vitamin D analogs are associated with less hypercalcemia than calcitriol.
83
How does Vit D worsen bone disease?
Contributing to hypocalcemia → ↑ PTH
84
Where is Vit D activated?
Kidneys
| Final active form: 1,25-dihydroxy vitamin D
85
Cholecalciferol Vitamin D[ _ ] and is synthesized in []
D3 & the skin by UV light
86
Ergocalciferol Vitamin D[ _ ] and is synthesized in []
D2 & plants
87
# Vit D Analogs
Drugs
Calcitriol (Rocaltrol)
Calcifediol (Rayaldee)
Doxercalciferol (Hectorol)
Paricalcitol (Zemplar)
| Calcitriol is the active form of D3
88
What is calcitriol the active form of?
D3
89
# Vit D Analogs
Effects
↑ calcium absorption in the gut
Inhibit PTH secretion
90
# Calcimimetic
Drugs
**Cinacalcet** (**Sensipar**)
Etelcalcetide (Parsabiv)
91
# Calcimimetic
MOA
↑ sensitivity of the calcium-sensing receptor on the parthyroid gland →
↓ PTH
↓ Ca
↓ PO4
92
Which of the following drug classes is used to treat ascites due to portal hypertension?
A. Anticholinergic
B. Neuraminidase inhibitor
C. Thiazide-like diuretic
D. Alpha antagonist
E. Aldosterone antagonist
Aldosterone antagonist
## Footnote
In cirrhosis, portal hypertension can lead to activation of the renin-angiotensin aldosterone system (RAAS), resulting in sodium and fluid retention.
These patients often have third spacing of fluid, called ascites.
Aldosterone antagonism (with spironolactone) improves ascites by increasing the excretion of sodium and water into the urine.
93
Ascites Tx
Spironolactone (↑ K) + furosemide (↓ K)
100 mg: 40 mg ratio
| Balances K
94
What is the mechanism of action for lactulose in treating hepatic encephalopathy?
A. Converts ammonia to ammonium, which cannot diffuse back into the blood.
B. Enhances water passage into the proximal renal tubule allowing more ammonia to be excreted in the urine.
C. Vasocontricts the splanchnic circulation to reduce ammonia metabolism.
D. Enhances the activity of urease-producing bacteria in the gut, leading to increased ammonia production.
E. Reduces GI motility allowing more time for colonic bacteria to break down ammonium.
Converts ammonia to ammonium, which cannot diffuse back into the blood.
## Footnote
Lactulose works in several ways.
It is metabolized in the gut to acetic acid and lactic acid; this acidification effectively traps ammonium in the GI tract and prevents it from diffusing back into the blood.
The lowering of pH also causes a laxative effect that reduces the time for ammonia to be absorbed.
Remember, lactulose can be used by any patient as a simple osmotic laxative.
Rifaximin, neomycin and metronidazole reduce ammonia-producing bacteria.
95
# Complications of Liver Disease & Cirrhosis
Hepatic Encephalopathy
Lactulose
Rifaximin (Xifaxin)
## Footnote
Can also use neomycin & metronidazole but long term use has toxicities
96
SC, a 33-year-old female, hands the pharmacist a prescription for ribavirin. She states this is a new prescription for her hepatitis C infection. She is not currently taking any other medications for hepatitis C. The following information is available from the clinic records:
Weight: 145 pounds
Albumin (g/dL) = 4.2 (3.5–5)
Potassium (mEq/L) = 5.1 (3.5–5)
BUN (mg/dL) = 23 (7–20)
SCr (mg/dL) = 1.3 (0.7–1.3)
AST (IU/L) = 83 (10–40)
ALT (IU/L) = 75 (10–40)
Bilirubin (mg/dL) = 0.7 (0.1–1.2)
INR = 1.1
Question: The pharmacist should not fill the prescription. What should the pharmacist discuss with the prescriber?
A. Ribavirin is contraindicated in female patients.
B. Ribavirin is contraindicated in patients with CrCl < 80 mL/min.
C. Ribavirin monotherapy is not effective.
D. Ribavirin is contraindicated in this degree of elevation of liver enzymes.
E. Ribavirin is not indicated for the treatment of hepatitis C.
Ribavirin monotherapy is not effective.
## Footnote
Ribavirin is approved for the treatment of hepatitis C only in combination with other medications.
This patient has a mild increase in liver enzymes (approximately 2x ULN), which is not a contraindication to therapy with ribavirin.
97
Which of the following is a non-pharmacological recommendation for managing hepatic encephalopathy?
A. Restricting sodium intake
B. Restricting fluid intake
C. Restricting glucose intake
D. Restricting animal protein intake
E. Increasing fluid intake
Restricting animal protein intake
## Footnote
Managing hepatic encephalopathy is done by restricting animal protein intake and drug therapy.
98
Which of the following is used to assess the severity of liver disease?
A. Ranson's Criteria
B. APACHE II Score
C. ASCVD Risk Score
D. Child-Pugh Classification
E. Well's Criteria
Child-Pugh Classification
## Footnote
The Child-Pugh Score (also called the Child-Turcotte-Pugh Score or CPT score) is used to assess the severity of liver disease.
It incorporates the presence of ascites and hepatic encephalopathy, bilirubin, albumin and INR (note that AST/ALT are not included).
99
# Child-Pugh Classification
0-6
Class A - Mild Disease
100
# Child-Pugh Classification
7-9
Class B - Mod Disease
101
# Child-Pugh Classification
10-15
Class C - Severe
