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NAPLEX Review UWorld > Renal & Liver Disease Part 1 > Flashcards

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)

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2
Q

Drugs that require ↓ dose or ↑ interval w/ low CrCl

Cardiovascular Drugs

A

Causes bleeding
* LMWHs (enoxaparin)
* Rivaroxaban (for Afib)

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3
Q

Drugs that require ↓ dose or ↑ interval w/ low CrCl

Gastrointestinal Drugs

A
  • H2RAs - CNS
  • Metoclopramide - EPS
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4
Q

Drugs that require ↓ dose or ↑ interval w/ low CrCl

Other

A
  • Bisphosphonates
  • Lithium
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5
Q

Vancomycin Renal Dose Adjustment

A

CrCl 20-49: Q24H

CrCl < 20: give one dose, then dose per levels

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6
Q

Enoxaparin (Lovenox) Renal Dose Adjustment

PPx of VTE

A

CrCl < 30: 30 mg SC QD

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7
Q

Enoxaparin (Lovenox) Renal Dose Adjustment

Tx of VTE & UA/NSTEMI

A

CrCl < 30: 1 mg/kg SC QD

Use TOTAL body wt

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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

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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

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10
Q

In general, what to do when

CrCl < 60

A

check for dose adjustments

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11
Q

In general, what to do when

CrCl < 30

A

check for dose adjustments OR
CI

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12
Q

CI Drugs

CrCl < 60

A

Nitrofurantoin

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13
Q

CI Drugs

CrCl < 50

A

TDF-containing products
Voriconazole IV

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14
Q

CI Drugs

CrCl < 30

A

TAF-containing products
NSAIDs
Dabigatran
Rivaroxaban

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15
Q

CI Drugs

GFR < 30

A

SGLT2 inhibitors
Metformin

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16
Q

CI Drugs: Renal

Other

A

Meperidine

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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.

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18
Q

What meds are

NS3/4A protease inhibitors

A

Glecaprevir

Grazoprevir

Voxilaprevir

-previr

P for Protease Inhibitors
Generally taken w/ food

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19
Q

What meds are

NS5A replication complex inhibitors

A

Elbasvir

Ledipasvir

Pibrentasvir

Velpatasvir

-asvir

A for NS5A

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20
Q

What meds are

NS5B polymerase inhibitors

A

Sofosbuvir (Sovaldi)

-buvir

B for NS5B

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21
Q

Treatment regimens for HCV

For All Genotypes

A

Glecaprevir/pibrentasvir (Mavyret)
OR
Sofosbuvirivelpatasvir (Epclusa)

Administer for 8-12 weeks

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22
Q

Treatment regimens for HCV

For Genotype 1, 4, 5, 6

A

Ledipasvir/sofosbuvir (Harvoni)

Administer for 8-12 weeks

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23
Q

Treatment regimens for HCV

For Genotype 1, 4

A

Elbasvir/grazoprevir (Zepatier)

Administer for 8-12 weeks

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24
Q

Treatment regimens for HCV

For Genotype 3

A

Sofosbuvir/velpatasvir/voxilaprevir (Vosevi)

Administer for 8-12 weeks

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25
Q

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.

A

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.

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.

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26
Q

Hep B Tx

A

Interferon Alfa - monotherapy

NRTIs

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27
Q

NRTIs Boxed Warnings

A

Lactic acidosis and hepatomegaly with steatosis

Exacerbation of Hep B once discontinued

Staeatosis - fat buildup in an organ (usually your liver)

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28
Q

NRTIs Side Effects

A

Gl upset
Rash
↑ LFTs

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29
Q

NRTIs approved for HBV

A

Tenofovir disoproxil (Viread)

Tenofovir alafenamide (Vemlidy)

Entecavir (Baraclude)

Adefovir (Hepsera)

Lamivudine (Epivir HBV)

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30
Q

TeNOFovir

Side Effects

A

N - nephrotoxic

O- osteoporosis

F - Fanconi syndrome

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31
Q

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.

A

Hyperphosphatemia causes an increase in the release of parathyroid hormone.

High serum phosphorus and low serum calcium trigger release of parathyroid hormone.

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32
Q

Complications of CKD

A

↑ PO4

↓ Vitamin D & Calcium

↓ Erythropoietin

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33
Q

Hyperphosphatemia Tx

A

Restrict diet

Phosphate binders
* Aluminum-based
* Calcium-based first line
* Aluminum & calcium free

Must take w/ food, skip if meal is skip

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34
Q

Phosphate binders

Aluminum-based

A

Potent, use short-term

Toxic to bone and CNS

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35
Q

Phosphate binders

Calcium-based

A

First-line

Hypercalcemia

Constipation

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36
Q

Phosphate binders

Aluminum- and calcium-free

A

Iron-based products

Lanthanum carbonate (Fosrenal): chew thoroughly (Gl obstruction, ileus)

Sevelamer carbonate (Renvela): N/V/D, LDL Boxed Warnings

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37
Q

Phosphate binders

Drug Intxn

A

Levothyroxine

Quinolones & Tetracyclines

PO Bisphophonates

There are others

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38
Q

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

A

Start rifaximin

Cause by ↑ in ammonia

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.

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39
Q

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)

Whichmedicationis best to initiate in this patient?

A. Hydrochlorothiazide

B. Verapamil

C. Ramipril

D. Amlodipine

E. Bumetanide

A

Ramipril

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 isfirst line regardless of patient race.

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40
Q

MB is a 28-year-old female beginning therapy with ribavirinfor 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.

A

It causes birth defects if she were to become pregnant.

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.

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41
Q

Ribavirin (RBV) Indication

A

Only for HCV

Oral

42
Q

Ribavirin Boxed Warnings

A

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
Q

RIBAvirin Effects

A

R - Renal (Cl when CrCl < 50 mL/min)*

I - In combination only

B - Birth Defects

A - Anemia: Hemolytic (primary toxicity)

44
Q

Interferon Alfa (Inf-Alfa) Indications

A

HBV, HCV, & some cancers

45
Q

Interferon Beta Indications

A

Multiple sclerosis (MS)

46
Q

Pegintron, Pegasys

A

Polyethylene glycol (PEG) added to pegylated products to ↑ t½

Added to Interferon Alfa (Inf-Alfa)

47
Q

Interferon Alfa (Inf-Alfa) Boxed Warnings

A

Neuropsychiatric, autoimmune, ischemic and infectious

48
Q

Interferon Alfa (Inf-Alfa) SE

A

CNS (depression, anxiety, fatigue)

GI, ↑ LFTs, myelosuppression

Flu-like syndrome 1-2 hours after administration (fever, chills, arthralgias)

49
Q

Interferon Alfa (Inf-Alfa)

Stop treatment or reduce dose based on:

A

ANC, platelets and CrCl

50
Q

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

A

Vitamin B1

Wernicke-Korsakoff usually associated w/ alcohol abuse

51
Q

Alcoholic Liver Disease Tx

A

Alcohol cessation

Thiamine

52
Q

SH is beginning therapy with Pegasys(pegylated interferon-alfa-2a).The pharmacist will counsel him on possible side effects from Pegasystherapy. 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

A

Depression

Flu-like syndrome

Fatigue

Liver damage

Interferons have numerous side effects (e.g., CNS effects, GI upset, increased LFTs), making treatment difficult for the patient.

53
Q

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 plusdextrose

D. Calcium gluconate

E. Sodium bicarbonate

A

Calcium gluconate

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
Q

Hyperkalemia Steps

A

Stabilize the heart

Move K intracellularly

Remove it

55
Q

Hyperkalemia Steps

Stabilize the heart

A

Calcium gluconate

Prevent arrhythmias

56
Q

Hyperkalemia Steps

Move K intracellularly

A

Insulin (regular) w/ dextrose

Sodium bicarbonate

Albuterol

Shift excess K intracellularly

57
Q

Hyperkalemia Steps

Remove it

A

Furosemide (Quick 5-10 mins)

Binding agents

Hemodialysis

58
Q

Hyperkalemia Steps

What are some binding agents?

A

Sodium polystyrene

Patiromer

59
Q

Which of the following medications is/are nephrotoxic? (Select ALL that apply.)

A. Cisplatin

B. Ibuprofen

C. Metformin

D. Nitrofurantoin

E. Furosemide

F. Amikacin

A

Cisplatin

Ibuprofen

Furosemide

Amikacin

60
Q

Select Drugs that Cause Kidney Disease

A

Aminoglycosides

Amphotericin B

Cisplatin

Cyclosporine

Loop diuretics

NSAIDs

Polymyxins

Radiographic contrast dye

Tacrolimus

Vancomycin

61
Q

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

A

Sodium polystyrene sulfonate

Furosemide

Hemodialysis

62
Q

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

A

Acamprosate

Disulfiram

Naltrexone

63
Q

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.

A

Smaller molecular compounds (smaller drugs) are more easily cleared by dialysis.

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
Q

Factors Affecting Drug Removal During Dialysis

A

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
Q

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

A

Pantoprazole

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
Q

Direct-Acting Antivirals (DAAs)

Boxed warning

A

Hepatitis B virus (HBV) reactivation: test for HBV before starting a DAA

67
Q

Direct-Acting Antivirals (DAAs)

Drug interactions

A

Avoid strong CYP3A4 inducers1 (↓ DAA serum concentration & efficacy)

68
Q

Direct-Acting Antivirals (DAAs)

Dispensing & administration

A

Keep in the original manufacturer container
Glecaprevir/pibrentasvir: must be taken with food

69
Q

Which DAA must be taken w/ food?

A

Glecaprevir/pibrentasvir (

70
Q

Direct-Acting Antivirals (DAAs): Sofosbuvir

Drug interactions

A

Avoid concurrent amiodarone (↑ risk of symptomatic bradycardia)

Includes carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifabutin & St. John’s wort.

71
Q

Direct-Acting Antivirals (DAAs): Ledipasvir & velpatasvir

Drug interactions

A

↓ Serum concentrations if used in combination with acid-suppressive drugs2

Administer antacids & H2RAs separately; avoid PPIs with velpatasvir-containing regimens.

72
Q

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.

A

Keep this medication in its original container.

Take this medication with food.

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
Q

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).

A

Divide the daily dose and chew before each meal.

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
Q

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

A

Hours to days

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
Q

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

A

Tylenol

Isoniazid

Depakote

Nefazodone

76
Q

Select Drugs w/ Boxed Warnings for Liver Damage

A

APAP (high doses, acute or chronic)

Amiodarone

Isoniazid

Ketoconazole (oral)

Methotrexate

Nafazodone

Nevirapine

NRTIs

Propylthiouracil

Valproic acid

Watch for LFTs when > 3x Normal (10-40) or > 150

77
Q

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

A

Initiate folic acid

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
Q

Folate deficiency

Causes

A

Drug-induced (eg, methotrexate)
Low intake or ↓ absorption (eg, gastric bypass, Crohn’s disease)
Alcohol use disorder
Pregnancy

79
Q

Folate deficiency

Signs & symptoms

A

Fatigue, weakness, shortness of breath, pallor
Oral ulcers
Skin, hair, nail pigmentation changes

80
Q

Folate deficiency

Laboratory findings

A

↓ Hgb, RBCs, reticulocyte count
↑ MCV (> 100 fL), homocysteine
↓ Serum folate

81
Q

Folate deficiency

Treatment

A

Folic acid 0.4–5 mg PO daily

82
Q

Which of the following statementsis correct regarding vitamin D?

A. Calcitriolis 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.

A

Cholecalciferol is synthesized in the skin with ultraviolet light exposure.

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
Q

How does Vit D worsen bone disease?

A

Contributing to hypocalcemia → ↑ PTH

84
Q

Where is Vit D activated?

A

Kidneys

Final active form: 1,25-dihydroxy vitamin D

85
Q

Cholecalciferol Vitamin D[ _ ] and is synthesized in []

A

D3 & the skin by UV light

86
Q

Ergocalciferol Vitamin D[ _ ] and is synthesized in []

A

D2 & plants

87
Q

Vit D Analogs

Drugs

A

Calcitriol (Rocaltrol)

Calcifediol (Rayaldee)

Doxercalciferol (Hectorol)

Paricalcitol (Zemplar)

Calcitriol is the active form of D3

88
Q

What is calcitriol the active form of?

A

D3

89
Q

Vit D Analogs

Effects

A

↑ calcium absorption in the gut

Inhibit PTH secretion

90
Q

Calcimimetic

Drugs

A

Cinacalcet (Sensipar)

Etelcalcetide (Parsabiv)

91
Q

Calcimimetic

MOA

A

↑ sensitivity of the calcium-sensing receptor on the parthyroid gland →
↓ PTH
↓ Ca
↓ PO4

92
Q

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

A

Aldosterone antagonist

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
Q

Ascites Tx

A

Spironolactone (↑ K) + furosemide (↓ K)

100 mg: 40 mg ratio

Balances K

94
Q

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.

A

Converts ammonia to ammonium, which cannot diffuse back into the blood.

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
Q

Complications of Liver Disease & Cirrhosis

Hepatic Encephalopathy

A

Lactulose

Rifaximin (Xifaxin)

Can also use neomycin & metronidazole but long term use has toxicities

96
Q

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. Ribavirinis 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.

A

Ribavirin monotherapy is not effective.

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
Q

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

A

Restricting animal protein intake

Managing hepatic encephalopathy is done by restricting animal protein intake and drug therapy.

98
Q

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

A

Child-Pugh Classification

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
Q

Child-Pugh Classification

0-6

A

Class A - Mild Disease

100
Q

Child-Pugh Classification

7-9

A

Class B - Mod Disease

101
Q

Child-Pugh Classification

10-15

A

Class C - Severe

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