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Fall 2024 > Therapeutics Exam 4 (Hepatology) > Flashcards

Therapeutics Exam 4 (Hepatology) Flashcards

1
Q

What are the functions of the liver?

A

-Bile production

-Drug/food/toxin metabolism

-Protein synthesis (albumin + coagulation factors)

-Storage/Adjustment of vitamins/gluconeogenesis

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2
Q

What do liver enzymes (AST, ALT, Alk phos) tell us?

A

These are markers of acute injury

-not true markers of liver function

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3
Q

What 3 proteins does chronic liver disease affect and what effects does it have?

A

Decreases albumin

Increases INR

Increases bilirubin

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4
Q

What is the main drug that can cause Drug-induced liver injury (DILI)?

A

Acetaminophen

-high doses (>8g)

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5
Q

How do high doses of acetaminophen cause drug-induced liver injury?

A

Results in toxic levels of N-acetyl-p-benzoquinone imine (NAPQI)

-this causes direct hepatotoxicity

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6
Q

What is the normal AST range?

A

0-50 IU/L

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7
Q

What is the normal ALT range?

A

0-50 IU/L

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8
Q

What is the normal Alk phos range?

A

30-120 IU/L

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9
Q

What drug can we use to reverse the toxic metabolite (NAPQI) produced by high doses of acetaminophen?

A

N-acetylcysteine +/- activated charcoal

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10
Q

To give activated charcoal, it must be within what amount of time to the time that the patient ingested acetaminophen?

A

<1 hour
-only prevents absorption if taken immediately after ingestion

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11
Q

How do we determine if we need to give a patient N-acetylcysteine?

A

Use the Rumack-Matthew Nomogram

-Hours post-ingestion vs plasma concentration

-Dark grey area= give med

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12
Q

What is the dosage form of N-acetylcysteine?

A

Oral or IV depending on what they tolerate

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13
Q

What is cirrhosis?

A

Severe, chronic, irreversible fibrosis of the liver

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14
Q

what are the S/S of cirrhosis?

A

Fatigue
Weight Loss
Ascites (fluid buildup in abdomen)
Jaundice
Hepatomegaly or Splenomegaly
Encephalopathy (confusion)

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15
Q

What are the causes of cirrhosis?

A

Alcohol use
Viral hepatitis
Liver disease
Drugs (amiodarone, methotrexate)

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16
Q

What is ascites?

A

Fluid accumulation in the peritoneal space

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17
Q

What are the non-pharmacologic treatments for ascites?

A

Sodium Restriction

Assess for liver transplant

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18
Q

What is the first-line therapy for ascites?

A

Aldosterone antagonist (spironolactone)
+
Loop diuretic (furosemide)

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19
Q

What is the second-line therapy for ascites?

A

Paracentesis
TIPS (surgery)

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20
Q

If a patient can only tolerate one of the first-line therapies for ascites, which drug class is preferred?

A

Aldosterone antagonist (spironolactone)

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21
Q

Which drug class should be avoided in patients with cirrhosis due to its ability to increase the risk of ascites and bleeding?

A

NSAIDs

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22
Q

At what ratio should the diuretics for ascites be initiated?

A

spiro 100:40 furo

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23
Q

What is the maximum daily dose of diuretics for ascites?

A

400mg spiro/ 160mg furo

24
Q

When is a paracentesis indicated for ascites?

A

Refractory/resistant ascites

Cases of AKI

25
Q

How much fluid needs to be removed via paracentesis for us to replace albumin?

A

> 5L

26
Q

How much albumin should be given to paracentesis patients who need it?

A

25% IV albumin

Give 6-8g albumin per liter removed*

27
Q

How does cirrhosis result in esophageal varices?

A

Portal hypertension causes hepatic/splanchnic vasodilation
-results in decreased perfusion
-compensatory varices (small offshoots) form

28
Q

Why are esophageal varices dangerous?

A

Dilation of EV can occur and result in variceal bleeding
-this can be severe

29
Q

What are the risk factors for variceal bleeding?

A

-Larger size varices
-Cirrhosis severity
-Red color markings seen on endoscopy
-Active alcohol use

30
Q

What are the 2 options for variceal bleeding prophylaxis (prevention)?

A

Non-selective beta-blockers (moderate disease)
Endoscopic variceal ligation

*NOTE that neither of these have mortality benefits

31
Q

What are the beta-blockers that can be used for variceal bleeding prophylaxis?

A

Nadolol
Propranolol
Carvedilol

32
Q

What is the HR goal with beta blockers?

A

55-60 bpm

33
Q

Immediately upon presentation of a patient with variceal bleeding, what needs to be done?

A

-Blood transfusion (Hg>7)
-Give octreotide
-Antibiotic prophylaxis

34
Q

What is the second thing we do after a patient presents with variceal bleeding?

A

Endoscopic variceal ligation

35
Q

After an EVL, what is the third thing we do after a patient presents with variceal bleeding?

A

Secondary prophylaxis
(indefinitely until compensated)

36
Q

What is the moa of octreotide?

A

Inhibits release of vasodilatory peptides
-results in splanchnic vasoconstriction and decreased blood flow

37
Q

What do we use octreotide for?

A

Acute variceal bleeds

38
Q

How long should octreotide be used for?

A

2-5 days

-or until EVL, then stop 1 day after

39
Q

What is the gold standard for variceal bleeding cessation?

A

Endoscopic variceal ligation

40
Q

What is the goal for how quickly we want patients to have an endoscopic variceal ligation after they appear with variceal bleeding?

A

Within 12 hours

41
Q

What is the downside to variceal ligation?

A

It is not a long-term solution

-bands can break
-new varices can form

42
Q

What other type of prophylaxis do patients with active variceal bleeding need?

A

Primary Antibiotic Prophylaxis

-due to increased infection risk

43
Q

What antibiotic is recommended for primary antibiotic prophylaxis?

A

Ceftriaxone

-use until the hemorrhage resolves (max 7 days)

44
Q

What therapy is not recommended in variceal bleeding despite elevated INR?

A

Vitamin K
-do not give

45
Q

What therapy do we use as secondary prophylaxis for varices?

A

Endoscopic variceal ligation (every 1-4 weeks)

Non-selective beta-blockers indefinitely (nadolol, propranolol, carvedilol)

46
Q

How does cirrhosis cause spontaneous bacterial peritonitis (SBP)?

A

-Due to bacterial translocation
-bacteria cross the intestinal barrier

47
Q

What is the clinical presentation of spontaneous bacterial peritonitis?

A

-Fever
-Abdominal pain/Tenderness
-Leukocytosis
-Encephalopathy
*can be asymptomatic

48
Q

How do we diagnose spontaneous bacterial peritonitis?

A

Therapeutic Paracentesis

-If the fluid has >/= 250 cells/mm^3 polymorphonuclear leukocytes (PMN) then diagnose

Note: PMNs= WBC from fluid x % Neutrophils

49
Q

What is the treatment for spontaneous bacterial peritonitis?

A

Ceftriaxone

50
Q

How long do we treat with ceftriaxone for spontaneous bacterial peritonitis?

A

5-7days

51
Q

What other drug is used in treatment of spontaneous bacterial peritonitis?

A

albumin

52
Q

What is the dosing of albumin for spontaneous bacterial peritonitis?

A

IV:
Day1: 1.5 g/kg once
Day 3: 1 g/kg once

*use ABW

53
Q

What agents can be used for secondary prophylaxis of spontaneous bacterial peritonitis?

A

Sulfamethoxazole/Trimethoprim (Bactrim)

Ciprofloxacin
-not used as much

54
Q

How long should secondary antibiotic prophylaxis be used in patients with SBP?

A

Indefinitely!

55
Q

What is the estimated incidence of drug-induced liver injury (DILI)?

A

0.02%

Fall 2024 (16 decks)

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