WEEK 7 Liver Disease Flashcards
Complications associated with cirrhosis of the liver:
Cirrhosis is caused by alcohol, hepatitis (B&C), nonalcoholic fatty liver disease, Hemochromatosis, etc. Process of Cirrhosis: Chronic insult to the liver->Destruction of hepatocytes->Replacement with scarring and nodules->Fibrosis->Disruption of hepatic blood flow->Decreased liver function Complications: •Portal Hypertension •Gastroesophageal variceal hemorrhage •Ascites •Hepatic encephalopathy •Hepatorenal syndrome •Spontaneous bacterial peritonitis (SBP)
Recommend appropriate pharmacologic primary prophylaxis for esophageal variceal hemorrhage
Primary Prophylaxis of Hemorrhage:
•Non-selective beta-blockers (BB)
–Propranolol initial10-20 mg PO BID
–Usual 40-80 mg PO BID (max 320 mg daily)
–Nadolol 40 mg PO daily (max 160 mg daily)
MOA:
•Decrease cardiac output and splanchnic blood flow (B1 blockade); splanchnic vasoconstriction (B2 blockade)
Goal: decrease HR by ~25% (~55-60 bpm)
Adverse effects: •Fatigue, drowsiness, diarrhea, constipation Precautions: •Bronchospastic disease •Bradycardia
Identify appropriate treatment options for a patient with ascites.
Non-pharmacologic: •Abstinence from alcohol •Sodium restriction •Paracentesis •TIPS
Pharmacologic: Spironolactone 100 mg PO daily (max 400 mg/day) MOA: •Competes with aldosterone for receptor sites in the distal renal tubules, increasing sodium chloride and water excretion while conserving potassium and hydrogen ions Place in therapy: •1st line diuretic Adverse effects: •Gynecomastia •Dizziness, drowsiness Precautions: •Hyperkalemia •Possible tumorigenic in animal studies
Furosemide 40 mg to 100 mg spironolactone MOA: •Competes with aldosterone for receptor sites in the distal renal tubules, increasing sodium chloride and water excretion while conserving potassium and hydrogen ions Place in therapy: •Only in combination with spironolactone Adverse effects: •Photosensitivity •Polyuria Precautions •Fluid/electrolyte loss •Sulfonamide allergy •Electrolyte imbalances may lead to hepatic encephalopathy **Only use with spironolactone
Identify appropriate treatment and prophylaxis options for spontaneous bacterial peritonitis, and when to consider treatment.
SBP Treatment •1st line: 3rd gen cephalosporins --Cefotaxime 2 g IV q8 hours --Ceftriaxone 1 g IV q24 hours Alternative: fluoroquinolones --Ciprofloxacin 400 mg IV q12-24 hours --Levofloxacin 500 mg IV/PO q 24 hours Duration: 5-10 days Change coverage according to culture results
•Albumin 1.5 g/kg IV x 1 within 6 hours of detection •1 g/kg IV x1 on day 3 if: --SCr > 1 mg/dL --BUN > 30 mg/dL --Or Tbili > 4 mg/dL MOA: increases intravascular oncotic pressure and causes mobilization of fluids from interstitial into intravascular space Place in therapy •Prevents renal failure (HRS)
Recognize the drug of choice for hepatic encephalopathy.
HE Treatment
•Lactulose 30 g (45 mL) hourly until first bowel movement, then 10-30 g (15-45 mL) q8-12 hours titrated to 2-3 stools daily
MOA: synthetic, non-absorbable sugar which draws water into the colon & lowers pH->lower pH converts ammonia (NH3) to ammonium (NH4+), which cannot cross into systemic circulation
Adverse effects:
•Dehydration
•Electrolyte abnormalities
•Rifaximin 550 mg PO BID
MOA: decreases ammonia-producing gut bacteria
Place in therapy: expensive, so reserved as add-on therapy
Adverse effects:
•Peripheral edema
•Dizziness, fatigue
•Nausea
Precautions
•Efficacy not established in Child-Pugh class C or MELD score >25
List the goals of therapy and treatment options for pancreatitis.
ACUTE PANCREATITIS •Goals: alleviate pain and nausea/vomiting, hydration •Stop offending agents •Fluid resuscitation --Lactated Ringer’s 250-500 mL/hr •Nutrition support (enteral preferred over parenteral) •Analgesia •Antibiotics if severe/necrosis
CHRONIC PANCREATITIS
•Goals: relief of pain, correction of malabsorption, treatment of endocrine insufficiency
•Avoid ethanol, cigarette smoking, and fatty meals
•Analgesics
Pancreatic enzymes
(Creon®, Pancreaze®, Zenpep®, etc.)
–Dosing based on lipase component
–500 units/kg/meal + 250 units/kg with snacks
Recognize when to treat viral hepatitis and what treatment options are available for each type of viral hepatitis (e.g. vaccine, immune globulin, and/or antiviral).
Hepatitis Pre and Post Exposure Prophylaxis:
•Immune Globulin: antibodies from sterilized pooled human plasma that provides passive immunization against HAV
•Does NOT provide lifelong immunity
•Hepatitis A (IV or IM)
•Hepatitis B (IM)
Vaccines:
•Hepatitis A w/in 2 weeks for postexposure prophylaxis
•Hepatis B w/in 24 hours for postexposure prophylaxis
Spontaneous Bacterial Peritonitis (SBP) Prophylaxis
SBP Prophylaxis
•Sulfamethoxazole/trimethoprim DS PO daily
•Ciprofloxacin 500 mg PO once daily or 750 mg once weekly
•Primary prophylaxis indicated in:
- -Cirrhosis and GI hemorrhage ->7 days maximum
- -Long term in patients with low ascitic fluid protein (<15 g/L) plus one of the following
- Scr ≥1.2mg/dL, or
- BUN ≥ 25mg/dL, or
- Serum sodium ≤ 130mEq/L, or
- CP score of ≥9 with bilirubin ≥3
Secondary prophylaxis
•All patients who survive SBP indefinitely
Hepatic Encephalopathy (HE)
Hepatic Encephalopathy (HE) •In severe hepatic disease, systemic circulation bypasses the liver; neurotoxic substances that are normally hepatically metabolized accumulate (e.g. ammonia)
Signs: decreased cognition, confusion, changes in behavior
Nonpharmacological Hepatic Encephalopathy (HE)
•Minimize protein intake during acute HE event --High fiber diet from vegetable protein •Remove offending triggers: --Infection --Variceal hemorrhage --Renal insufficiency --Electrolyte abnormalities --Increased dietary protein --Medications --Hypoxemia
Hepatorenal Syndrome
Hepatorenal Syndrome (HRS) •Peripheral vasoconstriction redistributes fluid from periphery to the venous system-> deceased renal perfusion •Diagnosis of exclusion
Treatment
•Albumin 1 g/kg IV x 1 (increase intravascular volume by increasing oncotic pressure) •Octreotide 100 mcg SQ TID
•Midodrine 7.5 mg PO TID
VIRAL HEPATITIS
Viral Hepatitis Definition
•Hepatitis: inflammation of the liver resulting in liver cell damage and destruction
Viral
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Hepatitis D
- Hepatitis E
Other
- Prescription Medications
- Autoimmune disease
- Alcohol
VIRAL HEPATITIS PRESENTATION
Most patients do not have symptoms •Possible symptoms: flu-like syndrome, fevers, fatigue/malaise, abdominal pain Signs: •Jaundice •Enlarged liver and spleen
Chronic Hepatitis B Treatment
Acute: supportive care only
Goal: undetectable HBV levels
•Depends on PMH, ALT, HBV DNA level, antibody status, severity of liver disease, and history of previous HBV therapy
**1st line: entecavir, tenofovir, pegylated interferon-alpha
**2nd line: adefovir
Adverse effects: lactic acidosis, hepatomegaly
Precautions: severe acute exacerbations of hepatitis upon discontinuing are possible
Resistance
Chronic Hepatitis C Treatment
Primary goal: sustained virologic response (SVR)
•Also known as a “virological cure”
•Undetectable HCV RNA levels at 12 weeks after treatment completion
Treatment regimen depends on genotype, baseline resistance, staging of liver disease, drug interactions, and cost for patient
–Treatment initiated by specialist in
managing HCV infections
