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Informatics in Pharmacy

Liver Disease

August 12, 2018 By Dr. G, PharmD

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Child-Pugh Scores for Cirrhosis

Variable1 Point2 Points2 Points
encephalopathyabsentmild-moderatesevere to coma
ascitesabsentslightmoderate
bilirubin<22-3>3
albumin>3.52.8-3.5<2.8
prothrombin time1-44-6>6

Class A = 5 points, class B=7-9 points, class C=10 or more points

Ascites:

  • Reduce dietary sodium, restrict fluid to 1.5 L/day
  • Diuretics – furosemide and spironolactone
  • No amount of weight restriction if edema, but if not 0.5 kg/day loss
  • Monitoring for electrolyte imbalances, renal impairment or gynecomastia (spironolactone causes).
  • Add midodrine (increases effective circulating blood volume and renal perfusion by increasing systemic and splanchnic blood pressure) and rifaximixin (lowers ammonia production in the bowel) as add-on to diuretics for enhanced diuresis in refractory ascites with improved systemic, renal hemodynamics and short-term survival.

Hepatic Encephalopathy:

Remember liver ABCs

  • A: Airway support.  Remove precipitating factors
  • B: Bowels – reduce nitrogen load in gut
  • C: If class C treat with:
    • Lactulose – may continue long-term to prevent reoccurrence
    • Antibiotics – reduce nitrogen producing bacteria in the gut: neomycin, metronidazole or rifaximin
    • Can use polyethylene glycol instead of lactulose.  If benzo overdose suspected, get flumazenil.  Supplement with zinc if needed.

Gastroesophageal Varices:

  • Fluid resuscitation and hemodynamic stabilization.  May need sclerotherapy
  • Reduce splenic flow and portal pressure with vasopressin drip or octreotide (octreotide preferred)
  • Flouquinonlone (Cipro preferred) for 7 days.  Alternative: ceftriaxone 1 g daily
  • Non-selective beta-blockers prevent a repeat (propranolol, nadolol, carvedilol). Titrate to HR of 55 bpm or a 55% reduction in baseline.

Filed Under: Gastrointestinal

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020