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pharm exam 4
liver pharmacotherapy
| Question | Answer |
|---|---|
| cirrhosis | scarring of liver |
| liver disease and cirrhosis | 11th leading cause of death |
| causes of liver disease | Metabolic Associated Steatotic Liver Disease (MASLD) Alcohol Viral (Hep B, C) Autoimmune (hep), Primary Sclerosing Cholangitis |
| Alcohol affect on liver disease | acute and chronic liver disease, age of people needing transplants is getting younger |
| alcohol and the liver: death | cirrhosis 11th leading cause in 2019 – HALF due to ETOH |
| alcohol and the liver: hospitalization | 48% of cirrhosis hospitalizations – due to ETOH |
| alcohol and the liver: transplant | 40% of listed patients – ETOH |
| abstinence | can reverse liver disease early on |
| alcohol and the liver: disparities | Women less likely to use AUD therapies/services Hospitalizations increasing in younger, women, American Indian, Hispanic |
| does alcohol effect everyones liver the same | no! |
| Alcohol-associated liver disease aka | ALD |
| spectrum of ALD | Steatosis - Steatohepatitis - Fibrosis - Cirrhosis - HCC |
| Steatohepatitis | inflammation of liver |
| Fibrosis | scarring of liver |
| HCC | most common cancer worldwide |
| Alcohol-Associated Hepatitis leads to | Acute or Chronic Liver Failure |
| MASLD: how do you know if you're at risk? | don't really know because we don't know risk factors yet |
| suspected risk factors | elevated LFTs, rule out viral and other causes, fatty liver?, cardiometabolic criteria (everywhere) |
| liver diseases | MASLD, Primary Biliary Cirrhosis, Autoimmune Hepatitis, Viral (Hepatitis A, B, C), Drug Induced Liver Injury |
| MASLD treatments | Resmetirom (Rezdiffra®) Semaglutide (Wegovy®) |
| Resmetirom (Rezdiffra®) | expensive and hard to get, specifically to treat MALD |
| Semaglutide (Wegovy®) | ozempic, GLPi, aid in glucose control so decrease weight, improve SLD and then got approved for MASLD |
| Primary Biliary Cirrhosis treatments | Ursodiol (Actigall®) Elafibranor (Iqirvo®) Seladelpar (Livdelzi®) |
| Autoimmune Hepatitis treatments | Prednisone Azathioprine, Mycophenolate Other Immune Suppressants |
| Viral (Hepatitis A, B, C) treatments | A – supportive care - because we don't have many vax B – antiviral - rarely curable, carcinome C - antiviral - now we have vax |
| Drug Induced Liver Injury (DILI) treatment | Alcohol abstinence, prednisolone Acetaminophen – n-acetylcysteine |
| what does the liver do synthetically | Bile production, cholesterol, Plasma protein synthesis (clotting factors, albumin), Gluconeogenesis |
| other liver functions | Vitamin storage (ADEK), Glycogen storage, Detoxification (medications, endogenous substances, e.g. ammonia), Immune response – Kupffer cells |
| cirrhosis complications | ascites/edema acute bleed/coagulopathy HepatoRenal Syndrome – Acute Kidney Injury Hepatic Encephalopathy Spontaneous Bacterial Peritonitis |
| ascites/edema is caused by | Portal Hypertension - Compensatory Vasodilatation - Perceived hypovolemia - Water Retention |
| acute bleeds caused by | Portal Hypertension - Varices in GI Tract |
| HepatoRenal Syndrome – Acute Kidney Injury is caused by | Portal Hypertension - Compensatory Vasodilatation - Decreased renal perfusion |
| Hepatic Encephalopathy is caused by | Decreased flow - decreased toxin clearance (ammonia, drugs) |
| each cirrhosis complication has | a treatment associated with it |
| ascites is treated with | diuretics like spironolcatone and furosemide |
| to decrease portal pressure, pt is on | Non-Selective Beta Blockers, Octreotide (for pt who bleed) |
| other pharmacotherapy for liver disease | Antibiotic Prophylaxis Lactulose, Rifaximin Albumin, Vasopressors, Terlipressin Eltrombopag, Avatrombopag |
| Hepatic Encephalopathy is assessed in | 4 grades |
| grade I of Hepatic Encephalopathy | altered, slowed hard to dx if you don't know the pt |
| grade II of Hepatic Encephalopathy | asterixis, worse with math flapping hands when held up, slow to find the answer to a question |
| grade III of Hepatic Encephalopathy | arousable, not very there, insomnia, can't maintain concentration |
| grade IV of Hepatic Encephalopathy | coma, unarousable, totally out, need airway protected to prevent from closing |
| patho of Hepatic Encephalopathy | altered neurotransmission mediated by ammonia |
| treatment of Hepatic Encephalopathy | decrease ammonia (doesn't relate to encephalopathy) lactulose rifaximin |
| lactulose to treat Hepatic Encephalopathy | increase elimination Goal 3-4 soft stools/day |
| rifaximin to treat Hepatic Encephalopathy | decrease production Poorly absorbed antibiotic against urease producing bacteria |
| Varices and Variceal Bleeding is a result of | portal hypertension |
| Variceal Bleeding is a | medical emergency |
| treatment of Varices and Variceal Bleeding | Non-selective beta-blockers: Carvedilol, Propranolol, Nadolol |
| goals with Non-selective beta-blockers | BP (MAP > 82), HR (55-60) - titrate dose to maximize tolerability |
| acute variceal bleed treatment | octreotide infusion |
| acute variceal bleed treatment goal | decrease splanchnic blood flow |
| adverse effects of acute variceal bleed | bradycardia |
| other things to remember about acute variceal bleeds | Endoscopic cauterization, banding Increased risk of peritonitis - Antibiotics, e.g. ceftriaxone |
| ascites pts are on | fluid and sodium restriction |
| meds used for ascites | diuretics like spironolactone and furosemide |
| spironolactone SE in men | painful man boobs |
| what to monitor during diuretic use | BP, electrolytes, gynecomastia (spironolactone), Urine Output |
| refractory ascites | Large volume paracentesis - if kidneys work if kidneys don't work - need cath albumin replacement |
| Spontaneous Bacterial Peritonitis signs | Fever, pain, WBC |
| Spontaneous Bacterial Peritonitis treatment | antibiotics, e.g. cefotaxime, ceftriaxone Albumin infusion |
| prevention of 2nd episode of Spontaneous Bacterial Peritonitis | Fluroquinolones Sulfamethoxazole/trimethoprim |
| Hepatorenal Syndrome (HRS-AKI) caused by | Peripheral Vasodilatation - decreased renal perfusion - dysfunction |
| HRS-AKI diagnosis | no dx test so exclude everything else first |
| treatment goal of HRS-AKI | increase renal perfusion |
| how to increase renal perfusion | Stop diuretics Stop nephrotoxins Hydrate Midodrine + Octreotide subcutaneous Norepinephrine + Octreotide Terlipressin Albumin |
| Coagulopathy – altered hemostasis | Decreased platelet production - thrombocytopenia Decreased clotting factor production - elevated INR (PT) Decreased production of natural anticoagulants Increased levels of procoagulant |
| liver makes thrombopoietin so | when liver is failing, thrombopoietin is blocked and therefore PLT decreases |
| Decreased production of natural anticoagulants | Antithrombin Protein C Protein S |
| Increased levels of procoagulant | Factor VIII von Willebrand factor |
| Thrombopoietin Receptor Agonists | Eltrombopag, Avatrombopag |
| Eltrombopag | thrombosis warning, hepatotoxicity warning |
| Avatrombopag | peri-procedural, temporary NOT long term because carries risk of clotting |
| Altered Medication Kinetics | Decreased metabolism – cytochrome p450 Increased volume of distribution Altered protein binding |
| since liver is responsible for removing meds, | may need different dose to remove |
| Current therapies for complications of cirrhosis are | palliative and not curative. |
| what provide "curative" option | liver transplant |
Created by:
leh195