PHRM 864: Therapeutics IV > Hepatology > Flashcards

Hepatology Flashcards

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1
Q

What is the function of the liver?

A
  • Makes Bile [Digests food]
  • Metabolism of Drugs/Food/Toxins [activates prodrugs]
  • Protien Synthesis [albumin and coag]
  • Storage of vitamins
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2
Q

What are some of the Objective markers for Liver failure?

A
  • Aspartate Transminase [AST]: 0-50 IU/L
  • Alanine Transaminase [ALT]: 0-50 IU/L
  • Alkaline Phosphatase [Alk Phos]: 30-120 IU/L
  • Bilrubin: 0-1.4 mg/dL
  • Albumin: 3.6-5.0g/dL
  • INR: 0.9-1.1
  • Thrombocyopenia: 150-450k
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3
Q

What is important to know about the Objective Markers in Liver Failure?

A
  • AST, ALT, Alk phos = acute liver injury
  • Decrease albumin, Increase INR, and/or Increase Bilirubin = Chronic Liver Disease
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4
Q

What is the estimated incidence of Drug-Induced Liver Injury?

A
  • 14-19 cases per 100,000 people [0.014%]
  • Have Jaundice
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5
Q

What are the classifications/mechanisms of liver injury/

A
  • Direct [Acetaminophen]
  • Idosyncratic [Beta-lactams, Fluoroquinolones, macrolides]
  • Indirect [metabolic abnormalities causing non-alcoholic fatty liver disease]
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6
Q

What are the medications that are highest risk of causing Drug-Induced Liver Injury?

A
  • ACETAMINOPHEN
  • Anti-fectives [Isoniazid, Beta-Lactams, Fluoroquinolone, Macrolide]
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7
Q

What do you do with the medication if you suspect DILI?

A
  • HOLD the agent
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8
Q

What is important to know about Acetaminophen DILI?

A
  • High dose [>8g] causes toxic levels of N-Acetyl-p-benzoquinoe imine (NAPQI) = hepatotoxicity
  • S/Sx: Abdominal pain, jaundice, N/V/D -^
  • Can be reversed
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9
Q

What is the way that we reverse Acetaminophen DILI?

A
  • N-Acetylcysteine [NAC] +/- activeted charcoal
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10
Q

What is the MOA for N-Acetylcysteine (NAC)?

A
  • Binds to NAPQI, mimics Glutathione helping make NAPQI non-toxic metabolite [decreases hepatotoxic effects}
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11
Q

What way do we know how to use N-Acetylcysteine [NAC]?

A
  • Conc. of Acetaminophen [>4hr after ingestion] and time of ingestion
  • ORAL & IV
  • USED RUMACK-MATTHEW NOMOGRAM
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12
Q

Describe how the Rumack-Matthew Nonogram is used?

A
  • The “white” side = NO NAC; the “grey” side = NEED NAC
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13
Q

What is the definition of Cirrhosis?

A
  • Severe, chronic, IRREVERSIBLE fibrosis of the liver
  • INCREASED morbidity and mortality`
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14
Q

What are some of the causative factors for Cirrhosis?

A
  • ALCOHOL [#1 in US]
  • Viral Hepatitis
  • Metabolic/Cholestatic Liver Disease
  • Drug [Amiodarone, Methotraxate]
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15
Q

What are the two drugs that could cause Cirrhosis?

A
  • Chronic use of Aminodarone or Methotrxate
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16
Q

What are the signs and symptoms of Cirrhosis?

A
  • Fatigue, Weight Loss, Ascites, Jaundice, Hepatomegaly, Encephalopathy
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17
Q

What is the way that we assessing severity of Cirrhosis?

A
  • Child-Pugh & Model for End-stage Liver Diease [MELD]
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18
Q

What is important to know about Child-Pugh score?

A
  • Predicts mortality in Cirrhosis
  • Class B: 7-9 = moderate severity
  • Class C: 10-15 = severe severity
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19
Q

What is important to know about Model for End-stage Liver Disease?

A
  • Predicts 3 month-mortality risk and used in transplant prioritization
  • <9 = 1.9% risk to >40 = 71% risk
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20
Q

What is Ascites in liver disease?

A
  • Fluid accumulation in the peritoneal space
  • S/Sx: Distension, Pain, SOB, Nausea
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21
Q

What is the pathophysiology of Ascites?

A

Increased pressure within the portal hypertension that moves fluids into the peritoneal space

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22
Q

What is the way that we manage Ascites in liver disease?

A
  • Non-pharm: restrict Sodium
  • 1st line: Spiro & Furo
  • 2nd line: Paracetesis
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23
Q

What is one class of drugs that should not be used in patients with Cirrhosis?

A
  • NSAIDS - could increase fluid retention & vasodilatoin
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24
Q

What is important to know about the 1st line treatment of Ascites?

A
  • Spiro 100 : Furo 40 once dialy
  • COMBO is better than MONO [SPIRO is better than Furo]
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25
What are some of the side effects and monitoring for Diuretics for Ascites?
- Spiro [Increased Potassium, Gynecomastia] - Furo [Decreased Potassium] - MONITOR: S/Sx of ascites, Scr, K+
26
What is Paracentesis?
- SECOND LINE for chronic; pulls fluids out of parental space
27
What happens when you remove >5L of fluids via Paracentesis?
- USED ALBUMIN [6-8g albumin per L] - Decreases morbidity and mortality
28
What is Esophageal Varices?
- Portal Hypertension were blood is blocked by a scar or clot and goes to another vein where it cant handle it and ruptures it; causing bleeds
29
What are some of the risk factors for Variceal Bleeding?
- Size [Larger = Rupture] - Child-Pugh - Red Marking via Endoscopy - ALCOHOL
30
What is the Prophylaxis treatment for Variceal Bleeding?
- Non-Selective Beta-Blockers [NSBBs] OR Endoscopic Variceal Ligation [EVL] --> decrease variceal and GI bleeds - NOT COMBO
31
What is the MOA to know about the NSBBs?
- b2 = vasoconstriction & b1 = decreased HR & CO - Helps manage portal hypertension
32
What are the 3 NSBBs that are used in Variceal Bleeding?
- Nadolol, Propranolol, Carvedilol
33
What are the side effects and monitoring parameters for the NSBBs?
- Drowsiness, Bradycardia, HYPOtension - HR: 55-60 BPM - BP: SBP > 90mmHg [dont want HYPOtension]
34
What is Endoscopic Variceal Ligation [EVL]?
- Endoscopic procedure which BANDS off varices; keeping it from rupturing - PRIMARY preventing and acute management
35
What are some of the clinical presentations for Variceal Bleeding?
- ENDOSCOPY [see it] - Hematemesis [throw up blood] - Melena [bloody stool] - Fatigue, dizziness, HYPOtension
36
What is the treatment for Variceal Bleeding?
- IMMEDIATELY: Blood transfusion, Octrotide, Antibiotic - Sugrical: EVL - gold standard of bleeding - After EVL: Secondary Prophylaxis
37
Wheat is NOT recommended for Variceal Bleeds?
- Proton Pump Inhibitors [PPIs]: no data to support
38
What is the MOA for Octrotide in Variceal bleeds?
- Inhibits release of vasodilatory peptide causing vasoconstriction and decreased blood flow - For the acute **variceal bleeds**
39
What are some of the side effects for Octrotide?
- N/V - HYPERtesion: monitor BP - Bradycardia: monitor HR - HYPERglycemia: monitor BG
40
What is the gold standard in variceal bleeding cessation?
- EVL - Bands might break so not really long term
41
What is the primary antibiotic prophylaxis that is used for Variceal Bleeding?
- Ceftriaxone - when increased risk of infections with active bleeding for 7 DAYS - DIARRHEA - NOT RENALLY CLEARED
42
What is the secondary prophylaxis that is used for Variceal Bleeding?
- EVL: every month - NSBB: Nadolol, Propranolol [same SE and Monitoring]
43
What is the proposed underlying pathophysiology for Hepatic Encephalopathy?-
- INCREASED ammonia - disorientation [A/Ox1]
44
For acute management, what are the recommended therapies? What are preferred vs second line?
- Lactulose 25ml BID - + Rifaximin [after failure second occurance]
45
When is HE prophylaxis recommended?
- After any occurrence of HE - Prophylaxis with Lactulose
46
What should we monitor within HE?
- Bowel Movements - Mental Status - NOT AMMONIA AGAIN
47
What is the clinical presentation of Spontaneious Bacterial Peritonitis [SBP]?
- Bacteria crossing the intestinal barrier - Fever, Abdominal Pain, Leukocytosis [Increase WBC], Encephalopathy
48
In what way do we diagnosis SBP?
- Theraputic Paracentesis [Remove little fluids] - [+] Culture & PMN > 250 cells/mm^3 - PMN = WBC * % neutrophils
49
What is the treatment for SBP?
- Ceftriaxone for 5-7days; DIARRHEA [C. Diff]; NOT RENALLY CLEARED - Albumin: decreases mortality [Days 1&3]
50
What is used for Secondary prophylaxis for SBP?
- SMZ-TMP [Bactrim] OR Ciprofloxacin - INDEFINTIE treatment
51
Cirrhosis Summary: When to treat for Ascites?
- When ascites is PRESENT
52
Cirrhosis Summary: What is the first line for Ascites?
- Spironolactone 100 + Furosemide 40
53
Cirrhosis Summary: When to use prophylaxis for Ascites?
- Primary: N/A - Secondary: Trying to prevent Paracentesis
54
Cirrhosis Summary: What should you monitor for some with Ascites?
- S/Sx of Ascites [distention, pain, SOB, nausea], SCr, K+
55
Cirrhosis Summary: When to treat someone with EV?
- Active Variceal Hemorrahge [current bleeding]
56
Cirrhosis Summary: What is the first line therapy for EV?
- +/- Blood Transfusion + Octreotide + Ceftriaxone + EVL
57
Cirrhosis Summary: When to use prophylaxis for EV?
- Primary: FYI - Secondary: After Hemorrhage, Indefinite as long as BP tolerates
58
Cirrhosis Summary: What is the first line Prophylaxis for EV?
- NSBBs OR EVL
59
Cirrhosis Summary: What shoudl you monitor for someone with EV?
- S/Sx of Bleeding, HR [goal 55-60 BPM], BP [Goal > 90 SBP]
60
Cirrhosis Summary: When to treat for SBP?
- + culture OR PMN > 250 cells/mm^3
61
Cirrhosis Summary: What is the first line threapy for SBP?
- Ceftriaxone [or 3rd gen ceph] + albumin days 1/3
62
Cirrhosis Summary: When to use prophylaxis for SBP?
- Primary: Active Hemorrhage - Secondary: After SBP; indefinite
63
Cirrhosis Summary: What is the first line prophylaxis for SBP?
- Bactrim [or Cipro]
64
Cirrhosis Summary: What should you monitor for in SBP?
- S/Sx of infection, SCr
65
Cirrhosis Summary: When to treat for HE?
- Encephalopathy +/- Increased Ammonia [rule out other causes]
66
Cirrhosis Summary: What is the first line therapy for HE?
- Lactulose [target > 3 Bowel Movements/day]
67
Cirrhosis Summary: When to use Prophylaxis in HE?
- Primary: N/A - Secondary: after any occurrence of HE
68
Cirrhosis Summary: What is the first line prophylaxis for HE?
- Lactulose
69
Cirrhosis Summary: What should you monitor for in HE?
- Bowel Movements [>3/day], Mental Status, NOT AMMONIA AGAIN
PHRM 864: Therapeutics IV
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