Liver Mediation Information
Hepatitis
General support
Antiemetics – Dramamine and Tigan
Avoid phenothiazines – hepatotoxic
Sedative or hypnotics – Benadryl or chloral hydrate
Chronic HBV
Pegylated a-interferon (Pegasys, PEG-Intron)
Blocks viral entry into cell, synthesis of viral proteins, and viral assembly and release
Long acting form Sub-Q weekly
Effective but many side effects such as nausea, weakness and flu like symptoms,
depression, hair loss, diarrhea, weight loss, and injection site reaction
Nucleoside Analogs - reduce viral load, limit liver damage, and decrease
liver enzymes, but all have been related to lactic acidosis, severe
hepatomegaly with steatosis and acute severe exacerbations of hepatitis
B when discontinued. These are:
Lamivudine (Epivir)
Usually used for patients who are pregnant or have HIV, pt.’s develop resistance after 1
year, blood levels of virus and liver inflammation returns when stopped, is also used in
liver transplant patients with HBV
Cautious use with impaired renal function
Adefovir (Hepsera)
Taken orally for one year, Not used during pregnancy
Drug is nephrotoxic, caution with cyclosporine, aminoglycosides, & vancomycin
Entecavir (Baraclude)
Used for pt. resistant to Lamivudine (Epivir), not used during pregnancy
Telbivudine (Tyzeka)
Side effect muscle pain, elevated creatine kinase, and upper respiratory infections
Chronic HCV
Pegylated a-interferon (Pegasys, PEG-Intron)
and
Ribavirin (Rebetol, Copegus) Given together are synergistic
Avoid pregnancy effects women and male partners taking Ribavirin
Decreased WBC esp. lymphocytes and RBC’s, hemolytic anemia, dyspnea, anorexia,
pruritus, insomnia are common
Alcohol metabolism
•
Two pathways in hepatocytes
– 1. acetaldehyde to acetone & H+ in hepatocyte cytoplasm &
mitochondria
– 2. long term abuse
• Acetaldehyde and free radicals in endoplasmic reticulum by
enzyme action
– Acetaldehyde and free radicals are highly damaging to
hepatocytes
– Enzyme wasted on alcohol not available for drug
metabolism and removal of excess A, D, E & K
– Enzymes wasted on alcohol not available for making
ATP, running Kreb’s cycle, & gluconeogenesis
– Lactic acid accumulation decreases uric acid excretion
and promotes formation of gout
A host of medications can cause abnormal liver enzymes levels. Examples include:
• Pain relief medications such as aspirin, acetaminophen (Tylenol), ibuprofen
(Advil, Motrin), neproxen (Narosyn), diclofenac (Voltaren), and phenybutazone
(Butazolidine)
• Anti-seizure medications such as phenytoin (Dilantin), valproic acid,
carbamazepine (Tegretol), and phenobarbital
• Antibiotics such as the tetracyclines, sulfonamides, isoniazid (INH),
sulfamethoxazole, trimethoprim, nitrofurantoin, etc.
• Cholesterol lowering drugs such as the "statins" (Mevacor, Pravachol, Lipitor,
etc.) and niacin
• Cardiovascular drugs such as amiodarone (Cordarone), hydralazine, quinidine,
etc.
• Anti-depressant drugs of the tricyclic type
• With drug-induced liver enzyme abnormalities, the enzymes usually normalize
weeks to months after stopping the medications.
Cirrhosis Interventions- Drugs
•Diuretics-Aldactone (spironolactone): decreases aldosterone levels, K+ sparing
•Salt-poor albumin
•Neomycin – decrease ammonia forming organisms
•Lactulose – decreases ammonia forming organisms and inc. acidity of bowel
•Ferrous sulfate and folic acid – to treat anemia
•Beta blocker: propranolol (Inderal) to prevent bleeding of varices - in conjunction with
isosorbide mononitrate (Imdur) lowers hepatic venous pressure
•Antacids – decrease irritation of varices
•Serax (oxazepam) – benzodiazepine for alcohol withdrawal, sedation, sleep. Is
metabolized in the liver – use cautiously.
Ascites
•
Diuretic therapy, to reduce sodium retention by the kidneys, is generally
required. This is achieved through blocking the effects of the salt-regulatory
hormone, aldosterone. Loop diuretics function at the ascending limb of the
loop of Henle. Generally, a combination of spironolactone or other
potassium-sparing diuretic along with a loop diuretic is required for
complete diuresis. Patients need to be monitored closely for side effects,
which include hyponatremia, hyperkalemia, hypokalemia , dehydration,
hypotension, and azotemia.
Varices
In active bleeding
Use of vasopressin in the acutely bleeding patient is effective and works by decreasing
splanchnic blood flow. Vasopressin therapy should be instituted in an intensive care unit
through a central venous access line. The use of this drug is associated with side effects
of vasoconstriction in other vascular beds, including cardiac vessels. Vasopressin should
be administered with sublingual nitroglycerin.
Somatostatin is currently the preferred drug for acute variceal bleeding. It also acts as a
vasoconstrictor, but works only on the splanchnic bed, and therefore has fewer side
effects. It is given as an intravenous bolus at 50 micrograms, followed by a constant
infusion of 50 micrograms per hour.
Later prevention of re-bleeding
• Beta-blockers
Liver Failure & Hepatic Encephalopathy
Neomycin -- intestinal antiseptic-decrease bacteria that produce ammonia but may cause
renal toxicity or hearing impairment
Lactulose
Converts to lactic and acetic acids
Acid environment decreases bacterial growth
Increased acidity in the gut converts ammonia to ammonium ion which is excreted in
feces thus decreases amount of ammonia available for re-absorption into the blood.
Laxative effect removes ammonia from bowel. Goal-2-3 loose stools/day
Give diluted with fruit juice or water- very sweet! Avoid giving with meals.
Liver Transplant immunosuppressants
azathioprine (Imuran), Cellcept (myophenolate mofetil), prednisone (Deltasone, Kedral,
Medrol, Orasone, Prelone, Sterapred DS), cyclosporine (Neoral), Prograf (a brand of
FK506), and Rapamune (sirolimus).
Most patients must take these drugs exactly as prescribed for the rest of your life.