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Questions to ask when giving medicines advice in liver impairment

Published
Topics: Liver disordersTraining and Development

Information should be gathered about the history of liver impairment or the type of liver disease to enable a risk assessment and decisions about treatment.

This article forms part of a series
  1. Assessing liver function and interpreting liver blood tests
    1. Questions to ask when giving medicines advice in liver impairment
    2. Information resources for managing medicines in liver impairment
    3. Calculating and using the Child-Pugh score

Contents

  1. Potential issues in liver impairment
    1. Red flags to refer
  3. Advice for undertaking medication reviews
  4. Gathering information
    1. Ask about the patient
    2. Ask about liver disease
    3. Ask about liver impairment
    4. Ask about medicines and therapies
    5. Look at information sources
    6. Make a decision
    7. Seek further advice

Potential issues in liver impairment

Asking the right questions and gathering information is important because using medicines in patients with liver impairment can lead to issues such as hepatotoxicity, increased side effects and reduced therapeutic effects.

Even where mild liver impairment is suspected, liver blood tests should be monitored, and medications reviewed.

It is also important to be aware of the early, late and red flag symptoms of liver disease as they help to build a clinical picture of the extent of liver disease or dysfunction.

Red flags to refer

Consider an urgent referral if the patient has any of the following red flag symptoms:

  • fever with high temperatures and shivers, often caused by an infection
  • shortness of breath
  • vomiting blood
  • very dark or black tarry stools (faeces)
  • periods of mental confusion or drowsiness

Further information on the symptoms of liver disease is available from the British Liver Trust.

Advice for undertaking medication reviews

It is important to distinguish between liver disease, liver dysfunction and drug induced liver injury as these have different considerations when completing a medication review.

Where possible, the prescribing of all medicines, including the use of hepatotoxic medicines, should be kept to a minimum in all patients with severe liver disease.

Gathering information

Take a stepwise approach for gathering information when managing medicines in people with liver impairment.

  1. The following information will help you understand the patient’s overall health:

    • the patient’s age, gender, height and recent weight
    • any other medical conditions that may affect the choice of medicine or dose such as heart failure, renal function, or sepsis
    • recent travel history, drug history or occupational exposure to explore possible risk of hepatitis B or C
    • alcohol consumption
    • risk factors for metabolic syndrome such as central obesity, hypertension, diabetes or insulin resistance and dyslipidaemia

  2. Find out if:

    • the patient is under the care of a hepatologist, gastroenterologist or other specialist for management of their liver disease
    • the patient has an established liver disease or liver dysfunction such as cholestasis, hepatocellular injury, hepatitis, fibrosis or cirrhosis
    • the liver disease or dysfunction appeared recently over the last few days or weeks (acute)
    • the liver disease or dysfunction appeared gradually (chronic)
    • the patient had a liver transplant

    Most patients will be on immunosuppressants for life after a liver transplant. Immunosuppressants often have a narrow therapeutic index, numerous side effects and complex drug-drug interactions.

    You may need to refer the patient in complex situations or where dose changes are required.

  3. Ask:

    • about the results of any recent liver blood tests (SPS page), and if any trends are available
    • if the patient has cirrhosis and calculate the Child-Pugh score
    • about any recent signs and symptoms of liver disease, the extent and severity
    • about the results of any liver scans or biopsies

  4. Undertake a full medication history to establish the following:

    If you are thinking about recommending an alternative to their current medicine, you may want to consider:

    • the indication and expected duration of treatment
    • if any alternatives have already been considered or tried
    • the preferred medicine and dose that would be used if the person did not have liver impairment

    If you suspect drug induced hepatoxicity, you may want to consider:

    • what medicines are being taken
    • when was the suspect medicine started
    • have any medicines been stopped

  5. Once you have collected as much information as you can, look at our article: Information resources for managing medicines in liver impairment (SPS page).

  6. Use the information about the patient, their liver impairment and their medication to decide if the medicine is appropriate and safe to use, and if any dose changes are required.

    Consider whether the person needs to be monitored for side effects or if medicines monitoring is required.

    Consider the hepatotoxic potential, side effects of any medications and any drug interactions between them.

  7. Seek further advice from a liver specialist or contact the SPS Medicines Advice service (SPS page) when:

    • there is no or limited information for the medicine in liver impairment
    • the clinical scenario is complex
    • you have doubts and require a second opinion