Evidence-Based Recommendations to Improve the Safe Use of Drugs in Patients with Liver Cirrhosis

Abstract

IntroductionThe presence of liver cirrhosis can have a major impact on pharmacodynamics and pharmacokinetics, but guidance for prescribing is lacking.ObjectiveThe aim of this study is to provide an overview of evidence-based recommendations developed for the safe use of drugs in liver cirrhosis.MethodsRecommendations were based on a systematic literature search combined with expert opinion from a panel of 10 experts. The safety of each drug was classified as safe, no additional risks known, additional risks known, unsafe, unknown or the safety class was dependent on the severity of liver cirrhosis (Child–Pugh classification). If applicable, drug-specific dosing advice was provided. All recommendations were implemented in clinical decision support systems and on a website.ResultsWe formulated 218 recommendations for a total of 209 drugs. For nine drugs, two recommendations were formulated for different administration routes or indications. Drugs were classified as ‘safe’ in 29 recommendations (13.3%), ‘no additional risks known’ in 60 (27.5%), ‘additional risks known’ in 3 (1.4%), and ‘unsafe’ in 30 (13.8%). In 57 (26.1%) of the recommendations, safety depended on the severity of liver cirrhosis and was ‘unknown’ in 39 (17.9%) recommendations. Large alterations in pharmacodynamics were the main reason for classifying a drug as ‘unsafe’. For 67 drugs (31%), a dose adjustment was needed.ConclusionsOver 200 recommendations were developed for the safe use of drugs in patients with liver cirrhosis. Implementing these recommendations into clinical practice can possibly enhance medication safety in this vulnerable patient group.Electronic supplementary materialThe online version of this article (10.1007/s40264-017-0635-x) contains supplementary material, which is available to authorized users.

Medication safety in patients with hepatic impairment: A survey of community pharmacists' knowledge level and their practice in caring for these patients

“…To improve medication safety in patients with hepatic impairment, pharmacists and prescribers can be supported by their CDSS . The practical guidance on medication safety in patients with hepatic impairment was published in English, yet only integrated in CDSS in the Netherlands . This study provides valuable insights for other countries that want to integrate decision support for safe use of medication in hepatic impairment.…”

“…The UPPER network consists of 1545 community pharmacies, representing 75% of all community pharmacies in the Netherlands at the time the survey was performed . An invitation for the pharmacist to participate in the electronic survey was sent in March 2018, one and a half years after the implementation of the first safety and dosing advices in cirrhosis . A reminder was sent 2 weeks later and the questionnaire was closed 2 weeks thereafter.…”

“…The topic of current practice was covered with questions on how often the pharmacists encountered a medication safety alert from their CDSS about a patient with hepatic impairment, the familiarity of pharmacists with the new recommendations and website, and questions about contact with other healthcare professionals. To include potential topics that were not covered by the survey, we added 3 open‐ended questions about current practice and difficulties experienced in providing pharmaceutical care to patients with hepatic impairment at the end of the questionnaire.…”

“…A barrier for pharmacists to fulfil this role was the lack of concrete prescribing recommendations for patients with hepatic impairment and deficiencies in the information for these patients in the product labels . However, in 2018, practical guidance for safe drug use in this specific patient group was published . In the Netherlands, the website containing all guidance (http://www.drugsinlivercirrhosis.org) has been available since 2017.…”

Antimicrobial sulphonamide azo dyes

“…There is a category of azo dyestuffs bearing a sulphonamide functional group. This category of azo‐sulphonamide dyes was prepared as potential antimicrobial drugs, in which sulphonamides were divided into three different classes, including anti‐bacterial sulphonamides bearing aniline moiety, non‐aniline sulphonamides, and prodrugs that are able to produce active sulphanilamides . There are a variety of azo‐sulphonamide or sulphanilamide common medications, such as furosemide and chlorthalidone as diuretics, and tolbutamide against hypoglycaemia, as well as sulphonamide‐trimethoprim against opportunistic infections in patients with AIDS .…”