WS10: Safe drug use in patients with liver cirrhosis: applying guidelines in clinical pharmacy

Katja Taxis, 3. University of Groningen, Unit of PharmacoTherapy, -Epidemiology & -Economics, Groningen, the Netherlands
Sander Borgsteede, 1. Health Base Foundation, Department of Clinical Decision Support, Houten, the Netherlands.


(Workshop on behalf of the SIG Clinical Decision Support)
Patients with liver cirrhosis have an increased risk of adverse outcomes with medication use due to the pharmacokinetic and pharmacodynamic changes. Most significant changes are the diminished first-pass effect caused by altered liver blood flow and the decreased activity of drug metabolism. This causes in general a higher exposure to medication and an increased risk of adverse drug reactions (ADRs). Moreover, pathophysiological changes in patients with cirrhosis increase the risk of specific ADRs, such as renal impairment or hepatic encephalopathy. Almost 30% of patients with liver cirrhosis experience ADRs, and it is estimated that 80% of the ADRs could probably be prevented.

Choosing appropriate drugs and doses for these patients is very important, especially because they often use multiple drugs. Recently, envidence- and expert-opinion-based practice guidelines have been developed to support healthcare professionals in safe use of medication in patients with liver cirrhosis.

Target audience:

The aim of the workshop is to apply guidelines for safe medication use to patients with liver cirrhosis and explore facilitators and barriers for implementation of these guidelines in your own clinical setting.

Learning Objectives:

After following this workshop, the participant can:
- knows why advices are directed at patients with liver cirrhosis, and not at other liver diseases,
- knows how patients with cirrhosis can be identified and what clinical and laboratory values are relevant,
- what pharmacokinetic and pharmacodynamic changes occur in patients with cirrhosis,
- can find the best evidence for safe drug use in patients with liver cirrhosis, and apply this information on his/her own patients,
- can identify facilitators and barriers that may stimulate/hamper application of guidelines for safe drug use in cirrhotic patients.

Content and Structure:

The workshop will start with a brief introduction in epidemiology, pathophysiology and treatment of liver cirrhosis, and the pharmacokinetic and pharmacodynamic changes caused by cirrhosis. Next, guidelines and (free available) data sources for safe prescribing in cirrhosis will be summarized.
Mail part of the workshop will be working on cases: the participants will apply the presented guidelines on four patients and discuss in small groups what changes in medication they might propose. Answers will be discussed plenary. Finally, the participants will explore potential opportunities and barriers to implement these guidelines in their daily clinical work.

By application of the guidelines on patients, participants will be able to know how they can advice the patient and the doctor about optimal pharmacotherapy in cirrhosis. The will know general misconceptions such as the fear many patients and doctors have to use the analgesic paracetamol in cirrhosis, and they know why other analgesics (NSAIDs) should never be prescribed.
Participants will be invited to share experiences from within their settings and countries in order to learn from each other how specific situations are handled. Special emphasis will go to the aspects that can be implemented ‘the next day at work’.

At the end of the workshop important aspects will be summarized.

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