Manage Dose Adjustments in Liver Disease

Most meds don’t need dose adjustments until liver function is at least 90% impaired…such as in patients with decompensated cirrhosis who have jaundice or variceal bleeding.

But it’s harder to quantify liver impairment than kidney impairment.

Liver enzymes (ALT, AST) are just markers of hepatic injury…not how well the liver is functioning. In fact, these labs may be normal in a patient with advanced cirrhosis.

Continue to think of elevated liver enzymes as a flag to evaluate if liver injury is due to a med or supplement…statins, kava, etc.

On the other hand, lean more on markers of liver function…such as albumin, bilirubin, or INR…to guide med adjustments.

For patients with cirrhosis, expect to hear more about the Child-Pugh score…which estimates the degree of liver impairment.

It uses labs (albumin, bilirubin, INR) and severity of ascites and encephalopathy to assign a score of 5 to 15. This correlates to Child-Pugh class A, B, or C…least to most severe.

For instance, ondansetron labelling advises a max of 8 mg/day for patients with moderate to severe hepatic impairment…which can be extrapolated to Child-Pugh class B and C.

And limit esomeprazole to 20 mg/day or bupropion SR to 150 mg every other day for those with severe impairment…or Child-Pugh class C.

Follow dose recommendations per labelling…if they exist.

Otherwise, recommend starting low and going slow…especially with meds highly metabolized in the liver, such as fluoxetine or propranolol. These can accumulate and increase side effects.

Also be alert for highly protein-bound drugs, such as phenytoin or warfarin…since low albumin levels may increase med effects.

Keep in mind, liver failure and kidney failure often go hand in hand. Continue to adjust doses based on renal function if needed.