1
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Markham PN, Bajaj JS, Thuluvath PJ, Koch D, Palumbo J. Potential augmentation of terlipressin antidiuretic effects by gabapentinoids. J Hepatol 2024; 81:e71-e73. [PMID: 38403026 DOI: 10.1016/j.jhep.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 02/27/2024]
Affiliation(s)
| | - Jasmohan S Bajaj
- Richmond VA Medical Center, Richmond, Virginia, USA; Virginia Commonwealth University, Richmond, Virginia, USA
| | - Paul J Thuluvath
- Mercy Medical Center, Baltimore, Maryland, USA; University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David Koch
- The Medical University of South Carolina, Charleston, South Carolina, USA
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2
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Wong RJ, Loeb R, Seal KH, Barry F, Stark Kent D, Seetharaman S, Sharma A, Lai JC, Rubin JB. The Complex Relationship Between Pain, Mental Health, and Quality-of-Life in Patients With Cirrhosis Undergoing Liver Transplant Evaluation. J Clin Gastroenterol 2024:00004836-990000000-00313. [PMID: 39008614 DOI: 10.1097/mcg.0000000000002028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/05/2024] [Indexed: 07/17/2024]
Abstract
GOALS AND BACKGROUND Patients with cirrhosis undergoing liver transplant evaluation have high rates of pain and mental health comorbidities; both may significantly impair health-related quality of life (HRQL). We investigated the association between pain, anxiety/depression, and HRQL in this population. STUDY In 62 patients with cirrhosis undergoing liver transplant evaluation, we performed 4 validated assessments to characterize: pain (Brief Pain Inventory-Short Form, BPI-SF), anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-8), and liver-specific HRQL (Chronic Liver Disease Questionnaire). The presence of pain was determined using the BPI-SF screening question. Linear regression was used to identify demographic or clinical factors predictive of pain severity (PS) and interference (PI) and to evaluate the association between pain, anxiety/depression, and HRQL. RESULTS Seventy-one percent of patients reported pain, 26% had clinical depression, and 24% had moderate-severe anxiety. Neither liver disease severity, nor its complications were associated with pain (PS or PI), but anxiety and depression were predictors of pain on bivariate analysis. Only depression remained a significant predictor of PS (b=0.28, P<0.05) and PI (b=0.30, P<0.05) in multivariable models. HRQL was inversely associated with PS, PI, depression, and anxiety, but only anxiety (b=-0.14, P=0.003) remained associated with HRQL in the adjusted model. CONCLUSIONS Pain is present in over 70% of patients with cirrhosis undergoing liver transplant evaluation. Anxiety and depression were highly correlated with pain and appeared to be key drivers in predicting poor HRQL. Evaluating and managing mental health comorbidities should be explored as a strategy to improve HRQL in patients with cirrhosis and pain.
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Affiliation(s)
- Randi J Wong
- University of California, San Francisco , Department of Medicine San Francisco, CA
- University of South Florida Morsani College of Medicine, Department of Medicine Tampa, FL
| | - Rebecca Loeb
- University of California, San Francisco , Department of Medicine San Francisco, CA
| | - Karen H Seal
- University of California, San Francisco , Department of Medicine San Francisco, CA
- San Francisco VA Medical Center Department of Medicine, San Francisco, CA
| | - Fawzy Barry
- University of California, San Francisco , Department of Medicine San Francisco, CA
| | - Dorothea Stark Kent
- University of California, San Francisco , Department of Medicine San Francisco, CA
| | - Sri Seetharaman
- University of California, San Francisco , Department of Medicine San Francisco, CA
| | - Arjun Sharma
- University of California, San Francisco , Department of Medicine San Francisco, CA
| | - Jennifer C Lai
- University of California, San Francisco , Department of Medicine San Francisco, CA
| | - Jessica B Rubin
- University of California, San Francisco , Department of Medicine San Francisco, CA
- San Francisco VA Medical Center Department of Medicine, San Francisco, CA
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3
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Velarde-Ruiz Velasco JA, Crespo J, Montaño-Loza A, Aldana-Ledesma JM, Cano-Contreras AD, Cerda-Reyes E, Fernández Pérez NJ, Castro-Narro GE, García-Jiménez ES, Lira-Vera JE, López-Méndez YI, Meza-Cardona J, Moreno-Alcántar R, Pérez-Escobar J, Pérez-Hernández JL, Tapia-Calderón DK, Higuera-de-la-Tijera F. Position paper on perioperative management and surgical risk in the patient with cirrhosis. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024:S2255-534X(24)00057-4. [PMID: 39003101 DOI: 10.1016/j.rgmxen.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/02/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context. AIMS The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients. RESULTS Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care. CONCLUSIONS The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.
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Affiliation(s)
- J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J Crespo
- Servicio de Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - A Montaño-Loza
- División de Gastroenterología y Hepatología, Hospital de la Universidad de Alberta, Alberta, Canada
| | - J M Aldana-Ledesma
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - A D Cano-Contreras
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | | | | | - G E Castro-Narro
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E S García-Jiménez
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J E Lira-Vera
- Servicio de Gastroenterología y Hepatología, Hospital Central «Dr. Ignacio Morones Prieto», San Luis Potosí, San Luis Potosí, Mexico
| | - Y I López-Méndez
- Departamento de Gastroenterología, Medica Sur, Mexico City, Mexico
| | - J Meza-Cardona
- Departamento de Gastroenterología, Hospital Español, Mexico City, Mexico
| | - R Moreno-Alcántar
- Departamento de Gastroenterología, Hospital de Especialidades «Dr. Bernando Sepúlveda», UMAE Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - J Pérez-Escobar
- Servicio de Gastroenterología y Unidad de Trasplante Hepático, Hospital Juárez de México, Mexico City, Mexico
| | - J L Pérez-Hernández
- Servicio de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | - D K Tapia-Calderón
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - F Higuera-de-la-Tijera
- Servicio de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico.
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Rubin JB, Loeb R, Fenton C, Huang CY, Keyhani S, Seal KH, Lai JC. The burden of significant pain in the cirrhosis population: Risk factors, analgesic use, and impact on health care utilization and clinical outcomes. Hepatol Commun 2024; 8:e0432. [PMID: 38780295 PMCID: PMC11124725 DOI: 10.1097/hc9.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND We aimed to characterize pain and analgesic use in a large contemporary cohort of patients with cirrhosis and to associate pain with unplanned health care utilization and clinical outcomes in this population. METHODS We included all patients with cirrhosis seen in UCSF hepatology clinics from 2013 to 2020. Pain severity and location were determined using documented pain scores at the initial visit; "significant pain" was defined as moderate or severe using established cutoffs. Demographic, clinical, and medication data were abstracted from electronic medical records. Associations between significant pain and our primary outcome of 1-year unplanned health care utilization (ie, emergency department visit or hospitalization) and our secondary outcomes of mortality and liver transplantation were explored in multivariable models. RESULTS Among 5333 patients with cirrhosis, 32% had a nonzero pain score at their initial visit and 25% had significant (ie moderate/severe) pain. Sixty percent of patients with significant pain used ≥1 analgesic; 34% used opioids. Patients with cirrhosis with significant pain had similar Model for End-Stage Liver Disease-Sodium scores (14 vs. 13), but higher rates of decompensation (65% vs. 55%). The most common pain location was the abdomen (44%). Patients with abdominal pain, compared to pain in other locations, were more likely to have decompensation (72% vs. 56%). Significant pain was independently associated with unplanned health care utilization (adjusted odds ratio: 1.3, 95% CI: 1.1-1.5) and mortality (adjusted hazard ratio: 1.4, 95% CI: 1.2-1.6). CONCLUSIONS Pain among patients with cirrhosis is often not well-controlled despite analgesic use, and significant pain is associated with unplanned health care utilization and mortality in this population. Effectively identifying and treating pain are essential in reducing costs and improving quality of life and outcomes among patients with cirrhosis.
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Affiliation(s)
- Jessica B. Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
| | - Rebecca Loeb
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Cynthia Fenton
- Division of Hospital Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Chiung-Yu Huang
- Department of Surgery, University of California-San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Salomeh Keyhani
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
- Division of General Internal Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Karen H. Seal
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
- Division of General Internal Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
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Ma J, Björnsson ES, Chalasani N. The Safe Use of Analgesics in Patients with Cirrhosis: A Narrative Review. Am J Med 2024; 137:99-106. [PMID: 37918778 DOI: 10.1016/j.amjmed.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/04/2023]
Abstract
Pain is prevalent in patients with cirrhosis. Due to potential alterations in drug metabolism, risk for adverse effects, and complications from cirrhosis, physicians are often faced with difficult choices when choosing appropriate analgesics in these patients. Overall, acetaminophen remains the preferred analgesic. Despite its potential for intrinsic liver toxicity, acetaminophen is safe when used at 2 g/d. In contrast, non-selective nonsteroidals should be avoided due to their multiple side effects, including worsening renal function, blunting diuretic response, and increasing risk of portal hypertensive and peptic ulcer bleeding. Celecoxib can be administered for short term (≤5 days) in patients with Child's A and Child's B cirrhosis (50% dose reduction). Opioids carry the risk of precipitating hepatic encephalopathy and should generally be avoided, when possible. If clinical situation demands their use, opioid use should be limited to short-acting agents for short duration. Gabapentin and pregabalin are generally safe. Duloxetine should be avoided in hepatic impairment. Topical diclofenac and lidocaine seem to be safe in patients with cirrhosis.
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Affiliation(s)
- Jiayi Ma
- Indiana University School of Medicine and Indiana University Health, Indianapolis
| | - Einar Stefán Björnsson
- Department of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland; Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Naga Chalasani
- Indiana University School of Medicine and Indiana University Health, Indianapolis.
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6
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Azoury SC, Matros E. Top 25 Medications the Plastic and Reconstructive Surgery Trainee Should Know for an Emergency Medicine Department Consult. Plast Reconstr Surg 2024; 153:474e-489e. [PMID: 37141488 DOI: 10.1097/prs.0000000000010609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
SUMMARY Plastic surgery trainees are often called to render care in the emergency department (eg, for established patients, trauma, burns). Broad-based knowledge in pharmacotherapeutics during these encounters is critical. This includes an understanding of pain medications, anxiolytics, local anesthetics, antibiotics, anticoagulants, antidotes, and more to ensure optimal patient care. The purpose of this report is to describe 25 frequently used and other important medications that plastic surgery trainees should know for an adult emergency department encounter.
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Affiliation(s)
- Saïd C Azoury
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Evan Matros
- Division of Plastic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
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7
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Bansal N, Campbell SM, Lin CY, Ashcroft DM, Chen LC. Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care-a modified e-Delphi study. BMC Med 2024; 22:5. [PMID: 38167142 PMCID: PMC10763174 DOI: 10.1186/s12916-023-03213-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Long-term opioid use is associated with dependency, addiction, and serious adverse events. Although a framework to reduce inappropriate opioid prescribing exists, there is no consensus on prescribing indicators for preventable opioid-related problems in patients with chronic pain in primary care in the UK. This study aimed to identify opioid prescription scenarios for developing indicators for prescribing opioids to patients with chronic pain in primary care. METHODS Scenarios of opioid prescribing indicators were identified from a literature review, guidelines, and government reports. Twenty-one indicators were identified and presented in various opioid scenarios concerning opioid-related harm and adverse effects, drug-drug interactions, and drug-disease interactions in certain disease conditions. After receiving ethics approval, two rounds of electronic Delphi panel technique surveys were conducted with 24 expert panellists from the UK (clinicians, pharmacists, and independent prescribers) from August 2020 to February 2021. Each indicator was rated on a 1-9 scale from inappropriate to appropriate. The score's median, 30th and 70th percentiles, and disagreement index were calculated. RESULTS The panel unanimously agreed that 15 out of the 21 opioid prescribing scenarios were inappropriate, primarily due to their potential for causing harm to patients. This consensus was reflected in the low appropriateness scores (median ranging from 1 to 3). There were no scenarios with a high consensus that prescribing was appropriate. The indicators were considered inappropriate due to drug-disease interactions (n = 8), drug-drug interactions (n = 2), adverse effects (n = 3), and prescribed dose and duration (n = 2). Examples included prescribing opioids during pregnancy, concurrently with benzodiazepines, long-term without a laxative prescription and prescribing > 120-mg morphine milligram equivalent per day or long-term duration over 3 months after surgery. CONCLUSIONS The high agreement on opioid prescribing indicators indicates that these potentially hazardous consequences are relevant and concerning to healthcare practitioners. Future research is needed to evaluate the feasibility and implementation of these indicators within primary care settings. This research will provide valuable insights and evidence to support opioid prescribing and deprescribing strategies. Moreover, the findings will be crucial in informing primary care practitioners and shaping quality outcome frameworks and other initiatives to enhance the safety and quality of care in primary care settings.
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Affiliation(s)
- Neetu Bansal
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK.
| | - Stephen M Campbell
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria, 0208, South Africa
- Centre for Epidemiology and Public Health, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Chiu-Yi Lin
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Darren M Ashcroft
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, M13 9PL, UK
| | - Li-Chia Chen
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
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8
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Zacharia GS, Jacob A. Acetaminophen: A Liver Killer or Thriller. Cureus 2023; 15:e47071. [PMID: 38022064 PMCID: PMC10645398 DOI: 10.7759/cureus.47071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 12/01/2023] Open
Abstract
Acetaminophen, or paracetamol, ranks among the most extensively utilized analgesic and antipyretic medications globally. The administration of acetaminophen to individuals with underlying liver disease has long sparked concerns regarding the potential risk of hepatotoxicity. However, the available literature and recommendations consider it a safe option in all forms of liver diseases and is deemed safe when used at recommended doses. This article aims to offer a concise review of the pharmacokinetics, toxicity profile, and the intricate considerations surrounding the safety of acetaminophen in patients with liver disease. By delving into the liver-acetaminophen interactions, we seek to provide a nuanced perspective on the use of acetaminophen in this critical patient population.
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Affiliation(s)
- George S Zacharia
- Gastroenterology and Hepatology, Al Ahalia Hospital Mussafah, Abu Dhabi, ARE
| | - Anu Jacob
- Anesthesiology and Perioperative Medicine, Al Ahalia Hospital Mussafah, Abu Dhabi, ARE
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9
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Corona A, Dominguez M, Eti S. Palliative Care in Kidney and Liver Diseases. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:387-395. [PMID: 37657885 DOI: 10.1053/j.akdh.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 09/03/2023]
Abstract
The role of palliative care is to recognize patients with advanced illnesses who are at risk for poor outcomes and to alleviate their pain and suffering. Patients with both kidney and liver disease are a very vulnerable population due to the unique pathophysiologic relationship these two organs share, which often leads to an abbreviated life expectancy and a significant symptom burden. These patients face many challenges in their care. This article discusses the importance of prognostication for early palliative care referrals as well as the management of the two most common complaints patients with kidney and liver disease face: pain and ascites.
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Affiliation(s)
- Antonio Corona
- Albert Einstein College of Medicine at Montefiore Medical Center.
| | - Mary Dominguez
- Albert Einstein College of Medicine at Montefiore Medical Center
| | - Serife Eti
- Albert Einstein College of Medicine at Montefiore Medical Center
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10
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Hamilton JP. Pain Management in Liver Disease. Gastroenterol Hepatol (N Y) 2023; 19:355-358. [PMID: 37706188 PMCID: PMC10496264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- James P Hamilton
- Director of Hepatology Division of Gastroenterology and Hepatology The Johns Hopkins University School of Medicine Baltimore, Maryland
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11
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Johnson AW, Golzarri Arroyo L, Mahendraker N, Hosty J, Kroenke K. Hospital Opioid Usage and Adverse Events in Patients With End-Stage Liver Disease. J Pain Symptom Manage 2023; 65:326-334.e2. [PMID: 36496114 DOI: 10.1016/j.jpainsymman.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 12/13/2022]
Abstract
CONTEXT Patients with end-stage liver disease (ESLD) commonly experience pain and other symptoms that result in a poor quality of life. Few studies have examined opioid usage, adverse events (AEs), and other outcomes in ESLD patients receiving opioid analgesia. OBJECTIVES This study aimed to compare outcomes in ESLD patients who received opioids to those who did not and to determine risk factors for AEs. METHODS This was a retrospective case-cohort study of 270 hospitalized patients with ESLD that used administrative and clinical data from the electronic medical record. RESULTS Two-thirds of patients with ESLD admitted during the study period received at least one opioid analgesic. Patients who received opioids presented with a greater number of liver related complications and higher rates of anxiety (32% vs. 17%, P= 0.007), had substantially worse initial and average pain scores (both P< 0.001), and received more palliative care consultations. The opioid group had somewhat more respiratory (22.2% vs. 11.1%, P= 0.02) and gastrointestinal (38.5% vs. 25.2%, P= 0.03) AEs, but no increase in CNS adverse events which included hepatic encephalopathy. Anxiety and disease severity (i.e., the number of liver related complications) but not opioid administration were risk factors for the number of AEs. CONCLUSION Opioid administration was not an independent risk factor for the number of AEs in hospitalized patients with ESLD, whereas anxiety and more liver-related complications increased AE risk. Our findings suggest that opioids have an appropriate and reasonably safe role in alleviation of pain in patients with ESLD.
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Affiliation(s)
- Amy W Johnson
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis.
| | - Lilian Golzarri Arroyo
- Department of Epidemiology and Biostatistics (L.G-A), School of Public Health, Bloomington
| | - Neetu Mahendraker
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis
| | - Jack Hosty
- Indiana University School of Medicine (J.H.), Indianapolis
| | - Kurt Kroenke
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis; Regenstrief Institute, Inc. (K.K.), Indianapolis, Indianapolis USA
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12
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Boisvert-Plante V, Poulin-Harnois C, Ingelmo P, Einhorn LM. What we know and what we don't know about the perioperative use of methadone in children and adolescents. Paediatr Anaesth 2023; 33:185-192. [PMID: 36281540 PMCID: PMC10416808 DOI: 10.1111/pan.14584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 02/05/2023]
Abstract
Postoperative pain control is essential to optimizing patient outcomes, improving satisfaction, and allowing patients to resume their baseline functional activities. Methadone, a synthetic mu-opioid agonist, has multiple pharmacologic properties that may be optimal for perioperative use. Compared to other opioids, methadone has a longer duration of action, rapid onset, extended dosing intervals, high oral bioavailability, low cost, lack of active metabolites, and action on multiple receptors. The current literature examining the use of methadone in the perioperative care of children and adolescents is limited and most often reported within the context of spine or cardiothoracic surgery. Overall, these studies support the hypothesis that perioperative methadone in pediatric patients may decrease postoperative pain, opioid consumption, length-of-stay, and the incidence of some opioid-related side effects, like constipation and urinary retention. A variety of protocols for the perioperative use of methadone have been described, including a single intraoperative dose as well as multiple small doses within multimodal pain protocols. The superiority of these protocols has not been established. Like all opioids, methadone has a side effect profile which includes nausea, vomiting, reduced GI motility, sedation, and respiratory depression at high doses. There is also a concern that it can cause QTc prolongation in patients. The primary aim of this educational review is to examine the pharmacologic data, published perioperative protocols, dosing considerations, and risks and benefits associated with inclusion of methadone in analgesic regimens for surgical patients. A secondary aim is to introduce opportunities for research around the perioperative use of methadone in children and adolescents. Based on our review, we would prioritize establishing optimal procedure-specific methadone protocols, determining generalizability for use in routine pediatric surgeries, and investigating methadone safety and efficacy prospectively as the primary opioid for pain management in the postanesthesia care unit or postsurgical floors.
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Affiliation(s)
| | - Christelle Poulin-Harnois
- Department of Pediatric Anesthesia, Montreal Children’s Hospital, McGill University Health Center, Montréal, Quebec, Canada
| | - Pablo Ingelmo
- Department of Pediatric Anesthesia, Montreal Children’s Hospital, McGill University Health Center, Montréal, Quebec, Canada
- Alan Edwards Centre for Pain Research, McGill University, Montreal, Quebec, Canada
- Edwards Family Interdisciplinary Complex Pain Centre, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Lisa M. Einhorn
- Department of Anesthesiology, Pediatric Division, Duke University School of Medicine, Durham, North Carolina, United States
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Philips CA, Kedarisetty CK. Palliative Care for Patients with End-Stage Liver Disease. J Clin Exp Hepatol 2023; 13:319-328. [PMID: 36950499 PMCID: PMC10025682 DOI: 10.1016/j.jceh.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/07/2022] [Indexed: 02/17/2023] Open
Abstract
End-stage liver disease (ESLD) is the culmination of progression of chronic liver disease to cirrhosis, decompensation, and chronic liver failure, featuring portal hypertension or hepatocellular failure-related complications. Liver transplantation offers improved long-term survival for these patients but is negatively influenced by donor availability, financial constraints in developing countries, active substance abuse, progression of disease or malignancy on wait-list, sepsis and extrahepatic organ involvement. In this context, palliative care (PC), an interdisciplinary medical practice that aim to prevent and relieve suffering, offers best possible quality of life and is not limited to end-of-life care. It also encompasses achievable goals such as symptom control and aggressive disease-modifying treatments or interventions that beneficially alter the natural course of the disease to offer curative intend. In this narrative review, we discuss the prognostic factors that define disease course in ESLD, various indications and challenges in PC for advanced cirrhosis and management options for major symptom burden in patients with ESLD based on evidence-based best practice.
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Key Words
- ACLF
- ACLF, acute-on-chronic liver failure
- CPT, Child–Pugh–Turcotte
- ESLD, end-stage liver disease
- HE, hepatic encephalopathy
- INR, international normalized ratio
- LSM, liver stiffness measurement
- LT, liver transplantation
- MELD, model for end stage liver disease
- PC, palliative care
- TE, transient elastography
- TIPS, transjugular intrahepatic portosystemic shunt
- ascites
- cirrhosis
- end of life care
- hepatic encephalopathy
- hyponatremia
- portal hypertension
- sepsis
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Affiliation(s)
- Cyriac A. Philips
- Department of Clinical and Translational Hepatology and the Monarch Liver Laboratory, Rajagiri Hospital, Aluva, Kerala, India
| | - Chandan K. Kedarisetty
- Department of Hepatology and Liver Transplantation, Gleneagles Global Hospital, Hyderabad, India
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Larney S, Jones NR, Hickman M, Nielsen S, Ali R, Degenhardt L. Does opioid agonist treatment reduce overdose mortality risk in people who are older or have physical comorbidities? Cohort study using linked administrative health data in New South Wales, Australia, 2002-17. Addiction 2023. [PMID: 36843415 DOI: 10.1111/add.16178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 02/07/2023] [Indexed: 02/28/2023]
Abstract
AIMS To quantify the association between opioid agonist treatment (OAT) and overdose death by age group; test the hypothesis that across different age groups, opioid overdose mortality is lowest during OAT with buprenorphine compared with time out of treatment or OAT with methadone; and test associations between OAT and opioid overdose mortality in the presence of chronic circulatory, respiratory, liver and kidney diseases. DESIGN Retrospective observational cohort study using linked administrative data. SETTING New South Wales, Australia. PARTICIPANTS A total of 37 764 people prescribed OAT, 1 August 2002 and 31 December 2017. MEASUREMENTS OAT exposure, opioid overdose mortality and key confounders were measured using linked population data sets on OAT entry and exit, hospitalization, mental health care, incarceration and mortality. ICD-10 codes were used to define opioid overdose mortality and chronic disease groups of interest. FINDINGS Relative to time out of treatment, time in OAT was associated with a lower risk of opioid overdose death across all age groups and chronic diseases. Among people aged 50 years and older, there was weak evidence that buprenorphine may be associated with greater protection against opioid overdose death than methadone [generalized estimating equation (GEE) adjusted incident rate ratio (aIRR) = 0.47; 95% confidence interval (CI) = 0.21, 1.02; marginal structural models (MSM) aIRR = 0.49; 95% CI = 0.17, 1.41]. Buprenorphine was associated with greater protection against overdose death than methadone for clients with circulatory (MSM aIRR = 0.27; 95% CI = 0.11, 0.67) or respiratory (MSM aIRR = 0.26; 95% CI = 0.07, 0.94) diseases, but not liver (MSM aIRR = 0.59; 95% CI = 0.14, 2.43) or kidney (MSM aIRR = 1.16; 95% CI = 0.31, 4.36) diseases. CONCLUSIONS Opioid agonist treatment (OAT) appears to reduce mortality risk in people with opioid use disorder who are older or who have physical comorbidities. Opioid overdose mortality during OAT with buprenorphine appears to be lower and reduced in clients with circulatory and respiratory diseases compared with OAT with methadone.
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Affiliation(s)
- Sarah Larney
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montreal, Canada
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, Canada
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Nicola R Jones
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | | | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Clayton, Australia
| | - Robert Ali
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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15
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Canillas L, Pelegrina A, Álvarez J, Colominas-González E, Salar A, Aguilera L, Burdio F, Montes A, Grau S, Grande L, Carrión JA. Clinical Guideline on Perioperative Management of Patients with Advanced Chronic Liver Disease. LIFE (BASEL, SWITZERLAND) 2023; 13:life13010132. [PMID: 36676081 PMCID: PMC9860873 DOI: 10.3390/life13010132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023]
Abstract
(1) Background: Patients with advanced chronic liver disease (ACLD) are living longer with more comorbidities because of improved medical and surgical management. However, patients with ACLD are at increased risk of perioperative morbidity and mortality; (2) Methods: We conducted a comprehensive review of the literature to support a narrative clinical guideline about the assessment of mortality risk and management of perioperative morbidity in patients with ACLD undergoing surgical procedures; (3) Results: Slight data exist to guide the perioperative management of patients with ACLD, and most recommendations are based on case series and expert opinion. The severity of liver dysfunction, portal hypertension, cardiopulmonary and renal comorbidities, and complexity of surgery and type (elective versus emergent) are predictors of perioperative morbidity and mortality. Expert multidisciplinary teams are necessary to evaluate and manage ACLD before, during, and after surgical procedures; (4) Conclusions: This clinical practice document updates the available data and recommendations to optimize the management of patients with advanced chronic liver disease who undergo surgical procedures.
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Affiliation(s)
- Lidia Canillas
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- Liver Section, Gastroenterology Department, Hospital del Mar, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
| | - Amalia Pelegrina
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Department of Surgery, Hospital del Mar, 08003 Barcelona, Spain
| | - Juan Álvarez
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Anesthesia Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Elena Colominas-González
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- Pharmacy Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Antonio Salar
- Haematology Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Lluís Aguilera
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Anesthesia Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Fernando Burdio
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Department of Surgery, Hospital del Mar, 08003 Barcelona, Spain
| | - Antonio Montes
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Anesthesia Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Santiago Grau
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- Pharmacy Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Luis Grande
- Department of Surgery, Hospital del Mar, 08003 Barcelona, Spain
- Department de Medicina, Universitat Autònoma de Barcelona, 08003 Barcelona, Spain
| | - José A. Carrión
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- Liver Section, Gastroenterology Department, Hospital del Mar, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Correspondence: ; Tel.: +93-248-3220; Fax: +93-221-8644
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Rubin JB, Lai JC, Shui AM, Hohmann SF, Auerbach A. Cirrhosis Inpatients Receive More Opioids and Fewer Nonopioid Analgesics Than Patients Without Cirrhosis. J Clin Gastroenterol 2023; 57:48-56. [PMID: 34653064 PMCID: PMC9008074 DOI: 10.1097/mcg.0000000000001624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 09/05/2021] [Indexed: 12/14/2022]
Abstract
GOALS/BACKGROUND Pain is common among cirrhosis patients, particularly those hospitalized with acute illness. Managing pain in this population is challenging due to concern for adverse events and lack of guidelines for analgesic use. We sought to characterize analgesic use among inpatients with cirrhosis compared with matched noncirrhosis controls, as well as hospital-level variation in prescribing patterns. METHODS We utilized the Vizient Clinical Database, which includes clinical and billing data from hospitalizations at >500 US academic medical centers. We identified cirrhosis patients hospitalized in 2017-2018, and a matched cohort of noncirrhosis patients. Types of analgesic given-acetaminophen (APAP), nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and adjuvants (eg, gabapentinoids, antidepressants) were defined from inpatient prescription records. Conditional logistic regression was used to associate cirrhosis diagnosis with analgesic use. RESULTS Of 116,363 cirrhosis inpatients, 83% received at least 1 dose of an analgesic and 58% had regular inpatient analgesic use, rates that were clinically similar to noncirrhosis controls. Cirrhosis inpatients were half as likely to receive APAP (26% vs. 42%, P <0.01) or NSAIDs (3% vs. 7%, P <0.01), but were more likely to receive opioids (59% vs. 54%, P <0.01), particularly decompensated patients (60%). There was notable variation in analgesic prescribing patterns between hospitals, especially among cirrhosis patients. CONCLUSIONS Analgesic use was common among inpatients, with similar rates among patients with and without cirrhosis. Cirrhosis patients-particularly decompensated patients-were less likely to receive APAP and NSAIDs and more likely to receive opioid analgesics. Because of lack of evidence-based guidance for management of cirrhosis patients with pain, providers may avoid nonopioid analgesics due to perceived risks and consequently may overutilize opioids in this high-risk population.
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Affiliation(s)
- Jessica B Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Samuel F Hohmann
- Vizient Inc
- Department of Health Systems Management, Rush University, Chicago, IL
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Holman A, Parikh N, Clauw DJ, Williams DA, Tapper EB. Contemporary management of pain in cirrhosis: Toward precision therapy for pain. Hepatology 2023; 77:290-304. [PMID: 35665522 PMCID: PMC9970025 DOI: 10.1002/hep.32598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 02/03/2023]
Abstract
Chronic pain is highly prevalent in patients with cirrhosis and is associated with poor health-related quality of life and poor functional status. However, there is limited guidance on appropriate pain management in this population, and pharmacologic treatment can be harmful, leading to adverse outcomes, such as gastrointestinal bleeding, renal injury, falls, and hepatic encephalopathy. Chronic pain can be categorized mechanistically into three pain types: nociceptive, neuropathic, and nociplastic, each responsive to different therapies. By discussing the identification, etiology, and treatment of these three mechanistic pain descriptors with a focus on specific challenges in patients with cirrhosis, we provide a framework for better tailoring treatments, including nonpharmacologic therapies, to patients' needs.
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Affiliation(s)
- Alexis Holman
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neehar Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Dan J. Clauw
- Chronic Pain and Fatigue Research Center, Anesthesiology Department, University of Michigan, Ann Arbor, Michigan, USA
| | - David A. Williams
- Chronic Pain and Fatigue Research Center, Anesthesiology Department, University of Michigan, Ann Arbor, Michigan, USA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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18
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Murthy P, Shadakshari D, Mahadevan J, Chand PK. Management of Alcohol Use Disorder in Patients With Alcoholic Liver Disease. J Clin Exp Hepatol 2022; 12:1514-1526. [PMID: 36340303 PMCID: PMC9630026 DOI: 10.1016/j.jceh.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/10/2022] [Indexed: 12/12/2022] Open
Abstract
Alcohol use disorder (AUD) is a common condition that develops on the background of heavy alcohol use and is characterised by the loss of control over alcohol use and a compulsion to use alcohol, often despite negative consequences. AUD is a leading cause for the resumption of alcohol use in patients with alcoholic liver disease (ALD) after treatment. Hence it is essential to screen all patients with ALD for the presence of AUD. Screening tools such as alcohol use disorders identification test (AUDIT) and AUDIT-C are used, following which the diagnosis and severity of AUD are determined using DSM-5 criteria. The management of AUD in patients with ALD is best carried out using an integrated approach involving psychiatrists and gastroenterologists/hepatologists. The treatment most often involves a combination of pharmacotherapy and psychosocial interventions which try to achieve and maintain abstinence. Although, there is limited evidence, Baclofen is the first line pharmacological agent for long-term management of AUD in patients with ALD. Intensive psychological interventions such as motivation enhancement therapy and cognitive behavioural therapy are also seen to be beneficial. Treatment retention and follow-up are vital and can positively influence outcomes.
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Key Words
- AA, Alcoholics Anonymous
- ALD, Alcoholic Liver Disease
- AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid
- AUD, Alcohol Use Disorder
- AUDIT – C, Alcohol Use Disorder Identification Test – Consumption
- AUDIT, Alcohol Use Disorder Identification Test
- CBT, Cognitive Behavioural Therapy
- CDT, Carbohydrate Deficient Transferrin
- CIWA – Ar, Clinical Institute Withdrawal Assessment for Alcohol Revised
- DALY, Disability Adjusted Life Years
- EtG, Ethyl glucuronide
- EtS, Ethyl Sulphate
- FAEE, Fatty acid ethyl ester
- FDA, Food and Drug Administration
- GABA, Gamma-Aminobutyric acid
- GGT, Gamma glutamyl transferase
- HCV, Hepatitis C Virus
- HE, Hepatic Encephalopathy
- LT, Liver Transplantation
- MCV, Mean corpuscular volume
- MET, Motivation Enhancement Therapy
- MI, Motivational Interviewing
- NMDA, N-Methyl-d-aspartate
- PEth, Phosphatidylethanol
- RCT, Randomised control trial
- SMS, Short Message Service
- alcohol use disorder
- alcoholic liver disease
- diagnosis
- pharmacotherapy
- psychotherapy
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Affiliation(s)
- Pratima Murthy
- National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Darshan Shadakshari
- Centre for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Jayant Mahadevan
- Centre for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Prabhat Kumar Chand
- Centre for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
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Schulte B, Tergast TL, Griemsmann M, Menti D, Deveci N, Kahlhöfer J, Dörge P, Hüffner L, Kraft ARM, Behrendt P, Wedemeyer H, Cornberg M, Stichtenoth DO, Maasoumy B. Metamizole-Associated Risks in Decompensated Hepatic Cirrhosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:687-693. [PMID: 35912424 PMCID: PMC9830680 DOI: 10.3238/arztebl.m2022.0280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/11/2022] [Accepted: 07/04/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Because of the increased risk of acute renal failure (ARF), the use of cyclooxygenase (COX) inhibitors is not recommended in patients with decompensated hepatic cirrhosis. Metamizole is not a classic COX inhibitor, but there are insufficient data to support its safe use. In this study, we investigate the effect of metamizole on the risk of ARF in these patients. METHODS Metamizole use, ARF incidence, and patient mortality were examined in a large, retrospective, exploratory cohort and validated with data from a prospective registry. RESULTS 523 patients were evaluated in the exploratory cohort. Metamizole use at baseline was documented in 110 cases (21%) and was independently associated with the development of ARF, severe (grade 3) ARF, and lower survival without liver transplantation at follow-up on day 28 (HR: 2.2, p < 0.001; HR: 2.8, p < 0.001; and HR: 2.6, p < 0.001, respectively). Interestingly, the risk of ARF depended on the dose of metamizole administered (HR: 1.038, p < 0.001). Compared to patients who were treated with opioids, the rate of ARF was higher in the metamizole group (49% vs. 79%, p = 0.014). An increased risk of ARF with metamizole use was also demonstrated in the independent validation cohort (p < 0.001). CONCLUSION Metamizole therapy, especially at high doses, should only be used with a high level of caution in patients with decompensated cirrhosis.
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Affiliation(s)
| | - Tammo L. Tergast
- * Joint first authors,Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School
| | - Marie Griemsmann
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School
| | - Denise Menti
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,Center for Individualized Infection Medicine (CiiM), Hannover
| | - Neslihan Deveci
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School
| | - Julia Kahlhöfer
- German Center for Infection Research (DZIF), German Liver Foundation, HepNet, Hannover
| | - Petra Dörge
- German Center for Infection Research (DZIF), German Liver Foundation, HepNet, Hannover
| | - Lucas Hüffner
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,Twincore, Center for Experimental and Clinical Infection Research, Hannover
| | - Anke R. M. Kraft
- * Joint first authors,German Center for Infection Research (DZIF), Hannover-Braunschweig
| | - Patrick Behrendt
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,German Center for Infection Research (DZIF), Hannover-Braunschweig
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,German Center for Infection Research (DZIF), Hannover-Braunschweig
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,Center for Individualized Infection Medicine (CiiM), Hannover,Twincore, Center for Experimental and Clinical Infection Research, Hannover,German Center for Infection Research (DZIF), Hannover-Braunschweig
| | | | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,German Center for Infection Research (DZIF), Hannover-Braunschweig,*Klinik für Gastroenterologie, Hepatologie und Endokrinologie Medizinische Hochschule Hannover Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Hundersmarck D, Groot OQ, Schuijt HJ, Hietbrink F, Leenen LPH, Heng M. Hip Fractures in Patients With Liver Cirrhosis: Worsening Liver Function Is Associated with Increased Mortality. Clin Orthop Relat Res 2022; 480:1077-1088. [PMID: 34978539 PMCID: PMC9263483 DOI: 10.1097/corr.0000000000002088] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/29/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Liver cirrhosis is associated with osteoporosis, imbalance leading to falls, and subsequent fragility fractures. Knowing the prognosis of patients with liver cirrhosis of varying severity at the time of hip fracture would help physicians determine the course of treatment in this complex patient popultaion. QUESTIONS/PURPOSES (1) Is there an association between liver cirrhosis of varying severity and mortality in patients with hip fractures? (2) Is there an association between liver cirrhosis of varying severity and the in-hospital, 30-day, and 90-day postoperative complications of symptomatic thromboembolism and infections including wound complications, pneumonia, and urinary tract infections? METHODS Between 2015 and 2019, we identified 128 patients with liver cirrhosis who were treated for hip fractures at one of two Level I trauma centers. Patients younger than 18 years, those with incomplete medical records, fractures other than hip fractures or periprosthetic hip fractures, noncirrhotic liver disease, status after liver transplantation, and metastatic cancer other than hepatocellular carcinoma were excluded. Based on these exclusions, 77% (99 of 128) of patients were eligible; loss to follow-up was 0% within 1 year and 4% (4 of 99) at 2 years. The median follow-up duration was 750 days (interquartile range 232 to 1000). Ninety-four patients were stratified based on Model for End-stage Liver Disease (MELD) score subgroup (MELD scores of 6-9 [MELD6-9], 10-19 [MELD10-19], and 20-40 [MELD20-40]), and 99 were stratified based on compensation or decompensation status, both measures for liver cirrhosis severity. MELD scores combine laboratory parameters related to liver disease and are used to predict cirrhosis-related mortality based on metabolic abnormalities. Decompensation, however, is the clinical finding of acute deterioration in liver function characterized by ascites, hepatic encephalopathy, and variceal hemorrhage, associated with increased mortality. MELD analyses excluded 5% (5 of 99) of patients due to missing laboratory values. Median age at the time of hip fracture was 69 years (IQR 62 to 78), and 55% (54 of 99) of patients were female. The primary outcome of mortality was determined at 90 days, 1 year, and 2 years after surgery. Secondary outcomes were symptomatic thromboembolism and infections, defined as any documented surgical wound complications, pneumonia, or urinary tract infections requiring treatment. These were determined by chart review at three timepoints: in-hospital and within 30 days or 90 days after discharge. The primary outcome was assessed using a Cox proportional hazard analysis for the MELD score and compensation or decompensation classifications; secondary outcomes were analyzed using the Fisher exact test. RESULTS Patients in the MELD20-40 group had higher 90-day (hazard ratio 3.95 [95% CI 1.39 to 12.46]; p = 0.01), 1-year (HR 4.12 [95% CI 1.52 to 11.21]; p < 0.001), and 2-year (HR 3.65 [95% CI 1.68 to 7.93]; p < 0.001) mortality than those in the MELD6-9 group. Patients with decompensation had higher in-hospital (9% versus 0%; p = 0.04), 90-day (HR 3.35 [95% CI 1.10 to 10.25]; p = 0.03), 1-year (HR 4.39 [95% CI 2.02 to 9.54]; p < 0.001), and 2-year (HR 3.80 [95% CI 2.02 to 7.15]; p < 0.001) mortality than did patients with compensated disease. All in-hospital deaths were related to liver failure and within 30 days of surgery. The 1-year mortality was 55% for MELD20-40 and 53% for patients with decompensated disease, compared with 16% for patients with MELD6-9 and 15% for patients with compensated disease. In both the MELD and (de)compensation analyses, in-hospital and postdischarge 30-day symptomatic thromboembolic and infectious complications were not different among the groups (all p > 0.05). Ninety-day symptomatic thromboembolism was higher in the MELD20-40 group compared with the other two MELD classifications (13% for MELD20-40 and 0% for both MELD6-9 and MELD10-19; p = 0.02). CONCLUSION The mortality of patients with preexisting liver cirrhosis who sustain a hip fracture is high, and it is associated with the degree of cirrhosis and decline in liver function, especially in those with signs of decompensation, defined as ascites, hepatic encephalopathy, and variceal hemmorrhage. Patients with mild-to-moderate cirrhosis (MELD score < 20) and those with compensated disease may undergo routine fracture treatment based on their prognosis. Those with severe (MELD score > 20) or decompensated liver cirrhosis should receive multidisciplinary, individualized treatment, with consideration given to palliative and nonsurgical treatment given their high risk of death within 1 year after surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Dennis Hundersmarck
- Department of Orthopaedic Surgery, Harvard Medical School Orthopaedic Trauma Initiative, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Olivier Q. Groot
- Department of Orthopaedic Surgery, Harvard Medical School Orthopaedic Trauma Initiative, Massachusetts General Hospital, Boston, MA, USA
| | - Henk J. Schuijt
- Department of Orthopaedic Surgery, Harvard Medical School Orthopaedic Trauma Initiative, Massachusetts General Hospital, Boston, MA, USA
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Luke P. H. Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Harvard Medical School Orthopaedic Trauma Initiative, Massachusetts General Hospital, Boston, MA, USA
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Kaplan A, Rosenblatt R. Symptom Management in Patients with Cirrhosis: a Practical Guide. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2022; 20:144-159. [PMID: 35313484 PMCID: PMC8928010 DOI: 10.1007/s11938-022-00377-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 12/03/2022]
Abstract
Purpose of the review
Though it is well known that cirrhosis is associated with significant morbidity and mortality, management of symptoms in cirrhosis can be difficult. This review serves to offer practical guidance in the management of liver-specific symptoms of cirrhosis as well as other symptoms with special hepatic considerations. Recent findings We discuss liver-specific symptoms and management, including ascites and refractory ascites, hepatic encephalopathy, pruritus, and muscle cramping. We also discuss the challenges of treating more generalized symptoms in cirrhosis, including pain, depression/anxiety, appetite, and fatigue. Medication management is, especially complex in this population given the altered metabolism of drugs, and we consider some strategies to approach this. Summary With the right tools, provided throughout this review, hepatologists should be well equipped to manage the nuanced liver-specific and generalized symptoms in patients with cirrhosis.
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Affiliation(s)
- Alyson Kaplan
- Department of Gastroenterology and Hepatology, New York Presbyterian, Weill Cornell Medicine, New York, NY USA
| | - Russell Rosenblatt
- Department of Gastroenterology and Hepatology, New York Presbyterian, Weill Cornell Medicine, New York, NY USA
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Corona AG, Garcia P, Gelfand SL. Palliative Care for Patients With Cancer and Kidney Disease. Adv Chronic Kidney Dis 2022; 29:201-207.e1. [PMID: 35817527 DOI: 10.1053/j.ackd.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/11/2021] [Accepted: 11/29/2021] [Indexed: 11/11/2022]
Abstract
Patients with cancer and kidney disease experience a range of symptoms that impact their quality of life. Pain, fatigue, decreased appetite, and depression are all common in this population. Kidney palliative care is patient-centered medical care focused on reducing symptoms and defining individualized goals of care for patients and their families. Pharmacologic management of pain in patients with cancer and kidney disease requires recognition of the type of pain, its cause, and the risks and benefits of different medication classes. This review describes basic symptom management options as well as considerations for discussing goals of care, prognosis, and end of life.
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Affiliation(s)
- Antonio G Corona
- Division of Geriatrics and Palliative Medicine, Northwell Health, Great Neck, NY; Division of Nephrology, Northwell Health, Great Neck, NY
| | - Pablo Garcia
- Division of Nephrology, Stanford Medicine, Stanford, CA
| | - Samantha L Gelfand
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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23
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Menon V, Ransing R, Praharaj SK. Management of Psychiatric Disorders in Patients with Hepatic and Gastrointestinal Diseases. Indian J Psychiatry 2022; 64:S379-S393. [PMID: 35602369 PMCID: PMC9122174 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_18_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
- Vikas Menon
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ramdas Ransing
- Department of Psychiatry, BKL Walalwalkar Rural Medical College, Ratnagiri, Maharashtra, India
| | - Samir Kumar Praharaj
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India E-mail:
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24
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Greten TF, Abou-Alfa GK, Cheng AL, Duffy AG, El-Khoueiry AB, Finn RS, Galle PR, Goyal L, He AR, Kaseb AO, Kelley RK, Lencioni R, Lujambio A, Mabry Hrones D, Pinato DJ, Sangro B, Troisi RI, Wilson Woods A, Yau T, Zhu AX, Melero I. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of hepatocellular carcinoma. J Immunother Cancer 2021; 9:e002794. [PMID: 34518290 PMCID: PMC8438858 DOI: 10.1136/jitc-2021-002794] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 12/11/2022] Open
Abstract
Patients with advanced hepatocellular carcinoma (HCC) have historically had few options and faced extremely poor prognoses if their disease progressed after standard-of-care tyrosine kinase inhibitors (TKIs). Recently, the standard of care for HCC has been transformed as a combination of the immune checkpoint inhibitor (ICI) atezolizumab plus the anti-vascular endothelial growth factor (VEGF) antibody bevacizumab was shown to offer improved overall survival in the first-line setting. Immunotherapy has demonstrated safety and efficacy in later lines of therapy as well, and ongoing trials are investigating novel combinations of ICIs and TKIs, in addition to interventions earlier in the course of disease or in combination with liver-directed therapies. Because HCC usually develops against a background of cirrhosis, immunotherapy for liver tumors is complex and oncologists need to account for both immunological and hepatological considerations when developing a treatment plan for their patients. To provide guidance to the oncology community on important concerns for the immunotherapeutic care of HCC, the Society for Immunotherapy of Cancer (SITC) convened a multidisciplinary panel of experts to develop a clinical practice guideline (CPG). The expert panel drew on the published literature as well as their clinical experience to develop recommendations for healthcare professionals on these important aspects of immunotherapeutic treatment for HCC, including diagnosis and staging, treatment planning, immune-related adverse events (irAEs), and patient quality of life (QOL) considerations. The evidence- and consensus-based recommendations in this CPG are intended to give guidance to cancer care providers treating patients with HCC.
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Affiliation(s)
- Tim F Greten
- Thoracic and GI Malignancies Branch, National Cancer Institute, Bethesda, Maryland, USA
| | - Ghassan K Abou-Alfa
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Medical College at Cornell University, New York, New York, USA
| | - Ann-Lii Cheng
- Department of Medical Oncology, National Taiwan University Cancer Center and National Taiwan University Hospital, Taipei, Taiwan
| | - Austin G Duffy
- The Mater Hospital/University College Dublin, Dublin, Ireland
| | - Anthony B El-Khoueiry
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Richard S Finn
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | | | - Lipika Goyal
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aiwu Ruth He
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Ahmed O Kaseb
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robin Kate Kelley
- Department of Medicine (Hematology/Oncology), UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Riccardo Lencioni
- Department of Radiology, University of Pisa School of Medicine, Pisa, Italy
- Miami Cancer Institute, Miami, Florida, USA
| | - Amaia Lujambio
- Oncological Sciences Department, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Donna Mabry Hrones
- Thoracic and GI Malignancies Branch, National Cancer Institute, Bethesda, Maryland, USA
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Bruno Sangro
- Clinica Universidad de Navarra-Instituto de Investigación Sanitaria de Navarra (IDISNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | | | - Andrea Wilson Woods
- Blue Faery: The Adrienne Wilson Liver Cancer Association, Birmingham, Alabama, USA
| | - Thomas Yau
- Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Andrew X Zhu
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
- Jiahui Health, Jiahui International Cancer Center, Shanghai, China
| | - Ignacio Melero
- Clinica Universidad de Navarra-Instituto de Investigación Sanitaria de Navarra (IDISNA), Pamplona, Spain
- Foundation for Applied Medical Research (FIMA), Pamplona, Spain
- Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain
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25
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McGill MR, James LP, McCullough SS, Moran JH, Mathews SE, Peterson EC, Fleming DP, Tripod ME, Vazquez JH, Kennon-McGill S, Spencer HJ, Dranoff JA. Short-Term Safety of Repeated Acetaminophen Use in Patients With Compensated Cirrhosis. Hepatol Commun 2021; 6:361-373. [PMID: 34558847 PMCID: PMC8793989 DOI: 10.1002/hep4.1810] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/09/2021] [Accepted: 08/02/2021] [Indexed: 12/29/2022] Open
Abstract
Current guidelines recommend restricting acetaminophen (APAP) use in patients with cirrhosis, but evidence to support that recommendation is lacking. Prior studies focused on pharmacokinetics (PK) of APAP in cirrhosis but did not rigorously examine clinical outcomes, sensitive biomarkers of liver damage, or serum APAP‐protein adducts, which are a specific marker of toxic bioactivation. Hence, the goal of this pilot study was to test the effects of regularly scheduled APAP dosing in a well‐defined compensated cirrhosis group compared to control subjects without cirrhosis, using the abovementioned outcomes. After a 2‐week washout, 12 subjects with and 12 subjects without cirrhosis received 650 mg APAP twice per day (1.3 g/day) for 4 days, followed by 650 mg on the morning of day 5. Patients were assessed in‐person at study initiation (day 1) and on days 3 and 5. APAP‐protein adducts and both conventional (alanine aminotransferase) and sensitive (glutamate dehydrogenase [GLDH], full‐length keratin 18 [K18], and total high‐mobility group box 1 protein) biomarkers of liver injury were measured in serum on the mornings of days 1, 3, and 5, with detailed PK analysis of APAP, metabolites, and APAP‐protein adducts throughout day 5. No subject experienced adverse clinical outcomes. GLDH and K18 were significantly different at baseline but did not change in either group during APAP administration. In contrast, clearance of APAP‐protein adducts was dramatically delayed in the cirrhosis group. Minor differences for other APAP metabolites were also detected. Conclusion: Short‐term administration of low‐dose APAP (650 mg twice per day, <1 week) is likely safe in patients with compensated cirrhosis. These data provide a foundation for future studies to test higher doses, longer treatment, and subjects who are decompensated, especially in light of the remarkably delayed adduct clearance in subjects with cirrhosis.
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Affiliation(s)
- Mitchell R McGill
- Department of Environmental and Occupational Health, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Laura P James
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Translational Research Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sandra S McCullough
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffery H Moran
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,PinPoint Testing, LLC, Little Rock, AR, USA
| | | | - Eric C Peterson
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Davis P Fleming
- Translational Research Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Morgan E Tripod
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joel H Vazquez
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Stefanie Kennon-McGill
- Department of Environmental and Occupational Health, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Horace J Spencer
- Department of Biostatistics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jonathan A Dranoff
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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26
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Patel D, Teckman J. Liver disease with unknown etiology - have you ruled out alpha-1 antitrypsin deficiency? Ther Adv Chronic Dis 2021; 12_suppl:2040622321995684. [PMID: 34408828 PMCID: PMC8367207 DOI: 10.1177/2040622321995684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/12/2021] [Indexed: 01/13/2023] Open
Abstract
Although a less well-known consequence of alpha-1 antitrypsin deficiency (AATD) liver disease is the second leading cause of death among patients with the condition. The alpha-1 antitrypsin (AAT) protein is produced by hepatocytes within the liver, which retain pathological variants of AAT instead of secreting the proteinase inhibitor into the systemic circulation. This intracellular retention is caused by inefficient folding and polymerization of mutant AAT and the accumulation of these AAT aggregates leads to diverse manifestations of liver disease, which can present differently in both children and adults. The progression from hepatocyte apoptosis to liver inflammation, fibrosis and cirrhosis, and liver failure is still not fully understood, but in older patients, liver disease can surpass lung disease as the principal cause of death. Liver function tests (LFTs) can measure plasma levels of liver enzymes to assess liver function but require careful interpretation. Non-invasive tests are being developed that can detect early liver disease, but liver biopsy is still the gold standard for assessing liver fibrosis once abnormal LFTs have been detected in a patient. Currently, there is no licensed treatment for AATD-related liver disease (intravenous AAT therapy is not indicated for this purpose), but liver transplantation is associated with positive outcomes and may even slow emphysema progression. Therefore, new strategies are being developed to address treatment of AATD-related liver disease, such as accelerating degradation of mutant AAT and assisting hepatocytes in the folding and secretion of mutant AAT, but these approaches remain at early stages of development.
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Affiliation(s)
- Dhiren Patel
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, St Louis University School of Medicine, St Louis, MO, USA
| | - Jeffrey Teckman
- Department of Pediatrics and Department of Biochemistry and Molecular Biology, St Louis University School of Medicine, St Louis, MO, USA
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27
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Rubin JB, Lai JC, Shui AM, Hohmann SF, Auerbach A. Patterns of Inpatient Opioid Use and Related Adverse Events Among Patients With Cirrhosis: A Propensity-Matched Analysis. Hepatol Commun 2021; 5:1081-1094. [PMID: 34141991 PMCID: PMC8183179 DOI: 10.1002/hep4.1694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/14/2021] [Accepted: 02/04/2021] [Indexed: 01/27/2023] Open
Abstract
Pain is common among patients with cirrhosis, yet managing pain in this population is challenging. Opioid analgesics are thought to be particularly high risk in patients with cirrhosis, and their use has been discouraged. We sought to understand patterns of opioid use among inpatients with cirrhosis and the risks of serious opioid-related adverse events in this population. We used the Vizient Clinical Database/Resource Manager, which includes clinical and billing data from hospitalizations at more than 500 academic medical centers. We identified all nonsurgical patients with cirrhosis hospitalized in 2017-2018 as well as a propensity score-matched cohort of patients without cirrhosis. Inpatient prescription records defined patterns of inpatient opioid use. Conditional logistic regression compared rates of use and serious opioid-related adverse events between patients with and without cirrhosis. Of 116,146 nonsurgical inpatients with cirrhosis, 62% received at least one dose of opioids and 34% had regular inpatient opioid use (more than half of hospital days), rates that were significantly higher than in patients without cirrhosis (adjusted odds ratio [AOR] for any use, 1.17; 95% confidence interval [CI], 1.13-1.21; P < 0.001; AOR for regular use, 1.07; 95% CI, 1.02-1.11; P = 0.002). Compared with patients without cirrhosis, patients with cirrhosis more often received tramadol (P < 0.001) and less commonly received opioid/acetaminophen combinations (P < 0.001). Rates of serious opioid-related adverse events were similar in patients with and without cirrhosis (1.6% vs. 1.9%; AOR, 0.96; P = 0.63). Conclusion: Over half of patients with cirrhosis have pain managed with opioids during hospitalization. Patterns of opioid use differ in patients with cirrhosis compared with patients without cirrhosis, although rates of serious adverse events are similar. Future studies should further explore the safety and efficacy of opioids in patients with cirrhosis, with the goal of improving pain management and quality of life in this population.
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Affiliation(s)
- Jessica B Rubin
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jennifer C Lai
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Amy M Shui
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCAUSA
| | - Samuel F Hohmann
- Vizient Inc.ChicagoILUSA.,Department of Health Systems ManagementRush UniversityChicagoILUSA
| | - Andrew Auerbach
- Division of Hospital MedicineDepartment of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
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28
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Thomson MJ, Lok AS, Tapper EB. Appropriate and Potentially Inappropriate Medication Use in Decompensated Cirrhosis. Hepatology 2021; 73:2429-2440. [PMID: 32911564 PMCID: PMC7943648 DOI: 10.1002/hep.31548] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 07/31/2020] [Accepted: 08/13/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Patients with decompensated cirrhosis are prescribed numerous medications. Data are limited as to whether patients are receiving medications they need and avoiding those they do not. We examined a large national claims database (2010-2015) to characterize the complete medication profile as well as the factors associated with appropriate and potentially inappropriate medication use in 12,621 patients with decompensated cirrhosis. APPROACH AND RESULTS Clinical guidelines and existing literature were used to determine appropriate and potentially inappropriate medications in decompensated cirrhosis. The total medication days' supply was calculated from pharmacy data and divided by the follow-up period for each decompensation. Ascites was the most common (86.5%), followed by hepatic encephalopathy (HE; 37.8%), variceal bleeding (VB; 17.5%), hepatorenal syndrome (6.3%), and spontaneous bacterial peritonitis (SBP; 6.1%). For patients with ascites, 55.8% filled a diuretic. For patients with HE, 32.4% and 63.3% filled rifaximin and lactulose, respectively. After VB, 60.3% of patients filled a nonselective beta blocker, and after an episode of SBP, 48.0% of patients filled an antibiotic for prophylaxis. The minority (4.5%-17.3%) had enough medication to cover >50% follow-up days. Potentially inappropriate medication use was common: 53.2% filled an opiate, 46.0% proton pump inhibitors, 14.2% benzodiazepines, and 10.1% nonsteroidal anti-inflammatory drugs. Disease severity markers were associated with more appropriate mediation use but not consistently associated with less inappropriate medication use. CONCLUSIONS Patients with decompensated cirrhosis are not filling indicated medications as often or as long as is recommended and are also filling medications that are potentially harmful. Future steps include integrating pharmacy records with medical records to obtain a complete medication list and counseling on medication use with patients at each visit.
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Affiliation(s)
- Mary J. Thomson
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Anna S. Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan,Veterans Affairs Hospital, Ann Arbor, Michigan
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29
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Wilder JM, Evon DM, Proeschold-Bell RJ, Yao J, Sohail MM, Niedzwiecki D, Makarushka C, Hodge T, Muir AJ. Why do patients with chronic hepatitis C drink alcohol? An examination of pain, depression and drinking motives. J Viral Hepat 2021; 28:699-709. [PMID: 33476429 PMCID: PMC10116388 DOI: 10.1111/jvh.13474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 11/17/2020] [Accepted: 01/11/2021] [Indexed: 02/06/2023]
Abstract
Alcohol consumption in the setting of chronic HCV is associated with accelerated progression towards cirrhosis, increased risk of hepatocellular carcinoma and higher mortality. This analysis contextualizes how sociodemographic factors, chronic pain and depression relate to the motivations of individuals with chronic HCV to consume alcohol. We conducted a secondary analysis of baseline data from the Hep ART trial of behavioural interventions on alcohol use among patients with HCV. Alcohol consumption was measured using the Drinking Motives Questionnaire and a novel 6-item measure of pain-related drinking motives. Statistical analyses performed included ANOVA for bivariate analyses and multivariable ordinary least-squares linear regression. At study baseline, 181 participants had an average age of 55 years; the majority (66.7%) reported beyond-minor pain; and a third (37%) met criteria for depression; drinking motives were higher for individuals with beyond-minor pain (means 9.9 vs. 4.6, p < .001) and who met criteria for depression (means 10.9 vs. 6.4, p < .001) when using the pain-related drinking motives items. Average pain(coef = 1.0410067141 < .001) was significantly associated with increased motives to drink to relieve pain in the full baseline model specification controlling for all covariates using ordinary at least squares; depression (coef = 7.06; 95% CI 1.32, 12.81; p = .016) was significantly associated with increased non-pain-related motives to drink. From baseline to 3-month follow-up, compared to participants who had mean average pain scores among the sample, motives to drink to relieve pain decreased in participants who had higher average pain scores (coef = -0.30; 95% CI -0.59, -0.01; p = .40). Physical pain and depression are associated with increased motives to consume alcohol. Patients with chronic liver disease should be screened for chronic pain and depression and, if present, referred to pain specialists or co-managed in partnership with pain specialists in hepatology clinics.
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Affiliation(s)
- Julius M Wilder
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Donna M Evon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Rae Jean Proeschold-Bell
- Duke Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jia Yao
- Duke Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Malik Muhammed Sohail
- Duke Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Christina Makarushka
- Duke Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Terra Hodge
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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30
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Zoe T, Jane C, Rebecca H, Joe W, Guha IN, Morling JR. Health related quality of life in individuals at high risk of chronic liver disease: Impact of a community diagnostic pathway. PUBLIC HEALTH IN PRACTICE 2021; 1:100033. [PMID: 33458714 PMCID: PMC7790448 DOI: 10.1016/j.puhip.2020.100033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/17/2020] [Indexed: 01/29/2023] Open
Abstract
Objectives There is a lack of understanding of health related quality of life (HRQoL) in chronic liver disease (CLD). With the rising prevalence of alcohol and obesity driven CLD, and the increasing ability to screen for fibrosis, it is important to understand the impact of the diagnostic process for patients. Study design Prospective cohort study. Methods A cohort study conducted utilising the Nottingham Adult Liver Disease Stratification Pathway, UK. All patients referred as high risk for CLD (due to metabolic, alcohol or abnormal liver enzymes) completed the EQ-5D before diagnosis and at three and 12 months after. HRQoL was investigated by domain, CLD severity (transient elastography) and temporally. Results 493 patients participated with 300 (60.9%) completing at least one follow-up HRQoL assessment. Pre-diagnosis the median (IQR) utility index was 0.75 (0.61–0.85) and visual analogue scale was 75/100 (60–90). The median utility index was significantly lower amongst those with advanced liver disease compared to those without at all time points (baseline 0.68 vs 0.77, three-months 0.65 vs 0.79, 12-months 0.69 vs 0.84, all p < 0.05). The majority of decrements in HRQoL score were in the pain domain. Conclusions There was no reduction, over three or 12 months, in HRQoL identified amongst high-risk individuals progressing through the diagnostic pathway. Overall the HRQoL of participants at high risk for the development of significant CLD was lower than the UK and regional (East Midlands) norms. Furthermore, we found reduced HRQoL in those going on to receive a diagnosis of advanced liver disease compared to those without.
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Affiliation(s)
- Tildesley Zoe
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Clinical Sciences Building 2, Nottingham, NG5 1PB, UK
| | - Chalmers Jane
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, NG7 2UH, UK
| | - Harris Rebecca
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, NG7 2UH, UK
| | - West Joe
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Clinical Sciences Building 2, Nottingham, NG5 1PB, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, NG7 2UH, UK
| | - Indra Neil Guha
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, NG7 2UH, UK
| | - Joanne Rebecca Morling
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Clinical Sciences Building 2, Nottingham, NG5 1PB, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, NG7 2UH, UK
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31
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Abstract
The liver is a major organ with multiple functions. A number of drugs are metabolized by the liver during phase 1 and 2 reactions which include complex processes involving cytochrome P450 enzymes. Genetic and acquired variability in cytochrome P450 activity may have profound effects on pharmacokinetics. Additionally, drugs can also modify how the liver functions and cause dysfunction or even failure of the organ both by a direct effect on the liver or by alteration in liver blood flow. It is important to recognize the signs and symptoms of liver failure in patients and identify possible causes including drug interactions. Furthermore, once a patient has been recognized to be suffering with liver dysfunction or failure drug choice and dosing regime will need to be rationalized. Paracetamol overdose can have severe and life threatening consequences for patients due to its effect on liver function. It is the leading cause of acute liver failure in the UK,1 Correct and early management is crucial and will be discussed within this article.
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32
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Gorospe FF, Istanboulian L, Puts M, Wong D, Lee E, Dale CM. A scoping review to identify and map the multidimensional domains of pain in adults with advanced liver disease. Can J Pain 2020; 4:210-224. [PMID: 33987500 PMCID: PMC7951148 DOI: 10.1080/24740527.2020.1785855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/26/2020] [Accepted: 06/04/2020] [Indexed: 11/16/2022]
Abstract
Background: Pain is a significant problem in adults living with advanced liver disease, having limited guidance available for its clinical management. While pain is considered a multidimensional experience, there have been limited reviews of the pain literature in advanced liver disease conducted with a multidimensional framework. Aims: The goal of this scoping review was to identify and map the multidimensional domains of pain in adults with advanced liver disease using the biopsychosocial model. Methods: We used Arksey and O'Malley's scoping framework. A search was conducted in MEDLINE, Embase, AMED, and CINAHL databases and the gray literature using specific eligibility criteria (1990-2019). Citation selection and data extraction were performed by two independent reviewers and in duplicate. Results: Of the 43 studies that met inclusion criteria, 51% were from North America and 93% utilized quantitative methods. The combined studies reported on 168,110 participants with ages ranging between 23 to 87 years. Only 9% reported an objective scoring system for liver disease severity. Few studies reported pain classification (9%) and intensity (16%). Pain prevalence ranged between 18% and 100%, with pain locations including joint, abdomen, back, head/neck, and upper/lower extremities. We identified and mapped 115 pain factors to the biopsychosocial model: physical (81%), psychological (65%), and sociocultural (5%). Only 9% measured pain using validated multidimensional tools. Pharmacological intervention (92%) prevailed among pain treatments. Conclusions: Pain is not well understood in patients with advanced liver disease, having limited multidimensional pain assessment and treatment approaches. There is a need to systematically examine the multidimensional nature of pain in this population.
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Affiliation(s)
- Franklin F. Gorospe
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Perioperative Services, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Laura Istanboulian
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Acute Inpatient Respiratory Unit, Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - David Wong
- Hepatology Division, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Elizabeth Lee
- Hepatology Division, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Craig M. Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Chang KT, Liu CJ, Tsai HT, Hsu TP, Chen PT, Hu SH. Effects and safety of body positioning on back pain after transcatheter arterial chemoembolization in people with hepatocellular carcinoma: A randomized controlled study. Int J Nurs Stud 2020; 109:103641. [PMID: 32535341 DOI: 10.1016/j.ijnurstu.2020.103641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/09/2020] [Accepted: 05/08/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND People with hepatocellular carcinoma who undergo transcatheter arterial chemoembolization usually experience back pain due to lie supine for at least 4 hours to avoid bleeding and hematoma. Body positioning is an effective and safe method for decreasing back pain in people with transfemoral cardiac catheterization; however, its effects and safety among patients with high bleeding tendency are unknown. OBJECTIVE To investigate whether body positioning could decrease back pain without increasing the chance of bleeding after transcatheter arterial chemoembolization. DESIGN A single-blind randomized controlled trial (ClinicalTrials.gov No.: NCT03784469). METHODS A total of 78 people with liver cancer who had undergone chemoembolization through the femoral artery were enrolled. Each person was randomly assigned to either the control or intervention group (each consisted of 39 participants). The control group received the usual care, remaining flat and lying in a supine position, whereas the intervention group had their positions changed in the second and fourth hour after chemoembolization. Participants' pain level was rated by using numerical rating scale -11 (score from 0 to 10), bleeding was measured by using volume of blood (cc.) in gauze and hematoma size in diameter (cm), and satisfaction was self-rated from 1 to 5. Repeated-measure analysis of variance (ANOVA) was used to compare the difference in pain levels over time within each group and independent t test to compare the mean difference of pain between groups at 5 endpoints, both methods with Bonferroni adjustment. Independent t test, chi-squared test, and Fisher's exact test compared postembolization discomfort, puncture sites bleeding, satisfaction between groups. RESULTS Significant changes of pain levels over time in both intervention [F(2.93, 111.20)=7.64, p<.001] and control groups [F(2.66, 101.17)=20.55, p<.001]. The intervention group had a significantly lower mean pain score in the second hour (t = -2.838, p = .006) and fourth hour (t = -4.739, p < .001) when patients turning to the side than did the control group lying supine. Furthermore, patients in the intervention group had significantly higher satisfaction than did those in the control group (t = -2.422, p = .018). No hematoma and significant difference of post-procedural bleeding between groups. CONCLUSION Changing patients' body positions in bed after transcatheter arterial chemoembolization is a safe and effective method of decreasing back pain, and increasing patients' satisfaction, without increasing the complications of bleeding and hematoma. Clinicians should change the positions of people with hepatocellular carcinoma 2 hours after they receive transcatheter arterial chemoembolization.
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Affiliation(s)
- Kai-Ting Chang
- Department of Nursing, National Taiwan University Hospital, No.7, Chung Shan S. Rd., Taipei City, 10002, Taiwan.
| | - Chun-Jen Liu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National, Taiwan University Hospital, No.7, Chung Shan S. Rd., Taipei City, 10002, Taiwan.
| | - Hsiu-Ting Tsai
- Post-Baccalaureate Program in Nursing, Taipei Medical University, No. 250 Wu-Xing Street, Taipei City, 110, Taiwan.
| | - Tse-Pin Hsu
- Department of Nursing, National Taiwan University Hospital, Chung Shan S. Rd., Taipei City, 10002, Taiwan.
| | - Po-Ting Chen
- Department of Medical Imaging, National Taiwan University Hospital, Chung Shan S. Rd., Taipei City, 10002, Taiwan.
| | - Sophia H Hu
- School of Nursing, College of Nursing, National Yang-Ming University, No.155, Sec.2, Li-Nong Street, Taipei City, 112, Taiwan.
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Moon AM, Watkins SE, Lok AS, Firpi-Morell RJ, Trinh HN, Kupec JT, Schoen C, Neuschwander-Tetri BA, Barritt AS. Opioid Use Is More Common in Nonalcoholic Fatty Liver Disease Patients with Cirrhosis, Higher BMI, and Psychiatric Disease. Dig Dis 2020; 39:247-257. [PMID: 32836224 PMCID: PMC7902739 DOI: 10.1159/000511074] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 08/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Opioid use is a topic of growing concern among patients with nonalcoholic fatty liver disease (NAFLD). Given safety concerns of opioids, proactively identifying subgroups of patients with an increased probability of opioid use may encourage practitioners to recommend alternative therapies for pain, thus reducing the likelihood of opioid misuse. This work assessed the prevalence and patient characteristics associated with opioid use in a real-world cohort of patients with NAFLD. METHODS TARGET-NASH, an observational study of participants at 55 academic and community sites in the United States, includes patients with NAFLD defined by pragmatic case definitions. Opioid use was defined as any documented opioid prescriptions in the year prior to enrollment. The association between patient characteristics and the odds of opioid use were modeled with stepwise multivariable logistic regression and tree ensemble methods (Classification and regression tree/Boosted Tree). RESULTS The cohort included 3,474 adult patients with NAFLD including 18.0% with documented opioid use. Variables associated with opioid use included presence of cirrhosis (OR 1.51, 95% CI 1.16-1.98), BMI ≥32 kg/m2 (OR 1.29, 95% CI 1.05-1.59), depression (OR 1.87, 95% CI 1.50-2.33), and anxiety (OR 1.59, 95% CI 1.27-1.98). In the boosted tree analysis, history of back pain, depression, and fibromyalgia had the greatest relative importance in predicting opioid use. CONCLUSION Prescription opioids were used in nearly 1 of 5 patients with NAFLD. Given the safety concerns of opioids in patients with NAFLD, alternative therapies including low-dose acetaminophen and nonpharmacologic treatments should be considered for these patients.
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Affiliation(s)
- Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, UNC Liver Center, Chapel Hill, North Carolina, USA,
| | | | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Roberto J Firpi-Morell
- Section of Hepatobiliary Diseases and Transplantation, University of Florida, Gainesville, Florida, USA
| | | | - Justin T Kupec
- Department of Medicine, Section of Digestive Diseases, West Virginia University, Morgantown, West Virginia, USA
| | - Cheryl Schoen
- TARGET PharmaSolutions, Inc., Durham, North Carolina, USA
| | | | - A Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, UNC Liver Center, Chapel Hill, North Carolina, USA
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Patel A, Ufere NN. Integrating Palliative Care in the Management of Patients With Advanced Liver Disease. Clin Liver Dis (Hoboken) 2020; 15:136-140. [PMID: 32395238 PMCID: PMC7206323 DOI: 10.1002/cld.936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/26/2020] [Indexed: 02/04/2023] Open
Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-reading-patel a video presentation of this article.
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Affiliation(s)
- Arpan Patel
- Digestive DiseasesUniversity of California Los AngelesLos AngelesCA,GastroenterologyWest Los Angeles Veterans Affairs Medical CenterLos AngelesCA
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36
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Li C, Liang L, Jia HD, Diao YK, Yang T. Letter: are opioid prescriptions associated with hepatic encephalopathy in patients with compensated cirrhosis? Aliment Pharmacol Ther 2020; 51:742. [PMID: 32162376 DOI: 10.1111/apt.15661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Chao Li
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China.,Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Hangzhou, China
| | - Lei Liang
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China.,Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Hangzhou, China
| | - Hang-Dong Jia
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China.,Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Hangzhou, China
| | - Yong-Kang Diao
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China.,Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Hangzhou, China
| | - Tian Yang
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China.,Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Hangzhou, China
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Fukazawa K, Rodriguez PJ, Fong CT, Gologorsky E. Perioperative Opioid Use and Chronic Post-Surgical Pain after Liver Transplantation: A Single Center Observational Study. J Cardiothorac Vasc Anesth 2019; 34:1815-1821. [PMID: 31952905 DOI: 10.1053/j.jvca.2019.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To investigate the opioid requirements and prevalence of chronic postsurgical pain (CPSP) in liver transplant (LT) recipients and to evaluate the association of opioid use with postoperative survival. DESIGN Retrospective analysis. SETTING A large academic medical center. PATIENTS Cadaveric liver transplants recipients from 2008 to 2016. INTERVENTIONS Analysis of demographic, perioperative, and outcome data. MEASUREMENTS AND MAIN RESULTS This study measured the incidence and quantity of preoperative opioid use, postoperative opioid requirements, the incidence of CPSP, and survival in patients with and without CPSP. Opioid requirements were calculated in morphine milligram equivalents. In total, 322 LT recipients satisfied the inclusion criteria. The cohort of interest included 61 patients (18.9%) who were prescribed opioids before LT, compared to the control group of 261. Postoperative opioid requirements were significantly higher in the cohort of interest in the first 24 hours (205.9 ± 318.5 v 60.4 ± 33.6 mg, p < 0.0001) and at 7 days after transplant (57.0 ± 70.6 mg v 19.2 ± 15.4 mg, p < 0.0001). Incidence of CPSP was significantly higher in the cohort of interest at 3 months (70.5% v 45.5%, p < 0.0001), at 2 years (38% v 12%), and at 5 years (29.8% v 6.9%) postoperatively. CPSP was a significant risk factor for patient mortality after transplantation (p = 0.038, HR 1.26). CONCLUSIONS Opioid use is relatively frequent in patients waiting for LT. It significantly affects the postoperative opioid requirements and the incidence of CSPS. CPSP may significantly affect survival after LT.
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Affiliation(s)
- Kyota Fukazawa
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA
| | - Patricia J Rodriguez
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA
| | - Christine T Fong
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA
| | - Edward Gologorsky
- Department of Anesthesiology, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA.
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Irsay L, Checiches A, Perja D, Borda IM, Dogaru G, Ungur R, Ciubean A, Ciortea V. Pharmacological pain management in patients with chronic hepatic disease. BALNEO RESEARCH JOURNAL 2019. [DOI: 10.12680/balneo.2019.249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
The liver has a central role in the pharmacokinetics (absorption, distribution, elimination, etc.) of drugs. With hepatic insufficiency, the metabolism of drugs decreases, which accumulates metabolically or toxic active products. Some medicines can aggravate a pre-existing liver disease. Medicines used in this group of patients (especially diuretics and centrally acting preparations) can often cause impaired renal function or hepatic encephalopathy. The general principles of assessment, pain management and analgesia should be prescribed taking into account the Word Health Organization (WHO) recommendations for these patients, with careful and frequent monitoring of patient progress during treatment administration.
Key words: hepatotoxicity, hepatic dysfunction, cirrhosis, pain medication,
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Affiliation(s)
- László Irsay
- “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
| | | | - Dănuț Perja
- “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
| | | | - Gabriela Dogaru
- “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
| | - Rodica Ungur
- “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
| | - Alina Ciubean
- “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
| | - Viorela Ciortea
- “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
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