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Seifi A, Hassannezhad S, Mosaddeghi-Heris R, Haji Kamanaj Olia A, Adib A, Hafeez S, Barthol C. Consciousness Recovery in Traumatic Brain Injury: A Systematic Review Comparing Modafinil and Amantadine. Clin Neuropharmacol 2023; 46:229-238. [PMID: 37962310 DOI: 10.1097/wnf.0000000000000577] [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: 10/20/2023]
Abstract
OBJECTIVES Acute traumatic brain injury is one of the most common causes of death and disability. Reduction in the level of consciousness is a significant complication that can impact morbidity. Glasgow Coma Scale (GCS) is the most widely used method of assessing the level of consciousness. Neurostimulants such as amantadine and modafinil are common pharmacologic agents that increase GCS in patients with brain trauma. This study aimed to compare the effectiveness of these 2 drugs. METHODS This systematic review obtained articles from Google Scholar, PubMed, Scopus, Embase, and MEDLINE databases. Extensive searches were conducted separately by 4 individuals in 3 stages. Ultimately, 16 clinical trials, cohort studies, case reports, and case series articles were obtained after reading the title, abstract, and full text and considering the exclusion criteria. The data of the final article were entered into the analysis table. This study was registered with PROSPERO (registration number CRD42022334409) and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Amantadine seems to be associated with a higher overall response rate. In contrast, modafinil is associated with the most remarkable change in GCS score during treatment. However, the number of clinical trials with high quality and sample size has not been satisfactory to compare the effectiveness of these 2 drugs and their potential side effects. CONCLUSIONS The authors recommend additional double-blind clinical trials are needed to be conducted with a larger sample size, comparing amantadine with modafinil to delineate the efficacy and adverse effects, both short and long term.
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Affiliation(s)
- Ali Seifi
- Department of Neurosurgery, UT Health, San Antonio, TX
| | - Sina Hassannezhad
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Mosaddeghi-Heris
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Ali Adib
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shaheryar Hafeez
- Division of Neuro Critical Care, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Colleen Barthol
- Department of Pharmacotherapy and Pharmacy Services, University Health System of San Antonio, San Antonio, TX
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Watt M, Hyde A, Spence JC, Wright GM, Vander Well S, Johnson E, Mason A, McLeod M, Tandon P. The feasibility and acceptability of an online mind-body wellness program for patients with primary biliary cholangitis. CANADIAN LIVER JOURNAL 2023; 6:314-331. [PMID: 38020194 PMCID: PMC10652984 DOI: 10.3138/canlivj-2022-0045] [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: 11/29/2022] [Accepted: 02/13/2023] [Indexed: 12/01/2023]
Abstract
Background Persons with primary biliary cholangitis (PBC) experience significantly higher rates of mental distress and impaired health related quality of life (HrQoL) than the general population. Given limited evidence, but a high need, our primary aim was to assess feasibility and acceptability of a 12-week, online, mind-body wellness program in people with PBC. Methods This was a single-group, sequential mixed-methods, pre-post feasibility, and acceptability study. Core program components included follow-along movement, meditation and breathwork videos, and cognitive behavioural therapy informed activities. This was supplemented by weekly phone check-ins. Feasibility was assessed by recruitment, adherence, and retention. The pre-post exploratory efficacy assessment included surveys for fatigue, perceived stress, anxiety, depression, HrQoL, and resilience. A qualitative descriptive approach with semi-structured interviews evaluated study experiences. Results Thirty-two participants were recruited within 30 days and 29 (91%) were retained to end-of-study. Of these, 25 (86%) adhered to carrying out the mind-body practice at least 2-3 days per week. Feedback supported acceptability (satisfaction score 90%). Significant improvements were observed in fatigue (13%, p = 0.004), anxiety (30%, p = 0.005), depression (28%, p = 0.004), and five PBC-40 domains (itch, fatigue, cognitive, emotional, general symptoms). Qualitative interviews revealed improved stress management, better coping, and a more positive mindset. Fatigue and self-sabotaging thoughts were cited as barriers to participation. Conclusions These findings suggest that a 12-week online mind-body intervention is feasible and acceptable in patients with PBC. After iterative refinement, a randomized controlled trial will be designed using this feedback.
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Affiliation(s)
- Makayla Watt
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ashley Hyde
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - John C Spence
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Emily Johnson
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew Mason
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Magnus McLeod
- Division of General Internal Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Puneeta Tandon
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Buchanan-Peart KA, Levy C. Novel Therapies in Primary Biliary Cholangitis: What Is in the Pipeline? Clin Liver Dis 2022; 26:747-764. [PMID: 36270727 DOI: 10.1016/j.cld.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Primary biliary cholangitis is a chronic autoimmune disease characterized by inflammation and the progressive destruction of small intrahepatic bile ducts. Current first-line treatment includes ursodeoxycholic acid; however, a significant number of patients have an inadequate response to therapy. These patients are at risk of liver failure requiring liver transplantation and experience a poor quality of life due to refractory symptoms. This manuscript aims to shed light on the current and prospective treatment options that may slow disease progression and improve these patients' symptoms.
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Affiliation(s)
- Keri-Ann Buchanan-Peart
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1500 Northwest 12th Avenue, Suite 1101-E, Miami, FL 33136, USA; Department of Internal Medicine, Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL 33136, USA
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, 1500 Northwest 12th Avenue, Suite 1101-E, Miami, FL 33136, USA.
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4
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Laschtowitz A, de Veer RC, Van der Meer AJ, Schramm C. Diagnosis and treatment of primary biliary cholangitis. United European Gastroenterol J 2020; 8:667-674. [PMID: 32299307 PMCID: PMC7437077 DOI: 10.1177/2050640620919585] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/23/2020] [Indexed: 01/26/2023] Open
Abstract
Primary biliary cholangitis is a cholestatic, chronic autoimmune liver disease with a wide individual variation in disease progression. The diagnosis is predominantly based on chronic elevation of alkaline phosphatase and the presence of anti-mitochondrial antibodies or other specific antinuclear antibodies (i.e. anti-gp210 and anti-sp100). Even in early-stage disease, health-related quality of life can be severely impaired by symptoms such as pruritus, fatigue, and sicca syndrome and metabolic bone disease should be assessed and treated. The prognosis of the disease is, however, largely determined by the development of cirrhosis and its complications. Ursodeoxycholic acid is associated with an improved prognosis and should be initiated and continued in all patients. Clinical outcome is related to the biochemical response to ursodeoxycholic acid, but the prognosis of those with an incomplete response is still better than those who remain untreated. Obeticholic acid was recently approved as second-line treatment and bezafibrate may serve as an adequate off-label alternative, particularly in patients with pruritus. Preliminary data suggest an additive effect of triple therapy with ursodeoxycholic acid, obeticholic acid, and bezafibrate, whereas other promising drugs are being evaluated in clinical trials.
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Affiliation(s)
- Alena Laschtowitz
- I Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases, Hamburg, Germany
| | - Rozanne C de Veer
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, the Netherlands
| | - Adriaan J Van der Meer
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, the Netherlands
| | - Christoph Schramm
- I Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases, Hamburg, Germany
- Martin Zeitz Center for Rare diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany *shared first co-authorship
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5
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Lee JY, Danford CJ, Trivedi HD, Tapper EB, Patwardhan VR, Bonder A. Treatment of Fatigue in Primary Biliary Cholangitis: A Systematic Review and Meta-Analysis. Dig Dis Sci 2019; 64:2338-2350. [PMID: 30632051 DOI: 10.1007/s10620-019-5457-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Fatigue is the most common complication of primary biliary cholangitis (PBC) and can be debilitating. Numerous interventions have been trialed targeting several proposed mechanisms of PBC-associated fatigue. We sought to summarize and perform a meta-analysis to determine the efficacy of these interventions. METHODS A comprehensive database search was conducted from inception through March 27, 2018. The primary outcome was proportion of fatigued patients or reduction in degree of fatigue. Adverse events were a secondary outcome. We assessed studies for risk of bias, graded quality of evidence, and used meta-analysis to obtain overall effect by pooling studies of the same class. RESULTS We identified 16 studies evaluating ursodeoxycholic acid (UDCA) (7), liver transplantation (2), serotonin reuptake inhibitors (2), colchicine (1), methotrexate (1), cyclosporine (1), modafinil (1), and obeticholic acid (1). On meta-analysis, UDCA was not associated with a reduction in risk of fatigue (RR = 0.86, 95% CI 0.69-1.08, p = 0.19, I2 = 56.2%). While liver transplantation did reduce degree of fatigue (SMD - 0.57, 95% CI - 0.89 to - 0.24, p = 0.001, I2 = 67.3%), fatigue did not return to baseline indicating the underlying cause may not be addressed. CONCLUSIONS While there is some improvement in fatigue with liver transplantation, there is a lack of high-quality evidence supporting the efficacy of any other intervention in the treatment of PBC-related fatigue. Further research into the underlying pathophysiology may help guide future trials.
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Affiliation(s)
- Jennifer Y Lee
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Christopher J Danford
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Dana 603, Boston, MA, 02215, USA
| | - Hirsh D Trivedi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Dana 603, Boston, MA, 02215, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University Hospital, University of Michigan, Floor 2, Room 2B353, 1500 E. Medical Center Dr SPC 5051, Ann Arbor, MI, 48109-5051, USA
| | - Vilas R Patwardhan
- Liver Center, Autoimmune and Cholestatic Liver Disease Program, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Alan Bonder
- Liver Center, Autoimmune and Cholestatic Liver Disease Program, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA.
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6
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Abstract
Primary biliary cholangitis (PBC) is a chronic, cholestatic, autoimmune disease with a variable progressive course. PBC can cause debilitating symptoms including fatigue and pruritus and, if left untreated, is associated with a high risk of cirrhosis and related complications, liver failure, and death. Recent changes to the PBC landscape include a name change, updated guidelines for diagnosis and treatment as well as new treatment options that have recently become available. Practicing clinicians face many unanswered questions when managing PBC. To assist these healthcare providers in managing patients with PBC, the American College of Gastroenterology (ACG) Institute for Clinical Research & Education, in collaboration with the Chronic Liver Disease Foundation (CLDF), organized a panel of experts to evaluate and summarize the most current and relevant peer-reviewed literature regarding PBC. This, combined with the extensive experience and clinical expertise of this expert panel, led to the formation of this clinical guidance on the diagnosis and management of PBC.
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Bruyneel M, Sersté T. Sleep disturbances in patients with liver cirrhosis: prevalence, impact, and management challenges. Nat Sci Sleep 2018; 10:369-375. [PMID: 30464664 PMCID: PMC6220431 DOI: 10.2147/nss.s186665] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Sleep-wake disturbances are common in liver cirrhosis and associated with impaired quality of life. The most common abnormalities are insomnia (difficulties falling asleep and maintaining sleep, or unrefreshing sleep), excessive daytime sleepiness, and sleep-wake inversion (disturbances of circadian rhythmicity). The underlying pathophysiological mechanisms for sleep disturbances in cirrhosis are complex and may include disturbed metabolism of melatonin and glucose, alterations in thermoregulation, and altered ghrelin secretion profiles. Sleep-wake abnormalities are related to the presence of hepatic encephalopathy (HE) and improvement in sleep parameters can be observed when HE is properly managed. A few non-specific treatments for sleep-wake abnormalities have been tried with encouraging results for hydroxyzine and modafinil. However, due to the potential for medication toxicity in these disabled patients, further studies are needed to address the potential role of non-drug therapies in this population (eg, cognitive behavioral therapy, mindfulness, yoga) that have demonstrated usefulness in insomnia disorders.
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Affiliation(s)
- Marie Bruyneel
- Sleep Unit, Department of Pneumology, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium,
| | - Thomas Sersté
- Department of Hepato-gastroenterology, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
- Liver Transplantation Unit, Department of Hepato-gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Burman BE, Jhaveri MA, Kowdley KV. An Update on the Treatment and Follow-up of Patients with Primary Biliary Cholangitis. Clin Liver Dis 2017; 21:709-723. [PMID: 28987258 DOI: 10.1016/j.cld.2017.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Primary biliary cholangitis (PBC) is an autoimmune liver disease characterized by chronic granulomatous lymphocytic cholangitis of the small bile ducts. PBC was a leading indication for liver transplant in the United States; with early diagnosis and treatment, the majority of patients with PBC have a normal life expectancy. Pathogenesis involves inflammatory damage of bile duct epithelium secondary to innate and adaptive immune responses, and toxicity from accumulated bile acids. Cholestasis and disease progression can lead to cirrhosis. Extrahepatic complications include dyslipidemia, metabolic bone disease, and fat-soluble vitamin deficiency. Ursodeoxycholic acid is a well-established therapy. Novel targeted therapeutics are being developed.
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Affiliation(s)
- Blaire E Burman
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98101, USA
| | - Manan A Jhaveri
- Department of Organ Transplant & Liver Center, Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, 1124 Columbia Street, WA 98101, USA
| | - Kris V Kowdley
- Department of Organ Transplant & Liver Center, Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, 1124 Columbia Street, WA 98101, USA.
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A Randomized, Placebo-Controlled Clinical Trial of Efficacy and Safety: Modafinil in the Treatment of Fatigue in Patients With Primary Biliary Cirrhosis. Am J Ther 2017; 24:e167-e176. [PMID: 27148676 DOI: 10.1097/mjt.0000000000000387] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Fatigue is a common symptom of primary biliary cirrhosis (PBC), and is associated with an impaired quality of life. STUDY QUESTION No studies have assessed the use of modafinil in fatigue related to PBC in a controlled manner. STUDY DESIGN, MEASURES, AND OUTCOMES A randomized, double-blind, placebo-controlled study was conducted to determine the safety and efficacy of modafinil for the treatment of fatigue in PBC. Forty patients were randomized to modafinil (n = 20) or placebo (n = 20) for 12 weeks. A verbal report of fatigue for at least 6 months was required for enrollment. Modafinil was administered at 100 mg by mouth once daily; a change by 50 mg every 2 weeks (maximum: 200 mg once daily) was allowed, depending on the subject's response to treatment. The primary outcome was defined as a ≥50% improvement in fatigue severity [quantified by the Fisk Fatigue Impact Scale (FFIS)] after 12 weeks of treatment, compared with baseline values. RESULTS Thirty-three PBC patients completed the study. After 12 weeks of therapy, only 5 patients had a ≥50% reduction in FFIS scores: 3 patients (17.6%) in the modafinil arm and 2 (12.5%) in the placebo arm (P = 1.00). Change in median FFIS score was not statistically different between patients in the 2 treatment groups (P = 0.36). Modafinil was associated with minimal adverse events (headaches, diarrhea, and rash). CONCLUSIONS In patients with PBC who have fatigue, treatment with modafinil for 12 weeks was safe and fairly well tolerated; however, it did not result in beneficial effects on fatigue compared with patients treated with placebo (CONSORT Table 1). ClinicalTrials.gov identifier NCT00943176.
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10
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Floreani A, Sun Y, Zou ZS, Li B, Cazzagon N, Bowlus CL, Gershwin ME. Proposed therapies in primary biliary cholangitis. Expert Rev Gastroenterol Hepatol 2016; 10:371-382. [PMID: 26577047 PMCID: PMC4935759 DOI: 10.1586/17474124.2016.1121810] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary biliary cholangitis (PBC), previously known as primary biliary cirrhosis, is a model autoimmune disease with chronic cholestasis characterized by the hallmark of anti-mitochondrial antibodies and treated with ursodeoxycholic acid (UDCA). However, approximately 20-40% of patients incompletely respond to UDCA and have an increased risk of disease progression. Although there have been significant advances in the immunobiology of PBC, these have yet to be translated into newer therapeutic modalities. Current approaches to controlling the immune response include broad immunosuppression with corticosteroids as well as targeted therapies directed against T and B cells. In contrast, ameliorating cholestasis is the focus of other therapies in development, including obeticholic acid. In this article the authors will discuss ongoing clinical trials and, in particular, the rationale for choosing agents that may effectively target the aberrant immune response.
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Affiliation(s)
- Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy
| | - Ying Sun
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California Davis School of Medicine, Davis, CA, USA.,Diagnostic and Treatment Center for Non-Infectious Liver Diseases, 302 Military Hospital, Beijing, China
| | - Zheng Sheng Zou
- Diagnostic and Treatment Center for Non-Infectious Liver Diseases, 302 Military Hospital, Beijing, China
| | - Baosen Li
- Diagnostic and Treatment Center for Non-Infectious Liver Diseases, 302 Military Hospital, Beijing, China
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Davis, CA, USA
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California Davis School of Medicine, Davis, CA, USA
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Jopson L, Dyson JK, Jones DEJ. Understanding and Treating Fatigue in Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis. Clin Liver Dis 2016; 20:131-42. [PMID: 26593295 DOI: 10.1016/j.cld.2015.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fatigue is a significant problem for patients with primary biliary cirrhosis and although experienced less by patients with primary sclerosing cholangitis, a minority still report significant fatigue. Fatigue is the symptom with the greatest impact on quality of life, particularly when associated with social dysfunction. The pathogenesis of fatigue in cholestatic liver disease is complex, poorly understood, and probably has central and peripheral components. Managing fatigue in cholestatic liver disease presents a challenge for clinicians given the complexity and its numerous associations. This article presents a structured approach to managing fatigue in cholestatic liver disease to improve fatigue severity and quality of life.
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Affiliation(s)
- Laura Jopson
- Institute of Cellular Medicine, Newcastle University, Level 3 William Leech Building, Medical School, Framlington Place, Newcastle upon Tyne NE24HH, UK
| | - Jessica K Dyson
- Institute of Cellular Medicine, Newcastle University, Level 3 William Leech Building, Medical School, Framlington Place, Newcastle upon Tyne NE24HH, UK
| | - David E J Jones
- Institute of Cellular Medicine, Newcastle University, Level 3 William Leech Building, Medical School, Framlington Place, Newcastle upon Tyne NE24HH, UK.
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12
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Zhao X, Wong P. Managing Sleep Disturbances in Cirrhosis. SCIENTIFICA 2016; 2016:6576812. [PMID: 27242950 PMCID: PMC4868900 DOI: 10.1155/2016/6576812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 04/04/2016] [Indexed: 05/16/2023]
Abstract
Sleep disturbances, particularly daytime sleepiness and insomnia, are common problems reported by patients suffering from liver cirrhosis. Poor sleep negatively impacts patients' quality of life and cognitive functions and increases mortality. Although sleep disturbances can be an early sign of hepatic encephalopathy (HE), many patients without HE still complain of poor quality sleep. The pathophysiology of these disturbances is not fully understood but is believed to be linked to impaired hepatic melatonin metabolism. This paper provides an overview for the clinician of common comorbidities contributing to poor sleep in patients with liver disease, mainly restless leg syndrome and obstructive sleep apnea. It discusses nondrug and pharmacologic treatment options in these patients, such as the use of light therapy and histamine (H1) blockers.
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Affiliation(s)
- Xun Zhao
- Department of Gastroenterology and Hepatology, Royal Victoria Hospital, McGill University, 1001 Boulevard Decarie, Montreal, QC, Canada H4A 3J1
| | - Philip Wong
- Department of Gastroenterology and Hepatology, Royal Victoria Hospital, McGill University, 1001 Boulevard Decarie, Montreal, QC, Canada H4A 3J1
- *Philip Wong:
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13
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Bittencourt PL, Cançado ELR, Couto CA, Levy C, Porta G, Silva AEB, Terrabuio DRB, Carvalho Filho RJD, Chaves DM, Miura IK, Codes L, Faria LC, Evangelista AS, Farias AQ, Gonçalves LL, Harriz M, Lopes Neto EPA, Luz GO, Oliveira P, Oliveira EMGD, Schiavon JLN, Seva-Pereira T, Parise ER, Parise ER. Brazilian society of hepatology recommendations for the diagnosis and management of autoimmune diseases of the liver. ARQUIVOS DE GASTROENTEROLOGIA 2015; 52 Suppl 1:15-46. [DOI: 10.1590/s0004-28032015000500002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT In order to draw evidence-based recommendations concerning the management of autoimmune diseases of the liver, the Brazilian Society of Hepatology has sponsored a single-topic meeting in October 18th, 2014 at São Paulo. An organizing committee comprised of seven investigators was previously elected by the Governing Board to organize the scientific agenda as well as to select twenty panelists to make a systematic review of the literature and to present topics related to the diagnosis and treatment of autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cirrhosis and their overlap syndromes. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of those recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present paper is the final version of the reviewed manuscript organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
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Abstract
Primary biliary cirrhosis is a chronic cholestatic liver disease characterised by destruction of small intrahepatic bile ducts, leading to fibrosis and potential cirrhosis through resulting complications. The serological hallmark of primary biliary cirrhosis is the antimitochondrial antibody, a highly disease-specific antibody identified in about 95% of patients with primary biliary cirrhosis. These patients usually have fatigue and pruritus, both of which occur independently of disease severity. The typical course of primary biliary cirrhosis has changed substantially with the introduöction of ursodeoxycholic acid (UDCA). Several randomised placebo-controlled studies have shown that UDCA improves transplant-free survival in primary biliary cirrhosis. However, about 40% of patients do not have a biochemical response to UDCA and would benefit from new therapies. Liver transplantation is a life-saving surgery with excellent outcomes for those with decompensated cirrhosis. Meanwhile, research on nuclear receptor hormones has led to the development of exciting new potential treatments. This Seminar will review the current understanding of the epidemiology, pathogenesis, and natural history of primary biliary cirrhosis, discuss management of the disease and its sequelae, and introduce research on new therapeutic options.
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Affiliation(s)
- Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Ahmad H Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA; Arizona State University, College of Health Solutions, Phoenix, AZ, USA.
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15
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Purohit T, Cappell MS. Primary biliary cirrhosis: Pathophysiology, clinical presentation and therapy. World J Hepatol 2015; 7:926-941. [PMID: 25954476 PMCID: PMC4419097 DOI: 10.4254/wjh.v7.i7.926] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 01/15/2015] [Accepted: 03/09/2015] [Indexed: 02/06/2023] Open
Abstract
Primary biliary cirrhosis (PBC) is an autoimmune, slowly progressive, cholestatic, liver disease characterized by a triad of chronic cholestasis, circulating anti-mitochondrial antibodies (AMA), and characteristic liver biopsy findings of nonsuppurative destructive cholangitis and interlobular bile duct destruction. About 10% of PBC patients, however, lack AMA. A variant, called PBC-autoimmune hepatitis (AIH) overlap, is characterized by the above findings of PBC together with findings of elevated serum alanine aminotransferase, elevated serum immunoglobulin G, and circulating anti-smooth muscle antibodies, with liver biopsy demonstrating periportal or periseptal, lymphocytic, piecemeal necrosis. PBC is hypothesized to be related to environmental exposure in genetically vulnerable individuals. It typically occurs in middle-aged females. Prominent clinical features include fatigue, pruritis, jaundice, xanthomas, osteoporosis, and dyslipidemia. The Mayo Risk score is the most widely used and best prognostic system. Ursodeoxycholic acid is the primary therapy. It works partly by reducing the concentration and injury from relatively toxic bile acids. PBC-AIH overlap syndrome is treated with ursodeoxycholic acid and corticosteroids, especially budesonide. Obeticholic acid and fibrate are promising new, but incompletely tested, therapies. Liver transplantation is the definitive therapy for advanced disease, with about 70% 10-year survival after transplantation. Management of pruritis includes local skin care, dermatologist referral, avoiding potential pruritogens, cholestyramine, and possibly opioid antagonists, sertraline, or rifaximin. Management of osteoporosis includes life-style modifications, administration of calcium and vitamin D, and alendronate. Statins are relatively safe to treat the osteopenia associated with PBC. Associated Sjogren’s syndrome is treated by artificial tears, cyclosporine ophthalmic emulsion to stimulate tear production; and saliva substitutes, cholinergic agents, and scrupulous oral and dental care. Complications of cirrhosis from advanced PBC include esophageal varices, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatoma formation.
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Abstract
Primary biliary cirrhosis (PBC) is a chronic, autoimmune, cholestatic liver disease. It is characterized by slow destruction of small intrahepatic bile ducts, impaired biliary secretion and stasis of toxic endogenous bile acids within the liver with progression to liver fibrosis and cirrhosis. It has an increasing prevalence worldwide. It occurs more commonly in women than men at a ratio of 10:1. In most cases, diagnosis relies on a positive antimitochondrial antibody in the context of chronic cholestasis, without the need for a liver biopsy. Ursodeoxycholic acid improves survival even in patients with advanced liver disease. Certain findings such as fatigue, anti-nuclear antibodies, anti-centromere antibodies and the GP210 antinuclear antibody predict a poor outcome. Up to 40% of patients do not respond satisfactorily to ursodeoxycholic acid therapy and should be considered for adjunctive therapies. Several adjunctive and newer therapies are being tested and some appear promising. We provide a review of PBC with a focus on advances in therapies that may impact the management of PBC in the near future.
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Abstract
The care of the patient with cholestasis hinges on identifying the etiology, treating reversible causes, and managing chronic cholestatic processes. PBC and PSC are important causes of chronic cholestasis, and are the most common causes of cholestatic liver disease. Effective therapy is available for patients with PBC, whereas none exists for patients with PSC. Awareness of the complications that may be associated with cholestasis and implementing the appropriate management are essential.
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Affiliation(s)
- Andrea A Gossard
- Cholestatic Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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18
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Zenouzi R, Weiler-Normann C, Lohse AW. Is fatigue in primary biliary cirrhosis cured by transplantation? J Hepatol 2013; 59:418-9. [PMID: 23742911 DOI: 10.1016/j.jhep.2013.05.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 05/29/2013] [Indexed: 12/04/2022]
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19
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Abstract
Cholestasis is defined as impairment of bile formation or bile flow. Care of the patient with cholestatic features is dependent on identifying the cause of the cholestasis, initiating appropriate treatment of reversible conditions, and the recognition and management of cholestasis-specific complications. Cholestasis may include extrahepatic ducts and intrahepatic bile ducts, or may be limited to one or the other. Jaundice and pruritus are the hallmarks of cholestasis clinically but biochemical evidence may, and often does, precede the clinical manifestations.
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Affiliation(s)
- Andrea A Gossard
- Cholestatic Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA.
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20
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Anderson K, Jones DEJ, Wilton K, Newton JL. Restless leg syndrome is a treatable cause of sleep disturbance and fatigue in primary biliary cirrhosis. Liver Int 2013; 33:239-43. [PMID: 23295055 DOI: 10.1111/liv.12035] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 10/11/2012] [Indexed: 02/13/2023]
Abstract
BACKGROUND Primary biliary cirrhosis (PBC) patients frequently describe sleep problems. The cause remains unclear and treatment is challenging. Restless leg syndrome (RLS) is a common sleep disorder. In this study, we systematically screened PBC patients for the presence of RLS. METHODS Participants were recruited from our specialist PBC clinical service. Subjects completed the International Restless Leg Syndrome Study Group rating scale (IRLSS) a validated measure of the presence of RLS and its severity. Those fulfilling diagnostic criteria for RLS underwent foot actigraphy (CamNtech Actiwatch) to objectively assess periodic limb movement index (PLMI) (normal <5/h). RESULTS Restless leg syndrome was assessed in 42 consecutive early stage PBC patients. Twelve (29%) fulfilled the IRLSS criteria for RLS. Scores were significantly higher in PBC compared to controls (P = 0.005). Twenty-four patients were further assessed with foot actigraphy for 3 nights (12 with subjective RLS symptoms and 12 with no RLS symptoms). Thirteen of twenty-four subjects had PLMI >5/h and four had moderate or severe PLMI >15/h. All moderate or severe PLMI subjects had subjective symptoms of moderate or severe RLS. No patients had PLMI >10 in the absence of RLS symptoms. Eleven PBC patients with symptomatic RLS went on to have treatment. Sixty-three per cent had clear benefit in restless leg symptoms and associated symptoms of fatigue. CONCLUSION Restless leg syndrome symptoms are common and underdiagnosed in PBC patients. RLS represents a potential therapy for PBC patients with daytime sleepiness, fatigue and unpleasant lower limb symptoms and this is worthy of further studies in larger cohorts.
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Affiliation(s)
- Kirstie Anderson
- Newcastle Hospitals NHS Foundation Trust, Newcastle University, Newcastle, UK
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21
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Abstract
Primary biliary cirrhosis (PBC) is a chronic inflammatory autoimmune disease that mainly targets the cholangiocytes of the interlobular bile ducts in the liver. It is a rare disease with prevalence of less than one in 2000. Its prevalence in developing countries is increasing presumably because of growth in recognition and knowledge of the disease. PBC is thought to result from a combination of multiple genetic factors and superimposed environmental triggers. The contribution of the genetic predisposition is evidenced by familial clustering. Several risk factors, including exposure to infectious agents and chemical xenobiotics, have been suggested. Common symptoms of the disease are fatigue and pruritus, but most patients are asymptomatic at first presentation. The prognosis of PBC has improved because of early diagnosis and use of ursodeoxycholic acid, the only established medical treatment for this disorder. When administered at adequate doses of 13–15 mg/kg/day, up to two out of three patients with PBC may have a normal life expectancy without additional therapeutic measures. However, some patients do not respond adequately to ursodeoxycholic acid and might need alternative therapeutic approaches.
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Affiliation(s)
- Nadya Al-Harthy
- Gastroenterology and Hepatology, Royal Hospital, Muscat, Oman
| | - Teru Kumagi
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
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22
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Noaiseh G, Li S, Derk CT. Management of gastrointestinal manifestations in systemic sclerosis (scleroderma). ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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23
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Carey EJ, Lindor KD. Current pharmacotherapy for cholestatic liver disease. Expert Opin Pharmacother 2012; 13:2473-84. [PMID: 23094715 DOI: 10.1517/14656566.2012.736491] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE OF THE FIELD The cholestatic liver diseases comprise a heterogeneous group of disorders which, left untreated, usually progresses to cirrhosis and liver failure. Most are recognized before the onset of advanced fibrosis, thereby affording an opportunity for disease modifying therapy. AREAS COVERED This review will cover the current pharmacologic management of the most common causes of cholestatic liver disease in adults, including primary biliary cirrhosis, primary biliary cirrhosis-autoimmune hepatitis overlap syndrome, primary sclerosing cholangitis, intrahepatic cholestasis of pregnancy, intestinal failure-associated liver disease, and immunoglobulin G4-associated cholangitis. Pharmacologic management of complications of cholestasis will also be reviewed. EXPERT OPINION Effective therapy for most cholestatic liver disease is lacking. Ursodeoxycholic acid (UDCA) slows the progression of primary biliary cirrhosis but the majority of patients do not have a full response. Even in those with a complete response, UDCA does not cure the disease. There is currently no effective medical therapy for primary sclerosing cholangitis. Symptoms and serum liver biochemistry values in intrahepatic cholestasis of pregnancy are improved with UDCA, but it is not certain if this alters the course of disease. Immunoglobulin G4-associated cholangitis is responsive to steroids but may relapse. The farnesoid X receptor agonists are a promising new class of drugs currently being tested in cholestatic liver disease.
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Affiliation(s)
- Elizabeth J Carey
- Mayo Clinic in Arizona, Division of Hepatology, Phoenix, AZ 85054, USA.
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Rabkin JG, McElhiney MC, Rabkin R. Modafinil and armodafinil treatment for fatigue for HIV-positive patients with and without chronic hepatitis C. Int J STD AIDS 2011; 22:95-101. [PMID: 21427431 DOI: 10.1258/ijsa.2010.010326] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Fatigue is prevalent among patients with hepatitis C virus (HCV) and with HIV/AIDS but there are no established fatigue treatments for either condition or their combination. We analysed data from three trials of modafinil or armodafinil for HIV-positive patients with fatigue, including 36 co-infected with HCV, to compare treatment response and safety parameters related to HCV status. One hundred and twenty patients received active drug and 70 were randomized to placebo. Fatigue response rate to modafinil/armodafinil was 100% for patients with HCV (18/18) and 73% (74/102) for patients without HCV. Placebo response rate was 28% (5/18) and 29% (15/52), respectively. Depressive symptoms improved only when energy improved. Viral load declined from baseline after 12 and 26 weeks of active medication. CD4 cell count did not change, nor did alanine transaminase and aspartate aminotransferase for patients with HCV. Patients with haematocrit below the reference range responded, as well as patients whose values were within the reference range. Modafinil and armodafinil appear effective and well tolerated for treating fatigue among both HCV-positive and HCV-negative patients with HIV/AIDS, suggesting that they may hold promise for HIV-positive patients considering alpha interferon/ribavirin treatment for HCV. Further investigation in a focused trial is warranted.
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Affiliation(s)
- J G Rabkin
- New York State Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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25
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Liver transplantation in PBC and PSC: indications and disease recurrence. Clin Res Hepatol Gastroenterol 2011; 35:446-54. [PMID: 21459072 DOI: 10.1016/j.clinre.2011.02.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 02/09/2011] [Indexed: 02/07/2023]
Abstract
Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) represent major indications for liver transplantation (LT). Despite the steady increase in the incidence and prevalence of PBC, the number of liver transplants for PBC has fallen in recent years, whereas the number of transplants for PSC has remained stable. Indications for LT for PBC and PSC are no different from those of other causes of chronic liver disease, apart from some disease-specific indications. PBC and PSC have more favourable outcomes after LT, compared to viral hepatitis and alcohol-associated liver disease. Numerous studies have clearly demonstrated that PBC and PSC recur after LT. The diagnosis of recurrent disease should be made on agreed criteria. The impact of recurrent disease on survival is unclear. Study of recurrent PBC and PSC may provide a better understanding of the mechanisms of these diseases in the native liver.
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26
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Abstract
Primary biliary cirrhosis is a chronic autoimmune inflammatory disease of the liver with a striking female preponderance. It has an insidious onset and typically affects middle-aged women. The disease manifests gradually with symptoms of fatigue, pruritis, and increased alkaline phosphatase levels on laboratory evaluation. The hallmark of the disease is the circulating antimitochondrial antibody. Histology is characterized by inflammation of the bile ducts, destruction of cholangiocytes, and subsequent cholestasis, progressing to biliary cirrhosis. The standard treatment for primary biliary cirrhosis is ursodeoxycholic acid, which improves survival, but the disease can still lead to cirrhosis and liver failure over decades.
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Affiliation(s)
- Bhavik M Bhandari
- Division of Gastroenterology & Hepatology, Drexel University College of Medicine, 219 North Broad Street, Fifth Floor, Philadelphia, PA 19107, USA.
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27
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Rodrigue JR, Nelson DR, Reed AI, Hanto DW, Curry M. Fatigue and sleep quality before and after liver transplantation. Prog Transplant 2010. [PMID: 20929106 DOI: 10.7182/prtr.20.3.x82q1832184j4733] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
CONTEXT Recent publications suggest that fatigue and sleep disturbance are problems in patients with chronic liver disease and in liver transplant recipients. OBJECTIVES To characterize the severity and nature of fatigue and sleep quality before and after liver transplantation, to examine the relationship between fatigue/ sleep quality and quality of life, and to identify their multivariate correlates. DESIGN, SETTINGS, AND PARTICIPANTS Cross-sectional survey administered to 110 patients before and 95 patients after liver transplantation at 2 transplant centers. MAIN OUTCOME MEASURES Fatigue and sleep quality. RESULTS Most pretransplant (86%) and posttransplant (76%) patients experienced high fatigue severity. Correlates of pretransplant fatigue severity were being female (odds ratio [OR] = 0.22, P = .04), higher body mass index (OR = 1.07, P = .04), higher mood disturbance (OR = 1.05, P = .02), and poor sleep quality (OR = 0.26, P = .02). Correlates of posttransplant fatigue severity were use of sleep medications in the past month (OR = 0.51, P = .02) and higher mood disturbance (OR = 1.06, P = .004). Seventy-three percent of pretransplant and 77% of posttransplant patients were classified as having poor sleep quality. Higher body mass index (OR = 1.06, P = .05), sleep medications (OR = 0.43, P = .03), and more mood disturbance (OR = 1.04, P = .007) were predictive of poor sleep quality in pretransplant patients, whereas higher body mass index (OR = 1.07, P = .04) and more anxious mood (OR = 1.28, P = .03) were predictive of poor sleep quality in posttransplant patients. CONCLUSION A very high proportion of both pretransplant and posttransplant patients experience clinically severe fatigue levels. Prospective research is necessary to identify causal mechanisms of these disorders and to evaluate strategies to reduce fatigue severity and improve sleep quality.
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Affiliation(s)
- James R Rodrigue
- Transplant Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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28
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Rodrigue JR, Nelson DR, Reed AI, Hanto DW, Curry M. Fatigue and Sleep Quality before and after Liver Transplantation. Prog Transplant 2010; 20:221-33. [DOI: 10.1177/152692481002000305] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Context Recent publications suggest that fatigue and sleep disturbance are problems in patients with chronic liver disease and in liver transplant recipients. Objectives To characterize the severity and nature of fatigue and sleep quality before and after liver transplantation, to examine the relationship between fatigue/sleep quality and quality of life, and to identify their multivariate correlates. Design, Settings, and Participants Cross-sectional survey administered to 110 patients before and 95 patients after liver transplantation at 2 transplant centers. Main Outcome Measures Fatigue and sleep quality. Results Most pretransplant (86%) and posttransplant (76%) patients experienced high fatigue severity. Correlates of pretransplant fatigue severity were being female (odds ratio [OR] = 0.22, P= .04), higher body mass index (OR = 1.07, P= .04), higher mood disturbance (OR=1.05, P= .02), and poor sleep quality (OR=0.26, P= .02). Correlates of posttransplant fatigue severity were use of sleep medications in the past month (OR = 0.51, P= .02) and higher mood disturbance (OR = 1.06, P = .004). Seventy-three percent of pretransplant and 77% of posttransplant patients were classified as having poor sleep quality. Higher body mass index (OR = 1.06, P= .05), sleep medications (OR=0.43, P= .03), and more mood disturbance (OR=1.04, P = .007) were predictive of poor sleep quality in pretransplant patients, whereas higher body mass index (OR=1.07, P= .04) and more anxious mood (OR=1.28, P = .03) were predictive of poor sleep quality in posttransplant patients. Conclusion A very high proportion of both pretransplant and posttransplant patients experience clinically severe fatigue levels. Prospective research is necessary to identify causal mechanisms of these disorders and to evaluate strategies to reduce fatigue severity and improve sleep quality.
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Affiliation(s)
- James R. Rodrigue
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (JRR, DWH, MC), University of Florida, Gainesville (DRN), University of Iowa, Iowa City (AIR)
| | - David R. Nelson
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (JRR, DWH, MC), University of Florida, Gainesville (DRN), University of Iowa, Iowa City (AIR)
| | - Alan I. Reed
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (JRR, DWH, MC), University of Florida, Gainesville (DRN), University of Iowa, Iowa City (AIR)
| | - Douglas W. Hanto
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (JRR, DWH, MC), University of Florida, Gainesville (DRN), University of Iowa, Iowa City (AIR)
| | - Michael Curry
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (JRR, DWH, MC), University of Florida, Gainesville (DRN), University of Iowa, Iowa City (AIR)
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29
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Abstract
Primary biliary cirrhosis (PBC) is a chronic, autoimmune, cholestatic liver disease with a slowly progressive course. Without treatment, most patients eventually develop fibrosis of the liver and may need liver transplantation in the late stage of disease. Fatigue and pruritus are the most common symptoms of PBC, but the majority of patients are asymptomatic at first presentation. There is no specific treatment for fatigue in PBC, but modafinil has shown some potential beneficial effects, such as increased energy levels and decreased total sleep time. This Review article discusses the natural history and the measurement of fatigue in patients with PBC. The central and the peripheral mechanisms that have been suggested for the pathogenesis of fatigue in PBC are also discussed and treatment options are reviewed.
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Zein CO, Lindor KD. Latest and emerging therapies for primary biliary cirrhosis and primary sclerosing cholangitis. Curr Gastroenterol Rep 2010; 12:13-22. [PMID: 20425480 DOI: 10.1007/s11894-009-0079-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are the two most common causes of chronic cholestatic liver disease in adults. In PBC, therapy with ursodeoxycholic acid (UDCA) is safe and has been associated with tangible biochemical, histologic, and survival benefits. However, a need for different or adjuvant therapies remains for specific subsets of PBC patients, including those who do not respond to UDCA and those who have advanced histologic disease at presentation. Similarly, beneficial therapies for disease-related symptoms that do not typically respond to UDCA (eg, fatigue and pruritus) are still needed. In contrast to PBC, no medical therapy of proven benefit has been identified for patients with PSC. In PBC and PSC, adequate management of complications of chronic cholestasis is important. For both diseases, liver transplantation is the only curative option.
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Affiliation(s)
- Claudia O Zein
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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MESH Headings
- Adult
- Child
- Cholangitis/diagnosis
- Cholangitis/immunology
- Cholangitis/therapy
- Cholangitis, Sclerosing/diagnosis
- Cholangitis, Sclerosing/therapy
- Cholestasis, Intrahepatic/diagnosis
- Cholestasis, Intrahepatic/etiology
- Cholestasis, Intrahepatic/prevention & control
- Cholestasis, Intrahepatic/therapy
- Cystic Fibrosis/complications
- Female
- Hepatitis, Autoimmune/diagnosis
- Hepatitis, Autoimmune/therapy
- Humans
- Immunoglobulin G/metabolism
- Infant
- Liver Cirrhosis, Biliary/diagnosis
- Liver Cirrhosis, Biliary/therapy
- Male
- Osteoporosis/etiology
- Osteoporosis/therapy
- Pregnancy
- Pregnancy Complications/diagnosis
- Pregnancy Complications/therapy
- Syndrome
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