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- Dose adjustment in patients with liver disease
- Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV
- Drug Dosing Adjustments in Patients with Chronic Kidney Disease
Dose adjustment in patients with liver disease
The liver plays a central role in the pharmacokinetics of the majority of drugs. Portal-systemic shunting, which is common in advanced liver cirrhosis, may substantially decrease the presystemic elimination i. Chronic liver diseases are associated with variable and non-uniform reductions in drug-metabolizing activities.
For example, the activity of the various CYP enzymes seems to be differentially affected in patients with cirrhosis. Glucuronidation is often considered to be affected to a lesser extent than CYPmediated reactions in mild to moderate cirrhosis but can also be substantially impaired in patients with advanced cirrhosis. Patients with advanced cirrhosis often have impaired renal function and dose adjustment may, therefore, also be necessary for drugs eliminated by renal exctretion.
In addition, patients with liver cirrhosis are more sensitive to the central adverse effects of opioid analgesics and the renal adverse effects of NSAIDs. In contrast, a decreased therapeutic effect has been noted in cirrhotic patients with beta-adrenoceptor antagonists and certain diuretics. Unfortunately, there is no simple endogenous marker to predict hepatic function with respect to the elimination capacity of specific drugs.
Several quantitative liver tests that measure the elimination of marker substrates such as galactose, sorbitol, antipyrine, caffeine, erythromycin, and midazolam, have been developed and evaluated, but no single test has gained widespread clinical use to adjust dosage regimens for drugs in patients with hepatic dysfunction. The semi-quantitative Child-Pugh score is frequently used to assess the severity of liver function impairment, but only offers the clinician rough guidance for dosage adjustment because it lacks the sensitivity to quantitate the specific ability of the liver to metabolize individual drugs.
The recommendations of the Food and Drug Administration FDA and the European Medicines Evaluation Agency EMEA to study the effect of liver disease on the pharmacokinetics of drugs under development is clearly aimed at generating, if possible, specific dosage recommendations for patients with hepatic dysfunction. However, the limitations of the Child-Pugh score are acknowledged, and further research is needed to develop more sensitive liver function tests to guide drug dosage adjustment in patients with hepatic dysfunction.
Skip to main content. User menu Cart Login. Search form Search. Verbeeck, Roger-K. Clin Pharmacokinet —15 Danielson PB The cytochrome P superfamily: biochemistry, evolution and drug metabolism in humans. Clin Pharmacokinet — Reichen J The role of the sinusoidal endothelium in liver function. Pharmacol Rev —47 Quigley EMM Gastrointestinal dysfunction in liver disease and portal hypertension: gut-liver interactions revisited. Hepatology — George J, Murray M, Byth K et al Differential alterations of cytochrome P proteins in livers from patients with severe chronic liver disease.
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Footer menu Conditions Copyright Contact Statistics. Drug dosage adjustment ; Hepatic dysfunction ; Liver disease ; Drug clearance ; Pharmacokinetics. Verbeeck, Roger-K..
Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV
Visit coronavirus. Please refer to the July 10, , guidelines in the Guidelines Archive section of ClinicalInfo or to the FDA product labels for these drugs for recommendations on dosing in persons with renal or hepatic insufficiency. See the reference section at the end of this table for CrCl calculation formulas and criteria for Child-Pugh classification. The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations. Guidelines search Guidelines search. Open Close.
Staphylococcus aureus methicillin susceptible , Coagulase negative Staphylococci, Streptococcus pneumoniae penicillin susceptible , Streptococcus spp. Cephalosporins exert bactericidal activity by interfering with bacterial cell wall synthesis and inhibiting cross-linking of the peptidoglycan. The cephalosporins are also thought to play a role in the activation of bacterical cell autolysins which may contribute to bacterial cell lysis. CrCl mL: g qh. Note: CVVH is mainly for fluid removal alone. Toxic: Urinalysis, BUN, SCr, AST and ALT, skin rash, Neutropenia and leukopenia, Prothrombin time in patients with renal or hepatic impairment or poor nutritional state, as well as patients receiving a protracted course of antimicrobial therapy, and patients previously stabilized on anticoagulant therapy.
Drug Dosing Adjustments in Patients with Chronic Kidney Disease
Unfortunately, there is no endogenous marker for hepatic clearance that can be used as a guide for drug dosing. In order to predict the kinetic behaviour of drugs in cirrhotic patients, agents can be grouped according to their extent of hepatic extraction. For drugs with a high hepatic extraction low bioavailability in healthy subjects , bioavailability increases and hepatic clearance decreases in cirrhotic patients. If such drugs are administered orally to cirrhotic patients, their initial dose has to be reduced according to hepatic extraction. Furthermore, their maintenance dose has to be adapted irrespective of the route of administration, if possible, according to kinetic studies in cirrhotic patients.
Estimating GFR and Creatinine Clearance
Metrics details. Dose adjustment for certain drugs is required in patients with reduced renal function to avoid toxicity as many drugs are eliminated by the kidneys. The aim of this study was to assess whether appropriate dosage adjustments were made in hospitalized patients with renal impairment.
If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Please consult the latest official manual style if you have any questions regarding the format accuracy. Compare the advantages and disadvantages of the use of drugs or endogenous substances as markers for the measurement of renal function. Describe the relationships between creatinine clearance, serum creatinine concentration, and glomerular filtration rate. Describe quantitatively using equations how renal or hepatic disease can alter the disposition of a drug.
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