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Diesveld MME, Pijnenburg DWMJ, Weersink RA, Barzel I, Drenth JPH, Lisman T, Metselaar HJ, Monster-Simons MH, Mulder MB, Okel E, Taxis K, Borgsteede SD. Recommendations for the safe use of direct oral anticoagulants in patients with cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. Eur J Clin Pharmacol 2024; 80:797-812. [PMID: 38430266 DOI: 10.1007/s00228-024-03648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/03/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE The popularity of direct oral anticoagulants (DOACs) is increasing among patients with cirrhosis. Cirrhosis has a major impact on the pharmacokinetics of drugs, potentially increasing adverse events. Safe use of drugs in cirrhosis requires a diligent risk-benefit analysis. The aim of this study is to develop practice recommendations for safe use of DOACs in cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. METHODS We conducted a systematic literature search to identify studies on pharmacokinetics, pharmacodynamics and safety of DOACs in cirrhosis. Data were collected and presented in summary tables by severity of cirrhosis using the Child-Turcotte-Pugh (CTP) classification. A multidisciplinary expert panel evaluated the results and classified the DOACs according to safety. RESULTS Fifty four studies were included. All DOACs were classified as 'no additional risks known' for CTP A. For CTP B, apixaban, dabigatran and edoxaban were classified as 'no additional risks known'. Apixaban and edoxaban showed fewer adverse events in patients with cirrhosis, while dabigatran may be less impacted by severity of cirrhosis based on its pharmacokinetic profile. Rivaroxaban was classified as 'unsafe' in CTP B and C based on significant pharmacokinetic alterations. Due to lack of data, apixaban, dabigatran and edoxaban were classified as 'unknown' for CTP C. CONCLUSION DOACs can be used in patients with CTP A cirrhosis, and apixaban, dabigatran and edoxaban can also be used in CTP B. It is recommended to avoid rivaroxaban in CTP B and C. There is insufficient evidence to support safe use of other DOACs in CTP C cirrhosis.
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Affiliation(s)
| | | | - Rianne A Weersink
- Deventer Hospital, Department of Clinical Pharmacy, Deventer, The Netherlands
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands
| | - Ina Barzel
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Joost P H Drenth
- Radboud University Medical Center, Department of Gastroenterology, Nijmegen, The Netherlands
| | - Ton Lisman
- University of Groningen, University Medical Center Groningen, Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Groningen, The Netherlands
| | - Herold J Metselaar
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | - Margje H Monster-Simons
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
- University of Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Midas B Mulder
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Eline Okel
- Pharmacy Zorgapotheken Flevoland, Almere, The Netherlands
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, -Epidemiology & -Economics, Groningen, The Netherlands
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2
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Principi N, Petropulacos K, Esposito S. Impact of Pharmacogenomics in Clinical Practice. Pharmaceuticals (Basel) 2023; 16:1596. [PMID: 38004461 PMCID: PMC10675377 DOI: 10.3390/ph16111596] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Polymorphisms of genes encoding drug metabolizing enzymes and transporters can significantly modify pharmacokinetics, and this can be associated with significant differences in drug efficacy, safety, and tolerability. Moreover, genetic variants of some components of the immune system can explain clinically relevant drug-related adverse events. However, the implementation of drug dose individualization based on pharmacogenomics remains scarce. In this narrative review, the impact of genetic variations on the disposition, safety, and tolerability of the most commonly prescribed drugs is reported. Moreover, reasons for poor implementation of pharmacogenomics in everyday clinical settings are discussed. The literature analysis showed that knowledge of how genetic variations can modify the effectiveness, safety, and tolerability of a drug can lead to the adjustment of usually recommended drug dosages, improve effectiveness, and reduce drug-related adverse events. Despite some efforts to introduce pharmacogenomics in clinical practice, presently very few centers routinely use genetic tests as a guide for drug prescription. The education of health care professionals seems critical to keep pace with the rapidly evolving field of pharmacogenomics. Moreover, multimodal algorithms that incorporate both clinical and genetic factors in drug prescribing could significantly help in this regard. Obviously, further studies which definitively establish which genetic variations play a role in conditioning drug effectiveness and safety are needed. Many problems must be solved, but the advantages for human health fully justify all the efforts.
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Affiliation(s)
| | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
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3
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Jibai N, Koch A, Ulmer TF, Erdmann P, Koeck JA, Eisert A. Pharmaceutical Interventions for Inpatients with Liver Cirrhosis and Liver Transplantation: A Systematic Review of Experimental Studies. J Clin Med 2023; 12:7030. [PMID: 38002644 PMCID: PMC10671912 DOI: 10.3390/jcm12227030] [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: 09/29/2023] [Revised: 10/29/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Liver cirrhosis, which is considered one of the leading causes of death in the world, can lead to severe complications, and is often followed by a liver transplantation. These patients take an average of nine medications daily. If not managed adequately, it can be accompanied by serious drug-related problems. To reduce this risk, a clinical pharmacist may be included as part of the healthcare team to optimize medication therapy in this population. This study aimed to systematically identify the pharmaceutical interventions which reduced drug-related problems and improved medication therapy for adult hospitalized liver cirrhotic and liver transplant patients when compared to standard care. Three databases (PubMed, Embase, and CENTRAL) were systematically searched from the inception of each database to 25 October 2023, and interventional studies in the English language were included. The risk of bias was assessed according to RoB-I for the UBA study and RoB2 for the identified RCT. The detected interventions to reduce drug-related problems in liver cirrhotic and liver transplant patients were extracted and classified according to a "Hierarchy of Controls" model. Two studies from Germany and the USA met our inclusion criteria, respectively. In these studies, we identified two interventions that included education, expert consultation, and the monitoring of the immunosuppressive medications serum level. The main objective of the two included studies was improving patients' compliance through adherence. These pharmaceutical interventions identified were classified as administrative controls, which is one of the lowest levels in the "Hierarchy of Controls" with which to address a potential risk. Pharmaceutical interventions to optimize medication therapy were found to be rare in the examined population, and were limited to "administrative controls". These interventions were limited to transplant patients' education and the monitoring of the immunosuppressive medication serum levels. No interventional studies were found to have investigated pharmaceutical interventions in patients with liver cirrhosis. Especially regarding this patient group, future studies to reduce DRPs using pharmaceutical interventions are needed. This study received no external funding and its PROSPERO registration number is CRD42022309122.
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Affiliation(s)
- Nagham Jibai
- Hospital Pharmacy, RWTH Aachen University Hospital, 52074 Aachen, Germany; (N.J.); (P.E.)
| | - Alexander Koch
- Department of Internal Medicine III, RWTH Aachen University Hospital, 52074 Aachen, Germany;
| | - Tom Florian Ulmer
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, 52074 Aachen, Germany;
| | - Pia Erdmann
- Hospital Pharmacy, RWTH Aachen University Hospital, 52074 Aachen, Germany; (N.J.); (P.E.)
| | | | - Albrecht Eisert
- Hospital Pharmacy, RWTH Aachen University Hospital, 52074 Aachen, Germany; (N.J.); (P.E.)
- Institute of Clinical Pharmacology, RWTH Aachen University Hospital, 52074 Aachen, Germany
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4
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Alsohaibani F, Peedikayil M, Alshahrani A, Somily A, Alsulaiman R, Azzam N, Almadi M. Practice guidelines for the management of Helicobacter pylori infection: The Saudi H. pylori Working Group recommendations. Saudi J Gastroenterol 2023; 29:326-346. [PMID: 36204804 PMCID: PMC10754383 DOI: 10.4103/sjg.sjg_288_22] [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: 07/01/2022] [Revised: 08/07/2022] [Accepted: 08/19/2022] [Indexed: 11/06/2022] Open
Abstract
The eradication rates for Helicobacter pylori globally are decreasing with a dramatic increase in the prevalence of antibiotic resistant bacteria all over the world, including Saudi Arabia. There is no current consensus on the management of H. pylori in Saudi Arabia. The Saudi Gastroenterology Association developed these practice guidelines after reviewing the local and regional studies on the management of H. pylori. The aim was to establish recommendations to guide healthcare providers in managing H. pylori in Saudi Arabia. Experts in the areas of H. pylori management and microbiology were invited to write these guidelines. A literature search was performed, and all authors participated in writing and reviewing the guidelines. In addition, international guidelines and consensus reports were reviewed to bridge the gap in knowledge when local and regional data were unavailable. There is limited local data on treatment of H. pylori. The rate of clarithromycin and metronidazole resistance is high; therefore, standard triple therapy for 10-14 days is no longer recommended in the treatment of H. pylori unless antimicrobial susceptibility testing was performed. Based on the available data, bismuth quadruple therapy for 10-14 days is considered the best first-line and second-line therapy. Culture and antimicrobial susceptibility testing should be considered following two treatment failures. These recommendations are intended to provide the most relevant evidence-based guidelines for the management of H. pylori infection in Saudi Arabia. The working group recommends further studies to explore more therapeutic options to eradicate H. pylori.
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Affiliation(s)
- Fahad Alsohaibani
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Musthafa Peedikayil
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | | | - Ali Somily
- Department of Pathology and Laboratory Medicine, King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Raed Alsulaiman
- Department of Medicine, King Fahad Hospital, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Nahla Azzam
- Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Majid Almadi
- Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
- Division of Gastroenterology, McGill University Health Center, Montreal General Hospital, Montreal, QC, Canada
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Zeleke TK, Bazezew ZA, Abebe RB. The Burden of Inappropriate Prescriptions and Predictors for Hospitalized Patients with Liver Cirrhosis in Ethiopia. Hepat Med 2023; 15:129-140. [PMID: 37790886 PMCID: PMC10542506 DOI: 10.2147/hmer.s423351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023] Open
Abstract
Background Pathophysiological alterations in liver cirrhosis affect how medications are metabolized and eliminated. Therefore, when prescribing medicines for patients with cirrhosis, appropriate prescription of medication is an accepted standard of practice. Since patients with cirrhosis require a complex therapy plan, it necessitates regular reviews of medication utilization. However, no research was conducted in Ethiopia. The aim of this study was to figure out the predictors of inappropriate prescriptions and the pattern of prescription in patients with cirrhosis. Patients and methods A cross-sectional study design was carried out at Felege-Hiwot, a specialized and comprehensive referral hospital, from June 30, 2022, to November 30, 2022, in 123 hospitalized patients with cirrhosis. Patients were recruited using a simple random sampling procedure, and data were collected using an interviewer-administered questionnaire. For the purpose of identifying determinants of inappropriate prescription, logistic regression analyses have been carried out and statistical significance was defined by a p-value of less than 0.05 and a 95% confidence range. Results The burden of inappropriate prescriptions among patients with cirrhosis was 35.8%. An increased number of medications prescribed (AOR = 4.88 (1.05-22.68)), prescription by a general practitioner (AOR = 3.57 (95% CI 1.07-11.44)), increased level of bilirubin (AOR = 3.54 (95% CI 1.95-6.45)), and decreased level of albumin (AOR = 0.18 (95% CI 0.04-0.72)) were predictors for an inappropriate prescription. Conclusion It has been found that there were inappropriate prescriptions among patients with liver cirrhosis. Prescribers should pay close attention to patients who have prescribed with higher number of medications, increased level of bilirubin and decreased level of albumin. Moreover, educational level of prescribers needs to be upgraded in order to adopt evidence-based medication prescriptions and adhere to recommended practices.
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Affiliation(s)
- Tirsit Ketsela Zeleke
- Department of Pharmacy, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Zegaye Agmassie Bazezew
- Department of Pharmacy, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Rahel Belete Abebe
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Abstract
As a consequence of the altered hepatic architecture in advanced liver disease, drug metabolism is modified by changes in pharmacokinetic and pharmacodynamic properties, leading to the appearance of adverse effects and drug interactions and increasing the risk of over- or underdosing of medications. However, there are no tests that accurately determine the degree of impairment of liver metabolic function; therefore, general recommendations are established based on the degree of hepatic extraction, degree of hepatic metabolism, and degree of protein binding. Although the hepatic toxicity of some frequently used drugs, such as acetaminophen, is well known, many health care professionals are unaware or not fully aware of the deleterious effects that other drugs can have on patients with advanced liver injury, as is the case for nonsteroidal anti-inflammatory drugs. It is very important to increase awareness among both health care professionals and patients with advanced liver disease to limit the use of inappropriate drugs and prevent drug-induced liver injury.
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Statin-Induced Rhabdomyolysis Associated With Transjugular Intrahepatic Portosystemic Shunt Placement. ACG Case Rep J 2022; 9:e00774. [PMID: 35919670 PMCID: PMC9287266 DOI: 10.14309/crj.0000000000000774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 12/03/2021] [Indexed: 11/24/2022] Open
Abstract
Rhabdomyolysis is a known rare and potentially lethal complication of statin use. This toxic effect is potentiated by alterations in hepatic physiology in patients with cirrhosis. Transjugular intrahepatic portosystemic shunt placement has the potential to further compound this effect; yet, examples of this have not previously been described in the literature. We present a case of a patient who experienced statin-induced rhabdomyolysis likely as a direct consequence of transjugular intrahepatic portosystemic shunt placement.
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8
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Istanbuly S, Matetic A, Mohamed MO, Panaich S, Velagapudi P, Elgendy IY, Paul TK, Alkhouli M, Mamas MA. Comparison of Outcomes of Patients With Versus Without Chronic Liver Disease Undergoing Percutaneous Coronary Intervention. Am J Cardiol 2021; 156:32-38. [PMID: 34348842 DOI: 10.1016/j.amjcard.2021.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/12/2021] [Accepted: 06/15/2021] [Indexed: 02/07/2023]
Abstract
There are limited data on the outcomes of chronic liver disease (CLD) patients admitted for percutaneous coronary intervention (PCI). All PCI hospitalizations from the Nationwide Inpatient Sample (2004 to 2015) were analyzed and stratified by the presence, cause and severity of CLD, as well as the indication for PCI. Multivariable logistic regression analysis was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in patients with CLD compared with those without CLD. Among 7,296,679 PCI admissions, 54,368 (0.7%) had a CLD diagnosis. Among patients with CLD, 36,853 (67.8%) had severe CLD. Patients with CLD had higher likelihood of adverse outcomes including major adverse cardiovascular and cerebrovascular events (MACCE) (aOR 1.25, 95%CI 1.20 to 1.30), mortality (aOR 1.43, 95%CI 1.35 to 1.51), major bleeding (aOR 2.22, 95%CI 2.12 to 2.32). When accounting for severity, only severe CLD subgroup was more likely to have MACCE and all-cause mortality compared to no-CLD patients (p <0.001). Among CLD etiologic subgroups, those with 'alcohol-related liver disease' and 'other CLD' were consistently more likely to develop MACCE, all-cause mortality and major bleeding in comparison to no-CLD patients, while 'chronic viral hepatitis' subgroup had only increased odds of major bleeding (p <0.001). In conclusion, CLD patients admitted for PCI are more likely to have worse in-hospital outcomes, particularly in the severe CLD subgroup and 'alcohol-related liver disease' and 'other CLD' etiologic subgroups.
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9
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Weersink RA, Hayward KL. Collaboration Is Needed to Translate Pharmacology Data Into Better Health Outcomes in Chronic Liver Disease. Hepatol Commun 2021; 5:715-716. [PMID: 33860129 PMCID: PMC8034564 DOI: 10.1002/hep4.1663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Rianne A Weersink
- Department of Clinical PharmacyDeventer HospitalDeventerthe Netherlands
| | - Kelly L Hayward
- Centre for Liver Disease ResearchFaculty of MedicineThe University of QueenslandTranslational Research InstituteBrisbaneAustralia.,Department of Gastroenterology and HepatologyPrincess Alexandra HospitalBrisbaneAustralia
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10
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Schwambach KH, Blatt CR. Effectiveness and potential drug interactions in antiviral therapy for the treatment of chronic hepatitis C: real-life data from a specialized center in southern Brazil. BRAZ J PHARM SCI 2021. [DOI: 10.1590/s2175-9790201900041874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Hayward KL, Weersink RA. Improving Medication-Related Outcomes in Chronic Liver Disease. Hepatol Commun 2020; 4:1562-1577. [PMID: 33163829 PMCID: PMC7603526 DOI: 10.1002/hep4.1612] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/20/2020] [Accepted: 09/08/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with chronic liver disease (CLD) are becoming increasingly complex due to the rising prevalence of multimorbidity and polypharmacy. Medications are often essential to manage the underlying liver disease, complications of cirrhosis and portal hypertension, and comorbidities. However, medication-related problems (MRPs) have been associated with adverse patient outcomes, including hospitalization and mortality. Factors that can contribute to MRPs in people with CLD are variable and often entwined. This narrative literature review discusses key barriers and opportunities to modify risk factors and improve medication-related outcomes for people with CLD.
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Affiliation(s)
- Kelly L Hayward
- Centre for Liver Disease Research, Faculty of Medicine The University of Queensland, Translational Research Institute Brisbane QLD Australia.,Department of Gastroenterology and Hepatology Princess Alexandra Hospital Brisbane QLD Australia
| | - Rianne A Weersink
- Department of Clinical Pharmacy Deventer Hospital Deventer The Netherlands
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12
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Drug Treatment of Patients with Liver Cirrhosis in a Tertiary Hospital in Northern Ghana: Does It Comply with Recommended Guidelines? Int J Hepatol 2020; 2020:9750194. [PMID: 32550025 PMCID: PMC7275961 DOI: 10.1155/2020/9750194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/21/2020] [Accepted: 04/27/2020] [Indexed: 12/25/2022] Open
Abstract
The diverse influence of liver function on drug disposition can lead health-care practitioners to inappropriate drug selection, inappropriate drug dosing, or some level of therapeutic negativism. The aim of this study was to assess how drug prescribing in patients with liver cirrhosis at the Tamale Teaching Hospital comply with recommendations of pharmacotherapy and safety guidelines. A prospective cross-sectional study was conducted from February to July, 2019, at the medical ward of the Tamale Teaching Hospital. A total of 152 liver cirrhotic patients were included in this study. Common etiologies for liver cirrhosis were chronic hepatitis B 80 (52.6%) and chronic hepatitis C 30 (19.7%); about 12.5% of etiologies were unknown. Of the 1842 prescription issued, 69% (1270/1842) were compliant. Of the 572 noncompliant prescriptions, about 32% (183/572) were due to pharmacotherapy and 68% (389/572) due to safety guideline recommendations. There was a substantial number (31%) of prescription noncompliance with recommendations for pharmacotherapy and safety guidelines in liver cirrhotic patients at the tertiary hospital in northern Ghana. Prescribers need to be conscious of the role of the liver in drug elimination and prescribe as recommended by guidelines.
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van Tongeren JMZ, Harkes-Idzinga SF, van der Sijs H, Atiqi R, van den Bemt BJF, Draijer LW, Hiel D, Kerremans A, Kremers B, de Leeuw M, Olthoff MV, Pham TKL, Valentijn-Robertz R, Tsoi K, Wichers I, de Wit M, Borgsteede SD. The Development of Practice Recommendations for Drug-Disease Interactions by Literature Review and Expert Opinion. Front Pharmacol 2020; 11:707. [PMID: 32499701 PMCID: PMC7243438 DOI: 10.3389/fphar.2020.00707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022] Open
Abstract
Background Drug-disease interactions negatively affect the benefit/risk ratio of drugs for specific populations. In these conditions drugs should be avoided, adjusted, or accompanied by extra monitoring. The motivation for many drug-disease interactions in the Summary of Product Characteristics (SmPC) is sometimes insufficiently supported by (accessible) evidence. As a consequence the translation of SmPC to clinical practice may lead to non-specific recommendations. For the translation of this information to the real world, it is necessary to evaluate the available knowledge about drug-disease interactions, and to formulate specific recommendations for prescribers and pharmacists. The aim of this paper is to describe a standardized method how to develop practice recommendations for drug-disease interactions by literature review and expert opinion. Methods The development of recommendations for drug-disease interactions will follow a six-step plan involving a multidisciplinary expert panel (1). The scope of the drug-disease interaction will be specified by defining the disease and by describing relevant effects of this drug-disease interaction. Drugs possibly involved in this drug-disease interaction are selected by checking the official product information, literature, and expert opinion (2). Evidence will be collected from the official product information, guidelines, handbooks, and primary literature (3). Study characteristics and outcomes will be evaluated and presented in standardized reports, including preliminary conclusions on the clinical relevance and practice recommendations (4). The multidisciplinary expert panel will discuss the reports and will either adopt or adjust the conclusions (5). Practice recommendations will be integrated in clinical decision support systems and published (6). The results of the evaluated drug-disease interactions will remain up-to-date by screening new risk information, periodic literature review, and (re)assessments initiated by health care providers. Actionable Recommendations The practice recommendations will result in advices for specific DDSI. The content and considerations of these DDSIs will be published and implemented in all Clinical Decision Support Systems in the Netherlands. Discussion The recommendations result in professional guidance in the context of individual patient care. The professional will be supported in the decision making in concerning pharmacotherapy for the treatment of a medical problem, and the clinical risks of the proposed medication in combination with specific diseases.
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Affiliation(s)
| | - S Froukje Harkes-Idzinga
- Medicines Information Centre, Royal Dutch Pharmacists Association (KNMP), The Hague, Netherlands
| | - Heleen van der Sijs
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Roya Atiqi
- Department of Internal Medicine, University Medical Center Groningen, Groningen, Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, Netherlands.,Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Deline Hiel
- Department of Hospital Pharmacy, Alrijne Zorggroep, Leiden, Netherlands
| | | | | | - Marc de Leeuw
- Medicines Information Centre, Royal Dutch Pharmacists Association (KNMP), The Hague, Netherlands
| | - Marleen V Olthoff
- Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands
| | - T Kim-Loan Pham
- Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands
| | | | - Kayan Tsoi
- Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands
| | - Iris Wichers
- Department of Guideline Development and Research, Dutch College of General Practitioners, Utrecht, Netherlands
| | - Maaike de Wit
- Medicines Information Centre, Royal Dutch Pharmacists Association (KNMP), The Hague, Netherlands
| | - Sander D Borgsteede
- Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
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Yu L, Wang L, Yi H, Wu X. LRP6-CRISPR prevents activation of hepatic stellate cells and liver fibrogenesis in rats. Am J Transl Res 2020; 12:397-408. [PMID: 32194892 PMCID: PMC7061824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/17/2020] [Indexed: 06/10/2023]
Abstract
This study elaborated on the function of Low-density lipoprotein receptor-related protein 6 (LRP6), a critical component of Wnt signaling, in liver fibrosis. This study enrolled sixty-eight patients with liver fibrosis, with ten healthy liver tissue samples, served as the controls. A lentiviral vector expressing LRP6-CRISPR was constructed. Immortalized HSC-T6 cells were transfected with LRP6-CRISPR. A rat model of CCl4-induced liver fibrosis was established, and rats were injected with lentiviral vectors expressing LRP6-CRISPR. LRP6 expression and fibrosis biomarkers were examined by PCR, Western blot, and immunofluorescence assay, respectively. HSC growth and its ability of migration and invasion were evaluated by MTT and Transwell assay, separately. Wnt signaling activity was examined by Luciferase reporter assay. LRP6 was overexpressed in human fibrotic-liver tissues, and the expression of LRP6 was correlated with liver fibrosis stages. LRP6 knockout with CRISPR suppressed the Wnt signaling activities and consequently repressed HSC activation and relived liver injury in fibrotic-liver model rats. Our data revealed that the knockout of LRP6 weakens the binding of Wnt ligand with its cell surface receptors, the first step of Wnt transduction cascade, and consequently repressed HSC activation.
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Affiliation(s)
- Linghua Yu
- Center for Gastroenterology and Hepatology, Institute of Liver Diseases, The First Affiliated Hospital of Jiaxing CollegeJiaxing, Zhejiang Province, PR China
| | - Linlin Wang
- Department of Basic Medicine Sciences, School of Medicine, Zhejiang UniversityHangzhou, Zhejiang Province, PR China
| | - Huixing Yi
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang UniversityHangzhou, Zhejiang Province, PR China
| | - Xiaojun Wu
- Center for Gastroenterology and Hepatology, Institute of Liver Diseases, The First Affiliated Hospital of Jiaxing CollegeJiaxing, Zhejiang Province, PR China
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15
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Weersink RA, Taxis K, Drenth JPH, Houben E, Metselaar HJ, Borgsteede SD. Prevalence of Drug Prescriptions and Potential Safety in Patients with Cirrhosis: A Retrospective Real-World Study. Drug Saf 2020; 42:539-546. [PMID: 30357649 PMCID: PMC6450857 DOI: 10.1007/s40264-018-0744-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Introduction Patients with cirrhosis are at risk for adverse drug reactions (ADRs) due to altered pharmacokinetics and pharmacodynamics. We aimed to determine the prevalence of drug prescriptions and the potential safety of these prescriptions in a real-world cohort of patients with cirrhosis. Methods This was a retrospective cohort study based on linked real-world data from the Out-patient Pharmacy Database and the Hospitalisation Database of the PHARMO Database Network. Patients with a diagnosis of cirrhosis between January 1998 and December 2015 were included. Follow-up ended when the patient underwent a liver transplant, died, transferred out of the database, or on 31 December 2015. Prescription data were derived from a community pharmacy database and were compared with our previously developed safety recommendations for 209 drugs. Results In total, 5618 patients were included and followed for a median of 3 years (interquartile range [IQR] 1–7). In the first year after the diagnosis, patients used a median of nine drugs (IQR 5–14), with proton pump inhibitors (prevalence 53.9%), aldosterone antagonists (43.6%), and sulfonamide diuretics (41.3%) being the most commonly used drug groups. Almost half (48.3%) of 102,927 prescriptions consisted of drugs with a safety recommendation. The prevalence of potentially unsafe drug use was 60.0% during the total follow-up. Three nonsteroidal anti-inflammatory drugs (NSAIDs) were among the five most commonly used potentially unsafe drugs. Conclusions Patients with cirrhosis use a large number of drugs. Almost two-thirds of patients in our cohort used potentially unsafe drugs. To prevent ADRs in these frail patients, personalised pharmacotherapy is necessary. Electronic supplementary material The online version of this article (10.1007/s40264-018-0744-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rianne A Weersink
- Department of Clinical Decision Support, Health Base Foundation, Papiermolen 36, 3994 DK, Houten, The Netherlands. .,Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology and Economics, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
| | - Katja Taxis
- Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology and Economics, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Eline Houben
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, 3528 AE, Utrecht, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sander D Borgsteede
- Department of Clinical Decision Support, Health Base Foundation, Papiermolen 36, 3994 DK, Houten, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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16
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Comparative Pharmacokinetic Study of Taxifolin after Oral Administration of Fructus Polygoni Orientalis Extract in Normal and Fibrotic Rats by UPLC-MS/MS. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:9348075. [PMID: 31976002 PMCID: PMC6955125 DOI: 10.1155/2019/9348075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/28/2019] [Accepted: 12/04/2019] [Indexed: 01/15/2023]
Abstract
Fructus polygoni orientalis (FPO) is widely used in clinical practice in China, especially in treatment of liver diseases including viral hepatitis, liver fibrosis, and liver cirrhosis. However, its pharmacokinetic (PK) alterations in liver fibrotic rats have rarely been reported. To study whether taxifolin, one of the main flavonoids in FPO can be absorbed into blood after oral administration of FPO extract and to compare the differences in pharmacokinetic parameters of taxifolin to normal and liver fibrotic rats induced by porcine serum (PS), a UPLC-MS/MS method was developed and validated for determination of taxifolin in rat plasma using puerarin as the internal standard (IS). All validation parameters met the acceptance criteria according to regulatory guidelines. The results indicated that after treatment of rats with PS alone for 12 weeks, the liver fibrotic model group was built successfully. The taxifolin can be absorbed into the blood after oral administration of the FPO extract. The C max of taxifolin was 1940 ± 502.2 ng/mL and 2648 ± 208.5 ng/mL (p < 0.05), the AUC0∼t of taxifolin was 4949.7 ± 764.89 h·ng/mL and 6679.9 ± 734.26 h·ng/mL (p < 0.05), the AUC0∼∞ of taxifolin was 5049.4 ± 760.7 and 7095.2 ± 962.3 h·ng/mL (p < 0.05), and the mean residence time (MRT) of taxifolin was 2.46 ± 0.412 h and 3.17 ± 0.039 h (p < 0.05) in the normal and fibrotic model groups, respectively. These results confirmed that the pharmacokinetic parameters of taxifolin are altered in liver fibrosis, manifested as C max, AUC0∼t , AUC0∼∞, and the mean residence time (MRT). It suggested that it is essential to consider the characteristics of pharmacokinetics after oral administration of FPO in liver disease patients.
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17
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Weersink RA, Burger DM, Hayward KL, Taxis K, Drenth JP, Borgsteede SD. Safe use of medication in patients with cirrhosis: pharmacokinetic and pharmacodynamic considerations. Expert Opin Drug Metab Toxicol 2019; 16:45-57. [DOI: 10.1080/17425255.2020.1702022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Rianne A. Weersink
- Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology and -Economics, University of Groningen, Groningen, The Netherlands
- Department of Clinical Decision Support, Health Base Foundation, Houten, The Netherlands
| | - David M. Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kelly L. Hayward
- Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Pharmacy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Katja Taxis
- Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology and -Economics, University of Groningen, Groningen, The Netherlands
| | - Joost P.H. Drenth
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sander D. Borgsteede
- Department of Clinical Decision Support, Health Base Foundation, Houten, The Netherlands
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Strobach D, Poppele A, Mannell H, Andraschko M, Schiek S, Bertsche T. Screening for impaired liver function as a risk factor for drug safety at hospital admission of surgical patients. Int J Clin Pharm 2019; 42:124-131. [PMID: 31807990 DOI: 10.1007/s11096-019-00948-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 12/01/2019] [Indexed: 11/29/2022]
Abstract
Background Hepatic insufficiency can affect patient safety and should therefore be considered during drug therapy. Hospital admission offers an ideal point to screen for patients at risk and to adjust drug therapy accordingly. Objective To assess the number of patients admitted to hospital with clinically elevated liver parameters. To identify high-risk patients in need of potential drug therapy adjustment to liver function by calculation of liver scores. Finally, to investigate whether pre-hospital medication needed adjustment to liver function. Setting Patients admitted to surgical wards of a tertiary teaching hospital. Method Surgical patients were included in a 3-month retrospective study. A pharmacist-led screening process, including recording of elevated liver parameters and calculation of liver scores (Child-Pugh-score, Model of End-stage Liver Disase [MELD], MELDNa), was used to assess frequency of hepatic insufficiency and patients potentially needing medication adjustment. Additionally, pre-hospital medication was checked for contraindications and correct dosage with regard to liver function. Main outcome measure Percentage of surgical patients with clinically elevated liver parameters at admission, percentage of patients with hepatic insufficiency potentially needing drug therapy adjustment, and percentage of pre-hospital drug intakes not adjusted to liver function. Results Of 1200 patients, 130 (11%) had at least one clinically relevant elevated liver parameter at hospital admission. Of these, need for drug adjustment to liver function was found for 16-36%, depending on the liver score used (equivalent to 2-4% of all patients), with the highest number of patients detected by the MELD- and MELDNa-score. Pre-hospital medication concerned 719 drug intakes and was contraindicated in 2%, dosage not adjusted in 3%, and evaluation not possible in 44% of all drug intakes due to lack of information on the drug. Conclusion A significant proportion of patients admitted for surgery have clinically elevated liver parameters and potentially need medication adjustment. A pharmacist-led screening already at hospital admission can support the identification of patients with clinically relevant elevated liver parameters and patients at risk by calculating liver scores under routine conditions. Evaluation of drug adjustment to liver function is challenging, since no data are available in routine resources for a considerable number of drugs.
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Affiliation(s)
- Dorothea Strobach
- Hospital Pharmacy, University Hospital Munich, Marchioninistr. 15, 81377, Munich, Germany. .,Doctoral Program Clinical Pharmacy, University Hospital Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Angelika Poppele
- Hospital Pharmacy, University Hospital Munich, Marchioninistr. 15, 81377, Munich, Germany.,Drug Safety Center and Department of Clinical Pharmacy, Leipzig University, Brüderstraße 32, 04103, Leipzig, Germany
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, University Hospital Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Monika Andraschko
- Hospital Pharmacy, University Hospital Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Susanne Schiek
- Drug Safety Center and Department of Clinical Pharmacy, Leipzig University, Brüderstraße 32, 04103, Leipzig, Germany
| | - Thilo Bertsche
- Drug Safety Center and Department of Clinical Pharmacy, Leipzig University, Brüderstraße 32, 04103, Leipzig, Germany
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19
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Weersink RA, Timmermans L, Monster-Simons MH, Mol PGM, Metselaar HJ, Borgsteede SD, Taxis K. Evaluation of Information in Summaries of Product Characteristics (SmPCs) on the Use of a Medicine in Patients With Hepatic Impairment. Front Pharmacol 2019; 10:1031. [PMID: 31607904 PMCID: PMC6758592 DOI: 10.3389/fphar.2019.01031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/12/2019] [Indexed: 12/17/2022] Open
Abstract
Background: In 2005, the European Medicines Agency (EMA) released guidance on pharmacokinetic studies in patients with hepatic impairment. This guidance describes the design of these studies and what information should be presented in the Summary of Product Characteristics (SmPC). We aim to evaluate the availability and clinical applicability of information on medicine use in patients with hepatic impairment in SmPCs and registrational dossiers of recently approved medicines. Methods: We reviewed SmPC information on use in patients with hepatic impairment of 51 new medicines authorized between 2015 and 2017. Per medicine, we assessed the availability of nine information items derived from the EMA guidance, i.e. type of hepatic disease studied; stratification by severity of hepatic impairment; influence of hepatic impairment on the pharmacokinetics; safety advice in mild, moderate, and severe hepatic impairments; and dosing recommendation in mild, moderate, and severe hepatic impairments. If unavailable, the European Public Assessment Report (EPAR) and study report were consulted consecutively. Of available items, clinical applicability was assessed by labeling information as "clear" or "ambiguous". Results: Of 51 medicines, 15 had no pharmacokinetic study in patients with hepatic impairment described in their SmPC. The other 36 SmPCs contained on average seven of the nine information items (range 4-9). One SmPC contained all 9 items, and after consulting, the study reports, 11 SmPCs were complete. The item "type of hepatic disease studied" was available in one SmPC, though it could be retrieved in 21 study reports. Regarding clinical applicability, there was no medicine with all information items available and clearly formulated in the SmPC. A total of 12 medicines (33%) contained only clearly formulated information, while 24 (67%) contained at least one ambiguously formulated information item (range 0-4). Items often ambiguously formulated were: "definition of mild, moderate, and severe hepatic impairment" (15 ambiguous SmPCs) and "safety advice in severe hepatic impairment" (17 ambiguous SmPCs). Conclusion: While SmPCs contain a large part of information requested by the EMA, clinical applicability seems low, as it is often unclear to which specific type of hepatic disease patient the advice applies. This can negatively influence the practical use by healthcare professionals.
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Affiliation(s)
- Rianne A Weersink
- Unit of Pharmacotherapy, Epidemiology & Economics, Department of Pharmacy, University of Groningen, Groningen, Netherlands.,Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands
| | - Lotte Timmermans
- Unit of Pharmacotherapy, Epidemiology & Economics, Department of Pharmacy, University of Groningen, Groningen, Netherlands.,Department of Pharmaceutical and Pharmacological Sciences, Unit of Clinical Pharmacology and Pharmacotherapy, Catholic University of Leuven, Leuven, Belgium
| | - Margje H Monster-Simons
- Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Peter G M Mol
- Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Sander D Borgsteede
- Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Katja Taxis
- Unit of Pharmacotherapy, Epidemiology & Economics, Department of Pharmacy, University of Groningen, Groningen, Netherlands
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Weersink RA, Bouma M, Burger DM, Drenth JPH, Harkes-Idzinga SF, Hunfeld NGM, Metselaar HJ, Monster-Simons MH, Taxis K, Borgsteede SD. Evidence-Based Recommendations to Improve the Safe Use of Drugs in Patients with Liver Cirrhosis. Drug Saf 2018; 41:603-613. [PMID: 29330714 PMCID: PMC5966501 DOI: 10.1007/s40264-017-0635-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction The presence of liver cirrhosis can have a major impact on pharmacodynamics and pharmacokinetics, but guidance for prescribing is lacking. Objective The aim of this study is to provide an overview of evidence-based recommendations developed for the safe use of drugs in liver cirrhosis. Methods Recommendations were based on a systematic literature search combined with expert opinion from a panel of 10 experts. The safety of each drug was classified as safe, no additional risks known, additional risks known, unsafe, unknown or the safety class was dependent on the severity of liver cirrhosis (Child–Pugh classification). If applicable, drug-specific dosing advice was provided. All recommendations were implemented in clinical decision support systems and on a website. Results We formulated 218 recommendations for a total of 209 drugs. For nine drugs, two recommendations were formulated for different administration routes or indications. Drugs were classified as ‘safe’ in 29 recommendations (13.3%), ‘no additional risks known’ in 60 (27.5%), ‘additional risks known’ in 3 (1.4%), and ‘unsafe’ in 30 (13.8%). In 57 (26.1%) of the recommendations, safety depended on the severity of liver cirrhosis and was ‘unknown’ in 39 (17.9%) recommendations. Large alterations in pharmacodynamics were the main reason for classifying a drug as ‘unsafe’. For 67 drugs (31%), a dose adjustment was needed. Conclusions Over 200 recommendations were developed for the safe use of drugs in patients with liver cirrhosis. Implementing these recommendations into clinical practice can possibly enhance medication safety in this vulnerable patient group. Electronic supplementary material The online version of this article (10.1007/s40264-017-0635-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rianne A Weersink
- Department of Clinical Decision Support, Health Base Foundation, Houten, The Netherlands. .,Department of Pharmacy, Unit of Pharmacotherapy, Epidemiology and Economics, University of Groningen, Groningen, The Netherlands.
| | - Margriet Bouma
- Department of Guideline Development, Dutch College of General Practice, Utrecht, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Froukje Harkes-Idzinga
- Center for Information on Medicines, Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands
| | - Nicole G M Hunfeld
- Department of Pharmacy and Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Margje H Monster-Simons
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
| | - Katja Taxis
- Department of Pharmacy, Unit of Pharmacotherapy, Epidemiology and Economics, University of Groningen, Groningen, The Netherlands
| | - Sander D Borgsteede
- Department of Clinical Decision Support, Health Base Foundation, Houten, The Netherlands.,SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
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21
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Weersink RA, Bouma M, Burger DM, Drenth JPH, Harkes-Idzinga SF, Hunfeld NGM, Metselaar HJ, Monster-Simons MH, van Putten SAW, Taxis K, Borgsteede SD. Safe use of proton pump inhibitors in patients with cirrhosis. Br J Clin Pharmacol 2018; 84:1806-1820. [PMID: 29688583 PMCID: PMC6046475 DOI: 10.1111/bcp.13615] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 12/16/2022] Open
Abstract
Aims Proton pump inhibitors (PPIs) belong to the most frequently used drugs, also in patients with cirrhosis. PPIs are extensively metabolized by the liver, but practice guidance on prescribing in cirrhosis is lacking. We aim to develop practical guidance on the safe use of PPIs in patients with cirrhosis. Methods A systematic literature search identified studies on the safety (i.e. adverse events) and pharmacokinetics of PPIs in cirrhotic patients. This evidence and data from the product information was reviewed by an expert panel who classified drugs as safe; no additional risks known; additional risks known; unsafe; or unknown. Guidance was aimed at the oral use of PPIs and categorized by the severity of cirrhosis, using the Child–Turcotte–Pugh (CTP) classification. Results A total of 69 studies were included. Esomeprazole, omeprazole and rabeprazole were classified as having ‘no additional risks known’. A reduction in maximum dose of omeprazole and rabeprazole is recommended for CTP A and B patients. For patients with CTP C cirrhosis, the only PPI advised is esomeprazole at a maximum dosage of 20 mg per day. Pantoprazole and lansoprazole were classified as unsafe because of 4‐ to 8‐fold increased exposure. The use of PPIs in cirrhotic patients has been associated with the development of infections and hepatic encephalopathy and should be carefully considered. Conclusions We suggest using esomeprazole, omeprazole or rabeprazole in patients with CTP A or B cirrhosis and only esomeprazole in patients with CTP C. Pharmacokinetic changes are also important to consider when prescribing PPIs to vulnerable, cirrhotic patients.
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Affiliation(s)
- Rianne A Weersink
- Health Base Foundation, Houten, The Netherlands.,Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology & -Economics, University of Groningen, Groningen, The Netherlands
| | - Margriet Bouma
- Department of Guideline Development, Dutch College of General Practice, Utrecht, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Froukje Harkes-Idzinga
- Center for Information on Medicines, Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Margje H Monster-Simons
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
| | | | - Katja Taxis
- Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology & -Economics, University of Groningen, Groningen, The Netherlands
| | - Sander D Borgsteede
- Health Base Foundation, Houten, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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