NAPLEX Question of the Week: Cirrhosis

While renal dosing adjustments are a common intervention among pharmacists, hepatic dosage adjustments are important as well for certain patient populations, such as patients with end stage liver disease like cirrhosis.

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A 51 year old female with past medical history of hypertension, hyperlipidemia, GERD, and allergic rhinitis presents to the emergency department with significant hypotension likely related to an upper gastrointestinal bleed as she has hematochezia and reports hematemesis. She denies no usage of NSAIDS or aspirin products but reports significant alcohol usage (1/5th of a gallon of vodka approximately) over past 5 years. After stabilization and treatment of confirmed upper GI bleed, she is ultimately diagnoses with cirrhosis. In order to dose her hepatically cleared medications appropriately, you choose to calculate a Child-Pugh score. Which of the following are components of the Child-Pugh score? Select all that apply.

A. Aspartate aminotransferase

B. Alanine aminotransferase

C. International normalized ratio

D. Encephalopathy

E. Albumin

Answer with rationale:

The correct answers are C, D, and E. Hepatic disease is extremely common in the United States, with nearly 3 million people affected. While hepatic injury can occur acutely, many times long-term recovery occurs back to normal function. However when cirrhosis occurs, many of the basic functions of the liver are no longer viable resulting in very high mortality unless liver transplantation occurs. Our patient would not be eligible for a transplant due to active alcohol abuse which would need to cease for often at least 6 months to be eligible. 

There are five components to the Child-Pugh Score: Answers C, D, E as well as presence of ascites and total bilirubin. Answers A and B are incorrect as AST and ALT can often be normal in patient with cirrhosis as the liver is no longer inflamed. These labs are often termed "liver function tests" but are best called "liver associated enzymes" as they in some populations reveal nothing related to liver function.

Child-Pugh scores will often be graded into Grades A (mild:score of 5-6), B (moderate:score of 7-9), and C (severe:10-15). The higher the score, the higher the risk of mortality in the short-term as well as the need for significant dosage reduction for hepatically metabolized medications. While data is somewhat available for mild-moderate hepatic insufficiency, often Class C patients are not included in clinical studies making good data difficult to obtain. Often dosage adjustments are made on a case by case basis with regard to risk/benefit ratios. 

Have a great week as you continue to study hard!


Dr. B

Christopher M. Bland

Clinical Professor, University of Georgia College of Pharmacy

Dr. Christopher M. Bland is a Clinical Professor at the University of Georgia College of Pharmacy at the Southeast GA campus in Savannah, GA. Dr. Bland has over 20 years of academic and clinical experience in a number of clinical areas. He is a Fellow of both the Infectious Diseases Society of America as well as the American College of Clinical Pharmacy. He is co-founder of the Southeastern Research Group Endeavor, SERGE-45, with over 80 practitioners across 14 states involved. Dr. Bland serves as Associate Editor for the NAPLEX Review Guide 4th edition as well as Editor-In-Chief for the Question of the Week. He has provided live, interactive reviews for more than 10 Colleges/Schools of Pharmacy over the course of his career.