Optimizing medication management for patients with cirrhosis: Evidence‐based strategies and their outcomes

Thomson, Mary; Lok, Anna S.; Tapper, Elliot B.

doi:10.1111/liv.13892

Cited by 26 publications

(33 citation statements)

References 56 publications

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“…Development of this list could be of benefit to assist non‐hepatology health care providers in the management of comorbidities. Ambulatory care multidisciplinary case management, such as in a chronic disease model of care, has been proposed to improve patient outcomes . However, outside of the post‐liver transplant setting, there is a paucity of appropriately powered clinical trials to inform development and implementation in CLD.…”

Section: Discussionmentioning

confidence: 99%

“…Ambulatory care multidisciplinary case management, such as in a chronic disease model of care, has been proposed to improve patient outcomes. (28)(29)(30) However, outside of the post-liver transplant setting, (31) there is a paucity of appropriately powered clinical trials to inform development and implementation in CLD. Our findings supporting pharmacist-led medication review to identify and aid resolution of MRPs in the ambulatory setting will be useful for future development and translation of chronic disease management models for people with decompensated cirrhosis.…”

Section: Discussionmentioning

confidence: 99%

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Medication‐Related Problems in Outpatients With Decompensated Cirrhosis: Opportunities for Harm Prevention

et al. 2019

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People with decompensated cirrhosis are often prescribed a complex regimen of therapeutic and prophylactic medications. In other chronic diseases, polypharmacy increases the risk of medication misadventure and medication‐related problems (MRPs), with associated increased morbidity, mortality, and health care costs. This study examined MRPs in a cohort of ambulatory patients with a history of decompensated cirrhosis who were enrolled in a randomized controlled trial of a pharmacist‐led, patient‐oriented medication education intervention and assessed the association between MRPs and patient outcomes. A total of 375 MRPs were identified among 57 intervention patients (median, 6.0; interquartile range, 3.5‐8.0 per patient; maximum 17). Nonadherence (31.5%) and indication issues (29.1%) were the most prevalent MRP types. The risk of potential harm associated with MRPs was low in 18.9% of instances, medium in 33.1%, and high in 48.0%, as categorized by a clinician panel using a risk matrix tool. Patients had a greater incidence rate of high‐risk MRPs if they had a higher Child‐Pugh score (incidence rate ratio [IRR], 1.31; 95% confidence interval [CI], 1.09‐1.56); greater comorbidity burden (IRR, 1.15; 95% CI, 1.02‐1.29); and were taking more medications (IRR, 1.12; 95% CI, 1.04‐1.22). A total of 221 MRPs (58.9%) were resolved following pharmacist intervention. A greater proportion of high‐risk MRPs were resolved compared to those of low and medium risk (68.9% versus 49.7%; P < 0.001). During the 12‐month follow‐up period, intervention patients had a lower incidence rate of unplanned admissions compared to usual care (IRR, 0.52; 95% CI, 0.30‐0.92). Conclusion : High‐risk MRPs are prevalent among adults with decompensated cirrhosis. Pharmacist intervention facilitated identification and resolution of high‐risk MRPs and was associated with reduced incidence rate of unplanned hospital admissions in this group.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Medication‐Related Problems in Outpatients With Decompensated Cirrhosis: Opportunities for Harm Prevention

et al. 2019

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“…(1,2) Complicating the increasing burden of cirrhosis is the complexity of the condition and its medical management. (3) Ascites requires close monitoring, dietary modification, and adjunctive diuretic therapy that requires frequent dose adjustment; hepatic encephalopathy is often unpredictable, reduces one's ability to effectively self-care, yet depends on insight regarding one's symptoms to guide frequent lactulose dose adjustment; pain is frequently comorbid, and concerns over medication safety increase anxiety while limiting the efficacy of pain-control strategies. This complexity demands substantial support and rapid "on-the-job" training in cirrhosis management for patients and caregivers.…”

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confidence: 99%

How Do Patients With Cirrhosis and Their Caregivers Learn About and Manage Their Health? A Review and Qualitative Study

Saleh¹,

Bloom

Grzyb

et al. 2021

Hepatology Communications

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The complexity of cirrhosis requires patients and their caregivers to be well educated to improve outcomes. Data are lacking regarding how to best educate patients and their caregivers in the setting of cirrhosis. Our aim is to understand (both through existing literature and by asking patients and their caregivers) how patients learn about their disease, barriers in their education and disease management, and self‐management strategies. We performed a structured search of published articles in PubMed (1973 to 2020) using keywords “cirrhosis” plus “barriers”, “education”, “self‐management”, or “self‐care”. Additionally, we conducted a focus group of a representative sample of patients and their caregivers to understand how knowledge about cirrhosis is found and incorporated into self‐management. Of 504 returned manuscripts, 11 pertained to barriers in cirrhosis, interventions, or educational management. Barriers are well documented and include disease complexity, medication challenges, comorbid conditions, and lack of effective education. However, data regarding addressing these barriers, especially effective educational interventions, are scarce. Current strategies include booklets and videos, patient empowerment, and in‐person lectures. Without widespread use of these interventions, patients are left with suboptimal knowledge about their disease, a sentiment unanimously echoed by our focus group. Despite linkage to subspecialty care and consistent follow‐up, patients remain uncertain about their disease origin, prognosis, and therapies to manage symptoms. It is clear that more data are needed to assess effective strategies to address unmet educational needs. Existing strategies need to be blended and improved, their effectiveness evaluated, and the results distributed widely.

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“…Examples of problems included nonadherence (patient-driven due to ADRs), and drug-drug and drug-disease interactions (often relating to risk of renal impairment or HE). These are common problems among patients with cirrhosis [128][129][130][131][132]. The patient-oriented medication intervention described in the trial was associated with a reduced incidence rate of unplanned hospital admissions compared to usual care, which coincided with 68.9% resolution rate of 'high' risk medication-related problems [128].…”

Section: Regularly Evaluate Pharmacotherapymentioning

confidence: 97%

Safe use of medication in patients with cirrhosis: pharmacokinetic and pharmacodynamic considerations

Weersink

Burger

Hayward

et al. 2019

Expert Opinion on Drug Metabolism & Toxicology

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Introduction: The global burden of cirrhosis is rising, and clinicians increasingly face the challenge of safely prescribing medicines for complications of hepatic disease and comorbidities. Prescribing in patients with cirrhosis is complicated by alterations that can occur in the pharmacology of medicines. Areas covered: This paper provides an overview of current knowledge on the pharmacokinetics and pharmacodynamics of medicines in patients with cirrhosis. We describe the pathophysiological changes that occur and their consequences on pharmacokinetic parameters. We explain that the influence of cirrhosis on the pharmacokinetics depends on several drug and patient characteristics. Patients with cirrhosis also have an increased susceptibility to some toxicological effects of medicines, such as renal impairment and hematological toxicity, which we describe in detail. In addition, we discuss approaches to apply this knowledge in practice and improve safe medication use in patients with cirrhosis. Expert opinion: Tailored pharmacotherapy is needed to ensure safe and appropriate use of medicines in patients with cirrhosis. Clinicians are supported by freely available recommendations on safe drug use in cirrhosis published on a website. In addition, a regular evaluation of medication use in patients with cirrhosis could resolve and prevent medication-related problems.

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Optimizing medication management for patients with cirrhosis: Evidence‐based strategies and their outcomes

Cited by 26 publications

References 56 publications

Medication‐Related Problems in Outpatients With Decompensated Cirrhosis: Opportunities for Harm Prevention

Medication‐Related Problems in Outpatients With Decompensated Cirrhosis: Opportunities for Harm Prevention

How Do Patients With Cirrhosis and Their Caregivers Learn About and Manage Their Health? A Review and Qualitative Study

Safe use of medication in patients with cirrhosis: pharmacokinetic and pharmacodynamic considerations

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