The most common diagnosis for liver impairment is alcohol-related liver disease which accounts for well over a third (37%) of all deaths from liver disease. Furthermore, 22% of deaths due to liver disease are from primary liver cancer, the majority of which will have alcohol-related liver disease as the underlying cause. Other major causes of liver disease include:
Many patients with advanced liver disease experience repeated episodes of deterioration, otherwise termed ‘decompensation’. This is when one or more of the sequelae of liver disease (e.g. ascites, oedema, encephalopathy, jaundice, bleeding) become more progressive, leading to a decline in the patient’s ability to function.
Symptoms may fully or partially resolve, either spontaneously or as a result of medical intervention, leading to an improvement in the patient’s ability to function. Some patients experience an episode of decompensation from which they do not recover and death follows. Several factors may influence whether a particular episode leads to terminal decompensation, including:
Patients with end stage liver disease experience significant symptom burden, either through the impact of their deranged liver function or through complications to which they are particularly vulnerable. These can include:
Prescribing for a patient with liver disease can be complex as it is affected by the specific cause of the liver disease and the degree of liver damage. As the hepatic reserve is large, liver disease must be severe before changes in drug metabolism occur. Traditionally, markers such as raised bilirubin, raised INR/prothrombin time, raised ALT, low albumin, and the presence of ascites, encephalopathy or jaundice are principally used to assess disease severity. However, there are no adequately sensitive biochemical markers or formulae that can accurately predict drug clearance and there is a lack of reliable information on drugs commonly used in palliative care.
Advice regarding drug treatment therefore, should be individualised to each patientand prescribing should be kept to a minimum where possible. Known hepatotoxic drugs should be avoided if possible.
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.