Optimizing Medication Management for Patients With Cirrhosis

Evidence-Based Strategies and Their Outcomes

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

Disclosures

Liver International. 2018;38(11):1882-1890. 

In This Article

Abstract and Introduction

Abstract

Cirrhosis is a morbid condition associated with frequent hospitalizations and high mortality. Management of cirrhosis requires complex medication regimens to treat underlying liver disease, complications of cirrhosis and comorbid conditions. This review examines the complexities of medication management in cirrhosis, barriers to optimal medication use, and potential interventions to streamline medication regimens and avoid medication errors. A literature review was performed by searching PUBMED through December 2017 and article reference lists to identify articles relevant to medication management, complications, adherence, and interventions to improve medication use in cirrhosis. The structural barriers in cirrhosis include sheer medication complexity related to the number of medications and potential for cognitive impairment in this population, faulty medication reconciliation and limited adherence. Tested interventions have included patient self-education, provider driven patient education, intensive case management including medication blister packs and smartphone applications. Initiatives are needed to improve patient, caregiver and provider education on appropriate use of medications in patients with cirrhosis. A multidisciplinary team should be established to coordinate care with close monitoring, address patient and caregiver concerns, and to provide timely access to outpatient evaluation of urgent/complex issues. Future studies evaluating the clinical outcomes and cost effectiveness of interventions are needed.

Introduction

Cirrhosis is the end result of chronic liver disease. It affects over 600 000 adults in the USA, with estimates that an additional five million have at least bridging fibrosis.[1,2] These numbers will rise as baby boomers with chronic hepatitis C age and the incidence of nonalcoholic fatty liver disease grows.[3] Indeed, patients with cirrhosis seeking medical attention has increased by 59% over the past decade,[4] and cirrhosis is now the 12th leading cause of death in the USA.[5] Compounding the problem of rising prevalence, cirrhosis is an expensive condition, with an estimated annual healthcare cost of $2 billion dollars in the USA.[6]

The primary drivers of morbidity and cost in cirrhosis are complications of decompensated disease: ascites, hepatic encephalopathy (HE) and variceal hemorrhage. Patients are frequently hospitalized for these conditions, with high 30–day readmission rates ranging from 25%–52%.[7,8] Providers prescribe a variety of medications with narrow therapeutic windows to treat these complications. Even for the most experienced provider, managing these medications is challenging. The risks of medication errors and serious side effects are magnified by difficulties with patient adherence, medication interactions, and the need for frequent dosage adjustments. Herein, we review the data on challenges and solutions for optimal medication management in patients with cirrhosis.

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