Inappropriate Prescriptions Common in Cirrhosis

Kerry Dooley Young

November 21, 2019

Only a minority of patients with decompensated cirrhosis are taking appropriate medications for the condition, a large review of prescription records shows.

Many patients were taking medications that could worsen their health, and some were taking appropriate drugs but for too short a time, said investigator Mary Thomson, MD, from the University of Michigan in Ann Arbor.

This study quantifies the inappropriate prescribing patterns that are all too familiar to physicians who treat people with liver conditions, said Kapil Chopra, MD, from the University of Pittsburgh Medical Center, who was not involved with the study.

It "validates what we see in day-to-day practice. It's a call for education — better education — for all levels of healthcare providers, including pharmacists," he told Medscape Medical News.

Patients with cirrhosis might see several clinicians — including a primary care physician, a gastroenterologist, a hepatologist, and an advanced practice provider — but not all are trained in the treatment of liver diseases, Chopra explained.

All clinicians should be careful not to prescribe drugs that can harm these patients and should try to address obstacles that can prevent patients from taking appropriate medications, he added.

Pharmacists could play a larger role in this work, he said. They already have tools to encourage the use of less-expensive drugs and the timely refill of medications. Their monitoring could be expanded to prevent the use of drugs potentially harmful to patients.

Even a nonsteroidal anti-inflammatory agent like ibuprofen in a patient with cirrhosis and ascites can do so much harm, but we see this all of the time in practice.

"Even a nonsteroidal anti-inflammatory agent like ibuprofen in a patient with cirrhosis and ascites can do so much harm, but we see this all of the time in practice. All of the time," Chopra said.

For their study, Thomson and her colleagues identified 12,695 patients with decompensated cirrhosis in a national insurance claims database maintained by Optum. She presented the findings at the Liver Meeting 2019 in Boston.

Of the 10,193 patients with ascites, only 5831, or 57.2%, had filled a prescription for a diuretic, which is considered the appropriate medication for the accumulation of fluid. In fact, an inpatient diagnosis code for ascites was associated with significantly higher rates of diuretic use.

However, 989 of the patients with ascites, or 9.7%, filled an inappropriate prescription for an NSAID. Also concerning is the fact that 7.8% of patients with a history of hepatorenal syndrome filled a prescription for an NSAID after a diagnosis of ascites, Thomson said.

Of the 3457 patients with hepatic encephalopathy, 2392, or 69.2%, filled lactulose prescriptions, and 899, or 26.0%, filled prescriptions for lactulose and rifaximin (Xifaxan). The investigators classified these medications as appropriate.

But in this group with hepatic encephalopathy, 1784 patients, or 51.6%, filled a prescription for an opiate, and 740, or 21.4%, filled a prescription for a benzodiazepine. The investigators classified both of these as inappropriate.

In addition, only 1173, or 59.8%, of the 1961 patients with variceal bleeding filled a prescription for a nonselective beta blocker after that episode, and only 163, or 50.1%, of the 325 patients who experienced an episode of spontaneous bacterial peritonitis filled prescriptions for appropriate antibiotics.

A Struggle to Pay

It would be valuable to compare this kind of prescription information with socioeconomic data to better understand what is happening with these patients, said Carlos Romero-Marrero, MD, chief of hepatology at the Cleveland Clinic.

Many people with cirrhosis struggle to pay for their medicines, he told Medscape Medical News. Nurse coordinators and case managers should be put into service to help such patients find financial aid.

The lowest price for the most common version of rifaximin, for example, is around $1624.76 for a 3-week course of treatment, which is 17% lower than the average retail price of $1957.24, according to the GoodRx website.

In addition, insurers could help keep tabs on how well people with cirrhosis are managing their prescriptions, said Romero-Marrero. "There should be good communication between payers and providers to make sure that the patients are receiving their medicines."

Also, physicians should encourage their patients to take more ownership of this aspect of their medical care and to avoid over-the-counter NSAIDs, Chopra added.

"Care of patients should include a conversation about what not to do, as well as what to do," Chopra said. "When people go to a doctor, they are looking at what to do. People are desperate to have you order additional tests, medications, etcetera. Everybody wants to leave the office visit with something, but it is also our responsibility to say what not to do."

The Liver Meeting 2019: American Association for the Study of Liver Diseases (AASLD): Abstract 55. Presented November 11, 2019.

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