Abstract
Background: The use of certain medications in patients with chronic liver disease and cirrhosis remains controversial. No formal evidence-based guidelines have been published regarding the use of acetaminophen or nonsteroidal anti-inflammatory drugs in patients in this setting. As a result, whether or not to prescribe these medications and at what dosages in patients with chronic liver disease or cirrhosis is often met with much consternation. Objective: We assessed the prescribing preferences of senior medical students, internal medicine residents, and gastroenterology fellows for using NSAIDs and acetaminophen in patients with chronic liver disease (CLD), including those with cirrhosis. Methods: A 21-question web-based survey was distributed to several major teaching hospitals in Washington, DC. An online survey software (Survey Monkey) was used to collect and analyze responses. Results: A total of 543 trainees were sent the survey with 174 (32%) responding. The majority of respondents who were willing to use acetaminophen recommended a daily dose of 2 gms or less regardless of their level of training. Internal medicine residents and senior medical students tended to recommend against acetaminophen at any dose in favor of NSAIDs in decompensated cirrhotics. All trainee levels showed a diminishing preference towards using a therapeutic dose of 4 gms acetaminophen per day as a function of CLD severity. Conclusions: There is a wide divide at the trainee level regarding the usage and dosing for acetaminophen in patients with chronic liver disease. Additional education on the safe use of NSAIDs and acetaminophen in CLD and cirrhosis needs to begin in medical school. Senior students in particular voiced the need for controlled prospective studies in order to develop evidence-based guidelines to determine the appropriate indications for use of NSAIDs and acetaminophen along the spectrum of hepatic impairment in chronic liver disease.
Highlights
ObjectiveThe safe use of medications in patients with Chronic Liver Disease (CLD) and cirrhosis remains clinically challenging [1]
Internal medicine residents and senior medical students tended to recommend against acetaminophen at any dose in favor of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) in decompensated cirrhotics
Additional education on the safe use of NSAIDs and acetaminophen in CLD and cirrhosis needs to begin in medical school
Summary
The safe use of medications in patients with Chronic Liver Disease (CLD) and cirrhosis remains clinically challenging [1]. The greater the degree of liver dysfunction, the higher the potential for impaired drug metabolism with the risk of adverse hepatic and other drug effects [1,2,3]. This may be especially true when it comes to the use of OTC prescription analgesics. Many clinicians still suggest that their chronic liver disease patients, especially those with cirrhosis, not use APAP in any dose or under any circumstances [1,10]. Whether or not to prescribe these medications and at what dosages in patients with chronic liver disease or cirrhosis is often met with much consternation
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