Medications in liver disease
Why do I need to be concerned about medicines in liver disease?
When you take a medicine, it is usually absorbed from your gut to your liver and eventually into the bloodstream where it can travel to exert its effect. One of the important functions of the liver is to help break down medicines and remove them from your blood. If the liver stops working properly, the medicine is less able to leave your blood. Having more medicine in your blood for longer can cause side effects that can be dangerous.
What medications are safe to use in liver disease?
Good news! Many people that have mild liver disease can safely take most common prescription and non-prescription medications at the normal recommended dose.
• Paracetamol is safe to use however patients with cirrhosis should limit their daily intake to 2 grams in divided doses. Many over-the-counter and prescription medications to treat cold and flu, fever or pain contain paracetamol, so it's important to check the labels to ensure you don’t exceed this recommended amount.
• Pain relief can be a complex subject in liver disease so it is always better to seek the advice of your gastroenterologist/GP for safe and effective options.
• Cholesterol-lowering medications (or “statins”) are safe to use in liver disease and are important for your cardiovascular health however they have been known to affect liver blood tests. Depending on the severity of your disease your doctor or pharmacist can advise on whether this medication is suitable for you or advise on a safer alternative for cholesterol control.
• Hormone replacement therapy/hormonal contraception can be used in patients with cirrhosis however your doctor may recommend a formulation other than a tablet for you, which will help reduce the likelihood of side effects or toxicity to the liver (eg. patch).
What medications should be avoided in liver disease?
People with cirrhosis may need to take less of certain medications than people with healthy livers; therefore it is always best to speak to your doctor or pharmacist if you are prescribed a new medication.
People with cirrhosis should avoid all substances that are known to damage the liver. This includes:
• Alcohol: Continuing to drink alcohol with a background of liver disease can damage your liver further and can increase your risk of liver cancer.
• Nonsteroidal anti-inflammatory drugs (e.g. ibuprofen, diclofenac and naproxen): These medicines can lead to complications that can affect both your liver and kidneys.
• Some dietary supplements, herbal remedies or Chinese medicine (e.g. kava kava and skullcap) have been known to be toxic to the liver. Be cautious about the claims about Chinese and herbal remedies, particularly those advertised on the internet. It is always best to seek the advice of your pharmacist, doctor or dietician before taking this kind of medication.
Other medications that can cause increased side effects in patients with cirrhosis include:
• Sedative medication: This includes sleeping tablets (or “Z drugs”), benzodiazepines and some pain relief medication with opioids (eg. Codeine, morphine & oxycodone) which can worsen hepatic encephalopathy.
• Constipating medications: This includes anti-sickness medications such as ondansetron, some antidepressants (e.g. amitriptyline) and opioid containing pain relief medication which can contribute to hepatic encephalopathy.
• High salt content medications: Large amounts of salt in effervescent (or fizzy) pain killers and supplements can cause an increase in volume of tummy fluid. Consult your pharmacist or dietician for alternatives to these medicines.
• Proton pump inhibitors: These medications have been linked to increase infection risk and worsening of hepatic encephalopathy (eg. Omeprazole, esomeprazole.) You should speak to your GP to ensure this medication is reviewed regularly and that you do need to be on this medicine longterm.
I have been prescribed a new medication by my gastroenterologist, what is it for?
The aim of treatment is to prevent your liver disease getting any worse and to treat any disabling complications.
Medicines for hepatic encephalopathy (HE):
In liver disease, the body struggles to get rid of the waste products effectively and they can be carried to the brain by your blood. This can cause confusion, short term memory problems as well as tiredness throughout the day.
• Lactulose is a sweet syrup-like medicine. It is a laxative which helps the body to remove toxins that can build up when the liver isn’t working as well. It also helps to prevent the growth of bacteria that produce ammonia in the bowel, which can affect brain function. It is important to have at least 2 to 3 bowel movements per day.
• Rifaximin (Targaxan) works by killing the bacteria which produce ammonia in your gut. Your doctor will prescribe this with lactulose if you have had previous episodes of HE.
Medications for ascites:
Ascites (fluid building up in the tummy) and swelling in the ankles or legs (peripheral oedema) can be a common complication of cirrhosis.
• Spironolactone and Furosemide are also known as diuretics. These medicines help the body get rid of excess fluid. These medications can affect your potassium and sodium therefore it is important to attend your doctor for regular blood tests.
• Co-trimoxazole or ciprofloxacin are antibiotics that may be prescribed if you have had an infection in the fluid building up in the tummy.
Medication for portal hypertension:
In cirrhosis blood is prevented from flowing through the liver easily and this can cause a build-up of pressure in the portal vein (the vein that carries blood to the liver). To relieve this pressure, blood goes around the portal vein, through other veins called varices that can be susceptible to bleeding.
• Propranolol and carvedilol are also known as beta blockers. They reduce the risk of bleeding by helping to lower the high blood pressure in the main vein that takes blood to the liver and can help to reduce the risk or severity of bleeding. Your doctor or nurse will monitor your heart rate and blood pressure while on this medication.
Other medication that you may get a prescription for by your gastroenterologist:
• Prednisolone/budesonide can help to reduce inflammation in the liver. Steroids are usually prescribed as a reducing course. It is best to take this medication with/after food.
• Calcium and vitamin D supplementation may be prescribed if you are taking steroids as a method of bone protection.
• Thiamine deficiency is common in patients with liver disease and your doctor may give you a prescription for this B vitamin.
• Ursodeoxycholic acid is a medication used in patients with primary billary cholangitis and helps delay damage to the liver. It works by reducing the retention of bile acids and increasing their elimination from the liver.
• Cholestyramine sachets act by binding to bile acids and preventing their reabsorption. This helps with itch associated with liver disease but can interact with other medications so best to take one hour after all other medications.
What should I do if I am worried about my medication?
• Make an appointment to speak to your gastroenterologist, GP or pharmacist regarding your medication.
• Keep an updated list of your medication or ask your community pharmacist for a print out of your regular medication for taking to appointments. Bring all medications including over the counter medications, supplements and herbal remedies so healthcare providers can check the safety of your medication with your liver function.
• Don’t be afraid to ask questions about your medications or to query why you are prescribed a medication.
• Bring a family member with you to the appointment if you feel overwhelmed about talking about medications.
• If you are experiencing any new or troubling side effects from a medication, make a diary of these and bring it to your next appointment.
• Never start any new medications or supplements without first checking with your doctor or pharmacist. Also, any time you are being prescribed a new medication, make sure the healthcare provider prescribing it knows about your liver disease.