Optimize PPI and H2 Receptor Antagonist Use in Cirrhosis Patients
Introduction
As a clinical pharmacist, you should optimize the use of proton pump inhibitors (PPIs) and H2 receptor antagonists (H2RA) in patients with cirrhosis. Use this guide to select and evaluate safe and effective options...
Optimizing PPIs and H2RAs in Cirrhosis
Choosing PPI in Cirrhosis
Use esomeprazole (Nexium, etc) for patients with cirrhosis and an indication for PPIs, as pharmacokinetic data supports its efficacy. Avoid omeprazole, lansoprazole, and rabeprazole in patients with decompensated cirrhosis to minimize risks.
- Note that long-term safety data for PPIs in cirrhosis patients are uncertain. Be aware that some studies suggest increased risks of infections like spontaneous bacterial peritonitis and Clostridioides difficile infection or hepatic encephalopathy, while other studies do not.
- Understand that the pharmacokinetics of PPIs vary by specific drug. Esomeprazole pharmacokinetics remain largely unchanged in hepatic impairment, whereas omeprazole, lansoprazole, and rabeprazole show altered pharmacokinetics due to decreased hepatic clearance.
Choosing H2 Receptor Antagonists in Cirrhosis
Avoid cimetidine (Tagamet, etc) as a histamine type 2 receptor antagonist in cirrhosis patients due to its association with encephalopathy. Prefer famotidine when H2RA are indicated for cirrhosis patients. Remember, dose adjustments are not typically needed for cirrhosis alone but are necessary for patients with coexisting renal impairment.
Take-home points
- Use esomeprazole for cirrhosis patients needing PPIs, as pharmacokinetic data supports its efficacy.
- Avoid omeprazole, lansoprazole, and rabeprazole in decompensated cirrhosis patients to minimize risks.
- Avoid cimetidine in cirrhosis patients due to its association with encephalopathy.
- Prefer famotidine when H2RA are indicated for cirrhosis patients.
- Remember, dose adjustments for H2RA are typically needed for patients with coexisting renal impairment.
References
- Jennings, J. (2024, February). Overview of medication adjustments for adult patients with cirrhosis. UpToDate, Inc. Retrieved July 1, 2024, from https://www.uptodate.com/contents/overview-of-medication-adjustments-for-adult-patients-with-cirrhosis
- Weersink RA, Bouma M, Burger DM, Drenth JPH, Harkes-Idzinga SF, Hunfeld NGM, Metselaar HJ, Monster-Simons MH, van Putten SAW, Taxis K, Borgsteede SD. Safe use of proton pump inhibitors in patients with cirrhosis. Br J Clin Pharmacol. 2018 Aug;84(8):1806-1820. doi: 10.1111/bcp.13615
- AJ, Boone L, et al. Drug Considerations for Medication Therapy in Cirrhosis. US Pharm. 2020;45(12)9-12
- Thomson MJ, Lok AS, Tapper EB. Optimizing medication management for patients with cirrhosis: Evidence-based strategies and their outcomes. Liver Int. 2018 Nov;38(11):1882-1890. doi: 10.1111/liv.13892
Keywords: Cirrhosis medication management, Proton pump inhibitors in cirrhosis, PPI safety in liver disease, Esomeprazole for cirrhosis patients, Avoiding omeprazole in decompensated cirrhosis, H2 receptor antagonists in cirrhosis, Famotidine safety in cirrhosis, Long-term PPI risks in liver disease, Pharmacokinetics of PPIs in cirrhosis, Drug therapy considerations in cirrhosis patients
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