SPS resources
SPS has a webinar on how to manage patients with chronic liver disease in the community.
The SPS medicines monitoring tool gives recommendations on liver monitoring for relevant medicines.
If relevant information is not available on the SPS website or the information resources listed, or if your clinical scenario is complex, we suggest you seek further advice from the SPS Medicines Advice service.
Questions to ask when giving medicines advice in liver impairment provides guidance on gaining any relevant background information.
National and expert guidance
The following resources will assist in understanding the considerations when managing medicines in liver impairment.
NICE guidance
The National Institute for Health and Care Excellence (NICE) have produced Clinical Knowledge Summaries (CKS) that provide guidance on managing:
NICE has published guidelines for:
Primary resource suggestions
We recommend the following resources for information about specific medicines in liver impairment.
The manufacturers information should always be followed unless a liver specialist advises otherwise. Prescribing or administering a medication outside the manufacturers information may render the medicine being used off-label.
SmPCs
Summary of Product Characteristics (SmPCs) give the UK licensed status of a medicine’s use in liver impairment and can be accessed at the electronic Medicines Compendium (eMC) or via the MHRA. Manufacturers may take a cautious approach because of a lack of clinical trial data and may not be able to give clinical advice.
The severity of liver disease in SmPCs is often non-standardised to general descriptions of mild, moderate and severe.
Some SmPCs will use the Child-Pugh score with regard to dosage adjustment, or contraindicate the use of a medicine in certain populations of patients with liver disease.
It is useful to check the SmPCs for the following information:
- contraindications
- precautions
- adverse effects
- pharmacokinetic data
BNF
Access the online British National Formulary (BNF) to find:
- a useful overview on prescribing in hepatic impairment
- brief statements on the use of medicines during liver impairment (based largely on the SmPC)
The BNF is rarely used as a sole information source for managing medicines in liver impairment.
LiverTox
LiverTox is a free online resource that provides liver-related information for prescription medications, over the counter medications and selected herbal and dietary supplements in the USA.
Each individual medicine monograph provides information on hepatotoxicity, mechanism of injury, outcome and management.
Patient.Info
Patient.Info is a free online resource that provides healthcare professionals with useful information on abnormal liver function tests.
Other specialist resources
The following organisations provide broader information on liver and associated diseases.
BLT
The British Liver Trust (BLT) summarise key aspects of liver impairment.
They have guidance and algorithms for interpreting abnormal liver blood tests.
BSG
The British Society of Gastroenterology (BSG) have guidelines on the management of abnormal liver blood tests for children and adults in both primary and secondary care.
They also have a series of best practice guidelines on the outpatient management of cirrhosis including compensated cirrhosis, decompensated cirrhosis and special circumstances (covering surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis).
BASL
The British Association for the Study of the Liver (BASL) is a multidisciplinary group. They offer support for all healthcare professionals who see patients with liver disease both as inpatients and outpatients.
It encompasses the British Hepatology Pharmacy Group (BHPG) whom have produced a position statement on prescribing weight-adjusted oral paracetamol in adults. This dosing guide also discusses the risk factors to consider for hepatotoxicity with paracetamol.
BASL have also produced a guideline for symptom control in end of life patients with advanced liver disease.
EASL
The European Association for the Study of the Liver (EASL) have produced a clinical practice guideline for drug-induced liver disease. This summarises the risk factors, diagnosis, management and risk minimisation strategies for drug-induced liver injury.
Training materials
Learn more about medicines and the liver with the following recommended resources.
Medicines Learning Portal
The Medicines Learning Portal have a tutorial on liver medicine aimed at foundation level hospital pharmacists.
CPPE
The Centre for Pharmacy Postgraduate Education (CPPE) liver gateway page hosts a range of learning resources for liver medicine.