Archive for the HCP Category

GAD – 7 Scale

Anxiety

Top tips:

  1. Anxiety is common and often underdiagnosed
  2. Validated tools should be used to differentiate anxiety from somatic symptoms
  3. In mild to moderate anxiety, lifestyle modification and psychotherapy may be sufficient
  4. Urgent assessment and treatment are needed in patients presenting with suicidality or function loss
  5. There is limited research on the use of pharmacological therapy for anxiety in cirrhosis; consider appropriate dose adjustments

Expand all Collapse all
Step 1: Assess for anxiety with validated assessment tools

Anxiety is common and may be pre-morbid, or occur secondary to physiological and psychological changes associated with cirrhosis. Overlapping somatic symptoms (fatigue, insomnia, impaired concentration, irritability) can complicate the diagnosis of anxiety.

Questionnaires are helpful to screen for “at risk” individuals but the diagnosis of anxiety requires a clinical interview

There are a range of screening tools that can be used. The GAD-7 (Generalized Anxiety Disorder) is advantageous because it emphasizes non-somatic symptoms, but other tools such as the HAM-A (Hamilton Anxiety Rating) Scale and Beck Anxiety Inventory can also be used.

GAD-7 (Generalized Anxiety Disorder)

Screening tool which emphasizes non-somatic symptoms

GAD – 7  calculator 

It is important to recognize when more urgent assessment is needed

More urgent assessment and possible admission are warranted if patients present with acute suicidality and/or severe functional impairment

Step 2: Consider potential contributing causes
Potential contributing factors include
  • Biological: Encephalopathy, uremia, pain, dyspnea, ascites, poor nutrition, impaired sleep, substance use history, medication side effects and medical co-morbidities
  • Psychological: Difficulties coping with chronic disease, inability to engage in prior activities, limited coping skills, past trauma and psychiatric co-morbidities
  • Social: Loss of employment, financial stressors, housing insecurity, change in social role (e.g. informal caregiving) or work, change in or loss of romantic and interpersonal relationships, social isolation, cultural factors
Step 3: Consider Non-pharmacological therapies for treatment of mild anxiety

Consider non-pharmacological management in all patients with mild anxiety.

These therapeutic techniques can be learned using online resources (apps) or text resources in situations where access to a therapist is difficult.

Lifestyle modification
Psychotherapy with CBT and MBSR

Cognitive Behavioral Therapy (CBT) and Mindfulness Based Stress Reduction (MBSR) are both effective for the management of anxiety in chronic illness.

Step 4: Both pharmacological and non-pharmacological therapies are typically needed for moderate to severe anxiety

If non-pharmacological therapy alone fails, consider adding pharmacological therapy, especially in cases of moderate to severe anxiety. There is limited evidence to guide the use of specific medications in cirrhosis.

Consider benzodiazepines as first-line management only with acute, severe symptoms. These medications are associated with significant adverse effects and are NOT first-line therapy for most patients

Benzodiazepines:

  • Typically used for severe anxiety symptoms or panic attacks. Avoid sudden benzodiazepine discontinuation in those patients on chronic benzodiazepines
  • May be used as bridge to long-term anxiety medication/treatment in selected patients
  • Should ONLY be used short-term (e.g. <2 weeks) to avoid dependence and tolerance
  • Caution: The use of opioids + benzodiazepines may increase the risk of falls/delirium
  • Caution: Be very cautious about starting benzodiazepines if there is a history of substance use disorder.
  • If needed, preferred benzodiazepines to use in liver disease have a short duration in action and are the least likely to cause toxicity = mnemonic ALOT (alprazolam, lorazepam, oxazepam and temazepam)
  • AVOID clonazepam
Long-term therapy can consist of an SSRI or SNRI (anti-depressant therapy)

Selection of an antidepressant should take into account potential interactions with other medications the patient is prescribed.

  • SSRIs and SNRIs need dose adjustment of 50% given impaired hepatic metabolism
  • SSRIs may also increase the risk of bleeding, especially if on an antiplatelet agent
  • Desvenlafaxine is the only antidepressant that does not undergo significant metabolism by the liver
Choice of medication may be tailored based on symptom patterns

Selection of an antidepressant should take into account potential interactions with other medications the patient is prescribed.

Medication: Recommended Dose Additional information
Well-tolerated

Citalopram (SSRI)(immediate release)

10 mg PO daily
Max:
20 mg PO daily

GI bleed risk, can lower seizure threshold, risk of QT prolongation, caution with eGFR <20 mL/min.

Mirtazapine

15 mg PO nightly
Max: 30 mg PO nightly

Caution with eGFR <30 mL/min (start with 7.5-15 mg, and titrate with close monitoring.
Sedating.

Escitalopram (SSRI)

5 mg PO daily
Max:10 mg PO daily

GI bleed risk, can lower seizure threshold, risk of QT prolongation, caution with eGFR <20 mL/min.

Sleep disturbance

Sertraline (SSRI)

25 mg PO daily
Max:100 mg PO daily

GI bleed risk.
NOT recommended in Child Pugh B/C disease.

Mirtazapine

15 mg PO nightly
Max: 30 mg PO nightly

Caution with eGFR <30 mL/min (start with 7.5-15 mg, and titrate with close monitoring.
Sedating.

Fatigue/Low energy

Fluoxetine (SSRI)

10 mg PO daily
Max:
20 mg PO daily

GI bleed risk.

Venlafaxine (SNRI)

37.5 mg PO nightly
Max: 112.5 mg PO nightly

GI bleed risk, nausea.
NOT recommended in Child Pugh B/C disease.

Desvenlafaxine (SNRI)

50 mg PO daily
Max:100 mg PO daily

GI bleed risk, nausea.

Low Appetite/Nausea

Mirtazapine

15 mg PO nightly
Max: 30 mg PO nightly

Caution with eGFR <30 mL/min (start with 7.5-15 mg, and titrate with close monitoring.
Sedating.

Co-morbid Neuropathic Pain

Venlafaxine (SNRI)

37.5 mg PO nightly
Max: 112.5 mg PO nightly

GI bleed risk, nausea.
NOT recommended in Child Pugh B/C disease.

Desvenlafaxine (SNRI)

50 mg PO daily
Max:100 mg PO daily

GI bleed risk, nausea.

 

Ensure the patient’s symptoms are reassessed, using validated tools

Once initiated, treatment should be re-assessed at 2 weeks using validated questionnaires (e.g. GAD-7) to evaluate response.

  • If there is improvement at two weeks, consider increasing the dose to further target symptoms
  • If there is no improvement or significant side effects at follow-up, the likelihood of symptom remission is low. An alternate medication trial should be considered
  • A full trial of an antidepressant (used for anxiety) occurs when the maximum allowable dose is used for 8 weeks.

 

Consider referral to psychiatrist or mental health specialist
  • Lack of response to an adequate trial of TWO anti-depressants (used for anxiety)
  • Severe symptoms or functional impairment

 

This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

Authors (Alphabetical): Amanda Brisebois, Sarah Burton-Macleod, Ingrid DeKock , Martin Labrie, Noush Mirhosseini, Nicholas Mitchell, Mino Mitri, Kinjal Patel, Aynharan Sinnarajah, Puneeta Tandon, Sarah Tymchuk

Thank you to pharmacists Omer Ghutmy and Meghan Mior for their help with reviewing these pages. 

Helpful Links: 
  1. Self-test for anxiety (GAD-7): https://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=abn2339
  2. Alberta Health Services Self-Help tips: https://www.albertahealthservices.ca/news/page13125.aspx
References:
  1. Davison SN on behalf of the Kidney Supportive Care Research Group. Conservative Kidney Management Pathway; Available from: https//:www.CKMcare.com.
  2. Medication prescribing in liver dysfunction. Ment Health Clin [Internet]. 2014;4(3):131-7, doi: https://doi.org/10.9740/mhc.n197913
  3. Mullish BH, Kabir MS, Thursz MR, Dhar A. Review article: depression and the use of antidepressants in patients with chronic liver disease or liver transplantation. Aliment Pharmacol Ther. 2014 Oct;40(8):880-92. doi: 10.1111/apt.12925. Epub 2014 Sep 1. PMID: 25175904.
  4. Telles-Correia D, Barbosa A, Cortez-Pinto H, Campos C, Rocha NB, Machado S. Psychotropic drugs and liver disease: A critical review of pharmacokinetics and liver toxicity. World J Gastrointest Pharmacol Ther. 2017 Feb 6;8(1):26-38. doi: 10.4292/wjgpt.v8.i1.26. PMID: 28217372; PMCID: PMC5292604.
  5. Wilcock A, Charlesworth S, Prentice W, Selby P, McKenna M, Cripps S, Considine A, Orr A, Wright M, Mihalyo M, Oxberry S. Prescribing in Chronic Severe Hepatic Impairment. J Pain Symptom Manage. 2019 Sep;58(3):515-537. doi: 10.1016/j.jpainsymman.2019.04.034. Epub 2019 May 9. PMID: 31077785.
We gratefully acknowledge the Physician Learning Program for their design assistance.

PHQ-9 Depression Scale

Poor appetite and intake

Top tips:

  1. Appetite loss and reduced caloric intake (anorexia) are common in cirrhosis
  2. Consider contributing causes and treat if appropriate according to goals of care.
  3. There is no robust cirrhosis specific data evaluating pharmacological therapy
  4. Refer to additional topics under the Healthy Living tab (malnutrition, frailty)
Expand all Collapse all
Step 1: Consider potential contributing causes and treat as appropriate

Anorexia is multifactorial, in part related to changes in pro-inflammatory upregulation and appetite mediators as liver disease progresses.

Potential contributing factors include
  • Poor palatability of prescribed diets– e.g. dietary restriction of sodium ± other restrictions based on clinical diagnoses – see Nutrition section for patient resources. Depending upon the course of the patient’s disease, it may also be relevant to have discussions to understand the potential benefits (e.g. reduction in volume retention) versus burden (e.g. impact on quality of living, ability to enjoy or intake food) of continued sodium restriction.
  • Early satiety, gastroparesis – medications, physical limitations such as ascites
  • Dysgeusia (altered sense of taste) – zinc deficiency – test and treat
  • Medications – culprits include antihistamines, opioids, certain antibiotics, antidepressants
  • Hypogonadism – hypothyroidism, adrenal insufficiency, see sexual dysfunction page
Anorexia may be a manifestation of another symptom such as
A dietician consult and guidance can help evaluate and improve a patient’s nutrition.
Step 2: Consider non-pharmacological therapies

 Interdisciplinary consultation as appropriate – Dietitian, speech language pathologist, occupational therapist, physical therapist 

Practical non-pharmacological therapies can be utilized to increase intake
  • Food should be treated as medication- consider setting alarms as reminders to eat
  • Smaller, more frequent high calorie meals and snacks (q3-4 hourly)
  • Limit fluid intake when eating to reserve room for food
  • Avoid drinks that reduce appetite and provide little nutrition such as coffee, tea and water
  • Liquid nutritional supplements are useful high calorie liquid snacks
  • Limit intake of spicy, acidic or overly sweet foods
  • Cold foods may cause less aversion if nausea is an issue
Initiation of enteral supplementation can be discussed in concert with a Dietitian or Nutrition Specialist. 
Step 3: Pharmacological therapy
Lifestyle modification

There is no data to support the routine use of appetite supplements in the setting of cirrhosis.

In cancer patients, appetite stimulants such as Megesterone acetate have not shown benefits on sarcopenia, physical function or survival. Use is associated with a risk of thrombosis.

 

Special considerations at End of Life (last few days to weeks)
Lifestyle modification

At End of life, as the patient’s condition deteriorates, anorexia will worsen and it will not be amenable to therapy (including enteral/parenteral nutrition). Discussions around eating for pleasure may help patients to be able to balance adverse effects versus benefits at this stage. If anorexia or conversations around the utility of nutritional therapy at end of life are of particular distress for the patient, family or team, a consultation from Palliative Care should be obtained.

 

The Nutrition in Cirrhosis Guide
About the Guide

To download the complete "Nutrition in Cirrhosis Guide" (40 pages) as a .pdf file, click here.

The Guide was made possible from extensive feedback from patients, and their family & friends, who attend The Cirrhosis Care Clinic (TCCC) at the University of Alberta in Edmonton, Alberta, Canada.

This Guide covers general topics relevant to all patients with cirrhosis. Specific nutrition issues are also addressed that may be helpful at other times. The Guide is a tool for use throughout your cirrhosis journey.

The Guide is intended to be read a few pages at a time, beginning with those most important to your health or of interest to you.

The recipes (Chapter 4) are suitable for all individuals and can be modified to accommodate food allergies, dietary restrictions, and preferences.

Funding for the Guide’s creation was obtained from a research grant from the Canadian Institutes of Health Research (CIHR) and Alberta Innovates. Alberta Health Services provided protected time to V DenHeyer.

The following organizations provided support in the form of unrestricted educational grants to support the Guide:

Peer review regarding the content and format of the Guide was obtained from registered dietitians (RDs) and gastroenterologists in Halifax, Montreal, Toronto, Edmonton, Calgary, and Vancouver. Additional input was obtained from experts across North America and Europe. Thank you for your valuable input and assistance.

If any portion of the Guide is used in research, communications, or patient care, please use the following citation:

Tandon P, DenHeyer V, Ismond KP, Kowalczewski J, Raman M, Eslamparast T, Bémeur C, Rose C. The Nutrition in Cirrhosis Guide. University of Alberta, Edmonton, Alberta. 2018. pp. 1- 40.

The Nutrition in Cirrhosis Guide may be reproduced for non-commercial use as is and in its entirety without further permission. Adaptations, modifications, unofficial translations, and/or commercial use of The Nutrition in Cirrhosis Guide are strictly prohibited without prior permission.

The Cirrhosis Care Clinic
University of Alberta
Edmonton, AB, Canada T6G 2X8
www.wellnesstoolbox.ca

Clinician Primer

Click here to download the .pdf file (1 page)

 

This chapter covers the following topics:

  • Malnutrition risk profile for patients with cirrhosis
  • How & why the Guide will be helpful in your clinic
  • Who should read the Guide
  • Other patient-friendly websites providing helpful cirrhosis-specific information
  • References used in the creation of the Guide

 

 

Who will benefit from reading this chapter?

  • Physicians & Other Healthcare Practitioners providing care to patients with cirrhosis
  • Researchers
  • Any Patient with Cirrhosis
  • Anyone interested in the Guide
Chapter 1 – Malnutrition

Click to download the .pdf file (4 pages)

 

 

This chapter covers the following topics:

  • What is malnutrition?
  • Warning signs of malnutrition
  • Who is at-risk for malnutrition?
  • Why are patients with cirrhosis so susceptible?

 

 

Who will benefit from reading this chapter?

  • Any Patient with Cirrhosis
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 2 – What to eat and what to avoid?

Click to download the .pdf file (14 pages)

 

This chapter covers the following topics:

  • What foods to avoid eating?  Which foods are good for the liver?
  • BMI Calculator (Body Mass Index)
  • Daily calorie intake - what is it and why it is important
  • Important nutrients: protein & sodium
  • How and why it's important to track body weight

Who will benefit from this chapter?

  • Any Patient with Cirrhosis
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 3 - Tips for eating even when not hungry

Click here to download the .pdf file (3 pages)

 

This chapter includes the following topics:

  • How to manage fatigue, cooking, and eating
  • How to cope when getting full after just a few bites
  • Smart tips for stretching the food budget
  • How to stick to a regular eating schedule

 

Who will benefit from reading this chapter?

  • Any Patient with Cirrhosis
  • Anyone who prepares food for person living with cirrhosis
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 4 – Recipes

Click here to download the .pdf file (4 pages)

This chapter includes liver-friendly recipes that are:

  • Nutritious
  • Easy to prepare & use inexpensive ingredients
  • Modifiable to accommodate dietary restrictions, tastes & preferences
  • Weight maintenance & weight loss friendly
  • Suitable for those with & without cirrhosis
Some recipe examples are:
  • Baked Chicken Dinner
  • Salmon Salad
  • Homemade Banana Muffins - YUM!
  • Black Bean Soup

 

Who will benefit from reading this chapter?

  • Anyone cooking for a Patient with Cirrhosis
  • Any Patient with Cirrhosis
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
  • Anyone looking for easy-to-make, nutritious & delicious recipes!
Chapter 5 – Meal supplements

Click here to download the .pdf file (2 pages)

This chapter includes topics about:

  • When are meal supplements useful?
  • Common meal supplement drinks
  • Which supplement drinks are best for which health conditions

 

 

Who will benefit from this chapter?

  • Any Patient with Cirrhosis with a poor appetite or needing snack ideas
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 6 - Managing weight loss & cirrhosis

Click here to download the .pdf file (3 pages)

This chapter includes sections on:

  • Diet priorities for non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH)
  • Protein intake - it's a priority!
  • Tips for reaching daily protein targets
  • Eating to help the liver & lose weight at the same time - Help?

 

Who will benefit from this chapter?

  • All Patients with NAFLD, NASH, or cirrhosis caused by NAFLD or NASH
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 7 - What to expect in the hospital

Click here to download the .pdf file (2 pages)

This chapter includes topics about:

  • What meals and snacks to expect
  • I can't follow my usual eating schedule - Help?
  • What is a "nasogastric (NG) feed"
  • Why an NG may be prescribed

 

 

Who will benefit from reading this chapter?

  • Any Patient with Cirrhosis who is being admitted to the hospital
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners

This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

Authors (Alphabetical): Amanda Brisebois, Sarah Burton-Macleod, Ingrid DeKock , Martin Labrie, Noush Mirhosseini, Mino Mitri, Kinjal Patel, Aynharan Sinnarajah, Puneeta Tandon

Thank you to pharmacists Omer Ghutmy and Meghan Mior for their help with reviewing these pages. 

References:
  1. Davison SN on behalf of the Kidney Supportive Care Research Group. Conservative Kidney Management Pathway; Available from: https//:www.CKMcare.com.
  2. Bruera E. ABC of palliative care. Anorexia, cachexia, and nutrition. BMJ. 1997 Nov 8;315(7117):1219-22. doi: 10.1136/bmj.315.7117.1219. PMID: 9393230; PMCID: PMC2127742.
  3. Bunchorntavakul C, Reddy KR. Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis. Aliment Pharmacol Ther. 2020 Jan;51(1):64-77. doi: 10.1111/apt.15571. Epub 2019 Nov 8. PMID: 31701570.
  4. Ruiz-García V, López-Briz E, Carbonell-Sanchis R, Bort-Martí S, Gonzálvez-Perales JL. Megestrol acetate for cachexia-anorexia syndrome. A systematic review. J Cachexia Sarcopenia Muscle. 2018 Jun;9(3):444-452. doi: 10.1002/jcsm.12292. Epub 2018 Mar 14. PMID: 29542279; PMCID: PMC5989756
We gratefully acknowledge the Physician Learning Program for their design assistance.

Calculators-TTV

Calculators-ALBI

Calculators – FeNa

Calculators – Child Pugh

Calculators – R factor

Spontaneous Bacterial Peritonitis and Spontaneous Bacterial Pleuritis

Top tips:

  1. Speed is life in cirrhosis when infection is suspected. Early and Appropriate antibiotics reduce mortality.
  2. Paracentesis and Thoracentesis before antibiotics is ideal. But, if you have a high suspicion of infection and these cannot be arranged in a timely manner, do not delay antibiotics.
  3. You must consider risk factors for multi-drug resistance (i.e. recent hospitalizations, colonization with multi-drug resistant organisms, nursing home resident) when choosing your antibiotics.
  4. De-escalate/narrow antibiotics as soon as a pathogen is identified on culture.
  5. All patients should be started on secondary prophylaxis with antibiotics once a diagnosis of SBPeritonitis or SBPleuritis is made. In patients with low protein ascites (<1.5 g/L), primary SBP prophylaxis does not change mortality, but could be considered in those at high risk (renal dysfunction – creatinine level ≥1.2 mg/dL (106 umol/L), BUN ≥ 25 mg/dL, sodium l 130 mEq/L) or liver failure (Child Pugh score ≥9 and bilirubin ≥3 mg/dL (51.3 umol/L))

Order panel for SB Peritonitis or SB Pleuritis:

For adults with cirrhosis admitted with Spontaneous Bacterial Peritonitis (ascites PMN >250 cells/µL) or Spontaneous Bacterial Pleuritis (pleural fluid PMN >500 cells/µL or >250 cells/µL with positive culture):
 SB-Peritonitis-Pleuritis Order Panel

Thank you to Dr. Saxinger for your efforts creating the content on this page!

Diagnosis

Specific Management

Patient materials:

You can direct patients to the following:
Paracentesis

Lab tests

Downloadable content:

You can download these to print or view offline:
EASL Guidelines

References:

This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.
Authors: Dr. Lynora Saxinger, Dr. Dean Karvellas, Dr. Uma Chandran, Dr. Puneeta Tandon
References:

  1. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018 Aug;69(2):406-460 PMID 29653741
  2. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology (Baltimore, Md.)74(2), 1014–1048. https://doi.org/10.1002/hep.31884 PMID 33942342