A 67 year old male patient was admitted to the male medicine ward with complaints of abdominal distension, bilateral lower limb oedema, pitting pedal oedema, distended and swelled scrotum and breathlessness since 15 days.

1. A CASE PRESENTATION
ON CHRONIC ALCOHOLIC
LIVER DISEASE
- AJITA SADHUKHAN
- PHARM D. 4TH YEAR
- ROLL No. – 1
26-03-2020 1

2. SUBJECTIVE EVIDENCE
• IPD No.: 18121806
• OPD No.: 18014293
• AGE: 67 YEARS
• SEX: MALE
• DEPARTMENT: MALE MEDICINE WARD
• UNIT: 3
• DATE OF ADMISSION: 04.08.2018
• DATE OF DISCHARGE: 09.08.2018
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3. • Complaints on admission: abdominal distension, bilateral lower limb oedema,
pitting pedal oedema, distended and swelled scrotum, breathlessness
• O/E: P.R. – 76bpm
B.P. – 140/90 mm Hg
SPO2 – 97%
• Origin, duration & progress: patient was relatively asymptomatic before 15
days, then c/o abdominal distension which is gradually increasing in size and also
c/o lower limb oedema. Pedal oedema appeared before 15 days → disappeared →
started on abdomen.
• Past History: jaundice at the age of 15-16 years. No H/O DM/ TB/ Asthma/ BP.
Cataract surgery.
• Addiction: H/O of chronic alcoholism and tobacco since 10 years.
• Family history: not significant
• Personal History: appetite- adequate, diet- non-veg, bowel habit – 2x, bladder
habit – 5x/7x, sleep- normal.
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4. • General examination:
- Built: fair
- Nutrition: adequate
- Clubbing, cyanosis, icterus,
lymphadenopathy: no
- Jaundice: +
- Pallor: +
- Oedema: B/L pedal oedema, pitting
- Eyes: normal
- Temperature: normal (afebrile)
- P.R.: 76 bpm
- B.P: 140/90 mm Hg
- Respiration: 16 breaths/min
• Local examination:
- Inspection: P/A abdominal distension
• Systemic examination:
- RS: AEBE clear
- CVS: clinically NAD, S1 S2 normal
- P/A: abdominal distension, soft
- CNS: clinically NAD
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5. OBJECTIVE EVIDENCE
• 04.08.2018
1. S. Vitamin B-12: 383 pg/mL (240-900
pg/mL)
2. S. Ferritin: 5.5 ng/mL ( F: 11-306.8
ng/mL, M: 23.9-336.2 ng/mL)
3. Urine analysis:
a. Physical Examination:
Colour: pale yellow
Appearance: hazy
b. Chemical Examination:
Protein: Trace
c. Microscopic Examination:
Pus cells: 4-6 /HPF (0-10 /HPF)
Epithelial Cells: occasional /HPF (Absent)
RBCs: absent (0-10 /HPF)
4. Blood group: O’’Rh. Positive
5. Renal function test:
a. S. Urea: 69 mg/dL (15-45 mg/dL)
b. S. Creatinine: 1.4 mg/dL (0.5-1.5 mg/dL)
c. S. Uric Acid: 7.6 mg/dL ( 3.5-7.2 mg/dL)
6. Random Plasma Glucose: 119 mg/dL
(70-140 mg/dL)
7. Serum Electrolytes:
a. S. Sodium: 142 mmol/L (135-148 mmol/L)
b. S. Potassium: 5.0 mmol/L (3.5-5.0 mEq/L)
c. S. Chloride: 101 mmol/L (98-107 mmol/L)
8. Haemostasis Profile:
a. PT: 18.3 sec (12.1-17.3)
b. INR: 1.35 (0-2)
9. APTT:
Patient’s value: 33.0 sec (30-40 sec)
Control: 29.426-03-2020 5

6. LIVER FUNCTION TEST: (04.08.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Total 0.6 0.3-1.2 mg/dL
Direct 0.2 0.0-0.4 mg/dL
Indirect 0.4 0.0-0.6 mg/dL
S. Bilirubin:
S. Protein:
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Total Protein 5.9 6.3-8.3 g/dL
Albumin 3.0 3.6-4.5 g/dL
Globulin 2.9 2.7-3.5 g/dL
Albumin-globulin ratio 1.03
Others:
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
S.G.P.T (ALT) 12 0.0-49 U/L
S.G.O.T (AST) 20 0.0-40 U/L
S. ALP 61 < 270 U/L
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7. Complete Blood Count (04.08.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Hb 3.8 12.5-16 g/dL
WBC 6190 4000-10500 /mcgL
Neutrophils 70 50-70 %
Eosinophils 03 0-7 %
Lymphocytes 21 20-40 %
Monocytes 06 <10 %
Basophils 00 <1 %
RBC 2.97 4.20-5.40 Millions/mcgL
MCH 12.8 27-31 pg
Platelets 446000 1.5-4.5*10^5 /mcgL
MCV 48.3 78-100 fL
Hematocrit (PCV) 14.3 37-47 %
MCHC 26.6 32-36 g/dL
RDW-CV 23.7 11-14.6 %
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8. • 06.08.2018
1. Renal function test:
a. S. Urea: 61 mg/dL (15-45 mg/dL)
b. S. Creatinine: 1.6 mg/dL (0.5-1.5
mg/dL)
c. S. Uric Acid: 9.2 mg/dL ( 3.5-7.2
mg/dL)
2. Ascitic Fluid Examination:
a. Physical Examination:
Colour: pale yellow
Appearance: Hazy
Turbidity: present
b. Microscopic Examination:
Total count: 100 cells/microL
Total RBCs: 1-2 /HPF /cumm
c. Differential Count:
Polymorphs: 20 %
Lymphocytes: 60 %
d. Biochemical Examination:
Sugar: 96 mg/mL
3. Abdominal and Pelvic Ultrasound:
Liver: shrunken in size, altered ECHO
texture
Pancreas: obscured by gas
Others: generalised anterior abdominal
wall oedema
Conclusion: cirrhosis of liver, gross
ascites.
4. Standing CXR: suggestive of
alcoholic cardiomyopathy.
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9. Complete Blood Count (06.08.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Hb 6.6 12.5-16 g/dL
WBC 12220 4000-10500 /mcgL
Neutrophils 83 50-70 %
Eosinophils 03 0-7 %
Lymphocytes 10 20-40 %
Monocytes 04 <10 %
Basophils 00 <1 %
RBC 3.77 4.20-5.40 Millions/mcgL
MCH 17.5 27-31 pg
Platelets 372000 1.5-4.5*10^5 /mcgL
MCV 60.4 78-100 fL
Hematocrit (PCV) 22.8 37-47 %
MCHC 28.9 32-36 g/dL
RDW-CV 29.4 11-14.6 %
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10. • 07.08.2018
1. HBsAg test: negative
2. Hepatitis C Virus: negative
3. HIV: negative
4. Serum Electrolytes:
a. S. Sodium: 135 mmol/L (135-148 mmol/L)
b. S. Potassium: 3.3 mmol/L (3.5-5.0 mEq/L)
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11. LIVER FUNCTION TEST: (07.08.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Total 0.9 0.3-1.2 mg/dL
Direct 0.4 0.0-0.4 mg/dL
Indirect 0.5 0.0-0.6 mg/dL
S. Bilirubin:
S. Protein:
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Total Protein 6.0 6.3-8.3 g/dL
Albumin 3.1 3.6-4.5 g/dL
Globulin 2.9 2.7-3.5 g/dL
Albumin-globulin ratio 1.07
Others:
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
S.G.P.T (ALT) 13 0.0-49 U/L
S.G.O.T (AST) 23 0.0-40 U/L
S. ALP 48 < 270 U/L
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12. 26-03-2020 12
08.08.2018 1. UGI scopy:
Interpretation: Grade 1 esophageal varices,
small GOV (gastro oesophageal varices)
type 1 varices, mild PHG (portal
hypertensive gastropathy), normal
duodenum, patient is advised medical line
of Rx.
2. Abdominal & Pelvic Ultrasound:
• Liver: shrunken in size with irregular
surface
• Pancreas: bulky
• Bladder: empty
• Conclusion: Heterogenously bulky
pancreas, cirrhosis of liver, ascites
moderate, mild hepatosplenomegaly, mild
anterior abdominal inflammation seen.

13. ASSESSMENT
• Provisional Diagnosis: Chronic alcoholic liver disease
• Justification:
• A 67 year old male patient was admitted to male medicine
ward unit 3 with complaints of abdominal distension,
bilateral lower limb oedema (pitting), distended scrotum
(swelled), breathlessness.
• Based on lab investigations, patient was presented with:
1. - Low S. Ferritin, S. Potassium, S. Albumin, Hb,
Lymphocytes, RBC, MCH, MCV, PCV & MCHC; high S.
Urea, S. creatinine, S. uric acid, WBC, Neutrophils & RDW-
CV; abnormal total count, polymorphs, lymphocytes &
sugar level in ascitic fluid; longer PT; abdominal and pelvic
USG concluded heterogenously bulky pancreas, cirrhosis of
liver, ascites moderate, mild hepatosplenomegaly, mild
anterior abdominal inflammation; UGI scopy revealed grade
1 esophageal varices, small GOV (gastro oesophageal
varices) type 1 varices & mild PHG (portal hypertensive
gastropathy and standing CXR suggested alcoholic
cardiomyopathy.26-03-2020 13
Final Diagnosis:
Chronic alcoholic
liver disease

14. GOALS OF TREATMENT
• Clinical improvement or resolution of acute complications, such as
variceal bleeding, and resolution of haemodynamic instability for an
episode of acute variceal haemorrhage.
• Prevention of complications.
• Adequate lowering of portal pressure with medical therapy using beta-
adrenergic blocker therapy.
• Support of abstinence from alcohol.
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15. TREATMENT OPTIONS
Approaches to treatment include the following:
• Identify and eliminate the causes of cirrhosis (e.g. alcohol abuse).
• Assess the risk for variceal bleeding and begin the pharmacologic prophylaxis
where indicated, reserving endoscopic therapy for high-risk patients or acute
bleeding episodes.
• The patient should be evaluated for clinical signs of ascites and managed with
pharmacologic treatment (e.g. diuretics) and paracentesis. Spontaneous bacterial
peritonitis (SBP) should be carefully monitored with ascites who undergo acute
deterioration.
• HE is a common complication of cirrhosis and requires clinical vigilance and
treatment with dietary restriction, elimination of CNS depressants, and therapy to
lower ammonia levels.
• Frequent monitoring for hepatorenal syndrome, pulmonary insufficiency and
endocrine dysfunction is necessary.
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16. MONITORING PARAMETERS
❑Disease related :
• LFT (AST, ALT, GGT, Se. Albumin)
• USG
• PT
• CBC
• CT scan
❑Drugs related :
• Ceftriaxone → RFT, white blood cell count,
differential count.
• Ranitidine → Hb, haematocrit, intragastric
pH, endoscopy, Se. creatinine, CBC, SGOT,
SGPT.
• Ondansetron → ECG
• Furosemide →Body weight, BP, Se.
electrolytes, Se. creatinine, BUN, Blood and
urine glucose, LFT, RFT.
• Spironolactone →BP, urine output, urine
electrolytes, Se. K, uric acid, blood glucose.
• Propranolol → HR, BP, RFT, LFT.
• Lactulose → Frequency of stool output.
• Ursodeoxycholic acid(Ursodiol) → LFT every month for three
months ,after start of therapy and than evry six months.
• Albumin → Se. Al, BP, pulmonary wedge pressure.
• Metronidazole →Total and differential WBC count.
• Vitamin K→PT, INR.
• Potassium chloride →Se. K, RFT, EKG, acid-base balance.
• Cefixime → PT
• Pantoprazole → Se. Mg2+, Vitamin B12,
• Torsemide → BP, Se. electrolytes, blood glucose
• Rifaximin → abdominal USG for hepatic encephalopathy
• Ursodiol (Ursodeoxycholic acid) → LFT every month for three
months ,after start of therapy and than evry six months.
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17. Day 1: 4.8.18
12:17 pm
• GC: stable
• c/o: abdominal
distension, b/l
pedal oedema
• T/P/R: normal
• BP: 140/90
mm HG
• SPO2: 96%
• RS,CVS,CNS:
clinically
NAD
• S/U: passed
• Adv: 2 pint
PCV, Ix S.
ferritin , iron
& Vit. B12
26-03-2020 17
7:00 pm
• Ix: Ascitic
fluid –
C,S,R,M for
cytology;
USG abdomen
• Ascitic
tapping with
inj. Albumin
or 3 pint FFP
• Vitals & temp.
charting
• I/O
monitoring →
salt restriction
• High protein
diet, high
glucose diet,
salt restricted
diet.
9:00 pm
• GC: poor
• B.P.: 130/80 mm Hg
• T/P/R: normal/92/
increased
• SPO2: 74% with RA
• RS: crepts + → adv
PFT
• CVS: NAD
• P/A: soft ascetic
• C/o: B/L pedal
oedema
• Adv.: SOS ICU Tx
• Inj. Lasix (40) IV
stat
• Neb. With Duolin
stat
9:30 pm
• GC: stable
• B.P.:
130/80 mm
Hg
• T: normal
• P: 80 bpm
• SPO2:
90% with
RA after
Neb.
• RS: O/E
crepts +
• P/A:
ascites +
• C/O: B/L
pedal
oedema
11:00 pm
• GC: stable
• B.P.:
125/80
mm Hg
• T/P/R:
normal/90
/normal
• SPO2:
96%
• RS, CVS:
NAD
• P/A: soft
• Adv.: Inj.
Lasix (40)
IV stat

18. Day 1 Medication Chart
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Cefotaxime 1 g IV BD Prophylactic treatment
for infections
Inj. Metronidazole 1 pint IV TDS Prophylactic treatment
for infections
Inj. Ranitidine 1 amp IV BD Acidity
Inj. Ondansetron 1 pint IV TDS Emesis
Inj. Furosemide 40 mg IV TDS Pedal Oedema
Tab. Spironolactone 25 mg PO 2-2-0 Fluid overload
Tab. Propranolol 20 mg PO 1-0-1 To treat varices
Syp. Lactulose 30 cc PO TDS To maintain frequency
of stool 3 times a day
Inj. Dextrose 25% +
multivitamins
1 pint IV TDS To maintain glucose in
diet + vitamin
supplement
26-03-2020 18

19. Day 2: 5.8.18
7: 30 a.m.
• Ascitic
tapping
• Inj PCV 1 pint
• Inj. FFP 3 pint
9:10 a.m.
• GC stable
• B.P.: 150/70 mm Hg
• T/P/R:
normal/80/normal
• SPO2: 98%
• U/S: passed
• Ascitic tapping done –
1500 mL fluid removed,
sample sent
3/26/2020 19
8: 30 a.m.
• GC stable.
• T/P/R: normal/61/ normal
• B.P.: 110/70 mm Hg
• SPO2: 99%
• R.S.: NAD
• C.V.S: NAD
• C.N.S.: NAD
• U/S: passed
• Adv: Continue same treatment
• 1 pint PCV pending today
• 3 pint FFP today
• USG Abd.
• Ascitic tapping with Inj Albumin or 3 pint FFP
• Ascitic fluid: R,M,C,S for cytology Ix

20. Day 2 Medication Chart
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone 1 g IV BD Prophylactic treatment
for infections
Inj. Metronidazole 1 pint IV TDS Prophylactic treatment
for infections
Inj. Ranitidine 1 amp IV BD Acidity
Inj. Ondansetron 1 pint IV TDS Emesis
Inj. Furosemide 40 mg IV TDS Pedal Oedema
Tab. Spironolactone 25 mg PO 2-2-0 Fluid overload
Tab. Propranolol 20 mg PO 1-0-1 To treat varices
Syp. Lactulose 30 cc PO TDS To maintain frequency
of stool 3 times a day
Inj. Dextrose 25% +
multivitamins
1 pint IV TDS To maintain glucose in
diet + vitamin
supplement
26-03-2020 20

21. Day 3: 6.8.18
7 a.m.
• GC: stable
• T: normal
• P: 84/min
• SPO2: 98%
• R.S.: NAD
• C.V.S: NAD
• C.N.S.: NAD
• P/A: NAD
• Urine: passed
• Stool: passed
8:00 a.m.
• No complaints
• B.P.: 110/70 mm Hg
• P: 89/min
• T: normal
• SPO2: 95%
• R.S.: NAD
• P/A: NAD
• C.V.S: NAD
• C.N.S: NAD
• U/S: passed
• Continue same treatment
3/26/2020 21
Adv.
• Vit. K stat 3 pint IV followed by Inj.
Vit. K 1 pint IV OD for 3 days
• Ix: CBC, RFT, USG abd.
• Ascitic tapping with 3 pint FFP
• USG abd, KUB (kidneys, ureter,
bladder) done.
• Requests for 3 units of FFP sent
• SPO2 monitoring
• Inj. Vit K 1 amp IV stat given

22. Day 3 Medication Chart
26-03-2020 22
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone 1 g IV BD Prophylactic treatment for
infections
Inj. Metronidazole 1 pint IV TDS Prophylactic treatment for
infections
Inj. Ranitidine 1 amp IV BD Acidity
Inj. Ondansetron 1 pint IV TDS Emesis
Inj. Furosemide 40 mg IV TDS Pedal Oedema
Tab. Spironolactone 25 mg PO 2-2-0 Fluid overload
Tab. Propranolol 20 mg PO 1-0-1 To treat varices
Syp. Lactulose 30 cc PO TDS To maintain frequency of
stool 3 times a day
Inj. Dextrose 25% +
multivitamins
1 pint IV TDS To maintain glucose in diet
+ vitamin supplement
Inj. Vit. K 3 pint IV Stat To prevent variceal bleeding
Inj. Vit. K 1 pint IV OD To prevent variceal bleeding

23. Day 4: 7.8.18
6: 29 a.m.
• GC stable
• BP: 100/60
mm Hg
• P: 68 bpm
• SPO2: 98%
• RS,CVS,CNS:
NAD
• PA: distended
• S/U: not passed
• CST
• Vit. K 2/3
10:30 a.m.
• S/O: dilated
alcoholic
cardiomyopathy
• Adv.: Gastro ref,
UGI scopy, 2D
echo, Report ECG,
X-ray report
3/26/2020 23
8: 00 a.m.
• No complaints
• T/P/R: normal/69/ normal
• B.P.: 100/60 mm Hg
• SPO2: 98%
• R.S., C.V.S., C.N.S., P/A:
NAD
• U/S: passed
• O/E: B/L scrotal swelling
• Adv: Continue same
treatment
• Adv.: 1 pint PCV
• Inj. Furosemide 40 mg IV
stat
• Ix: HIV, HCV, HBsAg
8:00 p.m.
• GC: stable, no F/C
• T: normal
• BP: 100/60 mm Hg
• SPO2: 95%
• RS, CVS, CNS:
NAD
• Adv.: UGI scopy
• NBM
• Inj. Albumin →
patient not affording
• Inj. PCV stat
• Inj. Cetrizine stat

24. Day 4 Medication Chart
26-03-2020 24
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone 1 g IV BD Prophylactic treatment for
infections
Inj. Metronidazole 1 pint IV TDS Prophylactic treatment for
infections
Inj. Ranitidine 1 amp IV BD Acidity
Inj. Ondansetron 1 pint IV TDS Emesis
Inj. Furosemide 40 mg IV TDS Pedal Oedema
Tab. Spironolactone 25 mg PO 2-2-0 Fluid overload
Tab. Propranolol 20 mg PO 1-0-1 To treat varices
Syp. Lactulose 30 cc PO TDS To maintain frequency of
stool 3 times a day
Inj. Dextrose 25% +
multivitamins
1 pint IV TDS To maintain glucose in diet
+ vitamin supplement
Inj. Vit. K 1 pint IV OD To prevent variceal bleeding

25. Day 5: 8.8.18
• No fresh complaints
• Temp: normal
• P: 68 bpm
• SPO2: 99%
• BP: 150/90 mm Hg
• CVS, CNS, RS, P/A: NAD
• U/S: passed
• Adv.: NBM for GI scopy, High protein
diet, Salt restricted diet, scrotal support,
glucose diet, vitals, temp, I/O charting
• Adv.: liq. KCl 2 tsf TDS
• Inj. KCl 2 amp + 250 mL Ns over 10 hrs
with dual flow
• Inj. 20% albumin @ 20 mL/hr
• Ix: 2D echo, USG, HIV, HCV, Na, K
26-03-2020 25
• No bowel sounds
• Tapping done → Se. K: 3.3 mmol/L
• Get done report of USG whole
abdomen and SOS X-ray standing
• Repeat CBC, S. creatinine, S Na+/K+,
uric acid
• 20% H Alb.
• Adv.: K+ correction
• Ix: CBC, Na+, K+, Albumin, Se.
creatinine
• T: normal
• P: 84 bpm
• BP:110/70 mm Hg
• SPO2: 97%

26. Day 5 Medication Chart
26-03-2020 26
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone 1 g IV BD Prophylactic treatment for
infections
Inj. Metronidazole 1 pint IV TDS Prophylactic treatment for
infections
Inj. Ranitidine 1 amp IV BD Acidity
Inj. Ondansetron 1 pint IV TDS Emesis
Inj. Furosemide 40 mg IV TDS Pedal Oedema
Tab. Spironolactone 25 mg PO 2-2-0 Fluid overload
Tab. Propranolol 20 mg PO 1-0-1 To treat varices
Syp. Lactulose 30 cc PO TDS To maintain frequency of
stool 3 times a day
Inj. Dextrose 25% +
multivitamins
1 pint IV TDS To maintain glucose in diet
+ vitamin supplement
Syp. KCl 2 tsf PO 2-2-2 To maintain K+ level

27. Day 6: 9.8.18
• Ix: CBC, Na+, S. Albumin, S. creatinine
• Repeat Se. K+ stat
• GI scopy → S/O varices
• HR syndrome
• e
26-03-2020 27

28. 26-03-2020 28
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone 1 g IV BD Prophylactic treatment for
infections
Inj. Metronidazole 1 pint IV TDS Prophylactic treatment for
infections
Inj. Ranitidine 1 amp IV BD Acidity
Inj. Ondansetron 1 pint IV TDS Emesis
Inj. Furosemide 40 mg IV TDS Pedal Oedema
Tab. Spironolactone 25 mg PO 2-2-0 Fluid overload
Tab. Propranolol 20 mg PO 1-0-1 To treat varices
Syp. Lactulose 30 cc PO TDS To maintain frequency of
stool 3 times a day
Inj. Dextrose 25% +
multivitamins
1 pint IV TDS To maintain glucose in diet
+ vitamin supplement
Syp. KCl 2 tsf PO 2-2-2 To maintain K+ level
Day 6 Medication Chart

29. 26-03-2020 29
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Cefixime 200 mg PO BD Prophylactic treatment
for infections
Tab. Pantoprazole 40 mg PO 1-0-1 For gastric disturbances
Tab. Propranolol 10 mg PO 1-1-1 To treat varices
Tab. Spironolactone +
Torsemide
50/20 PO 1-1-0 Pedal Oedema
Tab. Rifaximin 550 mg PO 1-1-1 Hepatic encephalopathy
Tab. Ursodiol
(Ursodeoxycholic acid)
300 mg PO 1-1-1 Hepatoprotective
DISCHARGE MEDICATIONS

30. GOALS ACHIEVED
• B.P. is controlled.
26-03-2020 30

31. POINTS TO BE INTERVENED WITH THE
DOCTOR
• Not treated for anaemia.
• Drug-drug interactions:
i. Metronidazole + Ondansetron : (Major) – concurrent use of metronidazole &
QT interval prolonging drugs may result in increased risk of QT interval
prolongation and arrhythmias.
ii. Spironolactone + KCl : (Major) – concurrent use of Spironolactone and
potassium may result in hyperkalaemia.
iii. Furosemide + Propranalol : (Moderate) – concurrent use of furosemide &
propranolol may result in hypotension & bradycardia.
• Se. Albumin & K+ levels aren’t corrected.
• Torsemide standard dose is 10 mg → instead prescribed 20 mg.
26-03-2020 31

32. PATIENT COUNSELLING
• ABOUT DISEASE:
• Alcoholic liver disease results
from chronic alcohol abuse
characterized by fibrosis and
abnormally functioning
hepatocytes.
• The progression of liver injury to
cirrhosis may occur over weeks to
years.
• The complications of cirrhosis
includes portal hypertension,
ascites, hepatorenal syndrome &
hepatic encephalopathy.
• Prep the patient for hepatorenal
disease.
26-03-2020 32

33. • ABOUT DRUGS:
➢Educate patients about the medications.
i. Tab. Cefexime: 2 tablets to be taken a day at least 30 min before food, one
before breakfast and another before dinner.
ii. Tab. Pantoprazole: 2 tablets to be taken a day at least 30 min before food, one
before breakfast and another before dinner.
iii. Tab. Propranolol: 3 tablets to be taken a day after meals.
iv. Tab. Spironolactone + Torsemide: 2 tablets to be taken a day, one after breakfast
and another after lunch.
v. Tab. Rifaximin: 3 tablets to be taken a day after meals.
vi. Tab. Ursodiol: 3 tablets to be taken a day after meals.
➢If any dose is missed, take the dose as soon as possible, but if the time of the next
dose is near, miss the previous dose and take the next dose.
➢Medication adherence is necessary.
➢In case if any side effect, consult your physician and stop the causative drug.
26-03-2020 33

34. • LIFESTYLE MODIFICATIONS:
26-03-2020 34

35. REFERENCES :
• A textbook of Pharmacotherapy : By Joseph P. Dipiro and Robert L.
Talbert, 7th Edition, Mc-Graw Hill Publications
• Medscape
• Cims
• Micromedex
• Mayoclinic.com

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