Counseling Patients on Managing Medication in HE

Arun B. Jesudian, MD: Any other things that you counsel your patients about? Certainly, medications can exacerbate hepatic encephalopathy. Do you go through their list in detail, and do you call out certain classes of medicines?

Kimberly A. Brown, MD: I do, particularly those patients who are taking any kind of narcotics. Oftentimes we struggle because those patients have often been on narcotics for a long period of time. Trying to work with their providers to see if there are alternatives and trying to help them understand that more narcotics are just not good. A dose of narcotics they may have been fine with 8 months ago may be too much for them now in terms of precipitating encephalopathy.

We try to avoid sleeping pills. I know it’s hard. You know, we tend to use the shortest-acting ones if we can—but recognizing that patients with liver disease don’t metabolize things well so they may have untoward effects from that. I think even with antidepressants, oftentimes doses might need to be adjusted in patients with advanced liver disease. Those are the biggest things.

I try to have them avoid supplements if they don’t know what’s in them because even though it’s over the counter, somehow patients think it’s safe. Oftentimes, it may not be safe, depending on what it is. I try to supplement vitamins in all of my patients, just a general multivitamin. And then, as you know, in patients who have more cholestatic liver disease or high bilirubin, they can become deficient in fat-soluble vitamins. I personally think that vitamin D is important. I know we’re not supposed to check it in all patients routinely, but I do check it in my patients with advanced liver disease. I think there’s lots of evidence that vitamin D, at least normal levels, are beneficial in patients for a variety of reasons. Those are the biggest things that I do.

People will often ask and probably ask you as well: What about milk thistle? Can I take it? What I tell them is that the studies that showed any benefit gave it in intravenous form for completely different reasons. So whether it works for their condition in oral form, I don’t really have an opinion, but I don’t think it’s harmful. Other things I think could potentially be harmful, but I think milk thistle is not harmful; but I’m not convinced it’s helpful.

Arun B. Jesudian, MD: That’s virtually identical to how I counsel my patients about milk thistle. But the other supplements for sure I try and dissuade them from, especially if it’s some sort of herbal supplement or multiple ingredients, because the last thing we want is some sort of liver toxicity on top of their end-stage liver disease. That would really be a bad combination.

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Transcript edited for clarity