Outcome Evaluation

• Reevaluate the pharmacotherapy regimen at each visit to assess adherence, effectiveness, adverse events, and need for drug titration.

• Determine adherence to lifestyle changes such as cessation of ethanol intake and avoidance of over-the-counter medications (particularly NSAIDs) and herbal remedies that may exacerbate complications of cirrhosis.

• Assess the effectiveness of P-blocker therapy by measuring heart rate. Heart rate reduction of 25% from baseline or to 55 to 60 bpm is desirable. Ask the patient specific, directed questions regarding adverse effects of P-blockers; inquire about symptoms of orthostatic hypotension (e.g., lightheadedness, dizziness, or fainting).

• Evaluate effectiveness of diuretic therapy with regard to ascitic fluid accumulation and development of peripheral edema. Ask the patient directed questions about abdominal girth, fullness, tenderness, and pain. Weigh the patient at each visit, and ask the patient to keep a weight diary. Assess for peripheral edema at each visit.

• Assess dietary sodium intake by patient food recall. Objectively measure dietary sodium adherence using spot urine sodium-to-potassium ratio. Assess for appropriate sodium excretion.

Patient Care and Monitoring

1. Obtain a complete history of alcohol intake and hepatotoxic drug use, including over-the-counter products and dietary supplements.

2. At each encounter, ask the patient specific questions about adherence to prescribed therapy, dietary restrictions and cessation of alcohol intake.

3. At each visit, evaluate the pharmacotherapy regimen for appropriate drug choice and dose, nonprescription drug use, adverse effects, and use of potentially hepato-toxic medications.

4. Question the patient about adverse effects, since hepatically metabolized medications may accumulate and cause adverse effects.

5. Consider antibiotic prophylaxis for SBP in patients with low-protein ascites or prior SBP.

6. Conduct a review of systems and physical examination at each visit to determine if the patient has had progression of complications.

7. Ask specific questions about bleeding, bruising, and fatigue. There is a direct link between loss of synthetic function and disease progression.

8. Refer the patient to substance abuse counseling for education about alcohol cessation if appropriate.

9. Provide education regarding dietary sodium restriction at each visit; consider referral to a dietician if appropriate.

• Obtain complete blood count and prothrombin time (PT)/INR to assess for anemia, thrombocytopenia, or coagulopathy. Ask about increases in bruising, bleeding, or development of hematemesis, hematochezia, or melena to assess for bleeding.

• Review biopsy reports and laboratory data. Transaminases and blood ammonia levels do not correlate well with disease progression, but increased coagulation times are markers of loss of synthetic function.

• Evaluate for signs and symptoms of HE. Mental status changes may be subtle; questioning family members or caregivers about confusion or personality changes may reveal mild HE even if the patient is unaware of the deficits.

• In patients taking lactulose therapy, titrate the dose to achieve two to four soft bowel movements daily.

Abbreviations Introduced in This Chapter

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