Deprescribing in Cirrhosis – Case Study

JD is a 58-year-old male with a history of cirrhosis due to alcohol-related liver disease. He has no medication allergies and is taking the following medications: Lactulose 30 mL twice daily, Spironolactone 100 mg daily, Furosemide 40 mg daily, Propranolol 20 mg twice daily

JD presents to the clinic with complaints of frequent loose stools, occurring about 6-8 times per day for the past week. He is concerned about dehydration and discomfort due to the increased bowel movements. He denies abdominal pain, nausea, or vomiting.

John was diagnosed with cirrhosis 2 years ago due to chronic alcohol consumption. He has been on lactulose therapy for the past 6 months to prevent hepatic encephalopathy and reduce ammonia levels. His lactulose dose was initially titrated to maintain 2-3 soft bowel movements per day. However, he has recently experienced an increase in loose stools and mild urgency without any significant dietary changes or new medications.

During today’s visit, the ammonia level was checked and came back within normal limits (35 µmol/L, reference range: 10-50 µmol/L). John has no history of overt hepatic encephalopathy symptoms in the last 6 months.

Laboratory Results:

Serum Ammonia: 35 µmol/L (normal)
Complete Blood Count: Within normal limits
Basic Metabolic Panel: Normal electrolytes, no hypokalemia
Liver Function Tests: Elevated ALT and AST consistent with cirrhosis, stable compared to previous results
INR: 1.3

JD is likely experiencing lactulose-induced diarrhea, which is likely secondary to the high dose of lactulose causing excessive stool output. Remember that we typically target 2-3 soft bowel movements per day (excellent board exam question) and his current report of 6-8 bowel movements per day is too much. His ammonia level is within the normal range, suggesting that the dose of lactulose can be safely reduced without risking hepatic encephalopathy.

This would be an excellent opportunity to target deprescribing in cirrhosis. It would be appropriate to reduce lactulose to 20 mL twice daily (from 30 mL twice daily) and monitor for bowel movement frequency and consistency. The goal is to maintain 2-3 soft bowel movements per day. In addition, it would be important to reeducate JD on the signs and symptoms of hepatic encephalopathy (i.e. confusion, drowsiness).

It would be reasonable to do repeat labwork in a couple of weeks to ensure that ammonia is not trending significantly higher. If it does, rifaximin would be an appropriate addition to consider. This case of deprescribing in cirrhosis is another excellent example of how pharmacists can help ensure that medications are used safely and according to best practices.

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