• H M Nguyen, A J Cutie, and D Q Pham.
• Pharmacy Practice, Western University of Health Sciences, College of Pharmacy, Pomona, CA 91766-1854, USA. mnguyen3@westernu.edu
• Int. J. Clin. Pract. 2010 Jun 1; 64 (7): 858-67.

ObjectiveReviewing the current literature to guide clinicians managing medications in the setting of liver disease.Literature SourcesUsing the terms liver disease, medication management, and therapeutic monitoring, a literature review was conducted to identify peer-reviewed articles in MEDLINE (1966-April 2009). Reference citations were reviewed as an additional resource. Published English-language literatures, articles and trials were reviewed. Emphasis was placed on prospective, randomised, double-blind, placebo-controlled clinical trials.Question SynthesisAn informed decision on how to manage medications in the setting of liver disease should account for changes that transpire in a medication's first-pass metabolism, protein binding, volume of distribution, clearance and pharmacodynamic interactions. To incorporate these issues within one's thought process, clinicians can utilise the following six questions to evaluate a medication use: (i) Is the patient experiencing acute or chronic liver failure? (ii) Does the drug have high hepatic first-pass metabolism? (iii) Is the medication highly protein-bound? (iv) Is there a change in the volume of distribution for the medication? (v) Is the clearance of the medication significantly altered? and (vi) Is there a pharmacodynamic interaction with the medication?ConclusionsThe introduction and use of six clinically relevant questions in the setting of liver disease can serve as a guide to clinicians who manage patients with liver disease.

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