Hepatobiliary Disease: A Brief Review of Medication Therapies

Background 

Drug therapy for hepatobiliary disease can encompass many pharmacologic categories.

Definitive treatment should be directed toward identifying and managing causative factors. This review highlights several drugs and drug classes that may be useful adjunctive treatments for hepatobiliary diseases.

Choleretics

Ursodiol, a hepatobiliary cytoprotectant, is a choleretic with antioxidant and anti-inflammatory effects. This drug is a useful adjunctive treatment for a variety of acute and chronic hepatobiliary disorders and is generally well-tolerated, although occasional GI upset (eg, nausea, diarrhea) may occur. Ursiodiol works best when administered with food, which may also mask its bitter taste.

Antioxidants 

A variety of antioxidants are administered in hepatobiliary disorders. S-adenosylmethionine (SAMe) is an endogenous compound that generates sulfur-containing compounds important for hepatic conjugation reactions (stores of SAMe may be depleted in patients with liver disease). SAMe is exceptionally well tolerated, and adverse effects are minimal or nonexistent. SAMe is best administered on an empty stomach. Silymarin (ie, the bioactive components of milk thistle) is an antioxidant and free-radical scavenger with an inhibitory effect on tumor necrosis factor. Silybin is the major active constituent of silymarin and is often found in combination products that also contain SAMe. N-acetylcysteine is another antioxidant and free-radical scavenger that is most commonly used to manage hepatotoxicity caused by drugs (eg, acetaminophen) or other hepatotoxins (eg, sago palm). Vitamin E is a fat-soluble vitamin with antioxidant and anti-inflammatory properties. 

Chelating Agents

Copper-associated chronic hepatitis can be managed, in part, with chelating agents. These drugs promote urinary copper excretion. D-penicillamine has a high affinity for copper and is the preferred chelator.¹ Adverse GI effects (eg, vomiting, hyporexia, diarrhea) are common and make administration on an empty stomach even more challenging. Trientine is an alternative chelator but may be cost-prohibitive. Zinc does not chelate copper but interferes with copper absorption and may be considered for long-term maintenance (ie, following chelator therapy).

Drug Therapy

Drug therapy may be indicated for complications that arise from hepatobiliary disease. Lactulose traps ammonia in the colon and may be used in patients with hepatic encephalopathy. Spironolactone can be considered to manage ascites. Vitamin K may be considered if clotting times are prolonged. Historically, it has been administered to patients with hepatic disease to minimize bleeding associated with invasive procedures (eg, hepatic biopsy); however, evidence of efficacy is lacking.^2-4

Management of hepatobiliary disease is continually evolving. Understanding how therapies differ in mechanism, onset, and safety is essential for tailoring treatment to each patient. Detailed information on agent selection and use is available through Plumbs.com.