Liver: Information sources

Last updated: Tuesday, September 27, 2022

As you have seen through this tutorial, there isn’t just one type of liver dysfunction, so there unfortunately isn’t a one-stop reference source with all the answers. You’ll often need to use more than one resource to build an answer, and you may need to revert to first principles. However, there are some key resources that may be helpful.

General resources

✦  This tutorial provides guidance that will help you solve clinical problems from first principles. (You might also find the Adverse reactions tutorial useful.)

✦  Drugs and the Liver by Penny North-Lewis (Pharmaceutical Press, 2008) has good coverage of how to approach questions, and chapters on specific topics such as choosing analgesics and antiemetics in patients with liver dysfunction.

✦  The adverse effects and pharmacokinetics sections of SmPCs are particularly useful. There is sometimes information in the posology, contraindications and cautions sections too. However, bear in mind that in clinical trials, patients with liver disease are often excluded so a manufacturer’s contraindication in liver disease may be due to a lack of information rather than observed harm. A manufacturer’s medical information department may have extra information to that in their SmPCs.

✦  Your Pharmacy or MI may have access to other general sources that can sometimes help such as Martindale, Micromedex, AHFS Drug Information, or Lexicomp.

Choice of medicine in liver dysfunction

The general resources above may help you, sometimes starting from first principles. Otherwise, you might:

✦  Check if any expert bodies have issued general guidance for treating the condition your patient is suffering from. They will often cover treatment for special groups such as patients with liver disease.

✦  Consider a Embase and Medline search. In addition to looking for published papers about your drug in liver disease, think ‘big picture’ and find out how the disease is treated in patients without liver disease – you may find some suitable alternatives you hadn’t considered.

✦  See if you have a liver or gastroenterology expert available locally who you can ask for advice. A specialist pharmacist of doctor will probably be familiar with your clinical situation, and may even know your patient.

Drug-induced hepatotoxicity

✦  LiverTox has information on the diagnosis, frequency, patterns, and management of liver injury attributable to medicines, herbals, and dietary supplements. It is a really useful American site hosted by the National Institutes of Health and supported by the National Library of Medicine.

✦ The European Association for the Study of the Liver has published a clinical practice guideline for drug-induced liver disease. It identifies the drugs commonly responsible, including herbals, and discusses presentation and management.

General internet searches

Be careful about conducting a general internet search on this subject. If you do, you may like to look at our brief guide to evaluating websites about medicines.

Presenting your answer 

Once you’ve asked sufficient questions, gathered the information required and assessed it, you’ll need to provide an answer. As a reminder, we offer some general guidance on answering clinical problems. You might like to refresh your memory if you’ve not looked at this recently.