Limited Knowledge of Acetaminophen in Patients with Liver Disease

Background andAims:Unintentional acetaminophen overdose remains the leading cause of acute liver failure in the United States.Patients with underlying liver disease are at higher risk of poor outcomes from acetaminophen overdose.Limited knowledge of acetaminophen may be a preventable contributor to elevated rates of overdose and thus acute liver failure.The purpose of this study is to assess knowledge of acetaminophen dosing and presence of acetaminophen in common combination products in patients with liver disease.Methods:We performed a cross-sectional study of patients with liver disease at the Pfleger Liver Institute at the University of California,Los Angeles between June 2015 and August 2016.Patients completed a demographic questionnaire and an acetaminophen knowledge survey.Additional information was obtained from the medical record.Results:Of 401 patients with liver disease,30 (15.7%) were able to correctly identify that people without liver disease can safely take up to 4 g/day of acetaminophen.The majority of patients (79.9%-86.8%) did not know that Norco(R) (hydrocone/acetaminophen),Vicodin(R) (hydrocone/acetaminophen) and Percocet(R) (oxycodone/acetaminophen) contained acetaminophen.Only 45.3% of the patients knew that Tylenol(R) #3 contained acetaminophen.Conclusions:We conclude that patients with liver disease have critically low levels of knowledge of acetaminophen,putting them at risk both of acetaminophen overdose,as well as undermedication,and inadequate management of chronic pain.We recommend an increase in education efforts regarding acetaminophen dosage and its safety in the setting of liver disease.Increasing education for those at risk of low acetaminophen knowledge is essential to minimizing acetaminophen overdose rates and optimizing pain management.

Elimination of Hepatitis C in Liver Transplant Recipients

Background and Aims:Recurrent hepatitis C(HCV)disease in liver transplant(LT)recipients is associated with significant morbidity and mortality.With the availability of noninterferon-based therapy,eliminating HCV may be achievable in LT recip-ients.Methods:We studied all consecutive recipients who underwent LT at the University of California Los Angeles be-tween January 2005 and June 2017.We collected data on date of transplant and last follow-up,as well as laboratory values.We also recorded type and timing of antiviral therapy relative to LT.Analyses were performed to assess the proportion of LT recipi-ents who are viremic after transplant.Results:Six hundred thirty-four patients underwent LTwith a diagnosis of HCV.There was a statistically significant trend for patients to be cured be-fore(p<0.001)and after liver transplantation(p<0.001)for the study period of 2014 to 2016 relative to 2005 and 2013,respectively.Of the 634 recipients eligible for therapy,8%and 74%were treated within 12 months of transplant for the study periods 2005 to 2013 and 2014 to 2016,respectively.There was a significant decrease between the two study periods in the proportion of patients undergoing re-LT 1 year after the original LT:5.5%(n=28/510)and 1.5%(n=2/124)respec-tively for study periods 2005 to 2013 and 2014 to 2016 respec-tively(p=0.011).Conclusions:The proportion of LTrecipients who are viremic has decreased over time.Eliminating HCV in LT recipients is feasible after the introduction of direct-acting agents.Curing HCV should translate to improved clinical out-comes in LT recipients who were transplanted for HCV infection with longer follow-up.Preliminary results suggest the de-creased need for transplant in the direct-acting agents era.

Decrease of Alpha-fetoprotein in Patients with Cirrhosis Treated with Direct-acting Antivirals

Background and Aims:The lack of specificity has limited the role of serum alpha-fetoprotein(AFP)for hepatocellular carcinoma(HCC)screening among patients with cirrhosis related to hepatitis C virus(HCV)infection.We sought to examine whether AFP may decrease after achieving a sustained virological response(SVR)in patients with HCV-related cirrhosis.Methods:We performed a retrospective study of patients with HCV-related cirrhosis who were cured with direct-acting antiviral(DAA)therapy at the University of California,Los Angeles.Laboratory values,including serum AFP,were measured before and after completing the DAA treatment.Results:Fifty-six patients met the inclusion criteria,with median(interquartile range[IQR])age of 67(58-69)years and with 51.8%being male.All patients received DAA therapy without interferon.AFP decreased from median(IQR)7.2(4.2-13.4)ng/mL before DAAs to 4.2(2.7-6.3)ng/mL at the end of treatment and 4.2(2.9-6.8)ng/mL at 12 weeks after treatment(P<0.001).Model for end-stage liver disease(MELD),fibrosis-4(FIB4),and aspartate transaminase(AST)to platelet ratio index(APRI)scores at baseline were not significantly associated with AFP reduction.On multivariate analysis,platelet count,AST and total bilirubin at baseline were significantly correlated to AFP reduction(P=0.04,0.009 and 0.04,respectively).The higher the baseline AFP,the greater the reduction in AFP.There was no statistically significant correlation between baseline AFP and MELD,FIB4 or APRI scores.Conclusion:There was a significant decrease in AFP in patients with cirrhosis who achieved a SVR with DAAs.Given a reduction in AFP after DAA treatment,AFP should be further studied as a screening modality for HCC in patients with cirrhosis.