CLD with Hypertension and Diabetes

Mellitus

Juveria mahveen
17455T0002
Pharm D (PB) 2st year
 Scenario:
• A 60 year old male patient has been admitted for treatment.

• Chief complaints and History of Present Illness:

Patient presented with 3-4 episodes of bloody vomitings (Haematemesis) since 1-2
hours with a history of chronic alcoholism.

• Symptoms during Admission:

3-4 episodes of haematemesis, no melaena, chronic alcoholic.

• Past Medical History:

Hypertension and Diabetes

• Surgical History:
CAD-Coronary Artery Bypass Graft (CABG) 5 years ago.

• Present Medication:
Amaryl 1gm (T), Telma 40mg (T), Post CABG-no medications.
 Physical Examination:
o Temperature: 98°F
o PR: 108bpm
o BP: 80/60 mmHg
o RR: 20/mins
o Imp: Chronic Liver Disease (CLD)

Working Diagnosis:
o Upper GI bleeding with hypotension.
Treatment:
• Inj. Pan 40 IV STAT
• Inj. Zofer 8mg IV STAT
• IVF NS 1000ml IV STAT
• Inj. HAI 15 IU/SC/STAT
• Inj. Octreotide 100mg IV STAT
• Fluctuating GRBS levels from 189mg/dl to 210 lead to administration of Insulin 14
units.
• Name of Procedure:
EVL Banding: Standard procedure for management of acute variceal bleeding

• Medical History:
CAD-CABG 5 years ago, CNS CCC, Renal Acidosis (corrected with Bicarbonate IV Infusion),
Chronic Alsoholism with Portal Hypertension, Haematemesis.

• Provisional Diagnosis:
Severe anaemia, UGI Bleed.

• Blood Srugar (GRBS):

The patient has fluctuating blood glucose levels. When a level of 210mg/dl was recorded,
Insulin was administered (1 U)
 Renal Function Test:
8/11 9/11 10/11 11/11 12/11 13/11
BSR (Blood 273 314 222 201 NR 149
Sugar
Random)

Blood Urea NR 76 67 63 53 49

Serum 2.6 1.8 1.8 1.7 1.6 1.6

Creatinine

Normal Ranges:
BSR: 79-160mg/dl
160-200mg/dl (Pre-diabetic)
>200mg/dl Diabetic
Blood Urea: 16.6-48.5mg/dl
Serum Creatinine: 0.7-1.20mg/dl
 Electrolytes:
8/11 9/11 10/11 11/11 12/11 13/11

Sodium 142 145 144 147 147 146

Potassium 4.6 4.3 4.6 4.0 3.5 4.2

Chloride 111 109 111 112 112 112

Normal Ranges:
Sodium: 137-145 mEq/l
Potassium: 3.5-5.1 mEq/l
Chloride: 98-107 mEq/l
 Complete Blood Picture:
8/11 9/11 10/11 11/11 12/11 13/11

Hemoglobin 5.3 6.7 7.9 7.3 7.4 9.1

RBCs 2.07 2.62 2.95 2.72 2.73 3.27

PCV (% of RBC) 16.5 21.0 24.1 22.4 22.5 28.1

WBCs 17,800 17,000 6,700 5,700 5,400 5,100

Platelet Count 1.76 1.55 1.20 1.50 1.50 1.50

Lymphocytes 15 18 15 20 35 36

Monocytes NR 01 02 2 1 01

Note: Endoscopy reveals severe PHG on 10th which verifies with thrombocytopenia, ie. Decreased PC on the same
date, which means hepatocyte damage.
However, normal levels of neutrophils also indicate that not much damage to liver has been done and exacerbation
can be prevented with cessation of alcohol.
Normal Ranges:
Hemoglobin: Male: 13.8-17.2g/dl; Female: 12.1-15.1g/dl
RBCs: 4.7-6.0million
WBCs: 4,000-10,000/cumm
Packed Cell Volume (PCV): 40.0-50.0%
Platelet Count: 1.5-4.1 lakhs/cumm
Lymphocytes: 20-40%
Monocytes: 2-10%
LIVER FUNCTION TEST:
8/11 9/11 10/11 11/11 12/11 13/11
Total NR - 2.6 1.0 - NR
Bilirubin
Direct NR - 0.9 0.7 - 0.9
Bilirubin
Indirect 0.2 - 1.7 0.3 - NR
Bilirubin
Serum 2.9 - 2.7 2.8 - 2.9
Albumin
Total 6.5 - 6.2 6.4 - NR
Proteins
Serum NR - 42 40 - NR
Alkaline
Phosphatase

AST/ALT 36/20 - 57/23 29/29 - NR

Note: AST levels are greater than ALT levels, Increased Bilirubin, reduced albumin levels,
and increased SAP levels are all indicative and verify for damage to hepatocytes.

Normal Ranges:
Total Bilirubin: ≤1.2 mg/dl
Direct Bilirubin: ≤0.3 mg/dl
Indirect Bilirubin: 0.4-1.0 mg/dl
Serum Albumin: 3.5-5.2 g/dl
SAP: Male: 40-130 IU/l; Female: 35-105 IU/l
AST/ALT: ≤40/≤41
Lactate Levels:
7/11 8/11 9/11 Normal Range

7.7 8.2 3.4 0.5-2.2mmol/l

PT with INR:
8/11 10/11 13/11 Normal Range

22.5 sec 19.5 sec 18.7 sec 11-13.5 sec

INR 1.79 INR 1.45 INR 1.45 INR 0.8-1.1
Complete Urine Examination:
Quantity: 15 ml, pale, yellow and clear.
pH: 6.0
Negative for Ketone bodies, leukocytes, Bilirubin, Blood and nitrates.
Urobilinogen: 0.2
Pus Cells: 2-4
Epithelial Cells: 1-2
 Soap Analysis:
 SUBJECTIVE EVIDENCE:
C/O haematemesis.

 OBJECTIVE EVIDENCE:
USG Abdomen shows liver parenchymal disease, bilateral renal parenchymal changes,
minimal ascites.
2D Echo indicates S/P CABG, mild pericardial effusion, tachycardia during Echo (HR
130pm)
Grade 1 LV diastolic dysfunction
Endoscopy revealed Large esophageal varices with active bleed, severe PHG (Portal
hypertensive Gastropathy) on 10th.

 ASSESSMENT EVIDENCE:
Patient was diagnosed with CLD with Portal Hypertension and severe Anemia.

 PLANNING:
Reduce UGI Bleed and treat anemia.
 Treatment Chart:
Drug Dose ROA Frequency
Inj. Pan 80mg IV Per hour
IVF NS/RL 50ml IV Per hour
Ionotropic Support 4ml with NS 46ml IV 6ml/hour
(Adr)
Inj. HAI According to GRBS Scales
Inj. Zofer 8mg IV TID
Inj. Octreotide 250mg with NS 50ml IV 1ml/hour
Sod. Bicarbonate 100ml IV Stat
Inj. PIPTAZ 2.25gm IV TID
Optineuron 1 amp IV BID
Inj. Vit K 1 amp IU IV OD

On 8/11: After checking Lactate levels, Diabetic ketoacidosis, Uncontrolled DM, BP:
140/70 mmHg with PR of 132bpm.
Blood Transfusion was done and Endoscopy revealed Esophageal varices, altered blood in
stomach and No fresh bleed.
On 9/11:
•Octreotide induced Hyperglycemia led to GRBS levels of 200-250mg/dl. HAI 4U/hour
was administered along withNS at 75ml/hour.
•CLD decompensated, Portal HTN with variceal bleed.
•Blood Transfusion was done.
•Duphalac Syrup 15mg TID and Loose enema (Lactulose) was given.
Drug Dose ROA Frequency
Pan 40 40mg IV BID
Inj. Perinorm 1 amp IV OD
PIPTAZ 2.25mg IV TID
Zofer 8mg IV TID
Optineuron 1 amp IV BID
Vit K 1 amp IV OD
Levolin P/N 6th hourly
IVF NS/RS 75ml IV Per hour
Octreotide 25mg IV BID
Librium 10mg Tab P/O

Further Medications:
•Repeat same drugs on 10th and 11th.
•Stop Zofer on 12th.
•Blood Transfusion is done on the 13th. Octreotide is stopped and Cardivaz 3.125mg BD
is given
Clinical Pharmacist Interventions:
• Adrenaline should not be administered with Librium (Chlordiazepoxide) because of
the counter-effects. Adrenaline decreases sedation while Librium increases it.
• Octreotide when given with Adrenaline causes increases in QTc intervals. Use with
caution in HTN and DM patients.
• Pantoprazole causes hyperglycemia and hepatic impairment.
• Octreotide and Pantoprazole decreases the levels of Optineuron when administered
concomitantly as seen here; might be the cause of CLD decompensation.
• PIPTAZ should be discontinued in patients with thrmbocyopenia, which is seen on
10th.
• Zofer when given with Octreotide increases QTc intervals.
• Octreotide also causes Hyperglycemia (As seen here)
• Perinorm causes hematological abnormalities, is contraindicated in patients with GI
hemorrhage and GI Anastomosis. Should be used with caution in HTN, cirrhosis.
• Concomitant administration with Sedatives, Hypnotics or Anxiolytics might inrease
their effects.
• Levolin (Levosalbutamol) causes Anxiety and nervousness.
• Librium causes respiratory depression and should be used carefully in patients with
hepatic impairment and chronic alcoholics.
• Non-benzodiazepines like Zolpidem or Zopiclone can be used instead of Librium as
they do not cause respiratory depression, drug tolerance or drug dependence.
• Barbiturates can also be considered an option.
• Cardivaz causes respiratory problems and hepatic impairment. Can be substituted with
Telma which was used by patient previously.