Hepatic disease and drug pharmacokinetics

Recent clinical investigations and reports of theoretical models have provided considerable insight into mechanisms of hepatic drug elimination and into derangements that may occur in drug absorption and disposition in patients with hepatic disease. Carefully conducted and well controlled clinical studies have demonstrated that hepatic disease may alter substantially one or more pharmacokinetic parameters of drug absorption and disposition. Physiological models of hepatic drug elimination have emphasised the importance of physiological variables such as hepatic blood flow, protein binding and intrinsic clearance of the liver on hepatic drug elimination. Both clinical investigations and theoretical considerations have indicated that the influence of hepatic disease on the pharmacokinetics of a drug may be complex and may result in either unchanged, retarded or even accelerated drug elimination. Changes in response to drugs in patients with hepatic impairment add to this complexity. Although general guidelines may be formulated now to assist clinicians in constructing dosage regimens of several important drug classes (notably the benzodiazepines and barbiturates) in hepatic disease, it is not now possible to predict in an individual the influence of a specific hepatic disease on the disposition of a drug, with the exception that the oral availability of drugs with high hepatic extraction ratios is increased in patients with cirrhosis and protacaval shunting of blood. Attempts to correlate concentrations of endogenous substances (such as bilirubin), or the pharmacokinetics of model drugs (such as antipyrine), with the pharmacokinetics of drugs that are useful in patients with hepatic impairment have not resulted in clinically useful tests of hepatic drug elimination. Following the administration of a drug to a patient with hepatic impairment, careful monitoring of the patient and also monitoring of plasma or blood drug concentrations remain important considerations.