Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

Appendix L: Child-Pugh Grading of Liver Disease and Liver Disease DosingNo single lab test can adequately access liver function. A common way to access metabolic ability is todetermine the Child-Pugh score which evaluates lab tests and clinical symptoms to determine the extentof liver dysfunction. A patient with a score of 5 has normal function, while a score of 15 representssevere hepatic failure and dysfunction.Scale for Assessing the Depth of Hepatic EncephalopathyGrade Cognitive/Motor Behavior1 Mild tremor, altered handwriting Anxiety, insomnia, mild confusion2 Dysarthria Lethargy, disorientation3 Seizure, muscle twitching Delirium, bizarre behavior4 Posturing ComaChild-Pugh Grading of Liver DiseaseClinical & BiochemicalPoints Scored for Increasing Abnormality*Measurements 1 2 3Encephalopathy None 1 and 2 3 and 4Ascites Absent Slight ModerateBilirubin (mg/dL) 3Albumin (G/dL) >3.5 2.8-3.5 2.3• INR (International Normalized Ratio) is an expression of prothrombin time (PT), corrected by thesensitivity of the reaction to anticoagulants, and should be validated as an alternative to PT inliver insufficiency.• Each row is given a point value of 1, 2, or 3. The sum of each row’s score provides the overallscore that is converted to a “grade of A, B, or C”• Grade A = 5-6 points Grade B =7-9 points Grade C >10 pointsFor drugs with > 60% hepatic metabolism general initial dosing recommendations can be made andsubsequently titrated as clinically indicated. Close clinical monitoring for efficacy and adverse reactions isimperative.Initial Dosing of Drugs with > 60% Hepatic metabolism(unless otherwise indicated by manufacturer)Child-Pugh Score Liver Dysfunction Dosage Adjustment8-9 Moderate Decrease dose by 25% of initial dose> 10 Severe Decrease dose by 50% of initial doseAn alternative method of measuring severity of liver disease and prognosis is the Model of End-StageLiver Disease (MELD) score, for which an on-line calculator can be found athttp://www.mayoclinic.org/meld/mayomodel7.html. However, no recommendations for dose adjustmentsspecific to MELD scores have been published.Bauer LA. Drug dosing in special populations: renal and hepatic disease, dialysis, heart failure, obesity, and druginteractions. In: Applied Clinical Pharmacokinetics. New York, NY: McGraw-Hill; 2001:57-67.Pugh RNH, Murray-Lyon IM, Dawson JL et al. Transection of the oesophagus for bleeding oesophageal varices. Br JSurg 1973;60: 649-9.Propst A, Propst T, Zangerl G, Ofner D, Judmaier G, Vogel W. Prognosis and life expectancy in chronic liver disease.Dig Dis Sci 1995;40:1805-1815.