Pediatric Fulminant Hepatic Failure Medication
- Author: Hisham Nazer, MB, BCh, FRCP, , DTM&H; Chief Editor: Carmen Cuffari, MD more...
No definite treatment is available for fulminant hepatic failure (FHF). Medical treatment is usually directed at causative agents or at minimizing morbidity or mortality caused by serious complications.
Vitamins are organic substances required by the body in small amounts for various metabolic processes. They may be synthesized in small or insufficient amounts in the body or not synthesized at all, thus requiring supplementation.
Vitamin K is a fat-soluble vitamin absorbed by the gut and stored in the liver. It is necessary for function of clotting factors in the coagulation cascade and, thus, is used in coagulopathy resulting from liver failure.
Hyperosmotic agents such as lactulose work by increasing the amount of stool water content and softening the stool, allowing for an increased number of bowel movements per day. They also cause decreases in the blood ammonia concentration.
Lactulose inhibits diffusion of NH3 into blood by producing an acidic pH that causes the conversion of NH3 to NH4, a nondiffusable form of ammonia. It is also used to evacuate the bowel and reduce intestinal stasis.
Aminoglycosides such as neomycin are used as adjunctive therapy to reduce the number of ammonia-forming intestinal bacteria.
Neomycin interferes with bacterial protein synthesis by binding to 30S ribosomal subunits, thus reducing the number of ammonia-producing bacteria in the intestine. The subsequent reduction in blood ammonia has resulted in neurologic improvement. Agents such as neomycin are used to prevent and treat portal systemic encephalopathy.
Osmotic diuretics may reduce subarachnoid space pressure by creating an osmotic gradient between cerebrospinal fluid in the arachnoid space and plasma. They are not for long-term use.
Mannitol is used to decrease intracranial pressure. Mannitol is used in patients with documented intracranial pressure greater than 30 mm Hg and can be considered in patients with progressive edema.
Antiviral agents inhibit activity of herpesvirus types 1 and 2. They have affinity for viral thymidine kinase and, once phosphorylated, cause DNA chain termination when acted on by DNA polymerase.
Acyclovir is a synthetic purine nucleoside analogue. Hepatitis is treated with acyclovir for herpesvirus hepatitis.
These agents are used in the management of poisoning and overdose, for prevention of toxic effects, or for metabolic disorders. In 2012, the Pediatric Acute Liver Failure Study Group, in a placebo–controlled clinical trial, evaluated intravenous N-acetylecysteine in pediatric patients with non-acetaminophen acute liver failure. The study group concluded that such a regimen did not improve one-year survival in this group of patients. However there is still a place for further controlled pediatric drug trials in this regard.
N-acetylcysteine is indicated in acetaminophen toxicity. It may provide a substrate for conjugation with a toxic metabolite of acetaminophen. All doses should be administered, even if the acetaminophen level has dropped below the toxic range.
These agents are used in autoimmune hepatitis for immunosuppression effect.
Prednisone is an immunosuppressant for treatment of autoimmune disorders; it may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte activity. It stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.
Azathioprine antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. It may decrease proliferation of immune cells, which results in lower autoimmune activity.
Histamine H2 antagonists
These agents inhibit histamine stimulation of the H2 receptor in gastric parietal cells, which, in turn, reduces gastric acid secretion, gastric volume, and hydrogen concentrations. These agents are used to prevent stress ulcer development and potential gastrointestinal (GI) bleeding.
A parenteral H2-receptor blocker is administered prophylactically to prevent potential GI bleeding. Ranitidine is indicated in peptic ulcer disease and upper GI bleeding for both treatment and prophylaxis.
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