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Drugs for liver disease – a Hepatologist’s perspective

This step is an interview with Dr Andrew Holt who discusses non surgical management of liver disease.
So there are lots of different drugs because there are lots of different symptoms of chronic liver disease. But although in the last 10 years we’ve made huge advances in treating some diseases like Hepatitis B, particularly Hepatitis C in the last five years and also other diseases like autoimmune liver disease it will probably surprise most people watching this video that in terms of the treatment for symptoms of chronic liver disease I’m still using many of the same drugs that Sheila Sherlock first advocated back in the ’50s, ’60s, and ’70s.
So in terms of gap for developing new ways of treating patients’ symptoms, we’ve not progressed hugely far in the last decade in that sense, whereas in treatments to treat the underlying cause in many diseases we’ve actually got as far as being able to say that we’ve almost cured some liver diseases. So we would use all sorts of things. If someone was itching, we have variety of medicines which might ameliorate itch. But I’ve used that word on purpose because it’s impossible to get rid of itch altogether, and for some people the itch is so bad that it drives them to suicide in some cases.
And sometimes it forces us to even consider doing a transplant just because the itch is so unmanageable. So there are many things which we can do a bit for, but there are other things where we’re a long way short of being able to treat all the symptoms. Another common symptom is encephalopathy, and people might know a little bit about that, but to an observer it’s abnormal behaviour in someone with liver disease. It’s completely unpredictable. It can be very socially embarrassing for the family and for the patient. It can sometimes be very dangerous if someone’s liable to lapse into coma.
Yeah, we’ve made some progress there, but we’re still a long way short of actually being able to control the underlying mechanisms and for most of these patients the endpoint, if it’s available to them, would be a transplant. But there are so many people in the UK with liver disease now, up to a fifth– it’s the fifth most common cause of death– that there’s no way that transplantation is big enough within the UK to provide a solution for those patients. So we’re going to have to work very, very hard at improving medicines which will make people’s lives better with what is ultimately a chronic and life-limiting disease.
Lots of different drugs. There is quite a lot of progress. Probably the one that most people will be aware of is Viral Hepatitis, so when we say that we’re referring mainly to Hepatitis B and Hepatitis C infections. So for about 10 to 12 years treatments for Hepatitis B have been pretty widely available that are very, very effective, and certainly in the last seven years those treatments have become very powerful, very resistant to viral mutation and therefore safe for people to take long term. So Hepatitis B is an eminently treatable infection now, both before and after a transplant.
It’s really in the last three years that Hepatitis C has started to catch up, and it’s on the back of scientific breakthroughs in understanding the viral genome and being able to tailor drugs to affect different components of the virus’ life cycle. Now that work has been so successful that it’s not ridiculous to suggest that in some Western countries, Hepatitis C could almost be eradicated in my lifetime if resources permitted. And that’s the problem. All of these new drugs come with a price because of the developmental costs, and they’re very expensive, but they’re very powerful. So Viral Hepatitis is the area most people think of, but also autoimmune liver disease.
We’re much better now at treating that and being able to tackle the processes that underlie that. We’ve got a better understanding of the mechanisms that drive those diseases. So we’re more precise in learning how to use immunomodulatory therapies. And other conditions as well, we’re learning much more about them. But for conditions like alcoholic liver disease there’s a gap, and we’re still a long way off being able to either tackle the underlying problem, which is alcohol addiction, or actually being able to undo the damage that alcohol causes, like scarring and fibrosis.
But that’s another very, very exciting area and a lot of the big pharmaceutical companies are interested in looking at developing anti-fibrotic strategies, which might be relevant to a number of diseases, like fatty liver disease as well as alcohol related cirrhosis.
There are lots. One of the nicest things about managing liver disease is that simple things done well are often the best way of managing the problem. And so dietary interventions, obviously for people with fatty liver disease, which is often related to obesity you’d expect diet to be important there. But actually less well known is that patients who present with very advanced decompensated liver disease, we can actually make huge improvements just by making small adjustments to the way that people eat, avoiding fasting, giving a big carbohydrate load at bed time. The dietitians will tell you more about this in their session, and it’s often amazing how you can turn things around.
It doesn’t always mean that you can rescue the situation entirely, but you can certainly improve the patient’s condition just by adjusting diet and what the diet comprises. And in terms of other things that they can do, remaining active is really important. The worst place for a liver patient is in bed because all of their muscles just disappear within weeks in some cases.
And things to avoid: salts, if they have a tendency to accumulate fluid, and salt is one of the major mechanisms whereby ascites and edema accumulate in liver disease. So lots of small things that we can teach patients to do that will make them better.

Your task: Watch the video interview with Dr Holt which serves as an introduction to how doctors can look after your liver. You may want to contrast this later with those steps in which we consider how you can look after your own liver. Reflect on any new information or ideas and share your thoughts with other learners in the comments area.

In the first series of steps this week we will consider treatments for liver disease. We will divide them up into drug-based treatments (which can either be used to treat the disease, or the symptoms it causes) and surgical treatments. We will do this by discussions with some of the staff from the Liver Unit at the Queen Elizabeth Hospital in Birmingham. We will mention many of the diseases we have covered so far and will remind you of features of liver and gallbladder anatomy that we covered in the first week of this course.

You may remember that as we progressed through our earlier steps, we commented on how some diseases can be tricky to treat and diagnose. We also noted how sometimes the only way to help someone is by performing a liver transplant. You will hear a little about transplantation here and we will also show you some new treatment options which may improve the situation for patients with advanced liver disease.

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Liver Disease: Looking after Your Liver

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