Hepatic Failure/GI/Endocrine Emergencies
iv.
Oral acetylcysteine has also been evaluated for the treatment of NAI-ALF in a prospective
non-interventional study in which it, compared with a historical cohort, was associated with
reduced mortality. In this study, oral acetylcysteine was given as a 140-mg/kg loading dose,
followed by 70 mg/kg every 4 hours for an additional 17 doses. However, at this time, only
intravenous acetylcysteine has been studied in a randomized controlled trial for NAI-ALF.
Route
Dose
Intravenous
150 mg/kg over 1 hr, followed by
12.5 mg/kg/hr for 4 hr, followed by
6.25 mg/kg/hr for 67 hr
Patient Case
A 60-year-old woman with rheumatoid arthritis was initiated on azathioprine 3 months ago and now presents
with NAI-ALF secondary to DILI. On presentation, her ALT and AST concentrations are 500 IU/L and 350
IU/L, respectively. Her INR is 1.7, and she is mildly confused and drowsy. Which intervention has been
shown most effective for the treatment of NAI-ALF?
Viral hepatitis
Hepatitis B
| (a) | Similar to prophylaxis, acute hepatitis B infection treatment requires a nucleos(t)ide |
|---|
analog: entecavir 1 mg daily or lamivudine 100 mg daily.
ii.
Herpes simplex virus
| (a) | Patients with HSV ALF can be treated with high dose acyclovir 5β10 mg/kg intravenously |
|---|
every 8 hours for at least 7 days.
| d. | Mushroom poisoning |
|---|
Gastric lavage and activated charcoal may be beneficial for patients still having GI symptoms
indicative of a recent ingestion.
ii.
Although data regarding efficacy are lacking, penicillin G or silibinin (silymarin or milk thistle)
can be used as an antidote to Ξ±-amanitin, a toxin released after mushroom ingestion. Intravenous
silibinin is guideline-preferred therapy based on the 2023 ACG guidelines, although this is a
low-level recommendation; however, it is only available in United States through compassionate
use, investigational drug access. Therefore, penicillin G is often used instead. Penicillin G
directly competes with and inhibits the ability of the toxin to bind to plasma protein and
penetrate the liver. Recommended dose of penicillin G for mushroom poisoning is 300,000 to
1 million units/kg/day given intravenously.
Autoimmune hepatitis
High-dose intravenous corticosteroids (greater than or equal to 1 mg/kg prednisone equivalent
or greater than or equal to 60 mg prednisone equivalent per day) should be initiated for patients
who present with ALF secondary to autoimmune hepatitis. However, patients with progressive
disease will require liver transplantation.