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The liver has a major role in the pharmacokinetics and pharmacodynamics of medicines and hepatic impairment could therefore lead to increased plasma levels and adverse drug reactions. Due to the large overcapacity of the liver, medication adjustments are only needed when a chronic liver disease has progressed to cirrhosis. Important pharmacokinetic alterations that could occur in cirrhosis are: (a) a decreased first-pass effect, (b) impaired metabolism by liver enzymes, and (c) in an advanced stage also impairment of renal elimination. Patients with cirrhosis could also be more sensitive to certain adverse drug reactions at normal drug levels, such as renal impairment due to NSAIDs or the sedative effect of morphinomimetics and psychotropic drugs. Prescribing in patients with cirrhosis is complex, which we illustrate by 5 common pitfalls. In practice, healthcare professionals could use a website with guidance for prescribing almost 300 medicines (www.geneesmiddelenbijlevercirrose.nl).

Background: Underlying liver disease is usually, quite rightly, suspected in patients with raised liver enzyme levels. Thesecan, however, actually have a different cause, such as a muscular disease., Case Description: A 41-year-old woman was referred to a gastroenterology clinic with unexplained elevated liver enzymelevels and fatigue. She had experienced mildly raised liver enzyme levels 10 years previously; following analysis these were interpreted as due to 'non-alcoholic fatty liver disease'. Further questioning revealed that the patient had also recently been experiencing muscular pain and had difficulty with rising from a sitting position. Laboratory investigation revealed elevated aminotransferase and creatinine kinase (CK) levels. The symptoms and the abnormal laboratory results were found to be due to a mutation of the ANO5 gene., Conclusion: A mild liver enzyme disorder can indicate a muscular disease. It is sensible to measure CK levels early, in order to distinguish between a muscular disease and other causes of the raised liver enzyme level. This may prevent unnecessary, invasive and expensive diagnostics.

Objective: To investigate whether a novel meal service, FoodforCare, improves dietary intake and patient satisfaction, compared to the traditional 3-meals a day service (TMS)., Design: We performed a prospective cohort study at medical (Gastroenterology) and surgical (Gynecology, Urology, Orthopedics) wards. Patients were offered TMS (July 2015 - May 2016; n = 326) or FfC meal service (after stepwise introduction per ward from January 2016 - December 2016; n = 311)., Method: Primary outcome was the mean percentage of protein and energy intake relative to requirements, between patients receiving TMS and those receiving FfC, on the first and fourth day of full oral intake. Patient satisfaction comprised rating of the experienced quality of the meals and the meal service by means of a validated questionnaire., Results: Patient characteristics were similar between groups, with the exception that the FfC group contained more oncology patients (p = 0.028). FfC improved mean daily protein intake (in g/day) relative to requirements (1.2 g/kg/day) at day 1 (mean % ± SD: 79 ± 33 vs. 59 ± 28; p < 0.05) and day 4 (73 ± 38 vs. 59 ± 29; p < 0.05). Mean daily energy intake (in kcal/day) relative to requirements improved at day 1 (88 ± 34 vs. 70 ± 30; p < 0.05) and day 4 (84 ± 40 vs. 73 ± 31; p = 0.05). On a scale of 1-10, patient satisfaction remained unchanged, in terms of food quality (7.7 ± 1.5 vs. 7.4 ± 1.4; p = 0.09) and meal service (7.8 ± 1.3 vs. 7.7 ± 1.1; p = 0.29). The FfC group was more satisfied with the appearance and smell of the meals (both p < 0.05)., Conclusion: Implementation of this novel meal service substantially improved protein and energy intake while maintaining, and to some extent, improving patient satisfaction.