Patient HL presents with clinical symptoms associated with hepatobiliary and gastrointestinal disorders, i.e., nausea, vomiting, and diarrhea. While these symptoms may be indicative of an underlying GI or hepatobiliary condition, it is difficult to make a conclusive diagnosis without further laboratory workup. It is also unclear why HL is taking the prescribed medication. Information on the duration of medication and presenting complications is pertinent in making an accurate diagnosis. The patient’s medical history indicates that past Hepatitis C infection and drug abuse. Based on the currently prescribed medication, the HL appears to have one or a combination of chronic infections whose etiology is still uncertain. The possible primary diagnosis or the patient is Hepatitis C.
The hepatobiliary and GI like are possibly the side effects of the prescribed medication. Synthroid is a hormone therapy for augmenting thyroid function and treatment of goiter and hypothyroidism. Side effects of Synthroid include diarrhea, severe nausea and vomiting, and appetite changes. Side effects are exacerbated with inappropriate dosages or non-adherence to the medication prescription. The drug is contraindicated in coronary artery disease and heart disease. Nifedipine is prescribed for the treatment of angina and hypertension. The dosage depends on the drug formulation, i.e., whether it is immediate release or extended-release tablets. Inappropriate dosage of nifedipine may result in liver injury (Drugs.com, 2019). Prednisone is an anti-inflammatory corticosteroid that is prescribed for several conditions such as allergies, lupus, asthma and breathing disorders, ulcerative colitis, skin conditions, and arthritis. Prednisone has an immune-suppression effect and is thus contraindicated in thyroid disorders. The drug may also cause pancreatitis and consequent symptoms of nausea, vomiting, and gastric pain (Drugs.com, 2019).
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The concomitant administration of the three drugs points out a high possibility that the GI symptoms the patient presents with are the side effects of the drugs. Contraindications and drug interactions further affect clinical outcomes. Given that it is uncertain from the patient’s history whether Hepatitis C was fully resolved, there is a likelihood that the patient is exhibiting a reoccurrence of Hepatitis C. The presenting symptoms of Hepatitis C are nausea, abdominal pain, appetite changes, diarrhea, fatigue, muscle and joint pain, and mild fever. Prednisone is a large spectrum drug and may have been prescribed to ameliorate or suppress the symptoms of Hepatitis C (European Association for The Study of The Liver, 2018).
Differential Diagnosis
Gastroenteritis
The patient’s presenting symptoms may also be due to viral, bacterial, parasitic, or toxin-mediated inflammation of the stomach and small intestines. Patients usually resolve after a few days by taking plenty of fluids and adequate bed-rest. Given that the duration of the patient’s chief complaints is uncertain, gastroenteritis can be ruled out.
Spontaneous Bacterial Peritonitis
This is a complication in patients with liver cirrhosis mediated by bacterial infection of the ascitic fluid. Symptoms include diarrhea, abdominal pain, and fever. Ascites usually form the basis for confirmatory diagnosis.
Treatment Plan
The treatment and management modality for Hepatitis C has two objectives, to achieve a sustained eradication of serum Hepatitis C virus (HCV), and to prevent the progression of the disease and development of complications such as carcinoma (Falade-Nwulia et al., 2017). The criteria for determination of the HCV antiviral and interferon therapy is based on a number of factors. These include the patient’s age, patient’s ALT levels and liver function, biochemical and hematologic indices, serum HCV RNA and HCV antibody levels, and drug interactions and contraindications.
Direct-acting antiviral agents (DAAs) and interferons are the treatment regimens of choice for the patient. The DAAs are often available in novel combinations. The combination to be prescribed is determined by the disease genotype (Falade-Nwulia et al., 2017). Based on HL’s presenting symptoms, it can be assumed that the HCV genotype is 1a (without the complication of cirrhosis). The drug combinations are:
Grazoprevir (100 mg)/elbasvir (50 mg) administered daily for 12 weeks.
Sofosbuvir (400 mg)/simeprevir (150 mg) daily for 12 weeks.
Ledipasvir (90 mg)/sofosbuvir (400 mg) daily for 12 weeks (Falade-Nwulia et al., 2017).
Regular monitoring (every 4 weeks) is required to determine the prognosis and clearance of serum HCV RNA. Nifedipine causes liver injury and thus affects the function of cytochrome P450. Consequently, the dosages will have to be lowered if the drugs are administered concomitantly (Falade-Nwulia et al., 2017).
References
Drugs.com. (2019). Nifedipine. Retrieved on 10 th July 2019 from https://www.drugs.com/search.php?searchterm=nifedipine&a=1
Drugs.com. (2019). Prednisone. Retrieved on 10 th July 2019 from https://www.drugs.com/search.php?searchterm=prednisone&a=1
European Association for The Study of The Liver. (2018). EASL recommendations on treatment of hepatitis C 2018. Journal of hepatology , 69 (2), 461-511.
Falade-Nwulia, O., Suarez-Cuervo, C., Nelson, D. R., Fried, M. W., Segal, J. B., & Sulkowski, M. S. (2017). Oral direct-acting agent therapy for hepatitis C virus infection: a systematic review. Annals of internal medicine , 166 (9), 637-648.
