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Recommendations on Drug Selection and Dose Adjustment for Patients with Liver Cirrhosis: Results from a Multidisciplinary Expert Panel.

Clinical drug investigation

Authors: Katharina Karsten Dafonte, Philipp Lutz, Christian Jansen, Marika Busse, Peter Dietrich, Katrin Farker, Hans-Peter Lipp, Jacob Nattermann, Tilman Sauerbruch, Sven Schmiedl, Dorothea Strobach, Jonel Trebicka, Dario Zocholl, Gunther Hartmann, Ulrich Jaehde, Martin Coenen

BACKGROUND AND OBJECTIVES: Liver cirrhosis profoundly alters pharmacokinetics and is frequently associated with medication-related problems. Stage-specific dosing guidance remains inconsistent, and prescribing information often lacks clarity. As a result, treatment decisions rely on individual clinical judgement and may differ between professional groups. This study assessed drug-selection and dose-adjustment practices among hepatologists, clinical pharmacologists, and clinical pharmacists, quantified consensus across Child-Pugh stages, and evaluated alignment with prescribing information as a basis for harmonised dosing guidance.

METHODS: Twelve experts from hepatology, clinical pharmacology, and clinical pharmacy evaluated prioritised drugs for patients with liver cirrhosis across Child-Pugh stages A-C in a structured survey. For each drug, experts indicated whether they would apply no dose adjustment, modify the dose, or avoid administration. Consensus was defined as at least 75% agreement, and interrater agreement was assessed by pairwise percentage agreement. Consensus recommendations were compared with the dosing information provided in each drug's Summary of Product Characteristics.

RESULTS: Consensus or strong consensus was achieved for only 20% of 177 recommendations, mainly for no dose adjustment or avoidance. Agreement decreased with disease severity (Child-Pugh A 83%; B 47%; C 41%). Of 36 consensus recommendations, 18 matched the summary of product characteristics, while six diverged from it. Pharmacists and clinical pharmacologists more often recommended dose adjustments, especially in Child-Pugh B and C, whereas hepatologists preferred standard dosing or avoidance.

CONCLUSIONS: Expert recommendations for dosing in cirrhosis showed marked variability and limited concordance with prescribing information, underscoring the need for harmonised interdisciplinary guidance integrating pharmacokinetic evidence and clinical feasibility.

© 2026. The Author(s).

PMID: 41806204

Participating cluster members