How do you adjust dosing in hepatic impairment?

• A. Increase the dose to compensate for reduced clearance.
• B. Do not adjust dose; hepatic impairment does not affect dosing.
• C. Switch to an entirely different drug class.
• D. Reduce the dose or extend the dosing interval based on predicted decrease in hepatic clearance; guidelines or models needed.

Answer: (D)

In hepatic impairment, the liver’s ability to metabolize and clear drugs declines, which often leads to higher exposure (larger area under the curve) and a longer half-life. Because the exact change in clearance depends on the drug’s clearance pathways and the severity of impairment, dosing must be adjusted rather than assumed constant. The best approach is to reduce the dose or extend the dosing interval based on the predicted decrease in hepatic clearance, using guidelines or models to estimate how much exposure will change. This helps avoid toxicity from overexposure while still achieving therapeutic effects. Increasing the dose isn’t appropriate, and assuming no effect isn’t correct; switching drug classes isn’t the standard first step—adjustment guided by clinical labels or predictive models is.