Editor – We very much enjoyed your article “Drug therapies in liver disease’ (Clin Med December 2013 pp 585–91). As emergency physicians it was a very useful summary; however, we did think there was one very useful drug missing – indomethacin. Hepatic encephalopathy is a complex manifestation of severe liver disease. The article clearly summarises the drugs used to try and decrease the amount of ammonia reaching the cerebral circulation, but does not mention those mitigating cerebral hyperaemia.
Cerebral hyperaemia is associated with high-grade encephalopathy, especially in the acute setting. Indomethacin has been shown to be an effective treatment of hepatic encephalopathy where this is the case and other treatments have failed.1 Therefore, we felt that it deserved a mention in your article given our positive experiences with it.
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- © 2014 Royal College of Physicians
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