Læknablaðið : fylgirit - 01.08.1978, Page 16

14
operations may delay surgery for up to 2
years. Psychological factors, ranging from
mild apprehension about the prospect of
a laparotomy to marked anxiety states
'when a cholecystectomy has been proposed,
may tip the balance in favour of choosing
medical treatment.
II Contraindications to CDCA
CDCA causes dose-related, and usually
transient, diarrhoea. Occasionally, how-
ever, this persists intermittently through-
out medical treatment. For this reason, one
should be cautious about prescribing
CDCA for patients who have diarrhoea
which is likely to persist — for example,
that associated with inflammatory bowel
disease or that occurring as a consequence
of small bowel resection.
Because of concern about hepatotoxicity,
some manufacturers also recommend that
CDCA should not be prescribed for
patients with liver disease. This is
probably a sensible precaution although
extensive studies of liver structure and
function have convincingly shown that
there is no evidence of hepatotoxicity in
patients treated with usual doses of CDCA
for up to 4 years. Indeed, in our own unit,
we have successfully treated patients with
established secondary biliary cirrhosis as-
sociated with gallstones.
III The patients choice and the doctors
advice
After all the factors listed above have
been considered, if the patient is judged
suitable for medical treatment, the final
decision about chenotheraphy, surgery or
a conservative approach rests with the
patient guided by his/her doctor. Practical
considerations, such as inability (or reluc-
tance) to leave children and home or pres-
sures of work may influence some patients
to opt for medical treatment rather than
spend 7—10 days in hospital for surgery.
On the other hand, the prospect of re-
peated visits to the doctor over a period of
up to 2 years with no guarantee of sucess
at the end of it, may make the patient
decide to refuse medical treatment in
favour of surgery. The policy of our own
unit is to guide the patient in one direction
or the other only when asked to do so.
Even then, it is important to be as fair and
objective as possible. By adopting this
approach, our rejection rate for patients
presenting for CDCA treatment may be
higher than elsewere but ultimately, such
careful selection results in a greater de-
gree of efficacy.
SELECTION OF DOSE AND DURATION
OF CDCA
I Most investigators now recommend that
the dose of CDCA should be based on
body vveight
However, since CDCA capsule or tablet
size is fixed and since patient size is not,
one cannot always give a precise dose/
Kg BW but in general, most patients
should be given 13—15 mg CDCA Kg-1
day-1. Some patients may respond to
smaller doses of CDCA than this and in
specialised centres, an early indication of
the response to treatment may be gained
from analysis of bile-rich duodenal fluid
one month after starting treatment. How-
ever, in most cases it is impractical (and
indeed unnecessary) to monitor bile lipids.
Therefore, although a few patients may
respond to smaller doses, to ensure that
most, if not all, patients will develop un-
saturated bile and dissolve their gall-
stones, the 13—15 mg/Kg dose is re-
commended.
II Timing of dose
The daily quota of CDCA is usuallv
taken in divided doses throughout the day
but preliminary results from one centre
suggest that there may be a better re-
sponse if the entire daily dose is taken at
bedtime.
III Duration of treatment
Gallstone dissolution is judged by
follow-up cholecystogram X-rays which
arbitrarly are taken at 6-monthly inter-
vals. Present experience suggests that only
small gallstones are likely to show partial
or comnlete dissolution by the time of the
first follow-up X-ray. To avoid disappoint-
ment, therefore, (for the doctor as well as
for the patient), one should be prepared
for unchanged X-rays after the first 6