What are the precipitating factors?

From the Guidelines

Precipitating factors for acute-on-chronic liver failure (ACLF) include bacterial infections, severe alcohol-related hepatitis, gastrointestinal hemorrhage with shock, hepatitis E virus infection, and acute encephalopathy caused by drugs, as identified in the most recent and highest quality study 1. These factors can trigger or worsen ACLF, and their identification is crucial for effective disease management. The precipitating events vary between different populations, geographic areas, and aetiologies, with bacterial infection and active alcohol intake being major precipitating events in Western countries, and exacerbation of hepatitis B and alcohol or bacterial infections being major causes in Eastern countries 1. Some key points to consider when evaluating precipitating factors for ACLF include:

• The number of precipitants present is a major determinant of short-term outcome in patients with ACLF 1
• A systematic workup should be used to identify common precipitants, including proven bacterial infections, severe alcohol-related hepatitis, gastrointestinal hemorrhage with shock, hepatitis E virus infection, and acute encephalopathy caused by drugs 1
• Rare disorders, such as drug-induced acute kidney injury, should also be considered as potential precipitants 1 In clinical practice, identifying precipitating factors is essential for developing personalized prevention strategies and treatment plans that address not only the condition itself but also the circumstances that exacerbate it, leading to better overall disease control and improved quality of life. Healthcare providers should work with patients to recognize their specific precipitating factors through careful history-taking and symptom tracking, and use the most recent and highest quality evidence to guide their management decisions, such as the study by 1.

From the FDA Drug Label

WARNINGS Heart Failure Beta-blockers, like metoprolol, can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock. Ischemic Heart Disease Do not abruptly discontinue metoprolol therapy in patients with coronary artery disease. Severe exacerbation of angina, myocardial infarction and ventricular arrhythmias have been reported in patients with coronary artery disease following the abrupt discontinuation of therapy with beta-blockers Bradycardia Bradycardia, including sinus pause, heart block, and cardiac arrest have occurred with the use of metoprolol. Exacerbation of Bronchospastic Disease Patients with bronchospastic disease, should, in general, not receive beta-blockers, including metoprolol. Diabetes and Hypoglycemia Beta-blockers may mask tachycardia occurring with hypoglycemia, but other manifestations such as dizziness and sweating may not be significantly affected Pheochromocytoma If metoprolol tartrate is used in the setting of pheochromocytoma, it should be given in combination with an alpha blocker, and only after the alpha blocker has been initiated

The precipitating factors for metoprolol include:

• Abrupt discontinuation of therapy in patients with coronary artery disease, which may lead to severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias
• Heart failure, as beta-blockers like metoprolol can cause depression of myocardial contractility
• Bradycardia, including sinus pause, heart block, and cardiac arrest
• Exacerbation of bronchospastic disease, as metoprolol is a beta-blocker
• Hypoglycemia, as beta-blockers may mask tachycardia occurring with hypoglycemia
• Pheochromocytoma, if metoprolol is not used in combination with an alpha blocker 2

From the Research

Precipitating Factors

• The study 3 highlights that most asthma exacerbations are associated with viral upper respiratory tract infections, but exposure to pollutants such as ozone, particulate matter, and biologicals like endotoxin can also trigger asthma exacerbations.
• Another study 4 found that viral-induced upper respiratory tract infections are the most frequent trigger of asthma-related exacerbations, and treatment with inhaled corticosteroids plus long-acting beta(2)-agonists can reduce the number of exacerbations associated with upper respiratory tract infections.
• Air pollution is also a significant precipitating factor for asthma exacerbations, with studies 5 showing associations between high levels of air pollution and poor lung growth, development of allergic sensitization, and airway inflammation.
• In the context of heart failure, studies 6, 7 have identified various precipitating factors, including infection, atrial fibrillation, anaemia, hypertension, acute coronary syndrome, and non-adherence to treatment, which can impact patient outcomes and mortality.
• The identification of precipitating factors can have a prognostic value and can inform specific treatments and prevention strategies, as seen in the study 7 where managing precipitant factors was associated with better outcomes in acute heart failure patients.