From the Guidelines
For patients with NAFLD cirrhosis and hypotension, norepinephrine is recommended as the first-line vasopressor, alongside appropriate fluid resuscitation, as an alternative to midodrine. When considering treatment options beyond midodrine, it's crucial to prioritize strategies that address the underlying pathophysiology of cirrhotic hypotension, including splanchnic vasodilation, reduced effective circulating volume, and autonomic dysfunction.
Key Considerations
- The use of norepinephrine as a first-line vasopressor is supported by recent guidelines, such as those outlined in the 2024 AASLD practice guidance on acute-on-chronic liver failure and the management of critically ill patients with cirrhosis 1.
- Fluid resuscitation with balanced crystalloids (e.g., lactated Ringer's) and/or albumin (in select indications) is recommended to optimize volume status in critically ill patients with cirrhosis and shock 1.
- A target mean arterial pressure (MAP) of 65 mm Hg is suggested for patients with cirrhosis and septic shock, with ongoing assessment of end-organ perfusion 1.
Additional Treatment Options
- Vasopressin may be considered as a second-line agent when increasing doses of norepinephrine are required 1.
- Screening for adrenal insufficiency or an empiric trial of hydrocortisone may be beneficial in cases of refractory shock requiring high-dose vasopressors 1.
- Non-pharmacological approaches, such as increasing salt intake, maintaining adequate fluid intake, wearing compression stockings, and elevating legs when sitting, can also be beneficial in managing hypotension in patients with NAFLD cirrhosis.
- Physical countermaneuvers like crossing legs when standing can temporarily increase blood pressure. Treatment should be individualized based on the severity of hypotension, renal function, and electrolyte balance, with regular monitoring of blood pressure, electrolytes, and renal function to adjust therapy as needed.
From the FDA Drug Label
Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock. In such circumstances, the use of an albumin infusion may be required to support the blood volume. The options to treat hypotension with NAFLD cirrhosis besides midodrine include:
- Albumin infusion: to support blood volume, especially after removal of ascitic fluid. No other options are directly mentioned in the provided drug labels. 2
From the Research
Treatment Options for Hypotension with NAFLD Cirrhosis
- Besides midodrine, there are no specific treatments mentioned in the provided studies for hypotension with NAFLD cirrhosis.
- However, the studies suggest that lifestyle modifications such as weight loss and dietary changes can help improve NAFLD symptoms 3, 4, 5.
- Some studies also mention the potential benefits of certain pharmacological treatments, such as thiazolidinediones or glucagon-like peptide-1 analogues, in improving NAFLD symptoms, but these are not specifically mentioned as treatments for hypotension 3, 6.
- The management of NAFLD typically focuses on addressing the underlying risk factors, such as obesity, metabolic syndrome, and type 2 diabetes mellitus, rather than treating hypotension specifically 4, 5, 7.
- It is essential to note that NAFLD is a complex disease, and its management often requires a multidisciplinary approach, including lifestyle modifications, pharmacological treatments, and monitoring for potential complications such as cardiovascular disease and hepatocellular carcinoma 5, 6.