From the Guidelines
For an 80-year-old female patient with suspected cirrhosis but low probability of advanced chronic liver disease (cACLD), the best management approach should prioritize a conservative and non-invasive strategy, focusing on preventing complications and improving quality of life. Given the patient's age and the low probability of cACLD, as suggested by the elastography results, alongside the presence of coarsened liver echotexture and moderate surface nodularity indicative of cirrhotic changes, a comprehensive yet cautious approach is warranted.
The management plan should include:
- Initial comprehensive laboratory testing, including complete blood count, liver function tests, coagulation profile, albumin, and renal function, to assess the patient's current liver status and identify any potential complications [ 1 ].
- Non-invasive fibrosis assessment, such as FibroScan or serum biomarker panels like FIB-4 or APRI, to further evaluate liver fibrosis without the need for invasive procedures.
- Ultrasound imaging of the liver to evaluate liver morphology, assess for any signs of portal hypertension, and rule out complications like ascites.
- Addressing any identified underlying causes of liver disease, such as alcohol cessation, weight management for fatty liver disease, or antiviral treatment for viral hepatitis, if applicable.
- Vaccination against hepatitis A and B, if the patient has not been previously immunized, to prevent additional liver insults.
- Regular monitoring, ideally every 3-6 months, with laboratory tests and annual ultrasound surveillance for hepatocellular carcinoma, given the patient's cirrhotic changes.
- Nutritional support with a balanced diet and adequate protein intake (1-1.2 g/kg/day) to support liver health and overall well-being.
- Management of comorbidities to reduce the risk of decompensation and improve quality of life.
This approach is supported by guidelines that emphasize the importance of comprehensive care, including the prevention of complications and the improvement of quality of life for patients with cirrhosis [ 1 ]. By adopting a conservative, non-invasive management strategy, we can balance the need for appropriate diagnosis and management with the considerations of the patient's advanced age and the lower likelihood of aggressive disease progression.
From the FDA Drug Label
In patients with cirrhosis, initiate spironolactone in the hospital [see Dosage and Administration (2.4) and Clinical Pharmacology (12. 3)] . Clearance of spironolactone and its metabolites is reduced in patients with cirrhosis. In patients with cirrhosis, start with lowest initial dose and titrate slowly [ see Dosage and Administration (2.4) and Clinical Pharmacology (12.3)] . The recommended initial daily dosage is 100 mg of spironolactone tablets administered in either single or divided doses, but may range from 25 mg to 200 mg daily. When given as the sole agent for diuresis, administer for at least five days before increasing dose to obtain desired effect.
The best management approach for an 80-year-old female patient with suspected cirrhosis and low probability of chronic advanced chronic liver disease (cACLD) is to:
- Initiate spironolactone in a hospital setting to closely monitor the patient's condition and potential adverse effects.
- Start with the lowest initial dose (25 mg) and titrate slowly to minimize the risk of hyperkalemia and other adverse reactions.
- Monitor renal function and potassium levels closely, as patients with cirrhosis are at increased risk of hyperkalemia and spironolactone is substantially excreted by the kidney 2.
- Consider the patient's age and potential decreased renal function, and adjust the dosage accordingly to minimize the risk of adverse reactions 2.
From the Research
Management Approach for Suspected Cirrhosis
The patient's elastography result suggests a low probability of chronic advanced chronic liver disease (cACLD), but the coarsened liver echotexture and moderate surface nodularity are indicative of cirrhotic changes.
- The diagnosis of cirrhosis can be confirmed by liver biopsy, but non-invasive methods such as elastography can also be used 3.
- Elastography measures liver stiffness, which can confirm cirrhosis at levels of 15 kPa or greater 3.
- The patient's symptoms, such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, are common in cirrhosis and can be treated with medications such as hydroxyzine, pickle brine and taurine, and tadalafil 3.
Treatment Options
Treatment options for cirrhosis include:
- Nonselective β-blockers (carvedilol or propranolol) to prevent variceal bleeding 3
- Lactulose for hepatic encephalopathy 3, 4
- Combination aldosterone antagonists and loop diuretics for ascites 3
- Terlipressin for hepatorenal syndrome 3
Adherence to Treatment
Adherence to lactulose treatment is crucial to prevent hepatic encephalopathy, but barriers to adherence include large volumes of lactulose, high frequency of dosing, difficulty remembering to take the medication, unpleasant taste, and medication side-effects 5.
- Patient and care-giver education are critical to assure adherence 5.
- Pharmacists and nurses can play an essential role in educating patients about proper medication use 5.
Role of Elastography
Ultrasound-based liver elastography is a non-invasive method of assessing diffuse liver disease and can be used to guide treatment strategy and evaluate treatment response 6, 7.