What are the treatment recommendations for patients with cirrhosis?

From the Guidelines

Treatment for cirrhosis focuses on managing complications and preventing disease progression, with a priority on reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, 1, provides guidelines for the management of liver cirrhosis, including recommendations for ascites and related complications. Key recommendations include:

• Abstaining from alcohol consumption
• Nutritional support with a protein intake of 1.2-1.5 g/kg/day
• Sodium restriction to <2 g/day for those with ascites
• Spironolactone starting at 50-100 mg daily, often combined with furosemide 20-40 mg daily, for ascites management
• Patients with spontaneous bacterial peritonitis should receive ceftriaxone 1-2 g IV daily for 5-7 days, followed by prophylaxis with norfloxacin 400 mg daily or trimethoprim-sulfamethoxazole
• Hepatic encephalopathy is treated with lactulose 25-30 mL every 1-2 hours until bowel movements occur, then 15-30 mL 2-3 times daily to maintain 2-3 soft bowel movements daily, often combined with rifaximin 550 mg twice daily
• For variceal bleeding, emergency management includes terlipressin 2 mg IV every 4-6 hours or octreotide 50 μg IV bolus followed by 50 μg/hour infusion, along with prophylactic antibiotics and endoscopic therapy
• Non-selective beta-blockers like propranolol 20-40 mg twice daily or carvedilol 6.25-12.5 mg daily are used for primary and secondary prophylaxis
• Regular screening for hepatocellular carcinoma with ultrasound every 6 months is recommended, and liver transplantation should be considered for appropriate candidates with decompensated cirrhosis, as supported by 1. It is essential to consider the patient's overall condition and adjust treatment accordingly, as emphasized in 1 and 1, and to prioritize care coordination and educational programs to improve adherence to guideline recommendations and quality of care, as highlighted in 1.

From the Research

Treatment Recommendations for Cirrhosis

The treatment recommendations for patients with cirrhosis involve a multi-faceted approach, including pharmacological therapy, management of complications, and lifestyle modifications.

• Non-selective beta-blockers (NSBBs) are recommended for primary and secondary prophylaxis of variceal bleeding, with carvedilol being a potentially more effective option than propranolol in lowering portal hypertension 2, 3, 4.
• For patients with ascites, combination therapy with aldosterone antagonists and loop diuretics is recommended, with lactulose being used to treat hepatic encephalopathy 3.
• Terlipressin is used to treat hepatorenal syndrome, and trials have demonstrated its efficacy in improving survival rates 3.
• For symptoms such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, treatments like hydroxyzine, pickle brine and taurine, and tadalafil have shown efficacy 3.
• In patients with alcohol use disorder, treatment with metadoxine and baclofen may be considered, along with psycho-social therapy and attendance at support groups 5.
• When prescribing medications to patients with cirrhosis, it is essential to consider the potential for drug-induced liver injury and to use lower doses or reduced dosing frequency due to altered pharmacokinetics 6.

Management of Complications

• Variceal bleeding: NSBBs, such as carvedilol or propranolol, are recommended for primary and secondary prophylaxis, with endoscopic variceal ligation being considered in cases of contraindication to NSBBs 2, 3.
• Ascites: combination therapy with aldosterone antagonists and loop diuretics is recommended, with lactulose being used to treat hepatic encephalopathy 3.
• Hepatorenal syndrome: terlipressin is used to improve survival rates 3.
• Hepatic encephalopathy: lactulose is recommended as first-line treatment, with rifaximin being considered as an adjunctive therapy 3.

Lifestyle Modifications

• Abstinence from alcohol is crucial in patients with alcohol-related cirrhosis, with psycho-social therapy and attendance at support groups being essential components of treatment 5.
• A healthy diet and regular exercise are recommended to improve overall health and reduce the risk of complications.
• Patients with cirrhosis should be vaccinated against hepatitis A and B, as well as influenza and pneumococcal disease, to reduce the risk of infections 3.