What are the management options for cirrhosis?

From the Guidelines

Management of cirrhosis should prioritize treating the underlying cause, preventing complications, and addressing symptoms, with a focus on improving morbidity, mortality, and quality of life. The most recent and highest quality study, 1, published in 2024, provides guidance on the use of vasoactive drugs and intravenous albumin in cirrhosis.

Key Management Strategies

• Identify and treat the primary cause of cirrhosis, such as stopping alcohol consumption for alcoholic cirrhosis, using antivirals for hepatitis B (entecavir or tenofovir) or direct-acting antivirals for hepatitis C, weight loss and diabetes control for NAFLD, and immunosuppressants for autoimmune hepatitis.
• Portal hypertension management includes non-selective beta-blockers (propranolol 20-40mg twice daily or nadolol 20-40mg daily) to prevent variceal bleeding.
• For ascites, restrict sodium (<2g/day) and use diuretics (spironolactone 100mg with furosemide 40mg daily, adjusting as needed).
• Paracentesis is performed for tense ascites or diagnostic purposes.
• Hepatic encephalopathy requires lactulose (30ml 2-4 times daily) and rifaximin (550mg twice daily) for recurrent episodes.
• Screen for hepatocellular carcinoma with ultrasound and alpha-fetoprotein every 6 months.
• Nutritional support is crucial—maintain protein intake (1.2-1.5g/kg/day), avoid prolonged fasting, and supplement with multivitamins and zinc.
• Liver transplantation evaluation should be considered when MELD score exceeds 15 or complications become difficult to manage.
• Regular monitoring of liver function, electrolytes, and renal function is essential as cirrhosis progresses to detect complications early and adjust management accordingly.

Additional Considerations

• Vasoconstrictors, such as terlipressin, can be used to reduce portal pressure in variceal hemorrhage.
• Intravenous albumin can be used to increase effective arterial blood volume and prevent acute kidney injury (AKI) and death after large-volume paracentesis and in patients with spontaneous bacterial peritonitis (SBP).
• The combination of vasoconstrictors and albumin can be used in the reversal of hepatorenal syndrome (HRS-AKI), the most lethal complication of cirrhosis. Overall, the management of cirrhosis requires a comprehensive approach that addresses the underlying cause, prevents complications, and improves quality of life, with a focus on reducing morbidity and mortality.

From the FDA Drug Label

Cirrhosis of the liver accompanied by edema and/or ascites: Aldosterone levels may be exceptionally high in this condition. Spironolactone tablets are indicated for maintenance therapy together with bed rest and the restriction of fluid and sodium

• The management options for cirrhosis include:
  • Maintenance therapy with spironolactone
  • Bed rest
  • Restriction of fluid and sodium 2

    In patients with hepatic cirrhosis and ascites, furosemide therapy is best initiated in the hospital.

• Additional management considerations for cirrhosis:
  • Hospital initiation of furosemide therapy
  • Strict observation during the period of diuresis
  • Supplemental potassium chloride and an aldosterone antagonist to prevent hypokalemia and metabolic alkalosis 3

From the Research

Management Options for Cirrhosis

The management of cirrhosis involves a multifaceted approach, including pharmacological therapies, lifestyle modifications, and treatment of complications.

• Pharmacological Therapies:
  • Non-selective beta-blockers, such as carvedilol or propranolol, are used to prevent variceal bleeding and reduce the risk of decompensation or death 4, 5.
  • Lactulose is used to treat hepatic encephalopathy and has been shown to reduce mortality and the risk of recurrent overt hepatic encephalopathy 4.
  • Combination aldosterone antagonists and loop diuretics are used to treat ascites, with a higher rate of resolution and lower rates of hyperkalemia compared to sequential initiation 4.
  • Terlipressin is used to treat hepatorenal syndrome and has been shown to improve the rate of reversal 4.
• Treatment of Complications:
  • Hepatic encephalopathy: lactulose, rifaximin 5
  • Ascites: diuretics, therapeutic paracentesis, plasma expanders 6
  • Spontaneous bacterial peritonitis: third-generation cephalosporins, norfloxacin 6
  • Hepatorenal syndrome: terlipressin 4
• Lifestyle Modifications:
  • Nutrition and physical activity in malnourished and obese patients 7
  • Avoidance of alcohol and smoking 7
  • Improvement of oral hygiene 7
• Emerging Therapies:
  • Anticoagulation therapy to reduce the incidence and increase recanalisation rates of non-malignant portal vein thrombosis 5
  • Chemopreventative therapies to reduce the risk of hepatocellular carcinoma and cirrhosis complications 8
  • Therapies to address non-pain symptoms of cirrhosis, such as pruritis, muscle cramps, sexual dysfunction, and fatigue 8