What are the treatment options for cirrhosis?

Treatment Options for Cirrhosis

The treatment of cirrhosis should focus on addressing the underlying cause, managing complications, and implementing specific interventions including sodium restriction (2000 mg/day), diuretic therapy with spironolactone and furosemide, and preventing progression to decompensation. 1

Addressing Underlying Causes

• Alcohol-induced liver disease: Abstinence from alcohol is critical and can result in dramatic improvement with approximately 75% 3-year survival in Child-Pugh C cirrhosis patients who stop drinking (versus 0% survival in those who continue) 2
• Viral hepatitis: Antiviral treatment for hepatitis B (entecavir or tenofovir) and hepatitis C 1
• Nonalcoholic fatty liver disease: Weight management and metabolic control 1

Nutritional Management

• Maintain adequate protein intake (1.2-1.5 g/kg/day) 2
• Restrict sodium intake to 2000 mg/day (88 mmol/day) 2, 1
• Fluid restriction is not necessary unless serum sodium is below 120-125 mmol/L 2, 1

Management of Ascites

Initial Treatment

1. Dietary sodium restriction: 2000 mg/day (88 mmol/day) 2
2. Diuretic therapy:
   • First-line: Spironolactone starting at 50-100 mg/day, increasing to maximum 400 mg/day 2
   • Add furosemide 20-40 mg/day (up to 160 mg/day) if response is insufficient 2
   • Maintain spironolactone:furosemide ratio of approximately 2.5:1 to 5:1 1

Monitoring

• Target weight loss: 0.5 kg/day without peripheral edema; no limitation with peripheral edema 2
• Monitor serum electrolytes and renal function regularly 1
• Reduce or stop diuretics if:
  • Hyponatremia (sodium <120-125 mmol/L)
  • Acute kidney injury
  • Hepatic encephalopathy
  • Severe muscle cramps 2

Refractory Ascites

• Large-volume paracentesis with albumin replacement (6-8 g per liter of ascites removed) 2
• Transjugular intrahepatic portosystemic shunt (TIPS) 1
• Liver transplantation evaluation 1

Management of Varices and Bleeding

• Primary prophylaxis: Nonselective β-blockers (propranolol or carvedilol) for patients with high-risk varices 1, 3
• Acute bleeding management:
  • Vasoactive drugs (terlipressin, somatostatin, octreotide)
  • Endoscopic variceal ligation within 12 hours
  • Prophylactic antibiotics
  • Restrictive transfusion strategy (hemoglobin threshold 7 g/dl) 1

Hepatic Encephalopathy Management

• Identify and treat precipitating factors (constipation, infection, GI bleeding, medications)
• Lactulose as first-line treatment 3
• Rifaximin as second-line or add-on therapy 4

Prevention of Decompensation

• Nonselective β-blockers reduce risk of decompensation or death (16% vs 27%) 3
• Consider statins for their pleiotropic effects on portal hypertension 2
• Avoid hepatotoxic medications 5

Monitoring and Surveillance

• Screen for hepatocellular carcinoma every 6 months 1
• Endoscopic monitoring: every 3 years if no varices, annually if small varices 1
• Calculate Child-Pugh and MELD scores every 6 months 5
• Consider liver transplantation for MELD score ≥15 or complications of cirrhosis 5

Common Pitfalls to Avoid

1. Overdiuresis can precipitate renal failure, hepatic encephalopathy, and electrolyte disorders 1
2. NSAIDs should be avoided as they can reduce urinary sodium excretion and induce azotemia 1
3. Inadequate albumin replacement after large-volume paracentesis can lead to circulatory dysfunction 1
4. Delayed recognition of spontaneous bacterial peritonitis (perform diagnostic paracentesis in all patients with new-onset ascites) 1
5. Failure to address the underlying cause of cirrhosis (especially alcohol cessation) 2

The prognosis of cirrhosis varies significantly between compensated and decompensated stages, with 1-year mortality ranging from 1% in early cirrhosis to 57% in decompensated disease 6. With the development of ascites, five-year survival drops from about 80% to 30% 2, highlighting the importance of early and aggressive management.