Do you use furosemide (Lasix) and spironolactone (Aldactone) in a patient with cirrhosis and hepatic encephalopathy, but without ascites?

From the Guidelines

I would not recommend using furosemide and spironolactone in a cirrhosis patient with hepatic encephalopathy who does not have ascites. These diuretics are primarily indicated for managing fluid overload in cirrhosis patients with ascites, and using them without this indication could potentially worsen hepatic encephalopathy. Diuretics can cause electrolyte abnormalities (particularly hypokalemia with furosemide) and volume depletion, which may precipitate or worsen hepatic encephalopathy. Additionally, spironolactone can accumulate in patients with impaired liver function, potentially leading to hyperkalemia. For patients with hepatic encephalopathy without ascites, management should instead focus on treating the encephalopathy with lactulose (typically 25-30 mL orally 2-4 times daily, titrated to achieve 2-3 soft bowel movements per day) and/or rifaximin (550 mg twice daily) as recommended by the French guidelines 1. Identifying and addressing precipitating factors such as infections, gastrointestinal bleeding, or medication side effects is also crucial. Protein restriction is no longer routinely recommended, and maintaining adequate nutrition is important for these patients. The use of diuretics in patients with cirrhosis is guided by the presence of ascites, and their use should be tailored to the individual patient's needs, with careful monitoring of electrolytes, renal function, and volume status, as outlined in the guidelines by the American Association for the Study of Liver Diseases 1 and the European Association for the Study of the Liver 1. In the absence of ascites, the focus should be on managing hepatic encephalopathy and optimizing the patient's overall condition, rather than on using diuretics, which are not indicated in this scenario.

From the FDA Drug Label

In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. Spironolactone can cause sudden alterations of fluid and electrolyte balance which may precipitate impaired neurological function, worsening hepatic encephalopathy and coma in patients with hepatic disease with cirrhosis and ascites.

The use of furosemide and spironolactone in a patient with cirrhosis and hepatic encephalopathy, but without ascites, is not directly addressed in the provided drug labels.

• The labels discuss the use of these medications in patients with cirrhosis and ascites, recommending hospital initiation of therapy and careful monitoring.
• However, the labels do not provide guidance on the use of these medications in patients with cirrhosis and hepatic encephalopathy without ascites.
• Therefore, no conclusion can be drawn regarding the use of furosemide and spironolactone in this specific patient population 2, 2, 3.

From the Research

Treatment of Cirrhosis and Hepatic Encephalopathy

• The provided studies do not directly address the use of furosemide (Lasix) and spironolactone (Aldactone) in a patient with cirrhosis and hepatic encephalopathy, but without ascites 4, 5, 6, 7, 8.
• However, it is known that spironolactone alone or in combination with furosemide is commonly used to treat ascites in patients with cirrhosis 4, 6.
• In patients with cirrhosis and ascites, the recommended initial dose is spironolactone 100-200 mg/d and furosemide 20-40 mg/d, with usual maximum doses of 400 mg/d of spironolactone and 160 mg/d of furosemide 4.
• For patients with hepatic encephalopathy, lactulose and rifaximin therapies are recommended to reduce the risk of recurrence 5.
• There is no clear evidence to support the use of furosemide and spironolactone in patients with cirrhosis and hepatic encephalopathy without ascites, and the treatment approach may vary depending on individual patient needs and circumstances.

Key Considerations

• The treatment of cirrhosis and hepatic encephalopathy requires a comprehensive approach, including management of ascites, hepatic encephalopathy, and other complications 4, 5.
• The use of diuretics, such as spironolactone and furosemide, should be carefully considered and monitored in patients with cirrhosis, as they can have significant effects on renal function and electrolyte balance 4, 6, 7, 8.
• Patients with cirrhosis and hepatic encephalopathy require close monitoring and follow-up to prevent and manage complications, and to optimize treatment outcomes 5.