What is the initial treatment plan for a patient with liver cirrhosis, including medication dosages?

Initial Treatment Plan for Liver Cirrhosis

The initial treatment plan for a patient with liver cirrhosis should include propranolol (starting dose 40 mg twice daily, increasing to 80 mg twice daily if necessary) for primary prophylaxis of variceal hemorrhage, and spironolactone (starting dose 100 mg daily) for management of ascites, with furosemide (40 mg daily) added if faster diuresis is needed. 1, 2

Diagnostic Assessment

• All patients with cirrhosis should undergo endoscopy at the time of diagnosis to assess for esophageal varices 1
• If no varices are observed, repeat endoscopy every 3 years 1
• If small varices are present, repeat endoscopy yearly 1
• Diagnostic paracentesis should be performed in patients with new-onset ascites, clinical deterioration, signs of infection, hepatic encephalopathy, or worsening liver/renal function 1
• Ascitic neutrophil count >250/mm³ is diagnostic for spontaneous bacterial peritonitis (SBP) 1

Management of Portal Hypertension

Primary Prophylaxis for Variceal Bleeding

• Propranolol is the first-line pharmacological therapy for primary prophylaxis of variceal hemorrhage 1
• Dosage: Start with 40 mg twice daily, increasing to 80 mg twice daily if necessary 1
• Long-acting propranolol at 80 or 160 mg can be used to improve compliance 1
• Target: Reduction in hepatic venous pressure gradient to less than 12 mm Hg 1, 3
• Indications for primary prophylaxis:
  • Grade 3 varices regardless of liver disease severity 1
  • Grade 2 varices with Child class B or C disease 1
• Carvedilol (target dose 12.5 mg/day) may be considered as an alternative NSBB with potentially superior efficacy in lowering portal pressure 4, 5

Alternative Options

• If propranolol is contraindicated or not tolerated, variceal band ligation is the treatment of choice 1
• In situations where neither propranolol nor band ligation can be used, isosorbide mononitrate (20 mg twice daily) is recommended 1

Management of Ascites

Dietary Recommendations

• Implement moderately salt-restricted diet with daily salt intake of no more than 5-6.5 g (87-113 mmol sodium) 1
• Provide nutritional counseling on sodium content in diet 1

Diuretic Therapy

• For first presentation of moderate ascites:
  • Start with spironolactone monotherapy 100 mg daily (can be increased to 400 mg) 1, 2
• For recurrent severe ascites or when faster diuresis is needed:
  • Combination therapy with spironolactone (starting dose 100 mg, increased to 400 mg) and furosemide (starting dose 40 mg, increased to 160 mg) 1
• For cirrhotic patients with ascites, the FDA-approved initial daily dosage of spironolactone is 100 mg administered in either single or divided doses (range 25-200 mg daily) 2
• When initiating therapy in cirrhotic patients, start in a hospital setting and titrate slowly 2

Monitoring and Management of Complications

• Monitor for adverse events with diuretic therapy; almost half of patients may require dose reduction or discontinuation 1
• For hypovolemic hyponatremia: discontinue diuretics and expand plasma volume with normal saline 1
• For hypervolemic hyponatremia with serum sodium <125 mmol/L: restrict fluid to 1-1.5 L/day 1
• For severe symptomatic acute hyponatremia: administer hypertonic sodium chloride (3%) with slow correction 1

Management of Spontaneous Bacterial Peritonitis (SBP)

• Immediate empirical antibiotic therapy should be initiated when SBP is suspected 1
• Cefotaxime has been widely studied, but antibiotic choice should be guided by local resistance patterns 1
• Patients with gastrointestinal bleeding and ascites should receive prophylactic antibiotics to prevent SBP 1
• Secondary prophylaxis after recovered SBP episode:
  • Norfloxacin (400 mg once daily), or
  • Ciprofloxacin (500 mg once daily), or
  • Co-trimoxazole (800 mg sulfamethoxazole and 160 mg trimethoprim daily) 1

Large Volume Paracentesis (LVP)

• For paracentesis >5 L: infuse albumin (20% or 25% solution) at 8 g albumin/L of ascites removed 1
• For paracentesis <5 L: consider albumin at same dose in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1
• Ultrasound guidance should be considered when available 1

Special Considerations

• Patients with decompensated cirrhosis and HCV infection should be treated with appropriate direct-acting antivirals based on genotype, with regimens that avoid protease inhibitors 1
• Spironolactone may have additional benefits in reducing portal pressure in propranolol-resistant portal hypertension 6
• Avoid sclerotherapy for prophylaxis of variceal hemorrhage in cirrhotic patients due to inconsistent results and potential complications 1