What are the treatment options for decompensated liver cirrhosis?

From the Guidelines

Liver transplantation is the treatment of choice for patients with decompensated liver cirrhosis, as it offers the only definitive treatment for end-stage liver disease. The management of decompensated liver cirrhosis involves a multifaceted approach, including the suppression of the aetiological factor(s) causing liver injury, treatment of complications, and prevention of further deterioration.

Treatment of Complications

• Diuretics like spironolactone (starting at 100mg daily) and furosemide (starting at 40mg daily) are used to control ascites, with doses adjusted based on response and electrolyte levels 1.
• For hepatic encephalopathy, lactulose (30ml 2-3 times daily, titrated to achieve 2-3 soft bowel movements per day) and rifaximin (550mg twice daily) are prescribed 1.
• Variceal bleeding requires immediate intervention with octreotide (50mcg IV bolus followed by 50mcg/hour infusion for 3-5 days), prophylactic antibiotics like ceftriaxone (1g daily for 7 days), and endoscopic band ligation 1.
• Beta-blockers such as propranolol (starting at 20mg twice daily) or carvedilol (6.25mg daily) are used for primary and secondary prophylaxis of variceal bleeding 1.
• Spontaneous bacterial peritonitis is treated with cefotaxime (2g IV every 8 hours) or ceftriaxone (1g daily) for 5-7 days 1.

Nutritional Support and Alcohol Abstinence

• Nutritional support is crucial, with a high-protein diet (1.2-1.5g/kg/day) unless severe encephalopathy is present 1.
• Alcohol abstinence is mandatory for alcoholic cirrhosis, as it can help prevent further liver damage and improve outcomes 1.

Liver Transplantation

• In advanced cases, liver transplantation evaluation should be initiated promptly, as it offers the only definitive treatment for end-stage liver disease, with patient selection based on Model for End-Stage Liver Disease (MELD) score and other clinical factors 1.
• Antiviral therapy may be used to modify the natural history of decompensated cirrhosis, improve liver function, decrease the need for liver transplantation, and improve survival 1.

The most recent and highest quality study 1 supports the use of liver transplantation as the treatment of choice for patients with decompensated liver cirrhosis, and highlights the importance of managing complications, preventing further deterioration, and considering antiviral therapy in the treatment of decompensated liver cirrhosis.

From the FDA Drug Label

In patients with cirrhosis, initiate therapy in a hospital setting and titrate slowly [see Use in Specific Populations (8. 7)] . The recommended initial daily dosage is 100 mg of spironolactone tablets administered in either single or divided doses, but may range from 25 mg to 200 mg daily. WARNINGS In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital.

The treatment options for decompensated liver cirrhosis include:

• Spironolactone: 100 mg daily, administered in either single or divided doses, which may range from 25 mg to 200 mg daily, initiated in a hospital setting and titrated slowly 2.
• Furosemide: therapy best initiated in the hospital, with careful observation and monitoring to avoid complications such as hepatic coma, hypokalemia, and metabolic alkalosis 3.

From the Research

Treatment Options for Decompensated Liver Cirrhosis

• The management of decompensated liver cirrhosis involves treating the underlying cause of decompensation, such as infection, hemorrhage, or drugs, as well as managing concomitant extrahepatic organ dysfunctions 4
• Non-selective beta-blockers can effectively prevent decompensation in patients with compensated cirrhosis and clinically significant portal hypertension, mainly by reducing the risk of ascites 5
• Diuretics remain the mainstay of uncomplicated ascites treatment, and early trials suggest alpha-adrenergic receptor agonists may improve diuretic response in refractory ascites 6
• The gut-selective antibiotic rifaximin is effective for secondary prophylaxis of hepatic encephalopathy, and recent small trials also indicate its potential superiority to norfloxacin for secondary prevention of spontaneous bacterial peritonitis 6
• Statins have been demonstrated to be safe in compensated cirrhosis and may have protective effects upon fibrosis progression, decompensation, and mortality 6
• Anticoagulation therapy may reduce the incidence and increase recanalisation rates of non-malignant portal vein thrombosis, and may impede hepatic fibrogenesis and decompensation 6
• Pharmacologic management of hepatic encephalopathy includes first-line therapies such as nonabsorbable disaccharides, antibiotics, and electrolyte management, as well as newer, second-line therapies including polyethylene glycol, albumin, branched-chain amino acids, probiotics, and fecal microbiota transplant 7

Organ-Specific Management

• Neurologic complications, such as hepatic encephalopathy, require specific management strategies, including pharmacologic therapies and electrolyte management 8, 7
• Cardiovascular complications, such as hemorrhage, require rapid identification and treatment of the underlying cause, as well as management of concomitant extrahepatic organ dysfunctions 4, 8
• Gastrointestinal complications, such as variceal bleeding, require management with non-selective beta-blockers and endoscopic therapies 5, 6
• Pulmonary and renal complications require management of concomitant extrahepatic organ dysfunctions and supportive care 8