What medications are started in a patient with newly diagnosed cirrhosis?

Medications for Newly Diagnosed Cirrhosis

Patients with newly diagnosed cirrhosis should be started on spironolactone (starting dose 100 mg daily) as first-line therapy for ascites management, with the addition of furosemide (starting dose 40 mg daily) for recurrent or severe ascites, and non-selective beta-blockers such as propranolol for portal hypertension management and prevention of decompensation. 1, 2

Diuretic Therapy for Ascites Management

• Spironolactone monotherapy (starting dose 100 mg, increased up to 400 mg as needed) is recommended for first presentation of moderate ascites 1
• For recurrent severe ascites or when faster diuresis is needed (e.g., hospitalized patients), combination therapy with spironolactone (starting dose 100 mg) and furosemide (starting dose 40 mg) is recommended 1
• Patients should be monitored closely for adverse events with diuretic therapy, as nearly half may require dose reduction or discontinuation 1
• Caution is needed when initiating diuretics in patients with hepatic impairment, as sudden alterations of fluid and electrolyte balance may precipitate hepatic encephalopathy 3, 4

Portal Hypertension Management

• Non-selective beta-blockers (propranolol or carvedilol) should be initiated to reduce portal pressure and prevent decompensation 2, 5
• In a 3-year randomized clinical trial, non-selective β-blockers reduced the risk of decompensation or death compared with placebo (16% vs 27%) 2
• Beta-blockers should be used cautiously in patients with advanced decompensation as they may compromise renal function and hemodynamic stability 1
• Dose adjustments may be necessary in patients with hepatic insufficiency, as propranolol clearance is reduced and half-life is prolonged in cirrhotic patients 6

Antibiotic Prophylaxis

• Patients with cirrhosis and ascites with protein count <1.5 g/dL should be considered for primary prophylaxis with antibiotics to prevent spontaneous bacterial peritonitis (SBP) 1
• Patients presenting with gastrointestinal bleeding and underlying ascites should receive prophylactic antibiotic treatment (cefotaxime is widely studied, but choice should be based on local resistance patterns) 1
• Patients who have recovered from an episode of SBP should be considered for secondary prophylaxis with norfloxacin (400 mg once daily), ciprofloxacin (500 mg once daily), or co-trimoxazole (800 mg sulfamethoxazole and 160 mg trimethoprim daily) 1

Nutritional and Dietary Management

• Patients should be placed on a moderately salt-restricted diet with daily salt intake of no more than 5-6.5 g (87-113 mmol sodium) 1
• Nutritional counseling on sodium content in the diet should be provided 1
• Fluid restriction to 1-1.5 L/day should be reserved for patients with severe hyponatremia (serum sodium <125 mmol/L) 1

Management of Complications

Hepatic Encephalopathy

• Lactulose should be initiated if hepatic encephalopathy develops 1, 2
• Meta-analyses show lactulose reduces mortality compared to placebo (8.5% vs 14%) and reduces risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 2

Variceal Bleeding

• For acute variceal hemorrhage, vasoactive drugs (terlipressin, somatostatin, or octreotide) should be initiated as soon as bleeding is suspected 1
• These drugs should be continued for 2-5 days after initial endoscopic hemostasis to prevent early rebleeding 1

Hepatorenal Syndrome

• In patients with spontaneous bacterial peritonitis and increased or rising serum creatinine, albumin infusion (1.5 g/kg within 6 hours of diagnosis) should be administered 1
• Terlipressin has been shown to improve the rate of reversal of hepatorenal syndrome from 39% to 18% 2

Medications to Avoid or Use with Caution

• NSAIDs should be avoided as they can precipitate renal failure 1, 7
• Aminoglycosides and other nephrotoxic drugs should be avoided 1
• Proton pump inhibitors should be used with caution as they have been linked to increased risk of spontaneous bacterial peritonitis 7
• Most hepatotoxic drugs can still be used in cirrhosis but often require dose adjustments 7

Special Considerations

• Patients with CTP class A cirrhosis should be considered for antiviral treatment if viral hepatitis is the underlying cause, as HCV eradication decreases the risk of long-term complications 1
• Even after successful treatment and reaching SVR, continuous monitoring for cirrhosis-related complications and HCC is needed 1
• Patients with refractory ascites may benefit from midodrine on a case-by-case basis 1

Careful monitoring of medication effects and side effects is essential in cirrhotic patients, with particular attention to electrolyte abnormalities, renal function, and signs of hepatic encephalopathy. Medication doses often need to be adjusted based on the severity of liver dysfunction.