What medications are used to treat liver conditions?

Medications for Liver Conditions

For patients with liver conditions, medication selection should be based on the specific liver disease, disease severity, and presence of complications, with careful consideration of potential hepatotoxicity and dose adjustments for hepatic impairment.

Viral Hepatitis Treatments

Hepatitis B Medications

• Nucleos(t)ide analogues are the mainstay of treatment for chronic hepatitis B 1:

  • Entecavir (0.5 mg once daily in treatment-naïve patients; 1 mg daily in lamivudine-resistant cases) 2
  • Tenofovir is recommended for its potent antiviral efficacy and high genetic barrier to resistance 1
  • For decompensated cirrhosis, oral antiviral therapy with entecavir (1 mg daily) or tenofovir is strongly recommended 1, 2

• Peginterferon-α may be used in patients with compensated liver cirrhosis with preserved liver function, but is contraindicated in decompensated cirrhosis 1

Hepatitis C Medications

• Direct-acting antivirals are the standard of care for hepatitis C 1:

  • Sofosbuvir-based regimens (including ledipasvir/sofosbuvir) 1, 3
  • Daclatasvir, simeprevir, paritaprevir/ombitasvir/ritonavir, and dasabuvir 1
  • For decompensated cirrhosis, IFN-free regimens are urgently recommended 1

• Treatment prioritization should be given to 1:

  • Patients with significant fibrosis or cirrhosis (METAVIR F3-F4)
  • Patients with decompensated cirrhosis
  • Patients with HIV or HBV coinfection
  • Patients with clinically significant extrahepatic manifestations

Non-Alcoholic Fatty Liver Disease (NAFLD/MASH) Treatments

• For NAFLD/MASH without cirrhosis (F0-F3) 1:

  • Resmetirom in F2/F3 fibrosis (if locally approved)
  • GLP-1 receptor agonists (semaglutide, liraglutide, dulaglutide)
  • SGLT2 inhibitors (empagliflozin, dapagliflozin)

• For NAFLD/MASH with compensated cirrhosis (F4) 1:

  • Metformin (if glomerular filtration rate >30 ml/min)
  • Insulin (in case of decompensated cirrhosis)

Management of Portal Hypertension and Complications

• For varices and portal hypertension 1:

  • Non-selective beta-blockers are recommended for clinically significant portal hypertension 1
  • Transjugular intrahepatic portosystemic shunt (TIPS) is suggested for recurrent variceal bleeding after medical and endoscopic intervention 1

• For hepatic encephalopathy 1:

  • Rifaximin is recommended as adjunctive therapy in ACLF patients with overt hepatic encephalopathy
  • L-ornithine L-aspartate (LOLA) is suggested for ACLF patients with overt hepatic encephalopathy

• For spontaneous bacterial peritonitis 1:

  • Appropriate antibiotics should be administered as soon as possible after recognition and within 1 hour of shock onset in ACLF patients with SBP and septic shock

Special Considerations for Medication Use in Liver Disease

Diabetes Management in Liver Disease

• Metformin can be used in adults with compensated cirrhosis and preserved renal function but is contraindicated in decompensated cirrhosis 1
• Sulfonylureas should be avoided in hepatic decompensation due to hypoglycemia risk 1
• GLP-1 receptor agonists can be used in Child-Pugh class A cirrhosis 1
• SGLT2 inhibitors can be used in Child-Pugh class A and B cirrhosis 1

Cardiovascular Medications in Liver Disease

• Statins can be used in chronic liver disease, including compensated cirrhosis, according to cardiovascular risk guidelines 1
• For fluid management in liver transplant recipients, balanced crystalloid solutions are preferred over normal saline 1
• Albumin is suggested over crystalloid for intraoperative volume replacement during liver transplantation 1

Pain Management in Liver Disease

• Acetaminophen remains safe at reduced doses (2-3g/day) in patients with liver cirrhosis 4
• Tramadol requires significant dose adjustment in advanced liver disease (no more than 50 mg within 12 hours for CLD4 patients) 4
• Fentanyl and hydromorphone have more favorable profiles in liver disease 4
• NSAIDs should be strictly avoided in advanced liver disease due to risks of renal failure, GI bleeding, and decompensation 4

Medications to Avoid or Use with Caution

• Hepatotoxic drugs should be avoided or used with extreme caution in patients with liver disease 1, 5
• Off-label COVID-19 treatments should be withheld in cases of moderate-to-severe liver injury 1
• For tuberculosis treatment in patients with liver disease, regimens with fewer hepatotoxic agents should be considered 1:
  • For severe liver disease, a regimen without isoniazid might include rifampin, pyrazinamide, and ethambutol 1
  • For advanced liver disease, a regimen without pyrazinamide might include isoniazid, rifampin, and ethambutol for 9 months 1
  • In cases of severe unstable liver disease, non-hepatotoxic regimens including streptomycin, ethambutol, a fluoroquinolone, and another second-line oral drug may be necessary 1

Monitoring Recommendations

• Liver function tests should be monitored in all hospitalized patients with liver disease 1
• For patients on potentially hepatotoxic medication, liver tests should be monitored at least twice weekly 1, 5
• Patients with abnormal liver function should be closely monitored when using off-label medications 1
• Long-term antiviral therapy in cirrhotic patients requires close monitoring for drug resistance and hepatitis flares 1