What medications are used to treat decompensated cirrhosis?

Medications for Decompensated Cirrhosis

The cornerstone of medical management in decompensated cirrhosis involves treating the underlying etiology immediately, combined with complication-specific therapies including diuretics for ascites, lactulose for hepatic encephalopathy, antibiotics for infection prophylaxis, and beta-blockers for portal hypertension in selected patients. 1, 2

Primary Strategy: Treat the Underlying Cause

Etiological treatment must be initiated immediately as this is associated with decreased risk of further decompensation and increased survival. 1, 2

Viral Hepatitis

• Hepatitis B: Initiate entecavir (1 mg daily for decompensated patients) or tenofovir monotherapy regardless of HBV DNA level 2, 3
• Hepatitis C: Use direct-acting antivirals (sofosbuvir/ledipasvir, sofosbuvir/daclatasvir, or sofosbuvir/velpatasvir) with ribavirin for 12-24 weeks depending on genotype and Child-Pugh class 1
• Critical caveat: Protease inhibitors are contraindicated in Child-Pugh B and C cirrhosis 1

Alcohol-Related Cirrhosis

• Complete alcohol cessation is mandatory and may lead to "re-compensation" in some patients 1, 3

Complication-Specific Medications

Ascites Management

First-line treatment consists of spironolactone with or without furosemide, initiated at low doses and titrated carefully. 2, 3, 4

• Spironolactone: Start at 50-100 mg daily, can increase to 400 mg daily 5
• Furosemide: Add if needed, typically 20-40 mg daily 2, 3
• Combination therapy (starting both simultaneously) resolves ascites more effectively than sequential initiation (76% vs 56%) with lower hyperkalemia rates (4% vs 18%) 4
• Important warning: Spironolactone should be initiated in the hospital for patients with hepatic disease, cirrhosis, and ascites due to risk of sudden electrolyte imbalances that may precipitate hepatic encephalopathy and coma 5
• Fluid restriction is unnecessary unless serum sodium drops below 120-125 mmol/L 2, 3

Hepatic Encephalopathy

Lactulose is first-line therapy and reduces mortality (8.5% vs 14% compared to placebo) and recurrent overt hepatic encephalopathy (25.5% vs 46.8%). 2, 4, 6

• Lactulose: Titrate to 2-3 soft bowel movements daily 2, 6
• Rifaximin: Add as second-line therapy at 550 mg twice daily for prevention of recurrent episodes 4, 6
• Rifaximin also shows promise in reducing other cirrhosis complications beyond hepatic encephalopathy, though prospective randomized data are lacking 1

Infection Prophylaxis

Antibiotic prophylaxis is critical in specific high-risk scenarios. 2, 3

For Variceal Bleeding:

• Ceftriaxone 1 g IV every 24 hours for up to 7 days in decompensated cirrhosis or quinolone-resistant settings 2, 3
• Norfloxacin 400 mg orally twice daily in remaining patients 2, 3

For SBP Prevention:

• Norfloxacin reduces risk of spontaneous bacterial peritonitis and hepatorenal syndrome 1, 2
• Major caveat: Use is limited by potential for resistant bacteria development 1

Hepatorenal Syndrome

Terlipressin combined with albumin is first-line treatment, improving reversal rates from 18% to 39%. 4

Portal Hypertension Management

Non-selective beta-blockers (propranolol or carvedilol) reduce risk of decompensation or death (16% vs 27% compared to placebo) in patients with portal hypertension. 4, 7

• Propranolol or carvedilol can decrease risk of ascites, hepatorenal syndrome, SBP, and hepatic encephalopathy beyond variceal bleeding prevention 1, 2
• Critical caveat: These effects are most pronounced in patients who respond with marked portal pressure reduction 1
• Use with extreme caution in patients with severe or refractory ascites 3

Emerging Therapies Requiring Further Validation

Statins

• Show promise in reducing portal hypertension and improving survival through pleiotropic effects 1, 2
• Require validation in future studies before routine recommendation 1

Long-term Albumin

• Two recent RCTs showed contradictory findings regarding long-term albumin administration for improving circulatory and kidney function 1
• Further studies needed to determine efficacy 1

Anticoagulation

• Enoxaparin (12-month course) was safe and effective in preventing portal vein thrombosis and may delay decompensation 1
• Requires further validation 1

Critical Monitoring Considerations

• Avoid nephrotoxic drugs and NSAIDs as they can precipitate renal failure and convert diuretic-sensitive to refractory ascites 3
• Monitor electrolytes closely, especially potassium with spironolactone use 5
• Early referral for liver transplantation evaluation is essential as decompensation significantly worsens prognosis (median survival 0.92-1.1 years after onset of hepatic encephalopathy or ascites) 2, 4, 8