What is the workup for hepatic cirrhosis and fluid overload in a patient with Rheumatoid Arthritis (RA) experiencing fluid overload while undergoing steroid treatments?

From the Guidelines

The workup of hepatic cirrhosis and fluid overload in a rheumatoid arthritis patient requires a comprehensive approach addressing both conditions simultaneously, with a focus on minimizing morbidity, mortality, and improving quality of life. Begin with a thorough clinical assessment including vital signs, weight monitoring, and examination for ascites, edema, and hepatomegaly. Laboratory evaluation should include liver function tests (ALT, AST, bilirubin, albumin), complete blood count, renal function tests, coagulation studies (PT/INR), and serum electrolytes. Assess hepatitis viral markers, autoimmune markers, and iron studies to determine cirrhosis etiology. For fluid status evaluation, obtain serum BNP levels and perform diagnostic paracentesis if ascites is present, with fluid analysis for cell count, albumin, and culture. Imaging should include abdominal ultrasound with Doppler to assess liver morphology, portal hypertension, and ascites volume.

Management involves sodium restriction (2g/day) and diuretic therapy typically with spironolactone 100mg daily and furosemide 40mg daily, titrated as needed, as recommended by the American Association for the Study of Liver Diseases 1. Fluid restriction is not necessary for ascites management unless there is concomitant moderate or severe hyponatremia (serum sodium ≤ 125 mmol/L), as stated in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1. For severe fluid overload, consider therapeutic paracentesis with albumin replacement (6-8g per liter removed). Regarding rheumatoid arthritis management, steroid doses should be minimized as they contribute to fluid retention and can worsen ascites, as suggested by the 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1. Consider transitioning to steroid-sparing agents like hydroxychloroquine 200-400mg daily or methotrexate 7.5-20mg weekly if liver function permits. DMARDs like leflunomide or biologics may be options depending on liver function.

Key considerations in management include:

• Monitoring for adverse effects of diuretics, such as AKI, hyponatremia, hypokalemia, and hepatic encephalopathy, as outlined in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1
• Regular monitoring of liver function, electrolytes, and weight, with follow-up every 1-2 weeks initially
• Adjusting diuretic doses to the lowest effective dose to prevent adverse effects, as recommended by the American Association for the Study of Liver Diseases 1
• Considering the use of human albumin solution or baclofen administration in patients with diuretic-resistant ascites, as suggested by the 2021 practice guidance by the American Association for the Study of Liver Diseases 1

From the FDA Drug Label

WARNINGS In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. In hepatic coma and in states of electrolyte depletion, therapy should not be instituted until the basic condition is improved Sudden alterations of fluid and electrolyte balance in patients with cirrhosis may precipitate hepatic coma; therefore, strict observation is necessary during the period of diuresis. Key Considerations:

• Patients with hepatic cirrhosis and ascites should have furosemide therapy initiated in the hospital.
• Therapy should not be started in hepatic coma or electrolyte depletion until the condition improves.
• Strict observation is necessary during diuresis to prevent hepatic coma. Given the patient has rheumatoid arthritis with fluid overload and is on steroid treatments, and considering the presence of hepatic cirrhosis, hospital initiation of furosemide therapy is recommended with strict observation during the period of diuresis to prevent complications such as hepatic coma 2.

From the Research

Workup of Hepatic Cirrhosis and Fluid Overload in a Rheumatoid Arthritis Patient

• The workup of hepatic cirrhosis and fluid overload in a rheumatoid arthritis patient with fluid overload and steroid treatments involves considering the potential causes of liver disease, including hepatotoxicity of medications, viral hepatitis, and autoimmune liver disease 3, 4.
• A study of 150 patients with rheumatoid arthritis found that liver involvement was diagnosed in 66 patients (44%), with the majority of cases being asymptomatic and revealed by increased gamma-glutamyl transferase levels 4.
• The aetiologies of liver involvement in rheumatoid arthritis patients were found to be mainly hepatotoxicity and viral hepatitis B and C, with non-steroidal anti-inflammatory drugs and methotrexate being the most common medications involved in hepatotoxicity 4.
• Another study found that patients with active rheumatoid arthritis frequently have hepatosplenomegaly and biochemical features of hepatic disease, but the hepatic abnormality in rheumatoid arthritis remains functional and unexplained in the large majority of patients 5.

Diagnostic Considerations

• The diagnosis of liver disease in rheumatoid arthritis patients can be challenging, as it is sometimes difficult to determine whether liver damage is a hepatic manifestation of rheumatoid arthritis, associated primary liver disease, or hepatotoxic liver disease developed during treatment 3.
• A comprehensive diagnostic workup, including liver function tests, imaging studies, and liver biopsy, may be necessary to determine the cause of liver disease in rheumatoid arthritis patients 3, 4.
• The presence of fluid overload and steroid treatments in a rheumatoid arthritis patient may also need to be considered in the diagnostic workup, as these factors can contribute to the development of liver disease and fluid overload 6, 7.

Management Considerations

• The management of liver disease in rheumatoid arthritis patients requires a multidisciplinary approach, involving rheumatologists, hepatologists, and other healthcare professionals 3, 4.
• The use of medications with potential hepatotoxicity, such as non-steroidal anti-inflammatory drugs and methotrexate, may need to be adjusted or avoided in patients with liver disease or at risk of developing liver disease 4, 7.
• The treatment of fluid overload in rheumatoid arthritis patients may involve the use of diuretics, fluid restriction, and other measures to manage fluid balance 6, 7.