What is a standard prescription regimen for an adult with chronic liver disease, covering both compensated cirrhosis (no clinical complications) and decompensated cirrhosis (ascites, variceal bleeding, hepatic encephalopathy, or jaundice)?

Standard Prescription Regimen for Cirrhosis

Management of cirrhosis must be stratified by compensation status, with compensated cirrhosis requiring surveillance and prevention strategies while decompensated cirrhosis demands aggressive treatment of life-threatening complications including ascites, variceal bleeding, and hepatic encephalopathy. 1

Compensated Cirrhosis Management

Core Surveillance and Prevention

• Screen for varices with upper endoscopy at diagnosis, then repeat every 2 years if no varices found (with ongoing liver injury) or every 3 years if etiology controlled 1
• Non-selective beta-blockers (NSBBs) such as propranolol or carvedilol should be initiated in patients with clinically significant portal hypertension (HVPG ≥10 mmHg) or medium-to-large varices to prevent first variceal hemorrhage and decompensation 1, 2
• Eliminate the etiologic agent (treat hepatitis B/C, enforce alcohol abstinence, manage NASH) as this can prevent progression and potentially achieve cirrhosis regression 1

Hepatocellular Carcinoma Surveillance

• Ultrasound with or without AFP every 6 months for HCC screening in all cirrhotic patients 3

Vaccinations and Preventive Care

• Hepatitis A and B vaccination if not immune 3
• Pneumococcal and annual influenza vaccination 3
• Avoid hepatotoxic medications including NSAIDs, which can precipitate renal dysfunction 1

Decompensated Cirrhosis Management

Decompensated cirrhosis is defined by ascites, variceal hemorrhage, hepatic encephalopathy, or jaundice, with median survival dropping to approximately 2 years. 1, 4

Ascites Management

• Sodium restriction to 2 grams daily combined with diuretics as first-line therapy 1
• Spironolactone 100 mg daily as initial diuretic, can increase to 400 mg daily 1
• Add furosemide 40 mg daily if inadequate response, can increase to 160 mg daily, maintaining 100:40 mg spironolactone:furosemide ratio 1
• Large-volume paracentesis (>5L) with albumin infusion (8 g per liter removed) for tense ascites or refractory ascites 1
• Consider TIPS for refractory ascites not responding to maximum diuretic therapy 1, 5

Spontaneous Bacterial Peritonitis (SBP) Prophylaxis and Treatment

• Diagnostic paracentesis in all patients with new-onset ascites, worsening ascites, or signs of infection (fever, abdominal pain, encephalopathy) 1
• Treat SBP with ceftriaxone 2g IV daily or cefotaxime 2g IV every 8 hours for 5-7 days if PMN count ≥250 cells/mm³ 1
• Albumin 1.5 g/kg on day 1 and 1 g/kg on day 3 to prevent hepatorenal syndrome in SBP patients 1
• Secondary prophylaxis with norfloxacin 400 mg daily or ciprofloxacin 500 mg daily indefinitely after SBP episode 1
• Primary prophylaxis with norfloxacin 400 mg daily in patients with ascitic fluid protein <1.5 g/dL and advanced cirrhosis (Child-Pugh ≥9 or creatinine ≥1.2 mg/dL) 1

Variceal Hemorrhage Management

Acute Variceal Bleeding

• Octreotide 50 mcg IV bolus followed by 50 mcg/hour continuous infusion for 2-5 days 1, 3
• Ceftriaxone 1g IV daily for antibiotic prophylaxis starting at presentation 1
• Emergency endoscopic variceal ligation (EVL) within 12 hours of presentation 1, 3
• Restrictive transfusion strategy targeting hemoglobin 7-8 g/dL to avoid increasing portal pressure 1
• Pre-emptive TIPS within 72 hours for high-risk patients (Child-Pugh B with active bleeding or Child-Pugh C score 10-13) 1, 5, 6

Secondary Prophylaxis (After Variceal Bleeding)

• Combination of NSBB (propranolol or carvedilol) plus EVL until variceal eradication, then continue NSBB indefinitely 1, 6
• TIPS if rebleeding occurs despite optimal medical and endoscopic therapy 1, 5

Hepatic Encephalopathy Management

• Lactulose 15-30 mL orally 2-4 times daily titrated to 2-3 soft bowel movements per day as first-line therapy 4, 3, 5
• Rifaximin 550 mg twice daily as add-on therapy for recurrent episodes or inadequate response to lactulose 3, 5
• Identify and treat precipitating factors: infection, GI bleeding, constipation, electrolyte abnormalities, medications (benzodiazepines, opioids) 4, 3

Hepatorenal Syndrome Management

• Terlipressin 0.5-2 mg IV every 4-6 hours plus albumin 1 g/kg day 1, then 20-40 g daily as first-line therapy 1, 5
• Midodrine 7.5-12.5 mg three times daily plus octreotide 100-200 mcg subcutaneously three times daily plus albumin as alternative if terlipressin unavailable 1, 5
• Discontinue diuretics and nephrotoxic agents immediately 1

Antiviral Therapy in Decompensated Cirrhosis

• Entecavir 1 mg daily or tenofovir 300 mg daily for hepatitis B-related decompensated cirrhosis (interferon contraindicated) 1
• Direct-acting antivirals for hepatitis C can be used cautiously in decompensated cirrhosis with appropriate regimen selection based on Child-Pugh score 1

Critical Monitoring Parameters

• Weekly weights and abdominal girth for ascites patients 1
• Electrolytes and creatinine every 1-2 weeks when initiating or adjusting diuretics 1
• MELD score calculation every 3-6 months to assess transplant candidacy 4, 3

Liver Transplantation Evaluation

• Refer for transplant evaluation when MELD ≥15, refractory ascites, hepatorenal syndrome, recurrent variceal bleeding, or recurrent hepatic encephalopathy develops 4, 3, 5

Critical Pitfalls to Avoid

• Never use NSAIDs in cirrhotic patients as they precipitate renal failure and worsen ascites 1
• Avoid aminoglycosides which increase hepatorenal syndrome risk 1
• Do not use NSBBs in patients with refractory ascites or spontaneous bacterial peritonitis as they may worsen outcomes in advanced decompensation 5
• Avoid aggressive diuresis (>1 kg/day weight loss with peripheral edema, >0.5 kg/day without edema) to prevent acute kidney injury 1