Cirrhosis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]
Overview
Medical Therapy
Treatment of cirrhosis is directed most of the times towards treatment of complications like ascites, Esophageal varices, hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis. But some chronic constitutional symptoms, which include pruritus, hypogonadism, osteoporosis and anorexia should be treated as well.
Pruritus
Pruritus is a common symptom in chronic liver disease. Endogenous opioids have been proposed as the culprits for causing pruritus. Less severe itching can be treated using antihistamines and ammonium lactate topical solution. Cholestyramine is the drug of choice for treating pruritus of chronic liver disease. Severe itching requires ultraviolet light therapy and or plasmapheresis.
Other drugs that can be used with varying results include: diphenhydramine, hydroxyzine, ursodeoxycholic acid, rifampin and naltrexone (opiate).
Hypogonadism
Males with cirrhosis sometimes complain of loss of libido due to hypogonadism. The possible treatment option for these patients is topical testosterone preparations, but there exists no studies to prove the efficacy of such preparations.
Osteoporosis
Cirrhosisis one of the major causes of osteoporosis[1]. Calcium and vitamin D supplementation is suggested for all the patients who are at risk for osteoporosis and also for patients who are on corticosteroids for autoimmune liver disease.
Pain management in Cirrhosis
Cirrhotic patients can develop pain from ascites (back pain and abdominal pain) and gynecomastia (mastalgia). Pain management in cirrhosis has a special consideration as many analgesic and anti-inflammatory drugs are metabolized by the liver and dosage regulations are required to prevent further liver damage and drug toxicity. Drug dosages should be titrated as per the level of hepatic function in the patient. Dosage changes are required in patients with cirrhosis when they have the following:
- Portal hypertension
- Renal failure
- Alcoholic patient on multiple medications.
Non-selective NSAIDs should be avoided in patients with cirrhosis because of the following complications:
- Increased bleeding from varices
- Impaired renal function
- Development of diuretic resistant ascites
As per a study in humans which involved 28 patients with cirrhosis and ascites celecoxib seemed to be a reasonable option for pain management and anti-inflammatory treatment. But further studies are needed to prove the potential advantage of celecoxib over other NSAIDs.
Opioids should be used cautiously in patients with cirrhosis because they are metabolized by the liver through oxidation and glucuronidation and in cirrhosis, because of the reduced liver blood flow, reduced protein binding and reduced hepatic enzyme capacity, these drugs accumulate and the patient is prone to develop opiate toxicity.
Treatment of Underlying Causes
Alcoholic cirrhosis caused by alcohol abuse is treated by abstaining from alcohol. Treatment for hepatitis-related cirrhosis involves medications used to treat the different types of hepatitis, such as interferon for viral hepatitis and corticosteroids for autoimmune hepatitis. Cirrhosis caused by Wilson's disease, in which copper builds up in organs, is treated with chelation therapy (e.g.penicillamine) to remove the copper.
Treatment of Complications
Ascites
Salt restriction is often necessary, as cirrhosis leads to accumulation of salt (sodium retention). Diuretics may be necessary to suppress ascites.
Esophageal Variceal Bleeding
For portal hypertension, propranolol is a commonly used agent to lower blood pressure over the portal system. In severe complications from portal hypertension, transjugular intrahepatic portosystemic shunting is occasionally indicated to relieve pressure on the portal vein. As this can worsen encephalopathy, it is reserved for those at low risk of encephalopathy, and is generally regarded only as a bridge to liver transplantation or as a palliative measure.
Hepatic Encephalopathy
High-protein food increases the nitrogen balance, and would theoretically increase encephalopathy; in the past, this was therefore eliminated as much as possible from the diet. Recent studies show that this assumption was incorrect, and high-protein foods are even encouraged to maintain adequate nutrition.
Hepatorenal Syndrome
The hepatorenal syndrome is defined as a urine sodium less than 10 mmol/L and a serum creatinine > 1.5 mg/dl (or 24 hourcreatinine clearance less than 40 ml/min) after a trial of volume expansion without diuretics.[2]
Spontaneous Bacterial Peritonitis
Cirrhotic patients with ascites are at risk of spontaneous bacterial peritonitis.
References
- ↑ Giouleme OI, Vyzantiadis TA, Nikolaidis NL; et al. (2006). "Pathogenesis of osteoporosis in liver cirrhosis". Hepatogastroenterology. 53 (72): 938–43. PMID 17153457.
- ↑ Ginés P, Arroyo V, Quintero E; et al. (1987). "Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study". Gastroenterology. 93 (2): 234–41. PMID 3297907.