Liver cirrhosis is a chronic disease that causes irreversible scarring of the liver. This scarring prevents the liver from functioning normally, which can lead to serious complications like liver failure, portal hypertension, easy bleeding, buildup of toxins in the brain (hepatic encephalopathy), fluid retention, and increased risk of liver cancer. There is no cure for cirrhosis, but certain medications can help slow progression, reduce complications, and improve quality of life.
What causes liver cirrhosis?
The most common causes of cirrhosis include:
- Chronic alcohol abuse – Drinking too much alcohol over many years can cause alcoholic liver disease that leads to cirrhosis.
- Chronic viral hepatitis – Hepatitis B and C viruses cause inflammation that damages the liver over time.
- Nonalcoholic fatty liver disease (NAFLD) – Fatty liver that is not due to alcohol can lead to cirrhosis.
- Autoimmune diseases – Autoimmune hepatitis causes the body’s immune system to attack liver cells.
- Inherited diseases – Genetic disorders like hemochromatosis and Wilson’s disease cause abnormal buildup of substances that damage the liver.
- Bile duct disorders – Conditions blocking bile flow from the liver can cause cirrhosis.
Less common causes include chronic drug reactions, congestive heart failure, and some inherited metabolic disorders.
Stages of cirrhosis
Cirrhosis has 4 stages based on the amount of scarring in the liver:
- Stage 1 (Compensated) – Some scarring but liver still functions normally.
- Stage 2 (Compensated) – More scarring but no major complications.
- Stage 3 (Decompensated) – Widespread scarring with complications like ascites or varices.
- Stage 4 (End-stage) – Severe scarring with liver failure.
Treatment is aimed at preventing progression through these stages.
Goals of treatment
The main goals with medication therapy for cirrhosis are to:
- Slow the progression of liver scarring
- Prevent and treat complications
- Reduce mortality
- Improve overall health and quality of life
Types of medications used
Some key types of medications used for liver cirrhosis include:
1. Corticosteroids
Corticosteroids like prednisone are used for autoimmune hepatitis to reduce inflammation and suppress the immune system from attacking the liver. They can help induce remission early in disease to prevent scarring.
2. Ursodeoxycholic acid (UDCA)
UDCA improves bile flow and protects liver cells. It is commonly used in primary biliary cholangitis and other cholestatic liver diseases to slow progression.
3. Antiviral medications
Medications that target hepatitis B and C viruses can treat the underlying infection to stop ongoing liver damage in viral hepatitis:
- Hepatitis B: Nucleoside/nucleotide analogs like tenofovir or entecavir.
- Hepatitis C: Direct-acting antivirals like sofosbuvir, ledipasvir, or velpatasvir.
4. Immunosuppressants
In addition to corticosteroids, other immunosuppressants like azathioprine may be used to treat autoimmune hepatitis.
5. Alcohol abstinence
Completely stopping alcohol use can help prevent progression of alcoholic liver disease to cirrhosis.
6. Diuretics
Diuretics like furosemide (Lasix) help reduce fluid retention and edema in more advanced cirrhosis.
7. Laxatives
Laxatives like lactulose treat constipation and prevent hepatic encephalopathy by reducing ammonia absorption.
8. Antibiotics
Antibiotics can treat infections that commonly occur in cirrhosis due to immune dysfunction. Rifaximin may also be used to reduce recurrent hepatic encephalopathy.
9. Beta blockers
Beta blockers like propranolol and nadolol reduce portal hypertension and prevent bleeding from esophageal varices.
10. Vitamin supplements
Supplements of vitamin A, D, E, K, and zinc may help correct nutritional deficiencies common in cirrhosis.
Specific medications by type of cirrhosis
Some medications are tailored based on the cause of liver cirrhosis:
Alcoholic cirrhosis treatment
- Abstaining from alcohol
- Prednisone or pentoxifylline to reduce inflammation
- Diuretics for fluid retention
- Lactulose for encephalopathy
- Propranolol or nadolol for varices
Hepatitis B cirrhosis treatment
- Tenofovir, entecavir, or other antivirals
- Lamivudine if co-infected with HIV
- Hepatocellular carcinoma screening
- Liver transplant if liver failure occurs
Hepatitis C cirrhosis treatment
- Direct acting antivirals like sofosbuvir
- Ribavirin and interferon if antivirals contraindicated
- Hepatocellular carcinoma screening
- Liver transplant if liver failure occurs
Autoimmune cirrhosis treatment
- Prednisone and azathioprine
- Mycophenolate mofetil
- Cyclosporine
- UDCA
- Liver transplant if poor response to medications
NASH cirrhosis treatment
- Weight loss
- Glycemic control for diabetes
- Lipid lowering medications
- Pentoxifylline
- Vitamin E
- Liver transplant if liver failure occurs
Medications to avoid
Certain medications should be avoided in liver cirrhosis due to potential toxicity or interactions:
- NSAIDs like ibuprofen
- Opioid narcotics
- High doses of acetaminophen
- Anticoagulants like warfarin
- Statins
- Amiodarone
- Oral hypoglycemics that undergo extensive liver metabolism
Medication to treat complications
Other medications may be used to manage complications of liver cirrhosis:
Ascites treatment
- Salt restriction
- Diuretics – furosemide, spironolactone
- Albumin for refractory ascites
- Large volume paracentesis
- Transjugular intrahepatic portosystemic shunt (TIPS)
Spontaneous bacterial peritonitis treatment
- Antibiotics – cefotaxime, amoxicillin
- Albumin infusion
- Prophylactic antibiotics
Variceal bleeding treatment
- Banding ligation
- Beta blockers – propranolol, nadolol
- Octreotide
- Antibiotics – ceftriaxone
- TIPS procedure
Hepatic encephalopathy treatment
- Lactulose
- Rifaximin
- Dietary protein restriction
- Avoid sedatives and tranquilizers
Hepatocellular carcinoma treatment
- Liver resection if possible
- Liver transplant
- Radiofrequency ablation
- Chemoembolization
- Sorafenib chemotherapy
Best overall medical treatment
The exact medications prescribed depend on the underlying cause and stage of cirrhosis. However, some of the most important medications for liver cirrhosis overall include:
- Diuretics – Help relieve fluid retention and edema.
- Beta-blockers – Reduce portal hypertension and prevent variceal bleeding.
- Antibiotics – Used to treat infections and prevent recurrent encephalopathy.
- Lactulose – Prevents encephalopathy by reducing ammonia.
- Statins – Improve outcomes in cirrhosis not due to non-alcoholic fatty liver disease.
- ACE inhibitors – May help delay progression in early stages of cirrhosis.
Along with specific treatment for the underlying liver disease, medications that prevent and treat complications provide the core medical therapy for many patients with liver cirrhosis.
Lifestyle changes
In addition to medication treatment, lifestyle changes are important in the management of liver cirrhosis:
- Alcohol cessation – Avoid alcohol to prevent worsening of disease.
- Diet – Eat a nutritious diet low in sodium and high in vegetables, fruits and lean proteins.
- Weight loss – If overweight, lose weight through diet and exercise.
- Immunizations – Stay up to date on vaccines to prevent infections.
- Avoid hepatotoxins – Stop illicit drug use and certain supplements.
Alternative and complementary therapies
Some alternative therapies may help complement medical treatment for cirrhosis:
- Milk thistle – Herbal supplement that may help protect liver cells.
- Probiotics – May reduce bacterial translocation from the gut.
- Coffee – Has been associated with reduced liver disease progression.
- Acetylcysteine – Antioxidant that can reduce liver injury.
- Curcumin – Derived from turmeric, may have anti-inflammatory effects.
However, most alternative therapies lack strong clinical evidence for cirrhosis. They should not replace standard medical treatment but can be considered as adjuncts.
When to consider liver transplant
For patients with severe cirrhosis that progresses to end-stage liver failure, liver transplant may become necessary. This is considered when:
- Symptoms like fatigue, nausea, weakness persist despite optimal medical therapy
- Complications like uncontrolled ascites, variceal bleeding, or encephalopathy develop
- Liver function tests severely abnormal and Child-Pugh score over 11
- Model for End-stage Liver Disease (MELD) score greater than 15
Patients with hepatocellular carcinoma within transplant criteria or acute liver failure may also require liver transplant.
Conclusion
While there is no cure for cirrhosis itself, medications can effectively treat complications, slow disease progression, and reduce mortality. Key medications include diuretics, beta-blockers, antibiotics, and lactulose. Treatment should also focus on the underlying liver disease, alcohol abstinence, and preventive care. For advanced disease with liver failure, liver transplant may be lifesaving.
The optimal medical treatment depends largely on the cause and stage of cirrhosis. By providing comprehensive care and managing complications, medication therapy can significantly improve outcomes in cirrhosis.