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- Proton Pump Inhibitors
- Pain Medications
- Antihypertensives
- Diabetes Medications
- Sedatives
- Lipid Lowering Therapies
- Antidepressants
| Proton Pump Inhibitors | Recommended Dose | Additional Information |
|---|---|---|
| Esomeprazole | Max: 20 mg PO once daily | Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing |
| Pantoprazole | Max: 20 mg PO once daily | Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing |
| Lansoprazole | 15 – 30 mg PO once daily | Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing |
| Rabeprazole | 20 mg PO once daily | Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing |
| Dexlansoprazole | Max: 30 mg PO once daily | Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing |
| Omeprazole | Max: 20 mg PO once daily | Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing |
| Pain Medications | Recommended dose | Additional Information |
|---|---|---|
| NSAIDs | Refer to Symptom Management→ Pain for dosing and additional information
| |
| Acetaminophen | Refer to Symptom Management→ Pain for dosing and additional information
| |
| Opioids | Refer to Symptom Management→ Pain for dosing and additional information
|
| Antihypertensives | Recommended Dose | Additional Information |
|---|---|---|
| Non-Selective Beta Blockers | Refer to Treatment → Varices for dosing and additional information Varices - Cirrhosis Care | |
| ACE Inhibitors/ARBs | Max: 20 mg PO once daily | Avoid in patients with ascites. |
| Nifedipine XL (CCB) | Initial: 30 mg PO once daily Max: 90 mg/day | Has not been studied in patients with hepatic dysfunction; use with caution. May cause small transient rises in liver enzymes which will resolve with continued drug use. However, clearance in cirrhotic patients is reduced, leading to increased systemic exposure. Monitor closely for adverse effects/toxicity and consider dose adjustments. |
| Amlodipine (CCB) | Initial: 2.5 mg PO once daily Max: 10 mg PO once daily | Titrate slowly in patients with cirrhosis/hepatic impairment. |
| Felodipine (CCB) | Initial: 2.5 mg PO once daily Max: 10 mg PO daily | |
| Diltiazem (CCB) | Initial:30 mg PO four times daily (immediate release), or 120 mg PO once daily (extended release) Max: 360 mg PO daily | Increased half-life in patients with cirrhosis therefore use with caution. Mild and significant elevations in hepatic transaminases have been observed, reversible upon discontinuation. |
| Verapamil Immediate Release (CCB) | Initial: 20 mg PO three times daily Max: 480 mg/day in three divided doses Max: 360 mg PO daily | |
| Verapamil Extended Release (CCB) | Initial: 100 mg PO at bedtime Max: 480 mg/day in one or two divided doses | |
| Thiazide Diuretics | Avoid use in ascites due to risk of hyponatremia | |
| Furosemide (Loop Diuretic) | Refer to Treatment →Ascites for dosing and additional information Ascites - Cirrhosis Care | |
| Spironolactone (Potassium-Sparing Diuretic) | Refer to Treatment →Ascites for dosing and additional information Ascites - Cirrhosis Care |
| Diabetes Medications | Recommended Dose | Additional Information |
|---|---|---|
| Acarbose | Contraindicated | |
| Metformin | Initial: 500 mg PO twice daily OR 850 mg PO once daily with meals; may adjust dose in 500 mg increments weekly OR 850 mg every 2 weeks. Max: 2550 mg/day | Use cautiously in those with advanced liver disease, and in patients at risk of lactic acidosis (e.g. patients with renal impairment, alcohol use). Contraindicated in hepatic failure. Metformin may reduce the risk of hepatocellular carcinoma. |
| Rosiglitazone (Thiazolidinedione) | Contraindicated | |
| Pioglitazone (Thiazolidinedione) | Contraindicated | |
| Glyburide (Sulfonylurea) | Initial: 2.5 – 5 mg PO once daily Max: 20 mg/day | Contraindicated in Child-Pugh Class C. Least likely sulfonylurea to cause clinically apparent liver injury. Discontinue if the transaminase levels go above 2.5x the upper limit of normal. |
| Gliclazide (Sulfonylurea) | Initial: 40 – 80 mg PO once daily with breakfast Max: 320 mg/day | Contraindicated in Child-Pugh Class C. Discontinue if the transaminase levels go above 2.5x the upper limit of normal. |
| Glimepiride (Sulfonylurea) | Initial: 1 – 2 mg PO once daily Max: 8 mg/day | Contraindicated in Child-Pugh Class C. Discontinue if the transaminase levels go above 2.5x the upper limit of normal. |
| Repaglinide | Initial: If HbA1c < 8%, 0.5 mg PO within 30 minutes before a meal, 2 to 4 times daily. If HbA1c > 8%, 1 – 2 mg PO within 30 minutes before a meal, 2 to 4 times daily. Max: 4 mg/dose (16 mg/day). Do not take dose if meal is skipped. | Use with caution. Consider longer intervals between dosage adjustments. Increased risk of hypoglycemia in patients with hepatic dysfunction. |
| Nateglinide | Initial: 60 mg PO three times daily, within 30 minutes before a meal. Max: 120 mg PO three times daily, within 30 minutes before a meal. | Use with caution. Consider longer intervals between dosage adjustments. Increased risk of hypoglycemia in patients with hepatic dysfunction. Theoretically safer than repaglinide based on pharmacokinetic observations from trials. |
| Sitagliptin (DPP-4 Inhibitor) | Initial: 100 mg PO once daily with or without food | DPP-4 inhibitors are minimally metabolized by the liver and are relatively safe in cirrhosis patients. |
| Alogliptin (DPP-4 Inhibitor) | Initial: 25 mg PO once daily with or without food | DPP-4 inhibitors are minimally metabolized by the liver and are relatively safe in cirrhosis patients. However, there have been post-marketing reports of hepatic failure with alogliptin. |
| Linagliptin (DPP-4 Inhibitor) | Initial: 5 mg PO once daily with or without food | DPP-4 inhibitors are minimally metabolized by the liver and are relatively safe in cirrhosis patients. |
| Saxagliptin (DPP-4 Inhibitor) | Initial: 2.5 mg – 5 mg PO once daily with or without food | DPP-4 inhibitors are minimally metabolized by the liver and are relatively safe in cirrhosis patients. |
| Liraglutide (GLP-1 Agonist) | Initial: 0.6 mg subcutaneous once daily for 1 week; maintenance 1.2 mg once daily. May increase to 1.8 mg/day after at least 1 week of treatment with the 1.2 mg/day regimen. Max: 1.8 mg/day | Use with caution due to limited experience. Few studies have demonstrated that liraglutide may decrease hepatic inflammation, liver fibrosis, and body weight. |
| Dapagliflozin (SGLT2 Inhibitor) | Initial: 5 mg PO once daily in the morning. Max: 10 mg/day | Studies have demonstrated higher systemic drug levels compared to healthy subjects. Long term efficacy has not been well studied. Use with caution in severe impairment. |
| Empagliflozin (SGLT2 Inhibitor) | Initial: 10 mg PO once daily in the morning. Max: 25 mg/day | Studies have demonstrated higher systemic drug levels compared to healthy subjects. Long term efficacy has not been well studied. Use with caution in severe impairment. |
| Canagliflozin (SGLT2 Inhibitor) | Initial: 100 mg PO once daily taken before the first meal of the day Max: 300 mg/day (if eGFR < 60 mL/min/1.73 m2, max 100 mg/day) | Studies have demonstrated higher systemic drug levels compared to healthy subjects. Long term efficacy has not been well studied. Use with caution in severe impairment. |
| Ertugliflozin (SGLT2 Inhibitor) | Initial: 5 mg PO once daily Max: 15 mg/day | Studies have demonstrated higher systemic drug levels compared to healthy subjects. Long term efficacy has not been well studied. Use with caution in severe hepatic impairment. |
| Insulin (many formulations) | Patient specific | Insulin requirements can change based on the severity of cirrhosis. Decompensated cirrhosis patients have decreased hepatic metabolism and reduced capacity for gluconeogenesis therefore lower doses are required. Compensated patients are predominantly insulin resistant which would potentially require higher doses of insulin. |
| Sedatives | Recommended Dose | Additional Information |
|---|---|---|
| Zopiclone | Refer to Symptom Management → Sleep Disturbance for dosing and additional information Sleep Disturbance – Cirrhosis Care |
| Lipid Lowering Therapies | Recommended Dose |
|---|---|
| Statins | Refer to Cirrhosis →Etiology management specific to cirrhosis for dosing and additional information Etiology management specific to cirrhosis – Cirrhosis Care |
| Ezetimibe | Child-Pugh Class A: No dosage adjustment necessary Child-Pugh Class B/C: Contraindicated |
| Fenofibrate | Contraindicated |
| Alirocumab (PCSK9 Inhibitor) | Child-Pugh Class A/B: No dosage adjustment necessary Child-Pugh Class C: Has not been studied |
| Evolocumab (PCSK9 Inhibitor) | Child-Pugh Class A/B: No dosage adjustment necessary Child-Pugh Class C:Has not been studied |
| Antidepressants | Recommended Dose | Additional Information |
|---|---|---|
| SSRIs | Refer to Symptom Management →Depression for dosing and additional information Depression – Cirrhosis Care | |
| SNRIs | Refer to Symptom Management →Depression for dosing and additional information Depression – Cirrhosis Care | |
| Amitriptyline (TCA) | For depression: Initial: 25 mg PO once daily or in divided doses Max: 100 mg PO once daily | |
| Nortriptyline (TCA) | For depression: Initial: 25 mg PO once daily or in divided doses Max: 100 mg PO once daily | |
| Bupropion (NDRI) | Child-Pugh Class A: Manufacturer recommends dose and/or frequency reduction. No specific recommendations provided, however, some experts recommend decreasing initial dose to 50% of usual dose and reducing dosing frequency Child-Pugh Class B/C: Max 150 mg every other day. | Half-life for active metabolites increased 2- to 5-fold in patients with severe hepatic impairment. |
| Mirtazapine | Refer to Symptom Management →Depression for dosing and additional information Depression – Cirrhosis Care |