Medications

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  1. Proton Pump Inhibitors
  2. Pain Medications
  3. Antihypertensives
  4. Diabetes Medications
  5. Sedatives
  6. Lipid Lowering Therapies
  7. Antidepressants

Proton Pump InhibitorsRecommended DoseAdditional Information
EsomeprazoleMax: 20 mg PO once dailyConsider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing
PantoprazoleMax: 20 mg PO once daily

Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing
Lansoprazole15 – 30 mg PO once daily

Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing
Rabeprazole20 mg PO once daily

Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing
DexlansoprazoleMax: 30 mg PO once daily
Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing
OmeprazoleMax: 20 mg PO once daily
Consider deprescribing. Algorithm can be found at: Proton Pump Inhibitor (PPI) Deprescribing
Pain MedicationsRecommended doseAdditional Information
NSAIDsRefer to Symptom Management→ Pain for dosing and additional information
Pain – Cirrhosis Care

AcetaminophenRefer to Symptom Management→ Pain for dosing and additional information
Pain – Cirrhosis Care

OpioidsRefer to Symptom Management→ Pain for dosing and additional information
Pain – Cirrhosis Care

 
AntihypertensivesRecommended DoseAdditional Information
Non-Selective Beta BlockersRefer to Treatment → Varices for dosing and additional information
Varices - Cirrhosis Care

ACE Inhibitors/ARBsMax: 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 DiureticsAvoid 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 MedicationsRecommended DoseAdditional Information
AcarboseContraindicated
MetforminInitial: 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.
NateglinideInitial: 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 foodDPP-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 foodDPP-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 foodDPP-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 foodDPP-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 specificInsulin 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.
 
SedativesRecommended DoseAdditional Information
ZopicloneRefer to Symptom Management → Sleep Disturbance for dosing and additional information
Sleep Disturbance – Cirrhosis Care

 
Lipid Lowering TherapiesRecommended Dose
StatinsRefer to Cirrhosis →Etiology management specific to cirrhosis for dosing and additional information
Etiology management specific to cirrhosis – Cirrhosis Care

EzetimibeChild-Pugh Class A: No dosage adjustment necessary

Child-Pugh Class B/C: Contraindicated
FenofibrateContraindicated
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
 
AntidepressantsRecommended DoseAdditional Information
SSRIsRefer to Symptom Management →Depression for dosing and additional information
Depression – Cirrhosis Care


SNRIsRefer 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.
MirtazapineRefer to Symptom Management →Depression for dosing and additional information
Depression – Cirrhosis Care