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The American Association for the Study of Liver Diseases has released its latest recommendations, including drugs to avoid or use with caution.

The American Association for the Study of Liver Diseases (AASLD) has published its fourth iteration of management guidelines for ascites — the most common manifestation of decompensated cirrhosis. The following are some of the major updates to the guidelines:

• Drugs that lower arterial pressure, including angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and even beta-blockers, should be avoided or, if used, should be accompanied by careful monitoring of blood pressure and renal function. This recommendation is based on emerging findings that arterial pressure is an independent predictor of survival in patients with cirrhosis.
• Vaptans, which inhibit the action of vasopressin on its receptors, should be avoided in patients with cirrhosis. In a recent, large, randomized, controlled trial in patients with cirrhosis, use of vaptans showed no clinical benefit in the long-term management of ascites and a possible increase in mortality (Gut 2012; 61:108).
• The use of intravenous albumin infusion after large-volume paracentesis has been controversial. A recent meta-analysis demonstrated that its use was associated with a reduction in mortality in this setting (odds ratio, 0.64; 95% confidence interval, 0.41–0.98; Hepatology 2012; 55:1172). Albumin infusion should be given at a rate of 6 to 8 grams per liter of fluid removed when >5 liters of ascites are drained.
• Terlipressin plus albumin was shown to reduce mortality compared with albumin alone (relative risk, 0.81; 95% CI, 0.68–0.97) in patients with type 1 hepatorenal syndrome (Hepatology 2010; 51:576). Terlipressin is not available in the U.S., but if results of a nearly complete phase III study are promising, it should receive FDA approval. Until then, octreotide plus midodrine should be considered.
• The common use of quinolones to prevent spontaneous bacterial peritonitis in high-risk patients with cirrhosis has led to an increase in multidrug-resistant organisms. To reduce the risk for resistance, prophylactic antibiotics should be used only when indicated and for a limited duration when possible. The spectrum should be narrowed once susceptibility results are available.

Comment: The updated AASLD guidelines for the management of ascites highlight the importance of avoiding medications that can lead to severe arterial hypotension, which can have detrimental renal effects, and the hope that we will soon have an FDA-approved treatment for hepatorenal syndrome in response to the recently completed phase III study of terlipressin.