Evolution of care in cirrhosis: Preventing hepatic decompensation through pharmacotherapy

Table 1 Chemoprevention for hepatic decompensation in cirrhosis: Current and emerging therapies

Agents	Mechanism of action	Primary benefits	Potential adverse effects	Other limitations	Supported by RCT
NSBBs	β1 and β2 blockade; α1 blockade (carvedilol)	Decreased portal pressure	Hypotension, bradycardia, fatigue	Dosing frequency (propranolol)	Yes
Statins	Inhibition of HMG-CoA reductase	Decreased inflammation and endothelial dysfunction	Myopathy, hepatitis, diabetes		Ongoing
Rifaximin	Broad-spectrum, gut-specific antibiotic	Reduced dysbiosis and bacterial translocation	Gastrointestinal upset	Cost	Included patients with prior decompensation
Anticoagulants	Inactivation of clotting factors	Reduced endothelial dysfunction	Hemorrhage	SQ injection (enoxaparin), dosing (warfarin)	Included patients with prior decompensation
ACE inhibitors	Inhibition of angiotensin II production	Decreased portal pressure1	Hypotension, AKI, electrolyte derangements, angioedema		No
ARBs	Inhibition of angiotensin II type 1 receptor	Decreased portal pressure	Hypotension, AKI, electrolyte derangements		No
MRAs	Inhibition of the aldosterone receptor in the distal nephron	Decreased portal pressure	Hypotension, AKI, electrolyte derangements	Gynecomastia (spironolactone)	Only in combination with NSBB
SGLT2 inhibitors	Inhibition of proximal tubule sodium-glucose cotransporter	Decreased portal pressure	Electrolyte derangements, mycotic genital infections	Cost, risk of ketoacidosis in AUD	No
Albumin	Anionic carrier protein with pleiotropic properties	Reduced inflammation; increased effective circulating volume	Volume overload	Cost, intravenous administration	Included patients with prior decompensation

¹Not demonstrated in prior clinical studies.

ACE: Angiotensin converting enzyme; AKI: Acute kidney injury; ARB: Angiotensin receptor blocker; AUD: Alcohol use disorder; BP: Blood pressure; HMG-CoA: Hydroxy β-methylglutaryl-CoA; MRA: Mineralocorticoid receptor antagonist; NSBB: Non-selective beta-blocker; SGLT2: Sodium-glucose cotransporter 2; SQ: Subcutaneous; RCT: Randomized controlled trial.