New therapeutic paradigm for patients with cirrhosis

Authors

  • Emmanuel A. Tsochatzis,

    1. Royal Free Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, UCL and Royal Free Hospital, London, UK
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  • Jaime Bosch,

    1. Hepatic Hemodynamic Laboratory, Hospital Clínic-IDIBAPS and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Spain
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  • Andrew K. Burroughs

    Corresponding author
    1. Royal Free Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, UCL and Royal Free Hospital, London, UK
    • The Royal Free Sheila Sherlock Liver Centre and Division of Surgery, Royal Free Hospital and UCL, Pond Street, Hampstead, London NW3 2QG, UK
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    • fax: 00442074726226


  • Potential conflict of interest: Dr. Bosch consults for and received grants from Chiasma and Microtech. He also consults for Gilead and Norgine.

Abstract

Cirrhosis is a major health problem, being the 5th cause of death in the U.K. and 12th in the U.S., but 4th in the 45 to 54 age group. Until recently cirrhosis was considered a single and terminal disease stage, with an inevitably poor prognosis. However, it is now clear that 1-year mortality can range from 1% in early cirrhosis to 57% in decompensated disease. As the only treatment for advanced cirrhosis is liver transplantation, what is urgently needed is strategies to prevent transition to decompensated stages. The evidence we present in this review clearly demonstrates that management of patients with cirrhosis should change from an expectant algorithm that treats complications as they occur, to preventing the advent of all complications while in the compensated phase. This requires maintaining patients in an asymptomatic phase and not significantly affecting their quality of life with minimal impairment due to the therapies themselves. This could be achieved with lifestyle changes and combinations of already licensed and low-cost drugs, similar to the paradigm of treating risk factors for cardiovascular disease. The drugs are propranolol, simvastatin, norfloxacin, and warfarin, which in combination would cost £128/patient annually—equivalent to U.S. $196/year. This treatment strategy requires randomized controlled trials to establish improvements in outcomes. In the 21st century, cirrhosis should be regarded as a potentially treatable disease with currently available and inexpensive therapies. (HEPATOLOGY 2012;56:1983–1992)

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