AGA Clinical Practice Update On The Use of Vasoactive Drugs and Intravenous Albumin in Cirrhosis - Expert Review

Gastroenterology 2024;166:202–210
CLINICAL PRACTICE UPDATES

AGA Clinical Practice Update on the Use of Vasoactive Drugs and
Intravenous Albumin in Cirrhosis: Expert Review
Guadalupe Garcia-Tsao,1,2 Juan G. Abraldes,3 Nicole E. Rich,4 and Vincent Wai-Sun Wong5,6
1
Section of Digestive Diseases, Yale University, New Haven, Connecticut; 2Veterans Affairs Connecticut Healthcare System,
West Haven, Connecticut; 3Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada; 4Division
of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas; 5Medical Data Analytics
Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; and 6State Key
Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
DESCRIPTION: Cirrhosis is a major cause of morbidity and safety profile. BEST PRACTICE ADVICE 4: IV albumin should
mortality in the United States and worldwide. It consists of be administered at the time of large-volume (>5 L) para-
compensated, decompensated, and further decompensated centesis. BEST PRACTICE ADVICE 5: IV albumin may be
stages; median survival is more than 15 years, 2 years, and 9 considered in patients with SBP. BEST PRACTICE ADVICE 6:
months for each stage, respectively. With each stage, there is Albumin should not be used in patients (hospitalized or not)
progressive worsening of portal hypertension and the with cirrhosis and uncomplicated ascites. BEST PRACTICE
vasodilatory–hyperdynamic circulatory state, resulting in a ADVICE 7: Vasoconstrictors should not be used in the man-
progressive decrease in effective arterial blood volume and agement of uncomplicated ascites, after large-volume para-
renal perfusion. Vasoconstrictors reduce portal pressure via centesis or in patients with SBP. BEST PRACTICE ADVICE 8: IV
splanchnic vasoconstriction and are used in the management of albumin is the volume expander of choice in hospitalized patients
variceal hemorrhage. Intravenous (IV) albumin increases with cirrhosis and ascites presenting with AKI. BEST PRACTICE
effective arterial blood volume and is used in the prevention of ADVICE 9: Vasoactive drugs (eg, terlipressin, norepinephrine,
acute kidney injury (AKI) and death after large-volume para- and combination of octreotide and midodrine) should be used in
centesis and in patients with spontaneous bacterial peritonitis the treatment of HRS-AKI, but not in other forms of AKI in
(SBP). The combination of vasoconstrictors and albumin is used cirrhosis. BEST PRACTICE ADVICE 10: Terlipressin is the
in the reversal of hepatorenal syndrome (HRS-AKI), the most vasoactive drug of choice in the treatment of HRS-AKI and use of
lethal complication of cirrhosis. Because a potent vasocon- concurrent albumin can be considered when accounting for pa-
strictor, terlipressin, was recently approved by the US Food and tient’s volume status. BEST PRACTICE ADVICE 11: Terlipressin
Drug Administration, and because recent trials have explored treatment does not require intensive care unit monitoring and
use of IV albumin in other settings, it was considered that a best can be administered intravenously through a peripheral line.
practice update would be relevant regarding the use of vaso- BEST PRACTICE ADVICE 12: Terlipressin use is contraindicated
active drugs and IV albumin in the following 3 specific sce- in patients with hypoxemia and in patients with ongoing coro-
narios: variceal hemorrhage, ascites and SBP, and HRS. nary, peripheral, or mesenteric ischemia, and should be used with
CLINICAL PRACTICE UPDATES
METHODS: This expert review was commissioned and caution in patients with acute-on-chronic liver failure grade 3.
approved by the American Gastroenterological Association The benefits may not outweigh the risks in patients with serum
(AGA) Institute Clinical Practice Updates Committee and the creatinine >5 mg/dL and in patients listed for transplantation
AGA Governing Board to provide timely guidance on a topic of with a Model for End-stage Liver Disease !35.
high clinical importance to the AGA membership. It underwent
internal peer review through standard procedures of Gastroen-
terology. These Best Practice Advice statements were drawn from Keywords: Portal Hypertension; Octreotide; Terlipressin;
a review of the published literature and from expert opinion. Ascites; Hepatorenal Syndrome.
Some of the statements are unchanged from published guidelines
because of lack of new evidence in the literature. Because sys-
tematic reviews were not performed, these Best Practice Advice
statements do not carry formal ratings regarding the quality and
evidence or strength of the presented considerations.
C irrhosis and liver cancer account for 3.5% of all
deaths worldwide; in 2017 there were more than
112 million and 10.6 million cases of compensated and
decompensated cirrhosis, respectively.1 In the United States,
BEST PRACTICE ADVICE STATEMENTS
Abbreviations used in this paper: ACLF, acute-on-chronic liver failure;
AGA, American Gastroenterological Association; AKI, acute kidney injury;
BEST PRACTICE ADVICE 1: Vasoactive drugs should be initi- AVH, acute variceal hemorrhage; FDA, US Food and Drug Administration;
ated as soon as the diagnosis of variceal hemorrhage is sus- HRS, hepatorenal syndrome; ICU, intensive care unit; IV, intravenous; LVP,
large-volume paracentesis; NE, norepinephrine; PCD, post-paracentesis
pected or confirmed, preferably before diagnostic and/or circulatory dysfunction; RCT, randomized controlled trial; SBP, sponta-
therapeutic endoscopy. BEST PRACTICE ADVICE 2: After neous bacterial peritonitis.
initial endoscopic hemostasis, vasoactive drugs should be Most current article
continued for 2–5 days to prevent early rebleeding. BEST
© 2024 by the AGA Institute. Published by Elsevier Inc.
PRACTICE ADVICE 3: Octreotide is the vasoactive drug of 0016-5085/$36.00
choice in the management of variceal hemorrhage based on its https://doi.org/10.1053/j.gastro.2023.10.016

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Gastroenterology 2024;166:202–210

CLINICAL PRACTICE UPDATES

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