HEPAT 01429 Medical treatment of ascites in cirrhosis

Medical treatment of cirrhotic ascites is essentially supportive, dictated by the patient's discomfort, impaired car-diovascular o respiratory function and potential for infection. Treatment of'simple ' ascites (moderate fluid accumula-tion, serum albumin> 3.5 g/dl, serum creatinine < 1.5 mg/di, no electrolyte disturbance) is implemented sequentially. Only 10 % of patients respond to dietary sodium restriction and bed rest; most require pharmacotherapy consisting of spironolactone, which increases the proportion of responding patients to 65 % and loop diuretics, which may pro-duce clinical improvement i an additional 20 % (85 % in all); in the remaining 15 % of refractory patients, use of novel adjunctive therapies may be attempted. Patients with tense ascites, impaired renal function and electrolyte distur-bances merit special consideration before diuretics are introduced. Spironolactone has long been a standard for the treatment of cirrhotic ascites because it directly antagonizes aldosterone. The loop diuretic most frequently added to spironolactone has been furosemide. However, there is preliminary evidence that torasemide may be more effective in some patients. Other investigational agents that may play a role in treatment of patients resistant to conventional drugs include ornipressin (a vasopressin analogue) and atrial natriuretic factor