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World J Gastroenterol. Jan 7, 2023; 29(1): 61-74
Published online Jan 7, 2023. doi: 10.3748/wjg.v29.i1.61
Evolution of care in cirrhosis: Preventing hepatic decompensation through pharmacotherapy
Seohyuk Lee, Saad Saffo
Seohyuk Lee, Saad Saffo, Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520-8019, United States
Author contributions: Lee S and Saffo S reviewed the literature and drafted the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Saad Saffo, MD, Academic Fellow, Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520-8019, United States.
Received: September 26, 2022
Peer-review started: September 26, 2022
First decision: October 18, 2022
Revised: October 22, 2022
Accepted: December 13, 2022
Article in press: December 13, 2022
Published online: January 7, 2023
Processing time: 100 Days and 5.5 Hours

Cirrhosis is a leading cause of morbidity and mortality, impacting more than 120 million people worldwide. Although geographic differences exist, etiologic factors such as alcohol use disorder, chronic viral hepatitis infections, and non-alcoholic fatty liver disease are prevalent in nearly every region. Historically, significant effort has been devoted to modifying these risks to prevent disease progression. Nevertheless, more than 11% of patients with compensated cirrhosis experience hepatic decompensation each year. This transition signifies the most important prognostic factor in the natural history of the disease, corresponding to a decline in median survival to below 2 years. Over the past decade, the need for pharmacotherapies aimed at reducing the risk for hepatic decompensation has been emphasized, and non-selective beta-blockers have emerged as the most effective option to date. However, a critical therapeutic gap still exists, and additional therapies have been proposed, including statins, rifaximin, and sodium-glucose cotransporter-2 inhibitors. Based on the results of innovative retrospective analyses and small-scale prospective trials, these pharmacotherapies represent promising options, but further studies, including randomized controlled trials, are necessary before they can be incorporated into clinical use. This report highlights the potential impact of these agents and others in preventing hepatic decompensation and discusses how this paradigm shift may pave the way for guideline-directed medical therapy in cirrhosis.

Keywords: Cirrhosis, Hepatic decompensation, Beta-blockers, Statins, Sodium-glucose cotransporter-2 inhibitors, Rifaximin

Core Tip: Hepatic decompensation is the most important clinical predictor of morbidity and mortality among patients with cirrhosis. New pharmacotherapies aimed at preventing hepatic decompensation in high-risk patients are emerging, augmenting traditional management strategies. These treatments represent safe, accessible, and effective options that may improve quality of life and prolong transplant-free survival, regardless of the etiologic factors involved.