# Liver Cirrhosis (Primary Care) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Baveno VII Consensus Report: Personalizing portal hypertension management 2022 · Carvedilol SmPC (https://www.medicines.org.uk/emc/product/1298/smpc) · Egyptian National Drug Formulary - Antimicrobial 2023 (rifaximin monograph) · Egyptian National Drug Formulary - Cardiovascular 2024 (furosemide monograph) · Egyptian National Drug Formulary - Cardiovascular 2024 (spironolactone monograph) · Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (lactulose monograph) · Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (ursodeoxycholic acid monograph) · NICE Guideline NG50: Cirrhosis in over 16s: assessment and management 2016 · NICE NG50 Cirrhosis in over 16s: assessment and management, 2023 update, recommendations 1.3.2 and 1.3.3 (NCBI Bookshelf NBK595473) - Verified date: 2026-08 ## Verified against - Carvedilol SmPC (https://www.medicines.org.uk/emc/product/1298/smpc) - Egyptian National Drug Formulary - Antimicrobial 2023 (rifaximin monograph) - Egyptian National Drug Formulary - Cardiovascular 2024 (furosemide monograph) - Egyptian National Drug Formulary - Cardiovascular 2024 (spironolactone monograph) - Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (lactulose monograph) - Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (ursodeoxycholic acid monograph) - Liver Cirrhosis (Primary Care) - disease-level clinical article (liver-cirrhosis-full.txt) ## Treatment metadata - Carvedilol — 6.25 mg — oral.solid - Referral & safety-netting (no drug therapy) - Ursodeoxycholic acid — 250 mg — oral.solid - Spironolactone — 100 mg — oral.solid - Furosemide — 40 mg — oral.solid - Lactulose — 667 mg — oral.liquid - Rifaximin — 550 mg — oral.solid ## Complete treatment card ```text LIVER CIRRHOSIS (PRIMARY CARE) Sources: Baveno VII Consensus Report: Personalizing portal hypertension management 2022 · Carvedilol SmPC (https://www.medicines.org.uk/emc/product/1298/smpc) · Egyptian National Drug Formulary - Antimicrobial 2023 (rifaximin monograph) · Egyptian National Drug Formulary - Cardiovascular 2024 (furosemide monograph) · Egyptian National Drug Formulary - Cardiovascular 2024 (spironolactone monograph) · Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (lactulose monograph) · Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (ursodeoxycholic acid monograph) · NICE Guideline NG50: Cirrhosis in over 16s: assessment and management 2016 · NICE NG50 Cirrhosis in over 16s: assessment and management, 2023 update, recommendations 1.3.2 and 1.3.3 (NCBI Bookshelf NBK595473) Review status: REVIEWED against Carvedilol SmPC (https://www.medicines.org.uk/emc/product/1298/smpc), Egyptian National Drug Formulary - Antimicrobial 2023 (rifaximin monograph), Egyptian National Drug Formulary - Cardiovascular 2024 (furosemide monograph), Egyptian National Drug Formulary - Cardiovascular 2024 (spironolactone monograph), Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (lactulose monograph), Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (ursodeoxycholic acid monograph), Liver Cirrhosis (Primary Care) - disease-level clinical article (liver-cirrhosis-full.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (3) - Cirrhosis can be found incidentally while investigating something else, such as suspected gallbladder disease [cirrhosis] - Many patients report only vague complaints such as fatigue, or are picked up from unexplained abnormal lab results [fatigue] - Others first present with a complication of portal hypertension: new fluid in the belly, confusion, or bleeding varices [bleeding · confusion · hypertension] SIGNS - what you find (1) - Jaundice, confusion, reddened palms, spider-like skin blood vessels, a swollen abdomen, weight loss, fluid retention, dilated veins, and a hand flap can all be found on exam [abdominal distension · confusion · jaundice · oedema · redness · weight loss] TESTS (3) - Bloodwork should screen for viral hepatitis, autoimmune markers, immunoglobulin levels, iron studies, alpha-1-antitrypsin, Wilson disease, and coeliac disease - AST and ALT are usually only mildly raised or normal when the cause is cryptogenic - A liver biopsy is required to confirm the diagnosis, showing inflammation, ballooned cells, Mallory-Denk bodies, glycogenated nuclei, fatty foci, bile duct proliferation, and apoptotic bodies IF NOT THIS - what else fits (12) - Alcohol-related liver disease - Non-alcoholic fatty liver disease - Chronic hepatitis B or C infection - Autoimmune hepatitis - Primary biliary cirrhosis - Primary sclerosing cholangitis - Hereditary haemochromatosis - Wilson disease - Alpha-1-antitrypsin deficiency - Budd-Chiari syndrome - Right heart failure causing congestive liver disease - IgG4-related cholangiopathy Source StatPearls "Cryptogenic Cirrhosis" - disease-level clinical article Status traced to the source above !! MULTI-DRUG REGIMEN - all 2 drugs are given TOGETHER. Not a choice between them. !! the regimen: Spironolactone + Furosemide Rx: Portal hypertension | Main treatment | Underlying liver disease | Ascites | Encephalopathy - first line | Add to prevent recurrence PORTAL HYPERTENSION 1. CARVEDILOL [1st line] Adult 6.25 mg once daily initially, titrate to 12.5 mg once daily as blood pressure allows - long-term Peds Not a primary-care prescription in children. Paediatric cirrhosis is managed by specialist hepatology. Source Carvedilol SmPC (https://www.medicines.org.uk/emc/product/1298/smpc) Why NICE 1.3.3 makes carvedilol the first choice for preventing decompensation in clinically significant portal hypertension, ahead of propranolol, because it has fewer side effects and a greater effect on portal vein pressure. Propranolol is the second choice, for when carvedilol is contraindicated. Caution If carvedilol is contraindicated, propranolol 40 mg twice daily is the second choice - NICE names both and puts carvedilol first. Off-label. NICE recorded in September 2023 that using either drug for the primary prevention of decompensation is outside their licence. Start at the low dose and go up slowly. These patients are often already hypotensive, and a beta-blocker that drops the pressure further does harm. Contraindicated in asthma, second or third degree heart block, and uncontrolled heart failure. Caution in refractory ascites, where a non-selective beta-blocker may worsen the circulation. Egypt VIDILOL 6.25 MG 10 TABS. MEMPHIS 3.50 EGP (0.35/unit) CARLOL-V 6.25MG 30 F.C.TAB AMOUN 19.50 EGP (0.65/unit) KARVEX 6.25MG 30 TAB. SIGMA 19.50 EGP (0.65/unit) CARDILOL 6.25MG 30 TAB. MARCYRL PHARM... 39.00 EGP (1.30/unit) CARVID 6.25MG 20 TAB. MULTI-APEX 30.00 EGP (1.50/unit) CARVID 6.25MG 30 TAB. MULTI-APEX 45.00 EGP (1.50/unit) DILATROL 6.25MG 30 TAB. CHEMIPHARM 48.00 EGP (1.60/unit) CARVIPRESS 6.25MG 20 SCORED TAB. GLOBAL NAPI P... 13.00 EGP MAIN TREATMENT 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Liver Cirrhosis (Primary Care) - disease-level clinical article (liver-cirrhosis- full.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Carry out surveillance screening for hepatocellular carcinoma (HCC) using ultrasound every 6 months. UNDERLYING LIVER DISEASE 3. URSODEOXYCHOLIC ACID [2nd line] Adult Primary biliary cholangitis: 12-16 mg/kg/day. Give in 3 divided doses for the first 3 months, then as a single dose in the evening - Indefinite - the formulary states treatment in primary biliary cholangitis may be continued indefinitely Peds Safety and effectiveness in children have not been established for primary biliary cholangitis. The monograph's only paediatric dose (20 mg/kg/day in 2-3 divided doses, increasing to 30 mg/kg/day) is for hepatobiliary disorders associated with cystic fibrosis - a different indication. Source Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (ursodeoxycholic acid monograph) Why 17 live products and the only disease-modifying drug for primary biliary cholangitis, which is one of the cirrhoses a GP will be co-managing. The other three rows here treat portal hypertension, ascites and encephalopathy - none treats the underlying liver disease. Caution Only for primary biliary cholangitis - it does nothing for cirrhosis due to hepatitis C, alcohol or steatohepatitis, which are the commoner causes in Egypt. CONTRAINDICATED where there are frequent episodes of biliary colic, radio-opaque calcified gallstones, a non-functioning gallbladder, biliary obstruction, or active peptic ulceration. Itching may worsen in the first weeks of treatment in advanced disease - reduce to 250 mg daily and re-titrate rather than stopping. Check liver function monthly for 3 months, then every 3 months. Do not give within 2 hours of an aluminium-containing antacid or a bile acid sequestrant. A woman taking it for gallstone dissolution should use non-hormonal contraception - hormonal contraceptives promote biliary lithiasis. Reduce the dose if diarrhoea occurs; stop if it persists. Egypt URSOCHOL 250 MG 20 CAPS. MUP 71.00 EGP (3.55/unit) EXOSIRYLIC 250 MG 20 F.C. TABS. GYPTO PHARMA 144.00 EGP (7.20/unit) URSODIOL 250 MG 20 CAPS. SEDICO 162.00 EGP (8.10/unit) URSOFALK 250 MG 20 CAPS. MINA PHARM > ... 162.00 EGP (8.10/unit) EGYRESOLVE 250 MG 10 S.G.CAPS. MEDIZEN PHARM... 9.00 EGP URSOGALL 250MG/5ML 100ML SUSP. SIGMA 24.00 EGP -> ? strength differs, ? different route - not oral solid ASCITES - give all together 4. SPIRONOLACTONE [1 of 2 - GIVE ALL TOGETHER] Adult 100 mg once daily in the morning, titrated by 100 mg every 3-5 days up to max 400 mg daily as continuous maintenance for ascites - Long-term ongoing maintenance Peds Pediatric ascites requires specialist pediatric hepatology guidance. Source Egyptian National Drug Formulary - Cardiovascular 2024 (spironolactone monograph) Why Aldosterone-antagonist diuretic added to dietary sodium restriction, not a replacement for it, that blocks the secondary hyperaldosteronism driving fluid retention in cirrhosis. First-line diuretic for cirrhotic ascites. Caution First-line diuretic in cirrhosis due to secondary hyperaldosteronism. Monitor serum potassium and renal function regularly due to risk of hyperkalemia and acute kidney injury. Discontinue or reduce dose if severe hyponatremia (<125 mmol/L), hyperkalemia (>6.0 mmol/L), or worsening encephalopathy occurs. Egypt EPILACTONE 100 MG 10 TABS. EIPICO 7.00 EGP (0.70/unit) SPIRONOLACTONE (DELTA) 100MG 20 TAB. GLOBAL NAPI PHARMACEUTI... 16.80 EGP (0.84/unit) POTASAVE 100 MG 20 TAB ALFACURE PHAR... 21.00 EGP (1.05/unit) ALDACTONE 100MG 20 TAB KAHIRA > SEAR... 22.00 EGP (1.10/unit) POTASPIRONO 100 MG 20 TAB. UNIPHARMA 90.00 EGP (4.50/unit) SPECTONE 100 MG 20 TABS. KAHIRA 90.00 EGP (4.50/unit) 5. FUROSEMIDE [2 of 2 - GIVE ALL TOGETHER] Adult 20-40 mg once daily in the morning, added to the spironolactone and titrated together with it - Long-term, titrated to the weight and the ascites Peds Paediatric ascites requires specialist paediatric hepatology guidance. The formulary's paediatric furosemide doses are for oedema generally, not for cirrhotic ascites. Source Egyptian National Drug Formulary - Cardiovascular 2024 (furosemide monograph) Why The formulary names cirrhotic ascites in the furosemide indication line. Spironolactone alone often will not shift moderate ascites and, given alone at the doses needed, drives the potassium up; the loop diuretic is what makes the combination work and keeps the potassium in range. Caution Added to the spironolactone, not instead of it. Spironolactone is the first diuretic in cirrhosis; furosemide is what you add when the spironolactone alone is not enough. Keep the two roughly in a 40 mg furosemide to 100 mg spironolactone ratio when you titrate, so the potassium stays put. Aim for weight loss of no more than 0.5 kg a day without peripheral oedema, or 1 kg a day with it. Faster than that causes renal failure and encephalopathy. Check sodium, potassium and creatinine at every dose change. Stop or reduce for sodium below 125, or for a rising creatinine. Avoid sudden shifts in fluid and electrolytes - the formulary warns these can precipitate hepatic encephalopathy. No NSAIDs in a cirrhotic on diuretics. They blunt the diuretic and precipitate hepatorenal failure. Egypt ODEMENT 40MG 10 TAB. EL NASR 1.30 EGP (0.13/unit) FRUZEX 40MG 12 TAB. MISR 3.25 EGP (0.27/unit) FUROSEMIDE 40MG 20 TAB. SEDICO 7.50 EGP (0.38/unit) FURORETIC 40 MG 30 TABS. DEBEIKY > VET... 14.25 EGP (0.47/unit) LAFUREX 40MG 20 TAB. AMOUN 9.50 EGP (0.47/unit) SALEX 40 MG 20 TABS. ARAB DRUG COM... 10.00 EGP (0.50/unit) FUROSEMIDE-ALEX 40MG 20 TAB. ALEXANDRIA 19.00 EGP (0.95/unit) LASIX 40 MG 24 TABS. SANOFI 30.00 EGP (1.25/unit) GENESEMIDE 20MG/5ML SYRUP 120 ML MEDIZEN PHARM... 56.00 EGP -> ? strength differs, ? different route - not oral solid ENCEPHALOPATHY - FIRST LINE - give alongside 6. LACTULOSE [add-on - not a substitute] Adult 30-45 mL three to four times daily to start, then titrated to 2-3 soft stools a day - Long-term ongoing maintenance Peds Safety and efficacy in hepatic encephalopathy have not been established in children. A child with encephalopathy is a paediatric hepatology referral. Source Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (lactulose monograph) Why Osmotic laxative added to overall cirrhosis care, not a substitute for finding and treating the precipitant of encephalopathy; acidifies the colon and traps ammonia as ammonium, lowering the ammonia absorbed into the bloodstream to prevent or treat hepatic encephalopathy. Caution 15-30 mL a day is the constipation dose, not this one. Encephalopathy needs 30-45 mL three or four times daily - several times as much - and under-dosing it is a common way for a patient to stay confused on treatment. Primary non-absorbable disaccharide for preventing hepatic encephalopathy in cirrhosis. Avoid excessive diarrhea which can precipitate dehydration, electrolyte disturbances, and acute kidney injury. Egypt FARCOLAC 667GM/L SYRUP 120 ML PHARCO 7.50 EGP [? strength differs] LACTOLINE 50% SYRUP 200ML ALEXANDRIA 9.25 EGP [? strength differs] LAEVOLAC 67GM/100ML SYRUP 120 ML SIGMA > FRESE... 12.00 EGP [? strength differs] SEDALAC 3.35GM/5ML SYRUP 120ML SEDICO 20.00 EGP [? strength differs] LAXOLAC 3.35GM/5ML SYRUP 300ML MUP 40.00 EGP [? strength differs] LAXOLAC 3.35GM/5ML SYRUP 120ML MUP 50.00 EGP [? strength differs] DUPHALAC 667GM/L SYRUP 200ML ABBOTT LABORA... 143.00 EGP [? strength differs] LACTULOSE-AUG PHARMA 3.35GM/5ML SYRUP 320ML AUG PHARMA 170.00 EGP -> ? strength differs VILLAPURG 67% SYRUP 120 ML AL ESRAA PHAR... 12.00 EGP -> ? strength differs, ? different route - not oral liquid VILLAPURG 67% SYRUP 200 ML AL ESRAA PHAR... 17.75 EGP -> ? strength differs, ? different route - not oral liquid ADD TO PREVENT RECURRENCE - give alongside 7. RIFAXIMIN [add-on - not a substitute] Adult 550 mg twice daily, added to the lactulose - Long-term, to prevent the next episode Peds The formulary's only paediatric rifaximin dose is 200 mg three times daily for travellers' diarrhoea from 12 years - a different indication. A child with encephalopathy is a paediatric hepatology referral. Source Egyptian National Drug Formulary - Antimicrobial 2023 (rifaximin monograph) Why The formulary's first listed rifaximin indication is reducing the risk of recurrent overt hepatic encephalopathy in adults. Lactulose alone leaves a substantial recurrence rate, and the patient who has already been confused once is the one who needs this. 27 products are marketed in Egypt, in both 200 mg and 550 mg. Caution Added to the lactulose, not instead of it. The licensed indication is preventing recurrence on top of lactulose, and stopping the lactulose loses most of the benefit. This is prevention after an episode has happened, not treatment of the acute confusion in front of you - that is still lactulose titrated to 2-3 soft stools a day. The 550 mg strength is the encephalopathy strength. The 200 mg tablets are the travellers' diarrhoea product and three of them a day is not the same prescription. Barely absorbed, so systemic side effects are few, but peripheral oedema and dizziness are reported in over 10%. No dose adjustment for renal impairment; use with caution in Child-Pugh class C. Cost is the real barrier in Egypt - check the patient can sustain it before starting, because stopping and restarting achieves nothing. Egypt IDIBACT 550 MG 20 F.C.TAB. INTERNATIONAL... 103.75 EGP (5.19/unit) ROLAXIMINE 550 MG 30 F.C. TAB. EVA PHARMA > ... 225.00 EGP (7.50/unit) RIFAXEROSE 550 MG 10 F.C. TABS. AVERROES PHARMA 82.00 EGP (8.20/unit) BIOREFAMIN 550 MG 10 F.C.TABS. P & C LABS > ... 148.00 EGP (14.80/unit) DUFAXIMIN 550 MG 28 F.C. TABS. AUG PHARMA 480.00 EGP (17.14/unit) FATROXIM 550 MG 30 F.C. TAB. EGPI > ATM PH... 516.00 EGP (17.20/unit) GASTROBIOTIC 550 MG 30 F.C. TAB. ANDALOUS PHARMA 516.00 EGP (17.20/unit) TRAVIGUARD 550 MG 20 F.C. TABS. P AND C LABS ... 344.00 EGP (17.20/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)