A 48-year-old woman with decompensated cirrhosis and ascites refractory to dietary sodium restriction and furosemide (80 mg daily) presents with progressive abdominal distension and dyspnoea. Which is the drug of choice for management of refractory ascites?

Explanation

## Pharmacological Management of Refractory Ascites in Cirrhosis **Key Point:** Spironolactone is the first-line diuretic for ascites management in cirrhosis, especially refractory ascites. It is a potassium-sparing aldosterone antagonist that addresses the underlying pathophysiology of secondary hyperaldosteronism. ### Pathophysiology of Ascites in Cirrhosis - Portal hypertension → splanchnic vasodilation → decreased effective arterial blood volume - Activation of RAAS and sympathetic nervous system - Secondary hyperaldosteronism → sodium and water retention - Spironolactone blocks aldosterone action at the collecting duct → promotes sodium excretion while retaining potassium ### Dosing and Efficacy | Parameter | Detail | |-----------|--------| | **Starting dose** | 100 mg once daily | | **Maximum dose** | 400 mg daily (titrate every 3–7 days) | | **Response rate** | 50–60% achieve complete ascites resolution | | **Onset** | 3–5 days (slower than loop diuretics) | | **Potassium-sparing** | Yes — monitor K^+^ and creatinine | **High-Yield:** Spironolactone is superior to loop diuretics alone because it: 1. Addresses the underlying aldosterone-mediated sodium retention 2. Preserves renal perfusion (less risk of hepatorenal syndrome) 3. Maintains potassium balance (critical in cirrhosis) 4. Is first-line even for refractory ascites (before paracentesis) ### Clinical Pearl - Combination therapy: Spironolactone + furosemide (1:2.5 ratio) is more effective than either drug alone - Refractory ascites defined as: ascites that does not resolve or recurs rapidly despite maximum diuretic therapy (spironolactone 400 mg + furosemide 160 mg daily) and sodium restriction < 2 g/day - If ascites persists despite maximum medical therapy → consider large-volume paracentesis (LVP) with albumin infusion or transjugular intrahepatic portosystemic shunt (TIPS) ### Monitoring During Therapy - Serum creatinine, electrolytes (K^+^, Na^+^), and liver function every 3–7 days during titration - Target weight loss: 0.5–1 kg/day (max 1.5 kg/day if peripheral oedema present) - Avoid over-diuresis → risk of hepatorenal syndrome, hyponatraemia, hyperkalaemia **Warning:** Do NOT use spironolactone alone in patients with baseline K^+^ > 5.5 mEq/L or creatinine > 2 mg/dL without careful monitoring.