Regimens.
| Drug | Dose and route | Hepatic adjustment and ceiling |
|---|
| Furosemide | 20 to 40 mg orally once or twice daily, titrated to weight and oedema | Combine with spironolactone in cirrhosis; maximum usually 160 mg daily |
| Spironolactone | 25 mg orally once daily in heart failure; 100 mg in ascites | Titrate with furosemide at a 100 to 40 ratio when ascites is present; maximum 400 mg daily |
| Bisoprolol | 1.25 mg orally once daily, doubled every 2 weeks | Maximum 10 mg daily; in severe impairment keep to 10 mg daily at most and titrate slowly |
| Carvedilol | 3.125 mg orally twice daily, doubled every 2 weeks | In cirrhosis with ascites do not exceed 12.5 mg daily; contraindicated in severe hepatic impairment in the heart failure label, so use only with specialist input |
| Metoprolol succinate | 12.5 to 25 mg orally once daily, doubled every 2 weeks | Maximum 200 mg daily; reduce in hepatic impairment |
| Sacubitril with valsartan | Child-Pugh B: start 24 mg with 26 mg orally twice daily | Avoid in Child-Pugh C and in ascites |
| Dapagliflozin or empagliflozin | 10 mg orally once daily | No adjustment in mild to moderate impairment; start dapagliflozin at 5 mg in severe impairment where permitted |
| Digoxin | 62.5 to 125 micrograms orally once daily | Renally cleared; aim for a level of 0.5 to 0.9 ng/mL; use lower doses in sarcopenia |
| Ivabradine | 2.5 mg orally twice daily | Caution in Child-Pugh B; contraindicated in Child-Pugh C |
| Hydralazine with isosorbide dinitrate | Hydralazine 25 mg three times daily with isosorbide dinitrate 20 mg three times daily | Alternative if angiotensin converting enzyme inhibitors are not tolerated; limited by hypotension |
Avoid. Amiodarone (hepatotoxic) where alternatives exist, non-steroidal anti-inflammatory drugs, non-dihydropyridine calcium channel blockers in systolic failure, and thiazolidinediones.
Statins and anticoagulants. Statins may continue for cardiovascular risk. Anticoagulant choice follows hepatic class: apixaban in Child-Pugh A, low molecular weight heparin when more advanced.
Pregnancy. Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, sacubitril with valsartan and spironolactone are avoided. Metoprolol, furosemide and hydralazine are used with specialist input.
Breastfeeding. Metoprolol, enalapril and furosemide are compatible; furosemide may suppress lactation.
Older adults. Higher risk of hypotension, hyponatraemia and falls; halve starting doses.
Kidney impairment. Common in both conditions; adjust digoxin, spironolactone and sodium glucose cotransporter 2 inhibitors to estimated clearance, interpreted with caution.
East Africa. Rheumatic heart disease and peripartum cardiomyopathy are common causes of heart failure. Alcohol-related cardiomyopathy and cirrhosis can coexist. Hepatitis B and schistosomiasis add liver causes.
Interactions. Digoxin with amiodarone, spironolactone or erythromycin raises digoxin levels. Diuretics with sodium glucose cotransporter 2 inhibitors cause volume depletion.
