Weersink et al give recommendations for prescribing proton pump inhibitors (PPIs) in patients with cirrhosis. The authors are from multiple institutions in The Netherlands.

Therapy with a PPI in a cirrhotic:

(1) may be associated with infections (spontaneous bacterial peritonitis, others)

(2) may precipitate hepatic encephalopathy

(3) may be continued for no clear indication


Proton pump inhibitors are metabolized in the liver (CYP2C19, CYP3A4). End-stage liver disease can result in accumulation of some PPIs.


PPI's for Child-Pugh-Turcotte (CTP) grade A and B, with reduction in maximum dose:

(1) omeprazole

(2) rabeprazole


PPI for CTP grade C:

(1) esomeprazole, with maximum dose 20 mg per day


PPIs to avoid:

(1) pantoprazole

(2) lansoprazole

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