Table 3.

Seven General Recommendations for Rational Medical Therapy for Uncomplicated Ascites in Patients with Cirrhosis

No.	Recommendation
1	Most patients with moderate ascites can be managed as outpatients. The treatment can be started with a diet that is moderately low in sodium (90 mmol/day). A sequential diuretic treatment should be preferred in patients who have their first episode of ascites, starting with an antialdosteronic drug (100–200 mg/day). A loop diuretic should be added only in nonresponders to 400 mg/day of an antialdosteronic drug. Combination therapy from the beginning of treatment should be preferred in patients with recurrent ascites, starting with 40 mg/day of furosemide and 100 to 200 mg/day of an aldosterone antagonist.
2	In nonresponders, the dose of diuretics should be increased stepwise in either a sequential or combination treatment, every 4 to 5 days to a maximum of 400 mg/day of antialdosteronic drug and 160 mg/day of furosemide.
3	The goal of diuretic treatment should be to achieve a weight loss of 300 to 500 g/day in patients without peripheral edema and 1 kg/day in patients with peripheral edema. Patients should be instructed to reduce the dose of diuretics if a greater loss of weight occurs.
4	Once ascites has been reduced, sodium restriction should be maintained while the diuretic dosage is reduced.
5	Patients on diuretic treatment should undergo frequent clinical and biochemical monitoring.
6	Patients not responsive to top diuretic doses or patients who develop complications under diuretic treatment should be checked for refractory ascites. Patient compliance with a low‐sodium diet should be checked by measuring urine sodium excretion. In addition, patients should be checked for the use of drugs that can interfere with diuretics (e.g., nonsteroidal anti‐inflammatory drugs) and for bacterial infections.
7	Patients with grade 3 or tense ascites should by treated with therapeutic paracentesis.