REVIEWPain Management in the Cirrhotic Patient: The Clinical Challenge
Section snippets
OTCA MEDICATIONS
Over-the-counter analgesics, principally acetaminophen and NSAIDs, are commonly used medications worldwide. Guidelines for the use of OTCAs in patients with chronic liver disease are not readily available despite the possibility that such patients may be more susceptible to adverse reactions. Patients are often counseled to modify use of these drugs. Health care professionals frequently recommend avoidance of the use of acetaminophen in patients with liver disease or cirrhosis, whereas NSAIDs
SUMMARY
No evidence-based guidelines exist on the use of analgesics in patients with liver disease and cirrhosis. This review underscores the paucity of prospective studies that have assessed the safety of various analgesics in patients with advanced hepatic dysfunction. It has been an unspoken standard of practice by hepatologists alike to err on the side of caution, recommending 2 to 3 g/d of acetaminophen. Because the FDA may recommend limiting acetaminophen to a maximum daily dosage of 2.6 g, we
CONCLUSION
In general, our recommendation (expert opinion) for long-term acetaminophen use in cirrhotic patients (not actively drinking alcohol) is for reduced dosing at 2 to 3 g/d.14 For short-term use or 1-time dosing, 3 to 4 g/d appears to be safe; however, with the new FDA recommendations, a maximum dosage of 2 to 3 g/d is recommended. NSAIDs and opioids may be used at reduced doses in patients with chronic liver disease without cirrhosis. Patients with cirrhosis have fewer analgesic options. NSAIDs
Acknowledgments
We thank Laura J. Myhre, PharmD, RPh, for her assistance in preparing Table 1.
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An earlier version of this article appeared Online First.
List of sources of written communication, expert opinion, is as follows: John J. Poterucha, MD; Michael R. Charlton, MD; J. E. Hay, MD; John B. Gross Jr, MD; Russell H. Wiesner, MD; Patrick S. Kamath, MD; William Sanchez, MD; W. Ray Kim, MD; Gerry M. Minuk, MD; William M. Lee, MD; Timothy M. McCashland, MD; Michael F. Sorrell, MD; Marie Laryea, MD; and Josh Levitsky, MD.