REVIEW
Pain Management in the Cirrhotic Patient: The Clinical Challenge

https://doi.org/10.4065/mcp.2009.0534Get rights and content

Pain management in patients with cirrhosis is a difficult clinical challenge for health care professionals, and few prospective studies have offered an evidence-based approach. In patients with end-stage liver disease, adverse events from analgesics are frequent, potentially fatal, and often avoidable. Severe complications from analgesia in these patients include hepatic encephalopathy, hepatorenal syndrome, and gastrointestinal bleeding, which can result in substantial morbidity and even death. In general, acetaminophen at reduced dosing is a safe option. In patients with cirrhosis, nonsteroidal anti-inflammatory drugs should be avoided to avert renal failure, and opiates should be avoided or used sparingly, with low and infrequent dosing, to prevent encephalopathy. For this review, we searched the available literature using PubMed and MEDLINE with no limits.

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.

REFERENCES (47)

  • JP Villeneuve et al.

    Pharmacokinetics and metabolism of acetaminophen in normal, alcoholic and cirrhotic subjects

    Gastroenterol Clin Biol

    (1983)
  • A Bohan et al.

    Mechanisms of hepatic transport of drugs: implications for cholestatic drug reactions

    Semin Liver Dis

    (2002)
  • F Delco et al.

    Dose adjustment in patients with liver disease

    Drug Saf

    (2005)
  • DW Cockcroft et al.

    Prediction of creatinine clearance from serum creatinine

    Nephron

    (1976)
  • S Rossi et al.

    Use of over-the-counter analgesics in patients with chronic liver disease: physicians' recommendations

    Drug Saf

    (2008)
  • WM Lee

    Etiologies of acute liver failure

    Semin Liver Dis

    (2008)
  • A Larson et al.

    Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study

    Hepatology

    (2005)
  • P Nourjah et al.

    Estimates of acetaminophen (Paracetamol)-associated overdoses in the United States

    Pharmacoepidemiol Drug Saf

    (2006)
  • US Department of Health and Human Services et al.

    Drugs: acetaminophen information

  • GD Benson et al.

    The therapeutic use of acetaminophen in patients with liver disease

    Am J Ther

    (2005)
  • R Dart et al.

    Does therapeutic use of acetaminophen cause acute liver failure?

    Pharmacotherapy

    (2007)
  • AR Temple et al.

    Aminotransferase activities in healthy subjects receiving three-day dosing of 4, 6, or 8 grams per day of acetaminophen

    Clin Toxicol (Phila)

    (2007)
  • LF Prescott

    Paracetamol overdosage: pharmacological considerations and clinical management

    Drugs

    (1983)
  • Cited by (0)

    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.

    View full text