Nociceptive pain.
–Acetaminophen “is an effective and safe analgesic for most patients with chronic liver disease.” Limit to 2g per day. Avoid it in patients with severe alcoholic hepatitis or acute liver injury.
–Opioids. Use “cautiously in patients with advanced chronic liver disease or cirrhosis”. “Fentanyl appears to be safe in patients with modest hepatic dysfunction”. “Morphine, oxycodone, and hydromorphone should be used at reduced doses and prolonged intervals of administration. Tramadol may be safe, but experience is limited.” Uptodate.com
Neuropathic pain.
Gabapentin, pregabalin, and nortriptyline “can be used to treat neuropathic pain in patients with advanced chronic liver disease or cirrhosis, but the doses are lower than those used in patients who do not have cirrhosis.”
Consult pain management to assist with these patients.
“NSAIDs should be avoided in all patients with cirrhosis, due to the risk of precipitating hepatorenal syndrome. Pregabalin and gabapentin are not metabolized by the liver and can be quite helpful. Acetaminophen, while toxic in high doses, can be used safely in dosages of 2–3 g/day. Tramadol is also safe in patients with cirrhosis.” ABFM
“In patients with significant renal or hepatic dysfunction, fentanyl (given IV) is the opioid of choice.”
Medications to Avoid
- NSAIDS. NSAIDs (including aspirin) should generally be avoided in patients with advanced chronic liver disease or cirrhosis because they are associated with an increased risk of variceal hemorrhage, impaired renal function, and the development of diuretic-resistant ascites.
- Selective COX-2 inhibitors. e.g.
Read: https://www.uptodate.com/contents/management-of-pain-in-patients-with-advanced-chronic-liver-disease-or-cirrhosis