Pain management in patients with cirrhosis

This topic was reviewed in an article in the February 2024 issue of the American Journal of Medicine, linked here:

The Safe Use of Analgesics in Patients with Cirrhosis: A Narrative Review

Here are key points regarding various categories of analgesics:

Acetaminophen

Contrary to prevailing myth, acetaminophen is safe in patients with liver disease, including cirrhosis, provided dose limitations are applied.

In patients with liver disease who are actively consuming ethanol, short-term use up to two grams per day is permissible. For chronic use in patients not actively consuming alcohol a limit of two grams per day is also advised. Up to four grams per day may be permissible in cirrhotic patients not consuming alcohol for short-term use

NSAIDs

Systemic use is contraindicated for a variety of reasons. Topical diclofenac appears safe.

Opiates

In general, opiate use in patients with cirrhosis is associated with increased rates of hospital admission, increased length of stay, and an increased incidence of hepatic encephalopathy.

According to the review, they should be limited to short-term use and confined to short-acting preparations.

Gabapentin and pregabalin

These agents undergo virtually no hepatic metabolism and are considered safe in cirrhosis. Of course, like any drug with sedative effects, there is the potential to precipitate hepatic encephalopathy.

Duloxetine

This is widely used in pain treatment.  However, adverse hepatic outcomes have been reported and it is considered contraindicated in liver disease.  This recommendation is in keeping with product labeling.

Topical lidocaine is considered safe.