Can patients with cirrhosis take Norco (hydrocodone and acetaminophen) or oxycodone?

From the Guidelines

Taking Norco (hydrocodone/acetaminophen) or oxycodone with cirrhosis is not recommended due to the increased risk of side effects, including sedation, respiratory depression, and worsening encephalopathy, as the liver's reduced ability to metabolize opioids can lead to drug accumulation 1.

Key Considerations

• The liver plays a crucial role in metabolizing opioids, and liver dysfunction can lead to increased side effects from these medications 1.
• Oxycodone is metabolized into several metabolites, including oxymorphone, which has an analgesic effect, and its blood concentrations can vary, making it difficult to estimate its analgesic effect 1.
• The European Association for the Study of the Liver (EASL) recommends avoiding NSAIDs, tramadol, codeine, and oxycodone in patients with end-stage liver disease 1.

Alternative Pain Management Strategies

• Non-opioid medications that don't require extensive liver metabolism should be considered first for pain management in patients with cirrhosis 1.
• Alternative pain management strategies, such as radiation therapy, may be effective for managing pain from metastatic hepatocellular carcinoma (HCC) 1.
• A multidisciplinary approach involving experts in palliative care is necessary to effectively manage acute, recurrent, and chronic pain in patients with HCC and cirrhosis 1.

Dosing Considerations

• If pain management with opioids is necessary, lower doses (typically 25-50% of standard doses) may be prescribed with more frequent monitoring 1.
• The severity of cirrhosis, measured by Child-Pugh classification, will influence how these medications affect patients, with more advanced cirrhosis requiring greater dose reductions 1.
• Acetaminophen doses should be limited to ≤325 mg per dosage unit to reduce the risk of liver damage 1.

From the FDA Drug Label

Because oxycodone is extensively metabolized in the liver, its clearance may decrease in patients with hepatic impairment. Initiate therapy in these patients with a lower than usual dosage of oxycodone hydrochloride tablets and titrate carefully. Monitor closely for adverse events such as respiratory depression, sedation, and hypotension [see Clinical Pharmacology (12.3)] .

Oxycodone and Cirrhosis:

• Patients with hepatic impairment may have decreased clearance of oxycodone, increasing the risk of adverse events.
• Initiate therapy with a lower than usual dosage and titrate carefully.
• Monitor closely for respiratory depression, sedation, and hypotension 2.

Norco and Cirrhosis:

• Since Norco contains hydrocodone and acetaminophen, and the provided drug labels are for oxycodone, there is no direct information available for Norco.
• However, considering that Norco is also an opioid, similar precautions may be necessary for patients with cirrhosis.
• It is recommended to exercise caution and consult the specific drug label for Norco or consult with a healthcare professional 2.

From the Research

Medication Use in Cirrhosis

• The use of medications such as Norco (hydrocodone) or oxycodone in patients with cirrhosis requires careful consideration due to the potential for altered drug metabolism and increased risk of adverse effects 3, 4, 5, 6, 7.
• Studies have shown that opioids, including oxycodone, can be used safely in cirrhotic patients with moderate to severe cancer pain, but with careful monitoring and dose adjustment 3.
• However, other studies have highlighted the risks associated with opioid use in cirrhosis, including the potential for hepatic encephalopathy, particularly with chronic or high-dose use 7.

Safe Use of Analgesics

• Acetaminophen is generally considered safe for use in patients with cirrhosis, but at reduced doses of 2-3 grams per day 4, 5, 6.
• Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with cirrhosis due to the risk of renal impairment, hepatorenal syndrome, and gastrointestinal hemorrhage 4, 5, 6.
• Gabapentin and pregabalin may be safe alternatives for pain management in cirrhotic patients, particularly those with neuropathic pain 4, 6.

Opioid Use in Cirrhosis

• Opioids should be used with caution in patients with cirrhosis, and only when necessary, due to the risk of hepatic encephalopathy and other adverse effects 3, 4, 6, 7.
• Short-acting opioids may be preferred over long-acting formulations, and co-prescription of laxatives is recommended to prevent constipation and encephalopathy 6.
• The duration of opioid use should be limited to the shortest duration possible, and patients should be closely monitored for signs of hepatic encephalopathy or other adverse effects 7.