What analgesic is suitable for patients with liver cirrhosis?

From the Guidelines

For patients with liver cirrhosis, acetaminophen (Tylenol) is generally considered the safest pain medication when used at appropriate doses, with a recommended maximum dose of 2-3 g per day, as stated in the 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma 1. The use of acetaminophen in patients with liver cirrhosis is supported by several studies, including a study published in the Journal of Hepatology in 2018, which recommends acetaminophen up to 3 g/day for the management of pain of mild intensity in patients with hepatocellular carcinoma on cirrhosis 1. Some key points to consider when using acetaminophen in patients with liver cirrhosis include:

• The recommended maximum dose is lower than for healthy individuals, typically no more than 2-3 g per day, divided into doses of 500-1000 mg every 6 hours as needed.
• Patients should avoid NSAIDs like ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin as these medications can increase bleeding risk, impair kidney function, and cause fluid retention, which are particularly dangerous in cirrhosis.
• Opioid medications may be used for severe pain under close medical supervision, but they require dose adjustments and careful monitoring as the liver normally metabolizes these drugs, as noted in the 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma 1.
• Patients with cirrhosis should always consult their hepatologist or gastroenterologist before taking any pain medication, even over-the-counter options, as individual circumstances may require personalized recommendations. The reason acetaminophen is preferred is that when used at appropriate doses, it causes minimal liver stress compared to alternatives, though the reduced maximum dose is crucial to prevent additional liver damage, as supported by a study published in the Clinical and Molecular Hepatology in 2022 1.

From the FDA Drug Label

Metabolism of tramadol and M1 is reduced in patients with advanced cirrhosis of the liver, resulting in both a larger area under the concentration time curve for tramadol and longer tramadol and M1 elimination half-lives (13 hrs. for tramadol and 19 hrs. for M1). In cirrhotic patients, adjustment of the dosing regimen is recommended (see DOSAGE AND ADMINISTRATION)

• Tramadol may not be the best option for patients with liver cirrhosis due to reduced metabolism and longer elimination half-lives.
• The FDA drug label recommends adjusting the dosing regimen for patients with advanced cirrhosis of the liver 2.
• However, it does not provide a specific alternative pain medicine that is good for liver cirrhosis.

From the Research

Pain Management for Liver Cirrhosis

• Acetaminophen is considered a safe analgesic for patients with compensated liver cirrhosis, as long as it is used at recommended doses 3, 4, 5, 6, 7.
• The recommended dose of acetaminophen for patients with liver cirrhosis is 2-3 grams per day, with a maximum dose of 2 grams per day for long-term use 5, 7.
• Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with liver cirrhosis due to the risk of renal impairment, hepatorenal syndrome, and gastrointestinal hemorrhage 4, 5, 7.
• Opioids can be used in patients with liver cirrhosis, but with caution and at low doses, due to the risk of toxicity and encephalopathy 5, 7.
• Adjuvant analgesics such as gabapentin, pregabalin, and tricyclic antidepressants may be used cautiously in patients with liver cirrhosis and neuropathic pain 5, 7.
• Topical diclofenac and lidocaine may be safe for use in patients with liver cirrhosis 5.
• Celecoxib can be administered for short-term use (≤5 days) in patients with Child's A and Child's B cirrhosis, with a 50% dose reduction 5.