Can a patient with liver failure take steroids or muscle relaxers?

From the Guidelines

Patients with liver failure should generally avoid steroids and muscle relaxers unless prescribed by a healthcare provider who is aware of their liver condition. Many steroids (like prednisone, methylprednisolone) and muscle relaxers (such as cyclobenzaprine, baclofen, and carisoprodol) are metabolized by the liver and could potentially worsen liver function or accumulate to toxic levels in patients with liver failure. However, some medications in these classes may be used cautiously with dose adjustments. For example, certain steroids like prednisolone might be preferred over prednisone in liver disease because they don't require liver activation, as suggested by 1. Similarly, muscle relaxers like tizanidine might be used with reduced dosing. The concern with these medications is that impaired liver function can lead to drug accumulation, increased side effects, and potential hepatotoxicity.

According to the most recent guidelines, such as those outlined in 1, patients with acute severe autoimmune hepatitis should be considered for early corticosteroid therapy before hepatic encephalopathy onset. However, this does not directly apply to all patients with liver failure, and caution is still advised. The use of muscle relaxants in patients with liver failure is also approached with caution, but guidelines like those in 1 suggest that the initial dose may not need to be modified in hepatic failure patients, depending on the type of muscle relaxant used.

Patients with liver failure should always disclose their condition to healthcare providers, have liver function monitored regularly if these medications are necessary, and watch for signs of worsening liver function such as increased jaundice, abdominal pain, confusion, or unusual bleeding. It's also important to consider the potential for drug interactions and the impact of liver disease on the metabolism of these medications, as discussed in 1 and 1.

In terms of specific recommendations:

• Steroids should be used with caution and under the guidance of a healthcare provider aware of the patient's liver condition.
• Muscle relaxers may be used but with careful consideration of the type and dose, and with monitoring for signs of toxicity or worsening liver function.
• Patients should be closely monitored for signs of drug accumulation or hepatotoxicity.
• Alternative medications or dose adjustments should be considered to minimize risk, as suggested by the guidelines and evidence provided in 1, 1, and 1.

From the FDA Drug Label

Since complications of treatment with glucocorticoids are dependent on the size of the dose and the duration of treatment, a risk/benefit decision must be made in each individual case as to dose and duration of treatment There is an enhanced effect due to decreased metabolism of corticosteroids in patients with cirrhosis. Because of the potential toxic hepatic effect of tizanidine, the drug should be used only with extreme caution in patients with impaired hepatic function.

The patient with liver failure should not take steroids or muscle relaxers without caution.

• Steroids: The use of steroids, such as prednisone, may be enhanced in patients with liver disease, such as cirrhosis, due to decreased metabolism 2.
• Muscle relaxers: The use of muscle relaxers, such as tizanidine, should be done with extreme caution in patients with impaired hepatic function due to the potential toxic hepatic effect of the drug 3. A risk/benefit decision should be made for each individual case, considering the size of the dose and the duration of treatment 2.

From the Research

Steroids and Liver Failure

• The use of anabolic steroids can be hepatotoxic, leading to elevated liver transaminases, acute cholestatic syndrome, chronic vascular injury, hepatic tumors, and toxicant-associated fatty liver disease 4.
• Glucocorticoids (GCs) are used to suppress excessive inflammatory reactions and immunological responses in liver failure, but the dose and time for GC therapy can vary depending on the etiology of liver failure 5.
• In patients with primary adult liver transplantation under tacrolimus, steroids may be reintroduced for late rejection, recurrence of autoimmune process(es), renal impairment, or concomitant medical conditions 6.

Muscle Relaxers and Liver Failure

• There is limited information available on the use of muscle relaxers in patients with liver failure.
• Muscle wasting is a frequent complication in cirrhosis and contributes to increased risk of sepsis-related mortality, but the impact on mortality of muscle wasting after liver transplantation is controversial and needs further study 7.

Corticosteroid Therapy in Liver Disease

• Corticosteroids have been widely used in drug-induced liver injury (DILI) due to their anti-inflammatory effects, but their efficacy remains controversial 8.
• The use of corticosteroids in liver disease can have both beneficial and adverse effects, and the decision to use them should be made on a case-by-case basis, considering the potential pros and cons 8.