From the Guidelines
Pain management in cirrhosis requires careful consideration due to altered drug metabolism and increased risk of complications, and acetaminophen is generally the first-line analgesic at reduced doses of 2 grams per day maximum to avoid hepatotoxicity. For patients with cirrhosis, the following analgesia options are available:
- Acetaminophen: reduced doses of 2 grams per day maximum to avoid hepatotoxicity, as recommended by the 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma 1
- Opioids: may be necessary for moderate to severe pain, but should be used cautiously with reduced starting doses (approximately 50% of standard dose) and careful titration, with consideration of the underlying liver disease and type of drug, dose, and interval of administration determined according to liver function 1
- Fentanyl: may be suitable for severe pain as it's primarily eliminated through renal pathways, with a recommended dose of 12/25/50/100 mcg 1
- Hydromorphone: often preferred over morphine or codeine, as it has less dependence on hepatic metabolism, and its half-life is reported to be stable even in patients with liver dysfunction 1
- Adjuvant medications: like gabapentin or pregabalin, starting at low doses and titrating slowly, can be helpful for neuropathic pain, but should be used with caution in patients with liver cirrhosis due to the potential for increased side effects 1
- Non-pharmacological approaches: such as physical therapy, heat/cold therapy, and psychological interventions, should be incorporated into the pain management plan whenever possible, as recommended by the 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma 1
NSAIDs should be avoided in cirrhosis due to increased bleeding risk and potential for renal impairment, especially in advanced disease, as reported by the 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma 1. Tramadol and codeine should also be used with caution, as they may have increased bioavailability and side effects in patients with liver cirrhosis, as reported by the 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma 1.
All medications should be monitored closely for side effects, particularly sedation and hepatic encephalopathy, and regular reassessment of pain control and medication effects is essential, with dose adjustments based on clinical response and liver function, as recommended by the 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma 1.
From the FDA Drug Label
Morphine pharmacokinetics have been reported to be significantly altered in patients with cirrhosis. Start these patients with a lower than usual dosage of morphine sulfate tablets and titrate slowly while monitoring for signs of respiratory depression, sedation, and hypotension [see Clinical Pharmacology (12.3)]. The analgesia option for patients with cirrhosis (liver cirrhosis) is morphine, but with caution:
- Start with a lower than usual dosage of morphine sulfate tablets
- Titrate slowly while monitoring for signs of:
- Respiratory depression
- Sedation
- Hypotension 2
From the Research
Analgesia Options for Patients with Cirrhosis
The following are analgesia options for patients with cirrhosis:
- Acetaminophen: considered safe for patients with chronic liver disease, with a recommended reduced dose of 2-3 g/d for long-term use 3, 4, 5
- Non-steroidal anti-inflammatory drugs (NSAIDs): best avoided due to risk of renal impairment, hepatorenal syndrome, and gastrointestinal hemorrhage 3, 6, 5
- Opioids: can have deleterious effects in patients with cirrhosis, with an increased risk of toxicity and hepatic encephalopathy, and should be administered with lower and less frequent dosing 3, 7, 5
- Adjuvants: gabapentin and pregabalin are generally safe, while duloxetine should be avoided in hepatic impairment 5
- Topical analgesics: topical diclofenac and lidocaine seem to be safe in patients with cirrhosis 5
Prescription Patterns
Prescription patterns for analgesics in patients with cirrhosis vary among physicians, with some preferring acetaminophen over NSAIDs 6. However, NSAIDs are often more frequently prescribed, despite their potential harmful effects in patients with cirrhosis 6.
Key Considerations
When managing pain in patients with cirrhosis, it is essential to consider the potential risks and benefits of each analgesic option, as well as the patient's individual clinical situation 3, 7, 5.