What alternative analgesics can be given to a patient with liver cirrhosis and hypotension?

From the Guidelines

For a patient with liver cirrhosis and hypotension, acetaminophen (Tylenol) is the safest pain medication option, administered at a reduced dose of no more than 2 grams per day. This recommendation is based on the most recent evidence from the 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma 1, which suggests that a daily dose of 2–3 g of acetaminophen is generally recommended for patients with liver cirrhosis, as they are at risk of metabolic disorder and prolonged half-life of acetaminophen.

When considering alternative analgesics, it is essential to avoid NSAIDs like ibuprofen and naproxen, as they can worsen liver function, increase bleeding risk, and further reduce blood pressure 1. Opioids may be used cautiously in severe pain under close medical supervision, with medications like hydromorphone or fentanyl being preferred over morphine or codeine, which rely heavily on liver metabolism 1. Dosing should start at 25-50% of the normal dose with careful titration. Tramadol should be avoided due to its complex metabolism and potential for accumulation, especially in patients with liver cirrhosis, where its bioavailability may increase two to three-fold 1.

Some key points to consider when managing pain in patients with liver cirrhosis and hypotension include:

• Monitoring blood pressure regularly when administering any pain medication
• Incorporating non-pharmacological pain management approaches like physical therapy, heat/cold therapy, and relaxation techniques into the treatment plan
• Implementing any pain management strategy under direct medical supervision
• Avoiding the use of codeine, as its metabolites may accumulate in the liver, causing side effects such as respiratory depression 1
• Considering palliative radiotherapy for bone metastases causing pain or at significant risk of spontaneous secondary fracture, as recommended by the EASL clinical practice guidelines for the management of hepatocellular carcinoma 1

From the Research

Alternative Analgesics for Patients with Liver Cirrhosis and Hypotension

• Acetaminophen can be used safely in patients with liver disease, including those with cirrhosis, at recommended doses of up to 2g/day 2, 3, 4, 5, 6
• Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided due to the risk of worsening renal function, blunting diuretic response, and increasing risk of portal hypertensive and peptic ulcer bleeding 3, 5, 6
• 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 3
• Opioids carry the risk of precipitating hepatic encephalopathy and should generally be avoided, but if necessary, should be limited to short-acting agents for short duration 3, 5
• Gabapentin and pregabalin are generally safe for use in patients with cirrhosis 3, 5
• Topical diclofenac and lidocaine seem to be safe in patients with cirrhosis 3
• Duloxetine should be avoided in patients with hepatic impairment 3

Considerations for Patients with Hypotension

• Patients with hypotension should be closely monitored when using analgesics, as some medications may exacerbate hypotension 6
• The choice of analgesic agent should be individualized, taking into account the severity of liver disease, history of opioid dependence, and potential drug interactions 5