From the Guidelines
In liver failure, it's crucial to avoid NSAIDs like ibuprofen (Advil, Motrin), naproxen (Aleve), and diclofenac, as they can worsen liver function and increase bleeding risk, and instead consider alternative pain management options under medical supervision, as recommended by the 2022 klca-ncc korea practice guidelines for the management of hepatocellular carcinoma 1. When managing pain in patients with liver failure, it's essential to consider the potential risks and benefits of various medications.
- NSAIDs, such as ibuprofen and naproxen, should be avoided due to their potential to worsen liver function and increase bleeding risk, as noted in the 2022 klca-ncc korea practice guidelines for the management of hepatocellular carcinoma 1.
- Acetaminophen, although not directly toxic to the liver at normal doses, should be used with caution, as high doses can cause liver toxicity, and its use is advised against in combination opioid-acetaminophen products to prevent excess acetaminophen dosing, as recommended by the Journal of the National Comprehensive Cancer Network 1.
- Opioid medications, such as morphine, oxycodone, and hydromorphone, require significant dose reductions, as the liver is responsible for metabolizing these drugs, and impaired metabolism can lead to drug accumulation and toxicity, as discussed in the 2022 klca-ncc korea practice guidelines for the management of hepatocellular carcinoma 1. Some patients may benefit from non-pharmacological approaches, such as physical therapy or topical treatments, which can help manage pain without the risks associated with certain medications.
- Tramadol, a nonopioid analgesic, may be used with caution, as its bioavailability may increase in patients with liver cirrhosis, and its use should be limited to no more than 50 mg within 12 hours, as recommended in the 2022 klca-ncc korea practice guidelines for the management of hepatocellular carcinoma 1.
- Fentanyl, a short-acting opioid, may be preferred in liver failure, as it does not produce toxic metabolites and its blood concentration remains unchanged in patients with liver cirrhosis, as noted in the 2022 klca-ncc korea practice guidelines for the management of hepatocellular carcinoma 1. It's essential to consult with a healthcare provider before taking any medication if you have liver disease, as they can recommend appropriate alternatives and dosing based on your specific liver function, and provide guidance on the safe use of pain medications in liver failure, as recommended by the Intensive Care Medicine journal 1.
From the Research
Pain Medications to Avoid in Liver Failure
- Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with liver disease due to the risk of renal impairment, hepatorenal syndrome, and gastrointestinal hemorrhage 2, 3.
- Opioids with toxic metabolites, such as pethidine (meperidine), should be avoided in patients with liver disease due to the increased risk of toxicity 3.
- Certain opioids, such as codeine or tramadol, may have reduced analgesic effect in patients with liver disease due to altered hepatic biotransformation 3.
- Opioids with high oral bioavailability, such as morphine, oxycodone, and hydromorphone, may require lower doses and/or longer administration intervals in patients with liver disease to avoid accumulation and adverse effects 3.
Safe Alternatives
- Paracetamol (acetaminophen) can be used safely in patients with liver disease at recommended doses, but reduced doses of 2-3 grams daily are recommended for long-term use 4, 2, 3.
- Phenylpiperidine opioids, such as fentanyl, sufentanil, and remifentanil, appear to be unaffected by liver disease and may be suitable alternatives 3.
- Adjuvant analgesics, such as tricyclic antidepressants and anti-convulsants, may be used cautiously in patients with liver disease and neuropathic pain 2.