The Therapeutic Use of Analgesics in Patients with Liver Cirrhosis: A Literature Review and Evidence-Based Recommendations

Abstract

Context:Pain management in cirrhotic patients is a major clinical challenge for medical professionals. Unfortunately there are no concrete guidelines available regarding the administration of analgesics in patients with liver cirrhosis. In this review we aimed to summarize the available literature and suggest appropriate evidence-based recommendations regarding to administration of these drugs.Evidence Acquisition:An indexed MEDLINE search was conducted in July 2014, using keywords “analgesics”, “hepatic impairment”, “cirrhosis”, “acetaminophen or paracetamol”, “NSAIDs or nonsteroidal anti-inflammatory drugs”, “opioid” for the period of 2004 to 2014. All randomized clinical trials, case series, case report and meta-analysis studies with the above mentioned contents were included in review process. In addition, unpublished information from the Food and Drug Administration are included as well.Results:Paracetamol is safe in patients with chronic liver disease but a reduced dose of 2-3 g/d is recommended for long-term use. Non-steroidal anti-inflammatory drugs (NSAIDs) are best avoided because of risk of renal impairment, hepatorenal syndrome, and gastrointestinal hemorrhage. Most opioids can have deleterious effects in patients with cirrhosis. They have an increased risk of toxicity and hepatic encephalopathy. They should be administrated with lower and less frequent dosing in these patients and be avoided in patients with a history of encephalopathy or addiction to any substance.Conclusions:No evidence-based guidelines exist on the use of analgesics in patients with liver disease and cirrhosis. As a result pain management in these patients generates considerable misconception among health care professionals, leading under-treatment of pain in this population. Providing concrete guidelines toward the administration of these agents will lead to more efficient and safer pain management in this setting.

The Role of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in the Treatment of Patients With Hepatic Disease: A Review Article

“…Indeed, NSAID-related DILI is the second most common cause of liver injury in France (2002) and Iceland (2013), as well as the third most common cause in Spain (2005) (23-25). Evidence shows that all NSAIDs have the potential for hepatotoxicity to different degrees (26, 27), which has been suggested as an important reason for withdrawing large numbers of these drugs from the market (e.g., rofecoxib). In most previous research studies and scientific reports, NSAID-induced liver injury has been reported in relation to the chronic use of the drug, while renal injury, gastrointestinal hemorrhage, and respiratory symptoms can occur even in a non-toxic dose (28-31).…”

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“…(Fig.3) The medical condition of the patient should be assessed before proceeding with the dental treatment as it may lead to potential complications when analgesics are prescribed which can be due to drug interactions. Opioid analgesics can worsen the condition in patients with cirrhosis posing risk of toxicity and hepatic encephalopathy 8 . NSAIDs are contraindicated in patients having gastric ulcers and bleeding 9 .…”

Limited Knowledge of Acetaminophen in Patients with Liver Disease

“…Providing safe and effective analgesia to patients with cirrhosis can be a clinical challenge. Despite the increased risk of overdose toxicity, acetaminophen is still considered the safest analgesic for patients with liver cirrhosis 20,21. Acetaminophen is preferred over nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with liver disease because of the risk of nephrotoxicity, gastrointestinal toxicity and platelet impairment associated with medications in that class 20,22–25…”