Analgesia for Cirrhotics: A Practical Approach

May 29, 2014 – 09:03 am

liver.jpg Commentary by Albert B. Knapp MD, NYU Clinical Professor of Medicine (Gastroenterology)

WS, a 49 yo year old Caucasian male with a known 35 year history of alcohol abuse, now presents with jaundice, tense ascites and a left shoulder fracture following a bar room brawl last night. He is admitted to the orthopedic service for elective pinning but is presently in great pain. You are consulted in regards to pain management….

How should you approach the use of analgesia in patients with cirrhosis?

The medical management of the cirrhotic patient is commonly fraught with peril and problems. Pain is a common complaint that ranges from a minor hindrance to a major impairment. The question of how and when to administer analgesia is a frequent and lively topic of ward management rounds.

Cirrhotic patients have a host of important problems that make straightforward analgesia potentially risky. These include profound impairments in synthetic and detoxification capacities, variable degrees of portal hypertension with resultant varices formation, frequent but sometimes subtle maldigestion and malabsorption, variable acute & and chronic mental status changes, and the omnipresent threats of pulmonary (hepatopulmonary syndrome, HPS) and renal compromise (hepatorenal syndrome, HRS).

The first clinical point to make is to assess the true extent of pain. The more intense the pain, the more powerful the analgesia required. One should always institute initial therapy with the mildest of medications and progress up the ladder of intensity analgesic strength should symptoms persist. Potential side effects vary by analgesic class but usually revolve around mental or hemodynamic status changes. This dovetails into clinical point number two, namely, to expect the unexpected.

The most efficacious way to think about analgesic agents is by class: The three most frequently used classes are acetaminophen (Tylenol, paracetamol), NSAIDs, and narcotics. I will also briefly discuss certain “crossover” compounds as well as non-classified drugs.

Tylenol (at low doses of 325mg PO every 4-6 hours) is eminently safe and bereft of any major CNS, hepatic, or hemodynamic side-effects. The medication is readily metabolized even in the most compromised of cirrhotic livers and no discernable changes in mental, portal, pulmonary or renal status are generally detected. Tylenol is a preferred analgesic, but unfortunately is too mild to meet the needs of most patients. “Extra strength” Tylenol (usually 650 mg per pill) must be used with caution as no patient with cirrhosis should receive more than 5-6 grams of Tylenol in a 24 hour period as this cumulative dose can result in sub-acute or even acute hepatic injury.


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