Patients with liver disease may develop acute or chronic pain from a variety of causes. In addition to causes common in the otherwise healthy population, those with advanced liver disease may have ascites (leading to abdominal and lower back pain) and gynecomastia (leading to mastalgia).
Management of pain in patients with liver disease raises special concerns. The choice of appropriate analgesic agents requires a thorough understanding of their pharmacokinetic and side effect profiles (table 1).
As a general rule, patients with mild liver disease can be treated with a similar choice of drugs as those who are otherwise healthy. Susceptibility to adverse effects increases with worsening liver function due to altered pharmacokinetics and hemodynamic changes. (See "Tests of the liver's capacity to transport organic anions and metabolize drugs".)
The exact cutoff at which drug doses and the selection of drugs should be altered is uncertain. Modifications of drug-prescribing should generally be considered in patients who have developed advanced chronic liver disease (eg, bridging fibrosis on biopsy) or cirrhosis, particularly when accompanied by portal hypertension (such as those with esophageal varices, ascites, or portal gastropathy/colopathy) or renal insufficiency. Important exceptions are patients who are actively drinking alcohol and those on multiple medications, who can develop severe hepatotoxicity from concomitant use of acetaminophen regardless of the severity of liver disease.
This topic review will summarize safety considerations of nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), selective NSAIDs (COX-2 inhibitors), opioids, acetaminophen, and agents for neuropathic pain in patients with advanced chronic liver disease or cirrhosis. The recommendations regarding analgesic use in patients with advanced chronic liver disease are also summarized in the accompanying table (table 1). A general approach to patients with cirrhosis is presented separately. (See "Cirrhosis in adults: Overview of complications, general management, and prognosis".)