Management of pain in patients with advanced chronic liver disease or cirrhosis
- James P Hamilton, MD
James P Hamilton, MD
- Assistant Professor of Medicine
- Johns Hopkins University School of Medicine
- Eric Goldberg, MD
Eric Goldberg, MD
- Associate Professor of Medicine
- University of Maryland School of Medicine
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology; Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
- Section Editor
- Bruce A Runyon, MD
Bruce A Runyon, MD
- Section Editor — Cirrhosis and Its Complications
- Clinical Professor of Medicine
- University of New Mexico, Division of Gastroenterology and Hepatology
- Special Hepatology Consultant to the Indian Health Service
- Northern Navajo Medical Center, Shiprock, New Mexico
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 antiinflammatory 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".)
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