INTRODUCTION

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.

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 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, and acetaminophen in patients with cirrhosis. A general approach to patients with cirrhosis is presented separately. (See "Overview of the complications, prognosis, and management of cirrhosis".)