ASK DIS: Analgesia : In Hepatic Failure

A pharmacological approach to analgesia in patients with cirrhosis who have no renal failure, active alcoholism, or active substance abuse.
Starting doses are used unless otherwise indicated.
Doses should be carefully titrated as tolerated
Avoid polypharmacy and monitor for adverse drug events.

Paracetamol

In general, for long-term use in cirrhotic patients it is recommended to reduce dosing at 2 to 3 g/d.
Although such patients may eliminate paracetamol more slowly than patients without liver disease, repeated administration of the drug does not result in accumulation of hepatotoxic intermediate, NAPQI.
Furthermore, there is no evidence of increased CYP enzymes activity or reduced hepatocellular glutathione stores in patients with liver disease.

NSAIDs

should be avoided in those with both compensated and decompensated cirrhosis, primarily because of the risk of acute renal failure due to prostaglandin inhibition.
An increased risk of GI mucosal bleeding, variceal hemorrhage, impaired renal function, and development of diuretic-resistant ascites is seen with use of NSAIDs in patients with cirrhosis with portal hypertension
Selective COX-2 inhibitors
inadequate data to establish the safety of selective COX-2 inhibitors in patients with advanced CLD or cirrhosis
If used, celecoxib product information suggests a 50% dose reduction for Child-Pugh class B cirrhosis

Opiods

should be administrated with a longer interval between doses and possibly lower doses, with individual titration to achieve optimal pain relief without signiﬁcant adverse effects.
Careful follow-up is necessary to check for signs of sedation, opioid-induced constipation and early encephalopathy.
Immediate discontinuation of the opioids should be considered if any sign of these complications is appeared.

Fentanyl

Generally a good choice for patients with CLD or cirrhosis when opiate treatment indicated.
Useful option in patients with renal failure in setting of cirrhosis.
No dose adjustment needed for single dose.
With repeated dosing, reduce dose and frequency by approximately 25 to 50%.
Initiate transdermal patch at half usual dose.

Morphine

Accumulation of metabolites with complex effects (eg, respiratory depression, analgesic tolerance, neurotoxicity) can occur in patients with cirrhosis and renal failure
Reduce dose and frequency by approximately 50% in advanced CLD or cirrhosis.
Titrate dose gradually to avoid accumulation of active drug.
Avoid in patients with cirrhosis and renal failure.

Tramadol

Unpredictable onset, variable analgesic efficacy, and risk of accumulation in patients with cirrhosis
Avoid use in patients with decompensated cirrhosis.
Avoid use in patients at risk for seizures.
Based upon limited experience, a reduced dose of 25 mg every eight hours may be considered for treatment of pain in patients with advanced CLD or well-compensated cirrhosis.

References

ASK DIS