The therapeutic use of analgesics in patients with advanced chronic liver disease or cirrhosis

The liver as an important organ in the body has many essential functions in physiological processes. Pain management in cirrhotic patients is a major clinical challenge for medical professionals. Unfortunately, there are no concrete guidelines available regarding the administration of analgesics in patients with liver cirrhosis. In this review, we aimed to summarize the available literature and suggest appropriate evidence-based recommendations regarding to administration of these drugs. Based on comprehensive PubMed search for publications on these areas in analgesics, we provided a review of what is known about the therapeutic use of analgesics in patients with liver cirrhosis and the search was conducted using the databases PubMed, Medline, EMBASE and Web of Science. An indexed MEDLINE search was conducted, using keywords analgesics , hepatic impairment , cirrhosis , acetaminophen or paracetamol , NSAIDs or nonsteroidal anti-inflammatory drugs , opioid for the period of 2000 to 2016. This study showed that 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. Paracetamol is safe in patients with chronic liver disease, but a reduced dose of 2-3 g/d is recommended for long-term use. Non-steroidal anti-inflammatory drugs (NSAIDs) are best avoided because of the risk of renal impairment, hepatorenal syndrome, and gastrointestinal hemorrhage. Most opioids can have deleterious effects in patients with cirrhosis. They have an increased risk of toxicity and hepatic encephalopathy. They should be administrated with lower and less frequent dosing in these patients and be avoided in patients with a history of encephalopathy or addiction to any substance. Management of pain in patients with liver disease raises special concerns. The choice of appropriate analgesic agents requires a thorough understanding of their pharmacokinetics and side effect profiles. As a result pain management in these patients generates considerable misconception among health care professionals, leading under-treatment of pain in this population. Providing concrete guidelines toward the administration of these agents will lead to more efficient and safer pain management in this setting.

Keywords:

Acetaminophen , Adverse drug events , Hepatic cirrhosis , Pain management