Pain management in cirrhosis.

[Hemegroup]

There are some contradicting opinions out there, and Epocrates lists everything as to be used with caution.

 

Any suggestions?

[archerry]

This may help:

 

pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf

[Hemegroup]

That is very helpful, thank you.

[bradtPA]

For sure, stay away from the acetaminophen combos....

[archerry]

For sure, stay away from the acetaminophen combos....

NSAIDS are much riskier. The misconception about (non-)use of acetaminophen in folks with liver disease likely stems from the deleterious effects on the liver from acute overdose or chronic excessive overuse. At appropriate doses, acetaminophen itself is actually fairly safe for use in this patient population.

[bradtPA]

We will just have to agree to disagree here. With the number one cause of liver failure in the US being Tylenol OD, max dozing per day of four grams, and chronic pain patients frequently taking more than the prescribed doses, I just think it is setting yourself up for failure to use percocet long term in that population when oxycodone will be safer.

[Hemegroup]

We will just have to agree to disagree here. With the number one cause of liver failure in the US being Tylenol OD, max dozing per day of four grams, and chronic pain patients frequently taking more than the prescribed doses, I just think it is setting yourself up for failure to use percocet long term in that population when oxycodone will be safer.

 

And where did I hear that max dosing for those with liver failure is now 2 grams. I have to agree with bradt, it doesn't seem wise. Anyhow, oxycodone is still advised to be used with caution, per the article posted above ... fentanyl appears to be the safest agent in this population.

 

http://pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf

 

http://www.fda.gov/drugs/drugsafety/informationbydrugclass/ucm165107.htm

[archerry]

At appropriate doses, acetaminophen itself is actually fairly safe for use in this patient population.

 

Hate to quote myself, but there is an important qualifier in my statement. For example, if you are writing for hydrocodone 5/325, max 3x/day, you are prescribing less than 1g of acetaminophen per day and less than 2g per day even if they "double up". Hydrocodone does not come in pill form without acetaminophen. This being said, I wasn't speaking to use of acetaminophen in combination pills nor would I necessarily advocate the use of Vicodin in this population at all, but I was taking about the use of acetaminophen in general.

 

The article from the Pain Medicine News speaks to the issue:

http://painmedicinenews.com/ViewArticle.aspx?d=Clinical%2BPain%2BMedicine&d_id=82&i=September%2B2010&i_id=661&a_id=15838

 

Review Addresses Acetaminophen Use in Cirrhosis Patients

 

by David Wild

Patients with cirrhosis can safely receive between 2 and 3 grams of acetaminophen daily for longer than two weeks, and individuals with and without cirrhosis using alcohol regularly can safely receive up to 4 grams on a short-term basis, according to Mayo Clinic researchers (Mayo Clin Proc 2010;85:451-458). Although the authors believe their review should alleviate concerns regarding the use of this analgesic at any dose in hepatically compromised patients, one expert told Pain Medicine News that more research on the topic is needed before definitive recommendations can be made.

 

“I think the published recommendations are reasonable but are really based on very little evidence,” commented Roger Chou, MD, associate professor of medicine, Oregon Health & Science University, Portland, and director of clinical guidelines development for the American Pain Society. “I would advise clinicians who follow these recommendations to monitor for signs of ongoing liver damage, given studies showing that acetaminophen can cause liver abnormalities at therapeutic doses even in healthy individuals.”

To clarify the controversy associated with acetaminophen use in these patients, senior author Kymberly Watt, MD, associate professor, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn., and a colleague reviewed the thin body of literature on the topic, including expert opinion, published reviews and studies catalogued on PubMed or MEDLINE.

They found one study demonstrating that cirrhosis patients do not have depleted glutathione stores, which, along with altered cytochrome P-450–related metabolism, is a risk factor for acetaminophen-induced hepatoxicity seen in regular alcohol consumers (Am J Ther 2005;12:133-141). Results from a double-blind, crossover study of 20 patients with chronic stable liver disease, including eight patients with cirrhosis, confirmed the low risk for acetaminophen-induced hepatoxicity, showing that 13 days of acetaminophen use at 4 grams per day was not associated with adverse events and was well tolerated in a group of individuals with cirrhosis (Clin Pharmacol Ther 1983;33:95-101).

In individuals without cirrhosis consuming one to three drinks per day, a randomized, controlled trial of acetaminophen at 4 grams per day for 10 days found no significant toxicity, but a small increase in liver enzymes did occur, the authors reported (Ail Pharm Ther 2007;26:283-290). Similarly, a systematic review of several short-term studies examining the safety of 4 grams per day of acetaminophen in patients with chronic alcohol use showed the drug did not cause liver injury. A separate study of 443 non-cirrhotic patients consuming more than six drinks daily for more than six weeks and undergoing chemical detoxification found that 4 grams per day of acetaminophen for a three-day period during detoxification also did not cause liver toxicity (BMC 2007;5:13). Dr. Watt and her colleague’s review yielded no literature examining the safety of long-term acetaminophen use in individuals consuming alcohol regularly.

Given their findings, the authors believe that long-term acetaminophen use is safe at a dose of up to 3 grams per day in cirrhotic patients and that short-term administration of 4 grams per day is safe in both cirrhotic and non-cirrhotic patients consuming mild to moderate amounts of alcohol regularly.

“An important caveat is that the care of patients with cirrhosis must be individualized and treatment depends on a number of factors, such as nutritional status, adherence, follow-up and renal and liver function,” the authors cautioned.

 

Even if the "rule of thumb" guidelines of 2g a day are ultimately deemed conservative, I would stick to no more than this amount until a greater amount of data is available demonstrating safety at higher levels.

 

NSAIDS can cause big problems with these patients.

[bradtPA]

And with all the hidden tylenol in mixed cold meds, etc, I will still choose to avoid them. There is a reason the FDA is considering lowering the max recommended dosing limit on the product to 2 grams per day in the healthy population. Its not something I am prepared to risk writing a million dollar settlement check on. As I said, we can respectfully disagree to disagree;).

 

And for what its worth, I agree on NSAIDs, and avoid them.