Table 1.

Important Considerations Regarding Analgesia Prescribing for Patients With Cirrhosis

Impaired hepatic metabolism	• Prescribe short‐acting (IR) analgesics whenever possible. • Start with low dosage and use extended dosing intervals (eg, every 6‐12 hour intervals). • Limit daily acetaminophen dose to 2000 mg.
Impaired renal excretiona	• Dose is based on renal function. • Avoid morphine in patients with renal disease.
Risk for precipitating renal failure and gastrointestinal bleed	• Avoid NSAIDs in patients with cirrhosis.
Risk for precipitating hepatic encephalopathy	• Monitor carefully and frequently for sedation. • If patient is not already receiving lactulose, a bowel regimen should be started and education on importance of avoiding constipation provided.
Potential for abuse	• When prescribing opioids, consider having patient sign a “pain agreement” (eg, obtaining opioids from only one provider, refills only during office visits or normal office hours)

^aUp to 50% of patients with cirrhosis have concomitant renal disorders, resulting in impaired drug excretion and increased risk for toxicity.