TABLE 4.

Summary of pharmacotherapies for and side effects of the symptomatic treatment of patients with DC^[105]

Medication	Side effects, cautions
Nociceptive pain
acetaminophen	Generally safe at low dose (2 gram daily maximum), can cause hepatic failure at high dose
Topical NSAIDs	Not tested in patients with cirrhosis (note that systemic NSAIDs are generally avoided in patients with cirrhosis)
Lidocaine patch	Site reactions (erythema), petechia, edema, pruritus, nausea, vomiting
Capsaicin cream	Site reactions (burning, pain, erythema), limb pain, hypertension
Opioids	HE, habit forming, respiratory depression, constipation/obstipation, overdose; preferred are oxycodone and hydromorphone
Neuropathic pain
Gabapentinoids	Ataxia, sedation, myoclonus/asterixis, dose adjust in renal impairment, withdrawal syndrome, possible increased viral infections
SNRIs	Discontinuation syndrome, nausea, vomiting, sexual dysfunction
Tricyclic antidepressant medications	Anticholinergic, orthostasis, drowsiness, weight gain, sexual dysfunction
Muscle cramps
Baclofen	HE, confusion, dizziness, sedation, nausea, vomiting, rare neurotoxicity in patients with renal failure, discontinuation syndrome
Zinc	Gastric irritation, rare neurological side effects
Methocarbamol	Hypotension, bradycardia, dyspepsia, pruritis, confusion, ataxia, HE, headache, sedation, changes in taste, seizure, vertigo, leukopenia, jaundice, changes in vision (dose reduced in cirrhosis)
Orphenadrine	Palpitations, tachycardia, confusion, sedation, pruritis, constipation, nausea, vomiting, tremor, urinary retention, blurred vision, central nervous system depression
L-carnitine	Side effects common with intravenous formulation; oral formulation generally tolerated well at normal doses
Vitamin E	Nausea, diarrhea
Taurine	Nausea, dizziness, headache
BCAAs	Possible nausea
Depression/anxiety
SNRIs	Discontinuation syndrome, nausea, vomiting, sexual dysfunction, rare hepatitis
SSRIs	QTc prolongation and seizure risk with citalopram, sedation with mirtazapine, nausea, vomiting, weight gain, sexual dysfunction, insomnia, bleeding risk
Benzodiazepines	Physical dependence, sedation, HE, only for short-term use at the end of life in cirrhosis
Dyspnea
Opioids	HE, habit forming, respiratory depression, constipation/obstipation
Benzodiazepines	Physical dependence, sedation, HE, only for short-term use at the end of life in cirrhosis
HE a
Zinc	Gastric irritation, rare neurological side effects
l-carnitine	Side effects common with i.v. formulation; p.o generally tolerated well at normal doses
Insomnia
Melatonin	Headache, fragmented sleep, confusion
Zolpidem	Headache, drowsiness, dizziness, palpitations, anxiety, disorientation, hallucination, use with caution and only in low doses for short time periods in patients with cirrhosis, particularly in the presence of HE
Fatigue
Modafinil	Headache, abdominal pain, decreased appetite, chest pain, tachycardia, anxiety, insomnia, confusion, diarrhea, exacerbation of psychiatric symptoms, dose reduction is generally recommended; evidence is poor
Methylphenidate	Not studied in cirrhosis, insomnia, headache, irritability, weight loss, anorexia, xerostomia, nausea, tachycardia, hypertension, emotional lability, dizziness, depression, anxiety, nausea, vomiting, diarrhea, abdominal pain, possible increased infection risk; evidence is poor
Pruritus
Cholestyramine	Edema, syncope, abdominal pain, anorexia, arthralgia, headache (caution in renal impairment)
Antihistamines	Sedation, dizziness, HE, rare QT prolongation, hallucination, headache
Nausea, vomiting, dyspepsia
Ondansetron	QTc prolongation, headache, constipation
Metoclopramide	QTc prolongation, drowsiness, fatigue, restlessness, dystonic reaction (age related, but can be severe), arrhythmia, hypotension, caution in renal impairment
Haloperidol	Increased risk of death in older adults with dementia, extrapyramidal symptoms (e.g., dystonia, akathisia, and tardive dyskinesia), aspiration risk, cytopenias, hyperprolactinemia, neuroleptic malignant syndrome, metabolic derangements, QTc prolongation, seizures, sexual dysfunction
Medical cannabinoids	Psychosis, encephalopathy, ascites, hyperemesis
Antihistamines	Sedation, dizziness, HE, rare QTc prolongation, hallucination, headache
Proton pump inhibitors	Increased infection risk in cirrhosis, abdominal pain, diarrhea, nausea, dizziness, headache, rash
H2 antagonists	Dizziness, delirium, confusion, agitation, headache, change in bowel habits
Erectile dysfunction
Tadalafil	Dyspepsia, headache, caution if encephalopathy or low blood pressure

Note: Lexicomp.com used for drug information.

^aAlternatives to standard treatments.