Pain control in cirrhotic patients
- Toradol/ibuprofen are extremely effective to control painful inflammation after procedures like renal cryoablation, hepatic embolization in NON-CIRRHOTIC patients (neuroendocrine, etc), UFE, etc,
- However, must minimize NSAID use in cirrhotic patients, and definitely avoid their use in patients with decompensated cirrhosis (ascites, high bili, encephalopathy, variceal bleeding), due to the particularly increased risk of nephrotoxicity / hepatorenal syndrome in this population.
- Acetaminophen is a first line medication for cirrhotic patients, for acute and chronic use, even those with severely decompensated cirrhosis, as long as daily maximums are respected.
- Based on a RCT, it appears that celecoxib does not have the negative effects on renal function, and would be the best NSAID to use, IF necessary.
Suggested algorithm for pain medications:
Mild pain:
Acetominophen
- Weight <50kg, max 2 grams daily (i.e. 500mg q6 hrs or 325mg q4 hrs etc)
- Weight >50kg (our normal patients), max 3 grams daily (i.e. 650mg q6 hrs or 500mg q4 hrs etc)
Moderate to severe pain:
Acetominophen PLUS either Oxycodone 5mg q6 hrs OR Tramadol 50mg q6 hrs
Severe pain not responding to above:
Acetominophen PO PLUS Dilaudid 1mg PO PRN q4 hrs
*prescribe Lactulose 20mL bid with any of the narcotics to minimize constipation / encephalopathy
IF NSAID necessary:
Celecoxib 200mg q12 hrs x 3d, can be combined with any of above
REFERENCES:
Dwyer JP, Jayasekera C, Nicoll A. Analgesia for the cirrhotic patient: a literature review and recommendations. J Gastroenterol Hepatol. 2014;29(7):1356-60. PMID: 24548074
Chandok N, Watt KD. Pain management in the cirrhotic patient: the clinical challenge. Mayo Clin Proc. 2010 May;85(5):451-8. PMID: 20357277
Clària J, Kent JD, López-Parra M, Escolar G, Ruiz-Del-Arbol L, Ginès P, Jiménez W, Vucelic B, Arroyo V. Effects of celecoxib and naproxen on renal function in nonazotemic patients with cirrhosis and ascites. Hepatology. 2005 Mar;41(3):579-87. PMID: 15723448
