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Analgesic and Antiemetic Prescribing in Patients with Decompensated Cirrhosis

Introduction

Cirrhosis affects the pharmacokinetics of many drugs, potentially leading to unpredictable therapeutic benefit and increased adverse effects. The following guideline summarises current best practice based on the Scottish Palliative Care Guidelines for end-stage liver disease. This guideline has been created to provide a safe guide when prescribing analgesics and antiemetics for patients with liver cirrhosis.

General prescribing tips for patients with cirrhosis 

  • Start at the lowest possible dose, increase slowly as required.
  • Regularly review drug indication, dosage and side effects.
  • Avoid hepatotoxic drugs. See BNF for details and dose reductions in hepatic impairment.
  • If increased PT/INR/bilirubin or decreased albumin, consider a dose reduction.
  • If you need further guidance, please contact your local hospital's Palliative Care Team, after checking with the patient's consultant gastroenterologist / hepatologist. 

Analgesia

Simple analgesia

  • Reduced dose paracetamol is generally safe for patients with advanced cirrhosis. Typical dose is paracetamol oral 500mg four times daily.
  • Non-topical non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in these patients. NSAIDs increase the risk of bleeding and hepatorenal syndrome.
  • Topical NSAIDs are safe.

Weak Opioids

Generally avoid. Codeine, dihydrocodeine and tramadol have an unpredictable therapeutic effect and can have adverse events in patients with cirrhosis.  

Strong Opioids

Normal Renal Function

  • Oramorph is generally safe for patients with cirrhosis and normal renal function.
  • Suggested initial dosing: Oramorph oral 2mg hourly when required,  maximum 6 doses in 24 hours.
  • Ensure SC option is also available and pragmatically use morphine SC 2mg hourly when required, maximum 6 doses in 24 hours.

Renal Impairment (≤ eGFR 30ml/minute)

  • Alfentanil is useful for patients with hepatic impairment and ≤eGFR 30 ml/minute.
  • Suggested initial dosing: Alfentanil SC 100 micrograms hourly when required, maximum 6 doses in 24 hours.
  • If pain is constant, consider starting continuous subcutaneous infusion (CSCI) alfentanil. A safe starting dose would be alfentanil 500micrograms/24 hours in a syringe pump,  with water for injection as diluent.

N.B. These are recommended starting doses of strong opioids. Dose can be titrated as required in accordance with analgesia need, ensuring ongoing monitoring of symptoms, in addition to renal and hepatic function where appropriate.

Constipation

Constipation is a major precipitant of hepatic encephalopathy. Lactulose should be co-prescribed as it prevents encephalopathy by multiple modes of action. Additional laxatives may be required- see Management of Constipation.

Aim for at least two soft stools per day in this patient group- titrate laxatives to achieve this, encouraging concordance with these as required.

Antiemetics

Consider a prokinetic agent (metoclopramide) if patient has tense ascites, gastric stasis or constipation:

  • Metoclopramide oral 10mg three times daily.
  • Metoclopramide SC 30mg in a syringe pump with water for injection as diluent.

Consider levomepromazine if patient has nausea/vomiting and is at end of life, or if metoclopramide is ineffective. Give:

  • Levomepromazine SC 5mg in a syringe pump with water for injection as diluent.

N.B. Levomepromazine can prolong the QT interval. Cyclizine and ondansetron are potentially sedating and constipating - if metoclopramide is not effective or contraindicated, seek specialist palliative care advice.

 

 

Guideline reviewed: March 2023

Page last updated: March 2023