For opioids, start with a low dose immediate release preparation and titrate slowly according to response and side effects. Regular review is essential with careful monitoring for signs of toxicity and prevention of constipation. Once established on immediate release opioids, the dose can then be converted to slow release preparations or transdermal patches. When transdermal patches are being considered, buprenorphine should be used in preference to other opioids.
Analgesics: recommendations based on type of liver disease
Paracetamol: Normal therapeutic doses (caution in malnourished or acute viral hepatitis)
NSAID: Normal doses
Opioid: Normal therapeutic doses
Paracetamol: Normal therapeutic doses
NSAID: Avoid if possible. If necessary, ibuprofen may be best option
Opioid: Use with caution. Monitor for adverse effects. May worsen pruritus
Paracetamol: Normal therapeutic doses (caution if malnourished, low body weight, severe liver or renal impairment or chronic alcohol use).
NSAID: Avoid.
Opioid: Avoid where possible.
Weak opioids: Dihydrocodeine may be preferred compared to codeine.
Preferred strong opioid: Morphine. Use small doses with reduced frequency of administration
Paracetamol: Normal dose with caution. Half-life may be prolonged
NSAID: Avoid
Opioid: As for compensated cirrhosis but greater caution needed as increased accumulation likely
Paracetamol: Extend dose interval
NSAID: Avoid
Opioid: As for compensated cirrhosis. Strong opioids preferably only considered after discussion with liver unit.
Recommendations on the use of analgesics in liver disease
Class: Non-opioid
Recommendations in liver disease: Oral route, use with caution & avoid intravenous route.
Comments: Can opt for a sub-maximal dose 500mg -1g TDS-QDS especially if at higher risk for paracetamol toxicity & consider dose reduction if on for >7 days*
* Some patients may be at increased risk of experiencing paracetamol toxicity at therapeutic doses, particularly those with a body-weight under 50kg and those with risk factors for hepatotoxicity. Clinical judgement should be used to adjust the dose of paracetamol in these patients.
Class: Weak opioid
Recommendations in liver disease: Avoid use
Class: Weak opioid
Recommendations in liver disease: Use with caution
Class: Weak opioid
Recommendations in liver disease: Avoid if severe
Comments: Moderate impairment – increase dosing interval
Class: Strong Opioid and NARI
Recommendations in liver disease: Avoid if severe
Comments: Immediate-release tablets, initial max. daily dose 150 mg; for modified-release tablets, initial max. daily dose 50 mg
Class: Strong Opioid
Recommendations in liver disease: Use with caution
Comments: Moderate impairment – use lower doses
Severe impairment – lower doses and extend dosing interval
Class: Strong Opioid
Recommendations in liver disease: Use with caution
Comments: Moderate impairment – use lower doses
Severe impairment – lower doses and extend dosing interval
Class: Strong Opioid
Recommendations in liver disease: Use with caution
Comments: May be opioid of choice in hepatorenal syndrome
Class: Strong Opioid
Recommendations in liver disease: Contra-indicated moderate to severe liver disease
Comments: Moderate impairment – lower doses; minimum dosing interval of 6 hourly for immediate release products
Class: Strong Opioid
Recommendations in liver disease: Contra-indicated moderate to severe liver disease.
Naloxone – Avoid in liver disease
Comments: Naloxone component may be systemically absorbed resulting in opioid withdrawal and thus precipitate pain
Class: Strong Opioid
Recommendations in liver disease: Use with caution
Comments: Avoid transdermal products when initiating opioids.
Single doses appear unaltered by liver disease.
May be suitable for treatment of breakthrough pain
Class: Strong Opioid
Recommendations in liver disease: Use with caution
Comments: Dosage reduction necessary
Class: Strong Opioid
Recommendations in liver disease: Use with caution
Comments: Dosage reduction necessary
Class: Strong Opioid
Recommendations in liver disease: Seek specialist advice
Comments: Seek specialist advice
Class: Adjuvant
Recommendations in liver disease: Avoid
Class: Adjuvant
Recommendations in liver disease: Use with caution
Comments: Avoid in severe liver disease
Class: Adjuvant
Recommendations in liver disease: Not affected by liver impairment
Comments: Normal doses can be used
Class: Adjuvant
Recommendations in liver disease: Use with caution
Comments: Dosage reduction necessary
Class: Adjuvant
Recommendations in liver disease: Not affected by liver impairment
Comments: Normal doses can be used
Co-administration of enzyme inducing antiepileptic medications may increase paracetamol toxicity – doses should be reduced.
The use of drugs in encephalopathy
10-30mls PO QDS; aim 2-3 soft stools/day.
1 enema PR OD/BD; aim 2-3 soft stools/day.
Indicated if ≥ 2 episodes of encephalopathy.
Should be initiated after discussion with a specialist.
The use of drugs in depression
Start at 15mg PO ON and titrate slowly to maximum dose 30mg ON. Avoid if patient has renal impairment. May help to stimulate appetite. Sedating effect greater at lower dose. Caution use in severe liver impairment, reduce dose in renal impairment.
Start at 10mg PO OD (morning), titrate slowly to maximum dose 20mg OD Half-life nearly doubles Can lower seizure threshold and increase gastrointestinal bleeding risk.
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.