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Analgesia for Chronic Liver Disease Patients - Which one do you prefer?

A 43 yrs male who is a known case of Alcoholic Cirrhosis presented to you with left leg fracture, mild jaundice and tense ascites. Patient is in severe pain. Which analgesic do you prefer and why?

Paracetamol?
Powerful NSAID's?
Opioid's?

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i go for tramadol ...opoid analgesics.......even the same for patients with renal problem

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I do agree that opioid's are the best analgesics available on earth, but they frequently produce mental status changes. They may exacerbate underlying mental status changes. These patients are under high risk for progression into hepatic encephalopathy. Opioid's cause constipation which in turn lead to more gut protein load and so high risk for hepatic encephalopathy.

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a powerful NSAID would be preffered in this case because it mite affect the live less than wht para n opiods might ...!!!i think so...not sure though.....

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NSAID's cause GI mucosal injury and hence GI bleed which may worsen Hepatic Encephalopathy. NSAID's cause fluid retention which may worsen systemic hypertension and probably portal hypertension too. You should monitor serum creatinine also.

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paracetemol- is metabolised in the liver. so it is not given when liver is compromised.
NSAIDS- cause bleeding. in the liver dysfunction synthesis of coagulation factors is adversely affected. so gi bleeding may cause anemia.

so OPIODS are the best choice....... subjected to challenge

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Ascites due to portal hypertension? varices likely, NSAIDS can lead to bleed so risks out weigh any benefits of treatment. Some opioids ok as long as patient does not become constipated which can precipitate encephalopathy. Ascites can reduce oral absorption. Start at low doses and monitor for side effects. Avoid tramadol and pethidine as they lower seizure threshold. Even in Liver disease paracetamol is only hepatotoxic in overdose. Dose interval may need to be prolonged if prothrombin time is increased. Paracetamol is the best choice,

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paracetamol is the safest analgesia in CLD patients in usual analgesics doses.
if it wl nt cntrl pain yhen we should go 4 opiods.
link- Am J Ther. 2005 Mar-Apr;12(2):133-41.

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Opioids like tramadol which is less likely to cause constipation. Even if it occurs, can always be treated symptomatically. Tramadol causes minimal CNS changes and not exacerbating or increasing the chances of encephalopathy.

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But in analgesic doses, if there is no severe elevation of liver enzymes, paracetamol can always be added if required to the milder opioids.

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paracetamol or may be opioids
but no way
nasaid(hemorrhage)
and best ,safer is acupuncture and meditation,i so believe

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Only opioids can be given in alcoholic cirrhosis
Otherwise paracetamol or NSAID's are not to be give as they metabolized in liver n they can worsen the disease as these drug can them self causes liver toxicity.....so they are absolutly contraindicated in any type of liver cell failure.
As cirrhosis is the final stage of liver cell failure.....if we add these drug then it can increase the complication.

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