As a pharmacist, you will hear myths perpetuated about medications in chronic liver disease. This means that patients with viral hepatitis, fatty liver disease, or cirrhosis can miss out on appropriate therapy. Get our note, "Prescribing medications in patients with liver cirrhosis"...
Myth 1. Medications often impair liver function. Explain that this is rare, even in patients with liver disease. Drugs are more likely to trigger liver disease complications, such as renal failure, GI bleeding, or altered mental status, especially in patients with advanced cirrhosis.
Myth 2. NSAIDs are safer than acetaminophen. Acetaminophen OVERDOSES are a common cause of acute liver failure, but < 4 g/day is unlikely to cause liver problems in most patients. Explain that NSAIDs can actually be riskier. For example, NSAIDs may precipitate renal failure or GI bleeding in cirrhosis. Use NSAIDs with caution, especially in cirrhosis. Use acetaminophen first for pain. But caution not to take more than 2 to 3 g/day and to use it only when needed. Prescribe tramadol when acetaminophen isn't enough or opioids for severe pain. But avoid combining tramadol and opioids, the combo might precipitate hepatic encephalopathy in patients with cirrhosis.
Myth 3. Statins should be avoided. Statin-related hepatotoxicity is very rare, if it occurs at all. In fact, statins may actually IMPROVE liver function in patients with fatty liver disease or viral hepatitis. If needed, use a statin in CHRONIC stable liver disease. But stop it in ACUTE liver failure or when reducing cardiovascular risk isn't a priority. In patients who have been shown to have an ALT level more than three times the upper limit of normal (>3 ULN) confirmed on a second occasion, a change of medications (you can recommend Pravastatin, [Lipostat, Colestat, etc.], as it is not extensively metabolized by the liver) or a reduction in the statin dose is recommended.
REFERENCES
-
Lewis JH, Stine JG. Review article: prescribing medications in patients with cirrhosis - a practical guide. Aliment Pharmacol Ther. 2013 Jun;37(12):1132-56. Available at: https://pubmed.ncbi.nlm.nih.gov/23638982. OR, https://onlinelibrary.wiley.com/doi/10.1111/apt.12324
Chandok N, Watt KD. Pain management in the cirrhotic patient: the clinical challenge. Mayo Clin Proc. 2010 May;85(5):451-8. Available at: https://pubmed.ncbi.nlm.nih.gov/20357277