Your patient has cirrhosis with well controlled ascites, HE, and unfortunately comes in with MSK back pain from raucously cheering in vain 4 the Winnipeg Jets.
They ask for advice/treatment. In addition to stretching/PT, you recommend...
This is prob ok in (short term) -ONLY IF they don’t have portal HTN
1. trigger diuretic resistance(fig1)
2. Provoke variceal bleed(fig2)
3. precipitate HRS(Throback2 )
So:🚫nsaids if ascites/varices
Patient: tylenol isn't cutting it. What else do you have for me?
1st, r they safe?
Fig1: Dame Sherlock gave morphine 2 ppl w/'impending HE' (BAD IDEA)
Fig2: But later study suggest NO EEG change s/p morphine
Fig3: Patwardhan showed that morph metabolism is PRESERVED in #cirrhosis
Don’t use opioids if you can avoid them. But sometimes u need em (e.g.fractures, hcc w/mets)
Start low/go slo. Choose med w/care.
The opioid effect of tramadol depends on CYP2D6
1. CYP2D6 activity varies widely @ baseline ascpt.onlinelibrary.wiley.com/doi/full/10.10…
2. 2D6 activity may ⬇️in ESLD (⬇️opioid effect, Fig1)
3. Then again, 2D6 may in⬆️HCC(Fig2)
Unpredictable @ getgo, ESLD makes it worse
👎🚫nsaids if ascites/varices
If u reach for an opioid: choose wisely, low/slo, 🚫constipation
Cirrhosis makes pain control challenging, but we cant shy away. We can all do better when managing pain for persons w/#cirrhosis