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Viral Hepatitis and Liver Disease

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Medication Safety for Patients with Advanced Liver Disease

for Veterans and the Public

Medication Safety for Patients with Advanced Liver Disease - Cirrhosis for Patients

Developed by the Hepatology FAB Cirrhosis Sub-board and approved by the Hepatology FAB | September 2022

When you have advanced liver disease or cirrhosis, some prescription or over-the-counter medications can harm you, especially if your liver disease is complicated by ascites (fluid build-up in the belly), encephalopathy (confusion), esophageal varices (swollen blood vessels in the area that connects the mouth to the stomach) or kidney problems. Make sure you bring a list of , to your every visit! Please see more information below:

Pain medicationsWhen and how are they safe to takeBe careful!Do not take!
Acetaminophen (Tylenol) Safest to take up to a total daily dose of 2000 mg/day (such as 4 extra-strength pills). AVOID ALL ALCOHOL Check labels carefully of ALL pain medications you take, as they can have acetaminophen! Acetaminophen can damage your liver if you take more than the recommended amount or if you drink alcohol while taking this medication. Acetaminophen in different types of pain medications can add up!

(non-steroidal anti-inflammatory drugs):

Ibuprofen (Motrin, Advil), Naproxen (Aleve), Diclofenac, Indomethacin (Tivorbex /Indocin)

Discuss with your gastroenterologist/ liver provider

Inappropriate use may result in:

  • kidney damage
  • fluid retention
  • worsening ascites
  • bleeding
  • liver damage
DO NOT TAKE any NSAIDs if you have ascites (fluid build-up in your belly) or kidney problems. Discuss with your providers about alternative treatments. Acetaminophen is the preferred over-the-counter pain/fever reducing medication (see above)
Many cold and flu medications have acetaminophen and/or NSAIDs — check the label!

Morphine (MS Contin), Fentanyl (Subsys), Hydromorphone (Dilaudid), Oxycodone (Oxycontin)

Use only if absolutely necessary and for the shortest duration possible. Requires close monitoring. May require laxatives to avoid constipation Best to avoid, as they may cause increased sleepiness and confusion DO NOT TAKE if you have been diagnosed with hepatic encephalopathy and take meds such as lactulose, rifaximin. Avoid especially if you had a recent hospitalization for hepatic encephalopathy. Discuss alternative treatments with your provider
Sedatives/sleeping aidsWhen and how are they safe to takeBe careful!Do not take!
Lorazepam (Ativan), Alprazolam (Xanax), Diazepam (Valium), Diphenhydramine (Benadryl, Tylenol PM), Doxylamine (Unisom), Zolpidem (Ambien), Zaleplon (Sonata), Eszopiclone (Lunesta), Ramelteon (Rozerem), Lemborexant (DayVigo), Suvorexant (Belsomra) If you have NO complications of cirrhosis, use the lowest effective dose for the shortest time possible Best to avoid, as they may cause increased sleepiness and confusion DO NOT TAKE them if you have hepatic encephalopathy (and take medications such as lactulose, rifaximin), especially if you have had a recent hospitalization for hepatic encephalopathy
Antacid medications (for acid reflux or stomach symptoms, or for stomach ulcers)When and how are they safe to takeBe careful!Do not take!
Famotidine (Pepcid), Calcium carbonate (Tums), Aluminum hydroxide/magnesium hydroxide (Maalox), Calcium carbonate/magnesium hydroxide (Mylanta) Generally safe to use. Talk to your provider regarding how long you are expected to take these medications, in order to reduce the number of pills you take and avoid potential interactions with other medication
PPIs (proton-pump inhibitors)
Omeprazole (Prilosec), Lansoprazole (Prevacid), Pantoprazole (Protonix), Esomeprazole (Nexium), Rabeprazole (Aciphex), Dexlansoprazole (Dexilant)
They should be used for a very clear indication, the lowest dose and shortest time May increase risk for fractures, kidney disease, and infections DO NOT TAKE them or use them for a very short time if you have ascites and/or hepatic encephalopathy