A patient with alcoholic liver cirrhosis requires an analgesic for dental pain. Which analgesic is MOST appropriate to avoid?

Correct answer: B. Acetaminophen in high doses

• A. Codeine is a prodrug metabolized by CYP2D6 to morphine; in cirrhosis with portosystemic shunting, opioids can precipitate hepatic encephalopathy.
• B. CORRECT. In liver cirrhosis, the liver's capacity to metabolize acetaminophen is reduced and glutathione reserves are depleted (especially with alcohol use), making APAP hepatotoxic even at standard doses if the patient drinks alcohol. HIGH-dose APAP (>2g/day) should be avoided. However, the answer depends on option context: NSAIDs (ibuprofen, aspirin) are ALSO contraindicated in cirrhosis due to GI bleeding risk, platelet inhibition, and impaired renal function.
• C. Ibuprofen is an NSAID that should be avoided in liver cirrhosis due to increased risk of GI hemorrhage, platelet dysfunction, and hepatorenal syndrome. In clinical practice, both APAP in excess and NSAIDs are avoided.
• D. Aspirin carries similar NSAID-related risks (GI bleeding, platelet inhibition) in cirrhosis patients.