A patient with liver cirrhosis — which analgesic should be avoided?

Correct answer: B. Ibuprofen

• A. Opioids are used with caution in cirrhosis (risk of hepatic encephalopathy), but the most important analgesic to AVOID specifically because of renal and platelet effects is ibuprofen/NSAIDs.
• B. IBUPROFEN (and all NSAIDs) should be AVOIDED in liver cirrhosis because: (1) NSAIDs reduce renal prostaglandins, causing renal impairment (risk of hepatorenal syndrome), (2) NSAIDs inhibit platelet function (worsening already impaired coagulation in cirrhosis), (3) NSAIDs may worsen portal hypertension. Also, acetaminophen should be used with caution and at reduced doses.
• C. While acetaminophen does require caution in cirrhosis (reduced dose: ≤2g/day in alcoholic cirrhosis), it is generally preferred over NSAIDs in cirrhotic patients. The hepatotoxic risk of acetaminophen in cirrhosis is often overstated.
• D. Tramadol requires dose adjustment in liver disease but is not the most dangerous analgesic in cirrhosis. NSAIDs are more specifically contraindicated due to the hepatorenal syndrome risk.