Safe Pain Killers With Liver Impairment

Our pharmacist answers the latest question regarding safe pain medications to use when you have liver impairment.

Sep 28, 2017

Maile asked

What painkillers, if any, are safe to take without causing more harm to the liver? Doctors have given conflicting advice concerning the safety of ibuprofen - one has even prescribed tramadol. What is safe to take?


First and foremost, you should completely avoid Tylenol (Acetaminophen) products, but i assume your health care provider has already relayed this information to you. Many people don't realize how toxic the effects of acetaminophen can be. Doses up to 6000mg (only 12 extra strength tablets) can cause liver toxicity. The fact that Tylenol is included in so many combination products makes it very easy to unintentionally overdose. In fact, it has been reported that half of acute liver failures due to acetaminophen are due to unintentional overdoses. That being said, somewhat surprisingly acetaminophen is usually considered OK and is generally recommended to take in those with chronic liver impairment at a max dose of 2 to 3 grams per day because this lower dosage has been shown to be unlikely to cause any liver damage. The fact that you are JUST being evaluated for liver problems now, I would still try and stay away from acetaminophen so you can rule that drug out while you are being diagnosed.

Medication use in those with liver impairment brings up a few concerns:

  • Whether or not the drug with cause liver impairment 
  • Whether or not the drugs metabolism will be impaired
  • Whether or not the drug will contribute to a complication of liver disease including renal failure and GI bleeding

So, let's talk about the two medications you mentioned in your question. It is not surprising that you have gotten conflicting recommendations on ibuprofen because there is conflicting evidence. Many practitioners are OK prescribing it in those with liver problems because it is not specifically metabolized by the liver and won't be affected itself by liver impairment. However, current evidence suggests that Ibuprofen, and NSAIDs in general should be used extremely cautiously in those with CHRONIC liver disease due to the fact that they may cause renal failure, or GI bleed at much higher rates in those with impaired liver disease versus healthy patients. There is not much data for use in patient with acute liver disease and it may be OK in low doses used for a short amount of time. 

Tramadol is actually one of the most recommended medications for those with liver impairment as it has been shown to be fairly safe. In those with advanced liver disease, the only change you need to make with dosing is to increase the dosage interval from every 4 to 6 hours to every 8 to 12 hours as metabolism of tramadol is somewhat reduced. 

So to specifically answer your question, I would recommend recommend the tramadol over the ibuprofen, just based on the safety data we have in those with liver impairment.

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