Pain Management for Arthritis

[Pete]

Hi folks, Thought I'd drop in to say hello and ask this question.

What are alternatives for pain management for those of us with advanced liver disease?

NSAIDS are basically out for those dealing with advanced Liver and Kidney problems, so what's left?  I'd try medical pot but I'm still working, and my employer has a zero tolerance policy even for medical  purposes.  I was thinking of trying CBD oil for arthritis pain in my shoulder.  DMSO helps but not much.  I did have a Cortisone shot which was like a miracle, but it only lasted about 4-5 months.

What do reach you for when achy joint pain strikes?

Best,
Pete

[Lynn K]

You should discuss  pain management with your liver specialist. Pain management is problematic in people with advanced liver disease.

Because of cirrhosis our platelet count's are reduced causing an increase in our prothrombin times which is why we bruise easily. We are at risk to have a dangerous bleeding episode especially if we have esophageal varices.  This is why we are to avoid NSAIDs as they increase the possibility of bleeding.

I have been advised by my hepatologist that if I need pain relief I may take Tylenol as long as I stay below 2000 mg per day.  As you probably know Tylenol can cause liver damage in itself but as long as we take it properly and not on a continual basis it is what we should be taking for pain management.

If pain is too much to handle the only remaining recommendation is opioid based pain medication.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861975/

"Pain management in patients with cirrhosis is a difficult clinical challenge for health care professionals, and few prospective studies have offered an evidence-based approach. In patients with end-stage liver disease, adverse events from analgesics are frequent, potentially fatal, and often avoidable. Severe complications from analgesia in these patients include hepatic encephalopathy, hepatorenal syndrome, and gastrointestinal bleeding, which can result in substantial morbidity and even death. In general, acetaminophen at reduced dosing is a safe option. In patients with cirrhosis, nonsteroidal anti-inflammatory drugs should be avoided to avert renal failure, and opiates should be avoided or used sparingly, with low and infrequent dosing, to prevent encephalopathy."

[Pete]

Hi Lynn - Hope all is good on your end.  I pretty much try to avoid all pain meds, and so far I've not needed any. I too have been advised to use only tylenol and watch the dosage if you need it.  However I'm reluctant to see if tylenol helps with the shoulder pain, simply because I don't want to start relying on it.  I suppose acupuncture is out for the obvious risk. Dang...

Now that you mention it, I probably should have an endoscopy to have a look, and thanks for the reminder on the PT.  I'll make sure that is included on my next lab work.
 
Thanks Lynn 

[Lynn K]

 That was one of the first things my doctor had me do was get an upper endoscopy when I was diagnosed with cirrhosis.

 On my first upper endoscopy I had grade one varices so we repeated in two years and I had grade 2 varices.  So I was checked again the following year and had grade 3 varicies which required banding

[Pete]

so I went back an looked over the radiologist report from my last MRI and noticed it mentioned Perigastric varices noted. That was it, nothing else along those lines.  I'd been so focused on the HCC result I must have just skimmed over that section of the report.   I'd better call next week and set up the exam, Ugh...

Thanks Lynn.   

[Lynn K]

perigastric
around the stomach; pertaining to the peritoneal coat of the stomach.

I was also diagnosed with GAVE (Gastric Antral Vascular Ectasia) which at a guess I am thinking might be the same or similar to your MRI result.

Not a lot can be done for those from what I understand but yeah it does look like it deserves a closer look

Kind of surprised your doctor didn't already recommend an EGD based on your MRI.

Does sound like you may have portal hypertension as you are developing gastric varicies.

Do you know your MELD score? If not familiar here is a calculator:

http://www.hepatitisc.uw.edu/page/clinical-calculators/meld

When you said you were focused on the HCC result are you saying you were diagnosed with HCC currently or just concerned about a reoccurrence? I recall you were treated previously for liver tumors so I am sure hoping they are not back.

[Pete]

My doctor did suggest an EGD, and it's been on my "probably ought to do" list for awhile now.  There was no sign of any new tumors on the last MRI, so I thought I'd take a break for spell, while I waited out the 12 week EOT results.  SVR 12 on Mar 15, one year post my resection surgery.   Just when you think you're out of the woods...

Thanks for pointing out what  perigastric pertains to.  I wondered about that and I also came to the same conclusion regarding treatment after reading up things a bit.  Seems there may be pharmacological options to help lower bp and resting heart rate?  I'm actually one of these folk with a relatively low resting heart rate, somewhere near 50 bpm give or take.  I hoping that's a plus.

Even though many have cleared the virus, the long term effects of liver disease present new set of challenges.    What's the old saying? I'm sick and tired of being sick and tired... I calculated my MELD at 5, so I guess I'm not all the sick, but surely tired of the testing and treatment.  Thanks Lynn.

Pete

[Lynn K]

I believe the lowest possible meld is 6 but low is good.

The medicine to reduce varicies is a beta blocker it lowers blood pressure by lowering heart rate. With the goal to titrate the dose to lower BPM to about 60. I had the same problem too low of a resting heart rate to take a beta blocker for my esophageal varicies so I underwent banding to eridicate the enlarged blood vessels. I had 4 EGD's to get all the vessels banded. I now have upper EGD's every year as surveillance against return.

I have read that enlarged blood vessels in the stomach lining if there is a concern of a bleed can either be treated basically with a superglue or possibly using cryofreezing to eliminate concerning vessels otherwise I think it is watchful waiting. But still would want to check for ones in the esophagus as well as those can be banded. But with a slow heart rate we are not candidates for beta blocker use.

[Pete]

Hi there Lynn - I dropped you a note.  Thx Pete