Medication Pearls

Cross Cover Pearls – Garren Montgomery


  • General rule is to avoid opioids in cirrhosis as they are largely metabolized by the liver and can cause confusion, which may be mistakenly attributed to HE
  • Alternative options:
    • Tylenol (up to 2g/day)
    • Tramadol 50mg BID or 25 mg q8h generally safe if not responsive to Tylenol
    • Increased risk of seizures and serotonin syndrome (avoid if on SSRI/SNRI)
    • Lidocaine patches for localized pain
    • Gabapentin, with added benefit of treating alcohol use d/o (up to 1200mg daily)
    • Pregabalin 50mg BID
    • Nortriptyline 10 mg qHS



  • Benzo’s should generally be avoided due to their risk for causing confusion
    • If needed for EtOH withdrawal, use lorazepam (Ativan) instead of chlordiazepoxide (librium) or diazepam (valium) due to its shorter half life
  • Antihistamines such as Hydroxyzine (Atarax) are preferred for prn



  • Cholestyramine 4g/day titrated up to 4 times daily = 16g/day max
    • SE: poor taste, bloating, constipation, GI distress
    • very important NOT to dose around other medications given potential for interaction/blocking absorption
  • Sertraline: 50-100 mg/day
  • Antihistamines: Benadryl, doxepin 10 mg qHS
  • Topicals such as sarna lotion
  • Rifampin 150-300 mg/day; second-line agent
    • Side effects: N/V/D, HA, flushing, thrombocytopenia, turns body fluids orange
    • Be VERY mindful of potential drug/drug interactions with Rifampin (there are many); would talk to hepatology attending/pharmacist before initiating



  • Melatonin preferred; Hydroxyzine (12.5mg-25mg); Trazodone (100mg); avoid benzo's