Clinical Trial: Intensive Supervised Nutritional Therapy Versus Guideline-Based Nutritional Advice for Sarcopenia in Decompensated Cirrhosis-A Randomised Controlled Trial.

In adults with cirrhosis, acetaminophen 500 mg every 6 h, up to a maximum of 2 g/day, is the preferred first-line analgesic (Statement 30), and systemic NSAIDs should be avoided (Statement 31). Opioids should be avoided when possible for chronic pain; when necessary, opioid use should be approached with caution and with careful discussion with patients and caregivers, and low-dose oxycodone or hydromorphone can be started in select cases on an as-needed basis and titrated to effect, often in consultation with pain-management experts (Statement 32). First-line opioids are low-dose, short-acting agents with extended dosing intervals: oxycodone 2.5 mg PO q6-8h PRN or hydromorphone 1 mg PO q6h PRN (hydromorphone 0.4 mg IV); the initial prescription should be a 7-day supply of a low-dose short-acting opioid with close follow-up, and extended-release formulations should be avoided. Codeine, morphine, and tramadol should generally be avoided; because morphine is relatively contraindicated in advanced cirrhosis, clinicians should first consider hydromorphone or oxycodone. Methadone should only be used in consultation with a specialist. IV fentanyl is a preferred opioid because of its favorable metabolism, but the transdermal fentanyl patch is problematic for outpatient use because its lowest available dose (12 µg/h) may be too high for patients with cirrhosis, and cachexia is a relative contraindication to the patch. When an opioid is started, prophylactic medications should be considered proactively to prevent constipation and hepatic encephalopathy (e.g., lactulose).