Brief Answer:
Cirrhosis patients have limitted pain management options

Detailed Answer:
Hello and Welcome

I appreciate your concern

One has to understand that a patient with a cirrhotic liver has very limited options w.r.t pain management. Acetaminophen is the safest drug though prolong use for acetaminophen is also not recommended. The dose for acetaminophen should ideally not exceed 3 g per day in a cirrhotic patient. NSAIDs can pose a threat for both renal failure as well as upper G.I bleed due to esophageal varices associated with portal hypertension in cirrhosis. Opioids like tramadol can precipitate or worsen encephalopathy in cirrhosis and should also be avoided. For the fibromyalgia as well as other chronic neuropathic pain disorders anti depressants like nortryptiline , duloxetine and anticonvulsants like gabapentin/pregabalin should be advised. Topical NSAIDs and substance P depleting agent like capsaicin can also be used.

Wishing you best of health

Thanks

Please consult your doctor before deciding on any course of action described above.

For future follow up / correspondence you may ask me directly at the link given below

http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68107

Dr. M.S. Khalil

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Brief Answer:
No problem, sarcoidosis it is

Detailed Answer:
Hello again,

OK, no problem. Sarcoidosis it is then.

Taking into consideration your history and the medications you listed , if the pain still was not managed despite meloxicam, naproxen, celecoxib and Cymbalta then osteoporosis workup should be considered. Sarcoidosis is initially managed by corticosteroids and long term use can predispose to osteoporosis. DEXA scan and vitamin D levels should be done. Osteoarthristis is a disabling condition and there are no effective medication to reverse the joint deterioration associated with it. Intra articular joint corticosteroid shots are a convenient option for better relief. Topical Capsaicin ( a substance P depletory agent) and topical NSAIDs can also be used along with physiotherapy to maintain joint mobility. Joint replacement depending upon the disability can be discussed with your doctor. The NSAIDs you listed are the usual line of treatment and other pain medication like diclofenac, beta piroxicam, ibuprofen haven't been shown to be superior to any of the above. Fibromyalgia can occur secondarily with either of these conditions. Trigger point injections, acupuncture, myofascial release have shown benefit in some patients and can be tried in addition to the duloxetine which has been prescribed.

Wishing you best of health

Thanks

Please consult your doctor before deciding on any course of action described above

Dr. M.S. Khalil

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