Medications to use cautiously in patients with liver cirrhosis
| Antimicrobials: azithromycin, cefoperazone, ceftazidime, ceftriaxone, chloramphenicol, erythromycin, griseofulvin, ketoconazole, metronidazole, nalidixic acid, nitrofuantoin (chronic use), piperacillin, roxithromycin, telithromycin, tetracycline | Avoid or use with caution any medications that undergo first-pass metabolism or detoxification in the liver29 |
| Acetaminophen | Should not exceed 2 g per day or 500 mg per dose5,30 |
| Nonsteroidal anti-inflammatory drugs | Contraindicated in patients with advanced cirrhosis due to risk of further hepatotoxicity and higher risks of renal failure5 |
| Antihypertensives | Monitor patients for evidence of hypotension or ascites; discontinue as necessary5 |
| Metformin | Recent studies have shown metformin may be beneficial in treatment of steatohepatitis and may protect against hepatocellular carcinoma5,29 Continue metformin in patients with diabetes5,29 |
| Statins | May be safely used and possibly beneficial to prevent decompensation, despite common practice to hold or deprescribe5,29,31 |
| Vitamin A | Restrict to < 5,000 IU daily5 |
| Opioids and benzodiazepines | Should be avoided5,32 |
| Proton pump inhibitors | Avoid due to the potential risk of potentiating spontaneous bacterial peritonitis5,29 |