10th July 2026

Specific drug modifications for hepatic impairment

Anticoagulants:

• Warfarin may require dose adjustment, as its effect may be increased due to a reduction of clotting factors being produced by the liver. Monitoring of International Normalised Ratio (INR) is important.

Analgesics:

• Opiates can precipitate encephalopathy.
• Aspirin and NSAIDs can increase the risk of bleeding due to the reduction in clotting factors. NSAIDs can also increase ascites and should be used cautiously.
• Opioids may need dose adjustments due to altered metabolism.  
• Paracetamol should be used with caution.

Antibiotics:

• Some antibiotics, such as erythromycin, clarithromycin, and co-amoxiclav, should be used with caution and may require dose adjustment. 

Antifungals:

• Azole antifungals, like ketoconazole, should be avoided.

Antidepressants and Antipsychotics:

• Tricyclic antidepressants should be used with caution and avoided in severe impairment.
• Selective serotonin reuptake inhibitors (SSRIs) have a prolonged half-life. Doses should be reduced, or dose intervals increased. 

Cardiovascular Medications:

• Beta-blockers, calcium channel blockers, and other cardiovascular medications should be used with caution and may need dose adjustment.
• Statins may need dose adjustments. If the liver transaminases are more than 3 times the upper limit of normal, statin therapy should not be commenced or should be discontinued if already established on treatment. 

Diuretics:

• Hypokalaemia induced by loop diuretics may precipitate hepatic encephalopathy and coma—potassium-sparing diuretics can be used to prevent this.
• Diuretics can increase the risk of hypomagnesaemia in alcoholic cirrhosis, leading to arrhythmias.

Hypoglycaemic Agents:

• Insulin requirements may be decreased in hepatic impairment. 

Some oral hypoglycaemics should be avoided in hepatic impairment:

• There is an increased risk of lactic acidosis with metformin; withdraw if tissue hypoxia likely.
• Increased risk of hypoglycaemia in sulphonylureas.
• Increased risk of hepatotoxicity with glitazones. 

Immunosuppressants:

• Tacrolimus and ciclosporin, commonly used as immunosuppressants, may require dose modification.

Antivirals:

• Some antiviral medications, e.g. nucleoside reverse transcriptase inhibitors, may require dose adjustment. They should be used with caution in HCV and HBV cirrhosis.
• Antivirals should be avoided in Child-Pugh class C due to risk of severe complications.