Hi Mostafa,

I would recommend Ibuprofen. Aspirin inhibits thrombocyte aggregation and depending on the extend of your patient's liver dysfunction, regular use of Aspirin might aggravate bleeding complications. Acetaminophen might not be the best choice due to obvious reasons (metabolized in the liver). But honestly, LOW doses of any of these drugs just a few times a month should not be harmful at all if your patient does not already have severe liver disease (e.g. Child B/C cirrhosis).

Best,

Daniel

Dr.Daniel, may you shed more light into the Aspirin complication (Thrombocyte aggregation and liver dysfunction)? Can Aspirin induce bleeding complication from just occasional use ?

Dear Mostafa,

acetylsalicylic acid inhibits cyclooxygenases irreversibly by acetylating them and subsequently reduce levels of prostaglandines and thromboxanes. Low doses of just 100mg do inhibit pro-thrombotic thromboxanes effectively for about 7 - 10 days and thus pose an increased risk of bleeding (probably even after one use). All studies that I am aware of and that do study the risk of major bleeding events (like intracranial hemorrhage) accompanying Aspirin use look at patient populations with long-term Aspirin use (e.g. indicated after myocardial infarction). I am not entirely sure whether there is any literature indicating that a tablet of Aspirin once or twice a month significantly increases bleeding risk (especially with concomitant liver disease). You might want to search UpToDate in this regard.

Best,

Daniel

Dr.Daniel, what is your take on this review ? I'm a little bit confused because there are contradictory data

Article Analgesia in patients with hepatic impairment

Article The Prescription Pattern of Acetaminophen and Non-Steroidal ...

And this one as well

Article The Therapeutic Use of Analgesics in Patients With Liver Cir...

Article Analgesia for the Cirrhotic Patient: A Literature Review and...

It is not an easy question to solve. The best thing is nothing or the less dose possible of everyone of these three medications

Dr.Luis, what about the reviews mentioned above which state that acetaminophen is the safest agent ?

Glutathione depletion ( worsen NAFLD) associated with chronic ingestion of acetominaphine has also associated with metabolic acidosis due to the accumulation of 5-oxoproline. Ibuprofin would be safer

Ali, what about the reviews mentioned above ?

There are numerous studies have catergorically clarified Acetominophine toxicity some of them were published in peer-reviewed journals compared to ibuprofin. Your articles represent the authors opinions and need some reviews!.Furthermore, about 90% of acetaminophine gets hepatic metabolism

Yeah, I'm aware about APAP toxicity, and the mechanism behind its toxicity, but I was referring to the doses recommended, no toxicity would occur, because the cases where toxicity occurs, there was overdosage.

Coadministered acetaminophine with ethanol containing products can cause hepatotoxicity, people who are on diet(let alone NAFLD) are at risk of glutathione depletion when they consume aceta at recommended dose.

I'm aware that NAFLD increases the risk of APAP toxicity, but is there any study or case report that confirm that at the recommended doses, any patient with NAFLD suffered APAP toxicity ?

You should find out since this is your study,I believe there are so many articles! just search in Pubmed engine .Though see this

https://www.ncbi.nlm.nih.gov/m/pubmed/24575957/