Treating Muscle Cramps in Patients with Cirrhosis: A Review

Summary and Comment |
November 25, 2013

Treating Muscle Cramps in Patients with Cirrhosis: A Review

  1. Atif Zaman, MD, MPH

What causes it, and how should we treat this common corollary of liver disease?

  1. Atif Zaman, MD, MPH

Muscle cramps are common in liver disease, especially in patients with cirrhosis, among whom the prevalence ranges from 22% to 88% based on varying definitions of cramps. A new review summarizes the state of knowledge on biological mechanisms and treatment options.

The underlying mechanism of muscle cramps in cirrhosis is still not fully elucidated, but possibilities include alterations in three overlapping categories: nerve function, energy metabolism, and electrolytes and plasma volume.

Nerve dysfunction in cirrhosis may be due to structural alterations and oxidative stress leading to increased excitability of motor neurons. Treatments such as vitamin E (300 mg three times daily), quinine sulfate (200 mg twice daily), and eperisone hydrochloride (a muscle relaxant; 150–300 mg daily) have been shown to be effective in small studies. However, quinine sulfate is not recommended because of associated risks for thrombocytopenia, hemolysis and cardiac arrhythmias.

Altered regulation of amino acid and protein metabolism in cirrhosis likely contributes to muscle cramps. Supplementation with taurine (3 g daily) and branched-chain amino acids (isoleucine, leucine, and valine) seems effective based on results of small, controlled studies.

Shifts in plasma volume may also contribute to cramps. Serum electrolyte concentrations and use of diuretics cause cramps by indirectly influencing plasma volume. Intravenous albumin at 25% concentration and zinc (220 mg twice daily) have been effective in small studies. However, intravenous albumin cannot be recommended due to the inconvenience of intravenous delivery and its cost.


As outlined in this excellent review, the first step in managing muscle pain is to exclude other etiologies and correct any electrolyte abnormalities. Once cirrhosis is determined as the cause, the best treatment options include supplementation with vitamin E, zinc, taurine, or branched-chain amino acids because they are safe, are available over the counter, and may improve nutritional parameters.

Editor Disclosures at Time of Publication

  • Disclosures for Atif Zaman, MD, MPH at time of publication Speaker’s bureau Bristol-Myers Squibb; Genentech; Gilead; Kadmon; Merck; Salix; Vertex


Reader Comments (10)

Byers, Clive I am a self employed artist.

Just a thank you for info and comments re. muscle cramps and cirrhosis. I am on a high dose of diuretics. Good clear site. I'll definately run my notes past my specialist here in Norwich, England and will inform you of my experience. I.e. If I stop waking up the whole house screaming in the night! ( O.k. last night was halloween but......fingers crossed).

Matthews homeduties /carer
Competing Interests: My husband has the same illness as yours I've read about the tonic water on line and tried it it really does work good luck.

Have u tried tonic water it works really well even bananas or magnesium tablets

Petunia Blue

I hope your hubby will try the philtrum squeeze to get rid of cramps. I've told so many people about this but apparently most just scoff at the idea. But it's harmless and worth a try, right? The philtrum is the area just below the nostrils and above the lips. When he feels a cramp coming on have him take his thumb and forefinger and pinch squeeze firmly but not hard enough that it hurts. Sometimes I get relief within seconds, sometimes it takes up to 20 seconds. Sometimes it doesn't work at all so try using the opposite hand. The best thing is it not only disappears but there's no remains or reminders that it even happened. I got this remedy years ago. Apparently it was used by the Royal Canadian Armed Forces during WW1 in the trenches so they didn't cry out and let the enemy hear them. I've had cramp relief while flying, driving, in the movie theatre and after being awakened from my sleep with cramps. Good luck!

Judy Steele Retired

I have just been prescribed quinine sulphate 250 mg for muscle cramps by my neuromuscular specialist. I have PBC and CMT.

Julie Restivo Self Employeed

My husband has cirrhosis and severe cramps. He's 52 years of age. Is Oral Magnesium Supplementation a over the counter vitamin? Or Is this in a sports drink or a food we can buy? We are desperate to get this under some kind of control, If not under control.

Cathrine Other Healthcare Professional, Other

Desperate need help my brother has liver cirrhosis and has muscle cramps he has difficult walking please any suggestions

ricardo e *de lascurain Physician, Gastroenterology, Physician, solo practice

What is the treatment of cramps in patients with no liver disease?

Josh Davis MBBS PhD Physician, Infectious Disease, Newcastle, NSW, Australia

I have found that oral magnesium supplementation (even with normal plasma magnesium) seems to be effective in reducing the number and severity of cramps in cirrhotic patients - not a clinical trial, just a clinical observation based on the last 20 or so patients I have seen with this problem.

Randy Minion MD Physician, Family Medicine/General Practice, Unity Point Family Practice

Doesn't vitamin E increase risk of MI? How is that safe?

LUIS DUARTE Physician, Surgery, General

I agree that the use of diuretics is the cause of cramps in liver disease and the use of oral electrolites is safe in thes kind of patients.

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