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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.

Comment

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.

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

Citation(s):

Reader Comments (5)

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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