All medicines must be administered with caution in the patient with cirrhosis, especially those eliminated or modified through hepatic metabolism or biliary pathways. In particular, care must be taken to avoid overzealous use of drugs that may directly or indirectly precipitate complications of cirrhosis. For example, vigorous treatment with diuretics may result in electrolyte disturbances or hypovolemia, which can lead to coma. Similarly even modest doses of sedatives can lead to deepening encephalopathy. Aspirin should be avoided in patients with cirrhosis because of its effects on coagulation and gastric mucosa. Acetaminophen should be used with caution and in doses of less than 2 g/day. Patients who drink alcohol are more sensitive to the hepatotoxic effects of acetaminophen, probably due to increased metabolism of the drug to toxic intermediates and decreased glutathione levels.