Psychiatry & Co-Morbid Medical Conditions: Hepatic
This is our first post in this series: “Psychiatry and Co-Morbid Medical Conditions“. This post will focus on clinically relevant questions related to the role of psychotropic medications in patients with underlying liver disease.
The presence of intra- and extra-hepatic shunts in end-stage liver disease can affect first-pass metabolism by diminishing liver perfusion. This mechanism is responsible for increase in concentration of medications with extensive first-pass metabolism. Physicians should avoid these medications with extensive first pass metabolism and prefer one least likely to be influenced by first pass metabolism.
(Q.1) Which of the following psychotropic medication is not as influenced by first-pass metabolism?
Answer: 2. Paroxetine.
The presence of these shunts in liver diseases affects particularly medications with extensive first pass metabolism. This results in increase in concentrations of these medications.
Medications with Extensive First-Pass Metabolism:
- Tricyclic antidepressants: first-pass metabolism greater than 50% after oral administration
- SNRI: venlafaxine
- SSRI: sertraline
- NDRI: bupropion
- Typical antipsychotics: chloropromazine
- Atypical antipsychotics: olanzapine (40%), quetiapine.
Note:- Medications such as diazepam and paroxetine, are not as influenced by first-pass metabolism.
Avoid these psychotropic medications with extensive first pass metabolism in patients with end stage liver disease.
Drugs with apparently lower risks are citalopram, escitalopram, paroxetine and fluvoxamine.
Source: Pharmacol Ther 1989; 40: 439-474; World J Gastrointest Pharmacol Ther 2017 Feb 6; 8(1): 26-38
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Dr. Harvinder Singh, M.D. (Admin)
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