Psychiatry & Co-Morbid Medical Conditions: Hepatic (Q.2)


Psychiatry & Co-Morbid Medical Conditions: Hepatic




(Q.1) Which of the following psychotropic medication is not as influenced by first-pass metabolism?

  1. Sertraline
  2. Paroxetine
  3. Venlafaxine
  4. Bupropion


Answer ==>

This is our second question 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. 


Psychotropic medications are metabolized in liver through phase I (cytochorome P450) and phase II (glucuronidation). Glucuronidation is conjugation of medications with glucuronic acid, and this process is normally preserved in liver disease.

(Q.2) Which of the following benzodiazepine only requires glucuronidation and hence is preferred in patients with underlying liver disease?

  1. Clonazepam
  2. Temazepam
  3. Diazepam
  4. Alprazolam

Answer: 2. Temazepam.

Benzodiazepines preferred in patient’s with liver disease:

  1. Lorazepam
  2. Oxazepam
  3. Temazepam

Pneumonic: OTL (Out The Liver).

  • Benzodiazepines like Chlordiazepoxide and diazepam are first metabolized by hepatic oxidation and then glucuronidation.
  • Lorazepam and Oxazepam undergo only hepatic glucuronidation.
  • Benzodiazepine oxidation is decreased in persons with liver disease and the elderly. This results in accumulation of benzodiazepines like chlordiazepoxide and diazepam, with resultant excessive sedation and respiratory depression.

Source: Pharmacotherapy. 1996 Jan-Feb;16(1):49-57.

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Dr. Harvinder Singh, M.D. (Admin)

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