Psychiatry & Co-Morbid Medical Conditions: Hepatic (Q.3)


Psychiatry & Co-Morbid Medical Conditions: Hepatic



This is our third 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. 


(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 ==>

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 ==>

Now time for Question 3:-


45 year old male with history of depression, seizure disorder, hepatitis and coronary artery disease. He is interested in medication options for his recent increase in alcohol craving and abuse. After detailed evaluation, he does meet criteria for alcohol use disorder, moderate.

– CBC (complete blood count) with Diff: normal.
– Liver function test: abnormal.
– Renal function test: normal.
– TSH: normal
– Urine drug screen: positive for cannabis.

Current Medications: Escitalopram, Metronidazole, Phenytoin and Methadone.

(Q.3) Which of the following is medication of choice for alcohol use disorder treatment in this patient with abnormal liver tests?

  1. Naltrexone
  2. Acamprosate
  3. Disulfiram.

Answer: (2) Acamprosate

(1) Naltrexone is not indicated because:-

  • Contraindicated in patients with hepatitis and abnormal liver function tests.
  • Avoid in patients taking opioid medications for risk of opioid withdrawals.

(2) Disulfiram is not indicated because:-

  • Contraindicated to use with metronidazole
  • Avoid use in patients with coronary artery disease and seizure disorder
  • Risk of drug interactions with phenytoin.


Member’s Question: Does this also means that the naltrexone monthly injection (brand name VIVITROL) would not be a good choice for anyone with Hep C, or would that all depend on their labs?


  • Patient with mild to moderate hepatic impairment (Groups A and B of the Child-Pugh classification): No dose adjustment is required. 
  • Patient with severe hepatic impairment: Not studied. 

More patients treated with VIVITROL results in treatment-emergent elevations in transaminases to more than three times the upper limit of normal than patients treated with placebo.

Also cases of hepatitis and clinically significant liver dysfunction were observed in association with VIVITROL exposure during the clinical development program and in the postmarketing period.

Based on this information:- Avoid VIVITROL in patient with underlying liver disease and discontinue use of VIVITROL in the event of symptoms or signs of acute hepatitis.

Source: VIVITROL® package insert.


Please do post your questions or comments below. 

Dr. Harvinder Singh, M.D. (Admin)

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