From the Guidelines
Quetiapine (Seroquel) should be avoided in patients with acute liver toxicity due to the increased risk of accumulation to toxic levels and subsequent adverse effects. The medication is primarily metabolized by the liver through the cytochrome P450 system, specifically CYP3A4, which means impaired liver function can lead to higher blood levels of the drug and increased risk of side effects 1. In acute liver toxicity, the liver's ability to metabolize medications is compromised, potentially causing quetiapine to accumulate to toxic levels.
Some key points to consider when evaluating the use of quetiapine in patients with liver impairment include:
- Dose adjustments are typically required for patients with hepatic impairment, with recommendations for a lower initial dose and slower titration while monitoring liver function 1
- Close monitoring of liver function tests is essential if treatment with quetiapine is deemed necessary despite liver concerns
- Alternative medications with less hepatic metabolism might be safer options for patients with significant liver impairment
- The risk-benefit ratio should be carefully evaluated by the prescribing physician, considering both the severity of the psychiatric condition and the degree of liver dysfunction
It's also important to note that liver derangement might be due to drug-induced liver injury, underlying medical disease, or concomitant medications, as highlighted in a recent position statement on the management of patients with liver derangement during the COVID-19 pandemic 1. However, this statement does not provide specific guidance on the use of quetiapine in patients with acute liver toxicity.
In real-life clinical practice, the safest approach would be to avoid using quetiapine in patients with acute liver toxicity, given the potential risks and the availability of alternative treatments with less hepatic metabolism. If quetiapine is deemed necessary, close monitoring and careful evaluation of the risk-benefit ratio are essential.
From the FDA Drug Label
Since quetiapine is extensively metabolized by the liver, higher plasma levels are expected in patients with hepatic impairment. In this population, a low starting dose of 25 mg/day is recommended and the dose may be increased in increments of 25 mg/day to 50 mg/day
The use of seroquel (quetiapine) in patients with acute liver toxicity is not directly addressed in the label. However, it does provide guidance on dosing in patients with hepatic impairment, recommending a low starting dose.
- Key consideration: The label does not provide information on the use of quetiapine in patients with acute liver toxicity, which may be a more severe condition than hepatic impairment.
- Clinical decision: Given the lack of direct information, it is uncertain whether seroquel can be safely given to patients with acute liver toxicity. 2
From the Research
Seroquel and Acute Liver Toxicity
- There is no direct evidence in the provided studies that specifically addresses the use of Seroquel (quetiapine) in patients with acute liver toxicity.
- However, a study from 2023 3 graded quetiapine as a moderate risk for causing or worsening liver disease.
- Another study from 2007 4 found that quetiapine, along with other atypical antipsychotic drugs, can cause asymptomatic increases in liver enzymes and serum bilirubin levels, but significant liver enzyme elevations are rare.
- A study from 2002 5 discussed the safe use of medications in patients with underlying liver disease and recommended clinical and biochemical monitoring for patients taking potentially hepatotoxic drugs.
- A study from 2022 6 reviewed the safety and side effect profile of pharmacological therapies used in the treatment of acute liver injury, but did not specifically address the use of Seroquel.
- A study from 2014 7 reported a case of risperidone-associated hepatocellular damage, but did not provide information on the use of Seroquel in patients with acute liver toxicity.
Monitoring and Precautions
- The studies suggest that careful monitoring of liver function tests is recommended for patients taking antipsychotic medications, including quetiapine 3, 4.
- Patients with underlying liver disease should be closely monitored for signs of liver injury, and the benefits of treating psychosis should be weighed against the risks of hepatotoxicity 5, 3.
- Regular lab monitoring and patient counseling are recommended for patients taking antipsychotic medications, especially those with a higher risk of liver injury 3.