From the Guidelines
Benzodiazepines, such as Ativan (lorazepam), are contraindicated in patients with decompensated cirrhosis due to the risk of precipitating hepatic encephalopathy. The most recent and highest quality study, published in 2023 in the journal Liver International 1, suggests a strong agreement on the contraindication of benzodiazepines in patients with decompensated cirrhosis. This is because benzodiazepines can accumulate in patients with cirrhosis, potentially causing excessive sedation, respiratory depression, or worsening of hepatic encephalopathy.
When managing a patient with cirrhosis and agitation, it is essential to first identify and address the underlying cause of the agitation, which could be due to encephalopathy, withdrawal, pain, or anxiety. Non-pharmacological approaches such as reorientation, family presence, or distraction techniques should be tried first. If medication is absolutely necessary, alternative medications with less hepatic metabolism, such as haloperidol at low doses (0.5-1mg), might be considered, although they also require caution.
Key considerations in managing these patients include:
- Monitoring blood sodium levels to prevent severe hyponatraemia, a predisposing factor for hepatic encephalopathy 1
- Limiting the prescription of proton pump inhibitors to their strict validated indications to reduce the risk of hepatic encephalopathy 1
- Controlling precipitating factors, such as gastrointestinal bleeding, infection, dehydration, and constipation, which can induce encephalopathy in cirrhotic patients 1
In the context of real-life clinical medicine, it is crucial to prioritize the patient's safety and well-being, and to avoid using medications that can potentially worsen their condition. Therefore, Ativan (lorazepam) should not be given to a patient with cirrhosis and agitation without careful consideration and exploration of alternative management options.
From the FDA Drug Label
As with all benzodiazepines, the use of lorazepam may worsen hepatic encephalopathy; therefore, lorazepam should be used with caution in patients with severe hepatic insufficiency and/or encephalopathy. Dosage for patients with severe hepatic insufficiency should be adjusted carefully according to patient response; lower doses may be sufficient in such patients
The patient with cirrhosis should be given caution when administering Ativan (lorazepam) due to the potential for worsening hepatic encephalopathy.
- Key considerations:
- Use with caution in patients with severe hepatic insufficiency
- Adjust dosage carefully according to patient response
- Lower doses may be sufficient in such patients 2
From the Research
Patient Considerations
- Patients with cirrhosis and agitation may require careful management to prevent worsening of their condition.
- The use of benzodiazepines, such as Ativan (lorazepam), may be problematic in patients with cirrhosis due to the increased risk of hepatic encephalopathy 3, 4.
- Alternative management strategies for agitation in patients with cirrhosis may include physical restraint and medication with safer options, such as haloperidol 5.
Medication Considerations
- Benzodiazepines are generally best avoided in patients with liver disease due to the risk of precipitating coma and worsening hepatic encephalopathy 5, 4.
- The risk of hepatic encephalopathy associated with benzodiazepine use in patients with cirrhosis may be increased, particularly during the initial days of use 4.
- Patients with cirrhosis may require tailored pharmacotherapy to ensure safe and appropriate use of medicines, taking into account alterations in pharmacokinetics and pharmacodynamics 6.
Treatment Options
- For patients with cirrhosis and agitation, alternative treatments such as haloperidol may be considered 5.
- In cases of hepatic encephalopathy, benzodiazepine receptor antagonists like flumazenil may be beneficial in a selected subset of patients 7.
- The use of benzodiazepines, including Ativan (lorazepam), should be carefully evaluated and considered on a case-by-case basis, taking into account the potential risks and benefits 3, 4.