From the Guidelines
For individuals with elevated liver enzymes or hepatitis, lorazepam is the safest benzodiazepine option due to its minimal liver metabolism and primary elimination through the kidneys 1. When considering the management of patients with elevated liver enzymes or hepatitis, it is crucial to select medications that do not extensively rely on hepatic metabolism to minimize the risk of adverse effects.
- Lorazepam, oxazepam, and temazepam are preferred over other benzodiazepines because they undergo direct glucuronidation, which is less affected by liver disease compared to the cytochrome P450 enzyme system 1.
- The use of benzodiazepines in patients with liver disease requires careful consideration of the dose, with a recommended reduction of approximately 50% in moderate liver disease to avoid accumulation and increased risk of adverse effects 1.
- Non-benzodiazepine options like buspirone may also be considered for patients with liver disease, as they have less impact on liver function and can provide an alternative for managing anxiety without the risks associated with benzodiazepine use in this population.
- Regular monitoring of liver function tests is essential for patients taking these medications to promptly identify any changes in liver function and adjust the treatment plan accordingly.
- It is not necessary to stop benzodiazepines completely in patients with elevated liver enzymes or hepatitis, but rather to use the lowest effective dose for the shortest duration possible and to closely monitor for signs of toxicity or worsening liver function 1.
From the FDA Drug Label
The usual precautions for treating patients with impaired renal or hepatic function should be observed 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 Although rare, leukopenia and hepatic dysfunction including jaundice have been reported during therapy. Periodic blood counts and liver-function tests are advisable.
Lorazepam and Oxazepam can be used with caution in patients with elevated liver enzymes and hepatitis.
- Lorazepam: should be used with caution in patients with severe hepatic insufficiency and/or encephalopathy, and the dosage should be adjusted carefully according to patient response.
- Oxazepam: periodic blood counts and liver-function tests are advisable, as rare instances of leukopenia and hepatic dysfunction have been reported. It is not required to stop the medication if the person is already taking it, but the dosage may need to be adjusted and the patient should be monitored frequently 2 3.
From the Research
Safe Tranquilliser Options
- Lorazepam and oxazepam are considered safer options for patients with liver disease, as their metabolism is minimally affected by age and liver disease 4.
- These benzodiazepines undergo hepatic glucuronidation, which is mainly preserved in patients with liver cirrhosis 5.
Considerations for Patients with Elevated Liver Enzymes and Hepatitis
- Patients with elevated liver enzymes and hepatitis should be cautious when taking tranquillisers, as liver disease can affect drug metabolism 5, 6.
- A reduction in drug metabolizing enzyme activity must be taken into consideration when adjusting doses, especially in patients with severe liver disease 5.
- In some cases, tranquillisers like lorazepam can cause drug-induced liver injury, and patients should be monitored closely 7.
Management of Elevated Liver Enzymes
- Emergency physicians should take an algorithmic approach to the interpretation of abnormalities in liver enzymes, considering the underlying biological basis and differential diagnosis 8.
- Patients with elevated liver enzymes should be evaluated and managed based on the magnitude of enzymatic elevation and the presence of underlying pathology 8.