Sedative-hypnotics: alcohol withdrawal in cirrhosis: practice question

A Pharmacology question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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Pharmacology · Sedative-hypnotics: alcohol withdrawal in cirrhosis

Sample item

A 48-year-old man with decompensated alcoholic cirrhosis (Child-Pugh C) is admitted on day 2 of abstinence with tremor, sweating and agitation. A benzodiazepine is needed. Which choice is the safest given his liver disease?

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

A. Lorazepam

Lorazepam, like oxazepam and temazepam, is cleared mainly by glucuronidation, which is relatively preserved in cirrhosis, and it has no active metabolites. Chlordiazepoxide and diazepam undergo oxidative metabolism to long-acting active metabolites that accumulate in liver failure and can precipitate encephalopathy. Phenytoin does not prevent withdrawal seizures.

Option by option

  • A. Lorazepam (correct)

    Lorazepam is conjugated directly and has no active metabolites, so it is safest in cirrhosis.

  • B. Phenytoin

    Phenytoin is not effective for alcohol withdrawal seizures and is metabolised by the liver.

  • C. Chlordiazepoxide

    Chlordiazepoxide has long-acting active metabolites that accumulate and risk encephalopathy.

  • D. Diazepam

    Diazepam is oxidised to long-acting active desmethyldiazepam, which accumulates in liver disease.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

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Questions about this Pharmacology question

What is the answer to this Pharmacology question?

The best answer is A, Lorazepam. Lorazepam, like oxazepam and temazepam, is cleared mainly by glucuronidation, which is relatively preserved in cirrhosis, and it has no active metabolites.

Why is "Phenytoin" not the answer?

Phenytoin is not effective for alcohol withdrawal seizures and is metabolised by the liver.

Why is "Chlordiazepoxide" not the answer?

Chlordiazepoxide has long-acting active metabolites that accumulate and risk encephalopathy.

Why is "Diazepam" not the answer?

Diazepam is oxidised to long-acting active desmethyldiazepam, which accumulates in liver disease.

What concept does this question test?

It tests Sedative-hypnotics: alcohol withdrawal in cirrhosis in Pharmacology. Chlordiazepoxide and diazepam undergo oxidative metabolism to long-acting active metabolites that accumulate in liver failure and can precipitate encephalopathy. Phenytoin does not prevent withdrawal seizures.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Sedative-hypnotics: alcohol withdrawal in cirrhosis?

Learn drugs as classes, then the exception in each class that an examiner would pick. Then use the flashcards and the other Pharmacology questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.