Intravenous and inhalational agents: benzodiazepine in hepatic impairment: practice question

A Anaesthesia 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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Anaesthesia · Intravenous and inhalational agents: benzodiazepine in hepatic impairment

Sample item

A frail 80-year-old woman with cirrhosis needs a benzodiazepine for sedation. Which drug is least likely to accumulate, because it is conjugated directly and has no active metabolites?

AChlordiazepoxideBFlurazepamCDiazepamDLorazepam

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

The answer and the reasoning

D. Lorazepam

Lorazepam is cleared by glucuronidation, which is relatively preserved in liver disease and old age, and it has no active metabolites. Diazepam, chlordiazepoxide and flurazepam undergo hepatic oxidation to long-acting active metabolites that accumulate.

Option by option

A. Chlordiazepoxide
Chlordiazepoxide is oxidised to several long-acting active metabolites.
B. Flurazepam
Flurazepam produces a very long-acting active metabolite that accumulates in the elderly.
C. Diazepam
Diazepam is oxidised to long-acting active metabolites, including desmethyldiazepam, which accumulate.
D. Lorazepam (correct)
Correct. Direct glucuronidation without active metabolites is preferred in liver disease and in the elderly.

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.

Questions about this Anaesthesia question

What is the answer to this Anaesthesia question?

The best answer is D, Lorazepam. Lorazepam is cleared by glucuronidation, which is relatively preserved in liver disease and old age, and it has no active metabolites.

Why is "Chlordiazepoxide" not the answer?

Chlordiazepoxide is oxidised to several long-acting active metabolites.

Why is "Flurazepam" not the answer?

Flurazepam produces a very long-acting active metabolite that accumulates in the elderly.

Why is "Diazepam" not the answer?

Diazepam is oxidised to long-acting active metabolites, including desmethyldiazepam, which accumulate.

What concept does this question test?

It tests Intravenous and inhalational agents: benzodiazepine in hepatic impairment in Anaesthesia. Diazepam, chlordiazepoxide and flurazepam undergo hepatic oxidation to long-acting active metabolites that accumulate.

How hard is this question?

We tag it as an application question: it asks you to use a fact on a patient or a finding. 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 Intravenous and inhalational agents: benzodiazepine in hepatic impairment?

Make a table of each agent, its key advantage and its main side effect. Then use the flashcards and the other Anaesthesia 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.