Substance use: benzodiazepine choice in liver disease: practice question

A Psychiatry 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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Psychiatry · Substance use: benzodiazepine choice in liver disease

Sample item

A 55-year-old man with decompensated cirrhosis (ascites, prolonged prothrombin time) is admitted with sweating, tremor and anxiety 20 hours after his last drink. Which benzodiazepine is the preferred choice for his alcohol withdrawal?

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

The answer and the reasoning

A. Lorazepam

Lorazepam and oxazepam are cleared by glucuronidation, which is relatively preserved in liver disease, and they have no active metabolites. Long-acting agents such as diazepam and chlordiazepoxide rely on oxidative metabolism and form active metabolites that accumulate, causing oversedation and precipitating hepatic encephalopathy.

Option by option

  • A. Lorazepam (correct)

    Correct. It is conjugated directly, has no active metabolites and does not accumulate in hepatic failure.

  • B. Flurazepam

    It has a very long-acting active metabolite and is poorly suited to a patient with failing liver function.

  • C. Diazepam

    Its oxidative metabolism is slowed in cirrhosis and its active metabolite desmethyldiazepam accumulates.

  • D. Chlordiazepoxide

    It is oxidised in the liver and its long-acting active metabolites build up in cirrhosis.

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 Psychiatry question

What is the answer to this Psychiatry question?

The best answer is A, Lorazepam. Lorazepam and oxazepam are cleared by glucuronidation, which is relatively preserved in liver disease, and they have no active metabolites.

Why is "Flurazepam" not the answer?

It has a very long-acting active metabolite and is poorly suited to a patient with failing liver function.

Why is "Diazepam" not the answer?

Its oxidative metabolism is slowed in cirrhosis and its active metabolite desmethyldiazepam accumulates.

Why is "Chlordiazepoxide" not the answer?

It is oxidised in the liver and its long-acting active metabolites build up in cirrhosis.

What concept does this question test?

It tests Substance use: benzodiazepine choice in liver disease in Psychiatry. Long-acting agents such as diazepam and chlordiazepoxide rely on oxidative metabolism and form active metabolites that accumulate, causing oversedation and precipitating hepatic encephalopathy.

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 Substance use: benzodiazepine choice in liver disease?

Learn each diagnosis by its core features and its first-line treatment. Then use the flashcards and the other Psychiatry 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.