09 - Summary of recommended psychotropics in hepat

Summary of recommended psychotropics in hepatic impairment

Prescribing in hepatic and renal impairment CHAPTER 8 Other psychotropics in hepatic impairment Table 8.6 gives a summary of other psychotropics recommended in hepatic impairment. Summary of recommended psychotropics in hepatic impairment Table 8.7 gives an outline of the drug groups of psychotropics recommended for use in hepatic impairment. Table 8.6  Other psychotropics in hepatic impairment. Drug Comments Bremelanotide7 No dose adjustment required in mild to moderate hepatic impairment. Use with caution in severe impairment; adverse effects more likely.30 One case of acute hepatitis reported. Deutetrabenazine6,28 Not studied in hepatic impairment but, based on experience with tetrabenazine, use is contraindicated. Limited information available but clinically relevant hepatotoxicity not reported. Occasional asymptomatic rises in ALT. Gabapentin Largely renally excreted but occasional cases of liver toxicity reported.94,95 Lemborexant, daridorexant, suvorexant7,30 No dose adjustments in mild or moderate impairment required for suvorexant. For lemorexant and daridorexant, no dose adjustment in mild impairment (risk of increased somnolence). In moderate impairment, starting and maximum dose of 5mg for lemborexant, 25mg for daridorexant. None is recommended in severe impairment. Little experience but hepatotoxicity not reported.96 Pitolisant6,30 Extensively hepatically metabolised. No dose adjustment in mild impairment. In moderate impairment the half-­life is doubled; daily dose can be increased 2 weeks after initiation, daily maximum 17.8mg. Manufacturers recommend monitoring patients with hepatic impairment for increased QTc. Contraindicated in severe impairment. Hepatic enzyme increases are uncommon. No reports of liver injury. Pregabalin Not metabolised and largely renally excreted.97 Rare cases of hepatoxicity.98,99 Solriamfetol6 Not metabolised. No known problems in liver impairment, no reports of liver injury. Valbenazine7,28 Hepatically metabolised pro-­drug of α-­dihydrotetrabenazine. Unlike deutetrabenazine, valbenazine is not contraindicated in liver disease, but maximum dose of 40mg in moderate to severe impairment. Few data, but no reports of clinically relevant liver injury other than a single report of reactivation of pre-­existing hepatitis C. ALT, alanine aminotransferase. Table 8.7  Psychotropic drug groups in hepatic impairment. Drug group Recommended drugs Antipsychotics Sulpiride/amisulpride: no dosage reduction required if renal function is normal Paliperidone: if depot required. Antidepressants Paroxetine, sertraline, citalopram, escitalopram or vortioxetine: start at low dose. Titrate slowly (if required) as above. Mood stabilisers Lithium: use plasma levels to guide dosage. Care needed if ascites status changes. Sedatives Lorazepam, oxazepam, temazepam: short half-­life with no active metabolites. Use low doses with caution, as sedative drugs used in severe disease can precipitate hepatic encephalopathy. Zopiclone: 3.75mg with care in moderate hepatic impairment.