# 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.