Some benzodiazepines are metabolized by the liver more extensively than others, and some knowledge of this can help with therapeutic decisions.
- Lorazepam and Temazepam can be used at normal doses, but there is still a risk of coma, so a reduced dose may be advisable initially.
- Midazolam – elimination is significantly reduced in cirrhosis and therefore a reduced dose is advisable to avoid prolonged sedation.
- Diazepam – half-life more than doubles in cirrhosis and should therefore be avoided in severe impairment.
- Clonazepam – avoid due to prolonged half-life. Can be useful for severe agitation/pain in terminal care – please seek specialist advice.