Psychiatric Pharmacy Essentials: Psychotropic Medication and Hepatic Impairment

Many individuals with hepatic impairment are impacted by psychiatric disorders. Co-occurring substance use disorders are also prevalent and have been associated with increased risk of liver disease. Though limited, literature exists to support safe medication prescribing in patients with hepatic dysfunction, including those with cirrhosis.

  • What are some of the pharmacokinetic, pharmacodynamic, and physiologic considerations for psychotropic medication use in patients with hepatic disease?1-2
  • What is the effectiveness and safety of antidepressants3-4, antipsychotics5-6, and other psychotropic medications7-8 in patients with hepatic disease?
  • How can a clinician manage alcohol use disorder in a patient with comorbid hepatic disease?9-11

Reviewer 1: Roisin Sabol, PharmD
Reviewer 2: Austin Smith, PharmD, BCPP
2024-2025 AAPP Resident and New Practitioner Committee

References

  1. Telles-Correia D, Barbosa A, Cortez-Pinto H, Campos C, Rocha NB, Machado S. Psychotropic drugs and liver disease: A critical review of pharmacokinetics and liver toxicity. World J Gastrointest Pharmacol Ther. 2017 Feb 6;8(1):26-38. [PubMed]
  2. Menon V, Ransing R, Praharaj SK. Management of psychiatric disorders in patients with hepatic and gastrointestinal diseases. Indian J Psychiatry. 2022 Mar;64(Suppl 2):S379-S393. [PubMed]
  3. Sahoo S, Mishra E, Premkumar M. Antidepressants in people with chronic liver disease and depression: when are they warranted and how to choose the suitable one? J Clin Exp Hepatol. 2024 Jul-Aug;14(4):101390. [PubMed]
  4. Voican CS, Corruble E, Naveau S, Perlemuter G. Antidepressant-induced liver injury: a review for clinicians. Am J Psychiatry. 2014 Apr;171(4):404-15. [PubMed]
  5. Borgsteede SD, Metselaar HJ, Mulder MB. Safety of antipsychotics and dose recommendations in patients with cirrhosis from a pharmacological perspective. J Acad Consult Liaison Psychiatry. 2023 May-Jun;64(3):316-317. [PubMed]
  6. Gunther M, Dopheide JA. Antipsychotic safety in liver disease: a narrative review and practical guide for the clinician. J Acad Consult Liaison Psychiatry. 2023 Jan-Feb;64(1):73-82. [PubMed]
  7. Doroudgar S, Chou TI. How to modify psychotropic therapy for patients who have liver dysfunction. Current Psychiatry. 2014;13(12)46-49. [Weblink]
  8. Gardner KN, Bostwick JR. Medication prescribing in liver dysfunction. Mental Health Clinician. 1 May 2014; 4(3):131–137. [Weblink]
  9. Ayyala D, Bottyan T, Tien C, Pimienta M, Yoo J, Stager K, et al. Naltrexone for alcohol use disorder: Hepatic safety in patients with and without liver disease. Hepatol Commun. 2022 Dec;6(12):3433-3442. [PubMed]
  10. Arab JP, Izzy M, Leggio L, Bataller R, Shah VH. Management of alcohol use disorder in patients with cirrhosis in the setting of liver transplantation. Nat Rev Gastroenterol Hepatol. 2022 Jan;19(1):45-59. [PubMed]
  11. Jophlin LL, Singal AK, Bataller R, Wong RJ, Sauer BG, Terrault NA, Shah VH. ACG clinical guideline: alcohol-associated liver disease. Am J Gastroenterol. 2024 Jan 1;119(1):30-54. [PubMed]