Which benzodiazepine is preferred for treating alcohol withdrawal in patients with cirrhosis?

The preferred benzodiazepine for treating alcohol withdrawal in patients with cirrhosis is lorazepam. This choice is primarily due to its pharmacokinetic profile and hepatic metabolism. Lorazepam is processed largely by conjugation in the liver, making it a safer option for patients with liver impairment compared to other benzodiazepines that are significantly metabolized via the cytochrome P450 system, such as diazepam.

In patients with cirrhosis, the liver's ability to clear medications is compromised. Using a drug that is dependent on hepatic metabolism can lead to increased serum levels, prolonged sedation, and a higher risk of adverse effects. Lorazepam’s metabolism is less affected by liver function, which supports its use in this population, ensuring effective treatment while minimizing the risk of accumulation and toxicity.

Oxazepam and temazepam are also safer alternatives to those that heavily rely on liver metabolism, but lorazepam is the more commonly recommended benzodiazepine in clinical guidelines for this specific scenario, particularly because of its potent effects and manageable dosing regimen. Diazepam is not preferred in this context due to its extensive hepatic metabolism and potential for accumulation in patients with liver disease.