Muscle Relaxant in Liver Disease — FRCA Final MCQ
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Correct answer: C — Atracurium
Atracurium is the best answer. Its neuromuscular blocking effect is terminated predominantly by Hofmann elimination, a non-enzymatic process dependent on physiological pH and temperature, together with ester hydrolysis by non-specific esterases. Its elimination is therefore independent of hepatic and renal function, and standard doses can be used in hepatic impairment. Vecuronium is eliminated mainly in bile, and reduced clearance can prolong blockade in liver or biliary disease. Rocuronium is excreted in bile and urine and may also have a prolonged effect in hepatic disease. Pancuronium depends substantially on organ clearance, particularly renal excretion, rather than organ-independent degradation. Suxamethonium is hydrolysed by plasma cholinesterase, which is synthesised in the liver; clinically important prolongation is more characteristic of severe hepatic failure or marked enzyme deficiency.
Reference: Hospira UK Ltd. Atracurium Besilate 10 mg/ml Solution for Injection/Infusion, Summary of Product Characteristics, sections 4.2 and 5.2; updated 27 February 2025. https://www.medicines.org.uk/emc/product/3785/smpc