Benzodiazepines in Liver Disease — MRCPsych Paper B MCQ
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Correct answer: A — Oxazepam
A. Oxazepam has the most favourable pharmacokinetic profile among the listed drugs. It is converted directly by glucuronidation to a pharmacologically inactive metabolite, so it is less liable to accumulation from impaired phase I oxidative metabolism. Diazepam and chlordiazepoxide undergo hepatic oxidation and produce long-lived active metabolites, increasing the risk of prolonged sedation. Midazolam is short acting after a single dose but depends substantially on CYP3A metabolism, which may be impaired in cirrhosis. Nitrazepam is relatively long acting and offers no comparable metabolic advantage. This is a relative preference, not evidence that oxazepam is generally safe: use the lowest effective dose for the shortest duration, exercise extreme caution because of alcohol dependence, and avoid all benzodiazepines in severe hepatic insufficiency because they may precipitate encephalopathy.
Reference: electronic Medicines Compendium, Oxazepam 10 mg Tablets, Summary of Product Characteristics, sections 4.2–4.4 and 5.2, revised 23 December 2025. https://www.medicines.org.uk/emc/product/11747/smpc