Hepatic disease and psychiatric illness: relationships and treatment

Worsening Hepatic Encephalopathy Secondary to Zolpidem

Objective:

To report a case of worsening hepatic encephalopathy secondary to ingestion of Zolpidem.

Case Summary:

A 41-year-old white man had postoperative complications 11 months after liver transplantation. Complications included narrowing of the choledochal anastomosis site, cyclosporine nephrotoxicity, and recurrent hepatitis C. Approximately seven months after transplantation, the patient experienced elevations in liver enzyme concentrations, lethargy, ascites, fever, chills, and nausea. Examination of a biopsy sample revealed recurrent hepatitis C. The patient's condition did not resolve despite administration of interferon alfa-2b, and his mental status began to deteriorate secondary to hepatic encephalopathy. One day before admission, the patient was given Zolpidem 5 mg for sleep; one hour after taking Zolpidem, he awoke in a stupor and was not oriented to place or time. When he became increasingly incoherent and verbally abusive, family members brought him to the emergency department. Although the patient exhibited mental status deterioration before receiving Zolpidem, considering the strong temporal relationship, his rapidly worsening state may be attributable to the drug. The patient subsequently required a second liver transplant in addition to a kidney transplant as a result of cyclosporine nephrotoxicity. The patient was not rechallenged with Zolpidem nor given flumazenil.

Discussion:

One pathophysiologic explanation for hepatic encephalopathy implicates endogenously produced benzodiazepine agonists. In patients with portal-systemic shunting, psychoactive compounds escape metabolism and are subsequently free to cross the blood-brain barrier. This mechanism is supported by reports of successful treatment of patients who have encephalopathy with flumazenil, a benzodiazepine antagonist. Hence, it follows that a benzodiazepine agonist could potentially exacerbate encephalopathic symptomatology. Zolpidem, although structurally unrelated to benzodiazepines, is a benzodiazepine agonist that binds preferentially to the benzodiazepine1 ω1 subtype of the γ-aminobutyric acid (GABAA) receptor complex. Therefore, administration of Zolpidem to patients with encephalopathy may worsen the condition by contributing to the accumulation of benzodiazepine agonists within the central nervous system.

Conclusions:

Although this patient's worsening mental status could be explained by a naturally evolving encephalopathic state, it is possible that Zolpidem exacerbated his decline. Existing evidence supports this view. First, an endogenously produced, benzodiazepine-related mechanism of hepatic encephalopathy is described in the literature. Second, benzodiazepine-like substances have been detected in the serum of patients with encephalopathy who have not received benzodiazepine therapy. Finally, clinical evidence supports the use of flumazenil in encephalopathic patients. Thus, it is likely that administration of Zolpidem hastened the mental decline of this patient.

Hypoalbuminaemia and impaired renal function are associated with increased anticholinergic drug prescribing

BACKGROUND

A higher anticholinergic risk score (ARS) is associated with an increased risk of anticholinergic adverse effects in elderly patients. It is unknown whether factors other than the use of anticholinergic drugs determine the ARS.

METHODS

A comprehensive medical record review was conducted in 155 consecutive hospitalised patients (median age 79.0 years, interquartile range 66.0-86.0). Information was collected on: demographics; clinical characteristics (including medications and their doses); history of anticholinergic-induced adverse effects; and biochemical markers of hepatic and renal function (serum albumin concentrations and estimated glomerular filtration rate, eGFR). The ARS was calculated for each patient using a standard scoring approach and Poisson regression was used for identifying variables associated with the ARS.

RESULTS

Patients with an ARS >or= 3 had a lower eGFR (p = 0.012) and were receiving more non-anticholinergic drugs (p < 0.001) than patients with an ARS < 3. In addition to being prescribed more anticholinergic drugs, patients with ARS >or= 3 were prescribed high doses of these drugs more often than patients with ARS < 3 (41.3% vs. 26.9%, p = 0.034). A higher number of non-anticholinergic drugs (p < 0.001), a lower serum albumin concentration (p = 0.014), and a lower eGFR (p = 0.012) were independently associated with a higher ARS.

CONCLUSIONS

Polypharmacy, hypoalbuminaemia and low eGFR are independently associated with the ARS. Patients with a higher ARS are also prescribed higher doses of anticholinergic medications than those with lower ARS.

New developments for the pharmacological treatment of alcohol withdrawal syndrome. A focus on non-benzodiazepine GABAergic medications

Alcohol withdrawal syndrome (AWS) can be a life-threatening condition affecting some alcohol-dependent patients who abruptly discontinue or decrease their alcohol consumption. The main objectives of the clinical management of AWS include: to decrease the severity of symptoms, prevent more severe withdrawal clinical manifestations and facilitate entry of the patient into a treatment program in order to attempt to achieve and maintain long-term abstinence from alcohol. At present, benzodiazepines represent the drugs of choice in the treatment of AWS. However, in line with the possible side effects and addictive properties related to benzodiazepine use, there is growing evidence to suggest that non-benzodiazepine GABAergic compounds represent promising medications in the treatment of alcohol-dependent patients. This review focuses on research into non-benzodiazepine GABAergic medications for the treatment of AWS. Among them, carbamazepine, gabapentin and valproic acid are the most studied. The studies on carbamazepine seem to be the most compelling. Preliminary data have also suggested the possible utility of baclofen and topiramate, although further evidence is needed. The promising results in terms of both safety and efficacy are reported. However, we also note the need of more methodologically controlled studies on a greater number of patients, involving more complicated forms of AWS.

The enzymatic formation of novel bile acid primary amides

Bifunctional peptidylglycine alpha-amidating monooxygenase (PAM) catalyzes the copper-, ascorbate-, and O(2)-dependent cleavage of C-terminal glycine-extended peptides and N-acylglycines to the corresponding amides and glyoxylate. The alpha-amidated peptides and the long-chain acylamides are hormones in humans and other mammals. Bile acid glycine conjugates are also substrates for PAM leading to the formation of bile acid amides. The (V(MAX)/K(m))(app) values for the bile acid glycine conjugates are comparable to other known PAM substrates. The highest (V(MAX)/K(m))(app) value, 3.1 +/- 0.12 x 10(5) M(-1) s(-1) for 3-sulfolithocholylglycine, is 6.7-fold higher than that for d-Tyr-Val-Gly, a representative peptide substrate. The time course for O(2) consumption and glyoxylate production indicates that bile acid glycine conjugate amidation is a two-step reaction. The bile acid glycine conjugate is first converted to an N-bile acyl-alpha-hydroxyglycine intermediate which is ultimately dealkylated to the bile acid amide and glyoxylate. The enzymatically produced bile acid amides and the carbinolamide intermediates were characterized by mass spectrometry and two-dimensional (1)H-(13)C heteronuclear multiple quantum coherence NMR.

Psychological distress in patients with chronic, nonalcoholic, uncomplicated liver disease

To study whether the presence of significant disease in a major organ, possibly with minimal or no clinical symptoms, would be associated with psychological disturbance, 80 subjects suffering from chronic hepatitis or cirrhosis, of nonalcoholic etiology were interviewed. Of these, 64 had either minimal or no physical symptoms. Patients completed the Brief Symptom Inventory (BSI) and the Impact of Event Scale (IES), questionnaires, which measure symptoms of psychological distress. It was found that 50% of the liver subjects were defined as cases by the BSI criteria including 15% who were defined as severe cases. There were no gender differences. Forty-five percent of asymptomatic liver subjects were defined as cases. Psychological distress was significantly pronounced in subjects with less than 12 years of education. This study points to a significant incidence of psychological distress, even in clinically asymptomatic subjects, suffering from chronic, nonalcoholic, uncomplicated liver disease.

The management of treatment-resistant depression in the medically ill

There are a few well-designed studies to systematically assess treatment-resistant depression in the medically ill patient. Psychiatrists, however, do have extensive clinical experience in treating depression in the medical patient. This experience can be useful in helping to determine treatment resistance and in selecting consequent treatment choices. A decision tree is offered in Table 1 to clarify the questions the clinician must answer. The first step is to evaluate the role of the medical illness and to decide whether or not treating that effectively will also clear the depression. Physicians may find it helpful to use a decision tree in initiating treatment of patients with depression and physical illness. Once it has been clarified that the diagnosis of depression is a correct one and that an antidepressant medication is in order, consideration of safety, side effects, and other current prescriptions used by the patient must occur. Drug-drug interactions as well as changes in the clearance of medications are critical to the effectiveness of the choice and tolerability for the patient. An antidepressant agent needs to be given for an adequate time with optimization of dosing. Augmenting a medication to increase its therapeutic action could be tried if one agent alone is not effective. An alternative approach is that the second drug selected might affect different neurotransmitters, and the combination of mechanisms would result in resolution of symptoms. Adding psychotherapy, especially when social supports are lacking, can be particularly helpful. ECT is an important consideration for severe depression when suicidal concerns are imminent or the patient has not responded to pharmacotherapy trials. While we await further studies of treatment-resistant depression in large enough numbers of patients with particular illnesses, we can use these guidelines to direct our decisions to switch or augment our initial choices to provide the safest, most effective care possible.