Psychotropics in renal and hepatic disease

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Target exams

Red flags

• Coarse tremor, ataxia, confusion or seizures on lithium — stop drug, serial levels, volume support, escalate toward EXTRIP when criteria met
• New benzodiazepine in decompensated cirrhosis with rising confusion or asterixis — treat as possible precipitated hepatic encephalopathy
• Jaundice, dark urine, coagulopathy or rising ALT/AST after a high-risk psychotropic — stop culprit and involve hepatology (DILI pathway)
• Valproate with unexplained lethargy or delirium and high ammonia even if LFTs near normal — stop VPA and treat as hyperammonemic encephalopathy until proven otherwise
• Full-dose paliperidone or amisulpride in moderate–severe CKD without CrCl adjustment — accumulation and EPS risk
• AKI or dehydration on ACE inhibitor/ARB + thiazide + NSAID + lithium — chronic accumulation toxicity