Prescribing benzodiazepines

Sedatives can lead to coma in advanced liver disease and a general approach would be to start with a reduced dose and titrate slowly. If treatment is necessary, benzodiazepines with shorter half-lives are safer.

Some benzodiazepines are metabolized by the liver more extensively than others, and some knowledge of this can help with therapeutic decisions.

  • Lorazepam and Temazepam can be used at normal doses, but there is still a risk of coma, so a reduced dose may be advisable initially.
  • Midazolam – elimination is significantly reduced in cirrhosis and therefore a reduced dose is advisable to avoid prolonged sedation.
  • Diazepam – half-life more than doubles in cirrhosis and should therefore be avoided in severe impairment.
  • Clonazepam – avoid due to prolonged half-life. Can be useful for severe agitation/pain in terminal care – please seek specialist advice.


This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.