The answer is B – decreased protein binding. Patients with cirrhosis have reduced albumin and alpha 1-acid-glycoprotein production, resulting in reduced protein binding with medications, leading to higher free pharmacologically active drug. Cirrhosis often leads to portal hypertension, with resulting splanchnic vascular congestion, DELAYING medication absorption through the small intestine vasculature. Use of osmotic laxatives such as lactulose to reduce ammonia may also shorten small bowel transit time, thus REDUCING medication absorption. Glucuronidation is a process of metabolism that takes place through type II hepatic enzymes, and is typically SPARED in patients with cirrhosis. Type I hepatic enzymes, such as those responsible for oxidation, are impaired in cirrhosis, leading to REDUCED oxidation.

Publication reference : Crone CC, Gabriel GM, DiMartini A. An overview of psychiatric issues in liver disease for the consultation-liaison psychiatrist. Psychosomatics. 2006;47(3):188-205.
Reference URL: https://doi.org/10.1176/appi.psy.47.3.188