Template:Inpatient management of ETOH withdrawal: Difference between revisions
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| Chlordiazepoxide||25||PO, IV||30 - 120||7-28||CYP; active metabolites | | [[Chlordiazepoxide]]||25||PO, IV||30 - 120||7-28||CYP; active metabolites | ||
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| Diazepam||5||PO, IV, IM||2 - 5||20-120||CYP; active metabolites | | [[Diazepam]]||5||PO, IV, IM||2 - 5||20-120||CYP; active metabolites | ||
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| Lorazepam||1||PO, IM, IV||15-20||8-19||Glucuronidation | | [[Lorazepam]]||1||PO, IM, IV||15-20||8-19||Glucuronidation | ||
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**Half-life 10-20 h (medium acting) | **Half-life 10-20 h (medium acting) | ||
===[[Propofol]] | ===Other Agents=== | ||
*If patient does not respond to high doses of [[benzodiazepines]] | ''For use in cases refractory to [[benzodiazepine]] treatment | ||
*0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours | *[[Propofol]] | ||
**If patient does not respond to high doses of [[benzodiazepines]] | |||
**0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours | |||
* | *[[Barbiturates]] ([[Phenobarbital]]) | ||
**Used when refractory to [[benzodiazepines]] (consider after patient has received equivalent of 200 mg diazepam) | |||
***[[Phenobarbital]] 130-260 mg IV q 15-20 minutes | |||
***Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions <ref> Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013; 44(3):592-598.</ref> | |||
*Used when refractory to [[benzodiazepines]] (consider after patient has received equivalent of 200 mg diazepam) | *α-2 agonists ([[Dexmedetomidine]]) | ||
*[[Phenobarbital]] 130-260 mg IV q 15-20 minutes | **Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines | ||
*Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions <ref> Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013; 44(3):592-598.</ref> | **Dexmedetomidine drip, start 0.2 mcg/kg/hr, likely needing no more than 0.7 mcg/kg/hr<ref>Rayner SG, et al. Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU. Ann Intensive Care. 2012; 2: 12. Published online 2012 May 23. doi: 10.1186/2110-5820-2-12.</ref> | ||
*[[Ketamine]] | |||
**May have some use in refractory cases | |||
*May have some use in refractory cases | **Blocks the NMDA receptor which is excited an unregulated. <ref>Wong, A et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015 Jan;49(1):14-9. PMID: 25325907</ref> | ||
*Blocks the NMDA receptor which is excited an unregulated. <ref>Wong, A et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015 Jan;49(1):14-9. PMID: 25325907</ref> | |||
===Special Situations=== | ===Special Situations=== | ||
*The propylene glycol diluent in [[lorazepam]], [[phenobarbital]], and [[diazepam]], may induce a hyperosmolar anion gap [[metabolic acidosis]] if given as a drip in high doses ≥ 48hrs.<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion [[lorazepam]] to serum propylene glycol concentration in critically ill adults*. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref> Consider alternatives such as [[propofol]] or [[dexmedetomidine]] if patients need long term sedation for [[delirium tremens]]. | *The propylene glycol diluent in [[lorazepam]], [[phenobarbital]], and [[diazepam]], may induce a hyperosmolar anion gap [[metabolic acidosis]] if given as a drip in high doses ≥ 48hrs.<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion [[lorazepam]] to serum propylene glycol concentration in critically ill adults*. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref> Consider alternatives such as [[propofol]] or [[dexmedetomidine]] if patients need long term sedation for [[delirium tremens]]. | ||
Latest revision as of 20:26, 31 May 2022
Benzodiazepine overview
| Agents | Equivalent PO dose (mg) | Route | Onset of Action (min) | Half Life (hr) | Metabolism |
| Chlordiazepoxide | 25 | PO, IV | 30 - 120 | 7-28 | CYP; active metabolites |
| Diazepam | 5 | PO, IV, IM | 2 - 5 | 20-120 | CYP; active metabolites |
| Lorazepam | 1 | PO, IM, IV | 15-20 | 8-19 | Glucuronidation |
Benzodiazepines
- Diazepam (Valium) 5-10 mg IV (depending on severity)
- May repeat q5-10 min for severe withdrawal (may increase dose by 10 mg every 5-10 min until desired effect achieved, max dose of 200 mg)
- Half-life 20-100 h (long acting)
- Lorazepam (Ativan) 1-4mg IV (depending on severity)
- May repeat q15-20 min for severe withdrawal (titrated to effect)
- Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis[1]
- Half-life 10-20 h (medium acting)
Other Agents
For use in cases refractory to benzodiazepine treatment
- Propofol
- If patient does not respond to high doses of benzodiazepines
- 0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours
- Barbiturates (Phenobarbital)
- Used when refractory to benzodiazepines (consider after patient has received equivalent of 200 mg diazepam)
- Phenobarbital 130-260 mg IV q 15-20 minutes
- Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions [2]
- Used when refractory to benzodiazepines (consider after patient has received equivalent of 200 mg diazepam)
- α-2 agonists (Dexmedetomidine)
- Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
- Dexmedetomidine drip, start 0.2 mcg/kg/hr, likely needing no more than 0.7 mcg/kg/hr[3]
- Ketamine
- May have some use in refractory cases
- Blocks the NMDA receptor which is excited an unregulated. [4]
Special Situations
- The propylene glycol diluent in lorazepam, phenobarbital, and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs.[5] Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for delirium tremens.
- ↑ National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm
- ↑ Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013; 44(3):592-598.
- ↑ Rayner SG, et al. Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU. Ann Intensive Care. 2012; 2: 12. Published online 2012 May 23. doi: 10.1186/2110-5820-2-12.
- ↑ Wong, A et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015 Jan;49(1):14-9. PMID: 25325907
- ↑ Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults*. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.