Ethanol withdrawal: Difference between revisions

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==Inpatient Management==
==Inpatient Management==
''Start aggressive [[Benzodiazepines|Benodiazepine]] therapy at CIWA score of 8. Consider ICU admission with score >20''
See [[Alcohol withdrawal: Inpatient management]]
===[[Benzodiazepines]]===
*[[Diazepam]] (Valium) 5-10mg IV (depending on severity)
**May repeat q5-10min for severe withdrawal (double dose until desired effect achieved)
*[[Lorazepam]] (Ativan) 1-4mg IV (depending on severity)
**May repeat q15-20min for severe withdrawal (titrated to effect)
**Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis<ref>National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm</ref>
===Alpha-2 agonists ([[Dexmedetomidine]])===
*Decrease severity of sxs, but only supplemental to GABA-ergic first-lines
* Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min
===[[Barbituates]] ([[Phenobarbital]])===
*Used when refractory to [[benzodiazepines]]
* [[Phenobarbital]] 130-260 mg IV q 15-20 minutes


===Ketamine===
==Outpatient Management==
*[[Ketamine]] may have some use in refractory cases
See [[Alcohol withdrawal: Outpatient management]]
*[[Ketamine]] 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>
===Nutritional supplementation===
*Banana bag
**Thiamine 100mg IV
**Folate 1mg IV (cheaper PO)
**MVI 1 tab IV (cheaper PO)
**[[Magnesium sulfate]] 2mg IV
**Normal saline as needed for hydration
 
 
==Outpatient Treatment==
===[[Chlordiazepoxide]]===
'''Generally for outpatient treatment of mild cases and as a taper'''
*25-50mg of chlordiazepoxide is equivalent to 10mg of diazepam
*50mg of chlordiazepoxide every 8 hours for two days, thel decrease to 25mg every 8 hours for another two days followed by 25mg PRN as needed.
 
===Anticonvulsants===
*[[Gabapentin]] 400mg PO TID<ref>Leung JG, Hall-Flavin D, Nelson S, et al. The role of gabapentin in the management of alcohol withdrawal and dependence. Ann Pharmacother. 2015; 49(8):897-906.</ref>
**Some protocols call for higher dosing - 600 or 800mg x1
*Similar efficacy to lorazepam in decreasing craving and anxiety<ref>Myrick, H et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. 2009 Sep;33(9):1582-8.  PMID: 19485969</ref>
 
==Delirium Tremens==
===Diagnosis===
*Onset after last drink - 48 to 96hrs
*Delirium
**Disconnected from the environment
*Hyperdynamic vital signs
*Febrile
===Treatment===
*Goal = sleepy, but arousable w/ HR <110
*[[Diazepam]]
**Long duration of action, max effect within 5min
**Start 10mg IV
***Redose q5min after observing effect
***Can double subsequent doses until achieve goal
*[[Propofol]]
**Consider intubation + propofol drip if benzo-nonresponsive
*[[Thiamine]] 100mg
 
==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 Delirum Tremens


==Disposition==
==Disposition==
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**Medication hx of benzodiazepines, BBs, CCBs, antipsychotics
**Medication hx of benzodiazepines, BBs, CCBs, antipsychotics
**Hx of head injury, epilepsy, medical instability, ECG abnormality, grossly abnormal lab value
**Hx of head injury, epilepsy, medical instability, ECG abnormality, grossly abnormal lab value
*Example regimens (please use discretion and balance risk/benefits with your own clinical judgment):
====Example outpatient [[lorazepam]] taper====
*2 mg tid x3 days
*2 mg bid on day 4
*2 mg once on day 5
====Example outpatient [[gabapentin]] taper====
''Similar in efficacy to lorazepam according to one RCT<ref>Myrick et al. A DOUBLE BLIND TRIAL OF GABAPENTIN VS. LORAZEPAM IN THE TREATMENT OF ALCOHOL WITHDRAWAL. Alcohol Clin Exp Res. 2009 Sep; 33(9): 1582–1588. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769515/</ref>''
*400 mg tid x3 days
*300 mg bid on day 4
*300 mg once on day 5


==See Also==
==See Also==
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<references/>
<references/>


[[Category:Tox]][[Category:Psych]]
[[Category:Psych]]
[[Category:Tox]]

Revision as of 17:51, 15 February 2016

Background

  • Withdrawal symptoms due to reduced GABA and increased glutamate
  • Benzos useful due to cross tolerance at ethanol GABA receptor
  • Symptom triggered therapy
    • As effective as fixed dose therapy, but w/ more rapid detox

Clinical Features

  • Reduction in alcohol use that has been heavy and prolonged
  • At least 2 of the following
    • Autonomic hyperactivity (e.g., diaphoresis, HR>100)
    • Increased hand tremor
    • Insomnia
    • Nausea/vomiting
    • Transient visual, tactile, or auditory hallucinations
    • Psychomotor agitation
    • Anxiety
    • Grand mal seizures

Seizures

  • Onset after last drink: 6-48h
  • Multiple seizures: 60% of pts
  • Progression to DTs: 33% of pts
  • Treat with benzos (not phenytoin)

Alcoholic Hallucinosis

  • Onset after last drink: 12-24hr
  • Visual hallucinations are most common
  • Different from delirium tremens
    • Resolves within 24-48 from last drink (before onset of DTs)
    • No delirium
    • Normal vital signs

Differential Diagnosis

Seizure

Diagnosis

CIWA score

Clinical Institute Withdrawal Assessment – Alcohol – revised (CIWA-Ar)

  • Headache 0-7
  • Orientation 0-3
  • Tremor 0-7
  • Sweating 0-7
  • Anxiety 0-7
  • Nausea (and Vomiting) 0-7
  • Tactile Hallucinations 0-7
  • Auditory Hallucinations 0-7
  • Visual Hallucinations 0-7
  • Agitation 0-7

Maximum Score = 67

Inpatient Management

See Alcohol withdrawal: Inpatient management

Outpatient Management

See Alcohol withdrawal: Outpatient management

Disposition

Admit

  • Multiple seizures
  • DTs
  • Decreased LOC
  • Inability to control withdrawal after administrating 3-4 doses of benzo's
  • Consider ICU admission with CIWA score >20

Discharge

See Also

External Links

References

  1. ↑ Myrick et al. A DOUBLE BLIND TRIAL OF GABAPENTIN VS. LORAZEPAM IN THE TREATMENT OF ALCOHOL WITHDRAWAL. Alcohol Clin Exp Res. 2009 Sep; 33(9): 1582–1588. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769515/
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