Ethanol withdrawal: Difference between revisions
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* Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min | * Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min | ||
===[[Barbituates]] ([[Phenobarbital]])=== | ===[[Barbituates]] ([[Phenobarbital]])=== | ||
*Used when refractory to [[benzodiazepines]] | |||
* [[Phenobarbital]] 130-260 mg IV q 15-20 minutes | |||
===Ketamine=== | ===Ketamine=== | ||
*[[Ketamine]] may have some use in refractory cases | *[[Ketamine]] may have some use in refractory cases | ||
Revision as of 15:07, 17 December 2015
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
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-compliance with anti-epileptic medications
- Hyponatremia
- INH toxicity
- Non-epileptic seizure
- Meningitis
- Encephalitis
- Brain abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Barbiturate withdrawal
- Baclofen withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
- Eclampsia
- Neurocysticercosis
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Acute hydrocephalus
- Arteriovenous malformation
- Seizure with VP shunt
- Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
- Psychogenic nonepileptic seizure (pseudoseizure)
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
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
Start aggressive Benodiazepine therapy at CIWA score of 8. Consider ICU admission with score >20
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[1]
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
- Ketamine may have some use in refractory cases
- Ketamine blocks the NMDA receptor which is excited an unregulated. [2]
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[3]
- Some protocols call for higher dosing - 600 or 800mg x1
- Similar efficacy to lorazepam in decreasing craving and anxiety[4]
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
- Propfol
- 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.[5] Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens
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
- Consider discharge with 3 day course of benzodiazepines if patients are attempting to quit alcohol
- Consider possible exclusions for outpatient treatment[6]:
- Substance use disorders except alcohol, nicotine, or cannabis
- Major Axis I psych disorder
- Medication hx of benzodiazepines, BBs, CCBs, antipsychotics
- 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[7]
- 400 mg tid x3 days
- 300 mg bid on day 4
- 300 mg once on day 5
See Also
- Beer Potomania Syndrome
- Alcohol (ETOH) Intoxication
- EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawl
External Links
References
- ↑ National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm
- ↑ 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
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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/
- ↑ 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/