Ethanol withdrawal

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

Diagnosis

1. Reduction in alcohol use that has been heavy and prolonged
2. 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
3. CIWA score
   • http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator
   • Start benzo therapy at score of 8. Consider ICU admission with score >20.

Treatment

General

• 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]
  • Chlordiazepoxide
    • Generally for outpt tx of mild cases
• Beta blockers
  • Improve VS, reduces craving
• Alpha-2 agonists (clonidine)
  • Decrease severity of sxs, but only supplemental to GABA-ergic first-lines
  • Dexmedetomidine gtt, 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
• Banana bag
  • Thiamine 100mg IV
  • Folate 1mg IV (cheaper PO)
  • MVI 1 tab IV (cheaper PO)
  • Magnesium sulfate 2mg IV
  • NS 1L IV

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

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. 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

Discharge

• Consider discharge with 3 day course of benzodiazepines if patients are attempting to quit alcohol

See Also

• Beer Potomania Syndrome
• Alcohol (ETOH) Intoxication
• EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawl