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

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

Differential Diagnosis

Seizure

Diagnosis

CIWA score

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[1]
    • 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)
  • 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.[2] 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
  • Example regimens (please use discretion and balance risk/benefits with your own clinical judgment)
  • Example lorazepam taper for outpatient detox:
    • 2 mg tid x3 days
    • 2 mg bid on day 4
    • 2 mg once on day 5
  • Example gabapentin taper (similar in efficacy to lorazepam according to one RCT)[3]
    • 400 mg tid x3 days
    • 300 mg bid on day 4
    • 300 mg once on day 5
    • Consider possible exclusions for outpatient treatment[4]:
      • 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

See Also

References

  1. ↑ National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm
  2. ↑ 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.
  3. ↑ 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/
  4. ↑ 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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