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

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

Management

Inpatient Treatment

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

Outpatient Treatment

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

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.[3] 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[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
  • 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[5]

  • 400 mg tid x3 days
  • 300 mg bid on day 4
  • 300 mg once on day 5

See Also

External Links

References

  1. ↑ National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm
  2. ↑ 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.
  3. ↑ 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.
  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/
  5. ↑ 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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