Difference between revisions of "Alcohol withdrawal"

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==Background==
 
==Background==
 +
*Withdrawal symptoms due to reduced GABA and increased NMDA receptors
 +
*[[Benzodiazepines|Benzos]] useful due to cross tolerance at [[Ethanol toxicity|ethanol]] GABA receptor and longer half-life
 +
*Symptom-triggered therapy
 +
**As effective as fixed dose therapy, but with more rapid detox
 +
*Don’t use [[phenytoin]] or [[fosphenytoin]] to treat seizures caused by drug toxicity or drug withdrawal.<ref>Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin-to-treat-seizures/</ref>
  
 +
==Clinical Features==
 +
*Reduction in alcohol use that has been heavy and prolonged
 +
*At least 2 of the following
 +
**Autonomic hyperactivity (e.g., diaphoresis, [[tachycardia|HR>100]])
 +
**Increased hand [[tremor]]
 +
**[[Insomnia]]
 +
**[[Nausea/vomiting]]
 +
**Transient visual, tactile, or auditory [[hallucinations]]
 +
**Psychomotor agitation
 +
**[[Anxiety]]
 +
**Grand mal [[seizures]]
 +
===Tremulousness===
 +
*Onset after last drink: 6-12h
 +
===[[alcohol withdrawal seizures|Seizures]]===
 +
*Onset after last drink: 6-48h
 +
*Multiple seizures: 60% of patients
 +
*Progression to DTs: 33% of patients
 +
*Treat with [[Benzodiazepines|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]]===
 +
*Onset after last drink: 48+hrs
 +
*Decreased attention and awareness
 +
*Disturbance in attention, awareness, memory, orientation, language, perception, visouspatial ability that fluctuates in severity
 +
*No evidence of coma or other evolving neurocognitive disorders
  
* Withdrawal symptoms due to reduced GABA pathway and increased glutamate transmission
+
==Differential Diagnosis==
* Benzos useful due to cross tolerance at ethanol GABA receptor (same place carbemazipine and valproate also work
+
{{Ethanol DDX}}
* Symptom Triggered Tx- quantify sx and give meds upon reaching threshold- as effective as fixed dose tx  and needs less drug and get more rapid detox
+
{{Sedative/hypnotic withdrawal types}}
+
{{Seizure DDX}}
  
==Diagnosis==
+
==Evaluation==
 +
*Consider workup for alternate etiologies if clinical presentation unclear
 +
*Consider workup to evaluate any symptoms that led patient to stop drinking (e.g. did patient stop in setting of feeling unwell due to [[abdominal pain]], [[pneumonia]], etc.?)
  
 +
{{CIWA score}}
  
* Sweating, anxiety, tremor, hallucinations, N/V, HA, visual disturbance, disorientation
+
==Inpatient Management==
* Alcohol withdrawal symptoms peak in 72 hrs
+
''Start aggressive [[Benzodiazepines|Benodiazepine]] therapy at CIWA score of 8. Consider ICU admission with score >20''
+
{{Inpatient management of ETOH withdrawal}}
 +
{{Vitamin prophylaxis for ETOH}}
  
==Treatment ==
+
==Outpatient Management==
 +
===[[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, then decrease to 25mg every 8 hours for another two days followed by 25mg PRN as needed.
  
 +
===[[Anticonvulsants]]===
 +
*Have less abuse potential but may not prevent seizures<ref>Muncie HL et al. Outpatient Management of Alcohol Withdrawal Syndrome. Am Fam Physician. 2013 Nov 1;88(9):589-595.</ref>
 +
*[[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>
 +
**Questionable efficacy in preventing alcohol withdrawal seizures
 +
*[[Carbamazepine]] taper<ref>Barrons R et al. The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome. J Clin Pharm Ther. 2010 Apr;35(2):153-67.</ref>
 +
**May start when BAL < 150 mg/dL
 +
**Varying evidence in support of whether agent truly reduces of alcohol withdrawal seizures and [[delirium tremens]]
 +
**800 mg per day be fixed or tapered over 5-9 days
  
* Do not need meds for more than 7 days unless have DT's
+
===DHS Expected Practice Example Tables (2020)<ref>LA County DHS Expected Practice Example Tables (2020). Available at: https://lacounty.sharepoint.com/sites/dhs-ccl/Addiction%20Medicine/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine%2FOutpatient%20Medication%20Management%20of%20Alcohol%20Use%20Disorder%2Epdf&parent=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine</ref>===
+
{| {{table}}
 +
| align="center" style="background:#f0f0f0;"|'''Days'''
 +
| align="center" style="background:#f0f0f0;"|'''Carbamazepine Montherapy'''
 +
|-
 +
| 1-3 ||200mg QID
 +
|-
 +
| 4-6||200mg TID
 +
|-
 +
| 7-9||200mg BID
 +
|-
 +
| 10-11||200mg QHS
 +
|-
 +
|}
  
BANANA BAG
+
{| {{table}}
 
+
| align="center" style="background:#f0f0f0;"|'''Days'''
100mg thiamine IV
+
| align="center" style="background:#f0f0f0;"|'''Gabapentin Monotherapy'''
 
+
|-
1mg folate IV (cheaper PO)
+
| 1||1,200mg BID plus 1,200mg x 1 PRN
 
+
|-
1 tab MVI IV (cheaper PO)
+
| 2-7||600mg TID plus 600mg x 1 PRN
 
+
|-
2mg magnesium sulfate IV
+
| 8||300mg TID
 
+
|-
1 L NS IV
+
| 9||300mg BID
 
+
|-
+
| 10||300mg QHS
 
+
|-
Benzodiazapines PRN
+
|}
 
 
* Valium 5-10mg IV or Ativan 2-4mg IV Q10min until no tremor, then Q1hr)
 
* Valium quicker to theraputic CNS levels
 
 
 
 
Consider Dilantin in non-classic cases
 
 
 
 
 
 
Medicationss
 
 
 
-    benzos- decrease severity of sx, sz, dt
 
 
 
-    anticonvulsants- same
 
 
 
-   beta blockers- improve vital signs and reduce craving
 
 
 
-    alpha agonists- decrease severity of sxs
 
 
 
 
 
 
Treatment
 
 
 
-    benzos best of alcohol wd- decrease severity, szs and dt
 
 
 
-    more abuse if have rapid onset of effect- valium, xanax, ativan,
 
 
 
-    phenobarb- less abused but poorer safety profile- resp depression
 
 
 
-   carbemazipine similar to benzos for adverse effects
 
 
 
 
 
 
Adjuvant Txs- not sole txs but for combination
 
 
 
-   phenothiazines- reduce signs and sxs but less effective than benzos for sz and dt
 
 
 
-   beta blockers/ clonidine- no sz protection, not for benzo wd
 
 
 
 
 
 
Anticonvulsants
 
 
 
-    dilantin no role
 
 
 
-    carb- less emotional distress and has anti sz prop too, does not inhibit mem like benzos, less abuse potential
 
 
 
o    can have dizzy, n/v
 
 
 
o    not for dts
 
 
 
o    has fewer protracted sxs than benzos, less relapse, less side effect
 
 
 
-    carb may be used for benzo wd
 
 
 
-    valproate- also useful
 
 
 
 
  
 
==Disposition==
 
==Disposition==
 +
===Admit===
 +
*Multiple [[seizures]]
 +
*[[delirium tremens|DTs]]
 +
*[[AMS|Decreased LOC]]
 +
*Inability to control withdrawal after administrating 3-4 doses of benzo's
 +
*Consider ICU admission with CIWA score >20
  
 
+
===Discharge===
Admission Criteria
+
*Two consecutive CIWA scores (two hours apart) <10 with resolution of tremor
 
+
*Consider discharge [[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawl|with 3 day course of benzodiazepines if patients are attempting to quit alcohol]] (controversial)
-status
+
*Consider possible exclusions for outpatient treatment<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>:
 
+
**Substance use disorders except alcohol, nicotine, or cannabis
-DTs
+
**Major Axis I psych disorder
 
+
**Medication history of benzodiazepines, beta-blockers, calcium-channel blockers, antipsychotics
-focal/first sz
+
**History of head injury, epilepsy, medical instability, ECG abnormality, grossly abnormal lab value
 
 
-dec loc
 
 
 
-inability to control wthdl
 
 
 
 
 
 
*Consider D/C with 3 day course if want to quit
 
 
 
 
  
 
==See Also==
 
==See Also==
 +
*[[Beer Potomania Syndrome]]
 +
*[[Alcohol (ETOH) Intoxication]]
 +
*[[Alcoholic ketoacidosis]]
 +
*[[Alcohol withdrawal seizures]]
 +
*[[Altered mental status]]
 +
*[[Delirium tremens]]
 +
*[[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal]]
 +
*[[Sedative/Hypnotic]]
  
 +
==External Links==
 +
*[http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator MDCalc - CIWA-AR Calculator]
 +
*Link to [https://lacounty.sharepoint.com/sites/dhs-ccl/Addiction%20Medicine/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine%2FOutpatient%20Medication%20Management%20of%20Alcohol%20Use%20Disorder%2Epdf&parent=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine DHS Expected Practice]
 +
*LA County Substance Abuse Service Helpline: 844-804-7500
 +
*[https://emcrit.org/ibcc/etoh/ The Internet Book of Critical Care: Alcohol Withdrawal]
  
FEN: Beer Potomania Syndrome
+
==References==
 
+
<references/>
Tox: ETOH Intoxication
 
 
 
 
 
 
 
  
[[Category:Tox]]
+
[[Category:Psychiatry]][[Category:Toxicology]]

Latest revision as of 05:39, 28 January 2021

Background

  • Withdrawal symptoms due to reduced GABA and increased NMDA receptors
  • Benzos useful due to cross tolerance at ethanol GABA receptor and longer half-life
  • Symptom-triggered therapy
    • As effective as fixed dose therapy, but with more rapid detox
  • Don’t use phenytoin or fosphenytoin to treat seizures caused by drug toxicity or drug withdrawal.[1]

Clinical Features

Tremulousness

  • Onset after last drink: 6-12h

Seizures

  • Onset after last drink: 6-48h
  • Multiple seizures: 60% of patients
  • Progression to DTs: 33% of patients
  • 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

  • Onset after last drink: 48+hrs
  • Decreased attention and awareness
  • Disturbance in attention, awareness, memory, orientation, language, perception, visouspatial ability that fluctuates in severity
  • No evidence of coma or other evolving neurocognitive disorders

Differential Diagnosis

Ethanol related disease processes

Sedative/hypnotic withdrawal

Seizure

Evaluation

  • Consider workup for alternate etiologies if clinical presentation unclear
  • Consider workup to evaluate any symptoms that led patient to stop drinking (e.g. did patient stop in setting of feeling unwell due to abdominal pain, pneumonia, etc.?)

CIWA score

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

  • Headache 0-7
  • Orientation 0-4
  • 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

  • <8: Typically do not require medication
  • 8-19: Medication
  • ≥20: Medication and admission

Inpatient Management

Start aggressive Benodiazepine therapy at CIWA score of 8. Consider ICU admission with score >20

Benzodiazepine overview

Agents Equivalent PO dose (mg) Route Onset of Action (min) Half Life (hr) Metabolism
Chlordiazepoxide 25 PO, IV 30 - 120 7-28 CYP; active metabolites
Diazepam 5 PO, IV, IM 2 - 5 20-120 CYP; active metabolites
Lorazepam 1 PO, IM, IV 15-20 8-19 Glucuronidation

Benzodiazepines

  • Diazepam (Valium) 5-10 mg IV (depending on severity)
    • May repeat q5-10 min for severe withdrawal (may increase dose by 10 mg every 5-10 min until desired effect achieved, max dose of 200 mg)
    • Half-life 20-100 h (long acting)
  • Lorazepam (Ativan) 1-4mg IV (depending on severity)
    • May repeat q15-20 min for severe withdrawal (titrated to effect)
    • Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis[2]
    • Half-life 10-20 h (medium acting)

Other Agents

For use in cases refractory to benzodiazepine treatment

  • Propofol
    • If patient does not respond to high doses of benzodiazepines
    • 0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours
  • Barbiturates (Phenobarbital)
    • Used when refractory to benzodiazepines (consider after patient has received equivalent of 200 mg diazepam)
      • Phenobarbital 130-260 mg IV q 15-20 minutes
      • Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions [3]
  • α-2 agonists (Dexmedetomidine)
    • Decrease severity of symptoms, 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
  • Ketamine
    • May have some use in refractory cases
    • Blocks the NMDA receptor which is excited an unregulated. [4]

Special Situations

Vitamin Prophylaxis for Chronic alcoholics

  • At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
  • Give multivitamin PO; patient at risk for other vitamin deficiencies

Banana bag

The majority of chronic alcoholics do NOT require a banana bag[6][7]

Outpatient Management

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, then decrease to 25mg every 8 hours for another two days followed by 25mg PRN as needed.

Anticonvulsants

  • Have less abuse potential but may not prevent seizures[8]
  • Gabapentin 400mg PO TID[9]
    • Some protocols call for higher dosing - 600 or 800mg x1
    • Similar efficacy to lorazepam in decreasing craving and anxiety[10]
    • Questionable efficacy in preventing alcohol withdrawal seizures
  • Carbamazepine taper[11]
    • May start when BAL < 150 mg/dL
    • Varying evidence in support of whether agent truly reduces of alcohol withdrawal seizures and delirium tremens
    • 800 mg per day be fixed or tapered over 5-9 days

DHS Expected Practice Example Tables (2020)[12]

Days Carbamazepine Montherapy
1-3 200mg QID
4-6 200mg TID
7-9 200mg BID
10-11 200mg QHS
Days Gabapentin Monotherapy
1 1,200mg BID plus 1,200mg x 1 PRN
2-7 600mg TID plus 600mg x 1 PRN
8 300mg TID
9 300mg BID
10 300mg QHS

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

  • Two consecutive CIWA scores (two hours apart) <10 with resolution of tremor
  • Consider discharge with 3 day course of benzodiazepines if patients are attempting to quit alcohol (controversial)
  • Consider possible exclusions for outpatient treatment[13]:
    • Substance use disorders except alcohol, nicotine, or cannabis
    • Major Axis I psych disorder
    • Medication history of benzodiazepines, beta-blockers, calcium-channel blockers, antipsychotics
    • History of head injury, epilepsy, medical instability, ECG abnormality, grossly abnormal lab value

See Also

External Links

References

  1. Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin-to-treat-seizures/
  2. National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm
  3. Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013; 44(3):592-598.
  4. 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
  5. 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.
  6. Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  7. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.
  8. Muncie HL et al. Outpatient Management of Alcohol Withdrawal Syndrome. Am Fam Physician. 2013 Nov 1;88(9):589-595.
  9. 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.
  10. 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
  11. Barrons R et al. The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome. J Clin Pharm Ther. 2010 Apr;35(2):153-67.
  12. LA County DHS Expected Practice Example Tables (2020). Available at: https://lacounty.sharepoint.com/sites/dhs-ccl/Addiction%20Medicine/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine%2FOutpatient%20Medication%20Management%20of%20Alcohol%20Use%20Disorder%2Epdf&parent=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine
  13. 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/