Alcohol withdrawal
(Redirected from ETOH withdrawal)
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
- 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
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 toxicity
- Alcohol use disorder
- Alcohol withdrawal
- Electrolyte/acid-base disorder
Sedative/hypnotic withdrawal
- Toxic alcohols
- Benzodiazepines
- Flunitrazepam (Rohypnol)
- Gamma hydroxybutyrate (GHB)
- Baclofen
- Barbiturates
- Opioids
- Chloral hydrate
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)
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]
- Used when refractory to benzodiazepines (consider after patient has received equivalent of 200 mg diazepam)
- α-2 agonists (Dexmedetomidine)
- Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
- Dexmedetomidine drip, start 0.2 mcg/kg/hr, likely needing no more than 0.7 mcg/kg/hr[4]
- Ketamine
- May have some use in refractory cases
- Blocks the NMDA receptor which is excited an unregulated. [5]
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.[6] Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for delirium tremens.
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[7][8]
- Thiamine 100mg IV
- Folate 1mg IV (cheaper PO)
- Multivitamin 1 tab IV (cheaper PO)
- Magnesium sulfate 2mg IV
- Normal saline as needed for hydration
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. An alternative dosing regimen to consider is chlordiazepoxide 50 mg PO q6-12h on d 1; 25 mg PO q6h on d 2; 25 mg PO q12h on d 3; 25 mg PO at night on d 4.
Anticonvulsants
- Have less abuse potential but may not prevent seizures[9]
- Gabapentin 400mg PO TID x 4 days[10]
- Carbamazepine taper[13]
- 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)[14]
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[15]:
- 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
- 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
- MDCalc - CIWA-AR Calculator
- Link to DHS Expected Practice
- LA County Substance Abuse Service Helpline: 844-804-7500
- The Internet Book of Critical Care: Alcohol Withdrawal
References
- ↑ 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/
- ↑ National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm
- ↑ 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.
- ↑ Rayner SG, et al. Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU. Ann Intensive Care. 2012; 2: 12. Published online 2012 May 23. doi: 10.1186/2110-5820-2-12.
- ↑ 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
- ↑ 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.
- ↑ Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
- ↑ Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.
- ↑ Muncie HL et al. Outpatient Management of Alcohol Withdrawal Syndrome. Am Fam Physician. 2013 Nov 1;88(9):589-595.
- ↑ 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 gaba pentin vs lorazepam in the treatment of alcohol withdrawl. Alcohol Clin Exp Res. 2009 Sep; 33(9): 1582–1588. PMID: 19485969
- ↑ 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
- ↑ Barrons R et al. The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome. J Clin Pharm Ther. 2010 Apr;35(2):153-67.
- ↑ 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
- ↑ 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/