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__NOTOC__
__NOTOC__
{{Alcohol withdrawal}}
{{Alcohol withdrawal}}
'''For patient information click [[{{PAGENAME}} (patient information)|here]].'''
'''For patient information click [[Alcohol withdrawal (patient information)|here]].'''


{{CMG}}; {{AE}} {{ADI}}
{{CMG}}; {{AE}} {{ADI}}


==Treatment==
* No clinical findings can reliably predict who will or will not develop withdrawal.  Risk factors for [[DT]]s: Previous DTs or detoxifications, Age >30, high degree of alcohol dependence, duration of abuse, the presence of moderate symptoms (CIWA >14) left untreated and concurrent medical illness are all strongly predictive.  These findings should prompt intervention. Time abstinent may be a helpful negative predictor. In one large study, patients who were asymptomatic 36 hours after their last drink did not develop symptoms.
* All patients with [[alcohol abuse]] should receive 1mg [[folate]] QD, [[magnesium]]/ [[phosphate]]/[[potassium]]/fluid volume repletion and [[thiamine]] 100 mg IV/IM x1 then 100 mg QD.
* Treatment of alcohol related seizures is on an as needed basis with [[benzodiazepines]].  They tend to be transient phenomenon.  [[phenytoin]] is ineffective in the management of withdrawal [[seizures]], but may be indicated if another seizure disorder or [[status epilepticus]] is present.  Long term medical suppression or prophylaxis is not indicated for withdrawal seizures.  [[Neuroleptics ]]lower the seizure threshold and should not be used in these patients; however, [[haloperidol]] has been used safely in conjunction with [[benzodiazepines]] (BDZs).
* BDZs are the cornerstone of therapy for minor withdrawal, [[seizures]] and DTs.  Fixed schedule therapy, front loading therapy and symptom-triggered therapy have all been evaluated with similar efficacy.  Symptoms triggered therapy was associated with less total administration of drug and shorter length of stay but has only been evaluated in patients without acute comorbid illness or [[seizures]] and should be restricted to only this limited group of patients.
* In the medically stable patient with no liver dysfunction 10 mg PO/IV is administered every hour till CIWA <10 or sedated.  If the patient is stable but has [[liver disease]], give 2 mg [[lorazepam ]]IV/PO Q 1H till CIWA <10 or sedated.  Calculate the total dose used and give this Q6H for 24 hrs.  Use that latter regimen for the unstable patient.
* If CIWA is stable x24 hours then decrease the dose by 20%/day.  If there is a history of [[DT]]s or [[seizures]] or the patient is unstable decrease the dose by 10%/day.  Give parentral doses of [[lorazepam]] recurrence of withdrawal (CIWA >10).
===Supportive Care===
'''Goal''' - Correction of associated disorders, their treatment, providing support for early recovery and prevention of complications.
* Vital signs have to be corrected first.
** [[Heart rate]] should be controlled.
** [[Blood pressure]] should be maintained using [[fluids]] and [[anti hypertensive medication]].
* Identification of comorbid conditions and their treatment.
* A few patients may be [[dehydrated]] and they may require [[intravenous fluid]] replacement.
** Care has to be taken to avoid fluid overload which can lead to [[heart failure]] or exacerbate underlying heart conditions.
* [[Chronic alcoholics]] are depleted in reserves of certain [[electrolytes]] like [[magnesium]], [[phosphate]]. Care has to be provided in correcting them as they play an important role in body metabolism.<ref name="pmid1979005">{{cite journal |author=Nutt DJ, Glue P |title=Neuropharmacological and clinical aspects of alcohol withdrawal |journal=[[Annals of Medicine]] |volume=22 |issue=4 |pages=275–81 |year=1990 |pmid=1979005 |doi= |url= |accessdate=2012-08-16}}</ref> Administration of magnesium may improve the overall outcome of the patient.
* Alcoholics are vitamin deficient owing to poor dietary habits. [[Thiamine]] and [[folic acid]] are of major concern.<ref name="pmid20615374">{{cite journal |author=Damsgaard L, Ulrichsen J, Nielsen MK |title=[Wernicke's encephalopathy in patients with alcohol withdrawal symptoms] |language=Danish |journal=[[Ugeskrift for Laeger]] |volume=172 |issue=28 |pages=2054–8 |year=2010 |month=July |pmid=20615374 |doi= |url= |accessdate=2012-08-16}}</ref>
** Patients who are experiencing withdrawal should be administered with multivitamins to support the body metabolism.
** Use of thiamine 100 mg daily for 30 days during withdrawal is recommended.<ref name="pmid21278319">{{cite journal |author=Talbot PA |title=Timing of efficacy of thiamine in Wernicke's disease in alcoholics at risk |journal=[[Journal of Correctional Health Care : the Official Journal of the National Commission on Correctional Health Care]] |volume=17 |issue=1 |pages=46–50 |year=2011 |month=January |pmid=21278319 |doi=10.1177/1078345810385913 |url=http://jcx.sagepub.com/cgi/pmidlookup?view=long&pmid=21278319 |accessdate=2012-08-16}}</ref>
** Thiamine should be administered before [[glucose]] as it may further deplete the reserve of thiamine.<ref name="pmid21278319">{{cite journal |author=Talbot PA |title=Timing of efficacy of thiamine in Wernicke's disease in alcoholics at risk |journal=[[Journal of Correctional Health Care : the Official Journal of the National Commission on Correctional Health Care]] |volume=17 |issue=1 |pages=46–50 |year=2011 |month=January |pmid=21278319 |doi=10.1177/1078345810385913 |url=http://jcx.sagepub.com/cgi/pmidlookup?view=long&pmid=21278319 |accessdate=2012-08-16}}</ref>
===Inpatient v/s Outpatient===
Treatment to alcohol withdrawal patients can be provided in outpatient and inpatient setup.
; Outpatient
* Criteria
**If there are no signs of severe alcohol withdrawal.
**If there is no previous history of alcohol withdrawal.
**If there is a supportive family for the patient.
**If there is no associated comorbid conditions.
* Potential considerations
**Patients may be non-complaint to medication.
** May resolve back to his drinking habits.
;Inpatient
* Criteria
**Severe alcohol withdrawal syndrome.
**History of alcohol withdrawal symptoms on treatment with outpatient basis.
**Presence of any other comorbid condition or psychiatric condition.
**Non supportive family
*Potential considerations
**Cost of inpatient facilities
===Nonpharmacological Treatment===
* Providing patient a quiet environment.
* Providing reassurance.
* Motivation for alcohol abstinence.
===Pharmacological Treatment===
*[[Benzodiazeipines]]
** For patients with severe symptoms of alcohol withdrawal.
** [[Diazepam]] is used initially to control the [[agitation]].
** Dose of  diazepam is tapered later.
** In patients with liver problems [[lorazepam]] may be better drug to use. <ref name="pmid8700792">{{cite journal |author=Peppers MP |title=Benzodiazepines for alcohol withdrawal in the elderly and in patients with liver disease |journal=[[Pharmacotherapy]] |volume=16 |issue=1 |pages=49–57 |year=1996 |pmid=8700792 |doi= |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0277-0008&date=1996&volume=16&issue=1&spage=49 |accessdate=2012-08-16}}</ref>
* [[Anticonvulsant]]s
** Anticonvulsants like [[carbamazepine]] are of low significance in case of [[seizures]] due to alcohol withdrawal.
** They can be used if seizures are not controlled by [[benzodiazepines]]([[diazepam]]).
** If a patient suffers two or more alcohol withdrawal seizures or develops status epilepticus, it should be assumed that the seizures are not a result of alcohol withdrawal and should be investigated.
* [[Anti psychotics]]
** Anti-psychotic medication should only be made available to patients experiencing [[hallucinations]] where [[benzodiazepines]] are not effective.
** The patient should also be monitored carefully for [[hypotension]].
*[[Baclofen]]
** With the use of [[baclofen]] whcih acts upon the GABA-B receptors , doses of [[diazepam]] can be reduced.<ref name="pmid21990176">{{cite journal |author=Lyon JE, Khan RA, Gessert CE, Larson PM, Renier CM |title=Treating alcohol withdrawal with oral baclofen: a randomized, double-blind, placebo-controlled trial |journal=[[Journal of Hospital Medicine : an Official Publication of the Society of Hospital Medicine]] |volume=6 |issue=8 |pages=469–74 |year=2011 |month=October |pmid=21990176 |doi=10.1002/jhm.928 |url=http://dx.doi.org/10.1002/jhm.928 |accessdate=2012-08-16}}</ref>
** It can be used in [[Chronic alcoholics|alcohol addicts]].
*[[Clonidine]]
** It acts upon the alpha 2 receptors is useful in controlling the symptoms of alcohol withdrawal by reducing the [[adrenergic surge]].
** [[Clonidine]] and [[dexmedetomidine]] can be used as adjunctive treatment to [[benzodiazepines]].<ref name="pmid21521867">{{cite journal |author=Muzyk AJ, Fowler JA, Norwood DK, Chilipko A |title=Role of α2-agonists in the treatment of acute alcohol withdrawal |journal=[[The Annals of Pharmacotherapy]] |volume=45 |issue=5 |pages=649–57 |year=2011 |month=May |pmid=21521867 |doi=10.1345/aph.1P575 |url=http://www.theannals.com/cgi/pmidlookup?view=long&pmid=21521867 |accessdate=2012-08-16}}</ref>
===Withdrawal Regimes===
<ref name="urlwww.alcohol.gov.au">{{cite web |url=http://www.alcohol.gov.au/internet/alcohol/publishing.nsf/Content/2C3FC9166082567DCA257260007F81F8/$File/alcprobguide.pdf |title=www.alcohol.gov.au |format= |work= |accessdate=2012-08-16}}</ref>
;Symptom triggered therapy
* In this regime patients CIWA-Ar score is evaluated hourly or bi-hourly and depending upon the score the treatment is administered.
* [[Benzodiazepines]] are used in the treatment
* It limits the use of excessive medication.
* This approach is cost effective and prevent complications.
; Fixed schedule therapy
* Fixed dosage of drug is given at scheduled intervals
* Can be used if patient is not in severe withdrawal
; Loading dose therapy
* It is used in patients who have experienced [[seizures]] during past alcohol withdrawal.
* In this regime doses are tailored for the patient's condition.
===Treatment of Complications===
* [[Delirium tremens]] - [[benzodiazepines]], [[antipsychotics]] are used for the treatment.
* [[Wernicke-Korsakoff’s syndrome]] - [[thiamine]] adminstration
* [[Covulsions]]- [[benzodiazepines]] are useful, if they are repetitive or [[status epilepticus]] develops other causes have to be investigated.
* Failure to manage the alcohol withdrawal syndrome appropriately can lead to permanent [[encephalopathy|brain damage]] or [[death]].
** It can be prevented by the administration of NMDA antagonists. The NMDA antagonist [[acamprosate]] reduces excessive glutamate causing the symptoms. <ref name="pmid22616110">{{cite journal |author=Hinton DJ, Lee MR, Jacobson TL, Mishra PK, Frye MA, Mrazek DA, Macura SI, Choi DS |title=Ethanol withdrawal-induced brain metabolites and the pharmacological effects of acamprosate in mice lacking ENT1 |journal=[[Neuropharmacology]] |volume=62 |issue=8 |pages=2480–8 |year=2012 |month=June |pmid=22616110 |doi= |url= |accessdate=2012-08-16}}</ref>
===Treatment in Special Groups===
; [[Pregnancy]]
* Pregnancy doesn't increase the risk of alcohol withdrawal.
* Medications used to treat alcohol withdrawal may cause some effect on the fetus.
* [[Benzodiazepines]] cause less effects on the fetus and are efficient.
; Hospitalized patients
* Patients hospitalized for some other illness may undergo alcohol withdrawal.
* Early recognition of symptoms of withdrawal is important.
* Early diagnosis and treatment helps in prevention of complications.<ref name="pmid7630218">{{cite journal |author=Lohr RH |title=Treatment of alcohol withdrawal in hospitalized patients |journal=[[Mayo Clinic Proceedings. Mayo Clinic]] |volume=70 |issue=8 |pages=777–82 |year=1995 |month=August |pmid=7630218 |doi= |url= |accessdate=2012-08-16}}</ref>


==References==
==References==
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[[Category:Toxicology]]
[[Category:Toxicology]]
[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
[[Category:Grammar]]

Latest revision as of 19:52, 20 February 2014
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Treatment

  • No clinical findings can reliably predict who will or will not develop withdrawal. Risk factors for DTs: Previous DTs or detoxifications, Age >30, high degree of alcohol dependence, duration of abuse, the presence of moderate symptoms (CIWA >14) left untreated and concurrent medical illness are all strongly predictive. These findings should prompt intervention. Time abstinent may be a helpful negative predictor. In one large study, patients who were asymptomatic 36 hours after their last drink did not develop symptoms.
  • Treatment of alcohol related seizures is on an as needed basis with benzodiazepines. They tend to be transient phenomenon. phenytoin is ineffective in the management of withdrawal seizures, but may be indicated if another seizure disorder or status epilepticus is present. Long term medical suppression or prophylaxis is not indicated for withdrawal seizures. Neuroleptics lower the seizure threshold and should not be used in these patients; however, haloperidol has been used safely in conjunction with benzodiazepines (BDZs).
  • BDZs are the cornerstone of therapy for minor withdrawal, seizures and DTs. Fixed schedule therapy, front loading therapy and symptom-triggered therapy have all been evaluated with similar efficacy. Symptoms triggered therapy was associated with less total administration of drug and shorter length of stay but has only been evaluated in patients without acute comorbid illness or seizures and should be restricted to only this limited group of patients.
  • In the medically stable patient with no liver dysfunction 10 mg PO/IV is administered every hour till CIWA <10 or sedated. If the patient is stable but has liver disease, give 2 mg lorazepam IV/PO Q 1H till CIWA <10 or sedated. Calculate the total dose used and give this Q6H for 24 hrs. Use that latter regimen for the unstable patient.
  • If CIWA is stable x24 hours then decrease the dose by 20%/day. If there is a history of DTs or seizures or the patient is unstable decrease the dose by 10%/day. Give parentral doses of lorazepam recurrence of withdrawal (CIWA >10).

Supportive Care

Goal - Correction of associated disorders, their treatment, providing support for early recovery and prevention of complications.

  • Vital signs have to be corrected first.
  • Identification of comorbid conditions and their treatment.
  • A few patients may be dehydrated and they may require intravenous fluid replacement.
    • Care has to be taken to avoid fluid overload which can lead to heart failure or exacerbate underlying heart conditions.
  • Chronic alcoholics are depleted in reserves of certain electrolytes like magnesium, phosphate. Care has to be provided in correcting them as they play an important role in body metabolism.[1] Administration of magnesium may improve the overall outcome of the patient.
  • Alcoholics are vitamin deficient owing to poor dietary habits. Thiamine and folic acid are of major concern.[2]
    • Patients who are experiencing withdrawal should be administered with multivitamins to support the body metabolism.
    • Use of thiamine 100 mg daily for 30 days during withdrawal is recommended.[3]
    • Thiamine should be administered before glucose as it may further deplete the reserve of thiamine.[3]

Inpatient v/s Outpatient

Treatment to alcohol withdrawal patients can be provided in outpatient and inpatient setup.

Outpatient
  • Criteria
    • If there are no signs of severe alcohol withdrawal.
    • If there is no previous history of alcohol withdrawal.
    • If there is a supportive family for the patient.
    • If there is no associated comorbid conditions.
  • Potential considerations
    • Patients may be non-complaint to medication.
    • May resolve back to his drinking habits.
Inpatient
  • Criteria
    • Severe alcohol withdrawal syndrome.
    • History of alcohol withdrawal symptoms on treatment with outpatient basis.
    • Presence of any other comorbid condition or psychiatric condition.
    • Non supportive family
  • Potential considerations
    • Cost of inpatient facilities

Nonpharmacological Treatment

  • Providing patient a quiet environment.
  • Providing reassurance.
  • Motivation for alcohol abstinence.

Pharmacological Treatment

Withdrawal Regimes

[7]

Symptom triggered therapy
  • In this regime patients CIWA-Ar score is evaluated hourly or bi-hourly and depending upon the score the treatment is administered.
  • Benzodiazepines are used in the treatment
  • It limits the use of excessive medication.
  • This approach is cost effective and prevent complications.
Fixed schedule therapy
  • Fixed dosage of drug is given at scheduled intervals
  • Can be used if patient is not in severe withdrawal
Loading dose therapy
  • It is used in patients who have experienced seizures during past alcohol withdrawal.
  • In this regime doses are tailored for the patient's condition.

Treatment of Complications

Treatment in Special Groups

Pregnancy
  • Pregnancy doesn't increase the risk of alcohol withdrawal.
  • Medications used to treat alcohol withdrawal may cause some effect on the fetus.
  • Benzodiazepines cause less effects on the fetus and are efficient.
Hospitalized patients
  • Patients hospitalized for some other illness may undergo alcohol withdrawal.
  • Early recognition of symptoms of withdrawal is important.
  • Early diagnosis and treatment helps in prevention of complications.[9]

References

  1. ↑ Nutt DJ, Glue P (1990). "Neuropharmacological and clinical aspects of alcohol withdrawal". Annals of Medicine. 22 (4): 275–81. PMID 1979005. |access-date= requires |url= (help)
  2. ↑ Damsgaard L, Ulrichsen J, Nielsen MK (2010). "[Wernicke's encephalopathy in patients with alcohol withdrawal symptoms]". Ugeskrift for Laeger (in Danish). 172 (28): 2054–8. PMID 20615374. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  3. ↑ 3.0 3.1 Talbot PA (2011). "Timing of efficacy of thiamine in Wernicke's disease in alcoholics at risk". Journal of Correctional Health Care : the Official Journal of the National Commission on Correctional Health Care. 17 (1): 46–50. doi:10.1177/1078345810385913. PMID 21278319. Retrieved 2012-08-16. Unknown parameter |month= ignored (help)
  4. ↑ Peppers MP (1996). "Benzodiazepines for alcohol withdrawal in the elderly and in patients with liver disease". Pharmacotherapy. 16 (1): 49–57. PMID 8700792. Retrieved 2012-08-16.
  5. ↑ Lyon JE, Khan RA, Gessert CE, Larson PM, Renier CM (2011). "Treating alcohol withdrawal with oral baclofen: a randomized, double-blind, placebo-controlled trial". Journal of Hospital Medicine : an Official Publication of the Society of Hospital Medicine. 6 (8): 469–74. doi:10.1002/jhm.928. PMID 21990176. Retrieved 2012-08-16. Unknown parameter |month= ignored (help)
  6. ↑ Muzyk AJ, Fowler JA, Norwood DK, Chilipko A (2011). "Role of α2-agonists in the treatment of acute alcohol withdrawal". The Annals of Pharmacotherapy. 45 (5): 649–57. doi:10.1345/aph.1P575. PMID 21521867. Retrieved 2012-08-16. Unknown parameter |month= ignored (help)
  7. ↑ "www.alcohol.gov.au" (PDF). Retrieved 2012-08-16.
  8. ↑ Hinton DJ, Lee MR, Jacobson TL, Mishra PK, Frye MA, Mrazek DA, Macura SI, Choi DS (2012). "Ethanol withdrawal-induced brain metabolites and the pharmacological effects of acamprosate in mice lacking ENT1". Neuropharmacology. 62 (8): 2480–8. PMID 22616110. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  9. ↑ Lohr RH (1995). "Treatment of alcohol withdrawal in hospitalized patients". Mayo Clinic Proceedings. Mayo Clinic. 70 (8): 777–82. PMID 7630218. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
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