Transcript Management of Alcohol Withdrawal

Management of
Alcohol Withdrawal
March 27, 2014
Megan Schabbing, MD
Consult Liaison Psychiatrist
OhioHealth Behavioral Health
Objectives
 Describe the variable presentation of alcohol
withdrawal
 Demonstrate the appropriate therapy in various
clinical scenarios
 Understand the appropriate use of CIWA
21 y/o M college student admitted after being found by
his roommates down in his apartment. On arrival, he
was unresponsive, intubated in ED, now markedly
agitated, requiring manual restraints.
80 y/o M POD #2 s/p hip replacement with acute onset
confusion, UE tremor, & tachycardia. His medical
history is notable for CHF, HTN & COPD.
35 y/o F admitted s/p fall, suspected syncope vs. seizure,
CT, EEG, echo negative. The patient is disoriented &
unable to provide a history but appears very anxious
and tearful.
Pathophysiology: Ethanol & CNS
 Effect of EtOH on CNS
 Enhances inhibitory tone (GABA agonist)
 Induces excitatory tone (inhibits glutamate binding)
 Chronic EtOH use>>insensitivity to GABA….abrupt
cessation>>CNS hyperactivity (withdrawal)
 Blood alcohol concentration (BAC) & clinical
presentation



~40 mg/dL: memory impairment (+/- blackout), ataxia
150-250 mg/dL: argumentative or assaultive behavior
400-500 mg/dL: coma or death
Alcohol Withdrawal:
Uncomplicated
 Symptoms emerge within hours & resolve in 3-5 days
 Early signs: loss of appetite, irritability, tremulousness
 Generalized tremor
Alcohol withdrawal seizures
 Seizures occur typically within first 48h
 Alcohol withdrawal seizures are self-limited
 In a patient with prolonged seizures, consider other
etiology (structural abnormality, infection)
 If left untreated, 1/3 w/d seizures progress to DTs
 Treatment: benzodiazepines, barbiturates
*avoid phenytoin (limited evidence in w/d seizures)
Alcoholic Hallucinosis
 Onset ~12-24h following alcohol cessation
 Resolution ~24-48h following alcohol cessation
 Vivid auditory illusions & hallucinations
 Clear sensorium (vs. delirium)
 Ideas of persecution often follow hallucinations
 Olfactory hallucinations may occur (rarely visual)
***Auditory hallucinations in the absence of tremor,
agitation, or disorientation
Alcohol Withdrawal Delirium:
Delirium Tremens
 Incidence 5% in hospitalized patients with AD
 Incidence 33% in patients with withdrawal seizures
 Classic time frame: 72h following last alcohol use
 Clinical features
 Disorientation
 Tremor
 Hyperactivity, increased wakefulness
 Increased autonomic tone
 Hallucinations (visual>auditory)
Alcohol Withdrawal Delirium:
Delirium Tremens
 Risk factors: history of DTs, comorbid medical
problems, age>30, chronic alcohol use, withdrawal in
the presence of an elevated BAC
 Treatment of choice: benzodiazepines (lorazepam)
 Refractory cases: barbiturates (phenobarbital),
propofol
Alcohol Withdrawal Management
 Address medical comorbidities
 Differential diagnosis for increased sympathetic
activity:
 anti-cholinergic toxicity
 cocaine or amphetamine intoxication
 Thyrotoxicosis
 Sedative-hypnotic withdrawal
 Consider other etiologies of altered mental status,
seizure: CNS infection, intracranial hemorrhage
Alcohol withdrawal management
 No universal protocol; must individualize treatment
plan
 Symptom-triggered dosing of benzodiazepines
(CIWA)
 Fixed-dose bezodiazepine therapy
 In patients with impaired liver function (cirrhosis,
elderly patients), avoid drugs which require oxidative
metabolism (use lorazepam, oxazepam)
Alcohol withdrawal management
 Benzodiazepines: stimulate GABA
receptors>decreased neuronal activity>sedation
*studies support increased efficacy in preventing
withdrawal seizures
 Barbiturates: increase duration of GABA Cl channel
opening, used with benzos in severe cases of delirium
tremens
 Anti-convulsants: limited evidence (withdrawal
seizures are self-limited)
Alcohol withdrawal management
 Anti-psychotics: limited evidence, can lower seizure
threshold; used for comorbid psychosis or agitation
management in withdrawal delirium
 Alpha 2 agonists: limited evidence, used as adjunct to
target autonomic instability
 Baclofen: limited evidence, selective agonist of
GABA-B receptor
 Gabapentin: structurally similar to GABA, low
toxicity
 Ethanol: difficult to titrate, safety not proven…DON’T
DO IT!
Alcohol Withdrawal Management:
Fixed dose therapy
 Uses a long-acting agent (e.g. diazepam t 1/2=10-15h)
 PROS: Self-tapering due to long half-life>>ease of
administration, minimal breakthrough symptoms;
useful in preventing withdrawal in patients at risk who
are asymptomatic
 CONS: patients may receive unnecessary
medication>>oversedation>>prolonged
hospitalization
Alcohol Withdrawal Management:
Symptom-triggered therapy
 Assesses symptoms on real-time
 Benzodiazepine dosing given in response to symptom severity
 PROS: generally safe & effective, can reduce medication doses &
duration of treatment
 CONS: need for constant monitoring & frequent medication
administration, requires staff training, greater risk of
benzodiazepine dependence, OFTEN MISUSED
 E.g. CIWA-AR Clinical Institue Withdrawal Assessment AlcoholRevised Scale
Clinical Institute Withdrawal
Assessment for Alcohol-Revised
scale (CIWA-Ar)
 Patient is evaluated q15 min – hourly, dependent upon severity of
symptoms
 Nausea/vomiting, tremors, anxiety, agitation, paroxysmal sweats,
sensorium, tactile disturbances, auditory & visual disturbances,
headache
 Each criterion is rated on a scale from 0 to 7, except for
Orientation/sensorium, which is rated on scale 0 to 4
 Total CIWA-Ar score >8: start prophylactic medication should
 Total CIWA-AR score >15: give additional PRN medication
https://www.ihs.gov/NC4/Documents/AlcoholWithdrawalAssess
mentSheets(PIMC%20Apr%2005).doc
CIWA Inclusion Criteria
*INTACT VERBAL COMMUNICATION
…the patient must have clear enough
sensorium to reply logically to questions
(7/10 questions require answers)
*RECENT ALCOHOL USE
Clinical Institute Withdrawal
Assessment for Alcohol-Revised
scale (CIWA-Ar)
Examples of when NOT to use CIWA
*patient intubated & sedated on propofol
*patient who is a recovering alcoholic (no recent use)
*a delirious patient


Verbal communication NOT intact
Agitation resulting from delirium secondary to underlying
medical issues (metabolic abnormalities, infection) may lead
to inappropriate excess dosing of benzodiazepines, which may
worsen delirium
CIWA vs. Fixed dose taper
 Numerous early trials support symptom-triggered
therapy (e.g. CIWA) due to advantages of rapid
symptom control & reduced total benzodiazepine
doses
 HOWEVER, most trials involved medically cleared
patients in detox units
 The few trials which involved medically ill patients DID
NOT attempt to validate CIWA-Ar scale as a tool for
managing seriously ill patients on specialty services or
in ICU
Alcohol withdrawal management:
On the Horizon
 CIWA-based algorithms
http://www.nahq.org/uploads/apps/files/ETOHWithdra
wlGuideline.pdf
 Non-benzodiazepine withdrawal protocol: alpha 2
agonists (clonidine, dexmedetomidine), anticonvulsants, anti-psychotics, beta blockers, baclofen
Summary
 Alcohol withdrawal can present across patient
populations in various clinical scenarios, so always
consider it in the differential diagnosis, but keep your
differential diagnosis open.
 To date, benzodiazepines remain the treatment of
choice in managing alcohol withdrawal
 When choosing the method of benzodiazepine dosing,
consider whether the patient has intact verbal
communication and recent alcohol use
 Avoid CIWA in patients who are unconscious or
delirious
References
Bayard M et al. Alcohol withdrawal syndrome. Am Fam Physician. 2004 Mar 15;69(6):1443-1450.
Daeppen JB et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a
randomized treatment trial, Arch Intern Med 162: 1117-1121, 2002.
Hecksel KA et al. Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general
hospital. Mayo Clin Proc 2008 Mar;83(3):274-9.
Hoffman RS et al. Management of moderate and severe alcohol withdrawal syndrome. UpToDate 2014.
Jaeger TM, et al. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients.
Mayo Clin Proc 2001; 76 (7): 695-701.
Maldonado JR et al. Benzodiazepine loading versus symptom-triggered treatment of alcohol withdrawal:
a prospective, randomized clinical trial. General Hospital Psychiatry 2012; 34: 611-617.
Minozzi AL and M Davoli. Efficacy and safety and pharmacological interventions for the treatment of
Alcohol Withdrawal Syndrome (Review). Cochrane Database Syst Rev 2011; 6: CD008537.
Ross JD et al. Alcoholic Patients: Acute and Chronic. Massachusetts General Hospital Handbook of
General Hospital Psychiatry 2010: 153-162.
Saitz R et al. Individualized treatment for alcohol withdrawal: a randomized double-blind controlled
trial, JAMA 272: 519-23, 1994.
Sullivan JT, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment
for alcohol scale (CIWA-Ar). Br J Addict 1989; 84 (11): 1353-7.