Author: John Carter

Treatment of Alcohol Withdrawal PMC

About 50% of patients who have had a withdrawal seizure will progress to delirium tremens. Alcohol withdrawal symptoms usually appear when an individual discontinues or reduces alcohol intake after a period of prolonged consumption. In most cases, mild symptoms may start to develop within hours of the last drink. This activity reviews the evaluation and management of alcohol withdrawal and highlights the interprofessional team’s role in the recognition and management of this condition. While most clinicians agree that severe AW requires pharmacological treatment, studies suggest that some patients with mild withdrawal symptoms may benefit from supportive care alone.

But severe or complicated alcohol withdrawal can result in lengthy hospital stays and even time in the intensive care unit (ICU). The prognosis often depends on the severity of alcohol withdrawal syndrome. Delirium tremens is the most severe form of alcohol withdrawal, and its hallmark is that of an altered sensorium with significant autonomic dysfunction and vital sign abnormalities.

Patients in alcohol withdrawal should preferably be treated in a quiet room with low lighting and minimal stimulation. All patients with seizures or DT should have immediate intravenous access for administration of drugs and fluids. Adequate sedation should be provided to calm the patient as early as possible and physical restraints may be used as required in order to prevent injuries due to agitation. Adequate nutrition must be ensured with care to prevent aspiration in over-sedated patients. Vitamin B supplementation helps to prevent Wernicke’s encephalopathy (WE). Antipsychotic medications, such as haloperidol (Haldol®), have been used in low doses to treat DT’s.

Enhancing Healthcare Team Outcomes

When not properly treated, AWS can progress to delirium tremens (Table 38–10). A fixed daily dose of benzodiazepines is administered in four divided doses. Approximately 5 mg of diazepam equivalents [Table 5] is prescribed for every standard drink consumed.

The most effective way to prevent alcohol withdrawal syndrome is to avoid drinking or drinking only in moderation. People with severe symptoms remain in the hospital for part or all of the detox process so a doctor can closely monitor their blood pressure, breathing, and heart rate and provide medications to ease the process. A doctor can often diagnose alcohol withdrawal syndrome by taking a person’s medical history and doing a physical exam. Alcohol withdrawal syndrome occurs when a person with alcohol use disorder stops or suddenly decreases their alcohol intake. Alcohol withdrawal syndrome is the group of symptoms that can develop when someone with alcohol use disorder suddenly stops drinking. For mild alcohol withdrawal that’s not at risk of worsening, your provider may prescribe carbamazepine or gabapentin to help with symptoms.

However, it needs to be based upon the severity of withdrawals and time since last drink. For example, a person presenting after 5 days of abstinence, whose peak of withdrawal symptoms have passed, may need a lower dose of benzodiazepines than a patient who has come on the second day of his withdrawal syndrome. However, in the presence of co-morbidities shorter acting drugs such as oxazepam and lorazepam are used. A ceiling dose of 60 mg of diazepam or 125 mg of chlordiazepoxide is advised per day.[18] After 2-3 days of stabilization of the withdrawal syndrome, the benzodiazepine is gradually tapered off over a period of 7-10 days. Patients need to be advised about the risks and to reduce the dose, in case of excessive drowsiness.

Can I prevent alcohol withdrawal?

GABA (gamma-aminobutyric acid) is the major inhibitory neurotransmitter in the central nervous center. GABA has particular binding sites available for ethanol, thus increasing the inhibition of the central nervous system when present. Chronic ethanol exposure to GABA creates constant inhibition or depressant effects on the brain. Ethanol also binds to glutamate, which is one of the excitatory amino acids in the central nervous system.

1. Alcohol withdrawal causes a range of symptoms when a person with alcohol use disorder stops or significantly decreases their alcohol intake.
2. Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.
3. When the onset of withdrawal like symptoms or delirium is after 2 weeks of complete cessation of alcohol, the diagnosis of alcohol withdrawal syndrome or DT becomes untenable, regardless of frequent or heavy use of alcohol.
4. In Europe, the antiseizure medications carbamazepine (Tegretol®) and valproic acid (Depakene® and others) have been used successfully to treat AW for many years.
5. Because these substances play a major role in metabolism, electrolyte disturbances may lead to severe and even life-threatening metabolic abnormalities.

Too much alcohol can irritate the stomach lining, cause dehydration, and lead to an inflammatory response in the body. As the alcohol wears off, these effects lead to common hangover symptoms, such as headache, nausea, and fatigue. Alcohol use disorder or drinking heavily over an extended period can change a person’s brain chemistry due to the continued exposure to the chemicals in alcohol. It’s also important to note that delirium tremens can be life-threatening. Each of these symptoms can increase in intensity depending on the severity of the withdrawal.

Physicians should monitor outpatients with alcohol withdrawal syndrome daily for up to five days after their last drink to verify symptom improvement and to evaluate the need for additional treatment. Primary care physicians should offer to initiate long-term treatment for alcohol use disorder, including pharmacotherapy, in addition to withdrawal management. It forms a major part of referrals received by a consultation-liaison psychiatrist. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on pharmacological management of alcohol withdrawal in humans with no limit on the date of publication.

Monitoring and Follow-up

In each case, close monitoring is essential as the symptoms can suddenly become severe. Other common household substances can also contain a significant amount of alcohol if ingested in large quantities, including mouthwash and cough syrup. Some of these items may also contain a high content of salicylates or acetaminophen, so consider checking aspirin and acetaminophen levels in patients presenting with alcohol withdrawal. A review by Hack et al.[32] suggests that a high requirement of intravenous diazepam (more than 50 mg in the 1sth, or 200 mg or more within the first 3 h) with poor control of withdrawal symptoms is a marker of non-response of DT to benzodiazepines. Dopamine is another neurotransmitter involved in alcohol withdrawal states.

Patients who are non-verbal (e.g. stupor due to head injury) may not be suited for this regimen as they may not be able to inform the nursing personnel if they were to experience any withdrawal symptoms. Recently, new practice guidelines were developed by the American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal (Mayo-Smith 1997). The Working Group reviewed data presented in 134 articles on the treatment of AW published between 1966 and 1995. Based on the review of data, the investigators concluded that BZ’s are “suitable agents for alcohol withdrawal.” All BZ’s appeared equally effective in treating AW symptoms.

Symptom-monitored loading dose (SML)

In most cases, water balance can be maintained by oral administration of fluids. This article explores the management of AW and co-occurring conditions, evaluates different treatment settings and medications, and addresses considerations in treating special populations. Drastic changes in blood pressure and heart rate can also develop, which may lead to a stroke or heart attack.

TREATMENT OF ACUTE ALCOHOL WITHDRAWAL SYNDROME

In addition, candidates for outpatient detoxification should have a sober significant other to serve as a reliable support person. Ambulatory AW patients should report to their treatment center daily so that the clinician can reassess the patient’s symptoms, the occurrence of medical complications, and ongoing treatment effectiveness. The hallmark of management for severe symptoms is the administration of long-acting benzodiazepines.