Management of Alcohol Withdrawal

March 27, 2014Megan Schabbing, MDConsult Liaison PsychiatristOhioHealth 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 & CNSEffect 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 48hAlcohol withdrawal seizures are self-limitedIn a patient with prolonged seizures, consider

other etiology (structural abnormality, infection) If left untreated, 1/3 w/d seizures progress to

DTsTreatment: benzodiazepines, barbiturates

*avoid phenytoin (limited evidence in w/d seizures)

Alcoholic HallucinosisOnset ~12-24h following alcohol cessationResolution ~24-48h following alcohol cessation Vivid auditory illusions & hallucinationsClear sensorium (vs. delirium)Ideas of persecution often follow hallucinationsOlfactory 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 ADIncidence 33% in patients with withdrawal

seizuresClassic time frame: 72h following last alcohol useClinical features

DisorientationTremorHyperactivity, increased wakefulnessIncreased autonomic toneHallucinations (visual>auditory)

Alcohol Withdrawal Delirium: Delirium TremensRisk 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 ManagementAddress medical comorbiditiesDifferential diagnosis for increased

sympathetic activity: anti-cholinergic toxicitycocaine or amphetamine intoxicationThyrotoxicosisSedative-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 therapyIn patients with impaired liver function

(cirrhosis, elderly patients), avoid drugs which require oxidative metabolism (use lorazepam, oxazepam)

Alcohol withdrawal managementBenzodiazepines: 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 managementAnti-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 therapyAssesses symptoms on real-timeBenzodiazepine dosing given in response to symptom

severityPROS: 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 Alcohol-Revised Scale

Clinical Institute Withdrawal Assessment for Alcohol-Revised scale (CIWA-Ar)Patient is evaluated q15 min – hourly, dependent upon

severity of symptomsNausea/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/AlcoholWithdrawalAssessmentSheets(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 taperNumerous 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 algorithmshttp://www.nahq.org/uploads/apps/files/ETOHWithdrawlGuideline.pdf

Non-benzodiazepine withdrawal protocol: alpha 2 agonists (clonidine, dexmedetomidine), anti-convulsants, anti-psychotics, beta blockers, baclofen

SummaryAlcohol 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

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