pharmacological management of alcohol withdrawal and newer medicines
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Pharmacological management of alcohol withdrawal and newer medicinesTRANSCRIPT
PHARMACOLOGICAL MANAGEMENT OF ALCOHOL WITHDRAWAL AND NEWER MEDICINES FOR RELAPSE
PREVENTION
Dr. Prasanna P. KhatawkarM.B.B.S.,D.P.M.,F.A.G.E.,D.N.B.(PSYCHIATRY)
Consultant PsychiatristAadhar Hospital – Specialty Centre for Psychiatry and De-addiction
Solapur
PHARMACOLOGICAL MANAGEMENT OF
ALCOHOL WITHDRAWAL
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TEAM
PSYCHIATRIST PHYSICIAN GOOD NURSING STAFF COOPERATIVE RELATIVES
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SETUP
SPECIALITY PSYCHIATRY SETUP WITH SOS MEDICAL / ICU BACKUP
GENERAL HOSPITAL SETUP WITH ATTACHED PHYSICIAN AND PSYCHIATRIST
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ALCOHOL INTOXICATION STATE
SAFE ENVIRONMENT ADEQUATE HYDRATION AND NUTRITION MAINTAIN VITALS AND PHYSIOLOGICAL
HOMEOSTASIS THIAMINE ANTIEPILEPTICS ANTIPSYCHOTICS BENZODIAZEPINE AVOIDED IN THIS STATE WAIT FOR THE EFFECT TO WAN OFF
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ALCOHOL WITHDRAWAL STATE
ALSO CALLED AS ‘ABSTINENCE SYNDROME’ IT IS A COMPLEX SYNDROME OCCURING IN
PATIENTS DEPENDENT ON ALCOHOL DUE TO SUDDEN CESSATION OF ALCOHOL
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SYMPTOMS
CONFUSION GENERALISED TREMELOUSNESS AUTONOMIC ARROUSAL DISORGANISED SYMPTOMS PSYCHOMOTOR AGITATION INSOMNIA PERCEPTUAL DISTURBANCE GRAND MAL SEIZURES DELIRIUM TREMENS
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DURATION
MAY START ANYTIME WITHIN 6 TO 8 HOURS AFTER LAST DRINK
MAY LAST UPTO 96 HOURS DEPENDS UPON VARIOUS FACTORS
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COMMON MEDICINESUSED IN ALCOHOL
WITHDRAWAL
BENZODIAZEPINES
LFT’s NORMAL : LONG t ½
(CHLORDIAZEPOXIDE, DIAZEPAM) LFT’s DERRANGED : INTERMEDIATE t ½
OR SHORT t ½ ( LORAZEPAM, OXAZEPAM) AVOID BENZODIAZEPINES WITH ULTRA SHORT
t ½ HIGH POTENCY DRUG LIKE MIDAZOLAM CAN BE
HELPFUL FOR IMMEDIATE EFFECT
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DOSE CALCULATION FOR BENZODIAZEPINES
LFT STATUS INTAKE OF ABSOLUTE ALCOHOL t ½ OF THE BENZODIAZEPINE USED PRESENT CLINICAL STATUS
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THIAMINE
B1 VITAMIN (ANEURIN) IMPORTANT ROLE IN VARIOUS CELLULAR
PROCESSES SPECIFICALLY IN CNS RDA 1.5 MG DEPLETED BODY RESERVES IN ALCOHOLICS BOLUS DOSE AND REGULAR PARENTAL DOSE
ESSENTIAL IN ACUTE WITHDRAWAL STATE 100 MG MAY BE ESSENTIAL FOR 7 DAYS
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ANTIEPILEPTICS
ACUTE WITHDRAWAL CARBAMAZEPINE OXCARBAZEPINE
ANTICRAVING TOPIRAMATE
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ANTIPSYCHOTICS
USED IN ALCOHOL WITHDRAWAL AS AN ADD-ON TO FIRST LINE MEASURES SUCH AS BENZODIAZEPINES TO CONTROL AGITATION OR PSYCHOSIS
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BETA BLOCKERS
USED TO REDUCE SIGNS OF AUTONOMIC NERVOUS SYSTEM HYPERACTIVITY AND AT HIGHER DOSES, ARRYTHMIAS
HELPFUL TO REDUCE DOSE OF BENZODIAZEPINES USED IN THIS PHASE
NOT FIRSTLINE DRUGS DUE TO THEIR INEFFICACY IN PREVENTING SEIZURE
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ELECTROLYTES
MAINTAINING PROPER ELECTROLYTE BALANCE ESSENTIAL FOR GOOD AND SPEEDY OUTCOME
RAPID CORRECTION TO BE AVOIDED
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MAGNISIUM
MAGNISIUM IS AN IMPORTANT COFACTOR IN VARIOUS CELLULAR PROCESSES
HYPOMAGNESEMIA ? IMPORTANT PRECIPITATING FACTOR FOR ACLCOHOL WITHDRAWAL SEIZURES
DEPLETIONS CORRECTED ORALLY OR PARENTALLY
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NEWER MEDICINES FOR RELAPSE PREVENTION
ACAMPROSET
AMINO ACID DERIVATIVE OF TAURIN HYPOTHESIZED TO HAVE ABILITY TO NORMALIZE
ABERRENT GLUTAMATE SYSTEM DOSE – 2 GM / DAY CAN BE USED IN LIVER DYSFUNCTION CAUTIOUS USE IN DERRANGED RENAL
FUNCTION
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NALTREXONE
OPIATE RECEPTOR ANTAGONIST ACTS BY PREVENTING OPIATE RECEPTORS
MEDIATED EUPHORIC AND REWARDING EFFECTS OF ALCOHOL
HEPATOXICITY NEEDS TO BE MONITERED DOSE : 25 – 100 MG – DAILY INITIALY
:50 MG ON ALTERNATE DAYS - LATER
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SSRI’s
SEROTONIN KNOWN TO MODULATE BEHAVIOURAL EFFECTS OF ALCOHOL
HELPFUL MAINLY FOR REDUCTION OF SHORT TERM ALCOHOL USE
HELPFUL FOR PATIENTS HAVING COMORBID ANXIETY AND DEPRESSIVE DISORDERS
ALL SSRI’s FOUND TO BE HELPFUL
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DISULFIRAM
CHEMICAL DETERENT (AVERSIVE AGENT) INHIBITS ALDEHYDE DEHYDROGENASE USED TO PREVENT IMPULSIVE DRINKING NEVER USE WITHOUT KNOWLEDGE AND
CONSENT OF THE PATIENT MULTIPLE ADVERSE EFFECTS DOSE : 250 TO 500 MG / DAY
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BACLOFEN
DERIVATIVE OF GABA (AGONIST FOR GABA-B RECEPTORS)
USED FOR SPASTICITY NEWER USE AS AN ANTICRAVING AGENT FOR
ALCOHOL AND COCAIN CAN CAUSE WITHDRAWAL SYMPTOMS DOSE : 10-20 MG / DAY
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OTHER MEDICINES
LITHIUM TCA’s 5HT-3 ANTAGONIST (ONDENSETRON) METRONIDAZOLE
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CHOICE OF BENZODIAZEPINE,
ANTIEPILEPTIC AND ANTIPSYCHOTIC
IF NO IMPROVEMENT IN 72 HOURS……
HYPOMAGNESEMIA HEAD INJURY INCREASED LEVELS OF AMMONIA POLYSUBSTANCE USE
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COMMON MISTAKES
NOT USING THIAMINE USE OF IV DEXTROSE WITHOUT USING
THIAMINE RAPID CORRECTION OF ELECTROLYTES IF PATIENT HAS FEVER AVOID INJECTION
HALOPERIDOL SUBTHERAPUTIC DOSE OF BENZODIAZEPINES
TO BE AVOIDED
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RESTRICTION OF PHYSICAL ACTIVITIES
ESSENTIAL IN INITIAL FEW DAYS PROPER CONSENT ESSENTIAL WATCH FOR FINGER-TIP INJURIES
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THANK YOU