Alcohol Withdrawal Syndromes

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Alcohol Withdrawal Syndromes

• By David Bridgers, M.D.

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Case Presentation

• 43 y/o AAM with a hx, HTN, and long term ETOH
  abuse, who presented to the Urology service after
  being seen in the ED for Hematuria, and being
  diagnosed with a renal mass. He was 1 day s/p
  nephrectomy. He was on epidural pain medications
  per pain control. He was reported to be agitated
  when the nursing staff evaluated him.The

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Case Presentation

• The Urology team evaluated the patient and after
  realizing that he had not had a drink in 36 hours
  they called for a Medicine consult for management
  of DTs.

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Definitions

• Alcoholism chronic alcohol abuse, dependence, or
  addiction chronic excessive drinking of
  alcoholic beverages resulting in impairment of
  health and/or social or occupational functioning,
  and increasing adaptation to the effects of
  alcohol requiring increasing doses to achieve and
  sustain a desired effect specific signs or
  symptoms of withdrawal are usually shown on
  sudden cessation of such drinking.
• Alcoholic One who suffers from alcoholism. One
  who abuses or is dependent on alcohol (Stedmans
  26th ed.)

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Alcoholism in the United States

• Alcoholism is a common condition, with
  complications that will eventually confront all
  clinicians.
• Estimated 10-18 million Alcoholics in the U.S. in
  1990.
• 15-20 of hospitalized and primary care patients.
• Studies show that b/w 13 and 71 percent of
  patients develop symptoms of ETOH withdrawal

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Various Presentations of Acute ETOH Withdrawal

• Minor Withdrawal Symptoms
• -occur w/i 6 hours of cessation
• -insomnia, tremulousness, mild anxiety, GI upset,
  diaphoresis, HA, palpitations, and anorexia.
• -usually resolve w/i 24-48 hrs.
• -vary from episode to episode

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Various Presentations of Acute ETOH Withdrawal

• Withdrawal Seizures
• -w/i 48 hours of last drink
• -generalized tonic-clonic
• -3 of chronic alcoholics develop this
• -3 of those who seize develop Status Epilepticus

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Various Presentations of Acute ETOH Withdrawal

• Alcoholic Hallucinosis
• - 12- 24 hr. onset after last drink
• - usually visual
• - Resolve w/i 24-48 hr.
• - NOT synonymous with DTs
• other signs may or may not be present
• time course is different
• not usually associated with clouding of the
  sensorium

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Various Presentation of Acute ETOH Withdrawal

• Delirium Tremens
• - 5 of patients who withdraw
• - typically begin b/w 48 and 96 hours
• - typically last 1-5 days
• - longer periods requiring massive doses of
  medications have been described (Wolf et. Al 1993)

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Delirium Tremens

• - Early figures of associated mortality were as
  high as 37
• - Now mortality is felt to be 5. This is likely
  due to earlier diagnosis, improved
  pharmacological, and non-pharmocologic
  management, and improved treatment of co-morbid
  conditions.

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Delirium Tremens

• -Mortality risk is greater
• 1. Elderly
• 2. Concomitant lung Dz
• 3. Core body temp 104
• 4. Co-existing liver Dz.
• - Death is usually due to arrhythmia or secondary
  complications. (pneumonia,liver failure)

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DT Risk Factors

• History of sustained drinking
• Previous DTs
• 30
• Greater number of days since last drink
• Presence of other illnesses

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Hallmarks of DTs

• Hallucinations
• Disorientation
• Tachycardia
• Hypertension
• Low Grade Fever
• Agitation
• Diaphoresis

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Hallmarks of DTs

• Elevated cardiac indices, oxygen delivery and
  oxygen consumption
• Hyperventilation and Respiratory alkalosis which
  result in reduced cerebral blood flow
• Sensorium Clouding

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Other Char. Of Delirium Tremens

• Fluid and electrolyte concerns
• Hypokalemia is common
• Hypomagnesemia - may predispose to sz. Activity
• Hypophosphatemia - may be present and contribute
  to heart failure and rhabdomyolysis.

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Non-Pharmacological Management Principals

• PT should be closely monitored
• -Ideally a quiet and protective setting, unless
  pt. Is at higher risk for complications, then
  they should be in a ICU.
• Frequent evaluation by nursing AND medical staff
• Other conditions may mimic DT infection, OD,
  trauma, hepatic failure, GIB

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Non-Pharmacological Management Principals cont.

• Appropriate diagnostic testing LP, CMP,
  Cultures etc.
• Mechanical Restraints in the swimmers position
  for pt. Protection
• Correction of volume and Electrolyte deficits
• Thiamine, MVT, Folate given regularly

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Pharmacological Management
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Pharmacological Management

• Working Group on Pharmacological Management of
  Alcohol Withdrawal
• - JAMA July 9,1997
• - Goal was to establish evidence based
  guidelines for the treatment of Alcohol
  withdrawal syndromes

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Working Group Outcomes Studied

• 1. Severity of withdrawal syndrome
• 2. Alcohol Withdrawal Delirium
• 3. Withdrawal Seizures
• 4. Completion of withdrawal
• 5. Entry into Rehab
• 6. Cost

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Working Group on ETOH Withdrawal Syndromes cont.

• Prospective controlled trials with documented
  reporting of the endpoint in question were
  investigated further.
• Available literature that addressed one of the
  clinical endpoints listed were assimilated and
  reviewed to formulate the pharmacological
  guidelines.

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CIWA-Ar

• Clinical Institute Withdrawal Assessment -
  revised version (CIWA-Ar)
• - Structured Severity Assessment Scale
• -Objective Scale for use by health care personel
  to evaluate patients at risk for developing
  alcohol withdrawal syndromes, and quantify the
  severity of withdrawal.

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CIWA-Ar

• Well documented reliability, reproducibility, and
  validity when based on comparison with ratings by
  experienced clinicians
• First used in ETOH detox, and psychiatric units
• Studies have proven usefulness in general
  medical/surgical wards

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CIWA-Ar

• High scores are predictive of development of
  seizures and delirium!!
• Scale is currently being used with strict
  protocalls for medication administration at many
  non-teaching facilities
• Using the CIWA-Ar was found to reduce patient
  effect from over-sedation cost of hospitalization
  by avoiding unnecessary use of medications

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CIWA-Ar
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Dosing of Pharmacological Agents

• Dosing Schedules which are acceptable
• 1. Fixed - most useful in high risk pts.
• 2. Symptom Triggered - Based on certain
  CIWA-Ar scores.
• 3. Front Loaded - Auto taper method. Not in
  Working Group Recommendations, but supported by
  other studies

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Working Group Recommendations on Choice of Agent

• -Benzodiazepines recommended
• 1. Long acting may be more effective in
  controlling seizures
• 2. Long acting contributes to smoother withdrawal
  and less rebound
• 3. Short acting have lower risk of oversedation

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Working Group on ETOH Withdrawal Syndromes cont

• 4. Certain Benzos have higher potential for abuse
• 5. Cost varies considerably

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Working Group Recommendations

• 1. Mild Symptoms (CIWA-Ar score option is non-pharmacological supportive therapy
  and cont. monitoring.
• Moderate Symptoms (score 8-15) symptomatic
  administration of medications, with hourly
  assessment. Regimen recommended
• 1.Librium 50-100 mg
• 2.Valium 10-20 mg
• 3.Ativan 2-4 mg.

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Dosing of Pharmacological Agents

• Severe Symptoms (score 15) - Provide Fixed
  scheduled medications in the amounts necessary to
  control symptoms. Regimen Recommended
• 1.Librium50 mg q 6 hrs. x 4 doses then 25 mg q
  6 hrs. x 4 doses
• 2.Valium 10 mg q 6 hrs. x 4 doses then 5 mg q
  6x 8 doses
• 3.Ativan 2 mg q 6 x 4 doses then 1 mg q6 x 8
  doses.
• Additional PRN dosing if necessary

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Dosing of Pharmacological Agents

• 2. For pts. With a hx of Sz. Provide 1 of the
  proposed fixed regimens on presentation,
  regardless of the severity of withdrawal.
• (monitoring and symptomatic tx is reasonable)
• 3. Early treatment of those with severe
  co-morbidities is warranted.

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More Recent Evidence on DT Management

• Pts. In DTs should receive IV diazepam 5-10 mg
  every 5 minutes until pt. Is awake but calm.
• Continue parenteral administration of Diazepam
  until pt. Is no longer delirious and absorption
  from gut is reliable.

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Other Agents Examined

• Beta Blockers, clonidine, and Carbamazepine - Not
  to be used as mono-therapy because they do not
  protect against delirium or seizures
• Neuroleptics - Only in conjunction with benzos
  for hallucinations. May increase seizures
• Magnesium - not recommended
• Ethyl ETOH - NOT recommended due to lack of
  controlled studies and well known adverse effects
• Thiamine - Administer at initial evaluation.

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Back to Our Case

• Pt. was seen by the internal medicine consult
  team. He was found to be mildly sedated from pain
  medicines but would answer questions. He had mild
  pain from incision site, but otherwise had no
  tremors, nausea, diaphoresis, or signs of
  anxiety/agitation. He had no visual or auditory
  hallucinations. Physical exam was benign.

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Case Presentation

• The CIWA-Ar score was used in assessing the
  patient, and he was found to have a CIWA-Ar of 0.
  The urology team was notified of findings and a
  copy of the CIWA-Ar scale was applied to his
  chart.

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Summary

• ETOH withdrawal is a common problem facing
  internists
• Has a wide range of presentations
• DTs, being the most severe form must be treated
  as a medical emergency with monitoring, frequent
  pt. assessment, and both pharmacological and
  non-pharmacological strategies

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Summary

• Clinical assessment tools, such as the CIWA-Ar
  are useful and should be considered when
  assessing pts who ETOH withdrawal is suspected
  in, to help guide medication administration.
• Clinical guidelines exist for medical treatment
  of withdrawal and should be followed