Acute Management of the Alcoholic Patient

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Acute Management of the Alcoholic Patient

• Sandhya Wahi-Gururaj, MD, MPH
• Department of Internal Medicine
• UNSOM (Las Vegas)

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Learning Objectives

• To recognize alcohol use disorders
• Recognize alcohol withdrawal syndromes
• Manage withdrawal syndromes

3
Some Stats

• Two-thirds U.S. population drinks EtOH
• 17 of drinkers have AUD
• 15-20 of primary care or hospitalized patients

Am J Addictions 200312S12-S25 JAMA
1997278(2)144-151
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• A 42 yo M presents with 4 days of N/V abdominal
  pain and LH. He drinks socially on a daily
  basis. He occasionally has a beer in the morning
  to get going and help with his tremors.
• PE T99 HR 110 BP 150/90 R 16 orthostatic
  changes
• Gen Appears somewhat uncomfortable
• Abd NABS, soft, TTP epigastrium, no
  rebound/guarding
• Neuro Fine tremor with extended hand

Does your patient have an AUD?
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Defining AUDs Alcohol Abuse

• Maladaptive pattern of use
• Failure to fulfill work, school, or social
  obligations
• Recurrent substance use in physically hazardous
  situations (driving)
• Recurrent legal problems
• Continued use despite social or interpersonal
  problems

DSM-IV-TR 2000
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Defining AUDsAlcohol Dependence

• 3 or more
• Tolerance
• Withdrawal
• Substance taken in larger quantity or longer
  duration than intended
• Persistent desire to cut down or control use
• Time spent obtaining, using, recovering
• Social, occupational, or recreational tasks
  sacrificed
• Use continues despite physical and psychological
  problems

DSM-IV-TR 2000
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Defining AUDs

• Alcoholic not technically recognized
• Alcohol Dependence (alcoholism until 1980)
• Primary chronic disease
• Craving
• Loss of Control
• Physical Dependence
• Tolerance
• Progressive and fatal

http//pubs.niaaa.nih.gov/publications/aa30.htm
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A Drink 14 grams of Ethanol

• Beer 12 oz.
• Malt-liquor 8 oz.
• Wine 5 oz.
• 80 Proof Spirits 1.5 oz.

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Alcohol Use (number of drinks)

• Moderate Places at low risk for ETOH problems
• M 0-2/day
• F 0-1/day
• Over 65 0-1/day
• Heavy
• M gt4/occasion 14/week
• F gt3/occasion 7/week
• Binge M 5/occasion F 4/occasion

www.niaaa.nih.gov
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For which withdrawal syndromes is your patient at
risk?

• On hospital day 1?
• On hospital day 3?

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Withdrawal Syndromes

• Minor Alcohol Withdrawal
• Alcohol Withdrawal Seizures
• Alcoholic Hallucinosis
• Delirium Tremens

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Minor Withdrawal

• Due to CNS and sympathetic hyperactivity
• Onset within 6 to 36 hours
• Resolves 24-48 hours
• May have significant serum ETOH level

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Minor Withdrawal

• Insomnia
• Tremulousness
• Mild anxiety
• GI upset
• Headache
• Diaphoresis
• Palpitations
• Anorexia

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Withdrawal Seizures

• Onset within 6 to 48 hours
• May be as early as 2 hours
• 3 of patients with alcohol dependence
• 3 status epilepticus
• Usually isolated to single episode
• Generalized tonic-clonic seizure

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Alcoholic Hallucinosis

• Onset 12-48 hours
• Resolve within 24-48 hours
• Usually visual
• Auditory, tactile occur
• No global clouding of sensorium

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Delirium Tremens

• 1-5 patients
• Onset 48-96 hours
• Lasts 1-5 days
• Mortality up to 5
• older age
• prior pulmonary disease
• Tgt104F
• Coexisting liver disease

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Delirium TremensRisk Factors

• Sustained drinking
• Previous DTs (OR 2.6)
• Previous DTs or withdrawal seizure (OR 3.1)
• Age gt30
• Concurrent illness (OR 6.9)
• SBP gt145 mmHg (OR 4.1)
• Chronic Medical Illness (OR 1.9)
• Presenting later

Sub Abuse 200223(2)83-94. Hosp Pract June 15,
1995
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Delirium Tremens Clinical Manifestations

• Hallucinations
• Disorientation
• Autonomic signs
• Tachycardia
• Hypertension
• Low-grade fever
• Agitation
• Diaphoresis
• Hyperventilation

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Which labs should be sent?

• CBC
• Renal Panel
• LFTs
• Urinalysis
• Coags
• Alcohol Level
• Urine Tox Screen

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Additional Complications due to Alcohol

• Volume depletion
• Hypokalemia
• Hypomagnesemia
• Hypophosphatemia
• Hypo or hypernatremia
• Hypoglycemia
• Alcoholic Ketoacidosis

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Hypophosphatemia

• Decreased intake
• Poor dietary intake phosphorus and Vit D
• Chronic diarrhea
• Phosphate binders OTC
• Increased urinary output
• Secondary hyperparathyroidism
• Proximal tubule defect
• Drops 12-36 hours

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Additional Laboratory Abnormalities

• Elevated serum transaminases
• Elevated serum GGT
• Elevated carbohydrate-deficient transferrin
• Hematologic derangements

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How will you manage your patient?
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ManagementGeneral Considerations

• Withdrawal diagnosis of exclusion
• Quiet, well-lit room
• Frequent reorientation
• Volume repletion
• Electrolyte monitoring and repletion
• Thiamine
• Multivitamins, Folate
• Glucose

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Management

• Benzodiazepines are drug of choice
• Oral therapy preferred unless DTs or a seizure
• Neuroleptics vs. sedative hypnotics
• RR mortality 6.6 (1.2-34.7)
• BDZ decrease duration of treatment
• No RCT for short vs. long-acting in DTs
• No RCT for intermittent vs. continuous

Arch Intern Med 20041641405-1412.
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Management Benzodiazepines

• Long-acting agents
• Chlordiazepoxide (Librium)
• Peaks in 2 hours
• T1/2 5-30 hours
• Diazepam (Valium)
• IV or po form
• Onset more rapid po peaks 30-90 min
• T1/2 20-50 hours
• Preferred due to active metabolites t1/2 2-5 days
• Meta-analysis shows reduced risk seizures

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ManagementBenzodiazepines

• Short-acting agents
• Lorazepam (Ativan)
• T1/2 12 hours
• Oxazepam (Serax)
• T1/2 2.8-8.6 hours
• Preferred with advanced cirrhosis

MICROMEDEX Healthcare Series Lexi-Comp, Inc.
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Dosing Schedule
JAMA 1994272(7)519-523.
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lt10 mild 10-14 mod gt15 major
Br J Addiction 1989841353-1357.
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Dosing Schedule
Symptom-Triggered Fixed Schedule
Total chlordiazepoxide 100 mg (0-400) 425 mg (350-750)
Total duration 9 hrs (0-43) 68 hrs (64-73)

• No differences in severity of withdrawal,
  incidence of seizures or DTs
• Mean CIWA-Ar score 9

JAMA 1994272(7)519-523.
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(No Transcript)
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Dosing Schedule
Arch Int Med 20021621117-1121.
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Dosing Schedule
Symptom-triggered Fixed-dose
Tx with oxazepam 22 (39) 61 (100)
Total mg (range) 37.5 81.7 (0-375) 231.4 29.4 (180-375)
Total mg if dose gt0 95.4 107.7 231.4 29.4
Tx duration (mean) 20 hrs 62.7 hrs
Major Complications 1 seizure 0
Arch Int Med 20021621117-1121.
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What About Medical Inpatients?

• Mayo Clinic Retrospective Review
• 216 Admissions
• STT
• No differences in duration, total BDZ use, BDZ
  use at all
• Decrease in DT occurrence, especially patients
  without a prior h/o DTs

Mayo Clin Proc 200176695-701.
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Management Dosing Schedule

• Fixed dosing
• High risk prior seizures or DTs
  prolonged/sustained drinking
• Front-loading
• Symptom triggered
• Patient centered
• Less meds and shorter hospital course
• Nursing dependent

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ManagementAlternate Therapy

• Alpha-2 agonists clonidine
• Beta blockers
• Antipsychotics lowers seizure threshold
• Baclofen
• Ethyl Alcohol
• Barbiturates
• Propofol

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Conclusions

• AUD maladaptive pattern of use
• 4 withdrawal syndromes
• Watch for concomitant medical complications
• Mainstay of therapy is BDZ
• Consider symptom-triggered therapy
• Pick one drug and increase dose/frequency if
  needed