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Acute Management of the Alcoholic Patient. Sandhya Wahi-Gururaj, MD, MPH Department of Internal Medicine UNSOM (Las Vegas). Learning Objectives. To recognize alcohol use disorders Recognize alcohol withdrawal syndromes Manage withdrawal syndromes. Some Stats.

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acute management of the alcoholic patient

Acute Management of the Alcoholic Patient

Sandhya Wahi-Gururaj, MD, MPH

Department of Internal Medicine

UNSOM (Las Vegas)

learning objectives
Learning Objectives
  • To recognize alcohol use disorders
  • Recognize alcohol withdrawal syndromes
  • Manage withdrawal syndromes
some stats
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 2003;12:S12-S25

JAMA 1997;278(2):144-151

slide4
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?

defining aud s alcohol abuse
Defining AUD’s: 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

defining aud s alcohol dependence
Defining AUD’s:Alcohol 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

defining aud s
Defining AUD’s
  • “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

a drink 14 grams of ethanol
“A Drink” =14 grams of Ethanol
  • Beer = 12 oz.
  • Malt-liquor = 8 oz.
  • Wine = 5 oz.
  • 80 Proof Spirits = 1.5 oz.
alcohol use number of drinks
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: >4/occasion; 14/week
    • F: >3/occasion; 7/week
  • Binge: M: 5/occasion; F: 4/occasion

www.niaaa.nih.gov

withdrawal syndromes
Withdrawal Syndromes
  • Minor Alcohol Withdrawal
  • Alcohol Withdrawal Seizures
  • Alcoholic Hallucinosis
  • Delirium Tremens
minor withdrawal
Minor Withdrawal
  • Due to CNS and sympathetic hyperactivity
  • Onset within 6 to 36 hours
  • Resolves 24-48 hours
  • May have significant serum ETOH level
minor withdrawal13
Minor Withdrawal
  • Insomnia
  • Tremulousness
  • Mild anxiety
  • GI upset
  • Headache
  • Diaphoresis
  • Palpitations
  • Anorexia
withdrawal seizures
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
alcoholic hallucinosis
Alcoholic Hallucinosis
  • Onset 12-48 hours
  • Resolve within 24-48 hours
  • Usually visual
    • Auditory, tactile occur
  • No global clouding of sensorium
delirium tremens
Delirium Tremens
  • 1-5% patients
  • Onset 48-96 hours
  • Lasts 1-5 days
  • Mortality up to 5%
    • older age
    • prior pulmonary disease
    • T>104F
    • Coexisting liver disease
delirium tremens risk factors
Delirium Tremens:Risk Factors
  • Sustained drinking
  • Previous DTs (OR 2.6)
  • Previous DTs or withdrawal seizure (OR 3.1)
  • Age >30
  • Concurrent illness (OR 6.9)
  • SBP >145 mmHg (OR 4.1)
  • Chronic Medical Illness (OR 1.9)
  • Presenting later

Sub Abuse 2002;23(2):83-94.

Hosp Pract June 15, 1995

delirium tremens clinical manifestations
Delirium Tremens: Clinical Manifestations
  • Hallucinations
  • Disorientation
  • Autonomic signs:
    • Tachycardia
    • Hypertension
    • Low-grade fever
  • Agitation
  • Diaphoresis
  • Hyperventilation
which labs should be sent
Which labs should be sent?
  • CBC
  • Renal Panel
  • LFTs
  • Urinalysis
  • Coags
additional complications due to alcohol
Additional Complications due to Alcohol
  • Volume depletion
  • Hypokalemia
  • Hypomagnesemia
  • Hypophosphatemia
  • Hypo or hypernatremia
  • Hypoglycemia
  • Alcoholic Ketoacidosis
hypophosphatemia
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
additional laboratory abnormalities
Additional Laboratory Abnormalities
  • Elevated serum transaminases
  • Elevated serum GGT
  • Elevated carbohydrate-deficient transferrin
  • Hematologic derangements
management general considerations
Management:General Considerations
  • Withdrawal diagnosis of exclusion
  • Quiet, well-lit room
  • Frequent reorientation
  • Volume repletion
  • Electrolyte monitoring and repletion
  • Thiamine
  • Multivitamins, Folate
  • Glucose
management
Management
  • Benzodiazepines are drug of choice
  • 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 2004;164:1405-1412.

management benzodiazepines
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
management benzodiazepines27
Management:Benzodiazepines
  • 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.

dosing schedule
Dosing Schedule

JAMA 1994;272(7):519-523.

slide29

<10 mild

10-14 mod

>15 major

Br J Addiction 1989;84:1353-1357.

dosing schedule30
Dosing Schedule
  • No differences in severity of withdrawal, incidence of seizures or DTs
  • Mean CIWA-Ar score ~9

JAMA 1994;272(7):519-523.

dosing schedule32
Dosing Schedule

Arch Int Med 2002;162:1117-1121.

dosing schedule33
Dosing Schedule

Arch Int Med 2002;162:1117-1121.

management dosing schedule
Management: Dosing Schedule
  • Fixed dosing
    • High risk: prior seizures or DTs
  • Front-loading
  • Symptom triggered
    • Patient centered
    • Less meds and shorter hospital course
    • Nursing dependent
management alternate therapy
Management:Alternate Therapy
  • Alpha-2 agonists – clonidine
  • Beta blockers
  • Antipsychotics – lowers seizure threshold
  • Baclofen
  • Ethyl Alcohol
  • Barbiturates
  • Propofol
conclusions
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