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Acute Management of the Alcoholic Patient

Acute Management of the Alcoholic Patient

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Acute Management of the Alcoholic Patient

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  1. Acute Management of the Alcoholic Patient Sandhya Wahi-Gururaj, MD, MPH Department of Internal Medicine UNSOM (Las Vegas)

  2. 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 2003;12:S12-S25 JAMA 1997;278(2):144-151

  4. 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?

  5. 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

  6. 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

  7. 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

  8. “A Drink” =14 grams of Ethanol • Beer = 12 oz. • Malt-liquor = 8 oz. • Wine = 5 oz. • 80 Proof Spirits = 1.5 oz.

  9. 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

  10. For which withdrawal syndromes is your patient at risk?

  11. Withdrawal Syndromes • Minor Alcohol Withdrawal • Alcohol Withdrawal Seizures • Alcoholic Hallucinosis • Delirium Tremens

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

  13. Minor Withdrawal • Insomnia • Tremulousness • Mild anxiety • GI upset • Headache • Diaphoresis • Palpitations • Anorexia

  14. 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

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

  16. 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

  17. 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

  18. Delirium Tremens: Clinical Manifestations • Hallucinations • Disorientation • Autonomic signs: • Tachycardia • Hypertension • Low-grade fever • Agitation • Diaphoresis • Hyperventilation

  19. Which labs should be sent? • CBC • Renal Panel • LFTs • Urinalysis • Coags

  20. Additional Complications due to Alcohol • Volume depletion • Hypokalemia • Hypomagnesemia • Hypophosphatemia • Hypo or hypernatremia • Hypoglycemia • Alcoholic Ketoacidosis

  21. 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

  22. Additional Laboratory Abnormalities • Elevated serum transaminases • Elevated serum GGT • Elevated carbohydrate-deficient transferrin • Hematologic derangements

  23. How will you manage your patient?

  24. Management:General Considerations • Withdrawal diagnosis of exclusion • Quiet, well-lit room • Frequent reorientation • Volume repletion • Electrolyte monitoring and repletion • Thiamine • Multivitamins, Folate • Glucose

  25. 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.

  26. 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

  27. 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.

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

  29. <10 mild 10-14 mod >15 major Br J Addiction 1989;84:1353-1357.

  30. Dosing Schedule • No differences in severity of withdrawal, incidence of seizures or DTs • Mean CIWA-Ar score ~9 JAMA 1994;272(7):519-523.

  31. Dosing Schedule Arch Int Med 2002;162:1117-1121.

  32. Dosing Schedule Arch Int Med 2002;162:1117-1121.

  33. 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

  34. Management:Alternate Therapy • Alpha-2 agonists – clonidine • Beta blockers • Antipsychotics – lowers seizure threshold • Baclofen • Ethyl Alcohol • Barbiturates • Propofol

  35. 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