Inpatient management of alcohol withdrawal
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Inpatient Management of Alcohol Withdrawal. Kim Tartaglia, MD. Objectives. Describe the different types of alcohol withdrawal Recognize the symptoms of alcohol withdrawal delirium (AWD or DTs) Review the management of AWD. Scope of the problem.

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  • Describe the different types of alcohol withdrawal

  • Recognize the symptoms of alcohol withdrawal delirium (AWD or DTs)

  • Review the management of AWD

Scope of the problem
Scope of the problem

  • 8 million people dependent on alcohol is the US

  • 3.5 million dependent on illicit drugs

  • 500,000 episodes/yr of alcohol withdrawal

  • 15% of pts in primary care have either an alcohol-related health problem or “at-risk” pattern of alcohol use

Spectrum of etoh withdrawal
Spectrum of EtOH withdrawal

  • Mild withdrawal

  • Withdrawal-associated seizures

  • Alcoholic Hallucinosis

  • Alcohol Withdrawal Delirium (aka Delerium Tremens)

Alcohol withdrawal pathophysiology
Alcohol Withdrawal Pathophysiology

  • GABA receptors have binding site for EtOH

    • EtOH induces an insensitivity to GABA

    • More EtOH needed to maintain inhibitory tone

  • EtOH inhibits glutamate-induced excitation

  • Withdrawal occurs w/ abrupt cessation after prolonged exposure (not a binge)

  • Leads to over-activity of CNS

Mild etoh withdrawal
Mild EtOH withdrawal

  • 6hrs after stop drinking (may occur w/ significant blood-alcohol levels)

  • Resolves in 1-2 days

  • CNS overactivity

    • Insomnia, anxiety

    • Tremulousness

    • Diaphoresis

    • GI upset

    • Headaches

Withdrawal associated seizures
Withdrawal-associated seizures

  • Occurs 12-48hr after last drink (can occur as soon as 2hr)

  • Generalized tonic-clonic

  • Usually single sz (but may be several clustered over short time)

  • Status epilepticus NOT consistent

  • If untreated, 30% will progress to DTs

Alcoholic hallucinosis
Alcoholic Hallucinosis

  • Develops 12hr after cessation

  • Resolves within 48hr

  • Usually visual (can be tactile or auditory)

  • Not part of DTs: Normal vitals and sensorium

  • These are hallucinations that occur before DTs

Alcohol withdrawal delirium
Alcohol Withdrawal Delirium

  • Symptoms

  • Risk factors

  • Timing

  • Prognosis

Diagnostic criteria for alcohol withdrawal delirium awd
Diagnostic Criteria for Alcohol Withdrawal Delirium (AWD)

  • Disturbance of Consciousness, with reduced ability to focus, sustain, or shift attention

  • Change in cognition or development of perceptual disturbance that is not better accounted for by pre-existing dementia

  • Develops in short period and tends to fluctuate throughout day

  • Evidence that symptoms developed during or shortly after a withdrawal syndrome

Arch Int Med Vol 164, July 12, 2004

Symptoms of awd
Symptoms of AWD

  • Agitation

  • Disorientation

  • Hallucinations

  • Autonomic instability

    • Tachycardia

    • HTN

    • Hyperthermia

    • Diaphoresis

Alcohol withdrawal delirium1
Alcohol Withdrawal Delirium

  • Occurs in ~5% of patients who experience alcohol withdrawal

  • Occurs 2-4 days after last drink and lasts 1-5 days (average of 2-3 days).

  • Be cognizant of a concurrent illness that may precipitate DTs

    • Infection, pancreatitis, hepatitis, GI bleed, cardiac ischemia

Timing of withdrawal
Timing of Withdrawal

UpToDate, 03/2009


  • Mortality is ~5%

  • Increased by older age, coexisting lung or liver disease, and temp>104 F

  • Death due to arrhythmia, complicating illness (pneumonia), or failure to recognize trigger illness (CNS infection, pancreatitis)

Risk factors for awd
Risk Factors for AWD

  • History of Previous DTs

  • Age >30 yr

  • Presence of concurrent illness

  • H/O sustained drinking

  • Experiencing EtOH withdrawal in presence of elevated alcohol level

  • Longer period since last drink (develop w/drawal >2 days since last drink)

Associated findings w dts
Associated findings w/ DTs

  • Dehydration (increased losses)

  • Hypokalemia (renal and extrarenal losses)

  • Hypomagnesemia (increases risk for seizures and arrhythmias)

  • Hypophosphatemia (increases risk for rhabdomyolysis and cardiac failure)

Management of etoh withdrawal
Management of EtOH withdrawal

  • Evaluate for other conditions

    • Labs for metabolic causes

    • Consider Head CT or LP for intracranial causes

    • Consider GI bleed

  • Supportive care

  • Medications

Supportive care for dts
Supportive Care for DTs

  • Replace volume deficits w/ isotonic fluids

  • Thiamine 100mg IV and glucose

  • MVI w/ folate

  • Aggressively correct abnormal K, Mg, Phos, and glucose

Overview of treatment
Overview of Treatment

  • Benzodiazepines = Mainstay of EtOH withdrawal treatment

    • 6 prospective trials comparing BZD to placebo

    • Risk reduction of 7.7 in preventing seizures

    • Risk reduction of 4.9 in preventing delirium

  • Work by stimulation GABA receptors

  • Treats agitation and prevents progression

Kosten TR. NEJM 2003; 348: 1786

Benzos vs neuroleptics
Benzos vs Neuroleptics

  • Meta-analysis based on 5 studies

  • Benzos more effective in reducing mortality from AWD (RR 6.6 for neuroleptics, CI 1.2-34)

  • Time to achieve adequate sedation was less w/ BZDs (1.1 vs 3 hr, p=0.02)

Arch Int Med, vol 164, 2004.

Fixed vs symptom triggered dosing
Fixed vs symptom-triggered dosing

  • Double-blind RCT

  • Fixed dose: rec’d chlordiazepoxide q6h (50mg x1d then 25mg x2d) plus prn for CIWA-Ar >8

  • Symptom-triggered: Rec’d 25-100mg q1h prn CIWA-Ar>8

  • Primary outcome: Duration of med txtmt and total amt of BZD given

Saitz R. JAMA 1994; 272: 519.

Individualized treatment for alcohol withdrawal a randomized double blind controlled trial
Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial

Figure 1 . Kaplan-Meier curves illustrate treatment times for both groups. Treatment time was shorter in the patients receiving symptom-triggered therapy (log rank test P <.001)

Results fixed vs symptom triggered dosing
RESULTS: Fixed vs symptom-triggered dosing randomized double-blind controlled trial

  • Median txtmt duration was shorter in symptom-triggered group (9hr vs 68hr, p<.001)

  • Symptom triggered group rec’d less BZD (100mg vs 425mg, p<.001)

  • No difference b/w groups in severity (CIWA-Ar scores), incidence of DTs, hallucinations, seizures, leaving AMA, or readmission rates

Saitz R. JAMA 1994; 272: 519.

Clinical institute withdrawal assessment ciwa ar scale
Clinical Institute Withdrawal Assessment (CIWA-Ar) scale randomized double-blind controlled trial

  • Maximum score of 67

  • Score > 8 necessitates treatment

The bottom line 2004 practice guidelines
The Bottom Line: randomized double-blind controlled trial2004 Practice Guidelines

  • Benzos should be primary agent for managing AWD (gr A)

    • Reduce mortality, duration of sx and have less complications than neuroleptics

  • Initial goal is control of agitation

    • Rapid, adequate control of agitation reduces adverse events

Arch Int Med, vol 164, 2004.

Benzodiazepines randomized double-blind controlled trial

  • Long-acting formulations preferred

  • Shorter acting (lorazepam) may be preferred in elderly or liver disease

  • Continuous infusions of BZDs are not cost-effective.

  • Onset of action for BZDs: 15sec – 2min

  • Peak action: 5-15 min

Examples of med regimens
Examples of Med Regimens randomized double-blind controlled trial

  • Diazepam 5mg IV (over 2 min)

    • Repeat in 10min if no effect

    • If still no effect, increase dose to 10mg IV

    • Give 5-20mg qhr prn light somnolence

  • Lorazepam 1-4mg IV

    • Repeat q15 min prn, then q1hr to maintain light somnolence

Prophylaxis against awd
Prophylaxis against AWD randomized double-blind controlled trial

  • Can be considered in pts w/ history of withdrawal seizures, AWD, or prolonged, heavy alcohol use

  • Benefit unclear and may lead to increased BZD overall dose and treatment duration

  • Can give chlordiazepoxide 50mg q6 x1 day, then 25mg q6 x2 days

  • Must still have CIWA-Ar scores and prn BZD.

Adjunctive meds neuroleptics
Adjunctive meds: Neuroleptics randomized double-blind controlled trial

  • Inferior to benzodiazepines

  • Increased risk of side effects, including lower seizure threshold, prolonged QTc and hypotension

  • No studies done on “newer” atypicals

  • Can be used in conjunction w/ benzo in setting of perceptual disturbances (gr C)

Adjunctive meds
Adjunctive meds randomized double-blind controlled trial

  • Beta-blockers: not well studied

    • Mild reduction in autonomic manifestations

    • One controlled study w/ propranolol: increased incidence of delirium

    • Can be used if persistent HTN or tachycardia (gr C)

  • Ethyl Alcohol – not recommended

    • No controlled trials, potential GI/neuro effects

    • Difficult to titrate, not readily available

Adjunctive meds1
Adjunctive meds randomized double-blind controlled trial

  • Clonidine

    • Effective for mild-mod symptoms of withdrawal

    • No studies that show decrease rate of delirium or seizures

  • Carbamazepine

    • Effective for mild-mod symptoms of withdrawal

    • Limited data on preventing seizures or delirium

Summary randomized double-blind controlled trial

  • Alcohol withdrawal includes a number of clinical syndromes that exists along a time and severity continuum

  • Benzodiazepines are the mainstay of txtmt

    • Admin should be guided by CIWA scores (>8)

  • Identification of a trigger for AWD and supportive txtmt w/ thiamine, glucose and electrolyte replacement are crucial

References and reading
References and Reading randomized double-blind controlled trial

  • Ferguson JA, et al. Risk factors for delirium tremens development. J Gen Intern Med 1996; 11: 410.

  • Hack JB, et al. Thiamine before glucose to prevent Wernicke Encephalopathy: examining the conventional wisdom. JAMA 1998; 279: 583.

  • Kosten TR. Management of Drug and Alcohol Witdrawal. NEJM 2003; 348: 1786.

  • Mayo-Smith MF. Pharmacological management of alcohol withdrawal. JAMA 1997; 278: 144

  • Mayo-Smith MF, et al. Management of Alcohol Withdrawal Delirium. Arch Intern Med 2004; 164: 1405

  • Ntais C, et al. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev 2005.

  • Saitz R, et al. Individualized treatment for alcohol withdrawal. JAMA 1994; 272: 519.