Alcohol Withdrawal Syndromes By: David Bridgers, M.D.
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
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.
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(Stedman’s 26th ed.)
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
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
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
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 DT’s *other signs may or may not be present * time course is different * not usually associated with clouding of the sensorium
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)
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.
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)
DT Risk Factors • History of sustained drinking • Previous DTs • >30 • Greater number of days since last drink • Presence of other illnesses
Hallmarks of DTs • Hallucinations • Disorientation • Tachycardia • Hypertension • Low Grade Fever • Agitation • Diaphoresis
Hallmarks of DTs • Elevated cardiac indices, oxygen delivery and oxygen consumption • Hyperventilation and Respiratory alkalosis which result in reduced cerebral blood flow • Sensorium Clouding
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.
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
Non-Pharmacological Management Principals cont. • Appropriate diagnostic testing : LP, CMP, Cultures etc. • Mechanical Restraints in the “swimmer’s position” for pt. Protection • Correction of volume and Electrolyte deficits • Thiamine, MVT, Folate given regularly
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
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
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.
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.
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
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
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
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
Working Group on ETOH Withdrawal Syndromes cont 4. Certain Benzos have higher potential for abuse 5. Cost varies considerably
Working Group Recommendations 1. Mild Symptoms (CIWA-Ar score <8-10) reasonable 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.
Dosing of Pharmacological Agents Severe Symptoms (score >15) - Provide Fixed scheduled medications in the amounts necessary to control symptoms. Regimen Recommended: 1.Librium:50 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
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.
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.
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.
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.
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.
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
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