1 / 51

Alcohol Withdrawal

Alcohol Withdrawal. Best Practice Tom Shiffler, MD 7/23/10. Goals. Understand the pathophysiology of alcohol withdrawal Recognize why we use symptom triggered therapy (CAGE or CIWA) Discuss the role of “prophylaxis” (oral benzodiazepine) Discuss when/where to use benzodiazepine drips

ailsa
Download Presentation

Alcohol Withdrawal

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Alcohol Withdrawal Best Practice Tom Shiffler, MD 7/23/10 UNM Hospitalist Best Practices- Alcohol Withdrawal

  2. Goals • Understand the pathophysiology of alcohol withdrawal • Recognize why we use symptom triggered therapy (CAGE or CIWA) • Discuss the role of “prophylaxis” (oral benzodiazepine) • Discuss when/where to use benzodiazepine drips • Become familiar with evidence on other agents (haldol, clonidine, barbiturates, baclofen, precedex) • Substance abuse resources for patients UNM Hospitalist Best Practices- Alcohol Withdrawal

  3. Epidemiology of Alcohol Withdrawal • 500,000 cases per year requiring pharmacologic treatment • Delirium tremens mortality 5% (down from 37% in the early 1900s) • Arrhythmia • Complication • Pneumonia • Pancreatitis • Hepatitis UNM Hospitalist Best Practices- Alcohol Withdrawal

  4. Course of Alcohol Withdrawal • Minor symptoms • 6 hours after cessation • Resolve in 24-48 hours • Insomnia • Tremulousness • Mild anxiety • GI upset • HA • Diaphoresis • palpitations UNM Hospitalist Best Practices- Alcohol Withdrawal

  5. Course of Alcohol Withdrawal • Withdrawal Seizures • 12-48 hours after cessation • Generalized tonic-clonic • More common in those with chronic alcoholism • Progress to delirium tremens in 1/3 if untreated UNM Hospitalist Best Practices- Alcohol Withdrawal

  6. Course of Alcohol Withdrawal • Alcoholic Hallucinosis • NOT DT’s • Develop within 12-24 hours of cessation • Resolve within 24-48 hours of cessation • Visual, auditory and tactile are possible • NOT associated with global sensorial clouding, rather specific hallucinations • Vital signs usually normal UNM Hospitalist Best Practices- Alcohol Withdrawal

  7. Course of Alcohol Withdrawal • Delirium Tremens • 48-96 hours after cessation • Hallucinations, disorientation, tachycardia, hypertension, fever, agitation and diaphoresis • Generally last 5-7 days • Risk factors • Sustained drinking • Previous DT • Age >30 • Concurrent illness • Withdrawal with elevated alcohol level UNM Hospitalist Best Practices- Alcohol Withdrawal

  8. Goals • Understand the pathophysiology of alcohol withdrawal • Recognize why we use symptom triggered therapy (CAGE OR CIWA) • Discuss the role of “prophylaxis” (oral benzodiazepine) • Discuss when/where to use benzodiazepine drips • Become familiar with evidence on other agents (haldol, clonidine, barbiturates, baclofen, precedex) • Substance abuse resources for patients UNM Hospitalist Best Practices- Alcohol Withdrawal

  9. Pathophysiology-general considerations • Apparent genetic predisposition • Longer period of continual use associated with more severe withdrawal UNM Hospitalist Best Practices- Alcohol Withdrawal

  10. Pathophysiology-Molecular • Alcohol increases inhibitory tone via enhancement of GABA activity (an inhibitory neurotransmitter) • Chronic alcohol reduces functional GABA receptors • Cellular internalization • Gene expression • Removal of alcohol leads to functional loss of GABA and unchecked excitatory neurotransmitters • Dopamine • Glutamate • norepinephrine UNM Hospitalist Best Practices- Alcohol Withdrawal

  11. Pathophysiology-acute Alcohol www.niaaa.nih.gov/.../31_4_acute_gaba.htm UNM Hospitalist Best Practices- Alcohol Withdrawal

  12. Pathophysiology-absence of alcohol after chronic use www.niaaa.nih.gov/.../31_4_acute_gaba.htm UNM Hospitalist Best Practices- Alcohol Withdrawal

  13. Goals • Understand the pathophysiology of alcohol withdrawal • Recognize why we use symptom triggered therapy (CAGE OR CIWA) • Discuss the role of “prophylaxis” (oral benzodiazepine) • Discuss when/where to use benzodiazepine drips • Become familiar with evidence on other agents (haldol, clonidine, barbiturates, baclofen, precedex) • Substance abuse resources for patients UNM Hospitalist Best Practices- Alcohol Withdrawal

  14. Symptom Triggered Therapy (CIWA or CAGE) • Benzodiazepine given in RESPONSE to signs or symptoms • Why is this standard of care? UNM Hospitalist Best Practices- Alcohol Withdrawal

  15. Individualized Treatment for Alcohol Withdrawal. Saitz et al. JAMA Aug 17, 1994 • Clinical question: • Is symptom triggered superior to fixed schedule in reducing quantity and duration of treatment of alcohol withdrawal? • Methods • Randomized Double-Blind Controlled Trial • 101 patients admitted to VA alcohol withdrawal unit • Control • Chlordiazepoxide q6h SCHEDULED • 50mg x4 • 25mg x8 • 25-100mg q 1hour per CIWA-Ar scale • Not administered if somnolent or refused UNM Hospitalist Best Practices- Alcohol Withdrawal

  16. Individualized Treatment for Alcohol Withdrawal. Saitz et al. JAMA Aug 17, 1994 • Symptom triggered group • 25-100mg chlordiazepoxide at CIWA-Ar >7 • See hand out UNM Hospitalist Best Practices- Alcohol Withdrawal

  17. Individualized Treatment for Alcohol Withdrawal. Saitz et al. JAMA Aug 17, 1994 • Outcomes • Duration of medication treatment from admission to last dose of benzodiazepine • Fixed schedule group: 68 hours mean • Symptom triggered group: 9 hours mean (p<0.001) • Amount of chlordiazepoxide administered • Fixed schedule group: 425mg mean • Symptom triggered group: 100mg mean (p<0.001) UNM Hospitalist Best Practices- Alcohol Withdrawal

  18. Individualized Treatment for Alcohol Withdrawal. Saitz et al. JAMA Aug 17, 1994 • Conclusions • “Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal.” UNM Hospitalist Best Practices- Alcohol Withdrawal

  19. Individualized Treatment for Alcohol Withdrawal. Saitz et al. JAMA Aug 17, 1994 • Limitations/concerns • Results expected • 66 hours • 400 mg chlordiazepoxide • morbidity/mortality differences? (n too small) • Take home • Symptom-triggered was better than standard of care (American Society for Addiction Medicine guidelines) for alcohol withdrawal • Weaning built into symptom-triggered treatment • Thank these authors for any alcohol withdrawal patient discharged in < 3 days UNM Hospitalist Best Practices- Alcohol Withdrawal

  20. Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal Daeppen et al. Arch Intern Med May 27 2002 • Clinical question: • Is symptom triggered superior to fixed schedule in reducing quantity and duration of treatment in patients AT RISK of withdrawal? • Methods • Prospective RCT • 117 patients entering alcohol TREATMENT program UNM Hospitalist Best Practices- Alcohol Withdrawal

  21. Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal Daeppen et al. Arch Intern Med May 27 2002 • Methods (cont) • Control (n=61) • 30mg oxazepam q6h for 4 doses scheduled • 15mg oxazepam q6h for 8 doses scheduled • Plus 15-30mg oxazepam q30 minutes for CIWA-Ar score >7 and >14 respectively • Experimental (n=56) • Received placebo, then q 30 minutes evaluated • CIWA-Ar >7 received 15mg oxazepam • CIWA-Ar >14 received 30mg oxazepam • Patients observed for 48 hours after study UNM Hospitalist Best Practices- Alcohol Withdrawal

  22. Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal Daeppen et al. Arch Intern Med May 27 2002 • Results • 22 of 56 (39%) in symptom-triggered received oxazepam • Dosage • 37.5mg mean symptom triggered group • 231.4mg mean fixed schedule group (p<0.001) • Duration • 20 hours mean symptom triggered group • 62.7 hours mean fixed schedule group (p<0.001) UNM Hospitalist Best Practices- Alcohol Withdrawal

  23. Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol WithdrawalDaeppen et al. Arch Intern Med May 27 2002 • Conclusion • “Symptom-triggered benzodiazepine treatment for alcohol withdrawal is safe, comfortable, and associated with a decrease in the quantity of medication and duration treatment.” UNM Hospitalist Best Practices- Alcohol Withdrawal

  24. Goals • Understand the pathophysiology of alcohol withdrawal • Recognize why we use symptom triggered therapy (CAGE OR CIWA) • Discuss the role of “prophylaxis” (oral benzodiazepine) • Discuss when/where to use benzodiazepine drips • Become familiar with evidence on other agents (haldol, clonidine, barbiturates, baclofen, precedex) • Substance abuse resources for patients UNM Hospitalist Best Practices- Alcohol Withdrawal

  25. Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol WithdrawalDaeppen et al. Arch Intern Med May 27 2002 • Limitations/concerns • Results expected • 66 hours • 240mg oxazepam • Patients were NOT in alcohol withdrawal • Safety not addressed (1 seizure in symptom-triggered group) • Take home • Used to support symptom-triggered management • Sort of addresses “prophylaxis” • Only 39% of “heavy” drinkers needed oxazepam per CIWA-Ar • When do we use “prophylactic” oral benzodiazepine? UNM Hospitalist Best Practices- Alcohol Withdrawal

  26. CIWA-Arvs CAGE • NO STUDIES COMPARING CIWA-Arvs CAGE • Thank you Sarah Morley • CIWA-Ar (see handout) • Used at VA (in ER, all inpatient wards and Psych) • “Gold standard” in studies, review articles • Symptom based evaluation (8 categories with 0-7 point scale) • Vital signs taken but not part of the scoring mechanism • Starts treatment much earlier in withdrawal UNM Hospitalist Best Practices- Alcohol Withdrawal

  27. CIWA-Arvs CAGE • CAGE (see handout) • Used at UNMH • More objective measures • Pulse • Temperature • Blood pressure • Respiratory rate • Tremor • Visible mild/marked • palpable UNM Hospitalist Best Practices- Alcohol Withdrawal

  28. CIWA-Arvs CAGE • Take Home • Anyone looking for a research project? • Neither group should feel superior UNM Hospitalist Best Practices- Alcohol Withdrawal

  29. Goals • Understand the pathophysiology of alcohol withdrawal • Recognize why we use symptom triggered therapy (CAGE OR CIWA) • Discuss the role of “prophylaxis” (oral benzodiazepine) • Discuss when/where to use benzodiazepine drips • Become familiar with evidence on other agents (haldol, clonidine, barbiturates, baclofen, precedex) • Substance abuse resources for patients UNM Hospitalist Best Practices- Alcohol Withdrawal

  30. How about a benzodiazepine drip? • Alcohol withdrawal severity is decreased by symptom-oriented adjusted bolus therapy in the ICU. Spies et al. Intensive Care Med 2003 29:2230-38 • Clinical Question: Does bolus vs continuous infusion adjustment affect severity and duration of alcohol withdrawal syndrome, medication requirements and effect on ICU stay? • Confounded by use of clonidine and haloperidol in addition to flunitrazepam (Rohypnol-yes that Rohypnol) • Summarized conclusion: Bolus titrated therapy decreased severity, medication requirements and ICU stay • Limitations: • In ICU setting • Flunitrazepam is illegal in the US • Again, use of clonidine and haloperidol confounds the study UNM Hospitalist Best Practices- Alcohol Withdrawal

  31. How about a lorazepam drip? • Where can this be used at UNMH? • 5 West • No cage or lorazepam drip allowed • Q4h IV lorazepam and/or chlordiazepoxide • No written protocol-d/w Aiko (charge nurse) • 4 West (All SAC floors the same, 4 E, 7S and ED the same) • Yes (on cardiac monitor and o2 sat monitor) • Close monitoring by physician • >10mg/hour room close to RN station, 3:1 • >25 mg/hour must be transferred to ICU • Weaned by 1mg/hour UNM Hospitalist Best Practices- Alcohol Withdrawal

  32. How about a lorazepam drip? • Where can this be used at the VA? • Emergency Room, Ward 7 • Have individual protocols for treatment • 3A, 5A, 5D telemetry • Low intensity CIWA Protocol • Q4 hour oral or iv bolus therapy • Nursing driven protocol, can be initiated by Physician or Nursing based on patient history • 5D Step-Down • Low or High intensity protocols • Q2 hour evaluation • Close monitoring by physician • <20mg/hour IV drip • 5C MICU • High intensity Protocol • Q1-2 hour monitoring • >20mg/hour IV drip +/- additional medications • So, when do you use a benzodiazepine drip? UNM Hospitalist Best Practices- Alcohol Withdrawal

  33. Goals • Understand the pathophysiology of alcohol withdrawal • Recognize why we use symptom triggered therapy (CAGE OR CIWA) • Discuss the role of “prophylaxis” (oral benzodiazepine) • Discuss when/where to use benzodiazepine drips • Become familiar with evidence on other agents (haldol, clonidine, barbiturates, baclofen, precedex) • Substance abuse resources for patients UNM Hospitalist Best Practices- Alcohol Withdrawal

  34. ADJUVANT Agents • Ethanol (Enhances GABA activity) • IV Ethanol for the Treatment of Alcohol Withdrawal Syndrome in Critically Ill Patients Hodges et al. Pharmacotherapy 2004:24 (11): 1578-1585. • Review article (looked at 9 studies) • Ethanol NOT recommended for alcohol withdrawal syndrome • Few well designed clinical trials • ? Efficacy of IV ethanol • Inconsistent pharmacokinetic profile (absorption, distribution, etc) • Narrow therapeutic index (difference between minimum therapeutic and minimum toxic concentration) UNM Hospitalist Best Practices- Alcohol Withdrawal

  35. ADJUVANT Agents • Ethanol (Enhances GABA activity) • Take home • Avoid as adjuvant or first line UNM Hospitalist Best Practices- Alcohol Withdrawal

  36. ADJUVANT Agents • Baclofen (GABA receptor agonist) • Baclofen in the Treatment of Alcohol Withdrawal Syndrome: A comparative study vs diazepam. Addolorato et al. American Journal of Medicine (2006) 119, 276.e13-e18. • Clinical question: In patients with alcohol withdrawal does baclofen compared to diazepam provide efficacious, tolerable and safe treatment of alcohol withdrawal? UNM Hospitalist Best Practices- Alcohol Withdrawal

  37. ADJUVANT Agents • Baclofen • Methods • 37 patients in alcohol withdrawal (CIWA-Ar >9) • Control • 19 patients • 0.5-0.75mg/kg 6 times per day for 10 days • Tapered 25% days 7-10 • Experiment • 18 patients • 10mg Baclofen TID for 10 days UNM Hospitalist Best Practices- Alcohol Withdrawal

  38. ADJUVANT Agents • Baclofen • Results Both baclofen and diazepam significantly decreased CIWA-Ar score (p<0.0001) UNM Hospitalist Best Practices- Alcohol Withdrawal

  39. ADJUVANT Agents • Baclofen • Conclusion • “The efficacy of baclofen in treatment of uncomplicated AWS is comparable to that of the “gold standard” diazepam. These results suggest that baclofen may be considered as a new drug for treatment of uncomplicated AWS.” • Limits • Excluded DT or hallucinations • Small n • Outpatient • Not clearly placebo controlled UNM Hospitalist Best Practices- Alcohol Withdrawal

  40. ADJUVANT Agents • Baclofen • Take home points • Consider baclofen as ADJUVANT to benzodiazepine • Makes sense molecularly • Thin data to support 1st line inpatient use • Potential outpatient use • “higher quality” studies needed UNM Hospitalist Best Practices- Alcohol Withdrawal

  41. ADJUVANT Agents • Haloperidol (Dopamine 2 antagonist) • “Frequently” used at UNMH • Recommend against per Up To Date • Lower the seizure threshold • based on study from 1976 on mice • Noted in JAMA review article from 1997 also • Take home • Absolutely not to be used as single agent • Would avoid ADJUVANT use • Medical-legal reasons UNM Hospitalist Best Practices- Alcohol Withdrawal

  42. ADJUVANT Agents • Anticonvulsants (Phenobarbital, carbamazepine) • No role for seizures in alcohol withdrawal • Recommended as a first ADJUVANT by UTD • BUT combination associated with respiratory depression • Pt. should be in ICU setting • Take home • Adjuvant use is dangerous • Withdrawal seizures self limited UNM Hospitalist Best Practices- Alcohol Withdrawal

  43. ADJUVANT Agents • Clonidine (alpha 2 agonist) • May prevent minor symptoms • Not shown to prevent seizures/DT • Take home • Not to be used as monotherapy • ? Adjuvant if indicated • Opioid withdrawal • On as outpatient (rebound hypertension) • May mask worsening withdrawal (CAGE) • Antihypertensive • Reduced heart rate UNM Hospitalist Best Practices- Alcohol Withdrawal

  44. ADJUVANT Agents • Beta-Blockers (Metoprolol, atenolol, etc) • May prevent minor symptoms • Not shown to prevent seizures/DT • Take home • Not to be used as monotherapy • ? Adjuvant if indicated • CAD • On as outpatient • May mask worsening withdrawal (CAGE) • Antihypertensive • Reduced heart rate UNM Hospitalist Best Practices- Alcohol Withdrawal

  45. ADJUVANT Agents • Precedex (Dexmedetomidine) • Central alpha(2)-receptor agonist that induces a state of cooperative sedation and does not overly suppress respiratory drive • Few (but very promising) case reports of primary treatment for alcohol withdrawal which does not respond to benzodiazepine • Currently used for difficult cases at VA and UNM ICU • Does not mask neurologic-exams • Major side effect are hypotension, bradycardia and respiratory depression UNM Hospitalist Best Practices- Alcohol Withdrawal

  46. Goals • Understand the pathophysiology of alcohol withdrawal • Recognize why we use symptom triggered therapy (CAGE OR CIWA) • Discuss the role of “prophylaxis” (oral benzodiazepine) • Discuss when/where to use benzodiazepine drips • Become familiar with evidence on other agents (haldol, clonidine, barbiturates, baclofen, precedex) • Substance abuse resources for patients UNM Hospitalist Best Practices- Alcohol Withdrawal

  47. Substance Abuse ResourcesDetox is only the first step • UNMH • Social worker • RN Case Manager • Included in handout • VA • SUD walk in clinic M-F 1-4pm • Social worker • SARRTP (residential program) • Inpatient Substance Abuse consultation • 4 available Addiction boarded attendings UNM Hospitalist Best Practices- Alcohol Withdrawal

  48. Conclusion • Alcohol withdrawal occurs when GABA mediated neuro inhibition is lost • Symptom triggered therapy (CAGE OR CIWA-Ar) with a benzodiazepine is standard of care • Consider low dose cage (or equivalent) instead of oral benzodiazepine prophylaxis • Clear evidence does not exist supporting the use of benzodiazepine drip vs bolus therapy • Adjuvant therapies have limited evidence supporting their use and may be contraindicated. • Substance abuse resources for patients are readily available from your social worker UNM Hospitalist Best Practices- Alcohol Withdrawal

  49. References • Addolorate, G et al. Baclofen in the Treatment of Alcohol Withdrawal Syndrome: a comparative study vs diazepam. Amer J Med 2006 119, 276.e13-276.e18. • Daeppen JB et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002 May 27;162(10):1117-21. • Hodges B et al. Intravenous Ethanol for the Treatment of Alcohol Withdrawal Syndrome in Critically Ill Patients. Pharmacotherapy 2004: 24 (11): 1578-85. • Hoffman RS et al. Management of moderate and severe alcohol withdrawal syndromes. UpToDate. • Jaeger, TM et al. Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome in Medical Inpatients. Mayo Clinic Proceedings vol 76 (7), July 2001. pp 695-701. • Mayo-Smith MF. Pharmacological Management of Alcohol Withdrawal: a Meta-analysis and Evidence-Based Practice Guideline. JAMA vol 278 (2), 9 July 1997, p144-151. • Saitz R et al. Individualized Treatment for Alcohol Withdrawal. JAMA, Aug 17, 1994. Vol 272 no. 7. • Spies CD et al. Alcohol withdrawal severity is decreased by symptom-oriented adjusted bolus therapy in the ICU. Intensive Care Med 2003 29:2230-38. • Dave Olson, MD UNM Hospitalist Best Practices- Alcohol Withdrawal

  50. Thank you, no really. UNM Hospitalist Best Practices- Alcohol Withdrawal

More Related