Alcohol withdrawal

1. Karen Neoh Alcohol withdrawal

2. Curriculum 2.5 Management of Concurrent Clinical Problems • Management of patients with pre-existing drug dependence 2.14 Management of Emergencies in Palliative Medicine • Recognition and management of alcohol and drug withdrawal

3. 2.15 Public Health Related to Palliative Care Effect of addictive and self harming behaviours on personal health, response to palliative intervention and symptom management

4. Overview • How big is the problem? • NICE/LTHT guidance • Alcohol withdrawal • Delirium tremens • Wernicke’s encephalopathy • Assessment of alcohol intake (not just CAGE!)

5. UK - 24% of adults drink in a hazardous or harmful way • Highest in the North East, North West and Yorkshire and Humber 26–28% of men, 16–18% of women • Approximately 20% of patients admitted to hospital for illnesses unrelated to alcohol are drinking at potentially hazardous levels

6. Alcohol withdrawalSigns vary, commonly peaking at 10 to 30 hours: • Tremor • Sweating • Agitation • Irritability • Insomnia • Anorexia and nausea • Increased heart rate and BP • Fever • Anxiety

7. NICE: Alcohol-use disorders: physical complications The care of adults and young people (aged 10 years and older) who have any of the following physical health problems that are completely or partly caused by alcohol use: • Acute alcohol withdrawal • Lack of thiamine (Wernicke’s encephalopathy) • Liver disease • Pancreatitis

8. Treatment for acute alcohol withdrawal (NICE) • Consider offering a benzodiazepine or carbamazepine • Clomethiazole may be offered as an alternative

9. LTHT • Oral chlordiazepoxide is the preferred choice of benzodiazepine as it has long half life, low potency and lower potential for abuse than diazepam. • The dose should be tailored to each patient dependent upon severity of withdrawal symptoms.

10. Chlordiazepoxide BNF • Fixed dose reducing regime in primary care • Symptom triggered flexible regime in hospital or other settings usually followed by a 5 day reducing dose schedule • 10-50mg QDS reducing over 5-7 days • 10-40mg PRN for the first 2 days • Max 250mg/day • Gradually reduce over 7-10days

11. LTHT

12. LTHT - Patients with liver failure • Chlordiazepoxide and diazepam should be avoided as these drugs are metabolised by the liver and can accumulate. • Lorazepam should be used as an alternative. 500 micrograms- 1mg orally every 6 hours to a maximum of 8mg/24 hours. • Contact liver team for advice.

13. LTHT – if unable to take oral treatment • Diazepam 10mg slow IV repeated after 4 hours if necessary • Lorazepam 1mg-2mg IV repeated after 6 hours if necessary • If IV access is a problem rectal diazepam (as solution, not suppositories), 500 micrograms/kg (up to a max of 30mg) • If PO/IV/PR not possible, IM but erratic absorption • If patient remains agitated contact senior member of team or liason psychiatry.

14. Carbamazepine • Unlicensed for alcohol withdrawal but can be used as an alternative if benzodiazepines are contraindicated or not tolerated • 800mg PO in divided doses, reduce gradually over 5 days to 200mg OD • Usual treatment duration 7-10 days

15. Clomethiazole • Licensed for use in acute alcohol withdrawal, benzodiazepines are preferred. Inpatient setting and abstinent. • Dose 2-4 capsules, can be repeated after some hours. Each capsule 192mg. • Day 1: 9-12 capsules in 3-4 divided doses • Day 2: 6-8 capsules in 3-4 divided doses • Day 3: 4-6 capsules in 3-4 divided doses • Gradually reduce over 4-6 days and treatment not for more than 9 days

16. Clomethiazole (chlormethiazole) • Heminevrin brand name • Sedative/hypnotic • Used for agitation, restlessness, short-term insomnia • Good in the elderly as no hangover but can lead to dependence • Alcohol combined with clomethiazole, particularly in alcoholics with cirrhosis, can lead to fatal respiratory depression even with short-term use

17. Delirium tremens • The symptoms/signs differ from usual withdrawal in that there are signs of altered mental status. • Hallucinations (auditory, visual, or olfactory) • Confusion • Delusions • Severe agitation

18. Management of delirium tremens (NICE) • Oral lorazepamfirst-line • If symptoms persist/oral medication declined, give parenteral lorazepam, haloperidol or olanzapine • If DT develops in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen

19. Management of alcohol withdrawal seizures (NICE) • Quick-acting benzodiazepine (lorazepam) to reduce the likelihood of further seizures • If alcohol withdrawal seizures develop in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen • Do not offer phenytoin to treat alcohol withdrawal seizures

20. Wernicke's encephalopathy (NICE)ataxia, opthalmoplegia, confusion • Offer thiamine to people at high risk of developing, or with suspected, Wernicke's encephalopathy. • Offer prophylactic oral thiamine to harmful or dependent drinkers: • if they are malnourished or at risk of malnourishment or • if they have decompensated liver disease or • if they are in acute withdrawal or • before and during a planned medically assisted alcohol withdrawal.

21. Thiamine • Mild deficiency 25-100mg OD PO • Severe deficiency 200-300mg/day PO in divided doses

22. Treatment of Wernicke’s • IV high potency 2-3 pairs daily for 2 days • If no response stop • If improves IV/IM high potency 1 pair daily for 5 days or as long as improvement continues

23. NICE guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. A clinical guideline covering identification, assessment, pharmacological and psychological/psychosocial interventions, and the prevention and management of neuropsychiatric complications.

24. Assessment tools • AUDIT – identification/outcome measure • SADQ (Severity of Alcohol Dependence Questionnaire ) or LDQ (Leeds Dependence Questionnaire) - severity of dependence

25. CIWA (Clinical Institute Withdrawal Assessment) - severity of withdrawal • APQ (Alcohol Problems Questionnaire) for the nature and extent of the problems arising from alcohol misuse.

26. Alcohol Use Disorders Identification Test (AUDIT) 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have six or more drinks on one occasion? 4. How often during the last year have you found that you almost were not able to stop drinking daily once you had started? 5. How often during the last year have you failed to do what was normally expected of daily you because of drinking? 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? 9. Have you or someone else been injured because of your drinking? 10.Has a relative, friend, doctor, other health care worker been concerned about your drinking last year last year

27. AUDIT-C (shortened form) • The AUDIT-C uses the first 3 questions only. • Using a cutoff of ≥3, AUDIT-C identifies 90% of patients with active alcohol abuse or dependence and 98% of patients with heavy drinking • A score of ≥3 on the AUDIT-C or a report of drinking 6 or more drinks on one occasion ever in the last year, should lead to a more detailed assessment of drinking problems (completion of the full questionnaire)

28. Thank you

29. References • publications.nice.org.uk/alcohol-use-disorders-diagnosis-and-clinical-management-of-alcohol-related-physical-complications-cg100/introduction • www.nice.org.uk/nicemedia/live/13337/53194/53194.pdf • LTHT. The management of alcohol withdrawal symptoms. Sarah Skitt (Lead medical Admissions Pharmacist) and Dr Michael Mansfield(Consultant Physician) • Joint Formulary Committee. British National Formulary. [64] ed. London: BMJ Group and Pharmaceutical Press; [2012]