Management of Acute Alcohol Withdrawal Syndrome

1. Management of AcuteAlcohol Withdrawal Syndrome Todd A. May, M.D. Co-Director, Family Practice Inpatient Service San Francisco General Hospital Associate Clinical Professor University of California, San Francisco

3. Perils of AWS Management Under-treatment ? Use of restraints, dangerous situations Progression to DTs, higher mortality Over-treatment Sedation, aspiration, intubation Benzodiazepine intoxication Inappropriate BZD choice Wrong Diagnosis

4. Goals Review manifestations of AWS Assess risk and severity Optimize benzodiazepine therapy Use adjunctive therapy for delirium and agitation

5. Alcohol Withdrawal Syndrome Symptoms anxiety insomnia tremulousness headache nausea Signs tremor diaphoresis agitation tachycardia hypertension low grade fever (<38.5)

6. Withdrawal Seizures Generalized, non-focal Seizure onset < 48 hours after cessation May recur Look for other etiology if: onset > 48 hours focal seizures fever or head trauma

7. Alcohol Hallucinosis Early onset�12 to 24 hours after cessation Able to maintain clear sensorium Resolves in 24 to 48 hours

8. Delirium Tremens Onset 48 - 96 hours after cessation Usually following prolonged, heavy drinking Clouding of consciousness Delirium

9. Delirium Tremens Delirium impaired attention/concentration disorientation waxing/waning level of consciousness hallucinations � visual > tactile > auditory delusions Tremens tremor

10. If delirium persists or atypical features, consider: infection CNS event (e.g., subdural hematoma) metabolic disturbance hepatic encephalopathy Wernicke�s encephalopathy BZD intoxication Delirium Tremens

12. Assessing Risk of AWS Frequency, amount, time of last drink H/O w/d; needing meds for detox H/O seizures, hallucinosis, or DTs Concurrent substance use Comorbid illness

14. Assessing Severity of AWS Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) Reliable, validated assessment tool Brief, easy to use Score correlates with severity of w/d Good educational tool Enhances communication between staff Can guide management decisions

15. CIWA-Ar Caveats Not diagnostic Must interpret score in clinical context Co-morbid illness can confound the scoring Assessment tool Bottom line: Interpret--don�t just treat a number Work together with the nurses

16. CIWA-Ar Score 8-15 Mild Score 16-25 Moderate Score > 25 Severe

18. Management of AWS General Measures Seizure precautions with h/o Sz Hydration Thiamine 100mg IM/IV prior to glucose Correct electrolytes�Mg, Ca, K, PO4 Treat concurrent illnesses Restraints prn safety

19. Management of AWS Benzodiazepines Which drug? What route? How to treat?

20. Benzodiazepines Chlordiazepoxide (Librium�) Oral dosing only Intermediate onset Long-acting parent compound and metabolites Smoother withdrawal Potential accumulation in elderly and patients with liver disease

21. Benzodiazepines Lorazepam (Ativan�) Versatile dosing�PO, IV, IM, SL Fast to intermediate onset Intermediate half-life, no metabolites Less likely to accumulate in elderly or with liver disease

22. Benzodiazepines Chlordiazepoxide generally preferred Indications for Lorazepam Elderly Established liver disease NPO Severe w/d requiring high doses

23. Benzodiazepines Route of administration Oral preferable Ease of administration More consistent blood levels Sublingual if NPO (e.g., surgical patients) Intravenous Severe w/d requiring rapid titration or NPO

24. Benzodiazepines Dosing Options �Fixed� Regimens Traditional approach Administer BZD around the clock Additional doses prn Taper by 25% per day when stable

25. Benzodiazepines

26. Three Clinical Scenarios Risk, but no active w/d Mild-moderate w/d Severe w/d

27. Risk for Withdrawal (CIWA <8) Prophylaxis Use only if known or reported h/o w/d Select drug based on patient profile Select dosing taper based on severity of hx Observation only No prior h/o w/d or not actively drinking Severe or decompensated liver disease Order: CIWA q 6hr, call HO > 8

28. Mild-mod Withdrawal (CIWA 8-25) Symptom-triggered therapy Select drug based on patient profile �Sliding scale� strategy Select drug, not dose Reassess periodically for adequacy of symptom control and over-sedation

29. Severe Withdrawal (CIWA>25) Urgent, serious, unstable situation Abandon CIWA; goal sedation score of 3 Lorazepam IV bolus q15-30min prn Avoid Lorazepam infusion if possible Infusion management tips Haloperidol recommended

30. Management problems High dose BZD (�Ativan drips�) Problem: Agitation/delirium treated with BZD--vicious cycle; acidosis Response: Adjunctive Haloperidol Treat hallucinations and reduce agitation, when autonomic Sx are controlled with BZD

31. Haloperidol Adjunctive therapy for hallucinations, delirium, and agitation Can help control disturbing symptoms Reduce amount of Benzodiazepine required and minimize additional confusion Haloperidol 1mg IV, IM, PO q 1hr prn Generally not more than 5mg/24hr Extra pyramidal side effects, NMS

32. Summary No prophylaxis with liver dz No Chlordiazepoxide with decompensated liver dz All symptom-triggered therapy Adjunctive Haloperidol for delirium Become familiar with CIWA scale

33. Case 1 RF is a 48yo male alcoholic with a history of alcohol w/d seizures who was brought in by ambulance after a witnessed generalized, tonic-clonic seizure. His last drink was 1-2 days prior to admission. Over several hours in the ED, he received intermittent doses of Lorazepam IV and PO and Diazepam PO and IV. He was ataxic and therefore admitted to hospital. He initially was managed with Chlordiazepoxide PO with Lorazepam IV prn tremor/withdrawal. He required higher doses of benzodiazepines over the second hospital day. Later the patient was found agitated, diaphoretic, tremulous, disoriented, and actively hallucinating consistent with DTs (CIWA 30).

34. Case 2 RP is a 53yo male alcoholic with CAD s/p CABG, chronic liver disease, anemia, and thrombocytopenia who was admitted to with acute, recurrent upper GI bleeding, anemia, and chest pain. He received 4 units of PRBCs and ruled out for MI. On hospital day 2, he developed symptoms of mild alcohol w/d (CIWA 14). At that time he was alert, fully oriented, and quite appropriate. He was started on Lorazepam 2mg po 6h with additional Lorazepam IV ordered �prn.�

35. Case 2 He received no prn doses over the next 12hr. He later was examined and found with his gown raised over his chest, fidgeting with his condom catheter (no longer able to use the urinal), tremulous, fearful, mumbling to himself, with mild tactile and visual hallucinations, oriented only to self and place (CIWA 26). Upon questioning, the nurse reported giving no �prn� doses due to lack of agitation and concern about potential sedation.