Alcohol Dependence Flashcards
In a GP setting, what regimen should be used for assisted alcohol withdrawal?
Fixed-dose reducing regimens.
Use a standard initial dose, determined by the severity of alcohol dependence, or level of alcohol consumption, followed by dose reduction to zero, usually over 7-10 days.
In an inpatient or residential setting, what regimen should be used for assisted alcohol withdrawal?
A fixed-dose regimen or a symptom-triggered regimen can be used. A symptom-triggered approach involves tailoring the drug regimen according to the severity of withdrawal and any complications in an individual patient; adequate monitoring facilities should be available.
Which long acting benzodiazepines are recommended to attenuate alcohol withdrawal symptoms in MODERATE dependence?
Chlordiazepoxide hydrochloride
- 10-30 mg 4 times a day
- Dose reduction over 5-7 days
- Oral
or
Diazepam
- 10 mg, then 10 mg after at least 4 hrs if required
- IV into a large vein
Which long acting benzodiazepine are recommended to attenuate alcohol withdrawal symptoms in SEVERE dependence?
Chlordiazepoxide hydrochloride
- 10-50 mg 4 times a day
- 10-40 mg as required for 1st 2 days
- Dose reduced over 7-10 days
- Max 250 mg per day
What the contraindications for Chlordiazepoxide hydrochloride?
- Chronic psychosis
- Respiratory depression
What the contraindications for all benzodiazepines?
- Acute pulmonary insufficiency
- Marked neuromuscular resp weakness
- Obsessional states
- Phobic states
- Sleep apnoea syndrome
- Unstable myasthenia gravis
What are the most common side effects for Benzodiazepines?
Alertness decreased Anxiety Ataxia (more common in elderly Depression Dizziness Drowsiness Dysarthria Hypotension Altered mood Muscle weakness Respiratory depression Tremor Sleep disorders
What cautions should be taken for benzodiazepines?
Pregnancy:
- High doses administered during late pregnancy or labour may cause neonatal hypothermia, hypotonia, and respiratory depression.
- Present in milk, should be avoided
Reduce dose in:
- Debilitated patients
- Elderly
Hx of alcohol dependance
Hx of drug dependance
Myasthenia gravis
Personality disorder
Respiratory disease
What drug can be used as an alternative treatment in acute alcohol withdrawal?
Carbamazepine
- 800 mg initially in divided doses initially, then:
- 200 mg daily for usual treatment duration of 7-10 days
- Dose reduced gradually over 5 days
What drug can be used as an alternative treatment in acute alcohol withdrawal for carbamazepine or a benzodiazepine?
Clomethiazole
- 2-4 capsules to be repeated if necessary after some hours
- 9-12 capsules daily in 3-4 divided doses on day 1
- 6-8 capsules daily in 3-4 divided doses on day 2
- 4-6 capsules daily in 3-4 divided doses on day 3
Dose then to be gradually reduced over days 4-6
Total duration of treatment for no more than 9 days
What are the contraindications of Clomethiazole?
Acute pulmonary insufficiency
Alcohol dependent patients who continue to drink (cause fatal respiratory depression even with short term use)
What drug should be used if alcohol withdrawal seizures occur which would reduce the likelihood of further seizures?
Lorazepam
- 4 mg for 1 dose
- 4 mg after 10 minutes if required
- Slow IV injection
What characterises Delirium tremens?
Agitation
Confusion
Paranoia
Visual and auditory hallucinations
What is the first line treatment of delirium tremens?
Oral Lorazepam
- Unlicensed
If symptoms persist:
Paraenteral Lorazepam
- Unlicensed
or
Haloperidol
- Unlicensed
In harmful drinkers or patients with mild alcohol dependence, what treatment should be offered before pharmacological treatment?
Psychological interventions e.g. CBD
In harmful drinkers or patients with mild alcohol dependence, what pharmacological treatment can be used?
Acamprosate calcium
or
Oral Naltrexone hydrochloride
(Opioid receptor antagonist)
What are the cautions and side effects of acamprosate calcium?
Cautions:
- Risk of treatment failure
- Severe hepatic failure
Side effects:
- Abdominal pain
- Diarrhoes
- Flatulence
- Nausea
- Sexual dysfunction
- Skin reactions
- Vomiting
What are the cautions and side effects of Naltraxone hydrochloride?
Caution:
- Concomitant use of opioids
Side effects:
- Abdominal pain
- Chest pain
- Dizziness
- Eye disorder
- Hyperhidrosis
- Altered mood
- Palpitations
- Sexual dysfunction
- Tachycardia
What treatment regimen should be used for relapse prevention in patients with moderate to severe alcohol dependance after successful withdrawal?
Acamprosate calcium
or
Oral Naltrexone hydrochloride
with
Psychological intervention
What drug can be used as an alternative to acamprosate and naltrexone hydrochloride?
Disulfiram
What drug is recommended in for the reduction of alcohol consumption in patients with alcohol dependence who have a high drinking risk level, without physical withdrawal symptoms?
Nalmefene
- 18 mg daily if required, taken on each day there is a risk of drinking alcohol
Contraindications of Nalmefene?
- Acute withdrawal syndrome
- Recent or current opioid use
Cautions and Side effects of Nalmefene?
Cautions:
- Treatment for >1 year
- Hx of seizure disorders
- Psychiatric illness
Side effects:
- Confusion
- Hyperhidrosis
- Libido decreased
- Muscle spasms
- Palpitations
- Decreased weight
What should a patient with chronic alcohol-related pancreatitis be given?
Nutritional support
What should a patient who have symptoms of steatorrhoea or who have poor nutritional status due to Exocrine pancreatic insufficiency be prescribed?
Pancreatic enzyme supplements
- Not indicated when pain is the only symptom
What should be given when a patient is suspected of Wernicke’s encephalopathy?
Paraenteral thiamine followed by oral thiamine
Harmful or dependent drinkers should be given this prophylactically.
