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PHA333 > alcohol misuse > Flashcards

alcohol misuse Flashcards

1
Q

problems that alcohol abuse can lead to

A 
psychological - depression
accidents/trauma
physical illness
- acute pancreatitis
- liver cirrhosis
- cancer
- heart disease
criminal activity
domestic violence
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2
Q

What is 1 unit of alcohol equivalent to?

A

10ml or 8g of pure alcohol

amount that can be processed in an hour

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3
Q

alcohol recommended limits

A
  • not more than 14 units a week
  • spread over 3+ days
  • several drink-free days a week
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4
Q

How does alcohol work/cause withdrawal?

A
  • causes sedation: causes down regulation in inhibitory GABA receptors and up regulation of excitatory neurotransmitter receptors (glutamine, 5HT)
  • abruptly stopping removes sedative effect but changes in brain persist leading to withdrawal symptoms
  • time taken for brain to re-establish normal brain neurotransmission determines duration of the withdrawal
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5
Q

usual time for withdrawal symptoms to occur

A

within 6-12hrs of last drink

most severe after 48-72hrs

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6
Q

symptoms of alcohol withdrawal

A 
tremor
sweating
anxiety/irratibility
N&V
sleep disturbances
headache
confusion
seizures
death
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7
Q

assessment tools of alcohol dependence

A
  1. AUDIT - 10 Q tool
  2. AUDIT-C - quick screening tool when time limited (A&E), 3 Q
    - > only full AUDIT if AUDIT-C >5 (>3 O65)
  3. SADQ - severity of alcohol dependence
  4. CIWA-Ar - clinical institute withdrawal asssessment of alcohol scale revised - severity of WD as part of symptom triggered regimen
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8
Q

how to assess severity of alcohol dependence

A

SADQ severity of alcohol dependence questionnaire

  • assess severity of dependence (mild/mod/severe)
  • to determine need to assisted withdrawal

CIWA-Ar clinical institute withdrawal assessment of alcohol scale revised - assess severity of withdrawal as part of a symptom triggered withdrawal regimen

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9
Q

How to manage alcohol withdrawal in community?

A
  • mild/mod dependence
  • planned detoxification with psychological support
  • fixed dose medication regimen using long acting benzodiazepine
  • initial dose based on severity SADQ
  • reduce dose over 7-10 days
  • monitor pt every 2nd day, involve family/carer
  • prescribe for installment dispensing, no more than 2 days supplied
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10
Q

benzodiazepines used in community alcohol withdrawal

A

chlordiazepoxide

diazepam

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11
Q

What drug is not used in community setting?

A

clomethiazole

-> risk of overdose and misuse

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12
Q

management of alcohol withdrawal in hospital/inpatient setting

A
  • planned if community detoxification not appropriate
  • can be unplanned
  • fixed dose or symptom triggered medication regimens
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13
Q

When can unplanned hospital alcohol withdrawal occur?

A
  • admitted with illness and no access to alcohol
  • admitted in acute alcohol withdrawal
  • often don’t want to stop drinking

aim = prevent complications of withdrawal until discharged

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14
Q

symptom triggered medication regimen

A
  • patient assessed regularly using tool like CIWS-Ar
  • scores based on symptoms
  • dose of BDZ PRN
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15
Q

advantages of symptom triggered med regimen

A
  • effective treatment with lower BDZ doses and shorter duration than fixed dose regimens
  • avoid over/under sedation
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16
Q

disadvantages of symptom triggered med regimen

A
  • requires close and regular supervision (time consuming)

- required trained staff (specific wards)

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17
Q

drug used for symptom triggered med regimen

A

chlordiazepoxide (benzodiazepine)

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18
Q

eg of symptom triggered med regimen

A

chlordiazepoxide 50mg PRN according to CIWA score

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19
Q

deficiency in alcohol dependent patients and reasons

A

deficient in B vitamins

  • poor diet
  • poor absorption
  • reduced liver storage
  • increased demands
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20
Q

problems with Vit B deficiency in alcohol dependent patients

A
  • thiamine (B1) deficiency can casue Wernicke’s Encephalopathy (WE - reversible) which can progress to Korsakoff’s psychosis (irreversible)
  • neuropsychiatric maifestations of WE include nystagmus, confusion, ataxia
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21
Q

treatment for WE (Wernicke’s encephalopathy)

A

give parenteral thiamine (IV Pabrinex) for at least 5 days followed by oral thiamine

-> Pabrinex is a combination of B vitamins

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22
Q

What is the most severe form of alcohol withdrawal?

A

delerium tremens (DT)

23
Q

symptoms of delerium tremens

A

agitation
confusion
paranoia
visual and auditory hallucinations

24
Q

What is delerium tremens (DT)?

A
  • most severe form of alcohol withdrawal
  • medical emergency
  • life threatening
  • specialist inpatient management
  • severe -> critical care for sedation and ventilation
25
Q

management of DT (delerium tremens)

A
  • oral lorazepam 1st line (short acting)

- symptoms persist/declines, IV/IM lorazepam/haloperidol

26
Q

treatment for withdrawal seizures in DT (delerium tremens)

A

IV lorazepam

-> NOT phenytoin

27
Q

treatment for maintaining abstinence

A

acamprosate or naltrexone

disulfiram (2nd line)

-> with psychological interventions eg. CBT

28
Q

Acamprosate MOA

A

promotes balance between excitatory and inhibitory NTs glutamate and GABA

29
Q

Acamprosate dose

A

666mg TDS

  • reduced dose if <60kg
  • > 666mg OM, 333mg lunch and ON
30
Q

side effects of Acamprosate

A 
abdominal pain
diarrhoea
flatulence
nausea
sexual dysfunction
skin reactions

(mostly GI s/e)

31
Q

Disulfiram MOA

A

alcohol deterrent

irreversible inactivation of liver enzyme ALDH

metabolism is blocked and intracellular acetaldehyde conc rises

causes DAR - disulfiram alcohol reaction

32
Q

side effects of DAR (disulfiram alcohol reaction)

A 
flushing
inc body temp
sweating
N&V
pruritis
anxiety
dizziness
headache
blurred vision
dyspnoea
palpitations
hyperventilation

-> symptoms can be severe and life threatening

33
Q

When do DAR symptoms develop?

A

within 15mins after exposure to ethanol
peak within 30mins-1hr
gradually subsude over next few hrs

34
Q

dose of disulfiram

A

200mg daily

inc up to 500mg daily

35
Q

caution for disulfiram

A

alcohol must not be consumed 24hrs before, during treatment and for 14 days after stopping

36
Q

counselling for disulfiram

A
  • rxns after exposure to small amounts of alcohol (perfumes, aerosols)
  • aware of signs of hepatotoxicity
37
Q

progression of alcohol related liver disease

A 
healthy
steatosis (inflammation) - reversible
fibrosis
cirrhosis - irreversible
HCC (hepato cellular carcinoma)
38
Q

1st sign of achoholic liver disease

A
  • alcoholic fatty liver disease
  • build up of fats in liver
  • can develop over a few days of heavy drinking
  • symptoms rare
  • 1st sign of harmful drinking
    reversible if stop drinking (no treatment needed)
39
Q

2nd stage of alcohol liver disease

A
  • alcoholic hepatitis (build up of biliruben)
  • alcohol misuse over long period of time
  • can be reversible if stop drinking depending on severity
  • can be serious and life-threatening
40
Q

signs of alcoholic hepatitis

A

sudden onset of jaundice with/without other signs of decompensated liver disease

  • ascites
  • encepthalopathy

derrages LFTs

  • biliruben >50 micromol/L
  • raised AST and ALT (liver enzymes)
  • AST/ALT ratio >2
41
Q

signs of alcoholic hepatitis

A

sudden onset of jaundice with/without other signs of decompensated liver disease

  • ascites
  • encepthalopathy

derrages LFTs

  • biliruben >50 micromol/L
  • raised AST and ALT (liver enzymes)
42
Q

ascites

A

fluid collects in spaces in abdomen

43
Q

What assess severity of alcoholic hepatitis?

A

modified maddrey discriminant function (mDF)

44
Q

therapy for alcoholic hepetitis and when to start treatment

A

if score >32 (mDF)

corticosteroid therapy indicated

prednisolone 40mg OD 28 days then stop

no response to steroids, consider liver transplant

45
Q

When not to use steroids for alcoholic hepetitis?

A

active infection

high risk of GI bleed

46
Q

What is cirrhosis?

A

liver has significant scarring

liver become shars and stops functioning normally

chronic, not reversible

47
Q

ompensated and decompensated cirrhosis

A

compensated - liver copes with damage and maintains functions

decompensated - liver can’t function properly and complications develop

48
Q

What does cirrhosis put pt at inc risk of?

A

HCC (hepatocellular carcinoma)

49
Q

other problems with decompensated liver disease

A

coagulopathy

hepatic encephalopathy (HE)

ascites

oesophageal varices

50
Q

coagulopathy

A 
raised INR (still at risk of clots)
prolonged PT

-> IV vitamin K

51
Q

hepatic encephalopathy HE

A

caused by build up of ammonia (toxic to brain)

lactulose 20-30ml TDS
- reduces intestinal production/absorption of ammonia

rifaximin can be added/alternative if recurrent HE
- only if tried lactulose/not tolerated

52
Q

ascites

A

casued by Na and water retention due to secondary aldosteronism

spironolactone 1st line (aldosteorne antagonist) 100mg daily

can add in furosemide 40mg daily titrated up to 160mg (if spironolactone not working)

53
Q

oesophagea varices (varicose veins in oesophagus)

A

due to portal hypertension

screen for using endoscopy

can result in acute upper GI bleed (variceal ahemorrhage)

non-selective beta blockers (propranolol)
- non-selective because only want peripheral benefits not cardiac

54
Q

What is monitored for closely in decompensated liver disease?

A

AKI

  • can get renal failure
  • reduce/stop diuretics is getting worse

PHA333 (27 decks)

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