Alcohol Misuse

Question 1

What is alcohol dependence?

Answer 1

Excessive drinking over a prolonged period of time

Question 2

What is alcohol often used as?

Answer 2

A coping mechanism

Question 3

What can harmful drinking lead to?

Answer 3

• Depression
• Liver cirrhosis
• Cancer
• Heart disease
• Associated with criminal activity and domestic violence

Question 4

What is one unit of alcohol?

Answer 4

10mls/8g of pure alcohol

Question 5

How many units of alcohol are recommended per week?

Answer 5

14 units/week

Question 6

What are alcohol-dependent patients at risk of if they stop drinking suddenly?

Answer 6

Alcohol withdrawal

Question 7

What does alcohol cause?

Answer 7

Down-regulation in inhibitory GABA receptors & up-regulation of excitatory neurotransmitter receptors

Question 8

How long for symptoms to occur?

Answer 8

6-12 hrs after last drink and more severe 48-72hrs later

Question 9

What are the symptoms of alcohol withdrawal?

Answer 9

• Tremor
• Sweating
• Confusion
• Seizures
• Headache
• Death

Question 10

How do we assess alcohol dependence?

Answer 10

• AUDIT (10 qs)
• AUDIT-C (3 qs)
• SADQ > determine severity
• CIWA-AR (Clinical Institute Withdrawal Assessment of Alcohol scale revised)

Question 11

Which benzodiazepine is used 1st line in management of alcohol withdrawal?

Answer 11

Chlordiazepoxide

Question 12

How to manage alcohol withdrawal plan?

Answer 12

Community
-Planned detoxification with support in place
- Fixed-dese regiment with diazepam or chlordiazepoxide
- Monitor
- No more than 2 days medication supplied at any time
- Do not offer clomethiazole due to risk of overdose

Inpatient
- Can be planned/unplanned
- Used to prevent complications as often these patients do not want to stop drinking

Question 13

How does the CIWA-Ar tool work?

Answer 13

• Scores patients depending on their symptoms
• Triggers a dose of benzodiazepines to be administered when required

Question 14

What are the advantages and disadvantages of regimens?

Answer 14

+
Effective treatment
Avoids over/under sedation
-
Requires trained staff
Time consuming

Question 15

What are alcohol dependent patients deficient in and what happens?

Answer 15

B vitamins
Thiamin (B1) can cause Wernicke’s Encephalopathy which is reversible but can progress to Korsakoff’s psychosis which is irreversible

• Confusion, ataxia, nystagmus

Parenteral thiamine (IV pabinex) given for 5 days followed by oral thiamine

Question 16

What is the most severe form of alcohol withdrawal?

Answer 16

Delirium Tremens (DTs)

• Requires specialist management and in severe cases admission to critical care for sedation and ventilation

Question 17

How to manage DTs

Answer 17

Oral lorazepam (1st line)

If symptoms persist/patient declines treatment
Offer IV/IM lorazepam/haloperidol

Question 18

If a patient develops alcohol withdrawal seizures what should be used?

Answer 18

IV Lorazepam NOT phenytoin

Question 19

What should be used to maintain abstinence?

Answer 19

Acamprosate/oral naltrexone

2nd line: Dilsulfiram

All these with CBT

Question 20

What is the MOA of acamprosate?

Dose?

SEs?

Answer 20

Not fully known
Promotes a balance between excitatory and inhibitory neurotransmitters, glutamate and GABA

Dose of 666mg TDS, reduced if below 60kg

SEs: nausea, sexual dysfunction, skin reactions, flatulence

Question 21

What is naltrexone, the dose and monitoring requirements?

Answer 21

Opioid receptor antagonist
25mg OD if tolerated 50mg OD

Measure LFTs before & during

Only suitable if not on opioids

Question 22

What is disulfiram?

DAR symptoms?

Dose?

Counselling?

Answer 22

Alcohol deterrent
Irreversible inactivation of liver enzyme ALDH
- Mechanism of ethanol is blocked and ALDH conc rises

Flushing, increased body temp, nausea, vomiting, sweating, urticaria, headache, dizziness

Develop after 15 mins, peak at 30-60 mins and subside over next few hours

Can be severe & life-threatening

200mg daily, increased to 500mg daily

No alcohol 24hrs before or 14hrs after discontinuation

Reactions after exposure
Awareness of hepatoxicity

Question 23

What is alcohol fatty liver disease?

Answer 23

Build up of fats in liver
Can develop over a few days
Reversible if stop drinking - no treatment required

Question 24

What is alcohol hepatitis?

Answer 24

Inflammation of the liver caused by alcohol
Can be reversible if stop drinking depending on severity but can be serious & life-threatening

Question 25

What are the signs of alcohol hepatitis?

Answer 25

Sudden onset of jaundice with encephalopathy & ascites

Bilirubin > 50micromol/L
Raised AST and ALT

Question 26

What is ascites a build up of?

Answer 26

Fluid

Question 27

How is alcohol hepatitis managed?

Answer 27

Modified Maddrey discrimination function (mDF)

Score > 32 prednisolone 40mg OD for 28 days and stop

If no response, highly selected patients should be considered for liver transplant

Question 28

What is cirrhosis?

Difference between compensated and decompensated?

Answer 28

Liver has significant scarring - becomes hard & stops functioning properly

Compensation - liver copes with damage and maintains function

Decompensated - liver can’t function properly & complications develop

Increased risk of HCC (hepatocellular carcinoma)

Question 29

Coagulopathy?

Hepatic encephalopathy (HE)?

Answer 29

Raised INR and prolonged prothrombin > give IV vit K

Build up of ammonia
- Give lactulose 20-30ml TDS
- Reduces intestinal production and absorption of ammonia
- Rifaximin if recurrent HE/lactulose intolerance

Question 30

What is rifaximin?

Answer 30

Antibiotic with topical effect in the bowel but not systemic

Question 31

What is ascites and how is it treated?

Answer 31

Sodium and water retention due to secondary aldosteronism

Spironolactone 1st line usually 100mg
OR
Furosemide 40mg titrated to 160mg

Question 32

What is oesophageal varices and why does it happen?

What should be monitored?

Answer 32

Bulging blood vessels in oesophagus due to portal hypertension

Treat with propranolol
Monitor for AKI