Alcohol rehabilitation medications

Question 1

List some hepatitis DDx?

Answer 1

• Infective- viral hepatitis HBV, HCV, EBV, CMV, viral gastroenteritis
• AI- SLE, autoimmune hepatitis
• Metabolic- Wilson’s disease, heamochromatosis, alpha-1-antitrypsin deficiency
• Drugs- Isoniazid, Paracetamol, NSAIDs, Sulphonamide, Amiodarone
• Neoplastic- HCC, liver mets

Question 2

List some causes of jaundice?

Answer 2

• Pre- hepatic: haemolytic disease
• Hepatic: haemolytic disease, viral, drugs, ETOH, malignancy, abscess
• Post-hepatic: biliary obstruction (cholelithiasis, cholangiocarcinoma), pancreatic ca, drugs (antibiotics, OCP, steroids)

Question 3

What are some causes of conjugated and unconjugated hyperbilirubinaemia?

Answer 3

• High unconjugated Br- excess RBC breakdown, bruising, genetic conditions (e.g. Gilbert’s syndrome), fasting, newborn jaundice, thyroid conditions
• High conjugated Br- liver disease (cirrhosis, hepatitis), infection, medication, biliary obstruction (cholelithiasis, carcinoma, pancreatitis)

Question 4

What are some non-pharmacological treatments for alcohol dependence?

Answer 4

Non-pharmacological:
• Motivational interviewing
• Pt education
• CBT
• AA group therapy
• D&A referral

Question 5

List some medications that may be used to aid alcohol reduction?

Answer 5

• Disulfram (Antabuse)
• Acomprosate
• Naltrexone
• Topiramate
• Gabapentine

Adjunct symptomatic Rx
⇒ Paracetamol- headache
⇒ Metoclopramide, scopolamine- N/V
⇒ Loperamide- diarrhoea

Question 6

What is the MA of Disulfram?

Answer 6

MA: inhibits aldehyde dehydrogenase

• > accumulating acetaldehyde
• > ‘aldehyde reaction’ (flushing, sweating, palpitations, N/V, tachycardia, tachypnoea, headache, panic)

Good prognosis: compliance, motivated pt, physically fit, nil ETOH in 24hrs

Question 7

Describe the metabolism of ETOH?

Answer 7

1) ethanol oxidised to acetaldehyde (via alcohol dehydrogenase IB)
2) acetaldehyde to acetic acid (via aldehyde dehydrogenase 2)
3) acetic acid to acetyl-CoA (via acyl-CoA synthetase and acetyl-CoA synthase 2)

Question 8

What are the SE and CI of Disulfram?

Answer 8

• SE: headache, metalic taste, neurotoxicity
• Interactions: disrupts metabolism of paracetamol, theophylline, caffeine
• CI: intoxication, receiving preparations containing alcohol (e.g. cough syrup), paraldehyde or metronidazole

Question 9

Describe the MA of Acomprosate?

Answer 9

MA: weak NMDA receptor antagonist
-> normalises dysregulated neutrotransmission
-> reducing cravings
⇒ increasing time to first drink, increased abstinence

Question 10

What are the SE and CI of Acomprosate?

Answer 10

• SE: arrhythmia, hyper/hypotension, allergic reaction, insomnia, impotence, headache, diarrhoea
• CI: renal impairment (removed by kidneys), breast feeding

Question 11

What is the MA of Naltrexone? Name some SE and CIs?

Answer 11

• MA: mu opioid receptor antagonist
-> reduces ETOH withdrawal -> fewer cravings
• Note: can be taken with ETOH
• SE: liver damage (dose higher than therapeutic), GI issues
• CI: chronic opioid Rx, recent opioid use, acute hepatitis, liver failure

Question 12

What is the MA of Topiramate and why is it used?

Answer 12

• MA: anti-epileptic

• > enhances GABA-A mediated currents at non-Benzo sites on GABA-A receptor
• > decreased withdrawal symptoms and cravings

Question 13

What is the MA of Gabapentine and why is it used?

Answer 13

MA: anti-epileptic

• > increases GABA production -> inhibits nerve transmission
• > calms nervous activity in brain

Question 14

What is alcohol withdrawal syndrome?

Answer 14

Def: a set of symptoms that can occur following a reduction in alcohol use after a period of excessive use
• Duration: begin 6-24hrs post consumption, last 2-7 days
• MA: CNS excitation post-depressant
• Clinical:
- Mild: irritable, tremor, insomnia
- Moderate: diaphoresis, fever, disorientation
- Severe: grand mal seizures, delirium, hallucinations, temor

Question 15

How would you treat alcohol withdrawal syndrome?

Answer 15

o Include pt education, monitoring, reassurance, low-stimulus environment
o Note: most do not require medication

Medication:

• Diazepam IV
• Nutritional support (Thiamine/B1, folic acid, multivit)
• glucose
• magnesium sulfate
• metoprolol

Question 16

Describe the MA and SE of Diazepam?

Answer 16

MA: benzodiazepine

• > allosterically modifies GABA receptors -> increase activity
• > sedative effect

SE:
o STM: sedative, resp depression, dizzy, poor coordination, decreased libido, erectile dysfunction, paradoxical reaction (increased aggressiveness, suicidality- rare)
o LTM: cognitive impairment, memory formation

CI: (risk resp depression) myasthenia gravis, sleep apnoea, COPD, bronchitis, pregnancy (neonatal withdrawal syndrome) elderly (dependency, sensitivity)

Question 17

Why does the pt require nutritional support during withdrawal?

Answer 17

Nutritional support: Thiamine (Vit B1) + folic acid + multivitamins (Banana bag)

Prevent Wernicke’s encephalopathy (STM) and Korsakoff’s syndrome (LTM)

Question 18

Describe the MA and SE of magnesium sulfate?

Answer 18

• MA: regulate neuronal excitability and interferes w Ca mediated neurotransmitter release
-> increasing seizure threshold (anticonvulsant)
• Aims to reduce risk of post-withdrawal seizures

• SE: hypermagnesaemia (cardiac arrest, bradypnoea, weakness, confusion)