Alcohol Use Disorder

Question 1

Wernicke’s Encephalopathy Triad

Answer 1

Delirium

Ataxia

Ophthalmoplegia and/or vertical + horizontal nystagmus

Question 2

Diagnostic criteria for alcohol use disorder

Answer 2

Within a 12 month period, 2 or more are present:

• Alcohol taken in larger amounts or over a longer time than intended
• Inability to reduce consumption despite desire to do so
• Great deal of time spent obtaining, using, recovering from alcohol
• Craving alcohol
• Recurrent use resulting in failure to fulfill major obligations
• Continued use despite persistent or recurrent social/interpersonal problems
• Important social, occupational, recreational activities given up or reduced due to alcohol use
• Alcohol use continued despite knowledge that it causes or worsens physical or psychological problems
• Tolerance for alcohol
• Withdrawal symptoms

Question 3

“Severity” of AUD

Answer 3

Question 4

Treatment of AUD

Answer 4

• 12 step programs are the first line therapy treatment
• Pharmacotherapy (for those with moderate to severe AUD):
  
  • Naltrexone is first-line
  • Acamprosate is second-line
  • Third line is either topiramate, gabapentin, or disulfiram (antabuse)
    *

Question 5

Acamprosate mechanism

Answer 5

Stabilizes glutaminergic functioning

Question 6

Disulfiram mechanism

Answer 6

Acetaldehyde dehydrogenase inhibitor

Causes buildup of acetaldehyde, which then causes nausea and emesis

Question 7

Glucose and thiamine

Answer 7

If a patient is thiamine deficient, giving glucose will exacerbate the symptoms of thiamine deficiency and worsen the clinical status of the patient.

Question 8

Best pharmacologic option for patients with AUD who are forgetful or cannot remember to regularly take medications

Answer 8

Naltrexone can be delivered as a long-acting, injectable medication, which takes this out of the equation

Question 9

Alcohol withdrawal symptom timeline

Answer 9

Question 10

Mortality rate of DTs

Answer 10

As high as 50%

DTs are no joke. The autonomic instability associated with them is serious.

Question 11

Pattern of LFTs in alcohol use

Answer 11

AST:ALT ratio > 2:1

Elevated GGT in the absence of elevated AlkP

Question 12

The criteria for and symptoms of alcohol withdrawal are identical to those of. . .

Answer 12

. . . sedative-hypnotic withdrawal

Question 13

Other medical conditions that may very closely mimic alcohol withdrawal in presentation

Answer 13

• Hypoglycemia
• DKA

For this reason, blood glucose should be checked as part of the workup

Question 14

Alcohol withdrawal is effectively a state of. . .

Answer 14

. . . disinhibited glutaminergic activity

Since glutaminergic activity is upregulated to balance the GABAergic activity of alcohol, when alcohol is withdrawn the glutamate takes predominance

Question 15

How many drinks per day, per history, does a patient have to drink to experience withdrawal symptoms when they stop?

Answer 15

3-4 per day

Question 16

Kindling effect

Answer 16

The more a patient experiences withdrawal, the more likely that are to experience withdrawal subsequently

Additionally, the more likely they are to have a seizure

Question 17

Are signs and symptoms enough to make a diagnosis of alcohol withdrawal?

Answer 17

NO

You need the history to make the diagnosis

Question 18

Minor alcohol withdrawal

Answer 18

Starts ~6 hours after cessation, lasts 24-48 hours.

Tremors, GI upset, headache, diaphoresis, anxiety

Note that tremors occur here too, but the patient is not delirious!

Question 19

Time range for alcoholic hallucinosis

Answer 19

24 hours - 6 days after last drink

Question 20

Hallucinations of alcoholic hallucinosis are usually not. . .

Answer 20

. . . auditory

They are typically visual

If a patient has auditory hallucinations, it is more likely some other form of psychosis

Question 21

Time range of delirium tremens

Answer 21

Starts 48-72 hours after last drink, lasts up to 14 days

Question 22

Time range of alcohol withdrawal seizures

Answer 22

6 hours - 48 hours

Note how early this is in the withdrawal course, when other withdrawal symptoms are just starting to set in

Typically these are tonic-clonic seizures

Question 23

Can patients with delirium tremens have hallucinations due to DT?

Answer 23

YES

This does not mean that they have alcoholic hallucinosis

Alcoholic hallucinosis is when the hallucinations occur in the absence of full DTs

Question 24

CIWA

Answer 24

Note: We tend to start treating withdrawal symptoms when CIWA score is 10 or greater.

Question 25

CIWA > 10?

Answer 25

10 mg Diazepam

Question 26

Banana bag contents (given along with benzo for alcohol withdrawal patients)

Answer 26

Thiamine

Multivitamin

Folate