Alcohol Use Disorder Flashcards
Wernicke’s Encephalopathy Triad
Delirium
Ataxia
Ophthalmoplegia and/or vertical + horizontal nystagmus
Diagnostic criteria for alcohol use disorder
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
“Severity” of AUD
Treatment of AUD
- 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)
*
Acamprosate mechanism
Stabilizes glutaminergic functioning
Disulfiram mechanism
Acetaldehyde dehydrogenase inhibitor
Causes buildup of acetaldehyde, which then causes nausea and emesis
Glucose and thiamine
If a patient is thiamine deficient, giving glucose will exacerbate the symptoms of thiamine deficiency and worsen the clinical status of the patient.
Best pharmacologic option for patients with AUD who are forgetful or cannot remember to regularly take medications
Naltrexone can be delivered as a long-acting, injectable medication, which takes this out of the equation
Alcohol withdrawal symptom timeline
Mortality rate of DTs
As high as 50%
DTs are no joke. The autonomic instability associated with them is serious.
Pattern of LFTs in alcohol use
AST:ALT ratio > 2:1
Elevated GGT in the absence of elevated AlkP
The criteria for and symptoms of alcohol withdrawal are identical to those of. . .
. . . sedative-hypnotic withdrawal
Other medical conditions that may very closely mimic alcohol withdrawal in presentation
- Hypoglycemia
- DKA
For this reason, blood glucose should be checked as part of the workup
Alcohol withdrawal is effectively a state of. . .
. . . disinhibited glutaminergic activity
Since glutaminergic activity is upregulated to balance the GABAergic activity of alcohol, when alcohol is withdrawn the glutamate takes predominance
How many drinks per day, per history, does a patient have to drink to experience withdrawal symptoms when they stop?
3-4 per day
Kindling effect
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
Are signs and symptoms enough to make a diagnosis of alcohol withdrawal?
NO
You need the history to make the diagnosis
Minor alcohol withdrawal
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!
Time range for alcoholic hallucinosis
24 hours - 6 days after last drink
Hallucinations of alcoholic hallucinosis are usually not. . .
. . . auditory
They are typically visual
If a patient has auditory hallucinations, it is more likely some other form of psychosis
Time range of delirium tremens
Starts 48-72 hours after last drink, lasts up to 14 days
Time range of alcohol withdrawal seizures
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
Can patients with delirium tremens have hallucinations due to DT?
YES
This does not mean that they have alcoholic hallucinosis
Alcoholic hallucinosis is when the hallucinations occur in the absence of full DTs
CIWA
Note: We tend to start treating withdrawal symptoms when CIWA score is 10 or greater.
CIWA > 10?
10 mg Diazepam
Banana bag contents (given along with benzo for alcohol withdrawal patients)
Thiamine
Multivitamin
Folate
