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PHAR358 > Alcohol Use Disorder > Flashcards

Alcohol Use Disorder Flashcards

1
Q

What is the DSM-5 diagnostic criteria for AWS?

A

2 or more of the following sx following a decrease in heavy & prolonged drinking, and causing distress or impairment
-hallucinations/illusions/delirium tremens
-autonomic hyperactivity
-seizures
-anxiety
-psychomotor agitation
-insomnia
-nausea/vomiting
-tremor
HAS A PINT

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2
Q

When do the symptoms of AWS peak?

A

day 2-3

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3
Q

What is the most serious complication of alcohol withdrawal?

A

delirium tremens

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4
Q

What is delirium tremens?

A

severe confusion, disorientation, +/- hallucinations with clouding of global sensorium, + severe autonomic hyperactivity (tachy/htn/sweating/agitation/hyperthermia)
-mortality rate 5%

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5
Q

What does the typical timeline look like for delirium tremens?

A

usually begins 48-96h after last drink
lasts 1-5 days

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6
Q

Which two neurotransmitters are involved in the pathogenesis of AWS?

A

GABA and glutamate
-the balance shifts towards glutamate

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7
Q

What are the risk factors for AWS?

A

increased quantity, frequency, and duration of use
previous withdrawal
family history of alcohol withdrawal
concurrent medical conditions
consumption of sedatives/hypnotics/anxiolytics

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8
Q

What are the complications of AWS?

A

death
seizures
arrhythmias
brain damage
prolonged hospitalization
aspiration
relapse
delirium tremens

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9
Q

What is the PAWSS tool?

A

most useful screening tool for predicting patients risk of developing severe complications related to alcohol withdrawal
-10 item risk assessment
-can be done before stopping or reducing drinking to determine risk of severe AWS complications
-could be used in ER setting
-useful to help determine level monitoring and support required

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10
Q

What score on PAWSS warrants outpatient management? What about the score indicating inpatient care?

A

3 or less: low risk of complications, outpatient
4 or more: high risk of complications, inpatient

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11
Q

What is the most commonly used class of medications in AWS?

A

benzodiazepines

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12
Q

What is the role of clonidine in AWS?

A

often used in addition to benzos (not on its own)
suppresses noradrenergic sx (anxiety/htn/tachy) that do not resolve with benzos
used for “symptomatic relief”

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13
Q

What are some examples of medications that have insufficient evidence to conclude benefit/harm in AWS?

A

CBZ
gabapentin
baclofen
beta-blockers
GHB
haloperidol

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14
Q

What is the MOA of benzodiazepines?

A

bind to the BZD binding site on GABAa receptors to increase GABA binding affinity and increase inhibitory action of GABA

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15
Q

Which benzodiazepines are used for AWS?

A

lorazepam
diazepam

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16
Q

Differentiate lorazepam and diazepam.

A

lorazepam:
-onset: 30-60 min
-t1/2: 10-14h
-metabolism: inactive metabolites
-IV/IM/SC
diazepam:
-onset: 15-30 min
-t1/2: 50-100h
-metabolism: active metabolites
-IV only

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17
Q

What are the side effects of benzodiazepines?

A

common:
-sedation
-confusion
-amnesia
-psychomotor impairment
rare:
-paradoxical reactions
-falls
-respiratory depression
-pancytopenia

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18
Q

What is CIWA?

A

10-item scale used to measure the severity of alcohol withdrawal symptoms
commonly used on inpatient settings as part of “symptom triggered dosing protocols”

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19
Q

Differentiate the different scores and their severity of alcohol withdrawal for CIWA.

A

0-9: very mild or absent
10-15: mild
16-20: moderate
>21-67: severe

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20
Q

What CIWA score requires treatment?

A

10 or greater

21
Q

What are the symptoms covered by CIWA?

A
  1. nausea and vomiting
  2. tremors
  3. paroxysmal sweats
  4. anxiety
  5. agitation
  6. orientation
  7. tactile disturbances
  8. auditory disturbances
  9. visual disturbances
  10. headache
22
Q

What are supportive care measures for AWS?

A

thiamine
-prevent Wernicke-Korsakoffs syndrome, peripheral neuropathy, cardiomyopathy
multivitamin
-prevent and correct micronutrient deficiency
folate
-prevent and correct anemia
electrolyte correction
-prevent elyte imbalances and life-threatening complications
fluids
-correct hypovolemia and dehydration

23
Q

What are examples of medications used in AUD?

A

naltrexone
acamprosate
topiramate
gabapentin

24
Q

What is AUD?

A

problematic pattern of drinking with clinically significant impairment or distress

25
Q

What are the many consequences of AUD?

A

CNS:
-cognitive impairment, dementia, stroke
PNS:
-neuropathy, myopathy
psych:
-depression, anxiety, eating disorder
CV:
-cardiomyopathy, afib, arrhythmia, HTN
GI:
-alcoholic hepatitis, cirrhosis, pancreatitis
cancers:
-mouth, larynx, pharynx, esophagus
others:
-FAS, B12 deficiency

26
Q

Describe the role of genetics in AUD.

A

first degree relative –> 3-4x prevalence
twin studies suggest genetics account for 50% of risk
children of alcohol dependent ppl adopted and raised by ppl not alcohol dependent remained at increased risk
theories include polymorphisms in GABA, D4, 5HT, ADH

27
Q

Describe the transtheoretical model.

A
  1. precontemplation: no recognition/interest in change
  2. contemplation: thinking about changing
  3. preparation: planning for change
  4. action: adopting new habits
  5. maintenance: ongoing practice of new, healthier behavior
    the patient must examine pros and cons and come to a decision themselves
28
Q

What are the goals of therapy for AUD?

A

abstinence
prolong survival
decrease morbidity and SAEs
minimize ADRs
improve daily functioning and QoL

29
Q

Which populations is AUD most common in?

A

males
middle aged (30-64)
early onset of drinking < 21y
single
lower income
white or Indigenous
military combat deployment

30
Q

What are some clinical markers of AUD?

A

medical:
-MCV > 96
-elevated GGT/ALT/AST (AST:ALT > 2:1)
-HTN, GERD, DM, pancreatitis
-chronic non-cancer pain
-alcohol on breath
mental:
-cognitive impairment
-mood/anxiety/sleep disorder
-behavioral or academic change

31
Q

What are Canada’s guidelines on alcohol use?

A

0 drinks/wk: most benefit
2 drinks/wk: likely to avoid consequences
3-6 drinks/wk: increased cancer risk
7 drinks/wk: increased CV risk

32
Q

What is the AUDIT tool?

A

used for patients that are challenging to engage
-score of 8 or more is considered to indicate hazardous or harmful alcohol use

33
Q

What are the 4 C’s of addiction?

A

control (loss of)
craving
compulsions
consequences

34
Q

Who are the candidates for AUD pharmacotherapy?

A

any patient with mod-severe AUD
any patient who has undergone withdrawal management, stopped, or reduced drinking and has ongoing alcohol cravings placing them at risk of relapse

35
Q

What are the goals of AUD pharmacotherapy?

A

prevent return to any drinking or return to heavy drinking
reduce # of heavy drinking days
reduce # of drinks per drinking day

36
Q

What are the 1st line agents for AUD?

A

naltrexone
acamprosate

37
Q

What is the MOA of naltrexone?

A

mu-opioid antagonist
-blocks euphoric effects to alcohol to decrease rewarding alcohol effects & reduces cravings
-prevents lapse from becoming a relapse

38
Q

How is naltrexone started?

A

titrate slowly due to GI AE

39
Q

What should naltrexone be avoided with?

A

concurrent opioids

40
Q

What is a monitoring parameter for naltrexone?

A

LFTs at baseline, 1, 3, and 6 months

41
Q

What is the MOA of acamprosate?

A

not fully understood
-thought to restore imbalance between glutamate and GABA to reduce neuronal hyperexcitability
-prevent lapse: more effective at supporting abstinence

42
Q

When should acamprosate be avoided?

A

CrCl < 30 ml/min
-adjust if 30-50 ml/min

43
Q

What is the efficacy of acamprosate and naltrexone?

A

safe and effective for AUD
-NNT 12-20 for return to any drinking

44
Q

Describe the role of topiramate and gabapentin for AUD.

A

topiramate:
-decreases cravings by reducing DA release from EtOH
-BRAIN FOG!!
gabapentin:
-reduces unpleasant withdrawal symptoms

45
Q

What is the MOA of disulfiram?

A

inhibits aldehyde dehydrogenase to block metabolism of alcohol
-results in unpleasant AE when patient drinks alcohol

46
Q

Is disulfiram commercially available?

A

no it has to be compounded

47
Q

What is the role of disulfiram in AUD?

A

due to severity of disulfiram rxn and weak evidence of benefit it should not be recommended for tx
-specific circumstances +/- highly motivated patients

48
Q

What is a precaution of disulfiram?

A

do not start until abstained from EtOH x 12 hrs minimum

PHAR358 (14 decks)

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