Alcohol Use Disorder Flashcards
what is the DSM-5 criteria for alcohol withdrawal syndrome?
2 or more of the following symptoms after a decrease in heavy and prolonged drinking and causing distress or impairment
HAS A PINT
Hallucinations/illusions/delirium tremens
Autonomic hyperactivity (sweats, HR >100)
Seizures
Anxiety
Psychomotor agitation
Insomnia
Nausea/vomiting
Tremor of the hand
when do symptoms of AWS start and how long does it last?
can appear as early as 4-12 hours after last drink, usually around 6-24h
peak on day 2-3, improved by day 5
may continue at low levels for 3-6 months
when is seizure risk at the highest in AWS?
first 72 hours
when is the peak of AWS?
day 2-3
what is the mortality rate of delirium tremens?
5%
what is delirium tremens?
severe confusion, disorientation, +/- hallucinations with clouding of global sensorium (decrease LOC) + severe autonomic hyperactivity (tachycardia, HTN, hyperthermia, agitation, sweating)
what is the most serious complication of AWS?
delirium tremens
how long does delirium tremens last for?
1-5 days
what 2 neurotransmitters are key to the pathogenesis of AWS?
GABA and glutamate
what does acute alcohol intoxication do to NT balance?
increases inhibitory effects of GABA and suppresses excitatory effect of glutamate
what does chronic and regular alcohol use to do NT balance? what are the consequences then in withdrawal?
brain develops tolerance and GABA receptors become less sensitive (downregulation) and glutamate receptors become more sensitive (upregulation), so that when alcohol is consumed, there is less overall suppression of the CNS
abrupt withdrawal of alcohol: downregulated GABA system cannot compensate for the rapid increase in glutamate activity resulting in a state of CNS hyper-excitation
what are risk factors for AWS?
increase quantity, frequency and duration of alcohol use
previous alcohol withdrawal
family history of alcohol withdrawals
concurrent medical conditions
consumption of sedatives/hypnotics/anxiolytics
what are complications of AWS?
death
brain damage
prolonged hospitalisation
delirium tremens
seizures
arrhythmias
aspiration
relapse
what scale is used to predict the risk of severe symptoms of AWS?
prediction of alcohol withdrawal severity scale (PAWSS)
what is the interpretation of PAWSS score?
a score of 3 or less indicates low risk and outpatient management is suitable
a score of 4 or more indicates a patient might be at high risk for developing complications of alcohol withdrawal and should be admitted to an inpatient setting
what is the first line treatment for AWS?
benzodiazepines: lorazepam or diazepam
when is clonidine used in AWS?
in addition to benzos
what is the role of clonidine in AWS?
suppress noradrenergic symptoms (anxiety, HTN, tachycardia) that do not resolve with benzos
used for symptomatic relief
what is the dosing of clonidine in AWS?
0.1-0.3 mg TID x 5d
what are other treatments (other than benzos/clonidine) that can be used for AWS?
carbamazepine
gabapentin
baclofen
beta-blockers
haloperidol
GHB
what is the MOA for benzos in AWS?
bind to BZD binding sites on GABA-A receptors to increase GABA binding affinity and increase the inhibitory action of GABA
what scale is used to asses the severity of AWS?
clinical institute withdrawal assessment for alcohol (CIWA)
what CIWA score constitutes treatment?
10 or more
what is the max CIWA score?
67
what are some things that are used in supportive care in AWS?
thiamine
folate
multivitamin
electrolyte correction
fluids
why is thiamine used in AWS?
to prevent Wenicke-Korsakoff’s syndrome, peripheral neuropathy, and cardiomyopathy
what are some consequences of AUD?
cognitive impairment, dementia, stroke
neuropathy, myopathy
depression, anxiety, eating disorders
cardiomyopathy, afib, arrhythmias, HTN
alcoholic hepatitis, cirrhosis, pancreatitis
mouth, esophagus, pharynx and larynx cancer
fetal alcohol spectrum disorders
vitamin B12 deficiency
what is the definition of alcohol use disorder?
problematic pattern of drinking with clinically significant impairment or distress
what is the transtheoretical model?
assess an individuals readiness to act on a new healthier behaviour, and provides strategies, or processes of change to guide the individual through the stages of change to action and maintenance
precontemplation –> contemplation –> preparation –> action –> maintenance
what are some medical markers of AUD?
MCV >96
elevated GGT, AST, ALT (especially AST:ALT >2:1)
GERD, HTN, diabetes, pancreatitis
chronic non-cancer pain
alcohol on breath
what are some mental markers of AUD?
cognitive impairment or decline
mood, anxiety, sleep disorder
significant behavioural or academic change
what are the 4 C’s of addiction?
loss of control
consequences
compulsions
cravings
who is a candidate for AUD treatment?
any patient with moderate-severe AUD
any patient who has undergone withdrawal management, stopped, or reduced drinking and has ongoing alcohol cravings placing them at risk of relapse
what is the MOA of naltrexone?
mu opioid antagonist
blocks euphoric effects to alcohol to decrease rewarding alcohol effects and reduces cravings
“prevents lapse from becoming a relapse”
what is the dosing of naltrexone?
start at 12.5 mg daily and increase by 12.5 mg every 4 days to target of 50 mg
what needs to be monitored with naltrexone therapy?
LFTs at baseline, 1, 3 and 6 months
what is the MOA of acamprosate?
not fully understood
though to restore imbalance between glutamate and GABA to reduce general neuronal hyperexcitability
“prevents lapse - more effective at supporting abstinence”
what is the dosing of acamprosate?
666 mg TID
333 mg TID if renal impairment, CrCl 30-50 mL/min
what is a CI of acamprosate?
CrCl </= 30 mL/min
how does topiramate work in AUD?
decreases cravings by reducing DA release when ETOH consumed
how does gabapentin work in AUD?
reduces unpleasant withdrawal symptoms
which treatment of AUD is a deterrent?
disulfram
what is the MOA of disulfram?
aversive agent that inhibits alcohol dehydrogenase enzyme and blocks the metabolism of alcohol
results in unpleasant s/e if patient drinks alcohol
what is the dosing of disulfram?
initial: 500 mg Od x1-2 weeks
maintenance: 250 mg OD
when should disulfram NOT be used
must be abstained from alcohol for at least 12 hours
