Alcohol Withdrawal Flashcards
When does minor withdrawal kick in?
5-10 hours after last drink
Symptoms of minor withdrawal
Autonomic hyperactivity: tremulousness, hyperhidrosis, tachycardia, HTN, GI upset, anxiety, insomnia, vivid dreams, diaphoresis, HA, palpitations, anorexia
When does minor withdrawal usually resolve?
24-48 hours
When does major withdrawal kick in?
12-72 hours after last drink
Symptoms of major withdrawal
Hallucinations, seizures
When does alcoholic hallucinosis occur?
Major withdrawal, usually 12-24 hours after last drink
When does alcoholic hallucinosis resolve?
24-48 hours
When do withdrawal seizures occur?
Major withdrawal, within 48 hours after last drink
What kind of seizures are withdrawal seizures?
Generalized tonic-clonic
When does delirium tremems occur?
48-96 hours- it’s a medical emergency!!!
Hallmarks of delirium tremens
Hallucinations
Disorientation
Tachycardia
HTN
Low grade fever
Agitation
Diaphoresis
Elevated cardiac indices, oxygen delivery, and oxygen consumption
Hyperventilation and respiratory alkalosis → reduced cerebral blood flow
Sensorium clouding
Mortality risk from delirium tremens is greater in what populations/disease states?
Elderly
Concomitant COPD (smokers)
Core body temperature >104º
Co-existing liver disease (cirrhosis)
Death is usually due to arrhythmia or secondary complications (pneumonia, liver failure)
True or false: ethanol withdrawal is clinically more serious than heroin withdrawal
True
Treatment of ethanol withdrawal (like an ER setting)
Thiamine 50-100mg QD- ADMINISTER FIRST!
D5W, 1/2 NS
Multivitamin
Standing orders for clonidine and a benzo
Alcohol withdrawal monitoring
Use the CIWA-Ar scoring system until score has been <8-10 for 24 hours q4-8h
Score <8-10: benzo may not be needed
Score 8-15: may need a benzo
Score ≥15: significant risk of major complications if left untreated
Symptom triggered regimens
Administer one of the following every hour when the CIWA-Ar ≥8-10:
Diazepam 10-20mg
Lorazepam 2-4mg
Fixed schedule regimens
Diazepam 10mg q4h x4, then 5mg q6h x8
Lorazepam 2mg q4h x4, then 1mg q6h x8
Other benzos can be used but no short-acting benzos!
Maintenance of sobriety
GROUP SUPPORT!!
Disulfiram, naltrexone, acamprosate
Disulfiram MoA
Inhibits aldehyde dehydrogenase to build up acetaldehyde and punishes the patient for drinking cuz they feel like doo doo
Disulfiram dosing
500mg PO QD x1-2wks, then 250mg PO QD
MDD is 500mg
Drugs that can precipitate a disulfiram reaction
Nitroimidazoles (metronidazole)
First generation sulfonylureas (tolbutamide)
Cephalosporins that have an N-methylthio-tetrazole moiety (cefoperazone, cefotetan)
Griseofulvin
CNS ADEs of disulfiram
drowsiness, HA, fatigue, polyneuritis, psychosis
Dermatologic ADEs of disulfiram
rash, acneiform eruptions, allergic dermatitis
GI ADEs of disulfiram
metallic/garlic-like taste
Genitourinary ADE of disulfiram
impotence
Hepatic ADEs of disulfiram
hepatitis, hepatitis failure
Neuromuscular and skeletal ADEs of disulfiram
peripheral neuritis and neuropathy
Ocular ADE of disulfiram
optic neuritis
Use disulfiram with caution in these disease states:
DM, hepatic impairment, hypothyroidism, nephritis, seizures
Naltrexone MoA
Acts as a competitive antagonist as opioid receptor sites (mu receptors especially)
Naltrexone dosing
50mg PO QD or 380mg IM q4w
Acamprosate MoA
Structurally similar to GABA; decreases the activity of the GABA-ergic system and decreases activity of glutamate within the CNS, including a decrease in activity at N-methyl D-aspartate (NMDA) receptors; may also affect CNS calcium channels
Acamprosate dosing
666mg PO TID, 333mg PO TID in renal failure (<30ml/min)
When should acamprosate be initiated?
ASAP following period of alcohol withdrawal when the patient has achieved abstinence
When should you not use naltrexone?
If the patient is on opiate therapy for something else- using the opiate and naltrexone at the same time won’t make the opiate effective
