Alcohol Withdrawal

Question 1

When does minor withdrawal kick in?

Answer 1

5-10 hours after last drink

Question 2

Symptoms of minor withdrawal

Answer 2

Autonomic hyperactivity: tremulousness, hyperhidrosis, tachycardia, HTN, GI upset, anxiety, insomnia, vivid dreams, diaphoresis, HA, palpitations, anorexia

Question 3

When does minor withdrawal usually resolve?

Answer 3

24-48 hours

Question 4

When does major withdrawal kick in?

Answer 4

12-72 hours after last drink

Question 5

Symptoms of major withdrawal

Answer 5

Hallucinations, seizures

Question 6

When does alcoholic hallucinosis occur?

Answer 6

Major withdrawal, usually 12-24 hours after last drink

Question 7

When does alcoholic hallucinosis resolve?

Answer 7

24-48 hours

Question 8

When do withdrawal seizures occur?

Answer 8

Major withdrawal, within 48 hours after last drink

Question 9

What kind of seizures are withdrawal seizures?

Answer 9

Generalized tonic-clonic

Question 10

When does delirium tremems occur?

Answer 10

48-96 hours- it’s a medical emergency!!!

Question 11

Hallmarks of delirium tremens

Answer 11

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

Question 12

Mortality risk from delirium tremens is greater in what populations/disease states?

Answer 12

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)

Question 13

True or false: ethanol withdrawal is clinically more serious than heroin withdrawal

Answer 13

True

Question 14

Treatment of ethanol withdrawal (like an ER setting)

Answer 14

Thiamine 50-100mg QD- ADMINISTER FIRST!
D5W, 1/2 NS
Multivitamin
Standing orders for clonidine and a benzo

Question 15

Alcohol withdrawal monitoring

Answer 15

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

Question 16

Symptom triggered regimens

Answer 16

Administer one of the following every hour when the CIWA-Ar ≥8-10:

Diazepam 10-20mg
Lorazepam 2-4mg

Question 17

Fixed schedule regimens

Answer 17

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!

Question 18

Maintenance of sobriety

Answer 18

GROUP SUPPORT!!
Disulfiram, naltrexone, acamprosate

Question 19

Disulfiram MoA

Answer 19

Inhibits aldehyde dehydrogenase to build up acetaldehyde and punishes the patient for drinking cuz they feel like doo doo

Question 20

Disulfiram dosing

Answer 20

500mg PO QD x1-2wks, then 250mg PO QD

MDD is 500mg

Question 21

Drugs that can precipitate a disulfiram reaction

Answer 21

Nitroimidazoles (metronidazole)
First generation sulfonylureas (tolbutamide)
Cephalosporins that have an N-methylthio-tetrazole moiety (cefoperazone, cefotetan)
Griseofulvin

Question 22

CNS ADEs of disulfiram

Answer 22

drowsiness, HA, fatigue, polyneuritis, psychosis

Question 23

Dermatologic ADEs of disulfiram

Answer 23

rash, acneiform eruptions, allergic dermatitis

Question 24

GI ADEs of disulfiram

Answer 24

metallic/garlic-like taste

Question 25

Genitourinary ADE of disulfiram

Answer 25

impotence

Question 26

Hepatic ADEs of disulfiram

Answer 26

hepatitis, hepatitis failure

Question 27

Neuromuscular and skeletal ADEs of disulfiram

Answer 27

peripheral neuritis and neuropathy

Question 28

Ocular ADE of disulfiram

Answer 28

optic neuritis

Question 29

Use disulfiram with caution in these disease states:

Answer 29

DM, hepatic impairment, hypothyroidism, nephritis, seizures

Question 30

Naltrexone MoA

Answer 30

Acts as a competitive antagonist as opioid receptor sites (mu receptors especially)

Question 31

Naltrexone dosing

Answer 31

50mg PO QD or 380mg IM q4w

Question 32

Acamprosate MoA

Answer 32

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

Question 33

Acamprosate dosing

Answer 33

666mg PO TID, 333mg PO TID in renal failure (<30ml/min)

Question 34

When should acamprosate be initiated?

Answer 34

ASAP following period of alcohol withdrawal when the patient has achieved abstinence

Question 35

When should you not use naltrexone?

Answer 35

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