Alcohol withdrawal

Question 1

• Alcohol withdrawal mechanism

Answer 1

• chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
• alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Question 2

Alcohol withdrawal symptoms

Answer 2

• symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
• peak incidence of seizures at 36 hours
• peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 3

• Peak incidence of seizures in hours for alcohol withdrawal

Answer 3

36 hours

Question 4

Peak incidence of delirium tremens in hours for alcohol withdrawal

Answer 4

48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 5

Start of symptoms in hours for alcohol withdrawal

Answer 5

6-12 hours
tremor, sweating, tachycardia, anxiety

Question 6

Alcohol withdrawal management

Answer 6

• patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
• first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
• carbamazepine also effective in treatment of alcohol withdrawal
• phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
• Ensure adequate hydration with fluids
• Provide Anti-emetics to manage nausea
• Pabrinex to replenish vitamins
• Refer the patient to local drug and alcohol liaison teams for further support and management

When patients present with seizures, sometimes they remain in hospital for inpatient detoxification. This is however rare and the evidence shows that community detoxification is more effective.

Question 7

scale that can be used to assess alcohol withdrawal severity

Answer 7

The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale can be used to assess alcohol withdrawal severity

Question 8

which medication is used as a DETERRANT to prevent alcohol relapse

Answer 8

Disulfiram (also known as Antabuse) is an irreversible inhibitor of acetaldehyde dehydrogenase. This inhibition causes the buildup of acetaldehyde.

The build-up of acetaldehyde within twenty to thirty minutes of alcohol consumption results in unpleasant symptoms, including facial flushing and nausea and vomiting. The reaction can be life-threatening, so disulfiram is not recommended for patients with underlying frailty, neurological, cardiac or hepatic conditions.

Disulfiram is taken once daily and its effects last seven days, working as a deterrent to prevent alcohol relapse

Question 9

which medication can be prescribed as “anti craving” for preventing alcohol relapse

Answer 9

Acamprosate (or Campral) is taken three times a day and has shown to be effective in preventing alcohol relapse in combination with psychological support following detoxification in alcohol dependence syndrome.

It is typically described as an ‘anti-craving’ medication and the underlying mechanism of action remains unclear.

Acamprosate has a minimal side-effect and risk profile and is safe in combination with alcohol.

Question 10

Korsakoff’s syndrome features and cause

Answer 10

Overview
marked memory disorder often seen in alcoholics
thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus
in often follows on from untreated Wernicke’s encephalopathy

Features
anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation

Question 11

why is pabrinex prescribed?

Answer 11

Pabrinex (1 pair of ampoules once daily) to prevent Wernicke’s encephalopathy. In the presence of Wernicke’s encephalopathy symptoms, two pairs of ampoules TDS should be prescribed.

Question 12

what is prescribed for patients with alcohol withdrawal seizures?

Answer 12

Rapid-acting benzodiazepines (such as intravenous lorazepam) for patients with alcohol-withdrawal seizures.

Question 13

first line treatment for delirium tremens

Answer 13

Oral lorazepam as the first-line treatment for delirium tremens, with parenteral lorazepam/diazepam offered if oral treatment is declined or symptoms persist.

Question 14

indications for inpatient withdrawal treatment

Answer 14

• Patients drinking >30 units per day
• Scoring over 30 on the SADQ score
• High risk of alcohol withdrawal seizures (previous alcohol withdrawal seizures or delirium tremens, or history of epilepsy)
• Concurrent withdrawal from benzodiazepines
• Significant medical or psychiatric comorbidity
• Vulnerable patients
• Patients under 18

Question 15

investigations in alcohol withdrawal

Answer 15

• AUDIT and SADQ questionnaires to assess the severity of alcohol misuse.
• Blood tests to assess liver function and electrolyte balance.
• Neuroimaging may be considered in cases of persistent confusion or seizures.

Question 16

The differential diagnosis for alcohol withdrawal may include:

Answer 16

• Benzodiazepine withdrawal: Similar symptoms to alcohol withdrawal, but may also include perceptual changes, depersonalization, derealization, hypersensitivity to light and sound, and numbness/tingling in extremities.
• Drug-induced delirium: Characterised by fluctuating mental status, inattention, and a disturbed sleep-wake cycle.
• Other conditions causing delirium: Infections, metabolic disturbances, and CNS disorders can all cause symptoms similar to alcohol withdrawal.

Question 17

Assisted alcohol withdrawal for patients drinking over…or scoring over… on the … questionnaire.

Answer 17

Assisted alcohol withdrawal for patients drinking over 15 units per day or scoring over 20 on the AUDIT questionnaire.

Question 18

What can be used to treat agitation and hallucinations in addition to benzos in alcohol withdrawal?

Answer 18

haloperidol