Alcohol Withdrawal Flashcards
Pathophysiology of alcohol withdrawal.
Chronic alcohol use enhances GABAergic inhibition and inhibits glutamatergic excitatory pathways.
Adaptation: over time the brain compensates by downregulating GABA receptors and upregulating NMDA/glutamate receptors to maintain balance.
Alcohol cessation leads to sudden loss of GABAergic inhibition and unopposed glutamatergic excitaiton.
Risk factors for alcohol withdrawal.
High alcohol consumption (>8 units/day (men) or >6 units/day (women)).
Sudden cessation or reduction.
Previous history of alcohol withdrawal.
Duration of alcohol misuse: longer duration=higher risk.
Coexisting medical conditions: liver disease, electrolyte imbalance, malnutrition e.t.c.
Concurrent drug use.
A 50-year-old man is admitted following a binge-drinking episode. He is currently medically stable but is know to be an alcoholic.
Why do you need to keep him in hospital i.e. what are you worried about? What clinical test might you want to perform?
He is at risk of alcohol withdrawal.
The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) should be used because it takes only a minute or two to administer, the scale can be used as frequently (i.e., every 1-2 hours).
What is the purpose of the CIWA score?
To gauge the severity of alcohol withdrawal — to determine how much intervention to give. Prevents overmedicalising.
What percentage of individuals with alcohol dependence experience withdrawal symptoms?
Approx. 50%.
What are the mild symptoms of alcohol withdrawal and when do they typically appear?
Mild symptoms include
- tremors, anxiety, restlessness,
- sweating, tachycardia,
- nausea, vomiting, headache, and insomnia.
They typically appear 6–12 hours after the last drink.
Why do alcoholics develop thiamine deficiency?
Thiamine is poorly absorbed in the presence of alcohol and alcoholics tend to have poor diets and rely on the alcohol for their calories.
What is the triad of Wernicke’s encephalopathy?
Ataxia (imbalance), ophthalmoplegia (impaired eye movement), confusion
Complication of Wernicke’s encephalopathy.
Korsakoff’s syndrome.
Irreversible brain damage causing anterograde amnesia and confabulation (fabrigated/distorted memory)
What is the most important and severe symptom of alcohol withdrawal that is tried to be prevented?
Occurs 24–48 hours post-cessation, when withdrawal starts.
Seizures (generalised tonic-clonic).
What is delirium tremens and when does it typically occur?
Delirium tremens is a severe form of alcohol withdrawal characterized by confusion, disorientation, hallucinations, severe autonomic instability, agitation, diaphoresis, and coarse tremor.
It typically occurs 48–72 hours post-cessation.
Fist-line pharmacological management of alcohol withdrawal.
First-line: benzo (e.g., chlordiazepoxide or diazepam).
Chlordiazepoxide is commonly used for symptom control. Prescribe a reducing regimen (e.g., over 5-7 days).
If Patient has seizures: short-acting benzo, such as lorazepam.
Delirium tremens: First-line: oral lorazepam, second-line: parenteral lorazepam or haloperidol.
If a patient has significant liver impairment, use short-acting benzos rather than long-acting benzos.
When are short-acting benzodiazepines preferred in alcohol withdrawal?
And give one example of a drug.
Significant liver impairment.
Delirium tremens.
Lorazepam.
What are some complications of alcohol withdrawal?
List 4, starting from most severe.
- Seizures,
- Delirium tremens,
- Wernicke’s encephalopathy (B1 def),
- electrolyte imbalances,
- dehydration, and
- malnutrition.
Alcoholic hallucinosis vs delirium tremens.
Develops about 12-24 hrs after cessation, and can last for days. It involves auditory and visual hallucinations. It typically has a sudden onset. Patients may have insight. AH is much less severe compared to DT.
