EXAM 4 Alcohol Use disorder Dr. Flores Flashcards
How long does alcohol withdrawal last?
3-5 days
it peaks after 1-2 days
What are the alcohol withdrawal symptoms?
6-12hr: Flu-like symptoms: headache, and more
12-24hr: Hallucinations
24-48hr: Withdrawal seizures
48-96hr: Delirium tremens
Hyperthermia
-also seen Wernicke’s encephalopathy (confusion state, eye movement changes, and loss of movement control)
-Korsakoff’s psychosis: memory loss, learning deficits -> from one or more episodes of Wernicke’s
How is Alcohol withdrawal treated?
Alcohol withdrawal is life-threatening because of the Delirium and Hypothermia
-patients die from autonomic and CNS hyperactivity
-Benzodiazepine is the standard of care
When should a patient be treated inpatient for withdrawal of alcohol/BZD?
-unable to stop drinking alcohol/taking BZD
-failed prior attempts of withdrawal
-pregnant
-can’t tolerate oral meds (need IV)
-psychiatric conditions (suicide)
-seizure disorder, head injury, epilepsy
-CV disease, liver disease, renal impairment, COPD
-using multiple substances or concurrent withdrawal from multiple substances
-severe withdrawal symptoms in the past (seizure, delirium)
-at risk for severe withdrawal symptoms (CIWA >19)
-lack of housing, transportation or social support
When does an outpatient consider to be switch to inpatient?
-when they develop severe tremor or agitation that doesn’t get better with multiple doses of meds
-severe symptoms: hallucination, seizures, confusion
-unstable vital signs
-over sedation if they use alcohol again
What is the screening tool PAWSS used for?
predicting alcohol withdrawal severity
> 4 indicates high risk for moderate to severe withdrawal
What is the screening tool CIWA-Ar used for?
assess withdrawal severity and guide ongoing treatment
-done every 1-2 hr -> adjust treatment based on the score
score over 10 -> need medication for withdrawal
>15 (severe withdrawal) = increased risk for seizures and delirium tremens
>35: consider transfer to critical care, since a high dose of BZD is needed to control symptoms; respiratory distress risk
max score is 67
What is the treatment approach for outpatient treatment?
fixed scheduled and daily reassessment
for inpatient, it is a more symptom-triggered approach -> symptoms occur -> check CIWA score and use the Benzo based on the score
Which benzos are preferred?
long-acting Benzos: more consistent coverage and less rebound
-Chlordiazepoxide
-Diazepam
consider short-acting and without metabolites for patients with liver impairment and elderly (oversedation)
-Lorazepam
-Oxazepam
all are effective
Which benzo should be used in an acute situation (risk for seizure or delirium tremens)?
Diazepam
bc it crosses the BBB quickly
Which dose is used for Hallucinations and Delirium tremens in an inpatient setting?
Hallucination: 5 mg IV and again after 30 minutes if needed
Delirium tremens: 5-10 mg IV q 5 minutes until calm but awake (max dose = 40mg)
What is the role of Phenobarbital in alcohol/BZD withdrawal?
-when patients have contraindications for BZD, or are at risk for severe and complicated withdrawal
-can be added to the Benzo
-monitor respiration depression and sedation and may check blood levels for safe use (narrow therapeutic window)
-patients may need inturbation/mechanical ventilation
-CYP2B6, 2C9, 3A4 inducer
When is Phenobarbital contraindicated?
-caution/contraindicated in advanced cirrhosis (due to CYP metabolism and therapeutic index?)
-contraindicated in pregnancy
How is Phenobarbital dosed?
!!!
Standard dose: 10mg/kg (range 6-16 mg/kg)
use IBW or actual BW, whichever is lower
How to administer Phenobarbital
with a loading dose
-use a lower dose in patients with decompensated cirrhosis, risk of respiratory compromise, or if they have received a significant amount of BZD before the Phenobarbital
-IV is preferred, may use IM or oral when IV is not available (split in multiple doses)
-need to taper due to long half-life
What other anticonvulsant adjuncts may be used?
Anticonvulsant:
Gabapentin: 1200mg/day in divided doses taper over 4-6 days (outpatient)
Carbamazepine: 800mg/day in divided doses, taper over 5-9 days
->BZD failure or multiple substance withdrawal
Role of Antipsychotics
less likely to use
-may be used for agitation, disturbed thinking or perceptual disturbance
-CAUTION: it lowers the seizure threshold and has EPS risk (Parkinson-like)
-do NOT use if 2 or more risk factors for Qtc prolongation: female, MI, sepsis, left ventricular dysfunction, using other Qtc prolongation drugs, age over 68, baseline Qtc over 450 ms, hypokalemia
-must do daily ECG/EKG
Which supplement is required for any patient on withdrawal treatment?
Preventive vitamins
-NS
-Multivitamin
-Thiamine (has to be given before dextrose, a cofactor for carb metabolism, would end up in Wernicke encephalitis)
-Folic acid
inpatient Thiamine dose: 200 mg IV then 200 mg PO BID
convert IV to PO once the nausea has improved and they can take it
Outpatient Preventive MVI dose
-Daily po multivitamin
-Folic acid 1mg po daily
-Thiamine 100mg po daily
Why is folic acid part of the “banana bag”?
to prevent megaloblastic or macrocytic folic acid deficiency anemia
Which fluids may be given after a banana bag in an inpatient setting?
D5 1/2 NS with 20 mEq KCl per liter at 50-100 ml/h (based on weight and hydration status)
-dextrose only after the first dose of thiamine
Which drug may be used for hypertension in alcohol withdrawal treatment?
-clonidine 0.1-0.3 mg PO PRN
-systolic >160 or diastolic >100
-may use labetalol or home meds
What is the screening tool SBIRT used for?
-to identify, triage, and initiate care for patients with risky alcohol use
Screening
-> Prescreening: decide if they qualify
->Screening: to determine the severity
Brief intervention: awareness and motivation for behavioral change
Treatment referral: for higher risk pateints
Which tool is used for Prescreening?
Singe Question Screen for At-Risk drinking (question for men or women)
-if they answer 1 or more with YES -> Positive
-> move on with AUDIT screening
What is the bigger screening tool?
AUDIT: Alcohol Use Identification Test
screens for hazardous or harmful alcohol use
-assesses alcohol consumption, drinking behavior, and alcohol-related problems
Low risk: 0-3
Risky: 4-9
Harmful: 10-13
Severe: 14+
Brief Intervention
-create awareness
define low-risk drinking and show them where their current risk is
-assess their willingness to change (ruler)
Which treatment approach has shown the greatest benefit in the COMBINE study?
naltrexone with behavioral intervention
-it opened the door to advanced outpatient alcohol use disorder for many healthcare providers
Drug choice in alcohol use disorder
-ER injectable Naltrexone
-Naltrexone
-Acamprosate
-Disulfiram
-Topiramate
-Gabapentin
Naltrexone dosing
Vivitrol (injectable): 380 mg gluteal IM every 4 weeks
->preferred
Depade, ReVia: 50 mg PO 1x day OR 100-150 mg 3x a week
-mu-antagonist: reducing the rewarding effect
-reduces binge drinking and the number of drinking days
When is Naltrexone contraindicated?
-when they have used opioids in the past 7-14 days
-opioid pain treatment will be difficult because the Naltrexone levels (antagonist)
ADE:
nausea, low energy
Role and dosing of Acamprosate
2nd line
666 mg PO 3x day (2x 333 mg per dose -> 1x 333 mg 3x a day if renal impaired)
-reduces the risk of any drinking and increases abstinence duration !!!
-may be used in those who can’t use naltrexone or need opioid treatment
-acceptable in patients with liver disease!
-most effective immediately after the withdrawal period
When might Disulfiram be used?
when patients have the GOAL of complete abstinence
the only drug that CAN NOT be used if they continue to drink
ADE:
metallic taste, headache
-it is hepatotoxic
When is Disulfiram contraindicated?
alcohol use or metronidazole use
-severe MI, coronary occlusion -> it has MI, heart failure, cardiac arrhythmia side effect
-psychoses
-DDI: metronidazole, warfarin, isoniazid, phenytoin, alcohol
What is the Role of Topiramate in alcohol withdrawal treatment?
-NMDA antagonist, increases GABA activity
-NOT FDA-approved
-reduces heavy drinking
-for patients who have seizures (treat seizures too), can’t tolerate naltrexone, or need to use opioids
-need titration and taper!
What is the Role of Gabapentin in alcohol withdrawal treatment?
-consider if the patient has neuropathic pain, insomnia, intolerance to naltrexone or acamprosate
-need titration and taper!
Which drug should be used in hepatic-impaired patients?
Acamprosate
Renal-impaired patients
-dose-adjust Acamprosate
-Topiramate
-Gabapentin
Adolescent patients
treat aggressively
-Naltrexone scheduled + PRN
Older adults
Naltrexone preferred
avoid Disulfram
Pregnant women
Behavioral intervention
-naltrexone and acamprosate are C
-avoid disulfiram
Bipolar disorder
Valproic acid may add Lithium
Depression
SSRI
Which meds are contraindicated in AUD?
-meds with Disulfiram reaction: metronidazole
-meds with addiction risk: opioids, skeletal muscle relaxant, BZD (except for withdrawal treatment)
-CNS depressants: 1st gen antihistamines, non benzo hypnotics, Mirtazapine, TCAs
CAUTION with:
Tramadol, Dextrmorphan, Pregabalin, Gabapentin
-Antidepressant, Antipsychotics
-high dose Tylenol
-narrow therapeutic agents (warfarin, antiepileptic, digoxin)
