GP - Alcohol Dependency Flashcards
What are the symptoms of alcohol withdrawal?
- Symptoms start at 6-12 hours:
- Headache
- Tremor
- Nausea
- Sweating
- Anxiety
- Tachycardia
- Breathing difficulties
- Seizure peak incidence at 36 hrs
- Peak incidence of delirium tremens at 48-72 hrs - this can last as long as 5 days and has high mortality:
- Coarse tremor
- Tachycardia and HTN
- Fever
- Insomnia
- Confusion
- Fluctuating motor activity (from hyperexcitabiltiy to lethargy)
- Delusions
- Auditory / visual hallucinations
What is the mechanism of alcohol withdrawal?
- 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)
What medications are 1st line for alcohol withdrawal?
1st line = benzodiazepines e.g. chlordiazepoxide
- Lorazepam - may be preferrable in hepatic failure
-
Carbamazepine - also effective in withdrawal
- Anticonvulsant
- Uses: 1st line for partial seizures, neuropathic pain, bipolar disorder
What condition can be caused by thiamine deficiency and who is this condition most commonly seen in?
Wernicke’s encephalopathy
- Commonly seen in alcoholics
-
Triad:
- Opthalmoplegia / nystagmus
- Ataxia
- Confusion
Investigations:
- ↓ red cell transketolase (↓ by thiamine deficiency)
- MRI
Treatment:
- Thiamine replacement e.g. straight thiamine or Pabrinex (injection containing vitamin C and B i.e. thiamine)
- Folic acid supplement
Complications:
- If not treated, pt may develop Korsakoff syndrome as well
What is Korsakoff syndrome?
Neuropsychiatric condition often caused by failure to treat Wernicke’s encephalopathy
- Associated with:
- Wernicke’s encaphalopathy triad: ophthalmoplegia / nystagmus, ataxia and confusion
- Anterograde + retrograde amnesia - immediate memory intact, but short-term is diminished
- Confabulations
What are the criteria for dependence syndrome?
e.g. alcohol
ICD-10 criteria
Require:
-
3 of the following either …
- present together at some point during the previous year OR
- constantly for 1 month
- Strong craving / compulsion to take substance
- Lost control of substance use - difficulty controlling substance-taking behaviour in terms of its onset, termination, or levels of use
- Tolerance
- Physiological withdrawal state when substance is stopped/reduced
- Neglect of other pleasures/interests because of substance use,↑ time for obtaining, taking or recovering from substance
- Persistant use of substance despite evidence of harmful effects
Another characteristic feature (not part of ICD-10) is narrowing of repertoire i.e. tendency to use the same substance, in the same way, on weekdays and weekends, regardless of social constraints.
What medication might be given to deter a patient from drinking alcohol e.g. trying to achieve abstinence but concerned about relapse?
Disulfiram
- Produces an acute sensitivity to alcohol i.e. symptoms of hangover are felt immediately with only a small amount of alcohol
- MoA: inhibits acetaldehyde dehydrogenase enzyme
- Need to avoid all sources of alcohol (can induce a reaction):
- Aftershave / perfume
- Mouthwashes
- Some vinegars
Name 2 drugs which might be given to reduce alcohol craving?
Acamprosate and Naltrexone / Nalmefene
-
Naltrexone / Nalmefene:
- Opioid antagonists
- Naltrexone can also be used for opiod dependence
What tool can be used to guage alcohol withdrawal severity + guide therapy?
CIWA-Ar
(Clinical Institute Withdrawal Assessment for Alcohol, revised)
- 10 questions
- Score (max = 67):
- ≤8 = absent or minimal withdrawal
- 9-19 = mild to moderate withdrawal
- ≥20 = severe withdrawal
-
Benzodiazepines - used to control psychomotor agitation + prevent progression to more severe withdrawal
- Chlordiazepoxide (Librium)
- Lorazepam (Ativan)
- Diazepam (Valium)
What kind of tremor does alcohol withdrawl present with?
Alcohol withdrawal tremors vary depending on severity of withdrawal and the patient in question
Features:
- Bilateral
- Intention tremor (+ resting tremor if withdrawal is severe)
- Fine –> coarse (worse with severity and duration of withdrawal)
Which 2 vitamins/minerals are most likely to be required as supplements during alcohol withdrawl?
Thiamine (B1)
and
Folic acid (B9)
- Alcohol consumption –> folate deficiency (due to reduced folate absorption and increased excretion in urine)
What tool can be used to screen for alcohol dependence?
CAGE questionnaire (4-questions):
- C - Have you felt the need to cut down on your drinking?
- A - Have you ever felt annoyed by someone criticising your drinking?
- G - Have you ever felt bad or guilty about your drinking?
- E - Have you ever had an eye-opener - a drink first thing in the morning to steady your nerves?
≥2 = positive-screen
(studies show >90% sensitivity for screening for alcohol disorders)
What are the issues with the CAGE questionnaire?
- CAGE is a screening tool and NOT for diagnosis
- Fails to detect binge drinking
- Fails to distinguish between active & past drinking problem
- Not as sensitive for mild-moderate alcohol withdrawal as other tools
In patients with alcohol dependence / withdrawal - where do detoxification regimes (form of treatment) occur?
It depends on severity of alcohol consumption / Hx of withdrawal symptoms!
- Mild alcohol dependency –> home detox without medication
- Moderate (e.g. > 20 units/day) or prior withdrawal symptoms –> home with medication (e.g. chlordiazepoxide)
- Severe –> specialist community clinic / hospital detox
How long does it take to get through alcohol withdrawal?
Worst of the symptoms occur in the first 48-72 hrs
Recovery from withdrawal can take up to 1-week
