Liver Guidelines 243 Flashcards
What are the dosing regimens of chlordiazepoxide? In community? In hospital?
In community:
Fixed dose reducing regimen usually used.
In hospital:
Symptom triggered flexible regimen used. Continued assessment and monitoring carried out for 24-48 hours. This is followed by a 5- day reducing dose regimen.
What drug is used for acute alcohol withdrawal?
Chlordiazepoxide
Used to get rid of alcohol withdrawal symptoms
What is a fixed dose reducing regimen?
This involves starting treatment with a standard (high) dose, which is determined by the severity of alcohol dependence I.e how many units a day the person is drinking. This dose is then reduced down to to zero over 7–10 days according to a standard protocol.
Who can’t be treated in community for alcohol withdrawal?
People with severe dependence. (Withdrawal without supervisors in severely addicted patients may lead to seizures and death)
Patients under 18 years old with alcohol dependence.
People who are at high risk of treatment reactions or treatment failure.
What would IV lorazepam (or rectal diazepam) be used for?
Patients taking a benzodiazepine (like chlordiazepoxide) that develop SEIZURES. These are fast acting.
Then consider increasing the dose of chlordiazepoxide to prevent further seizures
Diazepam or lorazepam can also be used as a withdrawal drug instead of chlordiazepoxide.
In RUH guidelines Lorazepam is used first before chlordiazepoxide is tried if lorazepam is not available.. But only in some specialist groups of patients (eg with comorbidities)
What is a symptom triggered dosing regimen?
This involves tailoring the drug regimen according to the severity of withdrawal and any complications.
The patient is monitored on a regular basis and pharmacotherapy only continues as long as the service user is showing withdrawal symptoms.
Only done in hospital or in another care setting where monitoring can be done.
Tell me about acamprosate?
Used for alcohol dependence (NOT withdrawal), used AFTER successful withdrawal. Used for keeping the patient off drink. Stops cravings, stops relapse.
It’s should be initiated ASAP after assisted withdrawal.
It should be used in combo with psychological counselling.
Treatment should be for 1 year
Stop treatment if patient starts excessively drinking again for 4-6 weeks (it’s not worked!)
Efficacy should be regularly assessed (monthly) as it doesn’t work for everyone.
Tell me about oral naltrexone?
It is used first line as an alternative to acamprosate
It is very similar to acamprosate
Used as an adjunct treatment in treatment of alcohol dependence after successful withdrawal.
Should be supervised
Reviewed monthly for first six months
Stop if person drinks excessively for 4-6 weeks
When do you use disulfram for alcohol dependence?
When the patient has not responded to either acamprosate or naltrexone.
Again should be used in combo with counselling.
It is second line because a horrible reaction occurs if a tiny bit of alcohol is consumed whilst person on it. Extremely unpleasant for the patient
Even tiny amounts of alcohol, such as those in oral medicines and mouthwashes etc may be sufficient to give the reaction!!! These should be avoided.
Monitoring needed every 2 weeks for 2 months
Do not drink alcohol 24 hours before or after starting treatment
What is used to PREVENT Wernickes encelpalopathy?
If a patient is at risk of Wernickes I.e they’re malnourished or have weight loss, then PARABINEX 1 pair IV once a day for 3 days. After this give oral thiamine (100mg tds).
If a patient has low risk of Wernickes but is still a chronic alcohol user, still give oral thiamine supplements.
How do you treat a patient with probable Wernickes?
If someone is showing symptoms of possible/ probable Wernickes, give PARABINEX 2 pairs IV for 5 days then 1 pair for 3 days.
Then onto oral thiamine.
What is the deal with lorazepam and being used for acute alcohol withdrawal?
In the bnf it does not state acute alcohol withdrawal as an indication as it does diazepam.
The nice guidelines from 2010 say that lorazepam doesn’t have a marketing authorisation for treating alcohol withdrawal therefore written consent needs to be taken from patient if going to use it.
It CAN be used for treating seizures that occur during alcohol withdrawal, administered IV (phenytoin is ineffective for these seizures)
