Management of acute and chronic LD Flashcards
What are some of the lifestyle modifications that are advised in early staged LD/Cirrhosis?
Avoid alcohol
Quit smoking
Lose weight if you’re overweight or obese
Do regular exercise to reduce muscle loss
Liver damage due to alcohol is reversible and therefore any patient presenting with some indicators of early stage fatty liver, should be advised to avoid alcohol. All recommendations can help to reduce chances of further complications and at any stage of liver disease.
Which liver diseases are curable?
Most aren’t however gallstones (which can be removed) and some viral infections can be. Therefore the main aim of management is to ease symptoms and reduce the risk of further complications.
Outline the main management strategies in cirrhosis and end stage LD.
Having a low protein diet due to the potential for waste products to build up causing hepatic encephalopathy.
Promoting a low Na+ diet and patients may be initiated on diuretics to reduce fluid retention
Patients may undergo ascites drainage by paracentesis
Surgery for the treatment of portal hypertension and to minimise the bleed risk
Introduction of medicines in the treatment of the disease and presence of complications
Potentially a liver transplant
At which time scale do each of the symptoms associated with acute alcohol withdrawal occur?
Minor symptoms resulting as a consequence of CNS hyperactivity, resolves within 24-48 hours
Depending on the extent of alcohol intake this can lead to:
Seizures which occur with 12-48 hours of the last drink in chronic alcoholics
If this is left untreated this will lead to delirium tremens which occur 48-96 hours after the last drink and if untreated can be fatal
Alcoholic hallucinations which resolve within 24-48 hours
Also results in fluid and electrolyte abnormalities
What are some of the symptoms you would expect to see in CNS hyperactivity?
Insomnia
GI upset
Mild anxiety
Tremulousness
Headache
Diaphoresis (excessive sweating)
Palpitations
What are some of the symptoms of Delirium tremens?
Hallucinations
Disorientation
Tachycardia
Hypertension
Hyperthermia
Agitation
Diaphoresis
What is the main treatment of acute alcohol withdrawal?
Symptom control by use of benzodiazepines which controls psychomotor agitation and prevent worsening.
Supportive care is also a key aspect of the management of acute alcohol withdrawal
What is the CIWA-Ar and when is it used?
It stands for Clinical Institute Withdrawal
Assessment – Alcohol, revised and is essentially is a questionnaire that helps professionals determine the severity of a patient’s alcohol withdrawal to help guide appropriate management and improve patient outcomes.
It consists of a number of symptoms which on patient assessment which can be scored based on severity, producing an overall total CIWA score.
What do the different CIWA scores mean?
7 or below: minimal to mild withdrawal
8-15: moderate withdrawal
16 or more: severe withdrawal (impending delirium tremens)
What is the SADQ and when is it used?
SADQ stands for the severity of alcohol dependency questionnaire it essentially a questionnaire a patient fills in with a number of questions with rated answers to calculate their overall alcohol dependency.
According to NNUH guidelines:
Never is rated 0
Sometimes 1
Often 3
Nearly always 4
What do the different SADQ scores mean?
- Scores between 1-9 indicates low dependence
- Scores between 10-19 indicates medium dependence and;
- A score of 20 or more indicates high dependence
What are the two types of regimens that guide benzodiazepine dosing in acute alcohol withdrawal?
There is a fixed standard regime whereas dosing of benzodiazepines is gradually reduced over about 10 days according to the hospital policy.
However where specially trained staff are available to monitor the patient a symptom triggered regime may be used which involves frequent assessment of the clinical Institute Withdrawal Assessment of Alcohol Scale – CIWA-Ar of the severity of the patients withdrawal to guide dosing of benzodiazepines.
When is a symptom triggered approach favoured?
In hepatic impairment a symptom triggered regimen is more appropriate to encourage regular monitoring of signs of accumulation and titrating the dose accordingly. Or in other conditions where there is risk of accumulation.
What is a rough dosing regimen for Chlordiazepoxide?
Dosing is based on severity of withdrawal.
According to NNUH guidelines:
The dose should be estimated by initial assessment of predicted withdrawal intensity based on current level of use and previous experience of withdrawal; and will usually be in the range of 20-40 mg QDS.
PRN chlordiazepoxide (10-20mg QDS) should also be available.
What is a rough dosing regimen for Oxazepam?
In mild withdrawal:
20-10mg QDS reduced over about 7 days
In moderate withdrawal:
30-10mg QDS reduced over about 7 days
In severe withdrawal:
40-10mg QDS reduced over about 9-10 days
Additional when required Oxazepam 10-20mg QDS MUST also be prescribed
Which benzodiazepines are recommended for treatment of acute alcohol withdrawal?
Chlordiazepoxide and Oxazepam
Why are longer acting benzodiazepines used preferentially to short acting benzodiazepines for acute alcohol withdrawal?
The longer acting benzodiazepine has been shown to be more effective than short-acting ones in: preventing seizures and delirium, allowing smoother withdrawal with less rebound, and are less prone to abuse.
What is the first line benzodiazepine used?
Chlordiazepoxide is the first line benzodiazepine recommended for the management of acute alcohol withdrawal.
It has been shown to have a more gradual onset of psychotropic effects, is perhaps less toxic in overdose, and has less potential for misuse (compared with diazepam).
In which circumstances would Oxazepam be used preferentially?
Oxazepam has a shorter half life and therefore should be used in patients at risk of toxic accumulation of the benzodiazepine such as in the elderly or when there is significant liver damage.
What is a dosing consideration to make regarding benzodiazepines?
Lowest possible dose to relieve symptoms without causing sedation due to increased risk of hepatic encephalopathy.
Why aren’t patients normally sent home on the reducing dose of benzodiazepines?
Ideally the patient is not sent home still on the reducing dose of benzodiazepines due to the risk of causing respiratory depression (especially when taken with alcohol) as well as dependence.
The only times patients may be sent home is when there is support available in the local community for them to be able to do so safely.
What is the appropriate management of alcohol withdrawal seizures?
If alcohol withdrawal seizures occur, a fast-acting benzodiazepine (such as lorazepam [unlicensed indication]) should be prescribed to reduce the likelihood of further seizures.
If alcohol withdrawal seizures develop in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen
What other supportive medications could be prescribed in acute alcohol withdrawal?
Nutritional supplements
IV fluids
What causes cholestatic pruritis?
Cholestatic pruritis is caused by deposition and accumulation of bile salts in tissues causing itching and discomfort. In patients with liver disease there are marked elevations in serum bile salts levels due to the inability of hepatocytes to remove bile acids from portal blood or due to portosystemic shunting by which the bile acids bypass hepatocyte and remain in circulation.
What type of LD is cholestatic pruritis associated with?
Cholestatic liver disease
What is the appropriate management of cholestatic pruritis?
Firstly identify and treat the underlying cause of the cholestasis.
First line Cholestyramine which is an ion exchange resin, binding to bile acids in the gut preventing their absorption, the dose:
4–8 g once daily
Non-sedating antihistamines may help such as Cetirizine and Loratadine
Calamine lotion or menthol in aqueous cream may also provide a cooling effect and relieve of irritation
