Wk 26 - Alcohol misuse Flashcards
What are the consequences of harmful drinking?
- Depression
- Accidents/trauma
- Acute pancreatitis
- Liver cirrhosis
- Cancer
- Heart disease
- Criminal activity
What are the alcohol UK recommendation limits?
- No more than 14 units a week
- Over 3/more days
- Drink-free days
What are some examples of alcohol equivalents?
- 14 units = 6 pints beer = 10 small glasses of wine
- 1 unit = 10ml pure alcohol
Why does alcohol withdrawal occur?
- Alcohol sedating, cause down-regulation in inhibitory GABA receptos + up-regulation of excitatory NT receptors
- Abrupt stopping removes sedative effect but adaptive change in brain function persists
Alcohol withdrawal symptoms occur within how many hours after last alcoholic drink?
- 6-12hrs
- Most severe: 48 to 72 hrs
What are symptoms of alcohol withdrawal?
- Tremor
- Sweating
- Vom
- Sleep disturbances
- Headache
- Hallucination
- Seizures
- Death
- Delirium tremens
What is used to assess alcohol dependence?
- AUDIT (10qs alcohol harm screening tool)
- AUDIT-C (where time is more limited, 3Qs, only need to do full audit if >5 + >3 over 65)
- SADQ (assess severity of dependence + need for assisted w/drawal)
- CIWA-Ar (severity of w/drawal)
Outline what is included in community based assisted withdrawal programmes
- Planned detoxification w/ social + psychological support
- Fixed dose regimen using long acting benzodiazepine eeg. chlordiazepoxide
- Start initial dose based on severity of alcohol dependence then red to 0 over 7-10 days
- Monitor every other day
- Prescribe installment dispensing no more than 2 days
- Don’t offer clomethiazole in community due to OD + misuse
Outline what is used to manage alcohol withdrawal in inpatient setting
Planned if community detoxification not appropriate
Unplanned:
- Admitted w/ physical illness + no access to alcohol as inpatient
- Admitted in acute alcohol w/drawal
- Don’t want to stop drinking
What is symptom-triggered medication regimens?
- Patients assessed using CIWA-Ar: scores based on symptoms + triggers dose of benzodiazepine when required
- Adv: Effective treatment w/ lower benzodiazepine doses + shorter duration - avoids under/over sedation
- Disadv: requires close + regular supervision
What is used for acute alcohol withdrawal?
- Chlordiazepoxide 50mg PRN
- Give parenteral thiamine for 5 days followed by oral thiamine
Why is thiamine given to alcohol-dependant patients:
- Vit B deficient: poor diet, poor abs, red liver storage
- Cause: Wernicke’s Encephalopathy (reversible) -> Korsakoff’s psychosis (irreversible)
What are symptoms of WE?
- Nystagmus
- Confusion
- Ataxia
What is delirium tremens?
- Most severe + life threatening
- Agitation, confusion, paranoia, visual + auditory hallucination
- Can require sedation + ventilation
How is delirium tremens managed?
- Oral lorazepam
- Persist/declines treatment: IV/IM lorazepam or haloperidol
- Seizures: IV lorazepam
What is given after a successful withdrawal from moderate to severe dependence to maintain abstinence?
- Acamprosate or oral naltrexone
- 2nd line: disulfiram
- W/ CBT
What is acamprosate?
- Promotes balance btw excitatory + inhibitory NT, glutamate + GABA
- 666mg TDS
- <60kg - 66mg OM, 33mg lunch + ON
- S/e: abdo pain, di, flatulence, sexual dysfunction, skin reactions
What is disulfiram?
- Alcohol deterrent
- MOA: irreversible inactivation of liver enzyme ALDH
- Metabolism of ethanol blocked + intracellular acetaldehyde conc rises
- Causes disulfiram alcohol reactions
What is DAR?
- Flushing, sweating, vom, urticaria, dyspnoea + hyperventilation
- Develop w/in 15 mins after exposure to ethanol, peak 30-1hr
What is the dose of disulfiram + counselling points?
- 200mg daily, inc 500mg daily
- Alcohol not consumed 24hrs before, during + upto 14 days after
- Awareness of hepatotoxicity
What is alcoholic fatty liver disease?
- Builds up fat in liver
- Develop few days of heavy drinking
- No symptoms
- Reversible if stop drinking
What is alcoholic hepatitis?
- Alcohol misuse over long period
- Reversible if stop drinking
- Can be life threatening
What are the symptoms of alcoholic hepatitis?
- Onset of jaundice
- Ascites
- Encephalopathy
- Raised AST + ALT
- Bilirubin >50 micromol/L
What is the management of alcohol hepatitis?
- Modified maddrey discriminant function asses severity
- Score >32 = corticosteroid therapy
- Pred 40mg OD 28 days
- No response = liver transplant
What is cirrhosis?
- Liver has scarring, becomes hard + stops functioning
- Chronic - irreversible
- Compensated: liver copes w/ damage + maintains function
- Decompensated: can’t function properly + complications occur
- Inc risk of HCC
What is coagulopathy characterised by + how is it treated?
- Raised INR + prolonged PT
- IV vit K
What is hepatic encephalopathy characterised by + how is it treated?
- Build up of ammonia
- Lactulose 20-30ml TDS
- Rifaximin added if lactulose intolerant
What is ascites characterised by + how is it treated?
- Due to sodium + water retention due to 2ndry aldosteronism
- 1st line: spironolactone 100mg daily
- Add: furosemide 40mg daily upto 160mg
What is esophageal varices characterised by + how is it treated?
- Due to portal hypertension
- Screen using endoscopy
- Propranolol for prophylaxis
- Results in acute upper GI bleeding
- Monitor AKI
