Alcohol Withdrawal
The most common treatment for alcohol withdrawal is what? How is it administered?
Benzodiazepines (administered either orally or parenterally)
Question 6: Hallucinations with intact orientation occurs: A Immediately B 6 to 8 hours C 8 to 12 hours D 12 to 24 hours E 24 to 72 hours
C 8 to 12 hours Withdrawal symptoms usually, but not always, occur in stages: tremulousness or jitteriness (6-8 hours), psychosis and perceptual symptoms (8-12 hours), seizures (12-24 hours), and DTs (24-72 hours, up to 1 week). Of note, alcoholic hallucinosis occurs earlier than hallucinations associated with delirium tremens, and are not usually associated with a clouded sensorium or abnormal vital signs.
Question 3: An elderly woman presents to the emergency department due to a hip fracture. She reports that she "hasn't been feeling very well" recently, and is vague and hard to pin down regarding details. You think that there might be the odor of alcohol on her breath and suspect alcohol use disorder. Which of the following findings would be most supportive of your concern? A A healed scar from a previous fall several years ago B Microcytic anemia C Elevated gamma-glutamyl transpeptidase D Slightly elevated aspartate aminotransferase (AST), with normal alanine aminotransferase (ALT) E Mini-mental state examination score of 28/30
C Elevated gamma-glutamyl transpeptidase Laboratory tests in alcoholics commonly show macrocytic anemia and elevated liver transaminase levels-particularly gamma-glutamyl transpeptidase.
Give the diagnostic criteria for alcohol withdrawal.
Cessation of or reduction in heavy, prolonged, alcohol use. Two or more of the following develop within hours to days: • Autonomic hyperactivity • Hand tremor • Insomnia • Nausea or vomiting • Transient hallucinations • Agitation • Anxiety • Seizures The symptoms cause distress or impairment in functioning. The symptoms are not due to a general medical condition or to another mental disorder.
What scale may be useful in standardizing the assessment of withdrawal severity and assist in guiding treatment?
Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar)
What actions will point to the correct diagnosis when considering a differential diagnosis?
A carefully recorded history, a physical examination, and laboratory results indicative of long-term, heavy alcohol use (eg, evidence of cirrhosis or liver failure, macrocytic anemia, elevated liver transaminase levels-particularly gamma-glutamyl transpeptidase) will point to the correct diagnosis.
What is a sympathomimetic?
A substance that mimics at least some adrenaline or catecholamine responses. Examples of sympathomimetic substances include caffeine, ephedrine, and amphetamines.
Question 7: Withdrawal seizures occur: A Immediately B 6 to 8 hours C 8 to 12 hours D 12 to 24 hours E 24 to 72 hours
D 12 to 24 hours Withdrawal symptoms usually, but not always, occur in stages: tremulousness or jitteriness (6-8 hours), psychosis and perceptual symptoms (8-12 hours), seizures (12-24 hours), and DTs (24-72 hours, up to 1 week).
Question 2: A 54-year-old man is admitted to the hospital for elective surgery. He has been through alcohol rehabilitation, but has continued to struggle with his drinking. He alerts the primary service taking care of him that he has continued to drink up to the time of his admission. In what time frame after cessation of all drinking is he at most risk for delirium tremens? A 6 to 8 hours B 8 to 12 hours C 12 to 24 hours D 48 to 96 hours E Over 1 week
D 48 to 96 hours Withdrawal symptoms usually, but not always, occur in stages: tremulousness or jitteriness (6-8 hours), psychosis and perceptual symptoms (8-12 hours), seizures (12-24 hours), and DTs (24-72 hours, up to 1 week).
Aside from benzodiazepines, which other drug class may be useful in treating a patient going through alcohol withdrawal?
Anticonvulsants such as carbamazepine and valproic acid are also effective in treating alcohol withdrawal, although it is a much less popular option in the United States given familiarity with treatment with benzodiazepines.
Question 8: Tremulousness occurs: A Immediately B 6 to 8 hours C 8 to 12 hours D 12 to 24 hours E 24 to 72 hours
B 6 to 8 hours Withdrawal symptoms usually, but not always, occur in stages: tremulousness or jitteriness (6-8 hours), psychosis and perceptual symptoms (8-12 hours), seizures (12-24 hours), and DTs (24-72 hours, up to 1 week).
Name some signs/symptoms of a person starting to go through alcohol withdrawal.
- irritable, - gastrointestinal disturbances - hallucinations, - diaphoretic - hypertensive - febrile - tachycardic
Medical conditions with similar signs and symptoms must be ruled out. Give examples of such conditions.
- thyroid storm (thyrotoxicosis), - pheochromocytoma, - inappropriate use of beta-agonist inhalers or sympathomimetics.
Withdrawal symptoms usually, but not always, occur in stages. Give the symptoms and their general timeline.
- tremulousness or jitteriness (6-8 hours), - psychosis and perceptual symptoms (8-12 hours), - seizures (12-24 hours), - delirium tremens (DTs, 24-72 hours, up to 1 week). Notably, alcohol withdrawal, particularly DTs, can be fatal.
Question 4: A 63-year-old man presents to the emergency department with complaints of anxiety. He describes a long history of daily heavy alcohol use and 2 days ago "quit cold turkey." He appears visibly tremulous, flushed, and diaphoretic. His temperature, blood pressure, and pulse rate are elevated. The results of his physical examination are otherwise unremarkable, but his laboratory tests demonstrate low serum albumin and low protein levels, as well as an elevated prothrombin time/partial prothrombin time value. He is admitted to the medical service for alcohol detoxification. Which of the following medications would be most appropriate in treating this patient? A Alprazolam B Chlordiazepoxide C Diazepam D Lorazepam E Clonazepam
D Lorazepam Although all these medications are benzodiazepines, only lorazepam is metabolized solely by glucuronidation, which is not as dependent on liver functioning. The metabolism of the other benzodiazepines is much more dependent on liver function. In this patient (who has evidence of poor liver function), using high doses of medications that are dependent on liver function for their degradation could result in excessive drug levels in the blood of an overly sedated patient.
Question 1: A 47-year-old man is admitted to a psychiatric unit for depression with suicidal ideation and detoxification. He has a long history of dependence upon both alcohol and cocaine. Which of the following signs is most characteristic of early alcohol withdrawal? A Decreased blood pressure B Hypersomnia C Persistent hallucinations D Tremor E Increased appetite
D Tremor Tremor is the most characteristic sign of alcohol withdrawal. Vital signs are elevated in alcohol withdrawal because of autonomic hyperactivity. Patients generally have insomnia as a result, not hypersomnia. Hallucinations associated with alcohol withdrawal usually resolve within a week, while those occurring in delirium tremens usually resolve with the delirium. Cocaine withdrawal more typically involves hypersomnia and hyperphagia.
Question 5: Delirium tremens happens: A Immediately B 6 to 8 hours C 8 to 12 hours D 12 to 24 hours E 24 to 72 hours
E 24 to 72 hours Withdrawal symptoms usually, but not always, occur in stages: tremulousness or jitteriness (6-8 hours), psychosis and perceptual symptoms (8-12 hours), seizures (12-24 hours), and DTs (24-72 hours, up to 1 week).
Question 9: Hallucinations with delirium A Immediately B 6 to 8 hours C 8 to 12 hours D 12 to 24 hours E 24 to 72 hours
E 24 to 72 hours Withdrawal symptoms usually, but not always, occur in stages: tremulousness or jitteriness (6-8 hours), psychosis and perceptual symptoms (8-12 hours), seizures (12-24 hours), and DTs (24-72 hours, up to 1 week).
Define diaphoresis.
Excessive sweating
If there is concern about decreased liver function, what treatment is preferred for alcohol withdrawal?
If liver function is impaired: lorazepam can be administered either orally or parenterally, as its metabolism is not as dependent on liver function, and, as such, is probably the most popular agent utilized. Similarly, oxazepam may be preferred in these instances.
If liver function is NOT impaired, what treatment is preferred for alcohol withdrawal?
If liver function is not impaired: a long-acting benzodiazepine such as chlordiazepoxide or diazepam is generally preferable (given PO or IV).
Although hallucinations are rare in alcohol withdrawal without delirium, if present they can be confused with those of schizophrenia. What features differentiate the two conditions?
In alcohol withdrawal: - the perceptual disturbances are transient, - there is not necessarily a history of a preexisting psychotic illness, - the associated symptoms of schizophrenia are not present, - the patient's reality testing ability remains intact.
Alcohol functions as a depressant much like benzodiazepines and barbiturates. Which receptors does it affect? What effect can this produce?
It has an effect on serotonin and gamma-aminobutyric acid type A (GABA-A) receptors, producing tolerance and habituation.
What is the next treatment step for a pt going through alcohol withdrawal?
Next step in treatment: The patient should be treated with a benzodiazepine immediately, starting with high doses and tapering as she recovers.
Should antipsychotics be used to treat alcohol withdrawal?
No. Antipsychotics should be avoided, because of their potential to lower the seizure threshold.
True or false: Alcohol withdrawal can occur within hours to days after heavy use and can include elevated vital signs, tremor, transient hallucinations, anxiety, and seizures.
True
True or false: Benzodiazepines are not dependent on liver function, such as lorazepam, but are often preferred in the treatment of alcohol withdrawal.
True
True or false: Positron emission tomographic (PET) studies have suggested a globally low rate of metabolic activity, particularly in the left parietal and right frontal areas in otherwise healthy persons withdrawing from alcohol.
True
True or false: The criteria (and symptoms) of alcohol withdrawal are identical to those for sedative-hypnotic withdrawal.
True
True or false: The treatment of choice for alcohol withdrawal is benzodiazepines. Anticonvulsants can also be used.
True
How much of a treatment drug should be given to aid a patient experiencing alcohol withdrawal?
Whatever the specific drug used, it should be given as frequently as necessary in order to normalize the vital signs and sedate the patient. The medicine should then be gradually tapered over the next several days, and the patient's vital signs monitored.
What else is in the differential diagnosis for alcohol withdrawal?
other drug withdrawal states, especially sedative-hypnotic withdrawal. In fact, the criteria for withdrawal from substances such as benzodiazepines (most commonly short-acting, high-potency drugs) and barbiturates are identical to those for alcohol withdrawal.
Severe alcohol withdrawal with autonomic instability (delirium tremens - DTs) has a high mortality and requires what?
requires stabilization in an acute medical facility