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| __NOTOC__
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| {| class="infobox" style="float:right;" | | {| class="infobox" style="float:right;" |
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| | [[File:Siren.gif|30px|link= Alcohol withdrawal resident survival guide]]|| <br> || <br> | | | [[File:Siren.gif|30px|link= Alcohol withdrawal resident survival guide]]|| <br> || <br> |
| | [[Alcohol withdrawal resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | | | [[Alcohol withdrawal resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| |} | | |} |
| '''For patient information, click [[Alcohol withdrawal (patient information)|here]]''' | | __NOTOC__ |
| {{SI}}
| | {{Alcohol withdrawal}} |
| | | '''For patient information click [[Alcohol withdrawal (patient information)|here]].''' |
| {{CMG}} ; {{AE}} {{ADI}}
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| == Overview ==
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| Alcohol withdrawal refers to symptoms that can occur when a person who has been drinking [[alcohol]] every day suddenly stops drinking alcohol.
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| == Pathophysiology ==
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| * Prolonged exposure to alcohol results in inhibition of the inhibitory GABA A-type and NMDA-type glutamate receptors located in the CNS. Without the alcohol, greater CNS excitability results, due to lack of inhibition on the CNS inhibitory receptors by alcohol.
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| * Elevated [[norepinephrine]] has been found in the [[CSF]] patients in acute alcohol withdrawal. It is postulated that there is a decreased amount of alpha 2-receptors, resulting in less inhibition of [[presynaptic]] [[norepinephrine]] release.
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| == Epidemiology and Demographics ==
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| * [[Alcohol abuse]] or dependence afflicts up to 15 million persons in the United States. It accounts for 100,000 deaths and an economic burden of over 100 billion dollars per year. The lifetime prevalence of alcohol abuse is approximately 14% and of alcohol dependence is 8%. Approximately 500,000 patients/year develop withdrawal that is severe enough to prompt pharmacologic management.
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| * Between 13% and 71% of persons admitted for alcohol detoxification have evidence of alcohol withdrawal symptoms.
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| * Approximately 3% of [[chronic alcoholics]] develop withdrawal [[seizures]]. Five percent of patients with alcohol withdrawal develop [[delirium tremens]] (DTs), which is associated with a mortality of approximately 5%.
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| == Natural History, Complications and Prognosis ==
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| How well a person does depends on the amount of organ damage and whether the person can stop drinking completely. Alcohol withdrawal may range from a mild and uncomfortable disorder to a serious, life-threatening condition. People who continue to drink a lot may develop health problems such as liver and heart disease. Most people who go through alcohol withdrawal make a full recovery. However, [[death]] is possible, especially if [[delirium tremens]] occurs.
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| == Diagnosis ==
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| === Criteria ===
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| # History of cessation or reduction in heavy and prolonged alcohol use.
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| # 2 or more of:
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| #:* Autonomic hypereactivity
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| #:* Hand [[tremor]]
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| #:* [[Insomnia]]
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| #:* [[Nausea ]]and [[vomiting]]
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| #:* Visual or auditory [[hallucinations]]
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| #:* Psychomotor agitation
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| #:* [[Anxiety]]
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| #:* [[Grand mal seizures]]
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| #:*:* Note history of [[blackouts]], morning shakes, prior detoxifications or [[DT]]s and frequency, amount and type of alcohol.
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| === Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) ===
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| The CIWA (Clinical Institute Withdrawal Assessment)<ref name="pmid16115538">{{cite journal |author=Puz CA, Stokes SJ |title=Alcohol withdrawal syndrome: assessment and treatment with the use of the Clinical Institute Withdrawal Assessment for Alcohol-revised |journal=Crit Care Nurs Clin North Am |volume=17 |issue=3 |pages=297–304 |year=2005 |month=September |pmid=16115538 |doi=10.1016/j.ccell.2005.04.001 |url=}}</ref> is a common measure used in North American hospitals to assess and treat alcohol withdrawal syndrome and for alcohol detoxification. This clinical tool assesses 10 common withdrawal signs.<ref name="pmid15029927">{{cite journal |author=McKay A, Koranda A, Axen D |title=Using a symptom-triggered approach to manage patients in acute alcohol withdrawal |journal=Medsurg Nurs |volume=13 |issue=1 |pages=15–20, 31; quiz 21 |year=2004 |month=February |pmid=15029927 |doi= |url=}}</ref> A score of more than '''15''' points is associated with increased risk of alcohol withdrawal effects such as [[confusion]] or [[seizures]].
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| [[Image:CIWA-Ar.PNG|550px|thumb|center|Alcohol withdrawal]]
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| ===Other Assessment Scales===
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| ; Alcohol Assessment Scale
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| [[Image:AWS.PNG|550px|thumb|center|Alcohol Withdrawal Scale]]
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| ===Level of Evidence===
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| {|border ="1"
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| |'''Assessment Scale''' || '''Level of Evidence'''
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| | The Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar) || align="center" | I
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| | Alcohol Assessment Scale (AWS) || align="center" | IV
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| |}
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| ===Alcohol Withdrawal Calculator===
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| {{#widget:Alcohol_Withdrawal_Calc}}
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| === Symptoms ===
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| * '''Common symptoms include:'''
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| :* [[Anxiety]] or [[nervousness]]
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| :* [[Clinical depression|Depression]]
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| :* Not thinking clearly
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| :* [[Fatigue ]]
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| :* [[Irritability]]
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| :* Jumpiness or shakiness
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| :* Mood swings
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| :* [[Nightmares]]
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| * '''Other symptoms may include:'''
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| :* [[Clammy skin]]
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| :* [[Enlarged (dilated) pupils]]
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| :* [[Headache ]]
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| :* [[Insomnia ]] ([[sleeping difficulty]])
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| :* [[Loss of appetite]]
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| :* [[Nausea]] and [[vomiting]]
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| :* [[Pallor]]
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| :* [[Rapid heart rate]]
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| :* [[Sweating]]
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| :* [[Tremor]] of the hands or other body parts
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| * A severe form of alcohol withdrawal called '''[[Delirium tremens ]]''' can cause:
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| :* [[Agitation]]
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| :* [[Confusion ]]
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| :* Seeing or feeling things that aren't there ([[Hallucination]])
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| :* [[Fever]]
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| :* [[Seizures]]
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| === Physical examination ===
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| :* Abnormal eye movements
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| :* [[Abnormal heart rhythms]]
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| :* Not enough fluids in the body ([[dehydration]])
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| :* [[Rapid breathing]]
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| :* [[Rapid heart rate]]
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| :* [[Shaky hands]]
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| :* Blood and urine tests, including a [[toxicology screen]]
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| == Treatment == | | {{CMG}}; {{AE}} {{SHA}}, {{ADI}} |
| | ==[[Alcohol withdrawal overview|Overview]]== |
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| * No clinical findings can reliably predict who will or will not develop withdrawal. Risk factors for [[DT]]s: Previous DTs or detoxifications, Age >30, high degree of alcohol dependence, duration of abuse, the presence of moderate symptoms (CIWA >14) left untreated and concurrent medical illness are all strongly predictive. These findings should prompt intervention. Time abstinent may be a helpful negative predictor. In one large study, patients who were asymptomatic 36 hours after their last drink did not develop symptoms.
| | ==[[Alcohol withdrawal historical perspective|Historical Perspective]]== |
| * All patients with [[alcohol abuse]] should receive 1mg [[folate]] QD, [[magnesium]]/ [[phosphate]]/[[potassium]]/fluid volume repletion and [[thiamine]] 100 mg IV/IM x1 then 100 mg QD.
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| * Treatment of alcohol related seizures is on an as needed basis with [[benzodiazepines]]. They tend to be transient phenomenon. [[phenytoin]] is ineffective in the management of withdrawal [[seizures]], but may be indicated if another seizure disorder or [[status epilepticus]] is present. Long term medical suppression or prophylaxis is not indicated for withdrawal seizures. [[Neuroleptics ]]lower the seizure threshold and should not be used in these patients; however, [[haloperidol]] has been used safely in conjunction with [[benzodiazepines]] (BDZs).
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| * BDZs are the cornerstone of therapy for minor withdrawal, [[seizures]] and DTs. Fixed schedule therapy, front loading therapy and symptom-triggered therapy have all been evaluated with similar efficacy. Symptoms triggered therapy was associated with less total administration of drug and shorter length of stay but has only been evaluated in patients without acute comorbid illness or [[seizures]] and should be restricted to only this limited group of patients.
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| * In the medically stable patient with no liver dysfunction 10 mg PO/IV is administered every hour till CIWA <10 or sedated. If the patient is stable but has [[liver disease]], give 2 mg [[lorazepam ]]IV/PO Q 1H till CIWA <10 or sedated. Calculate the total dose used and give this Q6H for 24 hrs. Use that latter regimen for the unstable patient.
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| * If CIWA is stable x24 hours then decrease the dose by 20%/day. If there is a history of [[DT]]s or [[seizures]] or the patient is unstable decrease the dose by 10%/day. Give parentral doses of [[lorazepam]] recurrence of withdrawal (CIWA >10).
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| ===Supportive Care=== | | ==[[Alcohol withdrawal classification|Classification]]== |
| '''Goal''' - Correction of associated disorders, their treatment, providing support for early recovery and prevention of complications.
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| * Vital signs have to be corrected first.
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| ** [[Heart rate]] should be controlled.
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| ** [[Blood pressure]] should be maintained using [[fluids]] and [[anti hypertensive medication]].
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| * Identification of comorbid conditions and their treatment.
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| * A few patients may be [[dehydrated]] and they may require [[intravenous fluid]] replacement.
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| ** Care has to be taken to avoid fluid overload which can lead to [[heart failure]] or exacerbate underlying heart conditions.
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| * [[Chronic alcoholics]] are depleted in reserves of certain [[electrolytes]] like [[magnesium]], [[phosphate]]. Care has to be provided in correcting them as they play an important role in body metabolism.<ref name="pmid1979005">{{cite journal |author=Nutt DJ, Glue P |title=Neuropharmacological and clinical aspects of alcohol withdrawal |journal=[[Annals of Medicine]] |volume=22 |issue=4 |pages=275–81 |year=1990 |pmid=1979005 |doi= |url= |accessdate=2012-08-16}}</ref> Administration of magnesium may improve the overall outcome of the patient.
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| * Alcoholics are vitamin deficient owing to poor dietary habits. [[Thiamine]] and [[folic acid]] are of major concern.<ref name="pmid20615374">{{cite journal |author=Damsgaard L, Ulrichsen J, Nielsen MK |title=[Wernicke's encephalopathy in patients with alcohol withdrawal symptoms] |language=Danish |journal=[[Ugeskrift for Laeger]] |volume=172 |issue=28 |pages=2054–8 |year=2010 |month=July |pmid=20615374 |doi= |url= |accessdate=2012-08-16}}</ref>
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| ** Patients who are experiencing withdrawal should be administered with multivitamins to support the body metabolism.
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| ** Use of thiamine 100 mg daily for 30 days during withdrawal is recommended.<ref name="pmid21278319">{{cite journal |author=Talbot PA |title=Timing of efficacy of thiamine in Wernicke's disease in alcoholics at risk |journal=[[Journal of Correctional Health Care : the Official Journal of the National Commission on Correctional Health Care]] |volume=17 |issue=1 |pages=46–50 |year=2011 |month=January |pmid=21278319 |doi=10.1177/1078345810385913 |url=http://jcx.sagepub.com/cgi/pmidlookup?view=long&pmid=21278319 |accessdate=2012-08-16}}</ref>
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| ** Thiamine should be administered before [[glucose]] as it may further deplete the reserve of thiamine.<ref name="pmid21278319">{{cite journal |author=Talbot PA |title=Timing of efficacy of thiamine in Wernicke's disease in alcoholics at risk |journal=[[Journal of Correctional Health Care : the Official Journal of the National Commission on Correctional Health Care]] |volume=17 |issue=1 |pages=46–50 |year=2011 |month=January |pmid=21278319 |doi=10.1177/1078345810385913 |url=http://jcx.sagepub.com/cgi/pmidlookup?view=long&pmid=21278319 |accessdate=2012-08-16}}</ref>
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| ===Inpatient v/s Outpatient=== | | ==[[Alcohol withdrawal pathophysiology|Pathophysiology]]== |
| Treatment to alcohol withdrawal patients can be provided in outpatient and inpatient setup.
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| ; Outpatient
| | ==[[Alcohol withdrawal causes|Causes]]== |
| * Criteria
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| **If there are no signs of severe alcohol withdrawal.
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| **If there is no previous history of alcohol withdrawal.
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| **If there is a supportive family for the patient.
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| **If there is no associated comorbid conditions.
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| * Potential considerations
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| **Patients may be non-complaint to medication.
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| ** May resolve back to his drinking habits.
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| ;Inpatient
| | ==[[Alcohol withdrawal differential diagnosis|Differentiating Alcohol withdrawal from other Diseases]]== |
| * Criteria
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| **Severe alcohol withdrawal syndrome.
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| **History of alcohol withdrawal symptoms on treatment with outpatient basis.
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| **Presence of any other comorbid condition or psychiatric condition.
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| **Non supportive family
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| *Potential considerations
| | ==[[Alcohol withdrawal epidemiology and demographics|Epidemiology and Demographics]]== |
| **Cost of inpatient facilities
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| ===Nonpharmacological Treatment=== | | ==[[Alcohol withdrawal risk factors|Risk Factors]]== |
| * Providing patient a quiet environment.
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| * Providing reassurance.
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| * Motivation for alcohol abstinence.
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| ===Pharmacological Treatment=== | | ==[[Alcohol withdrawal natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| *[[Benzodiazeipines]]
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| ** For patients with severe symptoms of alcohol withdrawal.
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| ** [[Diazepam]] is used initially to control the [[agitation]].
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| ** Dose of diazepam is tapered later.
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| ** In patients with liver problems [[lorazepam]] may be better drug to use. <ref name="pmid8700792">{{cite journal |author=Peppers MP |title=Benzodiazepines for alcohol withdrawal in the elderly and in patients with liver disease |journal=[[Pharmacotherapy]] |volume=16 |issue=1 |pages=49–57 |year=1996 |pmid=8700792 |doi= |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0277-0008&date=1996&volume=16&issue=1&spage=49 |accessdate=2012-08-16}}</ref>
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| * [[Anticonvulsant]]s
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| ** Anticonvulsants like [[carbamazepine]] are of low significance in case of [[seizures]] due to alcohol withdrawal.
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| ** They can be used if seizures are not controlled by [[benzodiazepines]]([[diazepam]]).
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| ** If a patient suffers two or more alcohol withdrawal seizures or develops status epilepticus, it should be assumed that the seizures are not a result of alcohol withdrawal and should be investigated.
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| * [[Anti psychotics]]
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| ** Anti-psychotic medication should only be made available to patients experiencing [[hallucinations]] where [[benzodiazepines]] are not effective.
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| ** The patient should also be monitored carefully for [[hypotension]].
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| *[[Baclofen]]
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| ** With the use of [[baclofen]] whcih acts upon the GABA-B receptors , doses of [[diazepam]] can be reduced.<ref name="pmid21990176">{{cite journal |author=Lyon JE, Khan RA, Gessert CE, Larson PM, Renier CM |title=Treating alcohol withdrawal with oral baclofen: a randomized, double-blind, placebo-controlled trial |journal=[[Journal of Hospital Medicine : an Official Publication of the Society of Hospital Medicine]] |volume=6 |issue=8 |pages=469–74 |year=2011 |month=October |pmid=21990176 |doi=10.1002/jhm.928 |url=http://dx.doi.org/10.1002/jhm.928 |accessdate=2012-08-16}}</ref>
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| ** It can be used in [[Chronic alcoholics|alcohol addicts]].
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| *[[Clonidine]]
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| ** It acts upon the alpha 2 receptors is useful in controlling the symptoms of alcohol withdrawal by reducing the [[adrenergic surge]].
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| ** [[Clonidine]] and [[dexmedetomidine]] can be used as adjunctive treatment to [[benzodiazepines]].<ref name="pmid21521867">{{cite journal |author=Muzyk AJ, Fowler JA, Norwood DK, Chilipko A |title=Role of α2-agonists in the treatment of acute alcohol withdrawal |journal=[[The Annals of Pharmacotherapy]] |volume=45 |issue=5 |pages=649–57 |year=2011 |month=May |pmid=21521867 |doi=10.1345/aph.1P575 |url=http://www.theannals.com/cgi/pmidlookup?view=long&pmid=21521867 |accessdate=2012-08-16}}</ref>
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| ===Withdrawal Regimes=== | | ==Diagnosis== |
| <ref name="urlwww.alcohol.gov.au">{{cite web |url=http://www.alcohol.gov.au/internet/alcohol/publishing.nsf/Content/2C3FC9166082567DCA257260007F81F8/$File/alcprobguide.pdf |title=www.alcohol.gov.au |format= |work= |accessdate=2012-08-16}}</ref>
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| ;Symptom triggered therapy
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| * In this regime patients CIWA-Ar score is evaluated hourly or bi-hourly and depending upon the score the treatment is administered.
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| * [[Benzodiazepines]] are used in the treatment
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| * It limits the use of excessive medication.
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| * This approach is cost effective and prevent complications.
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| ; Fixed schedule therapy
| | [[Alcohol withdrawal diagnostic criteria|Diagnostic Criteria]] | [[Alcohol Withdrawal Calculator]] | [[Alcohol withdrawal history and symptoms| History and Symptoms]] | [[Alcohol withdrawal physical examination | Physical Examination]] | [[Alcohol withdrawal laboratory findings|Laboratory Findings]] | [[Alcohol withdrawal CT|CT]] | [[Alcohol withdrawal other imaging findings|Other Imaging Findings]] | [[Alcohol withdrawal other diagnostic studies|Other Diagnostic Studies]] |
| * Fixed dosage of drug is given at scheduled intervals
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| * Can be used if patient is not in severe withdrawal
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| ; Loading dose therapy
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| * It is used in patients who have experienced [[seizures]] during past alcohol withdrawal.
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| * In this regime doses are tailored for the patient's condition.
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| ===Treatment of Complications===
| | ==Treatment== |
| * [[Delirium tremens]] - [[benzodiazepines]], [[antipsychotics]] are used for the treatment.
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| * [[Wernicke-Korsakoff’s syndrome]] - [[thiamine]] adminstration
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| * [[Covulsions]]- [[benzodiazepines]] are useful, if they are repetitive or [[status epilepticus]] develops other causes have to be investigated.
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| * Failure to manage the alcohol withdrawal syndrome appropriately can lead to permanent [[encephalopathy|brain damage]] or [[death]].
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| ** It can be prevented by the administration of NMDA antagonists. The NMDA antagonist [[acamprosate]] reduces excessive glutamate causing the symptoms. <ref name="pmid22616110">{{cite journal |author=Hinton DJ, Lee MR, Jacobson TL, Mishra PK, Frye MA, Mrazek DA, Macura SI, Choi DS |title=Ethanol withdrawal-induced brain metabolites and the pharmacological effects of acamprosate in mice lacking ENT1 |journal=[[Neuropharmacology]] |volume=62 |issue=8 |pages=2480–8 |year=2012 |month=June |pmid=22616110 |doi= |url= |accessdate=2012-08-16}}</ref>
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| ===Treatment in Special Groups===
| | [[Alcohol withdrawal medical therapy|Medical Therapy]] | [[Alcohol withdrawal surgery|Surgery]] | [[Alcohol withdrawal primary prevention|Primary Prevention]] | [[Alcohol withdrawal secondary prevention|Secondary Prevention]] | [[Alcohol withdrawal cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Alcohol withdrawal future or investigational therapies|Future or Investigational Therapies]] |
| ; [[Pregnancy]]
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| * Pregnancy doesn't increase the risk of alcohol withdrawal.
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| * Medications used to treat alcohol withdrawal may cause some effect on the fetus.
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| * [[Benzodiazepines]] cause less effects on the fetus and are efficient.
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| ; Hospitalized patients
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| * Patients hospitalized for some other illness may undergo alcohol withdrawal.
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| * Early recognition of symptoms of withdrawal is important.
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| * Early diagnosis and treatment helps in prevention of complications.<ref name="pmid7630218">{{cite journal |author=Lohr RH |title=Treatment of alcohol withdrawal in hospitalized patients |journal=[[Mayo Clinic Proceedings. Mayo Clinic]] |volume=70 |issue=8 |pages=777–82 |year=1995 |month=August |pmid=7630218 |doi= |url= |accessdate=2012-08-16}}</ref>
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| ===Cost Effectiveness=== | | ==Case Studies== |
| * In all possible cases outpatient detoxification and treatment is most cost effective. <ref name="pmid2913493">{{cite journal |author=Hayashida M, Alterman AI, McLellan AT, O'Brien CP, Purtill JJ, Volpicelli JR, Raphaelson AH, Hall CP |title=Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome |journal=[[The New England Journal of Medicine]] |volume=320 |issue=6 |pages=358–65 |year=1989 |month=February |pmid=2913493 |doi=10.1056/NEJM198902093200605 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198902093200605?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-08-16}}</ref>
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| * Outpatient treatment costs $175 to $388 per patientt.
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| * Inpatient treatment cost $3,319 to $3,665 per patient.
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| == References ==
| | [[Alcohol withdrawal case study one|Case#1]] |
| {{reflist|2}}
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| | * [[Mixing alcohol with medicines]] |
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| [[Category:Grammar]]
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