Alcohol withdrawal

Background

• Withdrawal symptoms due to reduced GABA and increased glutamate
• Benzos useful due to cross tolerance at ethanol GABA receptor
• Symptom triggered therapy
  • As effective as fixed dose therapy, but with more rapid detox

Clinical Features

• Reduction in alcohol use that has been heavy and prolonged
• At least 2 of the following
  • Autonomic hyperactivity (e.g., diaphoresis, HR>100)
  • Increased hand tremor
  • Insomnia
  • Nausea/vomiting
  • Transient visual, tactile, or auditory hallucinations
  • Psychomotor agitation
  • Anxiety
  • Grand mal seizures

Seizures

• Onset after last drink: 6-48h
• Multiple seizures: 60% of patients
• Progression to DTs: 33% of patients
• Treat with benzos (not phenytoin)

Alcoholic Hallucinosis

• Onset after last drink: 12-24hr
• Visual hallucinations are most common
• Different from delirium tremens
  • Resolves within 24-48 from last drink (before onset of DTs)
  • No delirium
  • Normal vital signs

Differential Diagnosis

Ethanol related disease processes

• Ethanol toxicity
• Alcohol withdrawal
  • Alcohol withdrawal seizures
  • Delerium tremens
• Electrolyte/acid-base disorder
  • Wernicke-Korsakoff syndrome
  • Beer potomania syndrome
  • Alcoholic ketoacidosis

Sedative/hypnotic withdrawal

• Toxic alcohols
  • Ethanol
  • Ethylene glycol
  • Methanol
  • Isopropyl alcohol
• Benzodiazepines
  • Flunitrazepam (Rohypnol)
• Gamma hydroxybutyrate (GHB)
• Barbiturates
• Opioids
• Chloral hydrate

Seizure

• Epileptic seizure
  • First-time seizure
  • Seizure with known seizure disorder
  • Status epilepticus
  • Temporal lobe epilepsy
• Non-epileptic seizure
  • Meningitis
  • Encephalitis
  • Intracranial hemorrhage
  • Alcohol withdrawal
  • Eclampsia
  • Neurocysticercosis
  • Posterior reversible encephalopathy syndrome
  • Impact seizure (head trauma)
  • Seizure with VP shunt
  • Toxic ingestion
• Intracranial mass
• Syncope
• Hyperventilation syndrome
• Migraine headache
• Movement disorders
• Narcolepsy/cataplexy

Evaluation

CIWA score

Clinical Institute Withdrawal Assessment – Alcohol – revised (CIWA-Ar)

• Headache 0-7
• Orientation 0-3
• Tremor 0-7
• Sweating 0-7
• Anxiety 0-7
• Nausea (and Vomiting) 0-7
• Tactile Hallucinations 0-7
• Auditory Hallucinations 0-7
• Visual Hallucinations 0-7
• Agitation 0-7

Maximum Score = 67

• <8: Typically do not require medication
• 8-19: Medication
• ≥20: Medication and admission

Inpatient Management

Start aggressive Benodiazepine therapy at CIWA score of 8. Consider ICU admission with score >20

Benzodiazepines

• Diazepam (Valium) 5-10mg IV (depending on severity)
  • May repeat q5-10min for severe withdrawal (double dose until desired effect achieved)
  • Half-life 20-100h (long acting)
• Lorazepam (Ativan) 1-4mg IV (depending on severity)
  • May repeat q15-20min for severe withdrawal (titrated to effect)
  • Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis
  • Half-life 10-20h (medium acting)

Alpha-2 agonists (Dexmedetomidine)

• Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
• Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min

Barbituates (Phenobarbital)

• Used when refractory to benzodiazepines
• Phenobarbital 130-260mg IV q 15-20 minutes
• Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions

Ketamine

• May have some use in refractory cases
• Blocks the NMDA receptor which is excited an unregulated.

Nutritional supplementation

• Banana bag
  • Thiamine 100mg IV
  • Folate 1mg IV (cheaper PO)
  • Multivitamin 1 tab IV (cheaper PO)
  • Magnesium sulfate 2mg IV
  • Normal saline as needed for hydration

Special Situations

• The propylene glycol diluent in lorazepam, phenobarbital, and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs. Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for delirium tremens.

Outpatient Management

Don’t use phenytoin or fosphenytoin to treat seizures caused by drug toxicity or drug withdrawal.

Chlordiazepoxide

Generally for outpatient treatment of mild cases and as a taper

• 25-50mg of chlordiazepoxide is equivalent to 10mg of diazepam
• 50mg of chlordiazepoxide every 8 hours for two days, then decrease to 25mg every 8 hours for another two days followed by 25mg PRN as needed.

Anticonvulsants^

• Gabapentin 400mg PO TID
  • Some protocols call for higher dosing - 600 or 800mg x1
• Similar efficacy to lorazepam in decreasing craving and anxiety

^These are example regimens (use discretion and balance risk/benefits with your own clinical judgment)

Example outpatient lorazepam taper

• 2mg tid x3 days
• 2mg bid on day 4
• 2mg once on day 5

Example outpatient gabapentin taper

Similar in efficacy to lorazepam according to one RCT

• 400mg tid x3 days
• 300mg bid on day 4
• 300mg once on day 5

Disposition

Admit

• Multiple seizures
• DTs
• Decreased LOC
• Inability to control withdrawal after administrating 3-4 doses of benzo's
• Consider ICU admission with CIWA score >20

Discharge

• Consider discharge with 3 day course of benzodiazepines if patients are attempting to quit alcohol
• Consider possible exclusions for outpatient treatment:
  • Substance use disorders except alcohol, nicotine, or cannabis
  • Major Axis I psych disorder
  • Medication history of benzodiazepines, beta-blockers, calcium-channel blockers, antipsychotics
  • History of head injury, epilepsy, medical instability, ECG abnormality, grossly abnormal lab value

See Also

• Beer Potomania Syndrome
• Alcohol (ETOH) Intoxication
• Alcoholic ketoacidosis
• Alcohol withdrawal seizures
• Altered mental status
• Delirium tremens
• EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal
• Sedative/Hypnotic

External Links

• MDCalc - CIWA-AR Calculator

References

Authors

Ross Donaldson