Alcohol withdrawal: Difference between revisions

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[[Randomized controlled trial]]s have found benefit from [[atenolol]]<ref name="pmid2863754">{{cite journal |author=Kraus ML, Gottlieb LD, Horwitz RI, Anscher M |title=Randomized clinical trial of atenolol in patients with alcohol withdrawal |journal=N. Engl. J. Med. |volume=313 |issue=15 |pages=905-9 |year=1985 |pmid=2863754 |doi=}}</ref> and [[clonidine]].<ref name="pmid3300587">{{cite journal |author=Baumgartner GR, Rowen RC |title=Clonidine vs chlordiazepoxide in the management of acute alcohol withdrawal syndrome |journal=Arch. Intern. Med. |volume=147 |issue=7 |pages=1223-6 |year=1987 |pmid=3300587 |doi=}}</ref>
[[Randomized controlled trial]]s have found benefit from [[atenolol]]<ref name="pmid2863754">{{cite journal |author=Kraus ML, Gottlieb LD, Horwitz RI, Anscher M |title=Randomized clinical trial of atenolol in patients with alcohol withdrawal |journal=N. Engl. J. Med. |volume=313 |issue=15 |pages=905-9 |year=1985 |pmid=2863754 |doi=}}</ref> and [[clonidine]].<ref name="pmid3300587">{{cite journal |author=Baumgartner GR, Rowen RC |title=Clonidine vs chlordiazepoxide in the management of acute alcohol withdrawal syndrome |journal=Arch. Intern. Med. |volume=147 |issue=7 |pages=1223-6 |year=1987 |pmid=3300587 |doi=}}</ref>


There are concerns about adverse effects from beta-blockers.<ref name="pmid6122874">{{cite journal |author=Zechnich RJ |title=Beta blockers can obscure diagnosis of delirium tremens |journal=Lancet |volume=1 |issue=8280 |pages=1071-2 |year=1982 |pmid=6122874 |doi= |issn=}}</ref><ref name="pmid7004240">{{cite journal |author=Zilm DH, Jacob MS, MacLeod SM, Sellers EM, Ti TY |title=Propranolol and chlordiazepoxide effects on cardiac arrhythmias during alcohol withdrawal |journal=Alcohol. Clin. Exp. Res. |volume=4 |issue=4 |pages=400-5 |year=1980 |pmid=7004240 |doi= |issn=}}</ref>
A complicated factorial [[randomized controlled trial]]<ref name="pmid7004240">{{cite journal |author=Zilm DH, Jacob MS, MacLeod SM, Sellers EM, Ti TY |title=Propranolol and chlordiazepoxide effects on cardiac arrhythmias during alcohol withdrawal |journal=Alcohol. Clin. Exp. Res. |volume=4 |issue=4 |pages=400-5 |year=1980 |pmid=7004240 |doi= |issn=}}</ref> has been misinterpreted leading to concerns about using beta-blockers.<ref name="pmid15249349">{{cite journal |author=Mayo-Smith MF, Beecher LH, Fischer TL, ''et al'' |title=Management of alcohol withdrawal delirium. An evidence-based practice guideline |journal=Arch. Intern. Med. |volume=164 |issue=13 |pages=1405-12 |year=2004 |pmid=15249349 |doi=10.1001/archinte.164.13.1405}}</ref>
 
{| class="wikitable" align="right"
|+ Incidence of treatment failures due to severe hallucinations or alcohol withdrawal.
!colspan="2" rowspan="2"| || colspan="2"| Chlordiazepoxide
|-
| Given || Not given
|-
| rowspan="2"|'''Propranolol || Given || 1|| 4
|-
| Not given|| 0|| 4
|-
| colspan="4" |Notes:<br>There were 15 patients in each group.
|}
 
 
There are concerns about adverse effects from beta-blockers.<ref name="pmid6122874">{{cite journal |author=Zechnich RJ |title=Beta blockers can obscure diagnosis of delirium tremens |journal=Lancet |volume=1 |issue=8280 |pages=1071-2 |year=1982 |pmid=6122874 |doi= |issn=}}</ref>


===Carbamazepine===
===Carbamazepine===

Revision as of 11:45, 3 April 2008

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Template:TOC-right Alcohol withdrawal is a group of syndromes that may occur after cessation of drinking ethanol alcohol.[1][2][3]

Classification

Autonomic hyperactivity

Seizures

Alcohol withdrawal seizures is a "condition where seizures occur in association with ethanol abuse (alcoholism) without other identifiable causes. Seizures usually occur within the first 6-48 hours after the cessation of alcohol intake, but may occur during periods of alcohol intoxication. Single generalized tonic-clonic motor seizures are the most common subtype, however, status epilepticus may occur".[4][5]

Delirium

Alcohol withdrawal delirium,formerly called delerium tremens, is an "acute organic mental disorder induced by cessation or reduction in chronic alcohol consumption. Clinical characteristics include confusion; delusions; vivid hallucinations; tremor; agitation; insomnia; and signs of autonomic hyperactivity (e.g., elevated blood pressure and heart rate, dilated pupils, and diaphoresis). This condition may occasionally be fatal."[6][7]

Treatment

Benzodiazepines

Benzodiazepines such as diazepam (Valium), lorazepam (Ativan) or oxazepam (Serax) are the most commonly used drugs used to reduce alcohol withdrawal symptoms. There are several treatment patterns in which it is used.

  1. One option takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3-10 days.
  2. Another option is to defer treatment until symptoms occur.[8][9] A non-randomized, before and after, observational study found that symptom triggered therapy was advantageous.[10]

Dosing of the benzodiazepines can be guided by the CIWA-Ar scale.[11] The scale is available online (see external links below).

Regarding the choice of benzodiazepine:

  • Chlordiazepoxide (Librium®) is the benzodiazepine of choice in uncomplicated alcohol withdrawal. [12]
  • Lorazepam or diazepam are available parenterally for patients who cannot safely take medications by mouth.
  • Lorazepam and oxazepam may be best in patients with cirrhosis (shorter half life).

Adrenergic antagonists

Randomized controlled trials have found benefit from atenolol[13] and clonidine.[14]

A complicated factorial randomized controlled trial[15] has been misinterpreted leading to concerns about using beta-blockers.[1]

Incidence of treatment failures due to severe hallucinations or alcohol withdrawal.
Chlordiazepoxide
Given Not given
Propranolol Given 1 4
Not given 0 4
Notes:
There were 15 patients in each group.


There are concerns about adverse effects from beta-blockers.[16]

Carbamazepine

A randomized controlled trial has found benefit from carbamazepine.[17]

Other drugs

Some hospitals administer alcohol to prevent alcohol withdrawal although there are potential problems with this practice.[18]

Sodium oxybate is the sodium salt of gamma-hydroxybutyric acid (GHB). It is used for both acute alcohol withdrawal and medium to long-term detoxification. This drug enhances GABA neurotransmission and reduces glutamate levels.

Baclofen has been shown in animal studies and in small human studies to enhance detoxification. This drug acts as a GABA B receptor agonist and this may be beneficial.

References

  1. ↑ 1.0 1.1 Mayo-Smith MF, Beecher LH, Fischer TL, et al (2004). "Management of alcohol withdrawal delirium. An evidence-based practice guideline". Arch. Intern. Med. 164 (13): 1405-12. DOI:10.1001/archinte.164.13.1405. PMID 15249349. Research Blogging.
  2. ↑ Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL, Hill A, Jara G, Kasser C, Melbourne J. (2004). Management of alcohol withdrawal delirium. An evidence-based practice guideline. (English). National Guidelines Clearinghouse. Retrieved on 2008-04-03.
  3. ↑ Mayo-Smith MF (1997). "Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal". JAMA 278 (2): 144-51. PMID 9214531. [e] Full text at OVID
  4. ↑ Anonymous (2024), Alcohol withdrawal seizures (English). Medical Subject Headings. U.S. National Library of Medicine.
  5. ↑ Ropper, Allan H.; Adams, Raymond Delacy; Victor, Maurice (1997). Principles of Neurology. New York: McGraw-Hill, Health Professions Division, 1174. ISBN 0-07-067439-6. 
  6. ↑ Anonymous (2024), Alcohol withdrawal delirium (English). Medical Subject Headings. U.S. National Library of Medicine.
  7. ↑ Ropper, Allan H.; Adams, Raymond Delacy; Victor, Maurice (1997). Principles of Neurology. New York: McGraw-Hill, Health Professions Division, 1175. ISBN 0-07-067439-6. 
  8. ↑ Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR (1994). "Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial". JAMA 272 (7): 519-23. PMID 8046805. [e]
  9. ↑ Daeppen JB, Gache P, Landry U, et al (2002). "Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial". Arch. Intern. Med. 162 (10): 1117-21. PMID 12020181. [e]
  10. ↑ Jaeger TM, Lohr RH, Pankratz VS (2001). "Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients". Mayo Clin. Proc. 76 (7): 695-701. PMID 11444401. [e]
  11. ↑ Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM (1989). "Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar)". British journal of addiction 84 (11): 1353-7. PMID 2597811. [e]
  12. ↑ Raistrick, D, Heather N & Godfrey C (2006) "Review of the Effectiveness of Treatment for Alcohol Problems" National Treatment Agency for Substance Misuse, London http://www.nta.nhs.uk/publications/documents/nta_review_of_the_effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf
  13. ↑ Kraus ML, Gottlieb LD, Horwitz RI, Anscher M (1985). "Randomized clinical trial of atenolol in patients with alcohol withdrawal". N. Engl. J. Med. 313 (15): 905-9. PMID 2863754. [e]
  14. ↑ Baumgartner GR, Rowen RC (1987). "Clonidine vs chlordiazepoxide in the management of acute alcohol withdrawal syndrome". Arch. Intern. Med. 147 (7): 1223-6. PMID 3300587. [e]
  15. ↑ Zilm DH, Jacob MS, MacLeod SM, Sellers EM, Ti TY (1980). "Propranolol and chlordiazepoxide effects on cardiac arrhythmias during alcohol withdrawal". Alcohol. Clin. Exp. Res. 4 (4): 400-5. PMID 7004240. [e]
  16. ↑ Zechnich RJ (1982). "Beta blockers can obscure diagnosis of delirium tremens". Lancet 1 (8280): 1071-2. PMID 6122874. [e]
  17. ↑ Malcolm R, Ballenger JC, Sturgis ET, Anton R (1989). "Double-blind controlled trial comparing carbamazepine to oxazepam treatment of alcohol withdrawal". The American journal of psychiatry 146 (5): 617-21. PMID 2653057. [e]
  18. ↑ Blondell RD, Dodds HN, Blondell MN, et al (2003). "Ethanol in formularies of US teaching hospitals". JAMA 289 (5): 552. PMID 12578486. [e]

External links

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