Alcohol withdrawal: Difference between revisions

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==Treatment==
==Treatment==
====Benzodiazepines====
===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.
''[[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.


# The first 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.
# 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.
# Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon.
# Another option is to defer treatment until symptoms occur.<ref name="pmid8046805">{{cite journal |author=Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR |title=Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial |journal=JAMA |volume=272 |issue=7 |pages=519-23 |year=1994 |pmid=8046805 |doi=}}</ref><ref name="pmid12020181">{{cite journal |author=Daeppen JB, Gache P, Landry U, ''et al'' |title=Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial |journal=Arch. Intern. Med. |volume=162 |issue=10 |pages=1117-21 |year=2002 |pmid=12020181 |doi=}}</ref> A non-randomized, before and after, observational study found that symptom triggered therapy was advantageous.<ref name="pmid11444401">{{cite journal |author=Jaeger TM, Lohr RH, Pankratz VS |title=Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients |journal=Mayo Clin. Proc. |volume=76 |issue=7 |pages=695-701 |year=2001 |pmid=11444401 |doi=}}</ref>
# A third option is to defer treatment until symptoms occur. This method should not be used in patients with prior alcohol related seizures. This has been effective in [[randomized controlled trials]].<ref name="pmid8046805">{{cite journal |author=Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR |title=Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial |journal=JAMA |volume=272 |issue=7 |pages=519-23 |year=1994 |pmid=8046805 |doi=}}</ref><ref name="pmid12020181">{{cite journal |author=Daeppen JB, Gache P, Landry U, ''et al'' |title=Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial |journal=Arch. Intern. Med. |volume=162 |issue=10 |pages=1117-21 |year=2002 |pmid=12020181 |doi=}}</ref> A non-randomized, before and after, observational study found that symptom triggered therapy was advantageous.<ref name="pmid11444401">{{cite journal |author=Jaeger TM, Lohr RH, Pankratz VS |title=Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients |journal=Mayo Clin. Proc. |volume=76 |issue=7 |pages=695-701 |year=2001 |pmid=11444401 |doi=}}</ref>


Dosing of the benzodiazepines can be guided by the [[CIWA-Ar]] scale.<ref name="pmid2597811">{{cite journal |author=Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM |title=Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar) |journal=British journal of addiction |volume=84 |issue=11 |pages=1353-7 |year=1989 |pmid=2597811 |doi=}}</ref> The scale is available online.<ref name="pmid10102003">{{cite journal |author=Holbrook AM, Crowther R, Lotter A, Cheng C, King D |title=Diagnosis and management of acute alcohol withdrawal |journal=CMAJ : Canadian Medical Association journal &#61; journal de l'Association medicale canadienne |volume=160 |issue=5 |pages=675-80 |year=1999 |pmid=10102003 |doi=}} ([http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1230114 see appendix 2])</ref>
Dosing of the benzodiazepines can be guided by the CIWA-Ar scale.<ref name="pmid2597811">{{cite journal |author=Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM |title=Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar) |journal=British journal of addiction |volume=84 |issue=11 |pages=1353-7 |year=1989 |pmid=2597811 |doi=}}</ref> The scale is available online.<ref name="pmid10102003">{{cite journal |author=Holbrook AM, Crowther R, Lotter A, Cheng C, King D |title=Diagnosis and management of acute alcohol withdrawal |journal=CMAJ : Canadian Medical Association journal &#61; journal de l'Association medicale canadienne |volume=160 |issue=5 |pages=675-80 |year=1999 |pmid=10102003 |doi=}} ([http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1230114 see appendix 2])</ref>


Regarding the choice of benzodiazepine:
Regarding the choice of benzodiazepine:
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* [[Lorazepam]] and [[oxazepam]] may be best in patients with cirrhosis (shorter half life).
* [[Lorazepam]] and [[oxazepam]] may be best in patients with cirrhosis (shorter half life).


====Sympatholytics====
===Adrenergic antagonists===
[[Randomized controlled trials]] 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>


====Carbamazepine====
===Carbamazepine===
A [[randomized controlled trial]] has found benefit from [[carbamazepine]].<ref name="pmid2653057">{{cite journal |author=Malcolm R, Ballenger JC, Sturgis ET, Anton R |title=Double-blind controlled trial comparing carbamazepine to oxazepam treatment of alcohol withdrawal |journal=The American journal of psychiatry |volume=146 |issue=5 |pages=617-21 |year=1989 |pmid=2653057 |doi=}}</ref>
A [[randomized controlled trial]] has found benefit from [[carbamazepine]].<ref name="pmid2653057">{{cite journal |author=Malcolm R, Ballenger JC, Sturgis ET, Anton R |title=Double-blind controlled trial comparing carbamazepine to oxazepam treatment of alcohol withdrawal |journal=The American journal of psychiatry |volume=146 |issue=5 |pages=617-21 |year=1989 |pmid=2653057 |doi=}}</ref>


====Other drugs====
===Other drugs===
Some hospitals administer alcohol to prevent alcohol withdrawal although there are potential problems with this practice.<ref name="pmid12578486">{{cite journal |author=Blondell RD, Dodds HN, Blondell MN, ''et al'' |title=Ethanol in formularies of US teaching hospitals |journal=JAMA |volume=289 |issue=5 |pages=552 |year=2003 |pmid=12578486 |doi=}}</ref>
Some hospitals administer alcohol to prevent alcohol withdrawal although there are potential problems with this practice.<ref name="pmid12578486">{{cite journal |author=Blondell RD, Dodds HN, Blondell MN, ''et al'' |title=Ethanol in formularies of US teaching hospitals |journal=JAMA |volume=289 |issue=5 |pages=552 |year=2003 |pmid=12578486 |doi=}}</ref>


Various '''vitamins''', especially from the B group, are often used during withdrawal treatment.
'''[[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.
 
'''[[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.  It is used in [[Italy]] in small amounts under the trade name [[Alcover]].


'''[[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.
'''[[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.

Revision as of 23:07, 2 April 2008

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https://en.citizendium.org/wiki/index.php?title=Alcohol_withdrawal&printable=yes
This editable Main Article is under development and subject to a disclaimer.

Alcohol withdrawal is a group of syndromes that may occur after cessation of drinking ethanol alcohol.[1]

Classification

Alcohol withdrawal associated autonomic hyperactivity

Alcohol withdrawal 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".[2][3]

Alcohol withdrawal delirium

Alcohol withdrawal delirium 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. It was formerly called delirium tremens".[4][5]

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.[6][7] A non-randomized, before and after, observational study found that symptom triggered therapy was advantageous.[8]

Dosing of the benzodiazepines can be guided by the CIWA-Ar scale.[9] The scale is available online.[10]

Regarding the choice of benzodiazepine:

  • Chlordiazepoxide (Librium®) is the benzodiazepine of choice in uncomplicated alcohol withdrawal. [11]
  • 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[12] and clonidine.[13]

Carbamazepine

A randomized controlled trial has found benefit from carbamazepine.[14]

Other drugs

Some hospitals administer alcohol to prevent alcohol withdrawal although there are potential problems with this practice.[15]

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. ↑ 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
  2. ↑ Anonymous (2024), Alcohol withdrawal seizures (English). Medical Subject Headings. U.S. National Library of Medicine.
  3. ↑ 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. 
  4. ↑ Anonymous (2024), Alcohol withdrawal delirium (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, 1175. ISBN 0-07-067439-6. 
  6. ↑ 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]
  7. ↑ 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]
  8. ↑ 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]
  9. ↑ 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]
  10. ↑ Holbrook AM, Crowther R, Lotter A, Cheng C, King D (1999). "Diagnosis and management of acute alcohol withdrawal". CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne 160 (5): 675-80. PMID 10102003. [e] (see appendix 2)
  11. ↑ 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
  12. ↑ 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]
  13. ↑ 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]
  14. ↑ 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]
  15. ↑ Blondell RD, Dodds HN, Blondell MN, et al (2003). "Ethanol in formularies of US teaching hospitals". JAMA 289 (5): 552. PMID 12578486. [e]
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