What is Medicine – Alcohol Withdrawal Syndrome
ESSENTIAL DESCRIPTION Alcohol withdrawal syndrome (AWS) is a range of symptoms brought on by a sudden reduction in alcohol consumption after a protracted time of use. It can cause everything from modest side effects like tremors and sleepiness to serious ones like seizures and delirious tremors. The majority of the time, symptoms appear within a few hours of the last drink and peak 24 to 48 hours later. EPIDEMIOLOGY Incidence As of 2019, 14.5 million Americans meet the diagnostic criteria for alcohol consumption disorder (AUD), according to the National Survey on Drug consumption and Health. AWS has been experienced by about 50% of people with AUD at some point in their lives. 4% of patients were given access to FDA-approved drugs to treat AUD. AWS risk increases for 2-7% of hospitalised patients who use alcohol heavily, and alcohol use accounts for 32% of ER visits. AUD are among the most common mental illnesses, with lifetime and 12-month prevalence rates of 13.9% and 29.1%, respectively. A higher prevalence is seen in men, younger, single persons, and people from poorer socioeconomic backgrounds. PATHOPHYSIOLOGY AND AETIOLOGY With chronic alcohol use, this recurrent activation downregulates the inhibitory effects of the neurotransmitter gamma-aminobutyric acid (GABA), which is stimulated by alcohol consumption. At the same time that alcohol use suppresses glutamate on the central nervous system (CNS), excitatory N-methyl-D-aspartate glutamate receptors are upregulated by long-term alcohol usage. When alcohol use is suddenly halted, the combined effects of a downregulated inhibitory system (GABA modulated) and an upregulated excitatory system (glutamate modulated) lead to brain hyperexcitability that is no longer inhibited by alcohol; this condition is known clinically as AWS. Genetics The aetiology of AUD is multifaceted, and research indicates that 50% of those who have AUD have a hereditary susceptibility. Long-term heavy alcohol use, a history of alcohol withdrawal episodes, seizures, and delirium tremens (DTs), elevated blood pressure at presentation, comorbid medical conditions, or a surgical illness, and physiological dependence on benzodiazepines (BZDs) or barbiturates are risk factors. Aspects of Geriatrics Elderly people with AUD are more vulnerable to withdrawal, and they are more likely to experience consequences from withdrawal due to chronic comorbid illnesses. pregnant women's issues For the management of acute alcohol withdrawal, inpatient hospitalisation is advised during pregnancy. GENERAL PREVENTION To decrease unhealthy alcohol use, the U.S. Preventive Services Task Force advises universal screening for all people. The most sensitive and precise screening question for identifying unhealthy alcohol use is "How many times in the past year have you had 5 or more (men) or 4 or more (women) drinks in one day." CAGE, AUDIT, or AUDIT-C are quick, common assessment screening techniques that can be used to identify unhealthy alcohol usage. CONDITIONS OFTEN Associated with Dehydration, poor nutrition, and weight loss are general symptoms. Renal symptoms include electrolyte abnormalities (hyponatremia, hypokalemia, hypomagnesemia, and hypophosphatemia). GI symptoms include hepatitis, cirrhosis, esophageal varices, pancreatitis, and portal hypertension. Haematological symptoms include thrombocytopenia and macrocytic anaemia. Cardiovascular symptoms include hypertension, atrial fibrillation, CNS symptoms include seizures, hallucinations, memory loss, atrophy, and Wernicke-Korsakoff syndrome. Peripheral nervous system symptoms include neuropathy. Psychiatric symptoms include depression, post-traumatic stress disorder, bipolar disorder, and polysubstance use disorder. Reproductive symptoms include amenorrhea and sexual dysfunction. Diagnostic criteria for AWS according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: - Two (or more) of the symptoms listed below appear within a few hours of stopping or cutting back on strong and extended alcohol consumption: Hyperactive autonomic function Hand tremor, generalised seizures, anxiety, insomnia, psychomotor agitation, nausea, and vomiting Transient hallucinations or illusions of the visual, auditory, or tactile types - Signs or symptoms seriously hinder a person's social, professional, or occupational functioning. – The presence of signs and symptoms does not imply an underlying physical or mental illness. Clinical signs of AWS can be categorised into three groups of symptoms. - Autonomic hyperactivity: peak 24 to 48 hours after peak commencement a few hours after cessation. - Neural excitation: Seizures linked to alcohol withdrawal are frequently transient and typically start 12 to 48 hours after the last drink. Alcohol withdrawal delirium appears 48 to 72 hours after ceasing to consume alcohol. HISTORY The following key historical details should be included: The amount and duration of alcohol consumed, as well as the time since the last drink Prior seizure activity, preexisting medical and psychiatric disorders, prior alcohol withdrawal symptoms, concurrent substance use, and social history including living circumstances, social support, stresses, and triggers Physical examinations must evaluate any conditions that are made worse by AWS. Heart failure, arrhythmias, and coronary artery disease are cardiovascular conditions. General: hand tremor (six to eight cycles per second), infections, GI bleeding, liver disease, and pancreatitis. Neuro: oculomotor dysfunction, gait ataxia, and neuropathy. Psych: orientation and memory. Hepatic encephalopathy may make these conditions worse. DIFFERENTIAL DIAGNOSIS Intoxication with cocaine and amphetamines; Withdrawal from opioids, marijuana, and other sedatives; Toxicity from anticholinergic medications; Neuroleptic Malignant Syndrome Mania, psychosis, anxiety, or panic disorder; ICU delirium; sepsis; CNS infection; or haemorrhage; and thyroid crisis DETECTION & INTERPRETATION OF DIAGNOSIS Initial examinations (lab, imaging) Blood alcohol content and a urine drug test Full metabolic panel; complete blood count Lipase, GGT, and amylase Head CT for individuals who report with symptoms that are not typical of withdrawal or who have unusually stable mental states for withdrawal If this is your first seizure, get a complete neurological examination including a lumbar puncture, EEG, and other tests. Tests in the Future & Special Considerations Consider abdominal ultrasonography or CT in patients who report unusual pain, elevated lipase or amylase levels. Electrocardiograms are advised for people older than 50 or those who have a history of cardiac issues. Interpretation of Tests Patients who have used alcohol for a long time metabolise it at a quicker rate of 20 to 30 mg/dL/hr. The average rate of alcohol metabolism is 10 to 15 mg/dL/hr. These equations can be used to estimate when withdrawal symptoms might get worse. Blood alcohol content (BAC): A blood alcohol level of 100% may result in loss of coordination and mood disturbances. In the US, a blood alcohol content of 80 is regarded as legally intoxicated. BAC: 100 to 199 neurological dysfunction, sluggish reflexes, or ataxia Unless the person has a clear tolerance, a BAC of 200 to 299 indicates evident intoxication. BAC levels of 300 or above have been linked to death, forgetfulness, slurred speech, and coma. GENERAL TREATMENT MEASURES - "Provide a safe withdrawal from the drug(s) of dependence." is one of the therapy's objectives. "Provide a humane withdrawal and uphold the dignity of the patient." "Get the patient ready for ongoing treatment for alcohol dependence." The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), can be used to determine the frequency and dosage of AWS medication. Except for orientation and sensorium clouding, which are scored on a scale from 0 to 4, the severity of symptoms are graded on a scale from 0 to 7, with 0 representing no symptoms and 7 representing the highest score. - Vomiting and nausea - Tactile disturbances - Tremor - Disturbances in hearing - Paroxysmal sweating - Disturbances in vision - Anxiety - Headache or feeling of heaviness in the head - Agitation - Orientation and sensorium clouding The highest possible CIWA-Ar score is 67. - Mild withdrawal = score of 8 or less: typically resolves without medication - Moderate withdrawal = 8 to 14: frequently needs medication management - Seizures and the emergence of DTs are most likely in patients with severe withdrawal (>15), according to research. It is essential to frequently reevaluate using the CIWA-Ar score. First Line: MEDICATION For CIWA scores more than 10, BZD monotherapy is still the preferred course of action. Based on the following factors, BZD should be chosen: - Agitation is more immediately controlled by substances with a rapid onset, such as IV diazepam. - Long-acting BZDs (diazepam, chlordiazepoxide) lessen breakthrough or rebound symptoms and are more effective at preventing seizures. - When persistent sedation is a problem (such as with elderly patients or those who have other major concurrent medical conditions), short-acting BZDs (such as lorazepam and oxazepam) are preferable. They are also preferable when there is severe hepatic impairment. The patient's BZD dosages will differ. can adopt regimens that are symptom-triggered or fixed in time. - Symptom-triggered regimens are favoured, are linked to lower BZD levels, and shorten hospital stays. - Fixed-schedule regimens are acceptable for patients with severe coronary artery disease, those who have a history of withdrawal seizures, or nursing staff who have not received training for symptom-triggered regimens. Symptom-triggered regimen: Give one of the drugs listed below every 4 to 6 hours, with additional doses as needed (PRN) when CIWA-Ar is below 8. One hour after each dose, evaluate the need for additional medicine. - 50–100 mg of chlordiazepoxide orally - Diazepam: 10–20 mg orally 30 to 60 mg orally of oxycodone.- 2 to 4 mg PO of lorazepam Administer one of the drugs listed below every 6 hours according to a fixed schedule: - Chlordiazepoxide: 50 mg PO for 4 doses, followed by 8 doses of 25 mg PO. - Diazepam: 4 doses of 10 mg PO followed by 8 doses of 5 mg PO - Lorazepam: 2 mg PO for four doses, followed by 1 mg PO for eight doses. - Vital to keep a tight eye on things and give out more BZDs if CIWA-Ar is above 8. Folic acid dosage: daily 1 mg Thiamine: 50 to 100 mg per day - Don't give IV glucose before providing thiamine as this could hasten Korsakoff psychosis and Wernicke encephalopathy. As soon as electrolyte imbalances or irregularities arise, correct them. -Blockers (such as atenolol or propranolol) and 2-agonists (such as clonidine) help to control hypertension and tachycardia but do not prevent severe symptoms like DT or seizures; not used as monotherapy Carbamazepine: associated with reduced seizures and effective at mild withdrawal; should not be used as a monotherapy If the patient exhibits significant withdrawal symptoms, such as DT or seizures, discontinu ADVANCED THERAPIES Physical therapy should be evaluated for peripheral neuropathy and cerebellar impairment. CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING Conditions for admittance as a patient: Poor ability to follow up or no reliable social support Pregnancy History of severe withdrawal symptoms History of seizure disorder, withdrawal seizures, or DTs Presence of cardiovascular disease Concurrent psychiatric illness, associated medical or surgical illness Concurrent nystagmus, confusion, which may indicate Werniecke encephalopathy Severe nausea or vomiting that prevents ingestion of medications CONTINUING CARE AFTERCARE RECOMMENDATIONS Treating the patient's underlying AUD is only the first step after managing alcohol withdrawal. Discharge plans should incorporate the following: - Creation of a strategy to involve the patient in additional therapy - Transition to outpatient substance use counselling, peer support groups, and/or a residential treatment centre. - Prescription of any FDA-approved medication-assisted therapy that is available. Glutamate and GABA modulator acamprosate (666 mg PO TID) is said to lessen cravings - Renal impairment (CrCl 30 mL/min) is a contraindication. Due to daily multidosing, compliance may be a problem; recent research cast doubt on the benefits. Naltrexone: an opiate receptor antagonist that lessens desire (50 mg/day PO; 380 mg IM every 4 weeks). After the patient has been without opioids for at least 7 days, start the therapy. Acute hepatitis/liver failure and concurrent opioid medication are contraindications, and the treatment is only effective for three to six months. Disulfiram (250 mg/day PO) causes an adverse reaction to alcohol by interfering with aldehyde dehydrogenase, blocking alcohol metabolism, and causing an accumulation of acetaldehyde. It is a second-line option due to limited evidence of its effectiveness for preventing relapse. However, it is contraindicated in cases of psychosis, severe myocardial disease, diabetes, seizures, emphysema, severe liver and renal patient observation Continual follow-up to check for relapse Advance your diet as tolerated EDUCATION OF PATIENTS www.aa.org is the website for Alcoholics Anonymous. Self-Management and Recovery Training (SMART Recovery): www.smartrecovery.org (not based on religion) http://www.niaaa.nih.gov/guide/ is the website of the National Institute on Alcohol Abuse and Alcoholism. Alcohol withdrawal syndrome on FamilyDoctor.Org (Spanish resources available) PROGNOSIS 1-5% of people die from severe withdrawal syndrome (DTs). COMPLICATIONS occurs more commonly in people with concurrent diseases or previous instances of withdrawal
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