Medical management of the hospitalized alcoholic patient

Goals and ObjectivesUnderstand the pathophysiology of alcohol withdrawal and treatment Discuss how to use the Signs and Symptoms Assessment SSA scoring system to prevent and treat alc

Medical Management of the

Hospitalized Alcoholic Patient:

Joseph S Bertino Jr., Pharm.D.

Goals and Objectives

Understand the pathophysiology of alcohol

withdrawal and treatment

Discuss how to use the Signs and

Symptoms Assessment (SSA) scoring

system to prevent and treat alcohol

withdrawal syndrome

Classes of Drugs of Abuse

Anticholinergic drugs

Cannabinoids (marijuana)

Dissociative drugs (phencyclidine, ketamine)

Opiates (morphine, heroin)

Hallucinogens (LSD, mescaline)

Sedative-hypnotics (barbiturates,

benzodiazepines, alcohol)

Stimulants (amphetamine, cocaine)

Volatiles (glue, gasoline, paint remover)

Drugs and Neurotransmitter

Actions that Cause Symptoms

GABA 5-HT NE AcCH β -endorphin Dopamine Opiates

Why Are the Neurotransmitters

Important?

You cannot use the same strategies for

treatment or withdrawal from alcohol for

other drugs of abuse

The primary neurotransmitter affected by

chronic alcohol use is GABA

You must replace GABA to treat alcohol

withdrawal syndrome

Etiology of Alcohol Withdrawal Syndrome

The brain adapts to chronic alcohol use Alcohol potentiates the post-synaptic effect

of GABA (sedation) Alcohol withdrawal causes a sudden deficiency of GABA

Deficiency of GABA causes hyperactivity

in a patient…A large adrenergic stimulation

Etiology of Alcohol Withdrawal

Alcohol stimulates norepinephrine (NE)

synthesis and release

receptor sensitivity to NE is reduced

In acute alcohol withdrawal

NE synthesis continues

NE release decreases

NE receptors become are very sensitive

Etiology of Alcohol Withdrawal

Dopamine receptor sensitivity increased by

alcohol

In acute alcohol withdrawal, dopamine receptors

become very sensitive

Kindling: repeated stimulation of brain causes

increased sensitivity of neurons

Repeated episodes of acute alcohol withdrawal

may stimulate kindling and seizures…each time a

patient has alcohol withdrawal syndrome the

symptoms are worse

Alcohol Withdrawal Syndrome

Stages of Alcohol Withdrawal

Syndrome

Stage 1: Autonomic hyperactivity (100%)

Occurs within hours of last use of alcohol and lasts

24-48 hours

Stage 2: Hallucinations (25%):

Occurs 8-48 hours after last use of alcohol

Stage 3: Brain stimulation and seizures (10%):

Occurs 6-48 hours after last use of alcohol

Stage 4: Delirium Tremens (DTs) (5%)

Occurs 2-5 days after last alcohol use, 15% die

Alcohol Withdrawal Symptoms

Symptom Onset after

Alcohol Withdrawal Symptoms

Symptom Onset after

alcohol stops

Usual duration Vivid dreams As EtOH Conc ↓ 48 hr

Insomnia As EtOH conc ↓ 48 hr

Tremor 6-24 hr 48 hr

Nausea/vomiting 6-24 hr 48 hr

Physical Signs of Acute

Alcohol Withdrawal (Stage 1)

Autonomic nervous system hyperactivity

Physical Signs of Acute Alcohol

Withdrawal (Stages 2 and 3)

Changes in perception, sensation, and

arousal may produce:

Hallucinations (Stage 2)

Occur in 3-10 % of patients

Increased risk with use of larger amounts

of alcohol

Are not predictive of DTs (stage 4) and are

not necessarily related to DTs

May be auditory (hearing), tactile (feeling),

olfactory (smelling)

Patients are rarely disoriented (i.e they

have ego-intact hallucinations)

Hallucinations (Stage 2)

Hallucinations may be confused with

schizophrenia

Hallucinations may persist for weeks

Hallucinations may be permanent

Seizures (Stage 3)

Usually 1-2 grand mal (tonic-clonic) seizures

Focal seizures are unusual

Second seizure usually occurs within 6 hours

after the first seizure

5-15% incidence

Occasionally, status epilepticus seen in < 3 % of patients

Seizures (Stage 3)

Seizure incidence increases with

increased or repeated alcohol abuse

(“kindling” phenomenon)

Predisposing factors for seizures:

Previous seizures for any reason

head trauma

previous alcohol withdrawal syndrome

seizures

Delirium Tremens (Stage 4)

Most severe manifestation of alcohol

As age increases, risk of DTs increases

Rare in patients < 30 years of age

Delirium Tremens (Stage 4)

Delirium tremens (DTs)

Large autonomic hyperactivity

gross tremor

delirium (hallucinations)

usually occurs after 3 days of untreated or

poorly treated AWS

may occur as late as 5-14 days after untreated

or poorly treated AWS

Delirium Tremens (Stage 4)

Symptoms:

disorientation

confusion

visual hallucinations

Increased autonomic activity

Hyperpyrexia (increased temperature)

Treatment: Provide adequate sedation

(large, frequent doses of benzodiazepines)

cannot stop DTs once they have begun

Medical Complications in

Patients with Alcoholism

Increased risk of all types of infections due

to:

decreased WBC function

decrease in other immunologic factors

Taking increased risks in lifestyle

Increased incidence of bacterial

pneumonia caused by pathogens rare in

the normal population

Medical Complications in

Patients with Alcoholism

Increased risk of aspiration pneumonia

Increased risk of spontaneous bacterial

peritonitis (SBP)

Cardiomyopathy and arrhythmias

associated with alcoholism and withdrawal

Hypertension is common in alcoholics

Assessment and Treatment of

Alcohol Withdrawal Syndrome

The Problem

Patients may not tell physician about

alcohol use if they are not asked about it

Patients usually will state they use much

less alcohol than they really do use

Surgical patients may never be asked

about alcohol use

Homemade alcohol drinks may vary in

alcohol content

Alcohol Use in Vietnam

WHO 2014

Prevalence of High Alcohol Use and Dependence in Vietnam 2010 WHO

Vietnamese consume twice as much beer as any other SE Asian country

Drugs to Treat Alcohol

Withdrawal Syndrome

Drug treatment of alcohol withdrawal

syndrome uses benzodiazepines (BZD)

BZD substitutes for alcohol at the GABA

receptor and reduces symptoms

Benzodiazepine (BZD) and Alcohol

Withdrawal Syndrome (AWS)

BZD are not useful in treating withdrawal

hallucinations (prevention important)

BZD are useful in reducing adrenergic

stimulation due to GABA deficiency

BZD also prevent seizures in AWS

No evidence that one BZD is more

effective than another as a substitute for

alcohol

Advantages

Good anticonvulsant properties

high therapeutic to toxic ratio

good pharmacokinetic profile

good pharmacodynamic profile

lower potential for tolerance and abuse

Disadvantages

no effect on hallucinations

Will not stop DTs once they have started

Benzodiazepines: Choice of

Drug and Dose/Dose Interval

May use a fixed dose schedule

or

Symptom triggered therapy (Therapy of

choice)

results in significantly less medication used

results in significantly shorter hospitalization

Management Goals of Alcohol

Detoxification

Symptomatic relief and prevention of

disease progression

Prevent medical complications

Fluid hydration, vitamins, thiamine, monitor

electrolytes

Minimize drug treatment related toxicity

Drugs Used in Alcohol

Withdrawal Syndrome

Thiamine 100 mg IM every 12 hours for 2

doses then 100 mg by mouth once daily

Glucose infusion

Folic Acid 1 mg by mouth daily

Multivitamins one a day by mouth

Benzodiazepine dosed based on a scoring

system

Signs and Symptoms Assessment

Protocol to Treat Alcohol

Withdrawal Syndrome

Alcohol Withdrawal Syndrome Scoring

System for BZD Dosing

) ) I

A P P E N D I X 4 THE MARY IMOGENE BASSETT HOSPITAL

a ) I f p a t i e n t h a s s i g n s a n d s y m p t o m s a s s e s s m e n t o f 4 - 6 , g i v e

c ) I f p a t i e n t h a s s i g n s a n d s y m p t o m s a s s e s s m e n t o f 9 - 1 0 , g i v e

d ) I f p a t i e n t h a s s i g n s a n d s y m p t o m s a s s e s s m e n t o f 1 1 - 1 2 , g i v e

T H E M A R Y I M O G E N E B A S S E T T H O S P I T A L

C O O P E R S T O W N , N E W Y O R K 1 3 3 2 6 - 1 3 9 4

N A M E

S I G N S A N D S Y M P T O M S A S S E S S M E N T

D A T E

- W I T H D R A W A L A S S E S S M E N T F O R M

H - 5 7 8 4 6 / 9 1 ; 4 / 9 2 ( d A t o r m s \ h o s p )

1

A s s e s s f o r s i g n s a n d s y m p t o m s o f w i t h d r a w a l q 2 h a n d p r n u n l e s s o t h e r w i s e o r d e r e d

2 S c o r e p a t i e n t u s i n g c r it e r i a o n b a c k o f f o r m

3 A d d p o i n t s a n d u s e t o t a l s c o r e t o d e t e r m i n e n e e d f o r m e d i c a t io n a s f o l l o w s :

q 2 h a n d p r n

b ) I f p a t i e n t h a s s i g n s a n d s y m p t o m s a s s e s s m e n t o f 7 - 8 , g i v e q 2 h a n d p r n

q 2 h a n d p r n

q 2 h a n d p r n

e ) I f p a t i e n t h a s s i g n s a n d s y m p t o m s a s s e s s m e n t o f > 1 2 , g i v e q 2 h a n d p r n

4 N o t i f y h o u s e o f f i c e r f o r c o n s e c u t i v e s i g n s a n d s y m p t o m s a s s e s s m e n t s c o r e s o f 1 0 o r g r e a t e r , o r a s c o r e w h i c h i n c r e a s e s b y g r e a t e r t h a n 5 o n c o n s e c u t i v e e v a l u a t i o n s

5 P a t i e n t s c o n s i s t e n t l y s c o r i n g 1 0 o r a b o v e s h o u l d b e a s s e s s e d e v e r y h o u r u n t i l i m p r o v e m e n t n o t e d

A s s e s s p a t i e n t q 2 h w h e n a w a k e o r a s l e e p w h i l e d e t o x i n g

D A T E B A C B / P P U L S E T E M P V O M I T I N G T R E M O R A G I T A T I O N L E S S N E S S S W E A T I N G T O T A L N A T I O N S I O N S D O S E I N I T I A L S

Blood Pressure Measurement

3 = Systolic over 200 or diastolic over 110 mmHg

Maximum score of 3 on any BP

Considerations for using SSA

Hallucinations:

Do not score as number

Need to treat if the hallucinations are not ego-intact

Treated with haloperidol

Consider haloperidol if hallucinations are threatening to

patient or staff

Haloperidol may increase the risk of hypotension

Haloperidol may increase the risk of seizures

Considerations for using SSA

Seizures:

Do not score as number

Assure patient is on seizure prophylaxis.

Consider need for further assessment of seizure.

Considerations for using SSA

Blood pressure may be elevated in presence of:

hypertension

pain (trauma, post op, acute rhabdomyolysis)

Temperature may be elevated in presence of:

Considerations for using SSA

Tremor may be present :

at baseline secondary to alcoholic

other neurologic or psychiatric conditions

Sleeplessness may be present with sleep apnea

caused by alcoholism

Considerations for using SSA

Sweating may occur in presence of:

infection or fever

Nausea/vomiting may be present with:

post operative effects of anesthesia

underlying gastrointestinal problem (gastritis, GI

bleeding, etc.)

Delay in appearance of alcohol withdrawal signs

and symptoms can occur after anesthesia.

Alcohol Detoxification Worksheet

Standard Regimen:

If SSA < 4 give no diazepam

If SSA 4-6, give diazepam 10mg po Q2H & prn

If SSA 7-8, give diazepam 15mg po Q2H & prn

If SSA 9-10, give diazepam 20mg po Q2H & prn

If SSA 11-12, give diazepam 25mg po Q2H & prn

If SSA > 12, give diazepam 30mg po Q2H & prn

Alcohol Detoxification Worksheet

Standard regimen for patients who cannot

use oral medications:

If SSA < 4 no drug is given

If SSA 4-6, give diazepam 5mg slow IV push Q2H & prn

If SSA 7-8, give diazepam 7.5mg slow IV push Q2H & prn

If SSA 9-10, give diazepam 10mg slow IV push Q2H & prn

If SSA 11-12, give diazepam 12.5mg slow IV push Q2H &

prn

Alcohol Withdrawal Syndrome

Use lorazepam instead of diazepam:

for patients with impaired liver function

for elderly patients who may be unable to

metabolize diazepam

for patients with poor venous access who

cannot take oral medication (can give

lorazepam IM, do not give diazepam IM)

Seizure Prophylaxis

Recommendations for seizure prophylaxis:

Recommended for patients with:

• suspected or documented history of seizures

• History of seizures during previous alcohol withdrawal

SSA Protocol Is the Starting

Point for Treatment

May increase the dose of BZD if required

to control symptoms

May increase the SSA score required to

receive medication if necessary to account

for underlying medical problems which can

increase SSA score:

hypertension

tremor

Benzodiazepine Dosing

Patients should receive a benzodiazepine

in the amounts necessary to control

symptoms.

Patients require close monitoring until

symptoms are controlled.

For patients with significant co-morbidities,

medications should be considered even if

withdrawal is mild to moderate.

Use of Large Doses of

Patients with large alcohol use or repeated

alcohol withdrawal syndrome may require

larger doses of benzodiazepines

Total daily dose is determined by efficacy and

toxicity

Use of Large Doses of

Benzodiazepines

Sedation is common

Respiratory depression is rare

Flumazenil should almost never be used to

reverse benzodiazepine side effects

Assess patient frequently with SSA (as often

as every 5-10 minutes)

Give additional doses as needed

The SSA protocol is the starting point for safe

and effective management of alcohol withdrawal.

The SSA protocol is only safe and effective if

properly used and interpreted.

Understanding the pathophysiology of alcohol

withdrawal and treatment makes treatment more

effective.

Pharmacists can implement and direct an alcohol

withdrawal syndrome treatment program

Thank you Questions and Comments

Nurses are the key personnel for assessing

the patient’s stage of withdrawal.

Nurses are the key personnel for assuring

patient safety.

Early intervention is the key to prevention of

medical complications of alcohol withdrawal

syndrome