Alcohol withdrawal: Difference between revisions
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− | == |
+ | == Background == |
+ | === Risk Factors for Severe Withdrawal === |
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− | * 6 to 12 hours after last drink: shaking, headache, sweating, anxiety, nausea, or vomiting |
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− | * 12 to 24 hours after last drink: confusion, hallucinosis (with awareness of reality), tremor, or agitation |
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− | * 24 to 48 hours after last drink: seizures |
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− | * 48 hours after last drink: delirium tremens, high blood pressure, and fever |
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− | ** Can persist anywhere from 4 to 12 days |
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+ | *Severity predicted by [[PAWSS scale]]: if score ≤3 can manage as outpatient |
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− | == Risk Factors == |
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+ | *History of alcohol withdrawal, especially if previously severe (e.g. delirium tremens) |
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+ | *Age |
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+ | *Alcohol tolerance |
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+ | *Concurrent sedative medications |
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+ | *Major medical comorbidities |
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+ | *Drinking all day long |
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+ | ==Clinical Manifestations== |
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− | * Severity predicted by [PAWSS scale](PAWSS scale.png) |
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− | * History of same |
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− | * Age |
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− | * Alcohol tolerance |
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− | * Concurrent sedative medications |
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− | * Major medical comorbidities |
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− | * Drinking all day long |
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+ | *6 to 12 hours after last drink: shaking, headache, sweating, anxiety, nausea, or vomiting |
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− | == Investigations == |
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+ | *12 to 24 hours after last drink: confusion, hallucinosis (with awareness of reality), tremor, or agitation |
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+ | *24 to 48 hours after last drink: seizures |
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+ | *48 hours after last drink: delirium tremens, high blood pressure, and fever |
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+ | **Can persist anywhere from 4 to 12 days |
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+ | ==Investigations== |
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− | * Monitor electrolytes and extended electrolytes for refeeding syndrome |
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+ | *Monitor electrolytes and extended electrolytes for refeeding syndrome |
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− | == Management == |
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+ | ==Management== |
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− | * CIWA-Ar (Clinical Institute Withdrawal Assessment - Alcohol revised) q1h |
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− | * Discontinue CIWA-Ar after two consecutive scores <10 |
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− | * CIWA-Ar 10-20 |
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− | ** First-line: diazepam 10mg PO/IV q1h |
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− | ** Liver dysfunction: lorazepam 2mg PO/IV/IM q1h |
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− | ** Liver failure, age >60, chronic opioid use, acute respiratory illness: lorazepam 1mg PO/IV/IM q1h |
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− | * CIWA-Ar >20 |
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− | ** 1L NS bolus over 30 minutes followed by 200mL/h |
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− | ** First-line: diazepam 20mg PO/IV q1h |
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− | ** Liver dysfunction: lorazepam 4mg PO/IV/IM q1h |
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− | ** Liver failure, age >60, chronic opioid use, acute respiratory illness: lorazepam 2mg PO/IV/IM q1h |
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− | * If history of seizures: |
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− | ** Diazepam 20mg q1h x3 doses before starting CIWA |
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− | * For seizures: |
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− | ** Lorazepam prn until terminates |
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− | ** After seizure, lorazepam 2mg IV once to prevent recurrence |
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− | * Alternatives to diazepam/lorazepam: |
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− | ** Chlordiazepoxide |
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− | ** Phenobarbital |
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− | *** Load 10mg/kg IV up front over 30min (if has not received significant benzos) |
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− | *** Then give 130-260mg IV prn for mild to severe withdrawal symptoms |
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− | *** Titrate to effect; there is no maximum dose |
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− | *** Maintenance with 100-200mg PO/IM q1h prn |
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− | * Thiamine: |
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− | ** Standard: 250mg IM/IV q24h x3d |
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− | ** High-dose: 500mg IV TID x3 |
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+ | * Given the balance of risks (minimal) and benefits (potentially large), almost all patients treated for alcohol withdrawal should receive supplemental [[thiamine]] |
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+ | ** Standard: 250 mg IM/IV q24h x3d |
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+ | **High-dose: 500 mg IV q8h x3 |
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+ | |||
+ | === Inpatient Management === |
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+ | |||
+ | ==== Benzodiazepine Protocols ==== |
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+ | |||
+ | *If history of seizures: [[diazepam]] 20mg q1h x3 doses before starting CIWA |
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+ | *Can use [[diazepam]], [[lorazepam]] (if liver disease), or [[Chlordiazepoxide]] |
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+ | *Start [[CIWA-Ar]] (Clinical Institute Withdrawal Assessment - Alcohol revised) q1h |
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+ | **[[CIWA-Ar]] 10-20 |
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+ | ***First-line: [[diazepam]] 10mg PO/IV q1h |
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+ | ***Liver dysfunction: [[lorazepam]] 2mg PO/IV/IM q1h |
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+ | ***Liver failure, age >60, chronic opioid use, acute respiratory illness: [[lorazepam]] 1mg PO/IV/IM q1h |
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+ | **[[CIWA-Ar]] >20 |
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+ | ***1L NS bolus over 30 minutes followed by 200mL/h |
||
+ | ***First-line: [[diazepam]] 20mg PO/IV q1h |
||
+ | ***Liver dysfunction: [[lorazepam]] 4mg PO/IV/IM q1h |
||
+ | ***Liver failure, age >60, chronic opioid use, acute respiratory illness: [[lorazepam]] 2mg PO/IV/IM q1h |
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+ | **Discontinue [[CIWA-Ar]] protocol after two consecutive scores <10 |
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+ | |||
+ | ==== Phenobarbital Protocols ==== |
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+ | |||
+ | ===== General Protocol ===== |
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+ | |||
+ | * Load [[phenobarbital]] 10 mg/kg IV up front over 30min (if has not received significant benzodiazepines) |
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+ | * Then give 130-260 mg IV prn for mild to severe withdrawal symptoms |
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+ | * Titrate to effect; there is no maximum dose |
||
+ | * Maintenance with 100-200 mg PO/IM q1h prn |
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+ | |||
+ | ===== CAMH protocol ===== |
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+ | |||
+ | * Loading: [[phenobarbital]] 120 mg po q1h until phenobarbital loading effect score is 3 to 4, then stop loading |
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+ | * Maintenance: [[phenobarbital]] 60 mg po qid |
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+ | * Taper: |
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+ | ** Decrease by 30 mg each day from a starting dose of [[phenobarbital]] 60 mg po qid |
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+ | ** 60/60/60/60, 60/30/60/60, 60/30/30/60, 60/30/30/30, 30/30/30/30, 30/–/30/30, 30/–/–/30, 30/–/–/–, stop |
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+ | ** Takes 8 days |
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+ | * [[Phenobarbital]] loading effect scale |
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+ | ** [[Nystagmus]]: absent (0); present on extension of lateral gaze (1); easily elicited and sustained (2); coarse, sustained nystagmus (3) |
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+ | ** [[Dysarthria]]: absent (0); minor slurring of some words (1); moderate slurring frequently (2); severe slurring, unintelligible (3) |
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+ | ** [[Ataxia]]: absent (0); mildly unsteady on tandem gait (1); moderately unsteady on regular gait (2); needs support on regular gait (3) |
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+ | ** Emotional lability: normal, as before loading (0); some mood change (1); obvious mood change, inappropriate (2); uninhibited, mood swings (3) |
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+ | |||
+ | ==== Seizures ==== |
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+ | |||
+ | *[[Lorazepam]] prn until terminates |
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+ | *After seizure, [[lorazepam]] 2mg IV once to prevent recurrence |
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+ | |||
+ | === Outpatient Management === |
||
+ | |||
+ | * For patients at low risk of complicated withdrawal, office-based management can be considered |
||
+ | ** Start on Monday or Tuesday, unless there is weekend coverage for the clinic |
||
+ | ** Assess the patient daily |
||
+ | * Typically use [[diazepam]] per schedule below, with [[thiamine]] 100 mg po daily for 5 days |
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+ | |||
+ | {| class="wikitable" |
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+ | !Schedule |
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+ | !Day 1 |
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+ | !Day 2 |
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+ | !Day 3 |
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+ | !Day 4 |
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+ | |- |
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+ | |Rigid |
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+ | |10 mg qid |
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+ | |10 mg tid |
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+ | |10 mg bid |
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+ | |10 mg qhs |
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+ | |- |
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+ | |Flexible |
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+ | |10 mg q4-6h prn |
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+ | |10 mg q6-8h prn |
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+ | |10 mg q12h prn |
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+ | |10 mg qhs prn |
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+ | |- |
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+ | |Front-loaded |
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+ | |20 mg q2-4h until sedated, followed by 10 mg q4-6h prn (max 60 mg daily) |
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+ | |10 mg q4-6h prn (max 40 mg) |
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+ | |10 mg q4-6h prn (max 40 mg) |
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+ | |none |
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+ | |} |
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[[Category:Addiction medicine]] |
[[Category:Addiction medicine]] |
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+ | |||
+ | * Symptoms to trigger prn doses in the above schedules include heart rate >100, DBP >90 mmHg, or signs of withdrawal |
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+ | * Front-loaded schedules often need very little medication after the load |
Latest revision as of 15:02, 31 December 2021
Background
Risk Factors for Severe Withdrawal
- Severity predicted by PAWSS scale: if score ≤3 can manage as outpatient
- History of alcohol withdrawal, especially if previously severe (e.g. delirium tremens)
- Age
- Alcohol tolerance
- Concurrent sedative medications
- Major medical comorbidities
- Drinking all day long
Clinical Manifestations
- 6 to 12 hours after last drink: shaking, headache, sweating, anxiety, nausea, or vomiting
- 12 to 24 hours after last drink: confusion, hallucinosis (with awareness of reality), tremor, or agitation
- 24 to 48 hours after last drink: seizures
- 48 hours after last drink: delirium tremens, high blood pressure, and fever
- Can persist anywhere from 4 to 12 days
Investigations
- Monitor electrolytes and extended electrolytes for refeeding syndrome
Management
- Given the balance of risks (minimal) and benefits (potentially large), almost all patients treated for alcohol withdrawal should receive supplemental thiamine
- Standard: 250 mg IM/IV q24h x3d
- High-dose: 500 mg IV q8h x3
Inpatient Management
Benzodiazepine Protocols
- If history of seizures: diazepam 20mg q1h x3 doses before starting CIWA
- Can use diazepam, lorazepam (if liver disease), or Chlordiazepoxide
- Start CIWA-Ar (Clinical Institute Withdrawal Assessment - Alcohol revised) q1h
Phenobarbital Protocols
General Protocol
- Load phenobarbital 10 mg/kg IV up front over 30min (if has not received significant benzodiazepines)
- Then give 130-260 mg IV prn for mild to severe withdrawal symptoms
- Titrate to effect; there is no maximum dose
- Maintenance with 100-200 mg PO/IM q1h prn
CAMH protocol
- Loading: phenobarbital 120 mg po q1h until phenobarbital loading effect score is 3 to 4, then stop loading
- Maintenance: phenobarbital 60 mg po qid
- Taper:
- Decrease by 30 mg each day from a starting dose of phenobarbital 60 mg po qid
- 60/60/60/60, 60/30/60/60, 60/30/30/60, 60/30/30/30, 30/30/30/30, 30/–/30/30, 30/–/–/30, 30/–/–/–, stop
- Takes 8 days
- Phenobarbital loading effect scale
- Nystagmus: absent (0); present on extension of lateral gaze (1); easily elicited and sustained (2); coarse, sustained nystagmus (3)
- Dysarthria: absent (0); minor slurring of some words (1); moderate slurring frequently (2); severe slurring, unintelligible (3)
- Ataxia: absent (0); mildly unsteady on tandem gait (1); moderately unsteady on regular gait (2); needs support on regular gait (3)
- Emotional lability: normal, as before loading (0); some mood change (1); obvious mood change, inappropriate (2); uninhibited, mood swings (3)
Seizures
Outpatient Management
- For patients at low risk of complicated withdrawal, office-based management can be considered
- Start on Monday or Tuesday, unless there is weekend coverage for the clinic
- Assess the patient daily
- Typically use diazepam per schedule below, with thiamine 100 mg po daily for 5 days
Schedule | Day 1 | Day 2 | Day 3 | Day 4 |
---|---|---|---|---|
Rigid | 10 mg qid | 10 mg tid | 10 mg bid | 10 mg qhs |
Flexible | 10 mg q4-6h prn | 10 mg q6-8h prn | 10 mg q12h prn | 10 mg qhs prn |
Front-loaded | 20 mg q2-4h until sedated, followed by 10 mg q4-6h prn (max 60 mg daily) | 10 mg q4-6h prn (max 40 mg) | 10 mg q4-6h prn (max 40 mg) | none |
- Symptoms to trigger prn doses in the above schedules include heart rate >100, DBP >90 mmHg, or signs of withdrawal
- Front-loaded schedules often need very little medication after the load