Patients experiencing withdrawal should be placed in a low-stimulation, reassuring environment that is calm and quiet. Dehydrated patients should receive IV fluids until they are euvolemic. Thiamine and glucose should be given to treat or prevent Wernicke’s encephalopathy. Multivitamins with folate should be initiated and electrolyte disturbances such as magnesium, potassium, glucose, and phosphate should be corrected. Depending on the severity, nutritional supplementation may need to be intravenous for at least the first day or two for aspiration prevention, as well as impaired gastrointestinal absorption in patients who chronically abuse alcohol. 171,212 Medications Benzodiazepines Benzodiazepines are a mainstay of alcohol withdrawal treatment. They are useful in preventing withdrawal symptoms from becoming more severe, preventing seizures and delirium, and for treating psychomotor agitation. Longer acting agents such as diazepam and chlordiazepoxide are preferrable to reduce the chance of seizures or recurrent withdrawal. Patients with severe liver disease are at a higher risk of benzodiazepine accumulation due to reduced metabolism. These patients should be treated with lorazepam because of its shorter half-life, or oxazepam because of the lack of active metabolites, which prevents prolonged oversedation. IV administration is often required in patients in severe withdrawal, for those who cannot tolerate oral administration, or those who are unconscious. Doses vary greatly and should be patient-specific. Patients should be monitored for signs of oversedation and respiratory depression. 171 Benzodiazepines are Schedule IV controlled substances that carry a risk of misuse or diversion. This risk can be mitigated by ordering the minimum amount needed to achieve stability and hold the patient over until their next appointment. Benzodiazepines should be discontinued once alcohol withdrawal treatment is complete. Patients and caregivers should be educated on the risks of combining alcohol with benzodiazepines, the risks of driving or using heavy machinery while taking benzodiazepines, and the interaction between benzodiazepines and other CNS depressants. Patients at a high risk of benzodiazepine abuse or diversion can be prescribed alternative medications or referred for inpatient management, depending on the severity of their case. 171 For patients in hospitals or treatment centers, the preferred dosing method is symptom-triggered dosing administered by trained staff. In this method, patients are given medication only when experiencing significant symptoms of withdrawal, as noted by a symptom severity scale such as the CIWA-Ar, and doses are based on symptom severity. Withdrawal symptoms can be monitored using the CIWA-Ar scale every 1 to 4 hours initially, and can be extended to every 4 to 8 hours once the patient has been stabilized. Symptom triggered treatment allows for individualized dosing based on real time
severity of symptoms, reducing the risk of over or under treatment. Patients may require large doses of benzodiazepines initially, with reduced doses over time. Studies have shown that symptom-triggered dosing reduces treatment duration and length of inpatient stay compared to fixed-dose schedules. 171 Fixed dosing is commonly used in ambulatory settings. This method allows for set amounts of benzodiazepines to be administered at regular intervals, and the dose and/or frequency is gradually tapered according to a set schedule. Fixed dosing is easier for patients to self-administer, though it is also easier to over or underestimate the dose needed, leading to oversedation or sub-optimal symptom control. Patients on fixed dose schedules still require frequent monitoring, and should be reassessed regularly to determine if dosage changes are necessary. 171 Front loading with benzodiazepines is recommended for patients in severe alcohol withdrawal, as noted by CIWA-Ar scores greater than 19. Front loading involves giving a moderate or high dose of a long- acting benzodiazepine to ensure withdrawal symptoms are rapidly controlled. Longer-acting agents such as diazepam or chlordiazepoxide are preferred agents for this purpose, to prevent the development of seizures or delirium. Studies have shown that front loading reduces the risk of withdrawal seizures, shortens treatment durations, and reduces the duration of delirium. Patients receiving front-loaded doses should be closely monitored for respiratory depression and signs of oversedation, as these side effects occur more frequently with this type of dosing regimen. 171 Phenobarbital Patients who have a contraindication to benzodiazepine use that are experiencing moderate to severe withdrawal, or are at risk of developing severe or complicated withdrawal, may be treated with phenobarbital. Phenobarbital, a barbiturate, was the first medication used to successfully treat alcohol withdrawal; its use for this purpose began in the 1920s. Phenobarbital is best administered by providers experienced with its use who are able to closely monitor the patient, due to the risk of toxicity when used in high doses or in combination with alcohol. Phenobarbital has a narrow therapeutic window which can create challenges in dosing it appropriately; it can cause respiratory depression and oversedation when used at high doses. Its dosing can also be complicated by its long half-life of up to seven days, and its metabolism by the liver, which can be impaired in patients who chronically abuse alcohol. Phenobarbital is associated with a number of other side effects, including hypotension, pulmonary edema, bradycardia, bradypnea, hypothermia, acute renal failure, and Steven-Johnson syndrome. When the effective use of benzodiazepines for the treatment of alcohol withdrawal was initiated in the 1960s, the use of phenobarbital fell out of favor. 171 Anticonvulsants Anticonvulsants such as carbamazepine, gabapentin, or valproic acid can be used as adjunct therapy with
Book Code: CA23CME
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