benzodiazepines to improve control of withdrawal. Carbamazepine or gabapentin can also be used as monotherapy if benzodiazepines are contraindicated; valproic acid does not have sufficient evidence to support its use as monotherapy. There is not enough evidence to support the use of anticonvulsants over benzodiazepines, particularly in patients at a high risk of severe withdrawal, delirium, or seizures. Gabapentin may be an effective adjunct bridge therapy between the treatment of alcohol withdrawal and long-term management of alcohol use disorder. Gabapentin has been associated with increased abstinence rates and fewer heavy drinking days compared with placebo in the management of alcohol use disorder. Valproic acid should be avoided in patients with liver disease as well as in women of childbearing potential. 171 Alpha2 Adrenergic Agonists and Beta Blockers Alpha2 adrenergic agonists such as clonidine can be useful as adjunct therapy in patients with anxiety or autonomic hyperactivity that is not controlled by benzodiazepines. Beta-adrenergic antagonists, also known as beta blockers, can also be used in appropriate patients to treat persistent hypertension or tachycardia. Since many alcohol withdrawal patients experience cardiac symptoms such as tachycardia or hypertension, those that are not alleviated by correcting electrolyte imbalances, dehydration, or through the use of benzodiazepines can benefit from the use of alpha2 agonists or beta blockers. These agents should not be used as monotherapy in withdrawal treatment: they can reduce the symptoms of withdrawal without treating the underlying pathophysiology, increasing the risk of developing more severe withdrawal. They are also not effective when used alone for the treatment of withdrawal seizures or delirium. 171 Managing Complicated Alcohol Withdrawal Seizures Patients who have experienced a seizure during their current withdrawal episode should be admitted to a setting that has close monitoring available for frequent reassessment every 1 to 2 hours for the next 6 to 24 hours. Electrolyte levels should be monitored to determine the need for IV fluids and patients should be closely monitored for delirium. Safety measures such as fall precautions, frequent check-ins, and assistance with activities of daily living can also be implemented to ensure patient safety. 171 Treatment should be initiated immediately with a medication that is effective at seizure prevention; parenteral administration through the intravenous route, or intramuscular if intravenous is unavailable, is preferred. Fast acting benzodiazepines such as lorazepam or diazepam are first line treatment. When compared to placebo in a double-blind clinical trial of emergency department patients, intravenous lorazepam significantly reduced the risk of recurrent seizures. Phenobarbital can be used in patients who are unable to use benzodiazepines; parenteral phenobarbital should only be given in intensive or critical care units due to the risk of oversedation and respiratory depression. 171
Delirium Patients experiencing delirium due to alcohol withdrawal often need to be admitted to intensive or critical care units to receive close nursing observation and supportive care such as regular vital sign monitoring and frequent reassessment. Intravenous access should be established quickly to allow for rapid administration of fluids and medication. CIWA-Ar scores are not recommended to monitor withdrawal symptoms in patients with delirium, since it relies on patient-reported symptoms. Instead, structured assessment scales such as the Confusion Assessment Method for ICU Patients (CAM-ICU) should be utilized. One on one observation should be initiated in patients who are agitated and disoriented. Restraints should be avoided unless necessary to prevent injury or comply with state laws. 171 Benzodiazepines are recommended as first line treatment for alcohol withdrawal delirium. Administration of intravenous benzodiazepines to achieve a light sedation where the patient is awake but tends to fall asleep unless stimulated is recommended to help control agitation and maintain patient safety. High doses of benzodiazepines may be required to control agitation in delirium patients as compared to other populations; providers should not hesitate to use large doses, but should monitor for oversedation and respiratory depression as well. Intermittent use of long and short acting benzodiazepines is recommended; continuous IV infusion has not shown superiority over intermittent dosing and is typically more expensive. Patients should be monitored for signs of metabolic acidosis or hyponatremia. 171 Phenobarbital can be used as an alternative to benzodiazepines, but is not preferred due to the need for close monitoring. Adjunctive antipsychotic agents can be used if delirium and hallucinations are not controlled by benzodiazepines; antipsychotics should not be used as monotherapy due to the risk of lowering the seizure threshold and increasing the risk of withdrawal seizures. Second generation antipsychotics such as risperidone or quetiapine are preferred because they have less of an effect on the seizure threshold when compared to first generation agents. Haloperidol has also been successfully used in the management of delirium. 171
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Book Code: CA23CME
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