Self-Assessment Quiz Question #3 Which of the following should be given to patients withdrawing from alcohol to treat or prevent Wernicke’s encephalopathy? a. Lorazepam. b. Thiamine. c. Folate. d. Magnesium. Medications Benzodiazepines Benzodiazepines are a mainstay of alcohol withdrawal treatment. They are useful for preventing withdrawal symptoms from becom- ing more severe, preventing seizures and delirium, and treating psychomotor agitation. Longer-acting agents such as diazepam and chlordiazepoxide are preferable, as their longer action and less frequent need for redosing reduces the chance of seizures or recurrent withdrawal. Patients with severe liver disease are at a higher risk of benzodiazepine accumulation because of 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 for patients in severe withdrawal, who cannot tolerate oral administration, or who are unconscious. Doses vary greatly and should be patient-specific. Patients should be monitored for signs of oversedation and respiratory depres- sion (American Society of Addiction Medicine, 2020). Benzodiazepines are Schedule IV controlled substances that carry a risk of misuse or diversion. This risk can be mitigated by order- ing 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 driv- ing or using heavy machinery while taking benzodiazepines, and the interaction between benzodiazepines and other CNS depres- sants. 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 (American Society of Addiction Medicine, 2020). 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 moni- tored 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 undertreatment. 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 (American Society of Addiction Medicine, 2020). Fixed dosing is commonly used in ambulatory settings. This meth- od 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 (American Society of Addiction Medicine, 2020). Front loading with benzodiazepines is recommended for patients in severe alcohol withdrawal (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 rap- idly controlled. Studies have shown that front loading reduces the risk of withdrawal seizures, shortens treatment duration, 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 (American Society of Addiction Medicine, 2020). Phenobarbital Patients who have a contraindication to benzodiazepine use and are experiencing moderate to severe withdrawal, or are at risk of developing severe or complicated withdrawal, may be treated with phenobarbital. Phenobarbital was the first medication used to successfully treat alcohol withdrawal, and its use for this indica- tion began in the 1920s. Because of the risk of toxicity when used in high doses or in combination with alcohol, phenobarbital is best administered by providers experienced with its use who are able to closely monitor the patient. Phenobarbital has a narrow therapeutic index, which can create challenges in dosing it ap- propriately. 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 7 days, and its metabolism by the liver, which can be impaired in patients who chronically abuse alcohol. Phenobarbital is associ- ated 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 al- cohol withdrawal was initiated in the 1960s, the use of phenobarbi- tal fell out of favor (American Society of Addiction Medicine, 2020). Anticonvulsants Anticonvulsants such as carbamazepine, gabapentin, or valproic acid can be used as adjunct therapy with benzodiazepines to im- prove control of withdrawal. Carbamazepine or gabapentin can also be used as monotherapy if benzodiazepines are contraindi- cated. 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 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 AUD. Gabapentin has been associated with increased absti- nence rates and fewer heavy drinking days compared with place- bo in the management of AUD. Valproic acid should be avoided in patients with liver disease as well as in women of childbearing potential (American Society of Addiction Medicine, 2020). Alpha-2 Adrenergic Agonists and Beta Blockers Alpha-2 adrenergic agonists such as clonidine can be useful as adjunct therapy in patients with anxiety or autonomic hyperactiv- ity that is not controlled by benzodiazepines. Beta-adrenergic an- tagonists, also known as beta blockers, can also be used to treat persistent hypertension or tachycardia. Patients with alcohol with- drawal who experience cardiac symptoms such as tachycardia or hypertension that are not alleviated by correcting electrolyte im- balances or 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, as they can reduce the symptoms of withdrawal with-
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