Ver el código de «Ethanol withdrawal»

==Background==
*Withdrawal symptoms due to reduced GABA and increased NMDA receptors
*[[Benzodiazepines|Benzos]] useful due to cross tolerance at [[Ethanol toxicity|ethanol]] GABA receptor and longer half-life
*Symptom-triggered therapy
**As effective as fixed dose therapy, but with more rapid detox
*Don’t use [[phenytoin]] or [[fosphenytoin]] to treat seizures caused by drug toxicity or drug withdrawal.<ref>Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin-to-treat-seizures/</ref>

==Clinical Features==
*Reduction in alcohol use that has been heavy and prolonged
*At least 2 of the following
**Autonomic hyperactivity (e.g., diaphoresis, [[tachycardia|HR>100]])
**Increased hand [[tremor]]
**[[Insomnia]]
**[[Nausea/vomiting]]
**Transient visual, tactile, or auditory [[hallucinations]]
**Psychomotor agitation
**[[Anxiety]]
**Grand mal [[seizures]]
===Tremulousness===
*Onset after last drink: 6-12h
===[[alcohol withdrawal seizures|Seizures]]===
*Onset after last drink: 6-48h
*Multiple seizures: 60% of patients
*Progression to DTs: 33% of patients
*Treat with [[Benzodiazepines|benzos]] (not [[phenytoin]])
===Alcoholic Hallucinosis===
*Onset after last drink: 12-24hr
*Visual hallucinations are most common
*Different from delirium tremens
**Resolves within 24-48 from last drink (before onset of DTs)
**No delirium
**Normal vital signs
===[[Delirium tremens]]===
*Onset after last drink: 48+hrs
*Decreased attention and awareness
*Disturbance in attention, awareness, memory, orientation, language, perception, visouspatial ability that fluctuates in severity
*No evidence of coma or other evolving neurocognitive disorders

==Differential Diagnosis==
{{Ethanol DDX}}
{{Sedative/hypnotic withdrawal types}}
{{Seizure DDX}}

==Evaluation==
*Consider workup for alternate etiologies if clinical presentation unclear
*Consider workup to evaluate any symptoms that led patient to stop drinking (e.g. did patient stop in setting of feeling unwell due to [[abdominal pain]], [[pneumonia]], etc.?)

{{CIWA score}}

==Inpatient Management==
''Start aggressive [[Benzodiazepines|Benodiazepine]] therapy at CIWA score of 8. Consider ICU admission with score >20''
{{Inpatient management of ETOH withdrawal}}
{{Vitamin prophylaxis for ETOH}}

==Outpatient Management==
===[[Chlordiazepoxide]]===
'''Generally for outpatient treatment of mild cases and as a taper'''
*25-50mg of chlordiazepoxide is equivalent to 10mg of diazepam
*50mg of chlordiazepoxide every 8 hours for two days, then decrease to 25mg every 8 hours for another two days followed by 25mg PRN as needed. An alternative dosing regimen to consider is chlordiazepoxide 50 mg PO q6-12h on d 1; 25 mg PO q6h on d 2; 25 mg PO q12h on d 3; 25 mg PO at night on d 4.

===[[Anticonvulsants]]===
*Have less abuse potential but may not prevent seizures<ref>Muncie HL et al. Outpatient Management of Alcohol Withdrawal Syndrome. Am Fam Physician. 2013 Nov 1;88(9):589-595.</ref>
*[[Gabapentin]] 400mg PO TID x 4 days<ref>Leung JG, Hall-Flavin D, Nelson S, et al. The role of gabapentin in the management of alcohol withdrawal and dependence. Ann Pharmacother. 2015; 49(8):897-906.</ref>
**Some protocols call for higher dosing - 1200 mg (400 mg t.i.d.) of gabapentin for three days then 800 mg (400 mg b.i.d.) for day 4 <ref>Myrick, H et al. A double blind trial of gaba pentin vs lorazepam in the treatment of alcohol withdrawl. 
Alcohol Clin Exp Res. 2009 Sep; 33(9): 1582–1588. PMID: 19485969</ref>
**Similar efficacy to lorazepam in decreasing craving and anxiety<ref>Myrick, H et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. 2009 Sep;33(9):1582-8.  PMID: 19485969</ref>
**Questionable efficacy in preventing alcohol withdrawal seizures
*[[Carbamazepine]] taper<ref>Barrons R et al. The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome. J Clin Pharm Ther. 2010 Apr;35(2):153-67.</ref>
**May start when BAL < 150 mg/dL
**Varying evidence in support of whether agent truly reduces of alcohol withdrawal seizures and [[delirium tremens]]
**800 mg per day be fixed or tapered over 5-9 days

===DHS Expected Practice Example Tables (2020)<ref>LA County DHS Expected Practice Example Tables (2020). Available at: https://lacounty.sharepoint.com/sites/dhs-ccl/Addiction%20Medicine/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine%2FOutpatient%20Medication%20Management%20of%20Alcohol%20Use%20Disorder%2Epdf&parent=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine</ref>===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Days'''
| align="center" style="background:#f0f0f0;"|'''Carbamazepine Montherapy'''
|-
| 1-3 ||200mg QID
|-
| 4-6||200mg TID
|-
| 7-9||200mg BID
|-
| 10-11||200mg QHS
|-
|}

{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Days'''
| align="center" style="background:#f0f0f0;"|'''Gabapentin Monotherapy'''
|-
| 1||1,200mg BID plus 1,200mg x 1 PRN
|-
| 2-7||600mg TID plus 600mg x 1 PRN
|-
| 8||300mg TID
|-
| 9||300mg BID
|-
| 10||300mg QHS
|-
|}

==Disposition==
===Admit===
*Multiple [[seizures]]
*[[delirium tremens|DTs]]
*[[AMS|Decreased LOC]]
*Inability to control withdrawal after administrating 3-4 doses of benzo's
*Consider ICU admission with CIWA score >20

===Discharge===
*Two consecutive CIWA scores (two hours apart) <10 with resolution of tremor
*Consider discharge [[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawl|with 3 day course of benzodiazepines if patients are attempting to quit alcohol]] (controversial)
*Consider possible exclusions for outpatient treatment<ref>Myrick et al. A DOUBLE BLIND TRIAL OF GABAPENTIN VS. LORAZEPAM IN THE TREATMENT OF ALCOHOL WITHDRAWAL. Alcohol Clin Exp Res. 2009 Sep; 33(9): 1582–1588. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769515/</ref>:
**Substance use disorders except alcohol, nicotine, or cannabis
**Major Axis I psych disorder
**Medication history of benzodiazepines, beta-blockers, calcium-channel blockers, antipsychotics
**History of head injury, epilepsy, medical instability, ECG abnormality, grossly abnormal lab value

==See Also==
*[[Beer Potomania Syndrome]]
*[[Alcohol (ETOH) Intoxication]]
*[[Alcoholic ketoacidosis]]
*[[Alcohol withdrawal seizures]]
*[[Altered mental status]]
*[[Delirium tremens]]
*[[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal]]
*[[Sedative/Hypnotic]]

==External Links==
*[http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator MDCalc - CIWA-AR Calculator]
*Link to [https://lacounty.sharepoint.com/sites/dhs-ccl/Addiction%20Medicine/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine%2FOutpatient%20Medication%20Management%20of%20Alcohol%20Use%20Disorder%2Epdf&parent=%2Fsites%2Fdhs%2Dccl%2FAddiction%20Medicine DHS Expected Practice]
*LA County Substance Abuse Service Helpline: 844-804-7500
*[https://emcrit.org/ibcc/etoh/ The Internet Book of Critical Care: Alcohol Withdrawal]

==References==
<references/>

[[Category:Psychiatry]][[Category:Toxicology]]