Guidelines for the In-Patient Management of Alcohol Withdrawal at Frimley Park Hospital NHS Foundation Trust Authors: Dr Aftab Ala, Consultant Gastroenterologist & Hepatologist Dr Tasneem Pirani, ST4 in Gastroenterology Dr Henna Wong, CT1 Core Medical Training Wing Lam Yeung, Medical Directorate Pharmacist Lead Director: Dr Aftab Ala, Consultant Gastroenterologist & Hepatologist Version No: 6 Implementation May 2010 Date: Ratified By: Drugs and Therapeutics Committee, April 2010 Date of Next May 2011 Review:
1 Introduction The Government recommended daily limits for alcohol are 2-3 units for a woman and 3-4 units for a man. Alcohol misuse can manifest as physical or psychological symptoms across a whole range of specialties. It is important for all healthcare professionals to be aware of patients that are at risk of withdrawal so that appropriate investigations and treatment can be instituted. We need to avoid either under- or over- treatment which may lead to delirium tremens (DT) or over treatment, which is associated with sedation and respiratory compromise. Benzodiazepines, especially Chlordiazepoxide, are central to the management of alcohol withdrawal. Chlordiazepoxide is used due to its reduced street appeal and dependence potential compared to Diazepam or Chlormethiazole. Purpose of Guidelines These guidelines should be used from initial admission through to discharge as an aid to ascertain who is at risk and how to prevent complications of alcohol withdrawal. 1. Identify patients at risk Ask about alcohol intake per day and type of alcohol Has there been a previous attendance related to alcohol? CAGE questionnaire o Cut down o Annoyed o Guilty o Eye-opener Figure 1: Table to estimate number of units of alcohol per type of beverage PINT CAN GLASS SINGLE BOTTLE BEER/LAGER/CIDER 2 1.5 330ml 1.3 STRONG BEER/LAGER/CIDER 5 4 3 WINE SHERRY/PORT/MARTINI 1 SPIRITS (GIN/VODKA/WHISKY) 1.5-2.5* 750ml 7.5-10.5* 1 30 ALCOPOPS * see website (depends on strength/size) http://www.drinking.nhs.uk/questions/unit-calculator/ 275ml 1.4
2 2. Alcohol Withdrawal Syndrome (AWS) Figure 2: Symptoms of withdrawal states Uncomplicated withdrawal (Symptoms typically seen within 6-8 hours of last drink, peaking at 10-30 hours) Tremors Sweating Fever Nausea, vomiting Anxiety Irritability Tachycardia Insomnia Anorexia Auditory/visual hallucinations Delirium tremens (onset commonly within 2-3 days of cessation) Auditory/visual hallucinations Severe tremor Confusion, disorientation, agitation Temp > 38.3 Autonomic over activity Delusions Alcohol withdrawal seizures (within 12-48 hours, rare beyond 48 hours) Usually grand-mal 3. Treatment of AWS See flow diagram on page 4 Patients prescribed Chlordiazepoxide should be monitored for respiratory depression. Monitor pulse, oximetry and respiratory rate. Review patient after TWO doses of Chlordiazepoxide. 4. Adjunctive treatment Patients are at risk of Wernicke s and subsequent progression to Korsakoff s psychosis due to thiamine depletion. All patients should be assessed for ophthalmoplegia/nystagmus/confusion/ataxia (difficult if patients acutely intoxicated) All patients who misuse alcohol and present with alcohol withdrawal should be prescribed the following: o Pabrinex 2 pairs tds for 3 days o Once parenteral vitamin supplementation has finished, commence: Thiamine 200mg od for at least 1 month Vitamin B co-strong II once a day for at least 1 month
3 5. Treatment of alcohol withdrawal seizures These usually occur within 12-48 hours of alcohol cessation If status epilepticus occurs, this should be treated with Lorazepam or Diazepam as Phenytoin is not effective. IV Diazepam 10mg stat, at a maximum rate of 5mg per min and repeated once after 10 minutes (if necessary) OR alternatively IV Lorazepam 4mg stat, at a maximum rate of 2mg per min and repeated once after 10minutes (if necessary) Inform ITU 6. Alternatives to Chlordiazepoxide Lorazepam can be used sublingually 30mg Chlordiazepoxide 1 mg Lorazepam Consider oral Lorazepam in patients with severe liver impairment or established cirrhosis as it is shorter-acting and therefore avoids the excessive build up of metabolites and over-sedation. Discuss with the Gastroenterology Team as soon as possible. 7. Checklist prior to discharge Check LFTs, Clotting, FBC [ ] Provide details of drug /alcohol addiction unit i.e. Self referral to ACORN [ ] o ACORN phone numbers Frimley - 01276 62566 Guildford - 01483 450256 Patients should NOT be discharged on Chlordiazepoxide except on Consultant advice Discussion with Gastroenterology Team prior to arranging follow up [ ] References A Time to Act: Improving Health and Outcomes in Liver Disease British Association of the study of the liver October 2009 O Shea et al. Alcoholic liver disease. American Association of the study of the liver. Practice Guidelines Hepatology 2010
4 MANAGEMENT OF ALCOHOL WITHDRAWAL SYNDROME All patients need the following investigations: U & E s, Mg2+, PO4-, Ca2+, Folate/B12, LFT s, FBC, Clotting Screen, Blood glucose. Watch for hyponatraemia. Vitamin supplementation for all patients prescribed with reducing regime of Chlordiazepoxide PABRINEX 2 pairs TDS IV for 3 days Once parenteral supplementation complete, start oral vitamins for at least 1 month THIAMINE 200mg od VITAMIN B CO-STRONG II od Does this patient drink >8-10 units of alcohol per day AND/OR have any alcohol withdrawal signs/symptoms? Anxiety/agitation/irritability Sweating Fever Tremor Tachycardia Nausea/vomiting/retching Insomnia Hallucinations Mild systolic hypertension Anorexia YES Give vitamin supplementation (see yellow box) NO No treatment necessary, continue to monitor Classification of symptoms Use the following Chlordiazepoxide regime Mild Moderate SEVERE <100 units /week 100-200 units /week >200 units/week Time Day Day Day Day Day 1 2 3 4 5 0800 20mg 10mg 5mg 5mg - 1200 20mg 10mg 5mg - - 1800 20mg 10mg 5mg - - 2200 20mg 20mg 10mg 10mg 5mg Time Day Day Day Day Day Day 1 2 3 4 5 6 0800 30mg 20mg 10mg 5mg 5mg - 1200 30mg 20mg 10mg 5mg - - 1800 30mg 20mg 10mg 5mg - - 2200 30mg 30mg 20mg 10mg 10mg 5mg Plus PRN 5mg Chlordiazepoxide Plus PRN 5-10mg Chlordiazepoxide Maximum total daily dose of 300mg Time Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 0800 40mg 30mg 20mg 10mg 10mg 5mg 5mg 1200 40mg 30mg 20mg 10mg 5mg 5mg 1800 40mg 30mg 20mg 10mg 5mg 5mg 2200 40mg 30mg 20mg 10mg 10mg 5mg 5mg Plus prn 10mg Chlordiazepoxide Maximum total daily dose of Chlordiazepoxide 300mg SEVERE ALCOHOL WITHDRAWAL Initiate high dose vitamin therapy & Chlordiazepoxide Monitor blood glucose 2hrly - correct hypoglycaemia (ALWAYS give Pabrinex first as may precipitate Wernicke s encephalopathy) If NBM or swallowing problems: IV Diazepam (Diazemuls) 10mg, repeated if necessary after not less than 4 hours (max 5mg/min by slow IV injection), or PR diazepam (rectal tubes) 500 micrograms/kg (maximum 30mg), repeated after 12 hours if required. Avoid IM where possible erratic absorption and bleeding risk Treat convulsions (page 3) and discuss with ITU