Managing Alcohol Withdrawal In The ED

 

Author: Kim Iwaki, MD (EM Resident Physician, PGY-3, NUEM) // Edited by: Teddi Rusinak, MD // Expert Review: Howard Kim, MD

Citation: [Peer-Reviewed, Web Publication] Iwaki K , Rusinak T (2016, November 29). Managing Alcohol Withdrawal In The ED [NUEM Blog. Expert Commentary By Kim H]. Retrieved from http://www.nuemblog.com/blog/etoh-withdrawal

Over 16.3 million adults have an alcohol use disorder as defined by the NIH [1]. Though the emergency department (ED) sees its fair share of intoxicated patients, many patients also present to the ED with withdrawal symptoms. Several of these patients come to the ED seeking symptomatic relief after intentionally trying to cut down on drinking, while others go into frank withdrawal secondary to an acute illness that prevents them from drinking.

What are the Symptoms of Alcohol Withdrawal?

Mild withdrawal symptoms including tremulousness, mild anxiety, palpitations, headache, diaphoresis, and GI upset, begin 6-36 hours after the last drink. Seizure may also occur between 6-48 hours after the last drink. Alcoholic hallucinations typically begin within 12-48 hours. Finally, Delirium tremens – with delirium, agitation, hypertension, fever, and diaphoresis - likely will occur between 48-96 hours after the patient’s last drink [2].

How do you treat Alcohol Withdrawal?

Benzodiazepines are used to treat the symptoms of alcohol withdrawal. Diazepam is often preferred since it is long-acting. Chlordiazepoxide is also a popular agent given it is long-acting and is thought to be less addictive. However, lorazepam may be preferable in those who metabolize the drug more slowly including the elderly and those with advanced liver disease. Lorazepam has a shorter half-life and therefore, its active metabolites are less likely to reach toxic levels [3,4].

What dosing is recommended?

Below is a treatment regimen recommended by Mayo-Smith MF et al [5].

Symptom-triggered Regimen, CIWA-Ar scores > 8:

  • Chlordiazepoxide: 50-100mg q hour
  • Diazepam: 10-20mg q 10 min
  • Lorazepam: 2-4mg q 20 min

Symptom-triggered vs. fixed-schedule dosing

Saitz et al [6] performed a randomized double-blind, controlled trial on 101 patients admitted to the Veterans Affair Medical Center. Exclusion criteria included patients who were also being admitted for acute medical or psychiatric illness, a history of seizures from any cause, an inability to take PO, and current use of benzodiazepines, opiates, clonidine, barbiturates, or beta blockers. Subjects were randomized to the fixed-schedule group or the symptom-triggered group. The baseline characteristics for each group – including initial CIWA-Ar score, prior hallucinations, prior detoxification, prior delirium tremens, and age were not significantly different (P>.05). The fixed-schedule group received chlordiazepoxide scheduled every 6 hours. The first 4 doses were of 50mg each and the next 8 doses were of 25mg each, for a total of 12 doses. In addition, their CIWA-Ar scores were assessed 1 hour after each dose of medication and they received an extra 25-100mg of chloriazepoxide when their CIWA-Ar scores were greater than 8. The symptom-triggered group received a placebo every 6 hours for 12 doses with nurses again calculating their CIWA-Ar score after every dose, giving them between 25-100mg of chlordiazepoxide based on their score. The primary outcome was the duration of medication treatment and the total amount of benzodiazepines administered. The duration of treatment was determined after the patient maintained a CIWA-Ar score less than 8 for 24 hours. An intention-to-treat analysis was used and they found that the duration of treatment was significantly shorter in the symptom-triggered group (9 hours vs 68 hours, p<0.001). The symptom-triggered group also received significantly less chlordiazepoxide (100mg vs 425mg, P<0.001).

Limitations of this study included the following:

CIWA-Ar (taken from aafp.org)&nbsp;

CIWA-Ar (taken from aafp.org) 

  • The as needed dose of chlordiazepoxide ranged from 25mg to 100mg. The study does not report how they determined whether to give a 25mg dose vs a higher dose (ie 50 or 100mg).
  • The study was not powered to detect differences in rare complications including seizures and DTs.
  • A history of hallucinations, DTs, and prior detoxification were more prevalent in the baseline characteristics for the fixed treatment group, though this did not reach clinical significance.
  • The study was performed in an alcohol detoxification unit with nurse who are trained to use the CIWA-Ar scale, which limits its generalizability to other medical centers without specialized training and the outpatient setting.
  • The study consisted mostly of men, which may limit its applicability to women
  • The study excluded those with a history of withdrawal seizures. This is a limitation under the assumption that a fixed-schedule regimen will prevent abrupt rebound symptoms and decrease the likelihood of withdrawal seizures.
  • The study only evaluated the use of chlordiazepoxide, so the findings cannot be applied to the use of other benzodiazepines.

Disposition: Inpatient vs. Outpatient

Patents may be safely discharged home if they have mild symptoms. Outpatient detoxification is often safe and more cost effective than inpatients treatment if the patient can be assessed daily by a medical provider. Only short prescriptions of benzodiazepines should be given to ensure close follow-up [8,9,10]. Because of the potential for rebound withdrawal with symptom-triggered treatment, some believe that a fixed-schedule regimen should be used though this is not evidence-based. Indications for inpatient admission include a history of withdrawal seizures, a history of delirium tremens, a history of severe withdrawal symptoms, multiple prior detoxifications, recent high levels of alcohol use, concomitant psychiatric or medical illness, pregnancy, and lack of an outpatient support system [10].

Take Home Points

  • Treating alcohol withdrawal must be individualized.
  • Evidence has demonstrated that symptom-triggered treatment is more effective than fixed-schedule dosing, leading to decreased medication requirement and faster recovery. However, this study excluded patients with prior withdrawal seizures.
  • Outpatient management may be appropriate and cost-effective for patients with mild symptoms, without prior severe withdrawal symptoms, and without comorbid conditions.

Expert Commentary

Hi Kim,

Thanks for the good review of managing alcohol withdrawal in the ED and the benefit of symptom-triggered therapy. Patients presenting with alcohol withdrawal can present anywhere on the spectrum of disease severity, and having a nuanced treatment strategy can make the difference between a good and bad outcome.

Obviously, the first step to effectively treating alcohol withdrawal is to diagnose it properly. In addition to the classic symptoms of withdrawal that you described, I look for physical exam findings that cannot be feigned, such as tachycardia, hypertension, and diaphoresis. Other findings such as tremors and tongue fasciculations may also be relevant, however, can be gamed more easily and have poor inter-rater reliability. I do not typically rely on patient history when considering the possibility of alcohol withdrawal, since time to onset of symptoms is highly variable and patient reporting is notoriously unreliable. Don’t forget that severe alcohol withdrawal can look very similar to sepsis (fever, tachycardia, tachypnea, leukocytosis) so keep this in your differential diagnosis when evaluating what you think may be an infectious complaint. Vice versa, pause to reconsider your diagnosis of alcohol withdrawal in a patient that does not appear to be responding to treatment.

As you point out, benzodiazepines are the mainstay of treatment of alcohol withdrawal. Whether you use diazepam or lorazepam is a matter of preference, but I would recommend staying consistent with whichever benzodiazepine you select. I often see ED providers give a smorgasbord of medications in severe cases of alcohol withdrawal (e.g. diazepam 5mg IV, lorazepam 0.5mg PO, lorazepam 1mg IV, diazepam 10mg PO), which can make it difficult to assess treatment effect and calculate total dosing requirements.

It is worth noting that the doses of benzodiazepines you have listed are more appropriate for cases of severe alcohol withdrawal and not minor withdrawal symptoms. For patients with severe withdrawal, my personal approach is to give escalating doses of lorazepam q 15min until the desired response is achieved: e.g. 2mg IV, if no/poor response then 4mg IV, if no/poor response then 6mg IV, of course reconsidering my diagnosis at each step. Patients with mild withdrawal symptoms do not require this attentive dose escalation strategy and can be managed with lower doses of benzodiazepines as needed.

At our county hospital in Denver, we had success using phenobarbital early in the course of severe alcohol withdrawal, although evidence for phenobarbital is limited to single-center studies [11], use in this context remains off-label, and phenobarbital does carry an increased risk of hypotension and mental status depression. My general advice would be that if your specific institution does not have familiarity with (and ideally a protocol for) use of alternative agents such as phenobarbital in severe alcohol withdrawal, then it would be best to stick to the devil you know in benzodiazepines.

Howard Kim, MD

Clinical Instructor, Research Fellow, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine

References

  1. National Institute on Alcohol Abuse and Alcoholism (2016, January). Alcohol Facts and Statistics. Retrieved from <http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics>.
  2. Etherington JM. Emergency management of acute alcohol problems. Part 1: Uncomplicated withdrawal. Can Fam Physician. 1996;4(2):2186.
  3. Turner RC, Lichstein PR, Peden JG Jr, Busher JT, Waivers LE. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med. 1989;4(5):432.
  4. DeBellis R, Smith BS, Choi S, Malloy M. Management of delirium tremens. J Intensive Care Med. 2005;20(3):164.
  5. Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997;278(16):1317-8.
  6. Saitz R, Mayo-Smith MF, Roberts M, Redmod HA, Bernard DR, Calkins DR. Individualized Treatment for Alcohol Withdrawal. JAMA. 1994;272(7):519-523.
  7. Sullivan JT, Sykora K, Schneiderman J, Nranjo CA, Sellers EM Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). J Addict. 1989;84(11):1353-7.
  8. Abbott PJ, Quinn D, Knox L. Ambulatory medical detoxification for alcohol. Am J Drug Alcohol Abuse. 1995;21(4):549–63.
  9. Hayashida M, Alterman AI, McLellan AT, O’Brien CP, Purtill JJ, Volpicelli JR, et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. N Engl J Med. 1989;320(6):358–65.
  10. Bayard M, Mcintyre J, Hill KR, Woodside Jr J. Alcohol Withdrawal Syndrome. Am Fam Physician. 2004 Mar 15;69(6):1443-1450.
  11. Rosenson J, Clements C, Simon B, Vieaux J, Graffman S, Vahidnia F, Cisse B, Lam J, Alter H. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013 Mar;44(3):592-598.e2. 
Posted on November 28, 2016 by Michael Macias and filed under Toxicology and tagged alcohol withdrawal etoh withdrawal delirium tremens CIWA withdrawal.